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Firearm suicide: pathways to risk and methods of prevention
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ScienceDirect Firearm suicide: pathways to risk and methods of prevention Claire Houtsma, Sarah E Butterworth and Michael D Anestis Firearms are utilized in approximately half of all US suicides, making them a serious public health concern and a target of suicide prevention efforts. Practical capability influences the transition from suicidal ideation to action and is particularly relevant to firearm suicide. Firearm ownership, experience using firearms, unsafe firearm storage, and high cultural acceptability of firearms increase risk for death by firearm suicide. Means safety strategies, which emphasize the reduction of practical capability for suicide through the limitation of access to and safe storage of firearms, are effective in preventing suicide and include interventions such as lethal means counseling, firearm legislation, and promoting safe storage practices. Public health interventions aimed at reducing firearm suicide are critical topics for continued research. Address Department of Psychology, University of Southern Mississippi, Hattiesburg, MS, USA Corresponding author: Houtsma, Claire ([email protected])
Current Opinion in Psychology 2017, 22:7–11 This review comes from a themed issue on Suicide Edited by Michael Anestis and Daniel Capron
http://dx.doi.org/10.1016/j.copsyc.2017.07.002 2352-250/ã 2017 Elsevier Ltd. All rights reserved.
Introduction In 2015, 44 193 individuals in the US died by suicide. Approximately half of these individuals utilized a firearm [1]. It is evident that firearm suicide is a profound public health issue that must be more clearly understood. A crucial aspect of furthering our understanding is identifying risk factors that differentiate individuals who experience suicidal thoughts from those who act on those thoughts. The three-step theory (3ST) examines suicide risk from this perspective and argues that severe suicidal ideation develops from the joint presence of psychological pain and hopelessness, particularly when this distress outweighs an individual’s perceived connectedness to others [2]. The theory posits that individuals will only engage in suicidal behavior if they also have the capacity www.sciencedirect.com
for suicidal behavior. Such capacity may be genetically driven (dispositional capability), acquired through repeated experiences that habituate the individual to pain and fear of death (acquired capability), and/or through the access to, knowledge of, and fluency with lethal means (practical capability [2]). Practical capability is especially relevant to firearm suicide and numerous studies have investigated elements of risk related to this component of the 3ST. Emerging strategies for preventing firearm suicide have also been the focus of recent research efforts. These strategies, referred to broadly as means safety, emphasize limitation of access, safe storage, or decrease in potency of methods for suicide and have been found to be effective in preventing suicide [3,4]. This review aims to clarify factors that increase risk for firearm suicide and describes recent advances in prevention efforts designed to mitigate this risk.
Risk for firearm suicide: practical capability Knowledge
One factor that increases risk for death by suicide is the lethality associated with a method. There is an 88–99.5% lethality rate associated with firearms, making them the most lethal means of suicide [5,6]. In fact, firearms have been found to be 2.6 times more lethal than the next most lethal method of suicide, suffocation [5]. In order to use a firearm in an attempt, however, individuals may need to develop comfort and fluency with the mechanics of a firearm. Indeed, Anestis and Capron found that the number of times an individual has fired a gun is associated with fearlessness about death, pain tolerance, and lifetime suicide attempts. This finding may indicate that experience with firearms habituates individuals to the concepts of death and pain, or that individuals with lower fear of death and higher pain tolerance are more likely to seek out experiences with firearms [7]. In either scenario, individuals may be at heightened risk for firearm suicide due to increased knowledge and comfort handling firearms. Availability
Another factor contributing to the disproportionate representation of firearm suicide decedents is the widespread availability of this means of suicide. It is estimated that one-third of US citizens own one or more firearms [8]. Access to firearms is particularly noteworthy given that researchers have found firearm ownership and availability significantly increase risk for suicide [9,10–14] Importantly, this increased risk extends to all members of the household, not just the legal owner of the firearm [15]. Furthermore, the relationship between firearm ownership Current Opinion in Psychology 2018, 22:7–11
8 Suicide
and death by suicide remains significant even when accounting for other robust predictors of suicide, such as mental illness, suicidal ideation, male gender, statewide rurality, religiosity, and state elevation [16]. This is not to suggest that firearm ownership causes individuals to become suicidal; in fact, research has shown that firearm-owning households are no more or less likely than non-firearm-owning households to possess other risk factors for suicide [15] and there is no significant relationship between firearm ownership and suicidal ideation [17]. Rather, these findings indicate that firearm ownership has the ability to arm thoughts of suicide if they develop, increasing risk for suicide through access to a highly lethal means. Supporting this perspective, Betz and colleagues found that once suicidal ideation is present, firearm owners are more likely than non-firearm owners to develop suicide plans involving