Prevention Efforts to Reduce Firearm Suicide among At Risk Individuals in the Western United States by Holly M Bevagna

Running head: PREVENTION EFFORTS TO REDUCE SUICIDE 1
Prevention Efforts to Reduce Firearm Suicide among At Risk Individuals in the Western
United States
August 20, 2018
Submitted by:
Holly M. Bevagna
in Partial Fulfillment of the Requirements for the Master of Public Health Degree, Milken
Institute School of Public Health, The George Washington University

PREVENTION EFFORTS TO REDUCE SUICIDE 2
Abstract
Firearm suicide among the elderly poses a serious challenge to public health. One of the
greatest barriers to finding a solution to this problem is the highly politicized and bipartisan
nature of the gun control debate. This paper studies the underlying risk factors contributing to
suicide and existing legislation to develop recommendations for reducing firearm suicide among
the elderly. Various databases were searched for evidence of successful interventions including
PscyhInfo, PubMed and Scopus. The search criteria were limited to studies published within the
U.S. between 2008 and 2018. Based on available evidence, the social ecological model provides
the best intervention for reducing firearm suicide and firearm mortality among the target
population through small interventions at the intrapersonal, interpersonal, community and
societal levels.

Background
In a 2015 report issued by the Centers for Disease Control and Prevention (CDC), nearly
44,200 deaths were attributed to intentional self-harm (i.e. suicide), making it the 10th leading
cause of death in the United States for that year (CDC, 2016). At the time of publication, the age-
adjusted suicide rate had steadily increased from 10.5 per 100,000 in 1999 to 13.3 per 100,000 in
2016, with the age-adjusted rate among males (21.0 per 100,000) being significantly higher than
that of females (6.0 per 100,000). Data stratification by age showed higher rates of suicide
among the individuals aged 65+ cohort. The most common mechanism/implement used in the
commission of suicide among the 44,193 decedents was firearms, constituting nearly half of
reported deaths (22,963) (WISQARS, 2016).
The issue of gun violence becomes most salient in the wake of a mass shooting. During
these times, the American public-united by collective grief and public outrage- is galvanized to
action, demanding stricter gun control reform to prevent the recurrence of these tragedies.
However, these shootings constitute a very small percentage of firearm-related fatalities, and
sensationalist coverage of mass shootings to the exclusion of all other causes of firearm mortality
neglects an increasingly important public health issue. Recent research suggests that firearm
suicides represent a larger and more insidious threat to public health (Murphy et. al, 2017) than
infamous mass shootings. Based on 2015 national estimates provided by the CDC National
Center for Health Statistics, firearm mortality constituted roughly 17% of injury deaths
(approximately 36,000 individuals) in the US, with suicides accounting for 60% of the death toll
(Murphy et. al, 2017). Furthermore, firearm suicides account for the greatest proportion of
suicides (CDC, 2015), as indicated in Figure 1 on the next page. These numbers far exceed
firearm suicide rates in other industrialized countries within the Organization for Economic

Cooperation and Development (Wintemute, 2015, p.12; Anglemyer, 2014, pg. 101; Grishteyn,
2016), as shown in Figure 2.
Figure 1: QuickStats: Suicide Rates,* by Mechanism of Injury† — National Vital Statistics
System, United States, 1999–2013. (CDC, 2015).
Figure 2: Mortality rates for firearm suicide and homicide for members of the Organization for
Economic Co-operation and Development. (GunPolicy.org, 2018).

Epidemiology of Firearm Suicide within the US
Data provided by the CDC revealed an age-adjusted national firearm suicide rate of 6.5
per 100,000 in 2015 (CDC WONDER, 2017). Subsequent queries grouped by sex, race and age
for the same year showed that firearm suicide mortality rates were highest among males (11.6
per 100,000), Caucasians (7.5 per 100,000), and individuals aged 85+ (13.7 per 100,000),
respectively (CDC WONDER, 2017). High suicide rates were also observed in the 70-74, 75-79
and 80-84 year subcategories. Figure 3 and Figure 4 depict firearm suicide mortality rates
stratified by age and race, respectively.
Figure 3: Firearm suicide death rates stratified by age in the United States from 2001-2016.
(WISQUARS, 2016).

