The associations between state veteran population rates, handgun legislation, and statewide suicide rates

How firearm legislation impacts firearm mortality internationally: A scoping review

Background

The literature on gun violence is broad and variable, describing multiple legislation types and outcomes in observational studies. Our objective was to document the extent and nature of evidence on the impact of firearm legislation on mortality from firearm violence.

Methods

A scoping review was conducted under PRISMA-ScR guidance. A comprehensive peer-reviewed search strategy was executed in several electronic databases from inception to March 2024. Grey literature was searched for unpublished sources. Data were extracted on study design, country, population, type of legislation, and overall study conclusions on legislation impact on mortality from suicide, homicide, femicide, and domestic violence. Critical appraisal for a sample of articles with the same study design (ecological studies) was conducted for quality assessment.

Findings

5057 titles and abstracts and 651 full-text articles were reviewed. Following full-text review and grey literature search, 202 articles satisfied our eligibility criteria. Federal legislation was identified from all included countries, while state-specific laws were only reported in studies from the U.S. Numerous legislative approaches were identified including preventative, prohibitive, and more tailored strategies focused on identifying high risk individuals. Law types had various effects on rates of firearm homicide, suicide, and femicide. Lack of robust design, uneven implementation, and poor evaluation of legislation may contribute to these differences.

Interpretation

We found that national, restrictive laws reduce population-level firearm mortality. These findings can inform policy makers, public health researchers, and governments when designing and implementing legislation to reduce injury and death from firearms.

Funding

Funding is provided by the Strategy for Patient-Oriented Research (SPOR) Evidence Alliance and in part by St. Michael's Hospital, University of Toronto.

Scoping review registration

Open Science Framework (OSF): https://osf.io/sf38n.

Examining predictors of suicide by firearm in young, middle, and late adulthood

INTRODUCTION

Suicide remains a leading cause of death in the U.S., and firearms are one of the most lethal methods of suicide. This study examines personal and contextual factors that predict suicide with a firearm compared to other methods across stages of adulthood.

METHODS

Data on adult suicide decedents from 2009 to 2019 were obtained from Colorado's National Violent Death Reporting System (NVDRS) data (N = 11,512). The dataset includes incident and person characteristics collected by law enforcement and coroners. Zip code level data were integrated from the American Community Survey.

RESULTS

Age, sex, race, marital status, military service, substance use, suicide attempt history, mental health, and location characteristics (population density, as well as age, education, veteran status, and household status of population) predicted suicide by firearm. Risk was particularly high for males in older adulthood. We further explored age-specific models (young, middle-aged, and older adults) to determine salient risk factors for each group.

CONCLUSION

This study highlights the need for comprehensive suicide prevention approaches that consider both individual and contextual risk factors, as well as unique risks in each stage of adulthood.

Veteran suicide rates mirror, but do not account for, elevated suicide rates among the general population in US cultures of honor

INTRODUCTION

Veteran total and firearm suicide rates are higher compared to the general population. Among the general population, total and firearm suicide rates are higher in US states deemed cultures of honor compared to non-honor states, likely because honor states have higher firearm ownership rates and fewer firearm laws. Considering that veterans tend to live in states with fewer firearm laws and that veteran population rates predict both statewide total and firearm suicide rates, it is possible that the elevated suicide rates seen in honor states in part due to those states having a greater presence of veterans compared to non-honor states.

METHOD

Publicly available databases were used to obtain total and firearm suicide rates (per 100 k) for veterans and non-veterans, as well as our covariates (e.g., rurality).

RESULTS

Veteran population proportions were higher in honor states than non-honor states. Veteran and non-veteran total and firearm suicide rates were higher in honor states compared to non-honor states. Statewide differences in all four suicide rates were indirectly explained by honor states having higher firearm ownership than non-honor states.

CONCLUSIONS

These findings add to a growing body of literature showing that enacting firearm regulations may be a viable public health approach for preventing suicide.

Emergency Departments Treating Veterans for Suicide: Ensuring Quality Care for Veterans Outside of Department of Veterans Affairs Health Care Facilities

INTRODUCTION

Veterans die by suicide at higher rates than nonveterans. Given that the emergency department is often the first point of entry to healthcare following a suicide attempt, it would be beneficial for community providers to have knowledge of the characteristics, medical issues, and effective treatments most often associated with those having served in the military to ensure guideline concordant and quality suicide care. This study aimed to identify assessment and referral practices of emergency departments at rural community hospitals related to care for suicidal veterans and explore the feasibility and acceptability of identifying veterans in need of postdischarge aftercare.

METHODS

This qualitative exploratory study involved content analysis of semistructured interviews. Ten emergency clinicians from 5 rural Arkansas counties with high suicide rates were interviewed about their experiences working with suicidal patients within the emergency department and perceptions of assessment, management, and referral practices.

