IMPORTANCE Suicide is the second leading cause of death in adolescents, with firearms the most common method, especially in rural communities. Identifying where to target lethal means safety interventions could better leverage limited resources. OBJECTIVESTo understand the associations of rurality, school-level prevalence of easy handgun access, and suicidality measures in Colorado youth, to explore spatial distribution of school-level measures, and to identify communities with high prevalence of both easy handgun access and suicidality. DESIGN, SETTING, AND PARTICIPANTSThis cross-sectional study used data from the 2019 Healthy Kids Colorado Survey, an anonymous cross-sectional school-based survey conducted at 256 participating Colorado high schools. Participants included students from schools recruited for statewide population-based estimates and additional schools opting in. Data were analyzed from November 9, 2020, to March 13, 2021.EXPOSURES Urban-centric locale according to a 7-level continuum. Geocoded location of schools was used for spatial analysis. MAIN OUTCOMES AND MEASURESThe main outcomes were weighted prevalence for easy handgun access and 4 measures of mental health and suicidality in the previous year (ie, feeling sad for 2 weeks and considering suicide, planning suicide attempt, or attempting suicide in the past year).RESULTS A total of 59 556 students (49.7% [95% CI, 49.3%-50.1%] male and 50.3% [95% CI, 49.9%-50.7%] female; 53.9% [95% CI, 53.5%-54.3%] in 9th and 10th grade; 36.4% [95% CI, 36.0%-36.8%] Hispanic and 50.8% [95% CI, 50.4%-51.2%] non-Hispanic White) from 256 schools participated. Most schools were rural or in small towns (56.8% [95% CI, 50.7%-62.9%]), while more students participated from urban and suburban schools (57.8% [95% CI, 57.6%-58.0%]). Prevalence of perceived easy access to handguns increased with increasing rurality, with 36.2% (95% CI, 35.2%-37.1%) of students in rural (remote) schools reporting easy access, compared with 18.2% (95% CI, 17.3%-19.1%) for city (large) schools. The spatial distribution of easy handgun access and suicidality measures had minimal overlap, but there was correlation at school-level between easy handgun access and considering suicide (ρ = 0.203 [95% CI, 0.0748-0.331]), planning suicide (ρ = 0.300 [95% CI, 0.173-0.427]), and attempting suicide (ρ = 0.218 [95% CI, 0.0869-0.350) in the previous year. The highest quartile for prevalence of both perceived easy access to handguns and planning suicide in the previous year included 21 schools (81.0% [95% CI, 64.0%-97.9%] rural [remote] or rural [distant]).
Background: American Indian and Alaska Natives (AI/ANs) veterans may be at elevated risk for suicide, but little is known about suicide among this population. Methods:We conducted a retrospective cohort analysis of AI/AN veterans who received health care services provided or paid for by the Veterans Health Administration (VHA) between October 1, 2002, and September 30, 2014, and who were alive as of September 30, 2003. Age-specific and age-adjusted suicide rates through 2018, per 100,000 person-years (PY) at risk and 95% confidence intervals were computed.Results: Age-adjusted suicide rates among AI/AN veterans in this cohort more than doubled (19.1-47.0/100,000 PY) over the 15-year observation period. In the most recent observation period (2014-2018), the age-adjusted suicide rate was 47.0 per 100,000 PY, with the youngest age group (18-39) exhibiting the highest suicide rate (66.0/100,000 PY). The most frequently used lethal means was firearms (58.8%), followed by suffocation (19.3%), poisoning (17.2%), and other (4.7%).Conclusions: Results suggest that: (1) suicide is an increasing problem among AI/AN VHA veterans; and (2) younger AI/AN VHA veterans are at particularly high risk and warrant focused prevention efforts. Findings are similar to those observed in general AI/AN population. There is a compelling need to review and strengthen VHA suicide prevention efforts directed towards AI/AN veterans.
Purpose of review Firearm injury is the leading mechanism of suicide among US women, and lethal means counseling (LMC) is an evidence-based suicide prevention intervention. We describe current knowledge and research gaps in tailoring LMC to meet the needs of US women.Social Determinants of Health (R Holliday, Section Editor)Recent findings Available LMC and firearm suicide prevention literature has not fully considered how LMC interventions should be tailored for women. This is especially important as firearm ownership and firearm-related suicides among women are increasing. Additional research is needed to better understand firearm characteristics, behaviors, and beliefs of US women, particularly related to perceptions of personal safety and history of trauma. Research is also needed to identify optimal components of LMC interventions (e.g., messengers, messages, settings) and how best to facilitate safety practices among women with firearm access who are not themselves firearm owners but who reside in households with firearms. Finally, it will be important to examine contextual and individual factors (e.g., rurality, veteran status, intimate partner violence) which may impact LMC preferences and recommendations. Summary This commentary offers considerations for applying existing knowledge in LMC and firearm suicide prevention to clinical practice and research among US women, among whom the burden of firearm suicide is increasing.