Figure 4: Firearm suicide death rates stratified by race in the United States from 2001-2016.
(WISQUARS, 2016).
States with the highest suicide rates were predominantly located to the west, including
Idaho, Wyoming, Montana and New Mexico (CDC WONDER, 2017). The mortality rate due to
firearm suicides in Wyoming (the state with the highest incidence of death by firearm suicide in
2015) was 16.6 per 100,000 (WISQARS, 2003). Stratification of Wyoming’s population by sex,
race and age produced mortality rates higher than national averages for all categories (28.3 per
100,000 for males, 17.2 per 100,000 for Caucasians and 35.9 per 100,000 for individuals aged 80
to 84) (WISQARS, 2003).
Figure 5: Statewide Gun Ownership and Firearm Suicide Rates. (Brady Center to Prevent Gun
Violence, 2016).

Numerous studies have demonstrated a positive correlation between firearm suicide rates
and gun ownership (Anglemyer, 2014; Miller, 2013; Mann & Michel, 2016). Researchers
postulate that this association explains most of the variation in firearm suicide across the United
States illustrated in Figure 5. The highest suicide rates are observed in states where gun
ownership is prevalent including Alaska, Wyoming, Montana, Idaho and Oklahoma. As a result,
many local and state governments have enacted laws to restrict access to guns, particularly
among individuals who have been deemed a danger to themselves or others by mental health
professionals or loved ones. Studies evaluating the effects of these laws have found that states
with stricter gun policies have lower suicide rates (Fleegler, et al., 2013; Santaella-Tenorio,
2016; Lewieki, 2013). Research by the Law Center to Prevent Gun Violence lends further
support to the purported relationship between gun policy and suicide rates. In their annual report,
states receiving a rank of F for weak gun policy had the highest rates of suicide. Conversely,
states classified into the A category had the lowest rates, as illustrated in Figure 6 below.
Figure 6: Annual Gun Law Scorecard. (Giffords Law Center, 2018).
Notwithstanding previously cited literature and a growing interest in firearm suicides
among public health researchers, the body of research on this topic is incommensurate with the

magnitude of the problem. The clear majority of studies use a cross-sectional or ecological
design methodology, which cannot be used to determine causality. Gun rights advocates and
lobbyists (i.e. the NRA) can then exploit this limitation to challenge the validity of the study and
refute the utility of proposed interventions. The dearth of methodologically robust studies on
firearm suicides and gun violence in general has been attributed to legislation passed by
Congress at the urging of gun lobbies, specifically the Dickey Amendment, which proscribes the
use of government funding for gun research pursuing a political agenda, namely gun control
(Hickey, 2013) Although it does not expressly prohibit funding for evidence-based gun research,
it has effectively constrained efforts by researchers to elucidate the etiology of gun violence and
develop tangible solutions. Questions that still require answers include, though are not limited to
the following: which types of legislation would be most effective in the U.S given the current
political landscape; which interventions are most effective in reducing firearm suicides among
individuals of different ethnicities, religious denominations and political affiliations; and what
level of intervention would be the most successful at preventing gun deaths (federal vs. state-
based interventions).
Disparity between Rural and Urban Environments
Firearm suicide is increasingly prevalent in rural regions, which exhibit the highest rates
of gun ownership and the weakest legislation. In contrast, the major metropolitan areas have
concurrently low rates of firearm suicide and gun ownership and rank higher in terms of their
gun control legislation (Kaskie, 2016; Kaplan, 2012). After controlling for potential confounders
using multivariate logistic regression, Kaplan and colleagues, 2012, found that living in a rural
area increased the odds of firearm suicide (Kaplan, 2012). One caveat is that it is virtually
impossible to control for all potential confounders. It is therefore likely that the odds of firearm

