Introduction

As the post-pandemic landscape comes into focus for the field of suicide prevention, the story is both the same and different; though the suicide rate has been on the rise for most of the past two decades,1 pandemic-related disruptions in support systems and access to services suggest that increases in suicide may have accelerated further over the past few years. Though we do not yet know the extent of changes in suicide rate, preliminary data suggest that these concerns may be well-grounded. Overall, suicide rates increased by 4% between 2020 and 2021.2 Suicide among adolescents and young adults aged 15–24 is particularly concerning, with rates among females increasing 5% and males increasing 8%.3 Additionally, there is some evidence that adolescent suicide rates may get worse before they get better, as data from the 2021 Youth Risk Behavior Survey suggest a bleak and worsening picture of mental health among American high school students.4

Adolescents and young adults in North Carolina have not been immune to these national trends. In fact, the suicide rate among those aged 15–24 increased by a startling 18.8% from 2020 to 2021.5 Unfortunately, there are very few answers to explain these increases: why individuals die by suicide remains elusive. However, an examination of how adolescents are dying by suicide not only reveals some troubling trends but also provides a roadmap for suicide prevention efforts moving forward. An examination of the methods by which young people die by suicide leads one to the clear conclusion that any discussion of suicide prevention among young people must include a discussion of firearms. In 2021, firearm suicides occurred at a rate of 8.4 per 100,000 and accounted for 68.1% of suicides among North Carolinians aged 15–24, the highest rate and proportion of firearm suicides of any year since 1996.1,2,5 Evidence also suggests that adolescents living in a home with firearms have a threefold to fourfold increased risk of dying by suicide.6 Clearly, reducing access to firearms by individuals in distress should be a priority in adolescent suicide prevention.

Data regarding the accessibility of firearms also raise concerns. The pandemic saw a massive increase in the number of guns in circulation, with 2020, 2021, and 2022 ranking as the top three years in firearm sales in US history.7–9 Additionally, the number of first-time gun owners increased substantially during the pandemic, with an estimated 1 in 20 American adults acquiring their first firearm.10 A survey estimated that 11 million individuals, 5 million of whom are children, have new exposure to a firearm as of April 202111; this estimate undoubtedly would be higher in 2023. Though it may be difficult to accurately predict the extent to which additional suicides will occur with the increase in firearm access for millions of Americans, evidence suggests that firearm ownership is associated with an increased risk of suicide that persists years after the initial acquisition of a gun.12 These factors suggest the possibility that firearm suicides may become more frequent unless prevention becomes a priority.

Preventing Firearm Suicides Among Adolescents and Young Adults

Though states with more stringent rules governing access to firearms do tend to have lower rates of firearm suicide,13 regulation by legislation appears unlikely to be a viable solution for North Carolinians for several reasons. At the federal level, most current calls for additional firearms regulations appear to focus on the prevention of mass shootings (e.g., restrictions on semiautomatic firearms and magazine capacity). Though these proposals may warrant discussion on their own merits, they are likely to do little to prevent firearm suicide as studies indicate that numerous firearm types are used in suicides.14,15 At the state level, little political appetite for tighter firearms regulations appears to exist; to the contrary, North Carolina recently has reduced regulatory oversight of handgun purchases.16 For this reason, firearm suicide prevention might best be addressed through a combination of provider education, greater public awareness of suicide as a firearm-safety issue, and bipartisan legislative initiatives that promote a range of safe firearm-storage options.

Providers face significant challenges working with individuals at risk for suicide. Suicide may best be described as a dynamic process in which suicidal thoughts may be acted upon quickly and unpredictably.17 For this reason, current methods of risk assessment suffer from poor sensitivity and/or specificity when attempting to predict who goes from thinking about suicide to making an attempt.18 Lack of confidence in the estimation of suicide risk is both frustrating and frightening for providers working with suicidal patients, as it can be difficult to determine the appropriate level of care in each case. However, what does remain constant is the need to keep patients safe while attempting to find effective treatment for underlying drivers of suicidality. Thus, means-safety interventions (MSIs) should be included in all treatment plans for those with heightened suicide risk. The rationale behind MSIs is simple: putting time and distance between at-risk individuals and the most lethal method of suicide can keep them safe during times of crisis. Typically, MSIs focus on reducing access to lethal doses of medications and firearms, as the former are the most common methods of suicide attempt and the latter are used in more than half of all suicides nationally. Findings examining outcomes of MSIs have shown great promise in reducing suicide death.19

Though the logic for using MSIs is relatively straightforward, conversations regarding means safety can be difficult. Patients may not view medical providers as credible sources of information regarding safe firearms storage for suicide prevention.20 Unfortunately, these discomfort and credibility problems may be preventing vital conversations from taking place. In a study of emergency department physicians and nurses, less than half reported asking suicidal patients about access to firearms despite more than half believing that it is their responsibility to do so.21 Fortunately, training programs like Counseling on Access to Lethal Means (CALM) appear to effectively increase providers’ knowledge of and comfort with MSI conversations and ultimately increase the likelihood of using this intervention.22 This three-hour workshop helps providers explain the rationale for MSIs, educates them on the range of options that can be used to increase the security of firearms (e.g., out-of-home storage options, in-home storage options), and uses group discussions and role-playing to prepare them to address common questions and concerns. Wider dissemination of CALM may increase the use of MSIs in clinical practice and make these conversations more effective in preventing suicide.