firearms [18]. Similarly, among currently suicidal individuals who have a history of one or more suicide attempts, those who own firearms demonstrate a stronger association between thoughts of suicide and self-perceived likelihood of engaging in a future suicide attempt (C Houtsma et al., unpublished). The manner in which firearms are stored is also relevant to suicide risk. For example, Anestis and colleagues found that a greater proportion of suicide decedents who stored their firearm at home and in a non-secure location died using a firearm rather than by another method of suicide [19]. Similarly, among firearm owning military personnel, storing a firearm loaded and in a non-secure location was associated with increased levels of fearlessness about death and a stronger association between current suicidal ideation and self-perceived likelihood of making a future suicide attempt [4]. Acceptability
Social gun culture, defined as social norms that emphasize participation in firearm-related activities, may also play a role in the availability and acceptability of firearms [8]. Kalesan and colleagues found that firearm ownership was 2.25 times higher among individuals reporting exposure to social gun culture, even when accounting for the strength of statewide firearm policies and firearm fatality rates [8]. This suggests that sociocultural context may meaningfully influence the decision to own a firearm, the exposure an individual has to firearms, and the acceptability of such exposure. It has also been suggested that firearms are a more culturally acceptable suicide method among US men, as it is considered more ‘masculine’ to die in a violent manner [20]. Additionally, Butterworth and colleagues found that suicide decedents who held conservative social and economic policy views were more likely than those with liberal policy views to have died by firearm suicide, versus other methods. Importantly, these differences were accounted for by higher rates of firearm ownership among those with conservative views [21]. Current Opinion in Psychology 2018, 22:7–11
This supports the notion that beliefs and culture influence firearm ownership, which in turn impacts risk for firearm suicide. At-risk groups
Several components of practical capability converge within certain groups, significantly elevating risk for death by firearm suicide. For example, men die by firearm suicide at a significantly higher rate than women. In 2015, the firearm suicide rate for US men was 11.95 per 100 000, whereas the rate for women was 1.90 per 100 000 [1]. In addition, firearm suicide rates are highest among older, White males living in rural areas; demographics which generally mirror those of firearm owners [22]. Men who suffer from physical health problems may be at even higher risk for firearm suicide. In a sample of male suicide decedents, Hempstead and colleagues found that firearms were utilized at a disproportionate rate among those who were also experiencing health problems at the time of their death [22]. Certain occupations that require the use of firearms, including law enforcement and military service, are associated with increased risk for firearm suicide. In fact, firearms are the most utilized method of suicide among both groups [23]. In these professions, access to and familiarity with firearms are believed to play a substantial role in suicide method choice [23].
Means safety Although means safety approaches are applicable to a variety of suicide methods, firearms are an ideal candidate for targeted interventions in the US because they are highly lethal, widely available, and popular [24]. However, these approaches are often met with distrust or resistance among firearm owners, so it is important to note that the term ‘means safety,’ as opposed to ‘means restriction,’ has been associated with greater intentions to adhere to clinician recommendations regarding decreasing access to firearms [25]. Decreasing availability: removal, safe storage, and other interventions
Several firearm-specific means safety approaches seek to alter an individual’s practical capability by decreasing firearm availability, including temporarily removing firearms from the household or storing them more safely. In a nationally representative sample of suicide decedents, Shenassa and colleagues found that firearm owners who stored their firearms unloaded or in a locked location were at least 60% less likely to die by firearm than those who stored firearms loaded and/or in an unlocked location [11]. A hazard countermeasures approach to firearm suicide prevention recommends safe storage practices, including storing firearms unloaded, separate from ammunition, in locked containers, and in locations outside the home (e.g., a gun club) [26]. Tools for the safe storage of firearms include cable and trigger locks, safes, and lock boxes (for a comprehensive list, see [27]). Another class of tools www.sciencedirect.com
Firearm suicide Houtsma, Butterworth and Anestis 9
incorporates technology to encourage safe storage. Smart gun or personalization technology refers to individualized technology, such as fingerprint recognition on a firearm, designed to restrict use to one designated owner. This may be particularly useful for preventing firearm suicide among children and other household members [9]. However, despite their potential to save lives and their ability to mitigate firearm owners’ concerns regarding quick access, firearms fitted with personalization technology are not popular or widely sold in the US and prove less valuable in preventing suicide by the firearm owner him or herself [9]. An essential aspect of firearm means safety strategies is planning for the safe storage and/or temporary removal of firearms at an individual level. This is typically accomplished through lethal means counseling, a collaborative process that engages individuals at risk for firearm suicide to reduce access to firearms [3]. Importantly, individuals at risk for firearm suicide do not usually present for traditional psychological treatment [3,28], so it is important to leverage providers across other settings [3]. For example, professionals working in emergency departments can assist by asking patients about firearm ownership and storage practices. Wintemute and colleagues provide a comprehensive guide for physicians in this domain, including suggestions on how and when to ask patients about firearms and information on disclosure policies in accordance with HIPAA [27]. Other professionals who may come into contact with those at risk for firearm suicide include attorneys, probation officers, and clergy members, so it is important that these potential ‘gatekeepers’ be informed of ways to identify risk and communicate means safety strategies [3]. Lethal means counseling in military settings carries its own guidelines and potential complications. Hoyt and Duffy provide culturally sensitive recommendations for increasing firearm safety in the US Army, including safe storage options in field settings (e.g., in unit arms rooms) and home settings (e.g., local veterans temporarily maintaining custody of a soldier’s firearm) [29]. Individuals within the firearm community (e.g., gun shop owners) are uniquely positioned to disseminate means safety strategies to those at risk for firearm suicide [3] and already appear to be open to doing so. In a recent study, roughly half of 65 identified firearm retailers in New Hampshire were willing to display materials that provided information about the relationship between firearms and suicide and promoted safe storage practices [30]. Interventions that focus on building relationships with the firearm owning community and promoting appropriate messaging regarding safe storage practices are vital components of future means safety efforts. Such efforts answer the call for a public health approach to suicide prevention and provide the opportunity to decrease capability and reduce suicide risk at a population level [31]. www.sciencedirect.com
Legislation
Research has demonstrated the significant potential for firearm-related legislation to prevent and reduce firearm suicides. In the US, permit to purchase, required registration, and license to own handgun laws are associated with lower overall suicide and firearm suicide rates by state [32]. Waiting period, background check, gun lock, and open carry restriction laws are also associated with lower statewide firearm suicide rates. Moreover, states with background check, gun lock, and open carry restriction laws in place also experienced lower overall suicide rates [33]. Furthermore, suicide rates differ significantly between states depending on the presence or absence of waiting period and background check laws; controlling for relevant confounds, those with the laws in place experienced a decrease in suicides between 2013 and 2014, whereas those without the laws in place experienced an increase. [34]. Additionally, the absence of background check and waiting period laws were associated with a more steeply increasing trajectory of statewide suicide rates from 1999 to 2015 [35]. Similar findings have been replicated on an international level [9]. Another potentially effective intervention that aims to decrease firearm ownership is a ‘do not sell list,’ which prevents future firearm purchases. In a recent study, 46% of participants currently receiving psychiatric care responded that they would voluntarily add their name to a list of this type to prevent their own potential suicide, suggesting that those at risk for suicide may be willing partners for such intervention efforts [36].
Conclusions As firearm suicide accounts for approximately half of all suicide deaths [1], it is crucial that we further our understanding of how risk emerges. When conceptualized through the 3ST framework, it is apparent that factors relevant to practical capability, such as access to, acceptability of, and fluency with firearms, have a meaningful impact on risk for death by firearm suicide [2]. Not all individuals with such practical capability are expected to die by firearm suicide; however, this form of capability may facilitate a more lethal transition from thoughts to action in the presence of suicidal ideation. This complicates intervention efforts, as firearm owners do not usually present for traditional psychological treatment [3,28], allowing risk to go undetected. Therefore, emphasis must be placed on reaching at-risk individuals within their communities and increasing safety for all who possess practical capability for firearm suicide. Accordingly, recent developments in means safety interventions have focused on recruiting the assistance of community members (e.g., physicians, gun shop owners) to provide lethal means counseling to those at risk for firearm suicide, in an effort to increase safe storage practices and decrease firearm availability [3,30]. Studies Current Opinion in Psychology 2018, 22:7–11
10 Suicide
designed to further assess the feasibility, acceptability, and effectiveness of such interventions will be essential in reducing the occurrence of firearm suicide in the US.
Conflict of interest statement
14. Hamilton D, Kposowa AJ: Firearms and violent death in the United States: gun ownership, gun control and mortality rates in 16 states, 2005–2009. Br J Educ Soc Behav Sci 2015, 7:84-98. 15. Miller M, Swanson SA, Azrael D: Are we missing something pertinent? A bias analysis of unmeasured confounding in the firearm-suicide literature. Epidemiol Rev 2016, 38:62-69.
Nothing declared.
16. Anestis MD, Houtsma C: The association between gun ownership and statewide overall suicide rates. Suicide LifeThreat Behav 2017.
References and recommended reading
17. Ilgen MA, Zivin K, McCammon RJ, Valenstein M: Mental illness, previous suicidality, and access to guns in the United States. Psychiatr Serv 2008, 59:198-200.