suicides in rural vs. urban areas will diminish if other variables are introduced into the logistic
regression model.
Purpose of Paper
This paper will fill an important gap in existing knowledge concerning the effectiveness
of legislation in the prevention of firearm suicides- a topic that has received little attention until
recently. In the pages that follow, I provide a detailed review of existing case law, federal and
state statutes, and evidence-based interventions, offering a fresh perspective on the gun debate
and a comprehensive solution to an important public health problem.
Specific Aims
This critical analysis paper will evaluate the sociopolitical, legal, epidemiological and
psychological basis for increased gun suicide among elderly Caucasian males in the Western
United States; and assess the feasibility of implementing evidence-based policies to ultimately
decrease the large incidence of gun suicide among said demographic. Specifically, the political
convictions and affiliations of the target population will be assessed to inform suitable and less
objectionable policy recommendations (to the extent possible). This should help to minimize the
political opposition that inevitably accompanies political reform movements, especially those
born from controversial issues like the gun control debate. The constitutionality of the proposed
legislation will be evaluated by weighing the interest of the government in preserving the
public’s welfare against the fundamental right to bear arms promulgated by the Second
Amendment. To that end, the legal context behind the enactment of the Second Amendment and
the precedent set by its interpretation/adjudication (i.e. via seminal court cases) will be
examined. Understanding human behavior is important for developing sustainable interventions.
The overarching objective of this study is to reduce the incidence of firearm suicide in a

susceptible population, predominantly elderly Caucasian males living in the Western United
States, by proposing gun control reform legislation. Existing policies aimed at reducing gun
violence or gun suicide will be compared for effectiveness and appropriateness. Legislation that
is culturally sensitive will result in less opposition from gun advocates, which in turn will lead to
longer lasting behavior change among the target population. Consequently, the number of
firearm suicides will decline. Knowledge of the current political landscape in general will help in
determining the feasibility of policy implementation.
The research questions guiding the study are:
1) What are the underlying individual risk factors that predispose the target population to
firearm suicide?
2) What are historical policy efforts that shaped the current political landscape and efficacy
of gun control reform efforts?
3) What are evidence-based and culturally appropriate policies and legislation
recommendations?
Methods
A literature review was conducted to determine the etiological risk factors of firearm
suicide and the efficacy of existing gun control legislation. Four databases were searched for this
information: PsychINFO, PubMed, Scopus, and Google Scholar. Each database query was
limited to peer-reviewed articles published in the U.S. between 2008-2018 due to fundamental
differences in governance and political structure between countries and the mutability of the
political landscape within the U.S. Subsequently, the abstracts of search results meeting the
inclusion criteria were screened and evaluated for inclusion in the present study based on
pertinence, credibility and study methodology. Ultimately, 29 studies were identified as relevant

to the current discussion. The search terms used to comb the aforementioned databases for
information consisted of three to four words describing the weapon employed (e.g. firearm,
handgun or gun), the cause of mortality (i.e. suicide), and the mechanism of legal/political
reform (e.g. legislation, statute, policy, and case law).
Government publications and websites were consulted for statistics on firearm suicide
and gun control policies, including CDC WONDER, the National Center for Health Statistics,
the Federal Bureau of Investigation (FBI) and the Bureau of Alcohol, Tobacco, Firearms and
Explosives (ATF). Non-governmental organizations and political fact tanks, such as the Gifford
Law Center and the Pew Research Center, respectively, were also consulted for information on
the efficacy of policy-based interventions and divergent policy views among survey respondents.
The National Rifle Association’s website provided a means of comparison against liberal gun
control platforms and of maintaining objectivity and non-partisanship. Periodicals were also
included to learn about attitudes and beliefs governing behavior, including gun-related suicide
and opposition to gun control reform.
Findings
Risk Factors
Scientific studies, government publications and political polls have identified a myriad of
underlying factors that increase susceptibility to firearm suicide among the target population,
including psychological, behavioral, dispositional, social, political, geographical and biological
determinants. The predominant risk factor for firearm suicide is access to lethal means vis-à-vis
gun ownership. Other major contributors to firearm suicide contained herein are social
deprivation, political affiliation and significant life changes. This is by no means an exhaustive
list of potential risk factors; only the most significant factors are represented.