RESULTS

Although most of the emergency departments had a process for assessing for suicide risk, emergency clinicians did not always feel confident in their knowledge of assessing and caring for suicidal patients. Military history was not included in assessment, treatment, or aftercare planning, nor were brief interventions such as safety planning or lethal means safety education provided.

DISCUSSION

Best practices for suicide assessment and management of veterans exist; however, challenges specific to the emergency department regarding staff training and engaging the community to effectively link at-risk veterans to needed care hinder implementation. Veteran-inclusive assessment and intervention practices could enhance the quality of care provided in community emergency departments.

Association of State Social and Environmental Factors With Rates of Self-injury Mortality and Suicide in the United States

IMPORTANCE

Self-injury mortality (SIM) combines suicides and the preponderance of drug misuse-related overdose fatalities. Identifying social and environmental factors associated with SIM and suicide may inform etiologic understanding and intervention design.

OBJECTIVE

To identify factors associated with interstate SIM and suicide rate variation and to assess potential for differential suicide misclassification.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used a partial panel time series with underlying cause-of-death data from 50 US states and the District of Columbia for 1999-2000, 2007-2008, 2013-2014 and 2018-2019. Applying data from the Centers for Disease Control and Prevention, SIM includes all suicides and the preponderance of unintentional and undetermined drug intoxication deaths, reflecting self-harm behaviors. Data were analyzed from February to June 2021.

EXPOSURES

Exposures included inequity, isolation, demographic characteristics, injury mechanism, health care access, and medicolegal death investigation system type.

MAIN OUTCOMES AND MEASURES

The main outcome, SIM, was assessed using unstandardized regression coefficients of interstate variation associations, identified by the least absolute shrinkage and selection operator; ratios of crude SIM to suicide rates per 100 000 population were assessed for potential differential suicide misclassification.

RESULTS

A total of 101 325 SIMs were identified, including 74 506 (73.5%) among males and 26 819 (26.5%) among females. SIM to suicide rate ratios trended upwards, with an accelerating increase in overdose fatalities classified as unintentional or undetermined (SIM to suicide rate ratio, 1999-2000: 1.39; 95% CI, 1.38-1.41; 2018-2019: 2.12; 95% CI, 2.11-2.14). Eight states recorded a SIM to suicide rate ratio less than 1.50 in 2018-2019 vs 39 states in 1999-2000. Northeastern states concentrated in the highest category (range, 2.10-6.00); only the West remained unrepresented. Least absolute shrinkage and selection operator identified 8 factors associated with the SIM rate in 2018-2019: centralized medical examiner system (β = 4.362), labor underutilization rate (β = 0.728), manufacturing employment (β = -0.056), homelessness rate (β = -0.125), percentage nonreligious (β = 0.041), non-Hispanic White race and ethnicity (β = 0.087), prescribed opioids for 30 days or more (β = 0.117), and percentage without health insurance (β = -0.013) and 5 factors associated with the suicide rate: percentage male (β = 1.046), military veteran (β = 0.747), rural (β = 0.031), firearm ownership (β = 0.030), and pain reliever misuse (β = 1.131).

CONCLUSIONS AND RELEVANCE

These findings suggest that SIM rates were associated with modifiable, upstream factors. Although embedded in SIM, suicide unexpectedly deviated in proposed social and environmental determinants. Heterogeneity in medicolegal death investigation processes and data assurance needs further characterization, with the goal of providing the highest-quality reports for developing and tracking public health policies and practices.

Firearm Suicide Among Veterans of the U.S. Military: A Systematic Review

INTRODUCTION

In the United States, firearm suicide represents a major cause of preventable, premature death among veterans. The purpose of this systematic review was to characterize the body of literature on veteran firearm suicide and identify areas for future research, which may facilitate the development of firearm suicide interventions in Veterans Health Administration (VHA) and non-Veterans Health Administration clinical settings.

MATERIALS AND METHODS

All randomized controlled trials, quasi-experimental, naturalistic, observational, and case study designs published between January 1, 1990 and February 21, 2019 were included in our review. Following title and abstract review, 65 papers were included in our full-text review and 37 studies were included in our analysis. We based our approach on a modification of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies were grouped into broad, nonmutually exclusive categories: (1) heterogeneity of datasets and veteran status determination for inclusion, (2) service histories, (3) firearm ownership, storage, behaviors, and risk perceptions, (4) patient and clinician attitudes toward firearm restriction interventions, (5) firearm suicide risk factors by study population, and (6) assessments of clinical firearm interventions.

