Firearm Suicide Among Veterans of the U.S. Military: A Systematic Review

Abstract

Introduction In the United States, firearm suicide represents a major cause of preventable, premature death among veterans. The purpose of this systematic review was to characterize the body of literature on veteran firearm suicide and identify areas for future research, which may facilitate the development of firearm suicide interventions in Veterans Health Administration (VHA) and non–Veterans Health Administration clinical settings. Materials and Methods All randomized controlled trials, quasi-experimental, naturalistic, observational, and case study designs published between January 1, 1990 and February 21, 2019 were included in our review. Following title and abstract review, 65 papers were included in our full-text review and 37 studies were included in our analysis. We based our approach on a modification of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies were grouped into broad, nonmutually exclusive categories: (1) heterogeneity of datasets and veteran status determination for inclusion, (2) service histories, (3) firearm ownership, storage, behaviors, and risk perceptions, (4) patient and clinician attitudes toward firearm restriction interventions, (5) firearm suicide risk factors by study population, and (6) assessments of clinical firearm interventions. Results This body of literature consists predominately of cross-sectional studies with mixed definitions and validation of veteran status, which revealed high concordance of increased risk of firearm suicide compared with nonveterans. Veterans have higher rates of firearm ownership than the general population, primarily citing personal protection as the reason for gun ownership. Veterans often exhibit risky firearm usage and storage behaviors but tend to favor measures that limit access to firearms by at-risk individuals. Despite this, there remains persistent hesitation among clinicians to screen and counsel veterans on firearm safety. Conclusions This systematic review highlights an urgent need to produce higher quality evidence and new data with standard definitions that are critical to inform clinical practice and enhance public health measures to reduce firearm suicide among veterans.

Clinical strategies for reducing firearm suicide

“…Among a large cohort of veteran suicide decedents, 45 % had no mental health or substance use diagnosis, and those without such diagnosis were significantly more likely to die by firearm suicide than by other means [58]. Efforts to raise awareness of risk, discuss the importance of suicide risk assessment regardless of the presence of a diagnosis, create guidance for acceptable counseling on reducing access to firearms for those at risk of self-harm, and increase access to mental health services are underway at the VA [59], and additional work is needed to address firearm suicide specifically among veterans [60].…”

Veteran suicide rates mirror, but do not account for, elevated suicide rates among the general population in US cultures of honor

“…Honor not only influences firearm ownership at both the state and individual levels (Bock et al, 2021;Brown, Imura, & Osterman, 2014;Cohen & Nisbett, 1994) but also influences limitations placed on firearm laws and regulations (Cohen, 1998). Given previous research showing that firearm ownership and firearm suicide rates are higher among veterans (Cleveland et al, 2017;Hoffmire & Bossarte, 2014;Theis et al, 2021) and that veterans tend to live in states with fewer firearm laws (Anestis & Capron, 2016), the present research provides a cultural lens through which to view veteran suicide by showing how honor cultures may make suicide among this already-at-risk group even more likely.…”

“…Second, although prior research on veteran suicide has observed regional differences in suicide rates (Hoffmire & Bossarte, 2014; Theis et al, 2021), not all southern and western states are classified as honor states (Cohen, 1998). Thus, the present work adds to the literature by demonstrating how the culture of honor framework can play a role in explaining public health outcomes, such as veteran suicide, and implicates the role of firearm accessibility in veteran suicide rates as well.…”

“…Beyond differences in suicide rates among the general population, these patterns are heightened among military veterans. Veterans die by suicide at greater rates than the general population, most frequently using firearms (for review, see Theis et al, 2021). This latter outcome may be due to elevated firearm ownership rates among veterans, coupled with their access to and knowledge of firearms from their military training (Cleveland et al, 2017).…”

Risk and Protective Factors for Self-Harm and Suicide Behaviours among Serving and Ex-Serving Personnel of the UK Armed Forces, Canadian Armed Forces, Australian Defence Force and New Zealand Defence Force: A Systematic Review

“…For instance, a recent systematic review in the US highlighted that US veterans are at a substantially increased risk of firearm suicide and have higher rates of firearm ownership than the US general population. 43…”