Firearms are the most common means of suicide in the United States and a leading cause of death among people aged 10–64. Suicide is the second leading cause of death among people aged 10–44. Most people who die by suicide see a clinician in the year before, and approximately 45% in the month before, so health care visits are important chances for prevention. But people who die by firearm suicide differ from others: firearm suicide rates are highest among military service members, men, adults 65 and older and rural residents, and they are less likely to have a recorded mental health or substance use condition or a past suicide attempt. This study asked whether their use of health care differs too.
The study
Researchers linked 2020–2022 state death records with electronic health records from three nonprofit health systems serving more than one million people: the Colorado and Washington regions of Kaiser Permanente, integrated insurers and care providers with about 500,000 members each, and the Southcentral Foundation, which serves about 70,000 American Indian and Alaska Native people in southcentral Alaska. The study included patients aged 13 and older who had received care in the 3 years before death, and it tracked their visits over the final year — primary care, urgent care, emergency care, inpatient care and mental health specialty care, virtual or in person.
Who died
683 patients died by suicide: 373 (54.6%) by firearm and 310 (45.4%) by other means.
| Firearm | Other means | |
|---|---|---|
| Male | 87.9% | 62.6% |
| Mean age | 50 | 45 |
| Anxiety diagnosis in past year | 24.9% | 39.0% |
| Depression diagnosis | 25.5% | 35.8% |
| Substance use problem | 12.9% | 20.0% |
| Nonfatal self-harm or suicide attempt | 7.0% | 11.6% |
| Serious chronic mental illness | 7.2% | 11.6% |
| Charlson Comorbidity Index of 2 or more | 15.5% | 7.1% |
The comorbidity index measures other medical conditions associated with a higher risk of death; on it, firearm decedents scored higher.
Care in the final year
Most had at least one outpatient visit in the year before death — 86.0% of firearm and 91.6% of other decedents — and overall patterns of care, including primary care, emergency care and hospital stays, were similar. Mental health care was the exception. In the four quarters before death:
- 18.2% of firearm decedents received mental health specialty care, against 33.9% of others;
- 26.3% had a primary care visit with a mental health diagnosis, against 37.7%.
Any visit, mental health specialty visit, primary care visit, and primary care visit with a mental health diagnosis in the year before death, by means of suicide. CDC.
Across everyone who died, past-year use was highest for primary care (62.5%), then emergency care (38.4%), mental health specialty care (24.6%), inpatient care (18.2%) and urgent care (16.5%). Among those who did use care, mental health specialty patients had the most visits (7.3 for firearm versus 10.9 for other decedents, a difference not statistically significant), then primary care (4.0 versus 4.4); emergency visits were fewer among firearm decedents (1.9 versus 2.9). Women used primary and mental health specialty care more than men, and women who died by firearm tended to have fewer mental health specialty visits than other women who died by suicide.
Emergency department and inpatient care in the year before death, by means of suicide. CDC.
What it means
Many people who die by firearm suicide never reach mental health care, and fewer than a quarter of everyone who died by suicide (24.6%) received specialty mental health care. Prevention in health care therefore has to reach beyond mental health visits — especially into primary and emergency care. In another study, depression screening followed by suicide risk assessment and safety planning in primary care cut suicide attempts by 25% in the 90 days after visits, though evidence for longer-term effect is limited. Screening combined with safety planning appears helpful, but some people have suicidal thoughts only shortly before an attempt, so screening at a visit can miss them. More research is needed on identifying and engaging people at risk across care settings.
The findings are guiding prevention practice in the three systems studied and may help others. The limits: these systems' patients may not resemble those of other U.S. health systems, and the study period included 2020, when the COVID-19 pandemic disrupted health care use.
If you or someone you know is thinking about suicide, call or text 988 to reach the 988 Suicide & Crisis Lifeline in the United States.
Sources
Based on Angerhofer JE, Cruz M, Shaw J, et al., "Health Care Use Preceding Suicide by Firearm Compared with Suicide by Other Means — Alaska, Colorado, and Washington, 2020–2022," MMWR Vol. 74, No. 21, CDC; a work of the United States government in the public domain.
Licence: CC0 1.0 (public domain) · Adapted from www.cdc.gov
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