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.