Family Gun Culture May Play a Role in Teens’ Risk of Firearm Suicide

SAN FRANCISCO — Many teens who died by firearm suicide grew up in gun-owning families, according to a small psychological autopsy study.

Interviews with family members of nine teens who died by firearm suicide showed that 89% of decedents had prior family engagement with firearms or the family considered itself to be engaged in firearm culture, said Paul Nestadt, MD, co-director of the Johns Hopkins Anxiety Disorders Clinic in Baltimore.

In addition, 67% of youth used a family-owned firearm to complete their suicide.

“Interventions must acknowledge culturally embedded routes of identity formation while re-scripting firearms from expressions of family cohesion to instruments that may undermine that cohesion — and might cost the life of their child,” Nestadt said during a press conference at the American Psychiatric Association (APA) annual meeting.

Suicide death rates have been steadily climbing since 2000, Nestadt explained, and now account for the second most common cause of death among youth.

“It’s a big problem,” Nestadt said. “And when we’re talking about suicide, it’s hard not to talk about firearm suicide.”

“One of the reasons so many suicides are by firearm … is that firearm attempts are much more lethal,” he added.

According to CDC data, firearms are the most common method used in suicide; they were used in 55% of suicides in 2021. Of suicide attempts that involved a firearm, 90% resulted in fatality.

For reference, Nestadt said only about 8% of all suicide attempts result in death. “That’s why having a firearm is such an important risk factor for completed suicide,” he said. In addition, most firearm deaths in the U.S. are suicides.

Prior to their death, 78% of decedents in the study had received some form of mental health treatment, reported suicidal ideation, or had a suicide plan. About 44% had a prior suicide attempt.

Psychological interviews (average length 2.5 hrs) were conducted with 11 family members — mostly mothers — of nine decedents from Maryland. All but one decedent was male, nearly all were white, and the average age was 19.

Family Firearm Culture

Three distinct themes emerged from the qualitative interviews. The first was how prevalent firearm culture was among families of youth who died by firearm suicide.

“[He] used to love shooting with his dad. That was something that they did together. It was a big point of connection for them,” one person said during the interview.

Firearm culture tended to play an integral role in how these families identified themselves and part of family traditions, Nestadt explained.

Understanding Firearm Risks

The second theme that emerged — and the most clinically relevant, according to Nestadt — was the perspective on firearm risk. Many family members tended to be unaware of the potential danger that access to firearms had for youth at risk for suicide and few locked up household guns. Most families said they would have removed guns from the house if it had been suggested to them.

“If [the hospital] had recommended it, we would’ve agree to it and removed the gun from the house. But I wasn’t worried, though — it wasn’t even a thought,” said one family member.

As most decedents in the study were engaged in active mental health treatment, Nestadt pointed out that parents were doing everything that they thought they had to do — making psychiatrist appointments, keeping their kids in treatment — but often didn’t take into account how access to a gun in the household would play into suicide risk.

This underscores the importance of healthcare providers, particularly mental health providers, starting a conversation about gun safety with both patients and caregivers. “They just should do it,” Nestadt told MedPage Today when asked how healthcare providers should initiate this discussion.

“I know these are politically valent topics of the time, but as healthcare providers, we ask about their sex life, rashes, all kinds of sensitive things, religion,” he said. “It’s important that we’re able to really do that.”

“I will point out for any healthcare provider that it’s never illegal to ask about gun access. It’s medically relevant to saving the life of your patient,” Nestadt added.

“Pediatricians: remember, this is the second leading cause of death,” he said. “It’s important to screen for all these things that can hurt your kid, but the most likely thing that will result in your child patient dying will be suicide. The number one is accidental death.”

Risk Mitigation Strategies

This theme was closely entangled with the third theme that emerged from interviews, which involved risk mitigation strategies. While some parents said they would have considered filing an Extreme Risk Protective Order (available in Maryland) in hindsight, others placed little emphasis on removing their child’s access to guns, saying they simply would have found a different method.

But Nestadt emphasized that people who are thwarted or fail in their suicide attempt seldom go on to die by suicide thereafter. “[This is] why the method used is so important,” he said. “It’s the myth we [as clinicians] have to work really hard to combat.”

Calling this “truly a courageous study,” session moderator Howard Liu, MD, MBA, of the University of Nebraska Medical Center in Omaha, praised the research for bringing up such an “important, timely public health discussion.”

“Of course, we’re all facing this challenge of, how do we reduce suicide in all ages … and I think this is a really vital discussion and such an important clue about access, and just trying to reduce access in the moment of impulsivity and a moment of grief.”