Suicide is complex, with psychiatric, cultural, and socioeconomic roots. Though mental illnesses like depression contribute to risk for suicide, access to lethal means such as firearms is considered a key risk factor for suicide, and half of suicides in the USA are by firearm. When a person at risk of suicide has access to firearms, clinicians have a range of options for intervention. Depending on the patient, the situation, and the access to firearms, counseling on storage practices, temporary transfer of firearms, or further intervention may be appropriate. In the USA, ownership of and access to firearms are common and discussing added risk of access to firearms for those at risk of suicide is not universally practiced. Given the burden of suicide (particularly by firearm) in the USA, the prevalence of firearm access, and the lethality of suicide attempts with firearms, we present the existing evidence on the burden of firearm suicide and what clinicians can do to reduce their patients risk. Specifically, we review firearm ownership in the USA, firearm injury epidemiology, risk factors for firearm-related harm, and available interventions to reduce patients risk of firearm injury and death.

Importance

A total of 19 states and the District of Columbia now have extreme risk protection order (ERPO) or similar policies, and others are considering them; however, little research exists describing their use.

Objective

To characterize early use of California's ERPO policy by providing the first aggregate, statewide description of ERPOs, individuals subject to them, and petitioners.

Design, setting, and participants

This cross-sectional study analyzed 1076 respondents to ERPOs recorded in the California Department of Justice California Restraining and Protective Order System from 2016 to 2019. Descriptive analyses of orders issued between January 1, 2016, and December 31, 2019 in California were performed, and univariate Moran I was calculated to examine county-level spatial autocorrelation of the policy's use.

Main outcomes and measures

The primary study outcomes included the characteristics of ERPO respondents (demographic characteristics), petitioners (law enforcement vs family or household members), and orders (type and service) as well as temporal and spatial variation in policy use during the first 4 years of implementation.

Results

Of 1076 respondents during the study period, most were men (985 [91.5%]) and white individuals (637 [59.2%]), with a mean age of 41.8 years (range, 14 to 98 years). A law enforcement officer was the petitioner in 1038 cases (96.5%). The number of respondents increased during the study period from 70 in 2016 to 700 in 2019, and there was substantial county-level variation in ERPO use (ranging from 0 to 354 respondents), with significant spatial clustering in counts of ERPO respondents among neighboring counties (observed Moran I, 0.18, mean [SD] Moran I from reference distribution, -0.01 (0.05); z value, 3.58; P = .004).

Conclusions and relevance

This study, among the first to describe the early utilization of an ERPO or similar policy, found a substantial increase in the use of ERPOs in California from 2016 to 2019. These results could inform policy makers and other stakeholders involved in policy implementation and outreach in California and elsewhere. Similar studies in other states would be useful to understand variation.

Background

Research on violence exposure emphasizes discrete acute events such as direct and witnessed victimization. Little is known about the broad range of experiences of violence (EVs) in daily life. This study assesses the prevalence and patterns of distribution of 6 EVs in an adult general population.

Methods

California state-representative survey administered online (English and Spanish), July 14-27, 2020. Adult (age ≥ 18 years) California resident members of the Ipsos KnowledgePanel were eligible to participate. Two EVs concerned community environments: (1) the occurrence of gunshots and shootings in the neighborhood and (2) encounters with sidewalk memorials where violent deaths occurred. Four concerned social networks: direct personal knowledge of individuals who (1) had purposefully been shot by someone else or (2) had purposefully shot themselves, and direct personal knowledge of individuals whom respondents perceived to be at risk of violence, either (3) to another person or (4) to themselves. Main outcome measures, expressed as weighted percentages with 95% confidence intervals (CIs), were the prevalence and extent (or dose) of each EV and of EVs in combination and associations between EVs and respondents' sociodemographic characteristics and firearm ownership status.

Results

Of 2870 respondents (57% completion rate), 52.3% (95% CI 49.5-55.0%) were female; mean [SD] age was 47.9 [16.9] years. Nearly two-thirds (64.6%, 95% CI 61.9-67.3%) reported at least 1 EV; 11.4% (95% CI 9.7-13.2%) reported 3 or more. Gender was not associated with the prevalence of any experience. Non-owners of firearms who lived with owners reported more extensive EVs through social networks than did firearm owners or non-owners in households without firearms. Knowledge of people who had been shot by others was most common among Black respondents, 31.0% (95% CI 20.9-43.3%) of whom knew 2 or more such persons. Knowledge of people who had shot themselves was greatest among respondents aged ≥ 60 years, but knowledge of persons perceived to be at risk of violence to themselves was greatest among respondents aged 18-29 years.

Conclusions and relevance

Experiences of violence in daily life are widespread. They occur in sociodemographic patterns that differ from those for direct victimization and suggest new opportunities for research and intervention.

Background

Firearm injury and death are significant public health problems in the U.S. and physicians are uniquely situated to help prevent them. However, there is little formal training in medical education on identifying risk for firearm injury and discussing safe firearm practices with patients. This study assesses prior education, barriers to counseling, and needs for improved training on firearm safety counseling in medical education to inform the development of future education on clinical strategies for firearm injury prevention.

