518Suicide and Life-Threatening Behavior 37(5) October 2007
2007 The American Association of Suicidology
Gun Safety Management with Patients
at Risk for Suicide
Robert I. Simon, MD
Guns in the home are associated with a five-fold increase in suicide. All
patients at risk for suicide must be asked if guns are available at home or easily
accessible elsewhere, or if they have intent to buy or purchase a gun. Gun safety
management requires a collaborative team approach including the clinician, pa-
tient, and designated person responsible for removing guns from the home. A
call-back to the clinician from the designated person is required confirming that
guns have been removed and secured according to plan. The principle of gun
safety management applies to outpatients, inpatients, and emergency patients, al-
though its implementation varies according to the clinical setting.
Guns in the home are associated with a five-
fold increase in suicide compared to homes
without guns (National Center for Health
Statistics, 2001). Regions with higher rates of
home gun ownership have higher rates of
suicide, controlling for other factors associ-
ated with suicide (Barber, 2005). In a study
by Wintemute, Parham, Beaumont, Wright,
and Drake (1999), the purchase of a handgun
was associated with a significant increase in
the risk of suicide by firearm and by any
other method. The increased risk of a firearm
suicide occurred within a week after purchase
of a handgun and remained at increased risk
for suicide by firearm for at least 6 years.
Within the first year of purchase, handguns
accounted for 24.5 percent of all suicide
deaths and 51.9 percent of deaths among
women 21 to 33 years of age (Wintemute et
al., 1999). In 2003, of the 32,439 suicides in
the United States, 16,750 were by firearms
(American Association of Suicidology, 2006).
Firearm suicide attempts end in death in ap-
proximately 85% of cases (Kellerman &
The method of storage and number of
guns influence suicide risk. A higher risk of
suicide is associated with handguns more
than long guns, with unlocked more than
locked guns, and with loaded more than un-
loaded guns (Brent, 2001). Total suicide rates
have a statistical association to household gun
prevalence (Markush & Bartolucci, 1984).
Persons with guns at home were more likely
to have died from a firearm suicide than by
suicide from a different method (Dahlberg,
Ideda, & Kresnow, 2004).
Most suicidal patients at moderate risk
for suicide are treated as outpatients (Simon,
2004). Carefully selected patients assessed at
high risk for suicide also may be treated as
outpatients, although most psychiatric pa-
tients at high risk for suicide are hospitalized.
Patients evaluated in the emergency depart-
ment often are at moderate to high risk for
suicide. Some of these patients have guns
stored at home or elsewhere (e.g., cars, work-
place, or with others). All patients at risk for
suicide must be asked about the availability
and accessibility of guns.
Robert Simon is Clinical Professor of Psy-
chiatry and Director of the Program in Psychiatry
and Law at Georgetown University School of
Medicine in Washington, DC.
Address correspondence to Robert I. Si-
mon, MD, 8008 Horseshoe Lane, Potomac, MD
20854-3831; E-mail: firstname.lastname@example.org
Impulsivity and guns are a lethal mix-
ture. In a study by Simon et al. (2001), sui-
cide attempters aged 15–34 were asked about
the time between the decision to complete
suicide and the attempt. Nearly 25% an-
swered less than 5 minutes. Suicide rehearsal
with a gun reinforces the belief that a firearm
suicide is quick and easy. The gun is placed
to the head or in the mouth and death is only
a trigger click away. It takes less time to reach
for a loaded gun than most other methods of
suicide (e.g., overdose, hanging, carbon mon-
oxide). Within a few minutes, the acute, time
limited impulse to commit suicide may pass.
Every psychiatric disorder except men-
tal retardation is associated with an increased
risk of suicide (Harris & Barraclough, 1997).
Should psychiatric patients be routinely
asked if they have guns at home? If the an-
swer is affirmative, should the patient be in-
formed of research finding an increased risk
of suicide when guns are in the home?
Should the clinician advise psychiatric pa-
tients, regardless of suicide risk, to have guns
removed from the home? Should only pa-
tients at current low risk for suicide, but with
a family history of suicide, receive such a rec-
ommendation? In answering the above ques-
tions, the decision to inform and intervene
can only be determined by clinical judgment
and discretion applied case by case. Asking
patients who are not at current risk for sui-
cide about guns in the home may unduly
alarm the patient and disrupt a fledgling
treatment. Patients at risk for suicide, how-
ever, require active implementation of a clini-
cal gun safety management plan.
Gun safety management is first and
foremost a treatment issue, but the clinician
must do more if the patient is at risk for sui-
cide (“Practice Guidelines,” 2003). Suicidal
patients must be asked if they have access to
guns. Some patients will volunteer that infor-
mation, while others will deny that there are
guns at home, even though guns are easily
accessible elsewhere. Thus, it is necessary to
ask the patient, “Do you have guns at home
or at any other place?” “Can you get one eas-
ily?” Additionally, the patient must be asked,
“Do you intend to obtain or purchase a
gun?” In the first week following the pur-
chase of a handgun, suicide by firearms
among purchasers was 57 times higher than
the adjusted rate for the general population
(Wintemute et al., 1999).
Patients who have a gun at home usu-
ally have more than one gun. Guns that are
described as locked up and safely stored may
still be accessible, for example, if the patient
has a duplicate key or is able to break into
the place where the guns are stored. The cli-
nician should not rely on “no suicide con-
tracts” given orally or in writing by the pa-
tient as part of gun safety management. No
PRINCIPLES OF GUN
Gun safety management of patients at
risk for suicide is a complex and difficult
challenge. While total prevention of suicide
by any method is an impossible task, prac-
titioners must be proficient in providing
competent clinical gun safety management
(see Table 1).
Principles of Gun Safety Management
with Patients at Risk for Suicide
• Inquire about guns at home or located outside
the home (e.g., car, office, other). Also inquire if
patient intends to obtain or purchase a gun.
• Designate a willing, responsible person to re-
move and safely secure guns and ammunition
outside the home, at a location unknown to the
• Have direct contact with or receive a phone call
from the designated person that guns and am-
munition are properly removed from the home
or from outside the home and safely secured ac-
cording to the pre-arranged gun safety manage-
ment plan. E-mail should not be used to com-
• Do not discharge inpatients or ED patients as-
sessed at low to moderate risk of suicide until
guns and ammunition are properly removed and
secured (outpatients case by case).
Gun Safety Management
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Manuscript Received: June 10, 2006
Revision Accepted: November 6, 2006