Papers of particular interest, published within the period of review, have been highlighted as: of special interest of outstanding interest 1.
Centers for Disease Control Prevention: Web-based inquiry statistics query and reporting system (WISQARS). 2015. URL: http://www.cdc.gov/injury/wisqars/index.html.
Klonsky ED, May AM: The three-step theory (3ST): a new theory of suicide rooted in the “ideation-to-action” framework. Int J Cog Therapy 2015, 8:114-129. This innovative paper introduces a new theory, which re-conceptualizes suicide risk through an ideation-to-action framework and presents preliminary evidence supporting the utility of this theory.
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18. Betz ME, Barber C, Miller M: Suicidal behavior and firearm access: results from the second injury control and risk survey. Suicide Life-Threat Behav 2011, 41:384-391. 19. Anestis MD, Khazem LR, Anestis JC: Differentiating suicide decedents who died using firearms from those who died using other methods. Psychiatry Res 2017, 252:23-28. 20. Canetto SS, Sakinofsky I: The gender paradox in suicide. Suicide Life-Threat Behav 1998, 28:1-23. 21. Butterworth SE, Houtsma C, Anestis JC, Anestis MD: Investigating the relationship between social and economic policy views, firearm ownership, and death by firearm in a sample of suicide decedents. Arch Suicide Res 2017. (in press).
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Barber CW, Miller MJ: Reducing a suicidal person’s access to lethal means of suicide: a research agenda. Am J Prev Med 2014, 47:264-272.
22. Hempstead K, Nguyen T, David-Rus R, Jacquemin B: Health problems and male firearm suicide. Suicide Life-Threat Behav 2013, 43:1-16.
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Khazem LR, Houtsma C, Gratz KL, Tull MT, Green BA, Anestis MD: Firearms matter: the moderating role of firearm storage in the association between current suicidal ideation and likelihood of future suicide attempts among United States military personnel. Mil Psychol 2016, 28:25-33.
23. Westefeld JS, Gann LC, Lustgarten SD, Yeates KJ: Relationships between firearm availability and suicide: the role of psychology. Prof Psychol Res Pract 2016, 47:271. 24. Sarchiapone M, Mandelli L, Iosue M, Andrisano C, Roy A: Controlling access to suicide means. Int J Environ Res Public Health 2011, 8:4550-4562.
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Shenassa ED, Catlin SN, Buka SL: Lethality of firearms relative to other suicide methods: a population based study. J Epidemiol Commun Health 2003, 57:120-124.
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Elnour AA, Harrison J: Lethality of suicide methods. Inj Prev 2008, 14:39-45.
25. Stanley IH, Hom MA, Rogers ML, Anestis MD, Joiner TE: Discussing firearm ownership and access as part of suicide risk assessment and prevention: “Means safety” versus “means restriction”. Arch Suicide Res 2016:1-17.
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Anestis MD, Capron DW: Deadly experience: the association between firing a gun and various aspects of suicide risk. Suicide Life-Threat Behav 2017. (in press).
26. Runyan CW, Brown TL, Brooks-Russell A: Preventing the invisible plague of firearm suicide. Am J Orthopsychiatry 2015, 85:221-224.
8. Kalesan B, Villarreal MD, Keyes KM, Galea S: Gun ownership and social gun culture. Inj Prev 2015:1-5. This study of 4000 US firearm owners found that approximately one-third of Americans own firearms and that rates of firearm ownership are doubled in areas of the US characterized by strong social gun culture, suggesting that firearm suicide prevention strategies should consider culture and region. 9.
Mann JJ, Michel CA: Prevention of firearm suicide in the United States: what works and what is possible. Am J Psychiatry 2016, 173:969-979. This review article found that increased firearm availability is associated with higher firearm suicide rates and highlights numerous means safety approaches, including legislation, smart gun technology, firearm safety messaging, and firearm violence restraining orders. This article demonstrates the importance of means safety approaches in preventing firearm suicide. 10. Miller M, Barber C, White RA, Azrael D: Firearms and suicide in the United States: is risk independent of underlying suicidal behavior? Am J Epidemiol 2013, 178:946-955.
