Secure Storage as a Critical Component in Suicide Prevention

Introduction

This executive summary outlines the key points and arguments presented during a Grand Rounds presentation at Baylor College of Medicine, featuring Dr. Ali Abbas Asghar-Ali, a renowned geriatric psychiatrist, and Mr. Brandon Shanahan, a health science specialist at the VA South Central Mental Illness Research Education and Clinical Center (MIRECC). The presentation focused on the critical role of secure storage of lethal means, particularly firearms, in suicide prevention efforts, with a significant emphasis on the veteran population. The speakers underscored the alarming statistics surrounding suicide in the US, the disproportionate risk faced by veterans, and the heightened lethality associated with firearm-related suicide attempts. They advocated for increased awareness and implementation of lethal means safety counseling, providing practical strategies and resources for healthcare professionals to engage in these vital conversations with patients and their families.

The Problem of Suicide in the U.S. and Among Veterans

Despite ongoing prevention efforts, suicide rates in the United States continue to rise. In 2022, there were over 49,000 completed suicides. Veterans are identified as a particularly high-risk group, with a suicide rate of 33.9 per 100,000 in 2021, more than double the general population rate of 14.2 per 100,000. Notably, the suicide rate among young veterans (18-34) and American Indian/Alaskan Native veterans is even higher. The increased risk among veterans highlights the importance of tailored prevention strategies within the Veterans Health Administration (VA) and beyond.

The Critical Role of Firearms in Suicide Deaths

Firearms are prevalent in the US, with more civilian-owned firearms than residents. While firearms are not the most common method of suicide attempts (poisoning is more frequent), they are the most common method for completed suicides, accounting for 52% of non-veteran and 72% of veteran suicides. Research indicates that handgun owners have a significantly higher suicide rate compared to non-owners. Importantly, studies suggest that firearm owners are not inherently more likely to have mental health problems or suicidal ideation, indicating that access to firearms itself increases the risk of suicide. Furthermore, firearm suicide attempts are far more likely to be fatal (approximately 90%) compared to other methods like overdose (around 3%). The presence of firearms in the home also increases the risk of suicide for family members, particularly adolescents.

Lethal Means Safety Counseling and Secure Storage

Lethal means safety counseling aims to reduce suicide risk by increasing the time and distance between an individual's suicidal ideation and access to the means of self-harm. Secure storage of lethal means, especially firearms, is a key component of this counseling. Secure storage prevents impulsive suicidal actions, as a significant percentage (24%) of suicide attempts occur within five minutes of the decision to attempt. Despite the clear evidence supporting its importance, most clinicians do not routinely conduct lethal means safety counseling. Professional organizations like the AMA and APA support counseling on secure firearm storage for suicide prevention.

Barriers and Facilitators to Discussing Secure Storage

Several factors contribute to clinicians' reluctance to discuss secure storage, including cultural factors related to firearm ownership, a lack of knowledge about firearm safety and secure storage options, time constraints, and a lack of readily available educational materials. However, clinician factors that can facilitate these conversations include employing communication strategies based on motivational interviewing and shared decision-making, establishing trust, creating a non-judgmental space, and practicing these conversations.

In-Home Secure Storage Options for Firearms

The presentation outlined various in-home secure storage options for firearms, ranging from least to most secure:

• Cable Locks: Keyed locks that go through the firearm's magazine well and chamber, preventing loading and firing. These are commonly distributed by the VA and firearm safety organizations.
• Lock Boxes: Simple keyed or biometric (fingerprint, rarely iris scan) boxes for storing handguns.
• Safes: More robust options, including standard safes with keypads or biometric access, capable of storing various types of firearms.
• Gun Cabinets: Larger locked cabinets designed to store rifles, shotguns, and handguns.
• Trigger Locks: Devices that lock into the trigger guard, preventing the trigger from being pulled.
• Storage Cases with Locks: Lockable cases specific to different types of firearms.

The speakers emphasized the spectrum of options, from storing firearms loaded and accessible to legally selling or giving them away, with each level offering varying degrees of safety.

Educational Initiatives and Resources for Healthcare Professionals

The presentation highlighted several valuable resources and educational initiatives aimed at equipping healthcare professionals with the skills and knowledge to engage in lethal means safety counseling:

• Counseling on Access to Lethal Means (CALM): An early and widely used training program focusing on identifying individuals who would benefit from lethal means counseling, asking about access to lethal means, working with individuals and families to reduce access, and providing resources on firearm basics and relevant laws. The speakers noted the availability of virtual training courses.
• Bullet Points (The Three A's Framework): A framework emphasizing Approach (understanding personal beliefs and harm reduction), Assess (risk factors and access to firearms), and Act (safe storage, temporary transfer, and legal options like mental health holds and civil protective orders). This resource offers downloadable information and training videos.
• The Five L's Model: A framework developed with older adults in mind, prompting consideration of whether the firearm is Locked, Loaded, if there are Little children present, if the operator is Feeling low, and how Learned the owner is about firearm safety.
• VA Educational Initiatives: The VA is actively involved in developing and implementing educational programs on secure storage, including:
  • A national team focused on creating resources for discussions of secure storage with older veterans with cognitive impairment and their care partners. This initiative involves needs assessments, literature reviews, and the development of training videos and didactic materials.
  • Virtual Reality (VR) based training: Utilizing MetaQuest 3 devices, this immersive training allows clinicians to learn about different firearms (handgun, revolver, shotgun, AR-15) and practice using cable locks and lock boxes in a safe environment, addressing the barrier of unfamiliarity with firearms.
  • Veteran-to-Veteran Training: A program designed to equip veterans with the skills to identify and talk to other veterans about suicide and secure storage. Pilot trainings with veteran service officers and clergy have shown promising results in improving knowledge and confidence in facilitating secure storage planning.

Key Takeaways and Conclusion

The presentation strongly advocated for the integration of lethal means safety counseling, with a focus on secure firearm storage, into routine healthcare practice, particularly when working with veterans. Key takeaways include:

• Secure storage is an effective means to prevent suicide by creating a barrier between suicidal thoughts and action.
• Clinicians can learn how to have comfortable and effective conversations about secure storage through available resources and training.
• Various practical and accessible secure storage options exist.
• The VA is actively developing and implementing innovative educational initiatives to support both clinicians and veterans in addressing this critical issue.

Ultimately, the speakers emphasized that as healthcare professionals, their role is to help individuals and their families stay safe, and discussing and promoting secure storage of lethal means is a crucial step in comprehensive suicide prevention efforts.

This executive summary was generated using an AI-powered tool to enhance clarity, efficiency, and readability. While AI assisted in drafting this summary, it has been reviewed and refined to ensure accuracy and alignment with our objectives.