Russell Lemle is Senior Policy Analyst, Veterans Healthcare Policy Institute and a Clinical Professor in the Department of Psychiatry, University of California, San Francisco. Correspondence: Russell Lemle (russelllemle@comcast.net)
Author disclosures The author reports he was a consultant for the PREVENTS workgroup and no other potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Firearms are, by far, the most common lethal means used by veterans who die by suicide. About 71% of male veteran suicide deaths and 43% of female veteran suicide deaths are with firearms, rates that far exceed those of nonveterans (Table).For all age groups, veterans are more likely to complete suicide by firearm than are nonveterans.5
Veteran suicide and gun ownership rates are highest in rural areas.6,7 When compared with veterans living in urban areas, veterans in rural areas are 20% more likely to die by suicide, with the excessive risk largely attributed to suicide by firearm.8
Access to firearms at home increases the risk of suicide. Individuals with any firearm at home are 3 times more likely to die by suicide than is a person with no firearms at home. The elevated suicide risk applies to other household members as well as the firearm owner.9-18 Survivors of suicide attempts using firearms report that the availability of guns at home is the primary reason for their method choice.19,20
There is a common misperception that people who are intent on suicide and are thwarted or survive an attempt using one method will try again with another.21 Suicidal crises often represent a conflicting wish to live or die,22 and approximately two-thirds of those who survive an attempt will never try again. About 23% reattempt nonfatally, and only 10% die by suicide.23-25 However, people who attempt suicide with a firearm usually won’t get a chance at a new start, because 90% of such acts are fatal.26
Although some suicide attempts might be contemplated or planned over an extended period, the decision is impulsive for most individuals. Surveys have found that many people who survive suicide attempts began the act only minutes or hours after making the decision to end their life.27-30 The high-risk, acute phase of many suicidal crises arise quickly and is fleeting.
Limiting the ease by which at-risk individuals can access firearms has been shown to prevent suicide. In 2006, the overall suicide rate in Israel dropped 40% when the Israeli Defense Forces began requiring soldiers to store their firearms on base before going on weekend leave.Since then, the suicide rate has declined even further.31,32
Delaying Access to Firearms for At-Risk Veterans
Among veterans, 45% own ≥ 1 firearms (47% male and 24% female veterans vs 30% male and 12% female nonveterans).3 Many veteran firearm owners (34% male and 13% female) store ≥ 1 gun loaded and unlocked; 44% store a firearm either loaded or unlocked. Only 23% safely store their firearms unloaded and locked at home. Storing ≥ 1 firearm loaded and unlocked is more likely among veterans who reside in rural areas, separated from service before 2002, and report personal protection as the primary reason for ownership.33
Because evidence shows that delaying access to firearms—especially by transferring them out of the home—saves lives, many US health organizations have advocated for strategies that promote evaluation of firearm access and counseling safe storage for individuals at risk for suicide. These organizations include the US Office of the Surgeon General, National Action Alliance for Suicide Prevention, Centers for Disease Control and Prevention, and American Public Health Association.34-36
Some health care systems—notably Kaiser Permanente and Henry Ford Health Systems—implemented protocols for lethal means assessment and counseling for behavioral health patients.37,38 Washington state requires specific health professionals to enroll in suicide prevention training that includes content on the risk of imminent harm by lethal means.39 California is designing a curriculum on counseling patients to reduce firearm injury for physicians and other health care practitioners (HCPs).40
The scope of these efforts, however, pale in comparison with the VA’s comprehensive, innovative lethal means safety approach. Since 2012, VA’s Suicide Prevention Program has distributed free firearm cable locks to veterans who request them. The VA has created lethal means public service announcements, social media messages, and websites.41-44 The VA distributes firearm and medication safe storage practice resource kits to its primary care, mental health and women’s health clinics, and Vet Centers, that include brochures, large poster cards, stickers, exam room posters, and provider pocket cards. VA developed an online lethal means safety counseling training that 20,000 VA HCPs have taken, and is moving toward a revamped mandatory training for VA’s mental health, pain, primary care, and emergency department (ED) providers and Veterans Crisis Line responders. VA offers free, individualized lethal means risk management consultation to all clinicians who work with veterans.45 VA includes lethal means safety procedures in its National Strategy for Preventing Veteran Suicide,VA/DoD Clinical Practice Guideline,and VA Suicide Risk Evaluation and Suicide Prevention Safety Planrequired of clinicians.46-48
The VA also added public health strategies that promote safe storage practices for veterans through a partnership with the National Shooting Sports Foundation (NSSF; the firearm industry trade association) and the American Foundation for Suicide Prevention (AFSP).49 Collectively, these organizations cobranded an educational, training, and resource toolkit to foster community coalitions and gun retailer projects that encourage veterans to securely store firearms.50 The VA partnered with NSSF to post billboards in 8 states, encouraging storing firearms responsibly to prevent suicide. VA invited states and cities in the Governor/Mayoral Challenge to Prevent Suicide (joint VA and Substance Abuse and Mental Health Services Administration endeavors) to develop plans for messaging regarding enhanced lethal means safety processes. The VA collaborated with local firearm advocates in community prevention pilot projects and in a “Together with Veterans” dissemination of material and outreach to rural veterans.51 Along with AFSP, VA hosted conferences for HCPs, policy makers, and stakeholders about innovations related to lethal means safety.52 In May 2020, the VA cosponsored a COVID-19 suicide prevention video with the United States Concealed Carry Association, NSSF, and AFSP, including ways that the firearm industry, gun owners, and their families can help.53
These programs are promising, and the Roadmap’s emphatic endorsement of lethal means safety approaches will accelerate advances. However, the Roadmap’s omissions are consequential. By focusing on population interventions, the document is silent about VA-specific or veteran-specific firearm access strategies. The means safety work of VA’s Suicide Prevention Program Office is scarcely recognized. Further, it stops short of specific legislative initiatives, making aspirational recommendations instead.
This paper will list proposed policy actions to bolster the acceptability and practice of lethal means safety with veterans. They cover an entire range of possibilities, from putting more teeth into the Roadmap’s population-wide interventions to initiatives tailored to veterans. Responsibility for leading and funding the changes would reside in a mix of Congress and state legislatures, the VA, and health system accreditation bodies. Although there is solid evidence that lethal means safety prevents suicide, it is unknown how these approaches affect firearm storage behaviors or suicide rates;therefore, the policy actions should come with federal and state funds for rigorous evaluation.54