11. Shenassa ED, Rogers ML, Spalding KL, Roberts MB: Safer storage of firearms at home and risk of suicide: a study of protective factors in a nationally representative sample. J Epidemiol Commun Health 2004, 58:841-848. 12. Miller M, Warren M, Hemenway D, Azrael D: Firearms and suicide in US cities. Inj Prev 2015, 21:116-119. 13. Kellerman AL, Rivara FP, Somes G, Reay DT, Fansisco J, Banton JG, Prodzinski J, Fligner C, Hackman BB: Suicide in the home in relation to gun ownership. N Engl J Med 1992, 327:467472. Current Opinion in Psychology 2018, 22:7–11
27. Wintemute GJ, Betz ME, Ranney ML: Yes, you can: physicians, patients, and firearms. Ann Intern Med 2016, 165:205-213. 28. Anestis MD: Prior suicide attempts are less common in suicide decedents who died by firearms relative to those who died by other means. J Affect Disord 2016, 189:106-109. 29. Hoyt T, Duffy V: Implementing firearms restriction for preventing US Army suicide. Mil Psychol 2015, 27:384-390. 30. Vriniotis M, Barber C, Frank E, Demicco R, the New Hampshire Firearm Safety Coalition: A suicide prevention campaign for firearm dealers in New Hampshire. Suicide Life-Threat Behav 2015, 45:157-163. This study found that nearly half of New Hampshire firearm retailers were willing and able to participate in a suicide prevention campaign designed to increase awareness of means safety strategies, indicating that firearm retailers may be willing and important partners in reducing firearm suicide. 31. Anestis MD, Law KC, Jin H, Houtsma C, Khazem LR, Assavedo BL: Treating the capability for suicide: a vital and understudied frontier in suicide prevention. Suicide Life-Threat Behav 2016. 32. Anestis MD, Khazem LR, Law KC, Houtsma C, LeTard R, Moberg F, Martin R: The association between state laws regulating handgun ownership and statewide suicide rates. Am J Public Health 2015, 105:2059-2067. 33. Anestis MD, Anestis JC: Suicide rates and state laws regulating access and exposure to handguns. Am J Public Health 2016, 105:2049-2058. This study found that background check, waiting period, gun lock, and regulated open carry laws in the US were associated with lower firearm suicide rates and that these laws, aside from required waiting periods, www.sciencedirect.com
Firearm suicide Houtsma, Butterworth and Anestis 11
were also associated with lower overall suicide rates. This study highlights the importance of legislation as a means of firearm suicide prevention.
35. Anestis MD, Selby EA, Butterworth SE: Rising longitudinal trajectories in suicide rates: the role of firearm suicide rates and firearm legislation. Prev Med 2017, 100:159-166.
34. Anestis MD, Anestis JC, Butterworth SE: Handgun legislation and changes in statewide overall suicide rates. Am J Public Health 2017, 107:579-581.
36. Vars FE, McCullumsmith CB, Shelton RC, Cropsey KL: Willingness of mentally ill individuals to sign up for a novel proposal to prevent firearm suicide. Suicide Life-Threat Behav 2016, 0:1-10.
www.sciencedirect.com
Current Opinion in Psychology 2018, 22:7–11
ScienceDirect Firearm suicide: pathways to risk and methods of prevention Claire Houtsma, Sarah E Butterworth and Michael D Anestis Firearms are utilized in approximately half of all US suicides, making them a serious public health concern and a target of suicide prevention efforts. Practical capability influences the transition from suicidal ideation to action and is particularly relevant to firearm suicide. Firearm ownership, experience using firearms, unsafe firearm storage, and high cultural acceptability of firearms increase risk for death by firearm suicide. Means safety strategies, which emphasize the reduction of practical capability for suicide through the limitation of access to and safe storage of firearms, are effective in preventing suicide and include interventions such as lethal means counseling, firearm legislation, and promoting safe storage practices. Public health interventions aimed at reducing firearm suicide are critical topics for continued research. Address Department of Psychology, University of Southern Mississippi, Hattiesburg, MS, USA Corresponding author: Houtsma, Claire ([email protected])
Current Opinion in Psychology 2017, 22:7–11 This review comes from a themed issue on Suicide Edited by Michael Anestis and Daniel Capron
http://dx.doi.org/10.1016/j.copsyc.2017.07.002 2352-250/ã 2017 Elsevier Ltd. All rights reserved.
Introduction In 2015, 44 193 individuals in the US died by suicide. Approximately half of these individuals utilized a firearm [1]. It is evident that firearm suicide is a profound public health issue that must be more clearly understood. A crucial aspect of furthering our understanding is identifying risk factors that differentiate individuals who experience suicidal thoughts from those who act on those thoughts. The three-step theory (3ST) examines suicide risk from this perspective and argues that severe suicidal ideation develops from the joint presence of psychological pain and hopelessness, particularly when this distress outweighs an individual’s perceived connectedness to others [2]. The theory posits that individuals will only engage in suicidal behavior if they also have the capacity www.sciencedirect.com
for suicidal behavior. Such capacity may be genetically driven (dispositional capability), acquired through repeated experiences that habituate the individual to pain and fear of death (acquired capability), and/or through the access to, knowledge of, and fluency with lethal means (practical capability [2]). Practical capability is especially relevant to firearm suicide and numerous studies have investigated elements of risk related to this component of the 3ST. Emerging strategies for preventing firearm suicide have also been the focus of recent research efforts. These strategies, referred to broadly as means safety, emphasize limitation of access, safe storage, or decrease in potency of methods for suicide and have been found to be effective in preventing suicide [3,4]. This review aims to clarify factors that increase risk for firearm suicide and describes recent advances in prevention efforts designed to mitigate this risk.