Gun ownership. Research shows a correlation between firearm suicide rates and gun
ownership (Anglemyer, 2014; Miller, 2013; Mann & Michel, 2016). This poses a substantial
challenge given the prevalence of guns in American society. According to a Pew Research
Center survey, approximately 40% of U.S. adults report having a gun in their household (Pew
Research Center, 2017), translating to over 283 million firearms nationwide (Mann, 2016).
Furthermore, approximately 66% have resided in a gun-owning household and an estimated 70%
have fired a gun during their lives (Pew Research Center, 2017). Among respondents, the most
commonly cited reason for gun ownership was for personal protection (approximately two-
thirds), followed by hunting (38%), sport shooting, (30%), gun collecting (13%) and job
requirements (8%). The common motivator behind these reasons, except for the latter, is a desire
for individual autonomy and freedom from tyranny.
The right to keep and bear arms is a deeply rooted U.S. tradition dating back to the late
18th century. Nearly 74% of gun owners consider gun ownership as a fundamental right and
believe guns are inextricably linked to their sense of personal and cultural identity (Pew
Research Center, 2017). For the most extreme gun rights advocate, depriving a gun owner of this
“inviolable” right is almost tantamount to severing an appendage. These individuals vehemently
oppose all legislation that attempts to regulate or restrict access to guns. Conversely, most gun
owners believe the right to keep and bear arms enumerated in the Second Amendment does not
mean unfettered access to guns and that it should be infringed to prevent harm to oneself and/or
others, insofar as it is done in strict accordance with the law (e.g. does not violate the due process
clause). One noteworthy example is the gun violence restraining order, which keeps guns out of
the hands of individuals who pose a threat to themselves or others. Notwithstanding, these gun

owners still hold staunch convictions regarding the right to keep and bear arms, which should be
considered in the development of gun policy.
Gun culture. Gun culture encompasses all aspects of U.S. society, including media and
entertainment outlets, internet websites, online forums and community events. At least a third of
gun owners watch TV programs or visit websites related to guns, hunting or shooting sports.
Another 25% of gun owners have reported attending a gun show (Pew Research Center, 2017).
This is cause for concern among public health researchers since social gun culture has been
found to be positively associated with gun ownership rates (Kalesan, 2016). A study by Kalesan
et. al found that gun owners had significantly more exposure to gun culture when compared with
gun non-owners (32.3% vs. 6.1%). Additionally, gun owners had distinct perceptions about the
acceptability of firearms amongst family and friends than their gun non-owner counterparts.
7.5% of respondents believed that their relatives and friends would not harbor the same respect
for them if they did not possess a gun, as opposed to 1.0% of gun non-owners. While this
percentage is small, it highlights a stark contrast in ideology between gun owners and gun non-
owners, and exposes another motivator for owning guns-dignity and respectability (Kalesan,
2016). Since gun ownership has been shown to be correlated with higher rates of gun suicide,
addressing the ideological and behavioral motivators behind gun ownership-including gun
culture-is paramount. More research on perceptions concerning gun ownership is needed in order
to develop interventions with the highest likelihood of success.
Medical history and access to healthcare. Health problems constitute a major risk
factor for firearm suicide among the demographic of interest. These encompass a broad spectrum
of conditions including the following: psychiatric illness (e.g. depression, post-traumatic stress
disorder), neurodegenerative disease and diseases causing functional impairment, among others

(Kaplan, 2012; Lewieki, 2013). Individuals with these conditions are more likely to experience
feelings of despair, uselessness and despondency, and are therefore more prone to suicidal
ideation. This in conjunction with capability (i.e. access to lethal means); substance abuse and
alcohol (Branas, 2016; Lewieki, 2013); and social isolation will most likely lead to suicide if the
person does not get the help they need.
Several factors are known to exacerbate suicidal ideation, thus increasing the likelihood
of suicide. First, some individuals may lack access to basic mental health services, either because
they lack decent insurance or physical barriers impede their ability to access care, such as being a
long distance from a mental healthcare facility. The clear majority of the target population is
likely retired and unable to afford private health insurance. Some may not have family members
to take them to and from their medical appointments and provide emotional support, further
contributing to suicidal ideation. Furthermore, perceived gender roles can adversely affect an
individual’s decision to seek care (Kaplan et. al, 2012). In this patriarchal society, men are
expected to act tough and manly. For many males, seeking professional help and social support
mechanisms is construed as a sign of weakness and detracts from his masculinity. Committing
suicide with a firearm is considered the most masculine and decisive way to commit suicide,
since it is more likely to result in death (Kaplan et. al, 2012). That is why means restriction is so
vital to preventing suicide.
Life changes. Similarly, important life changes, such as social isolation and lower
socioeconomic status affiliated with retirement, are significant predisposing factors for this target
population. According to Erik Erikson’s stages of psychosocial development, individuals over 65
experience an internal conflict called “Ego Integrity vs. Despair” (Macnow, 2015). At this age,
individuals tend to reflect on the purpose of their lives and whether they have reached self-