Knowledge regarding deaths due to suicide, alcohol-related, or drug-related causes may be limited by inconsistent and/or restrictive case definitions, resulting in concerns regarding validity of findings and underestimates of burden. In this proof-of-concept study, we assessed varying case definitions (suicide, alcohol-related, drug-related mortality using underlying cause of death [UCOD] versus multiple cause of death [MCOD]) based on counts and rates among Colorado Veterans who died (2009-2020). Suicide, alcohol-related, or drug-related ICD-10 codes were identified, and two case definitions were compared: UCOD; qualifying ICD-10 code listed as the UCOD; and MCOD; qualifying ICD-10 code in any cause of death field. Of 109,314 decedents, the number and age-adjusted mortality rate (per 100,000 persons) significantly increased when including MCOD: UCOD, n=4,930 (110.3/100,000) versus MCOD, n= 6,954 (138.4/100,000). While rates of suicide mortality did not change, alcohol-related mortality doubled with the more inclusive case-definition: UCOD 1,752 (27.3/100,000) versus MCOD 3,847 (59.8/100,000). Alcohol use disorder codes accounted for 71% of additional alcohol-related deaths captured with the MCOD definition. Studies that rely on UCOD codes may be underestimating the burden of deaths, especially alcohol-related deaths. Increased effort is required to reevaluate current classifications of deaths associated with suicide, alcohol-use, or drug-use.
Colorado has consistently had one of the highest rates of suicide in the United States, and El Paso County has the highest number of suicide and firearm-related suicide deaths within the state. Community-based solutions like those of the Suicide Prevention Collaborative of El Paso County may be more effective in preventing suicide as they are specific to local issues, sensitive to local culture, and informed by local data, community members, and stakeholders.
Background Suicide is the tenth leading cause of death in the United States, with over half of cases involving firearms. Despite research indicating negative effects of exposure to suicide, there is little research on who typically finds the body of the suicide decedent. Understanding who finds the body of the suicide decedent may be important to understand trauma and mental health effects. Findings Of the 332 people who died by suicide in El Paso County, Colorado, 182 (55%) used firearms. Those who died by firearm suicide were more likely to be male (83.5% vs. 67.3%) have military affiliation (39.0% vs. 19.3%) and were less likely to have a known mental health diagnosis (47.3% vs. 64.7%) compared to those who died from other means. Most suicide decedents were found by a family member or friend (60.2%). The remaining decedents were found by a stranger/acquaintance (21.0%) or a first responder (22.4%) One-fifth of suicides involved forced witnessing (19%) and the majority were already deceased when the body was discovered (73.2%). Conclusions While most suicide decedents are discovered by a family member or a friend, it is unknown what the bereavement and trauma-related outcomes are among people who discover a suicide decedent who has died by violent means, especially by firearms. Further studies exploring who discovers suicide decedents and targeted postvention strategies for supporting impacted family, friends, first responders, and strangers are needed.
Objective To develop and use planning maps to prioritize and facilitate county‐level recruitment for Together With Veterans (TWV), community‐based rural Veteran suicide prevention program. Method Choropleth maps were created for 49 U.S. states, with four mutually exclusive categories indicating eligibility for the TWV program and increasing levels of need assigned to each county based on (a) percent Veterans Health Administration enrollees residing in rural communities, (b) percent population that are Veterans, and (c) crude suicide mortality rate. Results Of 3113 counties, 78.2% were eligible for TWV and 25.8% met our highest priority definition. A national map and state map were provided to demonstrate final products used to engage stakeholders. A table of recommendations for creating and using planning maps was provided for future projects to reference. Conclusions Geographic information system (GIS) is useful for identifying and prioritizing counties that may benefit most from a rural Veteran suicide prevention program. Choropleth maps allow for dissemination of information about county suicide risk and need for suicide prevention to community members, researchers, and others with a vested interest in suicide reduction. The maps are one tool among many which can support decision‐makers in focusing available resources on populations with the most need.
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