Risk for firearm suicide: practical capability Knowledge
One factor that increases risk for death by suicide is the lethality associated with a method. There is an 88–99.5% lethality rate associated with firearms, making them the most lethal means of suicide [5,6]. In fact, firearms have been found to be 2.6 times more lethal than the next most lethal method of suicide, suffocation [5]. In order to use a firearm in an attempt, however, individuals may need to develop comfort and fluency with the mechanics of a firearm. Indeed, Anestis and Capron found that the number of times an individual has fired a gun is associated with fearlessness about death, pain tolerance, and lifetime suicide attempts. This finding may indicate that experience with firearms habituates individuals to the concepts of death and pain, or that individuals with lower fear of death and higher pain tolerance are more likely to seek out experiences with firearms [7]. In either scenario, individuals may be at heightened risk for firearm suicide due to increased knowledge and comfort handling firearms. Availability
Another factor contributing to the disproportionate representation of firearm suicide decedents is the widespread availability of this means of suicide. It is estimated that one-third of US citizens own one or more firearms [8]. Access to firearms is particularly noteworthy given that researchers have found firearm ownership and availability significantly increase risk for suicide [9,10–14] Importantly, this increased risk extends to all members of the household, not just the legal owner of the firearm [15]. Furthermore, the relationship between firearm ownership Current Opinion in Psychology 2018, 22:7–11
8 Suicide
and death by suicide remains significant even when accounting for other robust predictors of suicide, such as mental illness, suicidal ideation, male gender, statewide rurality, religiosity, and state elevation [16]. This is not to suggest that firearm ownership causes individuals to become suicidal; in fact, research has shown that firearm-owning households are no more or less likely than non-firearm-owning households to possess other risk factors for suicide [15] and there is no significant relationship between firearm ownership and suicidal ideation [17]. Rather, these findings indicate that firearm ownership has the ability to arm thoughts of suicide if they develop, increasing risk for suicide through access to a highly lethal means. Supporting this perspective, Betz and colleagues found that once suicidal ideation is present, firearm owners are more likely than non-firearm owners to develop suicide plans involving firearms [18]. Similarly, among currently suicidal individuals who have a history of one or more suicide attempts, those who own firearms demonstrate a stronger association between thoughts of suicide and self-perceived likelihood of engaging in a future suicide attempt (C Houtsma et al., unpublished). The manner in which firearms are stored is also relevant to suicide risk. For example, Anestis and colleagues found that a greater proportion of suicide decedents who stored their firearm at home and in a non-secure location died using a firearm rather than by another method of suicide [19]. Similarly, among firearm owning military personnel, storing a firearm loaded and in a non-secure location was associated with increased levels of fearlessness about death and a stronger association between current suicidal ideation and self-perceived likelihood of making a future suicide attempt [4]. Acceptability
Social gun culture, defined as social norms that emphasize participation in firearm-related activities, may also play a role in the availability and acceptability of firearms [8]. Kalesan and colleagues found that firearm ownership was 2.25 times higher among individuals reporting exposure to social gun culture, even when accounting for the strength of statewide firearm policies and firearm fatality rates [8]. This suggests that sociocultural context may meaningfully influence the decision to own a firearm, the exposure an individual has to firearms, and the acceptability of such exposure. It has also been suggested that firearms are a more culturally acceptable suicide method among US men, as it is considered more ‘masculine’ to die in a violent manner [20]. Additionally, Butterworth and colleagues found that suicide decedents who held conservative social and economic policy views were more likely than those with liberal policy views to have died by firearm suicide, versus other methods. Importantly, these differences were accounted for by higher rates of firearm ownership among those with conservative views [21]. Current Opinion in Psychology 2018, 22:7–11
This supports the notion that beliefs and culture influence firearm ownership, which in turn impacts risk for firearm suicide. At-risk groups
Several components of practical capability converge within certain groups, significantly elevating risk for death by firearm suicide. For example, men die by firearm suicide at a significantly higher rate than women. In 2015, the firearm suicide rate for US men was 11.95 per 100 000, whereas the rate for women was 1.90 per 100 000 [1]. In addition, firearm suicide rates are highest among older, White males living in rural areas; demographics which generally mirror those of firearm owners [22]. Men who suffer from physical health problems may be at even higher risk for firearm suicide. In a sample of male suicide decedents, Hempstead and colleagues found that firearms were utilized at a disproportionate rate among those who were also experiencing health problems at the time of their death [22]. Certain occupations that require the use of firearms, including law enforcement and military service, are associated with increased risk for firearm suicide. In fact, firearms are the most utilized method of suicide among both groups [23]. In these professions, access to and familiarity with firearms are believed to play a substantial role in suicide method choice [23].
