Winter 2024 - Vol. 19, No. 4 A 19-year-old male had no prior history of mental health problems. When he arrived at college, he had challenges structuring his time and managing relationships. After a semester of sporadic attendance, he received several failing grades and was unable to return. His parents remained supportive, but after an argument with his girlfriend, he died by suicide with firearm. He used a gun in the home that was stored in a “secret” yet unlocked location.

BACKGROUND
As health care providers, we know how devastating firearm deaths are for families and communities. While gun-related mortality has become more common, we will never become numb to it; instead, we grieve each loss acutely. Many of us remain frustrated and unsure how to prevent further deaths.

Over the last decade we have focused on improving mental health care and reducing stigma. The advent of telehealth and online counseling has made therapy more accessible, and many school systems now have anti-bullying policies, mental health support, and parent education. Evidence suggests these initiatives are making a difference. One recent study showed that fewer adults worry about retaliation in the workplace if they take time off to seek mental health care, and the percentage of kids who report being bullied at school is decreasing.^1,2 But there is more to do to prevent deaths due to firearm.

Preventing death by firearm should be understood as a public health opportunity much like other measures to prevent motor vehicle accidents and prevent lead poisoning. Health care providers can make a difference by asking their patients about firearms, offering information on safe storage, and educating about the link between firearms in the house and suicide. With proper training and a prevention approach, this important topic can be addressed comfortably.

EVIDENCE REVIEW
Firearms have become a leading killer of people ages 18 to 24 years in the United States³; Lancaster County is no exception. In 2023 there were 37 suicides by firearm in Lancaster County. Most firearm deaths each year are suicides, and firearms are the most common method used for suicide.³

Reports reveal that 82% of firearm suicides in the United States were completed using a family member’s gun.⁴ What’s more, easy access to weapons is a threat to the community because 77% of school shooters in the United States also use a family member’s gun.⁵ Gun sales have steadily increased since 2010, and it is estimated that 4.6 million children in the United States live in a home with a loaded, unlocked, firearm.⁶ Thus, safe storage and/or removal of firearms may help prevent these tragedies.

Limiting access to lethal means, like firearms, can play a significant role in decreasing the risk of suicide. Having a gun in the home, having a gun loaded, and having a gun unlocked are all associated with increased risk for firearm suicide.⁷ The Children’s Hospital of Philadelphia reports that in homes where there is an unlocked firearm, there is 4-10 times higher risk of suicide.⁸

With a firearm, once the trigger is pulled, there’s no turning back; suicide by firearm has a 90% completion rate, making it the quickest and most lethal method of suicide. Easy access to a loaded gun takes away the chance for second thoughts and seeking help, whereas other methods of self-harm often require planning and time, during which many will seek help and thus avoid harm.^9,10

Evidence suggests that information about safety from trusted health care providers is effective to spark change and compliance. A 2008 study found that brief counseling on safe firearm storage with the distribution of a cable gun lock during routine well-child evaluations yielded a substantial increase in safe storage behavior.¹¹ A 2016 meta-analysis found that distributing a free locking device was a critical ingredient for compliance.¹²

PROTOCOL
The Lancaster County Child Death Review Committee reviewed data noting that local trends follow national trends (see Figs. 1 and 2).
 

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Fig. 1. Firearm suicide vs. total suicides (all ages) in Lancaster County. Data sourced from the Pennsylvania Department of Health Bureau of Family Health and the Lancaster County Child Death Review.
 

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Fig. 2. Number of firearm suicide deaths per age group in Lancaster County (2015-2023). Data sourced from the Pennsylvania Department of Health Bureau of Family Health and the Lancaster County Child Death Review.
 

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Because there were few measures in place to promote firearm safety, members of the committee began searching for prevention opportunities. This led to the formation of alliances with community partners and a search for program funding.

In January 2024, Penn Medicine Lancaster General Hospital was awarded a grant from the Pennsylvania Department of Health’s Bureau of Health Promotion and Risk Reduction to fund the distribution of no-cost gun locks and biometric safes, firearm safety classes, and provider support/education in Lancaster County. See Figs. 3 and 4 for information and images of these safe storage options.
 

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Fig. 3. Page 1 of firearm safety brochure to be distributed with cable locks and biometric gun safes.
 

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Fig. 4. Page 2 of firearm safety brochure to be distributed with cable locks and biometric gun safes.
 

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The initiative included methods to push out firearm safety messages to the public in general, as well as to specific audiences such as parents and gun owners. The grant is for two years with the option to extend, and the team is being mindful about ways to make these initiatives permanent.

To strengthen the impact, we partnered with two vital organizations:

1. Mental Health America is a national organization with a local chapter whose mission is to promote mental health, as well as prevent and treat mental illness. The goal of this partnership focuses on preventing suicides by firearm through family and provider education and support.
2. The Sheriff’s Association of Lancaster County will provide the grant partners with firearm education expertise; specifically, members will act as firearm instructors to teach safety classes. The Lancaster County Sheriff’s Office, in addition to other participating police departments, will serve as a public resource to promote the use of gun locks.