Method

A 2018 survey administered to 218 residents and fellows at a large, academic medical center asked about medical training on firearm injury prevention, frequency of asking patients about firearm access, and perceived barriers.

Results

The most common barriers cited were not knowing what to do with patients' answers about access to firearms (72.1%), not having enough time (66.2%), not feeling comfortable identifying patients at-risk for firearm injury (49.2%), and not knowing how to ask patients about firearm access (48.6%). Prior education on firearm injury prevention was more strongly associated with asking than was personal exposure to firearms: 51.5% of respondents who had prior medical education reported asking compared with who had not received such education (31.8%, p=0.004). More than 90% of respondents were interested in further education about interventions, what questions to ask, and legal mechanisms to separate dangerous people from their firearms.

Conclusions

Education on assessing risk for firearm-related harm and, when indicated, counseling on safe firearm practices may increase the likelihood clinicians practice this behavior, though additional barriers exist.

Background

Research has documented sharp and short-lived increases in firearm acquisitions immediately following high-profile mass shootings and specific elections, increasing exposure to firearms at the community level. We exploit cross-city variation in the estimated number of excess handgun acquisitions in California following the 2012 presidential election and the Sandy Hook school shooting 5 weeks later to assess whether the additional handguns were associated with increases in the rate of firearm-related harms at the city level.

Methods

We use a two-stage modeling approach. First, we estimate excess handguns as the difference between actual handgun acquisitions, as recorded in California's Dealer Record of Sales, and expected acquisitions, as predicted by a seasonal autoregressive integrated moving-average (SARIMA) time series model. We use Poisson regression models to estimate the effect of city-level excess handgun purchasing on city-level changes in rates of firearm mortality and injury.

Results

We estimate there were 36,142 excess handguns acquired in California in the 11 weeks following the election (95% prediction interval: 22,780 to 49,505); the Sandy Hook shooting occurred in week 6. We find city-level purchasing spikes were associated with higher rates of firearm injury in the 52 weeks post-election: a relative rate of 1.044 firearm injuries for each excess handgun per 1,000 people (95% CI: 1.000 to 1.089). This amounts to approximately 290 (95% CI: 0 to 616) additional firearm injuries (roughly a 4% increase) in California over the year. We do not detect statistically significant associations for shorter time windows or for firearm mortality.

Conclusion

This study provides evidence for an association between excess handgun acquisitions following high-profile events and firearm injury at the community level. This suggests that even marginal increases in handgun prevalence may be impactful.

Background

Following the 2018 mass shooting at Marjory Stoneman Douglas High School in Parkland, Florida, there was a dramatic increase in media coverage of extreme risk protection orders (ERPOs) and in state policy proposals for ERPO laws. This study documents the frequency of news coverage of ERPOs throughout 2018 and examines the narratives used by media outlets to describe this risk-based firearm policy.

Methods

Using a mixed-method descriptive design, we examine the frequency of national news media coverage of ERPO legislation in 2018, before and after the Parkland shooting, and analyze the content of news articles related to a sample of states that considered ERPO legislation after the shooting.

Results

We find a sharp increase in the frequency of articles related to ERPOs following the Parkland shooting and smaller increases in coverage surrounding ERPO policy proposals and other public mass shootings that year. Nearly three-quarters of articles in our content analysis mentioned the Parkland shooting. The news media often mentioned or quoted politicians compared to other stakeholders, infrequently specified uses for ERPOs (e.g., prevention of mass violence, suicide, or other violence), and rarely included evidence on effectiveness of such policies. More than one-quarter of articles mentioned a mass shooting perpetrator by name, and one-third of articles used the term "gun control."

Conclusions

This study describes the emerging public discourse, as informed by media messaging and framing, on ERPOs as states continue to debate and implement these risk-based firearm violence prevention policies.

Background

Though research has established that firearms in the home increase risk for injury and death, a substantial number of Americans, especially gun owners, believe that guns make their homes safer. More than half of gun owners in a nationally-representative survey said "it depends" when asked whether guns make their homes safer or more dangerous, but little is known about the factors that affect perceived safety.

Objective

To determine whether the relationship between the presence of firearms and perceived home or neighborhood safety is fixed or depends on additional factors and to identify the additional factors on which it depends.

Methods

A mixed-methods cross-sectional analysis of the 2018 state-representative California Safety and Wellbeing Survey (n = 2558, completion rate 49%), including calculation of weighted proportions and qualitative analysis of write-in responses.

Findings

One in six respondents (17.2%, 95% CI 14.9% to 19.7%) reported "it depends" when asked whether a gun in their home made the home a safer or more dangerous place to be ("the home scenario"). One in six (16.6%, 95% CI 14.3% to 19.2%) reported "it depends" when asked whether the neighborhood would be safer if all neighbors had guns in the home ("the neighborhood scenario"). For the home scenario, 28.3% (95% CI 21.9% to 35.7%) cited firearm owner characteristics (e.g., training and proficiency, temperament, and mental health), 28.4% (95% CI 22.3% to 35.5%) cited firearm storage and access, and 28.0% (95% CI 21.5% to 35.7%) cited intended use for guns as factors affecting perceived safety. For the neighborhood scenario, respondents overwhelmingly cited gun owner characteristics (72.1%, 95% CI 63.4% to 79.3%). Factors on which "it depends" varied by gun ownership status.

