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By the Numbers

More than half of completed suicides in the U.S. are by firearm, despite the fact that only 6% of attempts are made with a gun.2

Suicide is the tenth leading cause of death in the United States, and the third leading cause among adolescents and young adults.1

Suicide rates in the United States rose steadily from 1999 to 2016, and that trend appears to be continuing.1 More than half of completed suicides in the U.S. are by firearm, despite the fact that only 6% of attempts are made with a gun.2 This is because firearms are by far the most lethal method of suicide, with less than a 15% survival rate.3 Research indicates that just having a firearm in the home increases a household member’s risk of suicide by more than three times.4 Over 80% of adolescents who complete suicide use a family member’s gun.5


Examples of escalating risk and interventions

Myths Facts
Most deaths from firearms happen in public mass shootings. Less than 1% of firearm-related deaths occur in public mass shootings. The majority are suicides, followed by homicides.
I’m not supposed to talk with my patients about guns. There are no state or federal statutes prohibiting discussions about a patient’s access to firearms. Research suggests that most patients, including gun owners, are receptive to having these conversations, especially when risk factors are present.
Most of my patients don’t own guns. About 1 in 3 US households has a gun, and gun owners are a diverse group. It is difficult to accurately predict who does and doesn’t own a gun.

Using a harm reduction approach

Suicide is a complex, multi-factorial problem with social, economic, cultural and psychiatric roots. In the United States, suicide rates vary with geography, being highest in rural areas, particularly the intermountain west, Appalachia, and Alaska. This may reflect a variety of other risk factors including social isolation, lack of access to medical and mental health care, high rates of firearm ownership, and economic hardship.6

Mental Illness

It is unknown exactly how much mental illness contributes to the suicide rates, but research has estimated about half of suicide decedents meet criteria for a mental illness at the time of their death.7 Major depressive disorder is one of the diagnoses most commonly associated with suicide (lifetime risk 3.4%) because of the relatively large number of people who have it.8 While fewer people are diagnosed with schizophrenia or bipolar disorder, the risk of suicide with those disorders is higher, approximately 5% and up to 20% respectively.9,10 While many firearm prohibitions are targeted at people with mental illness, these are not sensitive enough to be effective at preventing suicide, as most people with serious mental illness who completed suicide with a firearm are legally allowed to own a gun at the time of their deaths.11

More than half of completed suicides in the U.S. are by firearm, despite the fact that only 6% of attempts are made with a gun.

Other Factors

Other medical illnesses also contribute to the burden of suicide in the United States. Patients who suffer from chronic medical disorders, particularly chronic pain, are at elevated risk.12 Alcohol use disorder is also associated with an increase in suicide risk. 41% of suicide decedents in one study were intoxicated at the time of their death, and that number was higher for those who used firearms.13

Clinicians of various specialties are in a unique position to counsel patients at risk for firearm suicide, but though many believe it to be within their purview, few actually do it. One study of Emergency Medicine physician documentation found that for patient encounters in which suicidal ideation was the chief complaint, only 3% documented access to firearms in the chart.14 Another study looking at the practice and perceptions on guidance of firearms by psychiatrists found only 27% of psychiatrists had a routine system for asking patients if they owned firearms.15 Providers cite lack of time, uncertainty about how to have these conversations, and lack of knowledge about how to intervene appropriately.

What You Can Do

Putting time and space between a suicidal patient and their firearm can be the difference between life and death. Waiting periods and permit to purchase processes have both been shown to decrease suicide rates, presumably because may people’s suicidality will subside in the intervening time period.16,17 The majority of near lethal suicide attempts are impulsive, and only 10% of people who survive one attempt die by a subsequent one.18,19 This means that if an attempt can be aborted or survived because the means used are of low lethality, the person’s life may be saved. Firearms are lethal in over 90% of the attempts in which they are used.2

Depending on the acuity of the patient’s suicidality and their willingness to collaborate on lethal means safety, a variety of options are available to the clinician. If the suicidality is not imminent but poses a continued sub-acute or intermittent threat, safe storage counseling or temporary transfer may be viable options. If the person is at imminent risk of self-harm and needs mental health treatment, an involuntary psychiatric hold may be indicated. If criteria are not met for a mental health hold, and the patient is not willing to relinquish their firearm, a gun violence restraining order poses an option for temporary, civil removal of guns involuntarily.