actualization (Maslow’s hierarchy of needs) (Macnow, 2015). Self-fulfillment gives rise to the
preservation of the ego and the achievement of wisdom. Conversely, dissatisfaction with life
results in despair. Social engagement can help to alleviate these feelings and decrease
vulnerability to suicidal ideation.
Political conservatism. It is well known that political ideologies play an important role
in shaping the current political debate surrounding gun control reform. However, political
ideology influences more than just the political and legal environment. Research by Kposowa
and colleagues (2013) suggests that there is a connection between political conservatism and
increased odds of individual suicide (Kposowa, 2013). Republican states have the highest gun
ownership rates, in addition to the weakest gun control laws, which is consistent with Republican
perceptions regarding the scope of gun violence and the impact it has on public health. Only
32% of Republicans contend that gun violence is a serious problem, compared with 65% of
Democrats (Pew Research Center, 2017). Figure 7 provides an original, ecological framework
for understanding some of the risk factors associated with firearm suicide. Predisposing factors
are divided into four strata: intrapersonal, interpersonal, community and societal risk factors.
Figure 7: Risk factors for firearm suicide among target population divided into four strata.
(Kaplan, 2012).

* From bottom to top: intrapersonal, interpersonal, community and societal risk factors.
Political Landscape
The Second Amendment. Passed in 1791, the Second Amendment was the first major
piece of federal legislation addressing firearms. The interpretation of this amendment has been
hotly contested not only through public discourse and political debates, but also at all levels of
the judiciary. At the heart of the gun control debate lie two important issues: whether the right to
bear arms is a universal right of the people or belongs exclusively to the militia; and whether the
Second Amendment limits the powers of the federal government, the states or both.
The Supreme Court attempted to define the meaning and scope of the Second
Amendment in several landmark court cases. In Presser v. Illinois, the Supreme Court ruled that
while the Second Amendment protects the right of the people to bear arms, it does not grant
citizens the right to organize a private, unsanctioned militia (Presser v. Illinois, 116 U.S. 252,
1886). Further, in United States v. Miller, the Supreme Court held that the type of arm used
should “bear a reasonable relationship to the preservation or efficiency of a well-regulated
militia”, affirming the view that the purpose of the Second Amendment is to provide for the
common defense and ensure national security (United States v. Miller, 307 U.S. 174, 1939). This
legal precedent would eventually be overturned in District of Columbia v. Heller, which
Low HealthcareAccess; PervasiveGun culture; Weak
gun policies;IncumbentPolitical Party
Lack of social cohesion and
connectedness
Gun availability
Interpersonal
relationships;Major life
Changes
Political ideology;
Personality;
SubstanceAbuse

concluded that the intent of the Second Amendment was to protect the rights of individual
citizens, not only the militia. Despite this ruling, the Supreme Court maintained that the Second
Amendment right to bear arms is not limitless and does not afford the right to “keep and carry
any weapon whatsoever in any manner whatsoever and for whatever purpose” (District of
Columbia v. Heller, 554 U.S. 570, 2008).
Two federal court cases examined the applicability of the Second Amendment to
different levels of government. In United States v. Cruikshank, the Supreme Court ruled that the
Second Amendment serves as a check only on the power of the federal government, not the state
(United States v. Cruikshank, 92 U.S. 542, 1876). McDonald v. City of Chicago later reversed
the over a hundred-year decision by ruling that the right to keep and bear arms is in fact
incorporated as against the States (McDonald v. Chicago, 561 U.S. 742, 2010). By setting this
precedent, the power of state governments-in addition to the federal government- to pass
legislation restricting firearms is markedly diminished.
Federal gun control reform legislation. To ensure national security and promote the
common welfare, Congress has enacted numerous laws governing the purchase, sale and use of
guns, the earliest of which is the National Firearms Act (NFA). This federal statute levies a tax
on the manufacture and transfer of firearms and mandates that all NFA firearms be registered
with the Secretary of the Treasury (National Firearms Act. 26 U.S.C. Chapter 53, 1934). The
second major piece of federal legislation governing gun use is the Gun Control Act of 1968,
which requires that all persons “engaged in the business” of buying, selling or transferring
firearms must hold a license (Gun Control Act. 18 U.S.C. Chapter 44, 1968). This includes
individuals who routinely engage in firearms transactions or rely on firearms commerce as a
primary source of income. Additionally, the act prohibits certain individuals from being able to

