Two issues have surged in awareness across America in recent years: the toll of firearm injuries and deaths, and the impact of mental health conditions.
These two issues intersect in multiple ways – and a growing number of people are directly or indirectly affected by one or both of them.
That’s why it’s important for you to know some key things about the risk of firearm-related incidents involving people with mental health conditions, and take steps to reduce that risk, say three experts from Michigan Medicine, the University of Michigan’s academic medical center, and the Institute for Firearm Injury Prevention who have training and experience in both fields.
The group discusses these risks and risk-reduction steps in depth during a recent livestream.
Below are some key takeaways from that chat with Victor Hong, M.D., director of Psychiatric Emergency Services at U-M Health, child psychologist and firearm injury prevention researcher Cynthia Ewell Foster, Ph.D., and Mark Ilgen, Ph.D., director of U-M Addiction Treatment Services.
1. Suicide is the top concern when it comes to mental health and firearms – but not the only one
More than half of all firearm deaths in the United States are suicides, and firearms are involved in half of all suicide deaths.
Not all people who die by suicide have a formal mental health diagnosis, so it’s important for everyone to know the warning signs of suicide and what to do if someone they know is showing some or all of these signs.
There are some warning signs specific to children and teens too.
These signs include worsening or severe depression symptoms, expressing hopelessness or feelings of being a burden, extreme mood swings, an increase in use of drugs and alcohol, taking risks, seeming to be out of touch with reality, as well as speaking, writing or posting on social media about wanting to die, “unalive” themselves, or not live any longer.
2. Easy access to firearms increases risk
Being able to get access to a loaded handgun or long gun – their own or someone else’s – greatly increases the risk of suicide death for people experiencing a mental health crisis or suicidal thoughts and impulses.
Why?
“There’s a speed and irreversibility of firearm usage in a suicide attempt that is very unique,” said Hong, who leads a team that offers 24/7/365 care for psychiatric emergencies of all kinds.
“When somebody is in a mental health crisis and it’s clear that those imminent warning signs of suicide are there, firearms at the very least need to be secured in some fashion.”
Hong’s team members screen nearly every patient seeking emergency mental health care at U-M Health for firearm access.
If there are firearms in their home, those should be locked with a gun lock or in a gun safe, with ammunition stored elsewhere.
Many police stations, sheriff’s offices and other locations make gun locks available for free; the Project Childsafe website is one way to find local agencies that provide them.
Even better: temporarily remove firearms from all the places a person in crisis can access, and secure them in another location, whether that’s a gun shop, a law enforcement agency or the home of a trusted person who will keep them locked with ammunition stored separately.
Firearm owners should also keep their weapons secured if a child or teen might have access to them, to prevent needless tragedy including suicide and accidental or intentional shootings.
Michigan law now requires this.
“Everybody has a role to play in suicide prevention in this country, and one of the most important things we can all do is to be sure that we’re storing our firearms safely at all times and controlling who has access to them,” said Ewell Foster.
“If you look at kids in this country who have died by suicide, and you look at where they’re getting those firearms, they are getting them from people who love them. They’re getting them from their house, their parents, their grandparents, their aunts and uncles.”
Ilgen likens suicide risk to a graph with a curve that rises slowly or sharply to a peak – with the top of the curve being the moment where they are at highest risk of harming themselves.
“If someone enters that upward slope at a time where they have very easy access to something that’s very lethal, that’s when things get very concerning quickly,” he said.
“Even a step that isn’t foolproof but can slow access can buy someone a few minutes or hours before they might act on a suicidal thought. That can make all the difference in helping to keep someone safe and getting someone through that curve” and help them avoid death or injury.
3. Help is always available for a person in crisis
The 988 Suicide and Crisis Lifeline can be reached by dialing 988 from any phone, by texting 988 from any mobile phone, or using the webchat function at 988lifeline.org.
It offers live help around the clock, every day of the year and can connect the person in crisis, or a person assisting the person in crisis, to local services, too.
The 988 service includes specialized options for veterans, members of the LGBTQ+ community, people who speak Spanish and other languages, and people who are Deaf or hard of hearing.
No matter whether someone reaches out to 988 or to a trusted family member, friend, teacher, coach, clergy member or health care provider, it’s important for everyone to know that there are effective treatments available for mental health conditions of all kinds, and that there is hope.
4. Some groups of people have an elevated risk of firearm suicide
Middle-aged and older men account for most of the suicide deaths in Michigan and other states, and most of these deaths are due to firearms.
Native Americans, and Black youth, as well as young people living in rural areas, also have higher rates of firearm suicide than other groups, says Ewell Foster.
In order to reach some of those groups with messages about storing firearms safely and seeking help when they need it in a crisis, Ewell Foster and her colleagues have been working to understand which messengers will be most effective for different groups, and how to tailor messages to them.