In conjunction with training providers to use MSIs, it is essential to raise awareness among the general public of safe firearm storage as suicide prevention. Prevention messaging should present suicide risk as what it is: a firearm-safety issue affecting the lives of those in the gun-owning community. Correctly characterizing firearm suicide as a safety issue is likely to resonate with responsible firearm owners who pride themselves on safe firearm practices. The culture of safety in the firearm community has a history of effectiveness. For example, fatality rates from accidental discharge of a firearm have declined by almost 90% in the past 40 years despite a roughly equal proportion of households having firearms.1 Though some organizations have taken this approach (e.g., the New Hampshire Firearm Safety Coalition23), the inclusion of suicide risk as a firearm-safety issue could be promoted more broadly in collaboration with organizations like hunter education and firearm training groups.

Additionally, safe storage of firearms should be normalized in all attempts to educate the public on effective response to suicide risk. Though suicide prevention gatekeeper trainings (i.e., trainings that teach community members to recognize and respond to suicide risk) have increased in number and popularity over the past several decades, few if any include conversations about firearm safety. To address this gap, we recently have adapted a version of CALM for gatekeepers called Conversations on Access to Lethal Means, or CALM Conversations. CALM Conversations features elements typically found in other gatekeeper trainings (e.g., identifying risk, asking directly about suicidal thoughts, facilitating referral to formal care providers), but also features an in-depth discussion of steps that can be taken to temporarily reduce access to firearms when suicide risk is detected. We hope that the dissemination of this training will lead to wider public awareness of firearm safety as an effective pillar of suicide prevention.

Finally, several bipartisan legislative steps could be taken to support efforts to reduce firearms suicides. One promising example became law in March 2023 with the passage of North Carolina Senate Bill 41.16 One section of this bill explicitly sets a course for the promotion of a safe firearm storage agenda that includes the development of an informational toolkit and website, wider distribution of free firearm-locking devices, and outreach to help communities establish local safe storage initiatives. One such piece of this outreach includes the development of the North Carolina Safe Storage Map. This online resource shows the location of businesses and law enforcement offices that are willing to store firearms temporarily. The map is now available to both families and providers in order to maximize their available options for temporary out-of-home firearm storage.

However, the more controversial section of the bill—the repeal of North Carolina’s pistol purchase permitting system—may also increase safe storage options for families navigating suicide risk. In the past, the legal transfer of a handgun from one person to another required the recipient to apply for and get a pistol purchase permit. Each handgun required a separate permit and the transaction had to be recorded by a federal firearms licensee (FFL), even for what were intended to be temporary transfers. This process was slow, expensive, and cumbersome, especially when numerous handguns were involved or when moving the handguns was urgent for safety. While some might fairly question whether the repeal of the permitting system may make it easier for at-risk individuals to acquire a handgun more quickly (albeit no more quickly than buying a long gun has been), it does eliminate some of the barriers families might face when trying to temporarily store handguns outside of the home with friends or family members.

Though this legislation represents a step in the right direction for the promotion of safe firearm storage, additional initiatives should be considered. Firstly, businesses that offer temporary firearm storage to legal gun owners could be offered protections from legal and civil liabilities for offering this service. In our discussions with owners and managers of FFLs during the creation of the North Carolina Safe Storage Map, liability concerns were the most frequent reasons cited for not offering temporary storage. There is precedent for this type of legislation, as Louisiana passed such a provision in 2022.24 Secondly, gun owners could be incentivized to purchase firearm-locking devices through coupons, tax credits, or tax holidays for such purchases. Both Tennessee and Utah have passed such measures in recent years.25,26 These incentives may give additional momentum to the existing safe storage initiative. Thirdly, a number of states recently have passed mechanisms by which individuals can voluntarily enroll to be flagged in the National Instant Background Check System, thereby preventing FFLs from selling the enrollee a firearm. Though enrollment requires proactive registration by the at-risk individual and the process for removal varies widely from state to state, the attitudes of individuals in mental health treatment toward these programs appear positive.27 These are but a few examples of legislative action that may foster bipartisan support for suicide prevention, and continued discussions between the firearms community and suicide prevention experts could reveal more.

Conclusions

Though firearm suicide trends among adolescents and young adults are grim, there are actionable steps that can be taken that may appeal to both the gun-owning community and the suicide-prevention community, creating new opportunities for collaboration between these groups. Training care providers, educating the public, and passing bipartisan legislation to promote safe storage of firearms are all measures with the potential to save the lives of many young North Carolinians. Moreover, collaboration on these issues may help unite gun owners and public health experts as members of one community of safety, and this ultimately may be the most promising path forward in preventing firearm suicides.

Disclosure of interests

No interests were disclosed.