Veterans, Firearms, and Suicide: Safe Storage Prevention Policy and the PREVENTS Roadmap
Background: US veterans die by suicide at a higher rate than that of the civilian population and are more likely to use a firearm as their method. Systemic efforts to address the use of firearms in suicide had been largely evaded. In June 2020, the White House published the Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS) task force report, which verified the link between, and the need to address, at-risk veterans and their access to firearms. This paper reviews the literature on the intersection of veterans, firearms, and suicide, then explores existing VA prevention initiatives aimed at reducing at-risk veterans’ access to lethal means and offers policy recommendations to expand efforts in the context of the PREVENTS Roadmap.
Observations: The PREVENTS report recommends widespread distribution of safety education materials that encourage at-risk individuals to temporarily transfer or store their guns safely and the expansion of free or affordable options for storing weapons. Recommended policy actions to accomplish this goal include delaying access to firearms for at-risk veterans, facilitating temporary storage out of the home, improving in-home safe storage options, requiring that health care providers who care for high-risk veterans are trained in lethal means safety counseling, and creating campaigns to shift cultural norms for firearms’ storage during crises.
Conclusions: Suicide prevention requires a multimodal approach, and attention to firearms access must become a more salient component. The high rate of veteran suicides involving firearms requires far-reaching interventions at societal, institutional, community, family, and individual levels.
Improve In-Home Safe Storage Options
Out-of-home transfer of firearms might not be acceptable or feasible for some veterans. Accordingly, there is need for improved options for safer in-home storage, especially because of frequent unsafe storage practices among veterans. The VA could consider sponsoring another open-innovation Gun Safety Matters Challenge like the one it held in 2018 for in-home firearm storage technology that could prevent suicide.70 Further innovation and bringing winning entries to market has great potential.
Require Enhanced Lethal Means Safety Standards and Training
Broader lethal means safety competence is needed, both in the VA where modest levels of training has been implemented and in the community among Veterans Community Care Program (VCCP) HCPs where it hasn’t. Oversight for enhanced standards and training—as well as of all lethal means initiatives and their program evaluations—might best be accomplished by establishing a separate VA Suicide Prevention Program lethal means safety team. Veteran firearm suicide is a significant problem that warrants its own discrete, permanent VA team (although joining with the US Department of Defense might be advantageous). The VA Suicide Prevention Program has been the industry leader and innovator in this field and should be conferred continued stewardship going forward.
The VA is moving toward requiring lethal means safety counseling training for mental health, pain, primary care, women’s health, ED providers, and Veterans Crisis Line responders.
VCCP HCPs, however, have no required training in lethal means safety counseling or even in basic suicide risk identification and intervention, and the Roadmap did not stipulate that this deficiency should be remedied. Surveys have revealed that community HCPs rarely screen or counsel their patients—even those at high risk—about firearm safety.71 A bill was introduced in Congress August 21, 2020, to expand VA suicide prevention training with firearms community input on cultural competency components and mandate that VA and VCCP providers, and some others with frequent contact with veterans, receive this training.72
Training should be obligatory for VA and VCCP HCPs and trainees most likely to interface with at-risk veterans, including those working in mental health, primary care, pain, women’s health, and ED. Training also should include geriatrics, extended care, and oncology providers because most older adults who die by firearm suicide have physical health problems but no known mental illness.73-75 Lethal means safety counseling training has been shown to improve HCPs’ knowledge about the relationship between access to lethal means and suicide, and confidence in and frequency of having lethal means safety counseling conversations.76 Likewise, training should include peer counselors; veterans are receptive to fellow veterans raising the topic of safe storage.56,77 If feasible, the training should include time to rehearse skills shown to motivate behavior change among patients.
The VA should aim to improve semiyearly clinical pertinence reviews and safety plans for VA and VCCP mental health providers. VA could conduct clinical pertinence reviews that ascertain whether a suicide assessment is recorded in the health record, and when a patient is at elevated risk, whether a lethal means safety assessment and plan is documented.
VA’s safety plan template, although best practice, covers only the initial steps to take when suicide potential is identified. A standard for follow-up is needed. If an at-risk patient agrees to take a safe storage action, subsequent contact HCPs need to ask and document what action was performed. This action will help ensure that at-risk patients with ready access do not fall through the cracks. This suggestion lends itself to studying changes in veterans’ storage habits after intervention.
I also recommend that health care accrediting bodies include lethal means safety assessment, counseling, and follow up as a suicide prevention standard. This recommendation applies to more than just the VA health care system and recognizes that modifying accrediting body standards is an expeditious way to drive change in health care. The accreditation standards of the Commission on Accreditation of Rehabilitation Facilities for behavioral health and opioid treatment programs, and of the Joint Commission for medical centers do not require lethal means safety assessment and intervention.78,79
