Suicide is the 10th leading cause of death in the United States. In 2017, 51% of the 45 390 suicides among those 18 years or older were due to firearm injury.1 Efforts to limit access to lethal means (eg, firearms) are an important element of suicide prevention programs and are especially relevant among US veterans and servicemembers within some military branches given their high burden of suicide and firearm-related suicide in comparison with other US adults.2,3 Two-thirds of veteran and servicemember suicides are firearm related.2,3
A critical question is what clinicians should recommend to adults with elevated suicide risk who reside in households with firearms. Most evidence demonstrating the strong, independent association between firearm access and suicide is based on whether a firearm is present in the household. From this evidence, clinicians can reasonably recommend that at-risk patients remove firearms from their home. Other common suggestions include that firearms remain in the home but be stored unloaded or with external locking devices attached. Such recommendations are probably made because they are considered more palatable or likely to prompt behavior change than suggestions to remove firearms or perhaps because of an understandable “something is better than nothing” mentality among clinicians working to keep their patients safe. However, the evidence supporting these recommendations for adults is limited. A landmark case-control study showed that unsafely stored household firearms were associated with an increased risk of firearm injury, including suicide, among children and adolescents.4 However, there are differences in accessibility between a child whose parent locks up a household firearm and an adult who unloads or locks a firearm but keeps it in the home. The case-control study by Dempsey et al5 reports findings from the largest psychological autopsy study of US servicemember suicides ever conducted, to our knowledge, and adds to the limited literature regarding suicide risk associated with specific firearm behaviors among adults.
Investigators from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) research group compared the odds of firearm ownership and related behaviors between Army servicemembers who died by suicide during 2011-2013 and 2 groups of living controls.5 One group of controls consisted of active-duty servicemembers who were propensity score matched to cases based on established suicide risk factors. Structured interviews with next-of-kin were used to obtain firearm-related data. Investigators applied survey weights to account for selection bias and used multivariate modeling to compare the odds of firearm characteristics between groups. Consistent with prior literature, suicide decedents were more likely to own 1 or more firearms compared with controls (55% [32 of 61 individuals] vs 43% [51 of 128]). The odds of owning a handgun, storing any firearm loaded, or off-duty firearm carrying were 2- to 4-fold higher among suicide decedents compared with propensity score–matched controls. There were no statistically significant differences between the 2 groups in the odds of owning long guns or having aimed or fired a firearm at another person. The odds of the combined behaviors of owning a firearm, storing it loaded, and carrying a firearm off-duty was more than 3-fold higher among suicide decedents than propensity score–matched controls. In a separate analysis using data reported by participants’ military supervisors, there were no significant differences between groups in the odds of having aimed or fired a firearm at another person.
To better understand risk factors for transitioning from elevated suicide risk to death by suicide, investigators compared firearm characteristics between suicide decedents and another group of living controls who had suicidal ideation in the preceding 12 months. They observed no statistically significant differences in firearm characteristics, including firearm ownership, between groups. This does not mean that firearm access is not an important risk factor for suicide among high-risk populations. In a previous case-control study,6 the investigators compared the prevalence of mental disorders and suicide warning signs and behaviors between these same groups. There were no statistically significant differences in those risk factors between cases and servicemembers with suicidal ideation. In each study, however, there was a higher prevalence of many of the studied risk factors among cases compared with those with suicidal ideation. This raises a question as to whether these null findings are related to sample size limitations (as reflected by wide confidence intervals for this control group) or whether the mental health, suicidal behavior histories, and firearm characteristics are truly not dissimilar between high-risk servicemembers and their deceased counterparts. As the investigators noted, many well-established suicide risk factors may be associated with suicidal ideation and may not explain the transition from high risk to death by suicide.6
In the article by Dempsey et al,5 several study limitations should be considered. To our knowledge, the validity of using psychological autopsy to assess firearm behaviors has not been determined. Studies have also noted discrepancies in reporting firearm ownership and storage practices between owners and nonowners. There is reason to question whether family members or supervisors can accurately report whether a servicemember had aimed a firearm at another person. Investigators identified 290 servicemembers who died by suicide during 2011-2013, but analyses included only 135 decedents for whom next-of-kin and/or supervisor interviews were completed.5,6 Although investigators applied survey weighting to mitigate selection bias, the mechanisms leading to missing data and resulting biases are not fully clear.
Despite these limitations, this work5 is an important contribution to the field of lethal means safety and supports the concept that firearm-related behaviors, aside from ownership, may affect suicide risk. In another case-control study of US adults,7 other investigators similarly observed an increased odds of firearm ownership among suicide decedents compared with living controls. Storing firearms loaded or unlocked also was associated with an increased odds of suicide. In many cases, only minutes pass between a decision to end one’s life and an attempt. Storing firearms locked and/or unloaded may decrease risk simply by increasing the time needed to act on suicidal impulses. Alternatively, some firearm-related behaviors may increase risk by reducing intrinsic barriers to self-injury. According to the interpersonal-psychological theory of suicide,8 the act of attempting suicide is partially dependent on overcoming fear about self-injury and acquiring capability to act. Carrying firearms, for example, may habituate firearm owners to using a highly lethal item, which in turn increases self-harm capability.
Dempsey et al5 also showed that not all firearm types contribute equally to suicide risk. The odds of owning a handgun was higher among decedents than controls, whereas no differences were observed in long gun ownership. While this may be due in part to the small proportion who owned long guns, it is consistent with previous studies.7 Although this study did not identify the source of the implicated firearms among decedents, the US Department of Defense reported that 95% of firearms used in servicemember suicides in 2016 were personally owned rather than military issued.2 This statistic highlights a unique challenge of promoting lethal means safety among US servicemembers. In contrast, in countries with lower rates of personal ownership, interventions limiting access to military-issued firearms during high-risk periods has resulted in significant reductions in suicide.9
The most evidence-based and conceptually sound recommendation for suicide prevention remains the same for adults with elevated suicide risk who reside in homes with firearms: removing firearms from the home is likely to offer the greatest suicide risk reduction. However, studies have not delineated to what extent adults will follow this advice. In that scenario, Dempsey and colleagues5 have provided additional support for recommending changes in other firearm behaviors to potentially reduce suicide risk.
Published: June 7, 2019. doi:10.1001/jamanetworkopen.2019.5400
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Simonetti JA et al. JAMA Network Open.
Corresponding Author: Joseph A. Simonetti, MD, MPH, Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional VA Medical Center, Veterans Health Administration, 1700 N Wheeling St, Office G3-189, Aurora, CO 80045 (email@example.com).
Conflict of Interest Disclosures: None reported.
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Simonetti JA, Rowhani-Rahbar A. Limiting Access to Firearms as a Suicide Prevention Strategy Among Adults: What Should Clinicians Recommend? JAMA Netw Open. Published online June 07, 20192(6):e195400. doi:10.1001/jamanetworkopen.2019.5400
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