procure weapons, including the mentally ill and those who pose a danger to themselves and
others (Giffords Law Center, 2017). The Brady Handgun Violence Prevention Act of 1993
provided a means of enforcing this regulation by instituting the National Instant Criminal
Background Check (NICS), a national repository of information containing data on individuals’
convictions, mental health histories and civil orders (FBI, 2016). Because of this legislation, all
federally licensed dealers were required to conduct a background check at the point of purchase.
Although a step in the right direction, legal loopholes in the federal background check
limit the efficacy of these laws. First, unlicensed firearm dealers are not required to conduct
background checks. This allows individuals in prohibited categories to acquire access to
firearms. Second, in accordance with federal law, if the FBI does not finish conducting a
background check in three days, a federal licensed dealer may automatically proceed with the
transaction. This is known as the “default proceed rule” and poses a significant barrier to
preventing guns from falling into the wrong hands (Giffords Law Center, 2017). To close this
loophole, the FBI recommends extending the statute of limitations for the background check.
Another viable option would be to to conduct local and state-based background checks at the
point of purchase for all firearms dealers (Kalesan, 2016)
State and local provisions. Scientists and public health researchers are attempting to
answer the question of which types of legislation are most effective in preventing firearm
suicides and gun violence in general. However, due to the limited amount of funding available
for this research, many of these studies have severe limitations and possess less than optimal
study designs. Moreover, the paucity of research comparing the effect of different policies on
subsets of the population, as well as conflicting information on the efficacy of certain legislative
reform efforts, present a substantial challenge in terms of enacting legislation and issuing policy

recommendations. Nevertheless, four types of policies are presumably the most effective at
reducing firearm suicides: background checks, gun violence restraining orders, waiting periods
and safe storage.
Universal background checks. The consensus among researchers is that universal
background checks decrease firearm mortality (Anestis, 2013, Kalesan 2016; Santaella, 2016).
As mentioned, unlicensed dealers are not federally required to conduct a background check at the
point of purchase. Consequently, prohibited individuals can easily obtain guns from private
sellers and other unlicensed dealers. Several states have enacted universal background check
policies to prevent this from occurring including: California, Colorado, Connecticut, Delaware,
District of Columbia, Maryland, Nevada, New York, Oregon, Pennsylvania, Rhode Island and
Washington (Gifford Law Center). While the majority of these states are democratic, research
shows that most Republicans (at least 77%) support universal background checks (Pew Research
Center, 2017). Therefore, enactment of legislation at the state-level could prove effective among
said demographic.
Gun violence restraining orders (GVROs). Although only a small fraction of suicide
attempts involves the use of guns, firearm suicides account for over half of all suicides. This is
due to the fact that firearms are far more lethal than other implements used to induce self-harm,
including prescription pills. Whereas only a small percentage of suicides attempted through other
means result in death (1-2%), about 85% of individuals attempting suicide with a firearm die
(Miller, 2014). The GVRO is a court order authorizing the confiscation of guns from people
who could foreseeably hurt themselves and others, and prohibits said individuals from securing
replacements. This form of means restriction has been shown to be successful at decreasing
firearm suicides (Vernick, 2017, Lewiecki et al, 2013).

