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School shootings and mental health outcomes: a scoping review

Objective

Recent data indicate a rising frequency of school shootings over the past two decades. Although these events are relatively rare within the broader context of firearm violence, more than 357 000 students have been exposed to firearm violence in primary and secondary schools since 1999. However, the psychological impacts remain poorly understood. This scoping review synthesises existing evidence and highlights gaps for further research.

Methods

A systematic search was conducted across PubMed, PsycINFO, Web of Science and Criminal Justice Abstracts to identify empirical studies on school shootings and mental health outcomes. Inclusion criteria encompassed all publication dates, study designs and populations affected. Key attributes were extracted and analysed from included studies.

Results

Of 2798 studies identified, 84 met inclusion criteria, with 13% being qualitative. Despite covering 19 unique shootings, 40% of the articles focused on Virginia Tech and Northern Illinois University. Most studies were cross-sectional (42%), and students were the primary population studied (80%). Post-traumatic stress disorder (29%) and depression (11%) were the most commonly studied outcomes. Common predictors included age (13%) and trauma history (12%). Higher exposure levels to school shootings, prior trauma and existing mental health conditions were key predictors of adverse mental health outcomes. Social support from family or peers emerged as protective factors.

Conclusion

While findings of this review suggest that there is a substantial impact of school shootings on survivors’ mental health, additional research is needed to encompass impacted communities beyond students, integrate qualitative methods and incorporate longitudinal studies to track mental health outcomes over time.

Honor ideology and private firearm ownership in US active-duty soldiers

Objectives

This study investigated whether honor ideology, or a belief that one’s reputation must be defended at all costs, is related to firearms ownership in soldiers.

Methods

N=301 active-duty soldiers completed online self-report measures in this cross-sectional study.

Results

Honor ideology was higher in soldiers who privately own a firearm compared with those who do not currently own and do not plan to after military separation. Higher honor ideology was correlated with a disbelief that private firearms ownership is related to soldier suicide risk. Levels of honor ideology were equal in soldiers who own a private firearm for protection versus other reasons (eg, hunting, maintaining a collection).

Conclusions

Honor ideology may be related to suicide risk through increased likelihood of owning a private firearm and disbelief in private firearm ownership being related to one’s own suicide risk in soldiers. Honor ideology could be relevant to consider when means safety initiatives are developed for active-duty military personnel.

Population-level effects on crime of recovering firearms from armed prohibited persons: intention-to-treat analysis of a pragmatic cluster-randomised trial in California cities

Background

Too little is known about the effectiveness of efforts to prevent firearm violence. We evaluated California’s Armed and Prohibited Persons System (APPS), which identifies legal purchasers of firearms who have become prohibited persons and seeks to recover all firearms and ammunition to which they have access.

Design and methods

This cluster-randomised pragmatic trial was made possible by APPS’s expansion from a small pilot to a continuing statewide programme. We included 363 California cities, allocated to early (n=187) or later (n=176) intervention in blocks stratified by region within the state, and within region by population and violent crime rate. The study period began 1 February 2015; region-specific end dates ranged from 1 May 2015 to 1 February 2016. Analysis was on an intention-to-treat, difference-in-difference basis using generalised linear mixed models and generalised estimating equations with robust SEs. The population-level primary outcome measures were monthly city-level counts of firearm-related homicides, robberies and aggravated assaults. The primary model was adjusted for stratification variables; city-level population, population density, socioeconomic status and firearm purchasing; year; and month.

Findings

Allocation groups were well balanced on baseline characteristics and implementation measures. In adjusted models, allocation to early intervention was not associated with statistically significant differences in any primary outcome measure; these findings were robust to multiple sensitivity analyses. There was some heterogeneity across regions.

Conclusions

The APPS intervention directly affects a very small percentage of the population, limiting its potential for population-level effects. Individual-level analyses may provide a better estimate of the intervention’s effectiveness.

Trial registration number

NCT02318732.

Association between state minimum wage and firearm suicides in the USA, 2000-2020

Background

Firearm suicides constitute a major public health issue. Policies that enhance economic security and decrease community-level poverty may be effective strategies for reducing risk of firearm suicide. This study examined the association between state minimum wage and firearm suicide.

Methods

State minimum wage, obtained from Temple’s Law Atlas and augmented by legal research, was conceptualised using the modified Kaitz Index and a continuous variable centred on the federal minimum wage. State-level suicide counts were obtained from 2000 to 2020 multiple-cause-of-death mortality data from the National Vital Statistics System. Log-linear regressions were conducted to model the associations between state minimum wage and firearm suicides, stratifying by demographic groups. Analyses were conducted in 2023.

Results

A one percentage point increase in a state’s modified Kaitz Index was associated with a 0.3% (95% CI –0.6% to –0.0%) decrease in firearm suicides within a state. A US$1.00 increase in a state’s minimum wage above the federal minimum wage was associated with a 1.4% (95% CI –2.1% to –0.6%) decrease in firearm suicides. When stratified by quartile of firearm ownership, the modified Kaitz Index was associated with decreases in firearm suicides most consistently in the two lowest quartiles.

Conclusion

Increasing a state’s minimum wage may be a policy option to consider as part of a comprehensive approach to reducing firearm suicides. These findings expand the evidence base for how economic policies may be leveraged to reduce firearm suicides.

