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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

Virtual Train the Trainer Workshop on Clinical Firearm Injury Prevention- 4.25 CE Credits Available

Register today for this 10/25/2023 event! In this training, you will learn how to assess when a patient is at risk of firearm injury, how to have respectful and culturally appropriate conversations about their access to guns, and ways you can intervene to reduce that risk. You’ll also learn how to incorporate these skills into your clinical supervision and classroom teaching!

Resource type: PDF
External Resource

UC Davis Health Wraparound Program

Hospital-based violence intervention program that extends care of violently injured youth and young adults beyond the hospital to support long-term healing and recovery while also helping patients find hope and purpose.


Student Guide (PDF): Pallin et al. (2019)


Instructor Guide (PDF): Pallin et al. (2019)


Student Guide (Word): Pallin et al. (2019)


Instructor Guide (Word): Pallin et al. (2019)

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.

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  1. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2017. Web-based Injury Statistics Query and Reporting System (WISQARS). Centers for Disease Control and Prevention.
  2. Spicer R., & Miller T. Suicide acts in 8 states: incidence and case fatality rates by demographics and method. American Journal of Public Health 90, no. 12 (December 1, 2000): pp. 1885-1891.
  3. Miller, M., Azrael, D., & Hemenway, D. (2004). The epidemiology of case fatality rates for suicide in the northeast. Annals of Emergency Medicine, 43(6), 723–730. doi: 10.1016/j.annemergmed.2004.01.018.
  4. Anglemyer, A., Horvath, T., & Rutherford, G. (2014). The Accessibility of Firearms and Risk for Suicide and Homicide Victimization Among Household Members. Annals of Internal Medicine, 160(2), 101–110. doi: 10.7326/m13-1301.
  5. Johnson, R. M., Barber, C., Azrael, D., Clark, D. E., & Hemenway, D. (2010). Who are the Owners of Firearms Used in Adolescent Suicides? Suicide and Life-Threatening Behavior, 40(6), 609–611. doi: 10.1521/suli.2010.40.6.609.
  6. Steelesmith, D. L., Fontanella, C. A., Campo, J. V., Bridge, J. A., Warren, K. L., & Root, E. D. (2019). Contextual Factors Associated With County-Level Suicide Rates in the United States, 1999 to 2016. JAMA network open, 2(9), e1910936.
  7. Centers for Disease Control and Prevention. (2018). Suicide rising across the US: More than a mental health concern. Vital signs. Centers for Disease Control and Prevention.
  8. Blair-West, G. W., Cantor, C. H., Mellsop, G. W., & Eyeson-Annan, M. L. (1999). Lifetime suicide risk in major depression: sex and age determinants. Journal of Affective Disorders, 55(2-3), 171–178. doi: 10.1016/s0165-0327(99)00004-x.
  9. Palmer, B. A., Pankratz, V. S., & Bostwick, J. M. (2005). The Lifetime Risk of Suicide in Schizophrenia. Archives of General Psychiatry, 62(3), 247. doi: 10.1001/archpsyc.62.3.247.
  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.
  11. Swanson, J. W., Easter, M. M., Robertson, A. G., Swartz, M. S., Alanis-Hirsch, K., Moseley, D., et al. (2016). Gun Violence, Mental Illness, And Laws That Prohibit Gun Possession: Evidence From Two Florida Counties. Health Affairs, 35(6), 1067–1075. doi: 10.1377/hlthaff.2016.0017.
  12. Hooley, J. M., Franklin, J. C., & Nock, M. K. (2014). Chronic Pain and Suicide: Understanding the Association. Current Pain and Headache Reports, 18(8). doi: 10.1007/s11916-014-0435-2.
  13. Kaplan, M. S., Mcfarland, B. H., Huguet, N., Conner, K., Caetano, R., Giesbrecht, N., et al. (2012). Acute alcohol intoxication and suicide: a gender-stratified analysis of the National Violent Death Reporting System. Injury Prevention, 19(1), 38–43. doi: 10.1136/injuryprev-2012-040317.
  14. Naganathan, S., & Mueller, K. (2019). Physician Documentation of Access to Firearms in Suicidal Patients in the Emergency Department. Western Journal of Emergency Medicine, Volume 20, Issue 5 Western Journal of Emergency Medicine, 20(5). doi: 10.5811/westjem.2019.7.42678.
  15. Price, J. H., Kinnison, A., Dake, J. A., Thompson, A. J., & Price, J. A. (2007). Psychiatrists’ Practices and Perceptions Regarding Anticipatory Guidance on Firearms. American Journal of Preventive Medicine, 33(5), 370–373. doi: 10.1016/j.amepre.2007.07.021.
  16. Michael D. Anestis and Joye C. Anestis, (2015) “Suicide Rates and State Laws Regulating Access and Exposure to Handguns,” American Journal of Public Health 105, no. 10 (2015): 2049–2058.
  17. Anestis, M. D., Khazem, L. R., Law, K. C., Houtsma, C., LeTard, R., Moberg, F., & Martin, R. (2015). The Association Between State Laws Regulating Handgun Ownership and Statewide Suicide Rates. American journal of public health, 105(10), 2059–2067. https://doi.org/10.2105/AJPH.2014.302465.
  18. Miller, M., & Hemenway, D. (2008). Guns and Suicide in the United States. New England Journal of Medicine, 359(10), 989–991. doi: 10.1056/nejmp0805923.
  19. Simon, T. R., Swann, A. C., Powell, K. E., Potter, L. B., Kresnow, M.-J., & Ocarroll, P. W. (2002). Characteristics of Impulsive Suicide Attempts and Attempters. Suicide and Life-Threatening Behavior, 32, 49–59. doi: 10.1521/suli.
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