Means safety Although means safety approaches are applicable to a variety of suicide methods, firearms are an ideal candidate for targeted interventions in the US because they are highly lethal, widely available, and popular [24]. However, these approaches are often met with distrust or resistance among firearm owners, so it is important to note that the term ‘means safety,’ as opposed to ‘means restriction,’ has been associated with greater intentions to adhere to clinician recommendations regarding decreasing access to firearms [25]. Decreasing availability: removal, safe storage, and other interventions
Several firearm-specific means safety approaches seek to alter an individual’s practical capability by decreasing firearm availability, including temporarily removing firearms from the household or storing them more safely. In a nationally representative sample of suicide decedents, Shenassa and colleagues found that firearm owners who stored their firearms unloaded or in a locked location were at least 60% less likely to die by firearm than those who stored firearms loaded and/or in an unlocked location [11]. A hazard countermeasures approach to firearm suicide prevention recommends safe storage practices, including storing firearms unloaded, separate from ammunition, in locked containers, and in locations outside the home (e.g., a gun club) [26]. Tools for the safe storage of firearms include cable and trigger locks, safes, and lock boxes (for a comprehensive list, see [27]). Another class of tools www.sciencedirect.com
Firearm suicide Houtsma, Butterworth and Anestis 9
incorporates technology to encourage safe storage. Smart gun or personalization technology refers to individualized technology, such as fingerprint recognition on a firearm, designed to restrict use to one designated owner. This may be particularly useful for preventing firearm suicide among children and other household members [9]. However, despite their potential to save lives and their ability to mitigate firearm owners’ concerns regarding quick access, firearms fitted with personalization technology are not popular or widely sold in the US and prove less valuable in preventing suicide by the firearm owner him or herself [9]. An essential aspect of firearm means safety strategies is planning for the safe storage and/or temporary removal of firearms at an individual level. This is typically accomplished through lethal means counseling, a collaborative process that engages individuals at risk for firearm suicide to reduce access to firearms [3]. Importantly, individuals at risk for firearm suicide do not usually present for traditional psychological treatment [3,28], so it is important to leverage providers across other settings [3]. For example, professionals working in emergency departments can assist by asking patients about firearm ownership and storage practices. Wintemute and colleagues provide a comprehensive guide for physicians in this domain, including suggestions on how and when to ask patients about firearms and information on disclosure policies in accordance with HIPAA [27]. Other professionals who may come into contact with those at risk for firearm suicide include attorneys, probation officers, and clergy members, so it is important that these potential ‘gatekeepers’ be informed of ways to identify risk and communicate means safety strategies [3]. Lethal means counseling in military settings carries its own guidelines and potential complications. Hoyt and Duffy provide culturally sensitive recommendations for increasing firearm safety in the US Army, including safe storage options in field settings (e.g., in unit arms rooms) and home settings (e.g., local veterans temporarily maintaining custody of a soldier’s firearm) [29]. Individuals within the firearm community (e.g., gun shop owners) are uniquely positioned to disseminate means safety strategies to those at risk for firearm suicide [3] and already appear to be open to doing so. In a recent study, roughly half of 65 identified firearm retailers in New Hampshire were willing to display materials that provided information about the relationship between firearms and suicide and promoted safe storage practices [30]. Interventions that focus on building relationships with the firearm owning community and promoting appropriate messaging regarding safe storage practices are vital components of future means safety efforts. Such efforts answer the call for a public health approach to suicide prevention and provide the opportunity to decrease capability and reduce suicide risk at a population level [31]. www.sciencedirect.com
Legislation
Research has demonstrated the significant potential for firearm-related legislation to prevent and reduce firearm suicides. In the US, permit to purchase, required registration, and license to own handgun laws are associated with lower overall suicide and firearm suicide rates by state [32]. Waiting period, background check, gun lock, and open carry restriction laws are also associated with lower statewide firearm suicide rates. Moreover, states with background check, gun lock, and open carry restriction laws in place also experienced lower overall suicide rates [33]. Furthermore, suicide rates differ significantly between states depending on the presence or absence of waiting period and background check laws; controlling for relevant confounds, those with the laws in place experienced a decrease in suicides between 2013 and 2014, whereas those without the laws in place experienced an increase. [34]. Additionally, the absence of background check and waiting period laws were associated with a more steeply increasing trajectory of statewide suicide rates from 1999 to 2015 [35]. Similar findings have been replicated on an international level [9]. Another potentially effective intervention that aims to decrease firearm ownership is a ‘do not sell list,’ which prevents future firearm purchases. In a recent study, 46% of participants currently receiving psychiatric care responded that they would voluntarily add their name to a list of this type to prevent their own potential suicide, suggesting that those at risk for suicide may be willing partners for such intervention efforts [36].