These partnerships make this grant unique among firearm safety initiatives by bringing together primary care providers, mental health providers, and law enforcement as educators to prevent firearm deaths. The grant will fund several initiatives designed to reach specific populations.

Health care providers who work in primary care, behavioral health, the emergency department, and trauma surgery will be offered education regarding firearm deaths and safety. This may include talking points about guns to debunk frequently disseminated misinformation and will provide guidance about how to remain politically neutral when discussing firearm ownership and safety. In addition, providers will be given gun locks, along with educational materials regarding proper firearm storage and death prevention, which they can in turn distribute to patients.

Marketing campaigns will be funded across Lancaster County to reach the general population. This may include putting up billboards, setting up media events, and distributing coasters and posters to be placed in bars and pubs. These aspects of the initiative will keep the focus on firearm safety and suicide prevention.

Law enforcement in precincts throughout Lancaster County will be offered mental health first-aid classes, during which they will be provided talking points about firearm safety and suicide prevention. Alongside any gun lock or safe distributed by law enforcement, mental health resources and information on suicide prevention will be distributed.

METRICS
For the duration of the grant period — July 1, 2024, through June 30, 2026 — success will be measured using several metrics:

• Number of health care providers exposed to firearm safety education.
• Number of gun locks and gun safes distributed.
• Number of attendees in firearm safety classes taught by law enforcement.

CONCLUSION
The first safe firearm storage class was conducted in October 2024 with more than 40 attendees from various zip codes in the county. In addition to a biometric gun safe, each attendee was offered the brochure shown in Figs. 3 and 4 and additional materials detailing signs of mental health crisis and available mental health resources.

We are hopeful that this initiative, augmenting existing resources and implementing interventions tailored to specific Lancaster County needs, will yield fewer deaths by firearm and save lives here in Lancaster County. If your practice would like to participate by having firearm safety materials and gun locks to distribute, please email the authors.
 

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RESOURCES / LINKS
Click on the blue links to access the resources.

Lancaster County Safe Firearm Storage Initiative

Gun Violence: Safe Storage — NAMI

Firearm Access Is a Risk Factor for Suicide — Harvard University

Personal Firearms: Programs that Promote Safe Storage and Research on Their Effectiveness

When This Hospital Gave Gun Locks to Families in Crisis, More People Secured Their Firearms — Cincinnati Children’s Research Horizons

Stigma, Prejudice, and Discrimination Against People with Mental Illness — American Psychiatric Association
 

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REFERENCES
1. New Polling Data Shows Most Employers Offer Some Form of Mental Health Benefits, But Burnout Impacts Over 40% of Employees. American Psychiatric Association. May 22, 2024. Accessed November 22, 2024. https://www.psychiatry.org/news-room/news-releases/new-polling-data-on-workplace-mental-health
2. Fast Facts: Bullying. Institute of Education Sciences, National Center for Education Statistics. Accessed November 22, 2024. https://nces.ed.gov/fastfacts/display.asp?id=719
3. Gun Violence in the United States 2022: Examining the Burden Among Children & Teens. Johns Hopkins Bloomberg School of Public Health Center for Gun Violence Solutions. September 2024. Accessed November 22, 2024. https://publichealth.jhu.edu/sites/default/files/2024-09/2022-cgvs-gun-violence-in-the-united-states.pdf
4. Knopov A, Sherman RJ, Raifman JR, Larson E, Siegel MB. Household gun ownership and youth suicide rates at the state level, 2005-2015. Am J Prev Med. 2019;56(3):335-342.
5. Protecting America’s Schools: A U.S. Secret Service Analysis of Targeted School Violence. United States Secret Service. 2019. Accessed November 22, 2024. https://www.secretservice.gov/sites/default/files/2020-04/Protecting_Americas_Schools.pdf
6. Schaechter J. Guns in the home: how to keep kids safe. HealthyChildren.org. Updated June 24, 2024. Accessed November 22, 2024. https://www.healthychildren.org/English/safety-prevention/at-home/Pages/Handguns-in-the-Home.aspx
7. Shenassa ED, Rogers ML, Spalding KL, Roberts MB. Safer storage of firearms at home and risk of suicide: a study of protective factors in a nationally representative sample. J Epidemiol Community Health. 2004; 58(10):841-848.
8. Gun Safety and Your Adolescent. Children’s Hospital of Philadelphia. May 10, 2021. Accessed November 22, 2024. https://www.chop.edu/news/health-tip/gun-safety-and-your-adolescent
9. Pallin R, Barnhorst A. Clinical strategies for reducing firearm suicide. Inj Epidemiol. 2021;8(1):57.
10. Bennewith O, Hawton K, Simkin S, et al. The usefulness of coroners’ data on suicides for providing information relevant to prevention. Suicide Life Threat Behav. 2005;35(6):607-614.
11. Barkin SL, Finch SA, Ip EH, et al. Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial. Pediatrics. 2008;122(1):e15-e25.
12. Rowhani-Rahbar A, Simonetti JA, Rivara FP. Effectiveness of interventions to promote safe firearm storage. Epidemiol Rev. 2016;38(1):111-124.