A Moving Target: Firearm Deaths, Mental Health, and the Role of Physicians

TL;DR

This narrative review summarizes U.S. firearm deaths, mental health impacts, and clinical/legislative interventions, emphasizing that firearm suicides continue to rise while homicides have slightly declined. It argues that mental illness is only a small factor in most mass shootings and that physicians across specialties should discuss firearm safety and safe storage.

Key findings

• In 2021, firearms were involved in 54.3% of suicides, and firearm suicides increased by 24% over the past twenty years; suicide was the 11th leading cause of death in the US and the 2nd among individuals aged 10–34.
• People with mental illness are up to 8 times more likely to die by suicide, but individuals without a mental illness diagnosis were on average 55% more likely to use a firearm for suicide than those with a mental health diagnosis; nearly 70% of those who died by violent suicide methods had never been treated for a mental health or substance use disorder.
• Active shooter incidents accounted for less than 1% of gun homicides in 2021; in 168 mass shootings by 172 perpetrators, psychotic symptoms played a minor role in 11%, moderate in 9%, and major in 11% of cases, and almost 70% of public mass shooters were suicidal before or during the event.
• ERPOs have been associated with reduced firearm suicides, with an estimated one life saved for every 10 to 20 firearm removals; child access prevention laws have robust evidence for reducing child and adolescent suicides and homicides, and firearm fatalities increased 34.9% from 2010 to 2020, accounting for 400,000 deaths and 1.2 million emergency room visits.

Methods

• Narrative review of recent findings on firearm suicides and homicides, their relationship with mental illness, relevant policies, and medical education’s role in firearm safety; no systematic review protocol or formal search strategy is described.
• Synthesizes published literature and data sources including CDC/NVDRS data, RAND’s Gun Policy in America meta-analysis, National Institute of Justice data, meta-analyses, surveys, and case series.
• Main analysis is qualitative synthesis; no primary data collection, systematic quality appraisal, or new meta-analysis is reported.

Limitations

• Stated in the paper: data on specific mental health diagnoses and suicide risk by method are limited; NVDRS mental health data are not categorized by suicide method; one cited alcohol study did not include alcohol use disorder diagnoses; and firearm prevention research lacks comprehensive data sources due to underfunding.
• Evident from the text: as a narrative review, it does not describe a systematic search, inclusion criteria, or formal risk-of-bias assessment, so conclusions depend on the selected cited sources.