Conclusions As firearm suicide accounts for approximately half of all suicide deaths [1], it is crucial that we further our understanding of how risk emerges. When conceptualized through the 3ST framework, it is apparent that factors relevant to practical capability, such as access to, acceptability of, and fluency with firearms, have a meaningful impact on risk for death by firearm suicide [2]. Not all individuals with such practical capability are expected to die by firearm suicide; however, this form of capability may facilitate a more lethal transition from thoughts to action in the presence of suicidal ideation. This complicates intervention efforts, as firearm owners do not usually present for traditional psychological treatment [3,28], allowing risk to go undetected. Therefore, emphasis must be placed on reaching at-risk individuals within their communities and increasing safety for all who possess practical capability for firearm suicide. Accordingly, recent developments in means safety interventions have focused on recruiting the assistance of community members (e.g., physicians, gun shop owners) to provide lethal means counseling to those at risk for firearm suicide, in an effort to increase safe storage practices and decrease firearm availability [3,30]. Studies Current Opinion in Psychology 2018, 22:7–11
10 Suicide
designed to further assess the feasibility, acceptability, and effectiveness of such interventions will be essential in reducing the occurrence of firearm suicide in the US.
Conflict of interest statement
14. Hamilton D, Kposowa AJ: Firearms and violent death in the United States: gun ownership, gun control and mortality rates in 16 states, 2005–2009. Br J Educ Soc Behav Sci 2015, 7:84-98. 15. Miller M, Swanson SA, Azrael D: Are we missing something pertinent? A bias analysis of unmeasured confounding in the firearm-suicide literature. Epidemiol Rev 2016, 38:62-69.
Nothing declared.
16. Anestis MD, Houtsma C: The association between gun ownership and statewide overall suicide rates. Suicide LifeThreat Behav 2017.
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Papers of particular interest, published within the period of review, have been highlighted as: of special interest of outstanding interest 1.
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27. Wintemute GJ, Betz ME, Ranney ML: Yes, you can: physicians, patients, and firearms. Ann Intern Med 2016, 165:205-213. 28. Anestis MD: Prior suicide attempts are less common in suicide decedents who died by firearms relative to those who died by other means. J Affect Disord 2016, 189:106-109. 29. Hoyt T, Duffy V: Implementing firearms restriction for preventing US Army suicide. Mil Psychol 2015, 27:384-390. 30. Vriniotis M, Barber C, Frank E, Demicco R, the New Hampshire Firearm Safety Coalition: A suicide prevention campaign for firearm dealers in New Hampshire. Suicide Life-Threat Behav 2015, 45:157-163. This study found that nearly half of New Hampshire firearm retailers were willing and able to participate in a suicide prevention campaign designed to increase awareness of means safety strategies, indicating that firearm retailers may be willing and important partners in reducing firearm suicide. 31. Anestis MD, Law KC, Jin H, Houtsma C, Khazem LR, Assavedo BL: Treating the capability for suicide: a vital and understudied frontier in suicide prevention. Suicide Life-Threat Behav 2016. 32. Anestis MD, Khazem LR, Law KC, Houtsma C, LeTard R, Moberg F, Martin R: The association between state laws regulating handgun ownership and statewide suicide rates. Am J Public Health 2015, 105:2059-2067. 33. Anestis MD, Anestis JC: Suicide rates and state laws regulating access and exposure to handguns. Am J Public Health 2016, 105:2049-2058. This study found that background check, waiting period, gun lock, and regulated open carry laws in the US were associated with lower firearm suicide rates and that these laws, aside from required waiting periods, www.sciencedirect.com
Firearm suicide Houtsma, Butterworth and Anestis 11
were also associated with lower overall suicide rates. This study highlights the importance of legislation as a means of firearm suicide prevention.
35. Anestis MD, Selby EA, Butterworth SE: Rising longitudinal trajectories in suicide rates: the role of firearm suicide rates and firearm legislation. Prev Med 2017, 100:159-166.
34. Anestis MD, Anestis JC, Butterworth SE: Handgun legislation and changes in statewide overall suicide rates. Am J Public Health 2017, 107:579-581.
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