Waiting periods. The decision to commit suicide is seldom pre-meditated, often
stemming from an impulse or fleeting thought. According to surveys of people who have
attempted suicide, between 24 and 74% of attempters reach a decision to commit suicide in less
than 10 minutes (Miller, 2014; Hemenway, 2017). Curtailing the availability of firearms during
these key moments by extending wait periods has been shown to decrease firearm suicide rates
in states implementing this legislation (Anestis, 2015; Mann 2016; Rodríguez Andés and
Hempstead, 2011)).
Safe Storage. Given the transient nature of gun suicide, McCourt, 2017 advocate for the
temporary storage of firearms until it is determined that the person is no longer a danger to
themselves or others (McCourt, 2017). This storage option is the most likely to be effective,
since gun locks and personalized guns are unlikely to deter an adult once he/she has made up
their mind to commit suicide. Nevertheless, confiscation of guns from high-risk individuals must
be done in strict accordance with due process laws to be constitutional.
Indirect Factors Influencing Gun Violence
The Dickey Amendment. The National Rifle Association and other gun lobbies
pressured Congress into passing the Dickey Amendment, which prohibited the use of federal
funds to advocate for gun control. To avoid litigation and budget cuts, the CDC significantly
reduced the amount of grants for gun violence research (Hickey, 2013). By conceding more
power to the gun lobbies, the Dickey Amendment is another substantial barrier to comprehensive
gun control legislation
Citizens United v. Federal Election Commission. In 2010, Citizens United v. Federal
Election Commission (FEC) fundamentally altered the governance and structure of federal
election campaigns. The court ruled that corporations have a protected right under the First

Amendment to engage in political spending, as long as these entities do not directly contribute
money to financing campaigns. Based on this ruling, sanctioned spending included
advertisements and “independent expenditures “on behalf of a candidate (Citizens United v.
Federal Election Commission, 558 U.S. 310, 2010). This was a major victory for corporations
and the NRA lobby, which already had considerable clout. The NRA could now vilify and
malign political candidates who did not represent their interests or agree with their political
agenda, without fear of legal repercussions. Conversely, political candidates could expect
significant campaign contributions in the form of communication campaigns, rallies and
interviews with the press in exchange for heeding corporate interests-a quid pro quo. Citizens
United v. FEC severely hampers gun control reform by creating disincentives to pass legislation,
and therefore, should be overturned.
Recommendations
Physician counseling. The utility of health care-based interventions in the prevention of
firearm suicide is sorely understated. Rozko, 2016, and other studies have found that provider-
patient counseling could potentially limit firearm access among high-risk individuals (Rozko,
2016). The problem with this approach is that many providers lack the necessary training and/or
experience to screen candidates for mental illness. Therefore, an educational campaign targeted
toward providers and/or community health workers to promptly recognize the signs of suicide
and refer patients for treatment might be effective. Medical schools could also introduce changes
to the curriculum that emphasize mental health and the role of proper screening in the prevention
of suicide. Nonetheless, more studies are needed to determine the effect of such interventions.
Firearm training. Only a small percentage of firearms instructors (10-15%) inform their
trainees about firearm mortality and the risks associated with owning a firearm (Hemenway,

2017). If firearms instructors and dealers took a more proactive role in prevention of suicide
through the dissemination of information, some firearm deaths could potentially be averted.
Since most gun owners engage in some form of social activity, such as attending gun shows,
public service announcements would also help to increase awareness about the prevalence of
firearm suicide and raise cognizance of suicide prevention techniques. Given the contentious
nature of the gun control reform debate, the PSAs should be strictly informative, not persuasive.
Communication campaign to correct misinformation. The position of the NRA has
significantly evolved over the past few years. In the past, the NRA promoted and advocated for
the right to keep and bear arms safely and responsibly, supporting legislation that kept guns out
of the wrong hands. Today, however, the NRA is notorious for spreading misinformation, libel
and hateful rhetoric (Every Town Research, 2017). Many of the misconceptions that gun-owners
have regarding firearm mortality and suicide are propagated by the NRA. These include claims
that gun ownership is not associated with increased risk for gun suicide or that means restriction
through gun confiscation does not decrease overall suicide mortality. A recently conducted poll
found that two-thirds of gun owners believe that the NRA has lost touch with gun members and
that the organization no longer represents their interests. Therefore, discrediting the NRA’s
allegations should not have significant backlash among this population and will mitigate
opposition to certain gun control reform policies. Figure 8, located below, adapts the
interventions to fit an ecological framework, which is useful for multifaceted interventions.
Figure 8: Ecological Framework for Firearm Suicide Prevention at the Intrapersonal,
Interpersonal, Community and Societal Levels (Allchin, 2018).