Ilgen, who is also affiliated with the VA Ann Arbor Healthcare System, notes that veterans are also at higher risk of firearm suicide.
In fact, 70% of all veteran suicide deaths are firearm-related.
The VA has created multiple programs to try to prevent these tragedies among veterans who receive care from VA clinics and hospitals.
5. Drug and alcohol problems raise firearm injury and death risk
While many people may think of depression, bipolar disorder and post traumatic stress disorder as the mental health conditions most closely linked to a risk of firearm suicide, Ilgen notes that an increasing amount of evidence points to high risk among people who have substance use issues and use drugs or alcohol heavily.
“Substance use disorders are impairing – making your judgment a little cloudy – and they’re stigmatized, and that can make someone more likely to be suicidal,” he said.
“If they’re progressing rapidly from not thinking at all about suicide to engaging in a suicidal behavior, that that’s more likely to occur if they’re using substances and more risky if they have access to a particularly lethal means like a firearm.”
He also worries that one of the approaches used in some addiction treatment programs – having the patient’s loved ones tell them in a formal session what the patient’s addiction has done to harm those around them – may be counterproductive or even dangerous.
Doing this could increase the chance the patient feels like a burden to others, and turns toward suicide.
6. Risk factors for suicide and firearm violence toward others can be similar
When you hear about a violent event on the news that involves firearms used against other people, you might assume that the shooter has a mental illness.
But Hong notes that it’s important to know that people with serious mental illnesses are more likely to be victims of firearm violence than perpetrators.
That said, some of the same risk factors and warning signs that someone may be at high risk of turning a firearm on themselves also could signal a risk that they will use a firearm against someone else.
That’s why Hong and his psychiatric emergency team screen for those risk factors, as well as firearm access, when a patient comes to them in crisis.
Murder-suicides, in which a person kills a loved one immediately before killing themselves, often happen because someone has decided they don’t want to continue living and that they want to take loved ones or others with them, Hong says.
7. “Red Flag” laws can help reduce risk in extreme situations
What can someone do if they’re very concerned that a loved one, friend or co-worker who owns firearms could be at high risk of hurting themselves or others, but that person does not see the risk or want to secure their firearms voluntarily?
In a growing number of states, including Michigan, public safety and court officials can be asked to determine next steps under an Extreme Risk Protection Order law, also known as ERPO or “red flag” law.
Michigan’s ERPO law went into effect in February 2024.
The U-M Institute for Firearm Injury Prevention has a free online toolkit that explains the law and how individuals can use it to petition a judge to authorize law enforcement to remove firearms from a person’s possession in an orderly way.
It’s located at firearminjury.umich.edu/erpo-toolkit.
“This is an evidence-based policy intervention that can prevent a host of adverse outcomes with firearms,” saidEwell Foster, who has spent time with family members of those who have suffered a tragic loss of a loved one from a firearm injury that could have been prevented.
Prior to Michigan’s ERPO law, she said, “I’ve had moms of young adult males who have a high risk of suicide say, ‘I’m so worried, I’ve asked him to get rid of his firearm and I feel like there’s nothing I can do.’ When people are at risk their loved ones are worried about them and ERPO is another tool in our toolkit to try to support someone who’s at risk.”
She notes that U-M researcher April Zeoli, Ph.D., policy core director at the institute and associate professor in of the School of Public Health, is one of the nation’s top experts on studying what happens in states that enact ERPO laws, and helped inform the policy process that led to Michigan’s law.
“It’s really important for folks to know that there are legal checks and balances as part of this law, and that it’s not like someone is going to show up at a person’s house and take away their firearms,” immediately after someone files an ERPO petition, she explains.
Hong added, “This is not an effort to remove firearms from law-abiding citizens who are low-risk, minding their own business.
This is really for people for whom there are numerous red flags and risk factors of potential harm to self and others.”
He also notes that removal of firearms by law enforcement only takes place after a judge rules based on the evidence, and that the removal is temporary.
8. Everyone can make a difference
Ewell Foster likens this moment, when awareness of firearm injury and mental health are both rising, to a time decades ago when there was rising awareness and action around drunk driving.
“Our society has gotten comfortable saying to one another, ‘Hey, I think you’ve had too much to drink, I’m going to take your car keys and how about I run you home,’ and that’s a socially acceptable thing to do now in this country,” she said.
“I think we need to work on getting there around mental health and normalizing saying things like, ‘I really care about you, I’ve noticed these changes in you, I’m even wondering if you’re thinking about suicide. How can I help you?’”
“So much of what we’ve learned about how to protect people is about these caring behaviors, and actively working to be sure they feel like they have belonging and connectedness,” she said.
“I want people to feel empowered that they can reach out and ask, and they can make sure their firearms are stored safely.”