Conclusion

Perceived safety when firearms are in the home depends on numerous factors. Understanding these factors may inform tailored, targeted messaging and interventions for firearm injury prevention.

Background

Extreme risk protection order (ERPO) laws are a tool for firearm violence prevention (in effect in 19 states), often enacted in the wake of a public mass shooting when media coverage of gun violence tends to spike. We compared news media framing of ERPOs in states that passed and those that considered but did not pass such laws after the 2018 mass shooting in Parkland, Florida.

Methods

We conducted a content analysis of 244 newspaper articles about ERPOs, published in 2018, in three passing (FL, VT, RI) and three non-passing states (PA, OH, CO). Measures included language used, stakeholders mentioned, and scientific evidence cited. We use chi-square tests to compare the proportion of articles with each measure of interest in passing versus non-passing states.

Results

Compared to newspaper coverage of non-passing states, news articles about ERPOs in passing states more often used only official policy names for ERPOs (38% vs. 23%, p = .03), used less restrictive language such as "prevent" to describe the process of suspending firearm access (15% vs. 3%, p < .01), mentioned gun violence prevention advocacy groups (41% vs. 28%, p = .08), and referenced research on ERPOs (17% vs. 7%, p = .03). Articles about passing states also more often explicitly stated that a violent event was or could have been prevented by an ERPO (20% vs. 6%, p < .01).

Conclusions

Media messaging that frames gun violence as preventable, emphasizes identifiable markers of risk, and draws on data in conjunction with community wisdom may support ERPO policy passage. As more states consider ERPO legislation, especially given endorsement by the Biden-Harris administration, deeper knowledge about successful media framing of these life-saving policies can help shape public understandings and support.

Background

Uptake of gun violence restraining orders (GVROs), which temporarily prohibit the possession and purchase of firearms and ammunition from individuals at particularly high risk of harming themselves or others with a firearm, has been slow and heterogenous across California. Insights into the implementation process and perceived effectiveness of the law could guide implementation in California and the many states that have enacted or are considering enacting such a law.

Methods

We conducted 21 semi-structured interviews with 27 key informants, including judges, law enforcement officers, city and district attorneys, policy experts, and firearm violence researchers. Analysis of transcripts was guided by grounded theory and the Consolidated Framework for Implementation Research (CFIR).

Findings

The following constructs emerged within 4 CFIR domains as salient features of implementation: 1) implementation characteristics: risk of violence, cost, and adaptability; 2) outer setting: interagency coordination and local firearm ideology; 3) inner setting: readiness for implementation and law enforcement firearm culture; and 4) implementation process: planning and engaging with those involved in implementation. Key informants perceived the law to be effective, particularly for preventing firearm suicide, but agreed that more research was needed. While most indicated that the law resulted in positive outcomes, concerns about the potential for class- and race-based inequities were also raised.

Conclusions

Implementation of the GVRO law in California was hampered by a lack of funding to support local proactive implementation efforts. This resulted in ad hoc policies and procedures, leading to inconsistent practices and widespread confusion among those responsible for implementation. In states that have not begun implementation, we recommend dedicating funding for implementation and creating local procedures statewide prior to the law's rollout. In California, recommendations include providing training on the GVRO law-including an explication of agency-specific roles, responsibilities, and procedures-to officers, city attorneys, and civil court judges.

Urgent, individualized interventions to reduce firearm access, such as extreme risk protection orders (ERPOs, colloquially known as "red flag" orders), provide a rapid, focused response when risk for imminent firearm violence is high. Studies to date suggest such interventions are most commonly used to prevent suicide and are effective. Authorizing legislation has often been enacted after public mass shootings but, to our knowledge, there have been only 2 reported cases of ERPO use in efforts to prevent mass shootings. California enacted the nation's first ERPO statute, which took effect in January 2016. The authors are evaluating that statute's implementation and effectiveness and are seeking to obtain court records for all 414 cases occurring in 2016 to 2018. Based on 159 records received thus far, this article presents an aggregate summary and individual histories for a preliminary series of 21 cases in which ERPOs were used in efforts to prevent mass shootings. Most subjects were male and non-Hispanic white; the mean age was 35 years. Most subjects made explicit threats and owned firearms. Four cases arose primarily in relation to medical or mental health conditions, and such conditions were noted in 4 others. Fifty-two firearms were recovered. As of early August 2019, none of the threatened shootings had occurred, and no other homicides or suicides by persons subject to the orders were identified. It is impossible to know whether violence would have occurred had ERPOs not been issued, and the authors make no claim of a causal relationship. Nonetheless, the cases suggest that this urgent, individualized intervention can play a role in efforts to prevent mass shootings, in health care settings and elsewhere. Further evaluation would be helpful.