RESULTS

This body of literature consists predominately of cross-sectional studies with mixed definitions and validation of veteran status, which revealed high concordance of increased risk of firearm suicide compared with nonveterans. Veterans have higher rates of firearm ownership than the general population, primarily citing personal protection as the reason for gun ownership. Veterans often exhibit risky firearm usage and storage behaviors but tend to favor measures that limit access to firearms by at-risk individuals. Despite this, there remains persistent hesitation among clinicians to screen and counsel veterans on firearm safety.

CONCLUSIONS

This systematic review highlights an urgent need to produce higher quality evidence and new data with standard definitions that are critical to inform clinical practice and enhance public health measures to reduce firearm suicide among veterans.

Austrian firearm legislation and its effects on suicide and homicide mortality: A natural quasi-experiment amidst the global economic crisis

Background:

Restriction of access to suicide methods has been shown to effectively reduce suicide mortality rates.

Aims:

To examine how the global economic crisis of 2008 and the firearm legislation reform of 1997 affected suicide and homicide mortality rate within Austria.

Methods:

Official data for the years 1985–2016 for firearm certificates, suicide, homicide, unemployment rates and alcohol consumption were examined using auto regressive error and Poisson regression models.

Results:

Firearm certificates, total suicide mortality rate, suicide and homicides by firearms, and the fraction of firearm suicides/homicides among all suicides/homicides decreased after the firearm legislation reform in 1997. However, significant trend changes can be observed after 2008. The availability of firearm certificates significantly increased and was accompanied by significant changes in trends of firearm suicide and homicide rates. Concurrently, the total suicide mortality rate in 2008, for the first time since 1985, stopped its decreasing trend. While the total homicide rate further decreased, the fraction of firearm homicides among all homicides significantly increased.

Conclusion:

The initially preventative effect of the firearm legislation reform in Austria in 1997 seems to have been counteracted by the global economic downturn of 2008. Increased firearm availability was associated with corresponding increases in both firearm suicide and firearm homicide mortality. Restrictive firearm legislation should be an imperative part of a country’s suicide prevention programme. Although firearm legislation reform may have long-lasting effects, societal changes may facilitate compensatory firearm acquisitions and thus counteract preventive efforts, calling in turn again for adapted counter-measures.

Political Beliefs, Region of Residence, and Openness to Firearm Means Safety Measures to Prevent Suicide

Firearms account for approximately half of all suicides in the United States and are highly lethal, widely available, and popular; thus, are an ideal candidate for targeted means safety interventions. However, despite their value as a suicide prevention tool, firearm means safety strategies are not widely utilized, possibly due to factors which impede openness to their use. This study examines the relationship between region, political beliefs, and openness to firearm means safety in a sample of 300 American firearm owners. Overall, firearm owners were more willing to engage in means safety for others than for themselves and to store firearms safely than temporarily remove them from the home. Social policy views and region were significantly associated with openness to firearm means safety measures, however, economic policy views were not. This study provides further context for the development and implementation of efficacious means safety measures capable of overcoming potential barriers to their use.

Banning open carry of unloaded handguns decreases firearm-related fatalities and hospital utilization

Background

Since 1967, in California it has been illegal to openly carry a loaded firearm in public except when engaged in hunting or law enforcement. However, beginning January 1, 2012, public open carry of unloaded handguns also became illegal. Fatal and non-fatal (NF) firearm injuries were examined before and after adoption of the 2012 ban to quantify the effect of the new law on public health.

Methods

State-level data were obtained directly from California and nine other US state inpatient and emergency department (ED) discharge databases, and the Centers for Disease Control Web-Based Injury Statistics Query and Reporting System. Case numbers of firearm fatalities, NF hospitalizations, NF ED visits, and state-level population estimates were extracted. Each incident was classified as unintentional, self-inflicted, or assault. Crude incidence rates were calculated. The strength of gun laws was quantified using the Brady grade. There were no changes to open carry in these nine states during the study. Using a difference-in-difference technique, the rate trends 3 years preban and postban were compared.

Results

The 2012 open carry ban resulted in a significantly lower incident rate of both firearm-related fatalities and NF hospitalizations (p<0.001). The effect of the law remained significant when controlling for baseline state gun laws (p<0.001). Firearm incident rate drops in California were significant for male homicide (p=0.023), hospitalization for NF assault (p=0.021 male; p=0.025 female), and ED NF assault visits (p=0.04). No significant decreases were observed by sex for suicides or unintentional injury. Changing the law saved an estimated 337 lives (3.6% fewer deaths) and 1285 NF visits in California during the postban period.

Discussion

Open carry ban decreases fatalities and healthcare utilization even in a state with baseline strict gun laws. The most significant impact is from decreasing firearm-related fatal and NF assaults.

Level of evidence

III, epidemiology.