Crisis Services

For emergency medical attention, dial 911.

Content Type
External Resource

EM Pulse Podcast: BulletPoints Project Series Part 4-Act

In episode four of the EM Pulse Podcast, Dr. Barnhorst and the hosts discuss Act, the third component of the BulletPoints 3A's Framework. Dr. Barnhorst explains what physicians can do to help mitigate risk, including temporary transfer of firearms, psychiatric holds when appropriate, and “red flag” laws that allow for emergent removal of firearms in extremely high risk situations.

External Resource

Worried about a Veteran (WAV)

Are you worried about a veteran? When a loved one struggles, it's hard to know how to help. WAV is here to help with resources to start direct conversations, reduce access to lethal means, and reach support.


Mental Illness & Violence Fact Sheet

Have questions about the relationship between mental illness and violence? Check out this fact sheet for answers to help you prevent firearm injury and death in your patients.

Resource type: PDF
External Resource

EM Pulse Podcast: BulletPoints Project Series Part 3-Assess

In episode three of the EM Pulse Podcast, Dr. Barnhorst and the hosts delve into Assess, the second component of the BulletPoints 3A's Framework. This step helps clinicians determine whether it’s clinically relevant to ask patients about access to firearms, and, if such a discussion is indicated, how to ask about access and then gauge willingness to work together on reducing risk.

External Resource

Start Your Recovery

Start Your Recovery is a resource for individuals who may be struggling with substance use disorder. Developed by experts from leading nonprofit, academic, and government institution, this resource offers professionals the opportunity to hear stories from people with similar experiences, discover the answers they need for recognizing and dealing with substance use disorder, and locate support.

External Resource

EM Pulse Podcast: BulletPoints Project Series Part 2-Approach

In episode two of the EM Pulse Podcast, Dr. Barnhorst and the hosts discuss the Approach, the first component of the BulletPoints 3A's Framework for counseling about firearm injury prevention. Conversations with patients are more effective when clinicians use an informed, culturally-appropriate, respectful approach rooted in harm reduction.


BulletPoints: Our First 3 Years Infographic

Download the infographic

Resource type: PDF
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EM Pulse Podcast: BulletPoints Project Series Part 1-Blood On My Shoes

The first episode of the EM Pulse Podcast series on the BulletPoints Project features Dr. Amy Barnhorst covering the role of healthcare providers in preventing firearm injury and the work of our team here at BulletPoints.

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Project Opal

Project Opal is the joining together of the National Domestic Violence Hotline (The Hotline) and the National Coalition Against Domestic Violence (NCADV) toward a bold vision for the future that can change the landscape for survivors. NCADV and The Hotline will pioneer uniting efforts to institute a national ecosystem of holistic and inclusive services, policy, education, and resources for survivors of domestic violence AND the advocates who work closely with them.

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2022 National Veteran Suicide Prevention Annual Report

The report provides two decades of Veteran suicide information, from 2001 through 2020. The report also evaluates Veteran suicide during 2020, in the initial period of the COVID-19 pandemic, comparing patterns of Veteran suicide and Veteran COVID-19 mortality over time and across Veteran subgroups.

External Resource

Hold My Guns

Hold My Guns’ mission is to connect responsible firearm owners with voluntary, private off-site storage options, through our national network of partnering gun shops and FFLs, during times of mental health crisis or personal need.


Episode 14 – The Impact of Firearm Violence and Threats on Student Health

In the fourteenth episode of our webinar series, Robin Cogan covers the role school nurses have as healthcare providers charged with the responsibility of protecting students and faculty while fostering safe school environments and the most effective approaches and strategies to create safe and supportive school environments through comprehensive, coordinated efforts.

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  10. Goodwin, F. K. (2003). Suicide Risk in Bipolar Disorder During Treatment With Lithium and Divalproex. Jama, 290(11), 1467. doi: 10.1001/jama.290.11.1467.
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