Firearm Access and Suicide: Lethal Means Counseling and Safe Storage Education in a Comprehensive Prevention Strategy

Most firearm-related deaths are deaths by suicide, and approximately half of all suicide deaths involve a firearm.¹ Recent research has identified a sustained risk of suicide by firearm for those who own handguns and has suggested that risk for suicide peaks just after an individual’s first handgun purchase.² During the coronavirus disease 2019 pandemic, the United States has seen record-breaking gun sales, and many purchasers are first-time owners, which may mean that a large section of the population is at newly elevated risk for suicide.³ Although policymakers tend to focus on certain laws to reduce gun violence, these laws are not sufficient to fully address suicide risk when an individual’s risk is not apparent.

In this issue of AJPH, Anestis et al. (p. 309) describe the potential of preventive individual-level interventions—lethal means counseling and safe storage education—to spur members of the Mississippi National Guard to safely store firearms and reduce suicide risk. Using these findings, I explain the problems with relying solely on law to prevent suicide and outline the need for a comprehensive approach to firearm suicide prevention that incorporates evidence-based practices and leverages existing policy mechanisms.

LIMITATIONS OF STATE GUN LAWS

Many gun laws popular among advocates have shown the capability to reduce firearm suicide but have inherent limitations. These laws focus on firearm access; because firearms are so lethal, individuals in the midst of a crisis with access to a firearm are at high risk for fatal harm.¹ Laws like purchaser licensing and Extreme Risk Protection Orders can reduce firearm suicide but rely on identifying and acting on risk.^4,5 Purchaser licensing laws keep those with a statutory prohibiting condition from acquiring firearms. Extreme Risk Protection Order laws are intended to remove firearms from the home of someone at high risk for harming himself or herself or others. Because suicide is often an impulsive act taken in response to acute stressors, it is not always possible to preemptively identify and act on risk of suicide.¹ A person experiencing a transient crisis may not satisfy any statutory or other legal criteria prohibiting gun acquisition. For individuals in this scenario, the lethality of immediately available means of harm is quite important.

Removing a gun from the home or preventing a gun from entering a home may be ideal when someone is at risk for harming himself or herself, but safe storage is another evidence-driven strategy for reducing risk. The hallmarks of safe storage are (1) locking the firearm, (2) storing the firearm unloaded, and (3) storing the firearm separate from ammunition. Child access prevention laws require gun owners to store guns safely if they live in a house with children. These laws are associated with reductions in adolescent suicide mortality.⁶ Child access prevention laws are very difficult to enforce, may have low compliance, and apply to only certain households, but the evidence is instructive—if guns are stored safely, access is reduced, and suicide risk decreases. This principle can contribute to a comprehensive, multilevel approach to suicide prevention.⁷

PREVENTIVE INDIVIDUAL-LEVEL INTERVENTIONS

Researchers, advocates, and policymakers have promoted efforts to educate the public and expand the use of safe storage. These efforts include community-level interventions like the Gun Shop Project that seek to use gun shops and firing ranges to distribute educational materials about suicide prevention and provide gun storage maps that help community members find retailers and law enforcement agencies that will temporarily store firearms. This work also has included individual-level interventions like lethal means counseling and safe storage education that seek to work with individuals to limit their access to specific means of self-harm.⁷ As Anestis et al. note, little previous research is available on this type of counseling—it has been difficult to determine whether counseling actually leads to safer storage, and some previous studies have focused solely on those for whom a suicidal crisis has already emerged.

Anestis et al. make a crucial point about lethal means counseling that also illustrates a problem with many firearm laws: “Because 90% of suicide attempts with firearms are fatal, lethal means counseling cannot only be offered after a suicidal crisis has emerged, as this would result in many high-risk individuals not being exposed to the intervention.” This is true for counseling but also for gun laws—if the laws rely on apparent or articulated risk, many experiencing suicidal crises will not benefit from any protection afforded by these laws. Anestis et al. use a strong methodology to show that in a population in which firearm suicide is a significant problem—military personnel—a preventive approach using lethal means and safe storage counseling can result in sustained adoption of safe storage practices. Importantly, the findings also show that the intervention was acceptable to the study population.

Anestis et al. make an important contribution to the lethal means and firearm suicide prevention literature, but a few remaining questions are ripe for future work. The authors asked participants about safe storage practices but did not ask about separately storing ammunition, which is a key component of safe storage. Future iterations of this work should incorporate that practice. It would also be interesting to know more about the households of the study population. The counseling interventions were offered to gun owners, but those gun owners may not be the members of their households at the highest risk for death from suicide. Children, for example, may be at higher risk but may benefit from safer storage to an even greater extent than the gun owners themselves. Finally, researchers should seek to evaluate similar interventions in other populations. The studied interventions were tailored to a specific, high-risk population, and the authors appropriately caution against generalization. Future work should use similar practices to identify strategies for intervening with other high-risk populations and with the general public.

Policymakers and practitioners can leverage existing policy mechanisms to implement lethal means and safe storage counseling. Lethal means counseling is usually offered in clinical settings, but the principles may be applicable in other contexts. Many people who purchase or own guns will have contact with the state or with firearm sellers. These interactions provide opportunities for creative interventions that can educate new gun owners about safe storage and the link between suicide risk and firearm access. For example, many states require training courses before receiving a license to purchase or carry a handgun. These courses may already discuss safe storage practices, but that discussion could be expanded to discuss suicide explicitly and perhaps even to offer individualized counseling. If the right language, communication strategies, and messengers are chosen, the findings of Anestis et al. suggest that gun owners might be amenable to such an intervention.

CONCLUSIONS

Despite the protective effects of certain state laws, the gaps in coverage mean that they do not directly reduce suicide risk for many individuals. Importantly, even to the extent they do provide uniform protection, the laws are not universally adopted and face political and legal threats. Many states have not adopted these laws and may not ever adopt them. In addition, the new ideological composition of the Supreme Court suggests that gun rights may be expanded, and certain gun laws may face significant judicial scrutiny. Policymakers, practitioners, and advocates in search of an effective strategy for firearm suicide prevention must use a comprehensive approach, including laws and tailored community- and individual-level interventions.