Conclusion/Discussion
Based on the complex interaction of factors shaping gun culture and political discourse in
the United States, the best intervention to reduce firearm suicide among the target population
(individuals aged 65+) would employ the Social Ecological Model. The social ecological model
is a theory-based intervention that targets multiple environments and levels of human interaction
to address a public health issue of concern and has been recommended by Allchin, 2018, for
preventing gun violence. A comprehensive, multifaceted approach is required to permanently
address the myriad of barriers to gun control reform and lower gun suicides. The four levels of
the social ecological model are intrapersonal, interpersonal, community and societal based
interventions.
The societal level factors that influence firearm suicide in the U.S. are access to mental
healthcare services and federal law. To improve access to mental health services for individuals
with psychiatric disorders, the government needs to uphold and enforce the provisions of the
Affordable Care Act and provide subsidies to mental health clinics to help defray the costs of
treatment. If one of the main barriers to access is distance, Congress should use its power of the
Public Policy, Improved
Access to Mental
Healthcare
FFL partnerships, PSAs
at Gun Shows,
Community
Engagement
Provider counseling
Improved knowledge
Behavioral modification
Changed Perceptions

purse to build clinics in regions with limited facilities. In terms of legislation, Congress should
repeal the Dickey Amendment and allocate a higher percentage of its budget toward gun
violence research. It should then use this research to issue a formal recommendation for
improving firearm suicide and/or firearm mortality, irrespective of the NRA’s position or views.
The government of the United States is vested with protecting the interests of the people. For this
to be effective, corporations and organizations cannot be entitled to the same rights as ordinary
citizens. Overturning Citizen’s United v. Federal Election Commission would go a long way in
shifting the balance of power away from the corporations back toward the people of the United
States. Third, the government needs to enforce the First Amendments restrictions on free speech,
such as prohibiting speech that is directly misleading or incites violence.
At the community level, public health practitioners should partner with stakeholders such
as federally licensed firearm dealers, physicians and firearm training instructors to screen for
suicidal behaviors and disseminate accurate information on gun violence. One of the largest
barriers to effective gun control is the sheer amount of misinformation out there. Training and
educating key stakeholders about suicide prevention will reduce the stigma associated with
suicide, build social support networks for suicidal individuals through effective counseling and
prevent the loss of life by limiting access to lethal means. Public service announcements can
further increase awareness among the community by informing loved ones and friends about the
factors predisposing to firearm suicide. Lastly, public health organizations should work with the
media to refute and/or discredit inaccurate claims made by gun lobbies and special interest
groups.
Family and friends of suicidal individuals can play an important role in the prevention of
suicide by taking their loved ones to appointments, providing emotional support, encouraging

their loved one to seek help, and making providers and law enforcement officials aware of
suicidal behaviors. Often, family members are unaware that their family member is thinking
about suicide until it is too late to do anything about it. If they are informed about the risks, they
can watch over their loved one and dissuade them from committing suicide. Since one of the risk
factors for suicide is social isolation, feeling cherished and appreciated will reduce the person’s
likelihood of attempting suicide.
Lastly intrapersonal factors, such as erroneous beliefs, increased capability and substance
abuse, can significantly increase a person’s risk for suicide. Correcting erroneous beliefs has
already been addressed in the preceding paragraph. In the review of the literature, gun
ownership/gun availability was the predominant contributor to firearm suicide. Therefore,
limiting access to guns among the target population by closing background check loopholes
through federal and state legislation and implementing gun violence restraining orders is one of
the most important components of gun control interventions. The best approach for combating
alcoholism is to address the underlying depression and its causes and to increase social support.
Changing the political landscape regarding gun control will not be an easy endeavor. It
will require tact, culturally tailored messages and a certain degree of finesse. However, there is
cause for optimism. Recent polls show that most gun owners support legislation limiting access
to guns for people with psychiatric disorders (82%) and universal background checks (77%
among gun owners and 87% among non-gun owners (Pew Research Center). These numbers
demonstrate that most people agree on one issue: the right to bear arms is not without limits and
should be regulated to promote public good, much like cars and smoking. The best way to
promote firearm safety is through education, improved healthcare and avoiding common
stereotypes inevitably resulting in more polarization and divisiveness.

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