Examining the impacts of firearm purchaser licensing laws on firearm deaths among youth aged 15 to 24, by age group–USA, 1990-2019

Background

Youth aged 15–24 experience high rates of firearm homicide and suicide, yet there is limited research on the impact of promising preventative policies, such as firearm purchaser licensing (FPL) laws, among this age group. The purpose of this study was to evaluate the effect of adopting or repealing an FPL law on homicide and suicide among those aged 15–24, by age subgroup (ie, 15–17, 18–20, 21–24).

Methods

Mortality data from 1990 to 2019 were obtained from the National Center for Health Statistics. We used augmented synthetic controls to estimate the effect of FPL law adoption in Connecticut and Maryland and repeal in Missouri and Michigan on youth homicide and suicide rates. Analyses were stratified by age subgroup and firearm involvement.

Results

FPL adoption was associated with decreases in firearm homicide and suicide among those aged 15–24 overall and among most age subgroups in Connecticut. FPL repeal was consistently associated with increases in firearm suicide among each age subgroup, with less consistent results for firearm homicide.

Discussion and conclusions

FPL law changes had meaningful impacts on firearm homicide and suicide among youth aged 15–24, with consistent protective effects observed following adoption in Connecticut and consistent harmful effects following repeal in Missouri. Mixed results in Maryland and Michigan highlight the importance of policy features and sociopolitical context in shaping the effectiveness of these laws. These findings reinforce the effectiveness of FPL laws as a strategy to reduce firearm-related mortality among youth.

Injury and violence: undertaught and overdue in public health education

Injuries and violence remain leading causes of death for Americans, yet undergraduate public health education programmes continue to offer few courses in injury and violence epidemiology and prevention (IVEP). We assessed current IVEP course offerings at 146 US undergraduate public health programmes through catalogue searches and programme contacts. Among the 114 responding programmes, 46 (40%) confirmed at least one relevant course, though many were not offered regularly due to limited faculty expertise and/or low perceived student interest. Course content varied, with many focusing solely on violence. The limited offering of IVEP coursework contrasts with the substantial burden of injuries and violence. Strengthening IVEP education requires increasing student engagement, integrating relevant content across core curricula areas and expanding faculty capacity to teach relevant courses. Without such efforts, the public health workforce will remain insufficiently prepared to address injury and violence.

JAMA Summit Report on Reducing Firearm Violence and Harms—Reply

In Reply We appreciate the comments of Drs Beard and Healy on the report of the JAMA Summit on Reducing Firearm Violence and Harms. A significant focus of the Summit and report was on community interventions to reduce violence and firearm harms, and members of the Summit did include experts in hospital violence intervention programs as well as individuals who provide trauma care. The participants viewed hospital violence intervention programs as part of several other community violence interventions, which start at the bedside and extend out into the community for months after the injury. These programs do not focus on “stigmatizing measures of recidivism,” but rather look far beyond to address immediate needs and long-term impact on life trajectories.

Social isolation and firearm secure storage in the USA: results from the 2022 BRFSS

Background

Firearm secure storage (ie, storing firearms unloaded and locked) is recommended to reduce unintentional injuries and suicides. However, the relationship between psychological states, such as social isolation, and firearm secure storage practices is under-researched.

Methods

Data are from 7136 individuals with firearms in their households from the 2022 Behavioral Risk Factor Surveillance System. Multinomial logistic regression was used to explore the relationship between social isolation and firearm storage.

Results

Among respondents, 71.6% reported storing firearms unloaded, 14.2% stored firearms loaded and locked and 14.2% stored firearms loaded and unlocked. Most respondents reported feeling ‘never’ (40.7%) or ‘rarely’ (33.3%) socially isolated, with 18.7% reporting ‘sometimes’, 4.3% ‘usually’ and 3.0% ‘always’ feeling socially isolated. Covariate-adjusted multinomial logistic regression analysis revealed that respondents who felt ‘always’ socially isolated had an over threefold greater risk of storing firearms loaded and unlocked (relative risk ratio=3.733, 95% CI 1.443 to 9.662, p=0.007) compared with unloaded.

Conclusion

Results suggest a link between feelings of social isolation and unsecured firearm storage. Public health strategies should address both firearm safety education and the underlying issue of social isolation.

State assault weapons bans are associated with fewer fatalities: analysis of US county mass shooting incidents (2014-2022)

Background

The need for evidence to inform interventions to prevent mass shootings (MS) in the USA has never been greater.

Methods

Data were abstracted from the Gun Violence Archive, an independent online database of US gun violence incidents. Descriptive analyses consisted of individual-level epidemiology of victims, suspected shooters and weapons involved, trends and county-level choropleths of population-level incident and fatality rates. Counties with and without state-level assault weapons bans (AWB) were compared, and we conducted a multivariable negative binomial model controlling for county-level social fragmentation, median age and number of gun-related homicides for the association of state-level AWB with aggregate county MS fatalities.

Results

73.3% (95% CI 72.1 to 74.5) of victims and 97.2% (95% CI 96.3 to 98.3) of shooters were males. When compared with incidents involving weapons labelled ‘handguns’, those involving a weapon labelled AR-15 or AK-47 were six times more likely to be associated with case-fatality rates greater than the median (OR=6.1, 95% CI 2.3 to 15.8, p<0.00001). MS incidents were significantly more likely to occur on weekends and during summer months. US counties in states without AWB had consistently higher MS rates throughout the study period (p<0.0001), and the slope for increase over time was significantly lower in counties with AWB (beta=–0.11, p=0.01). In a multivariable negative binomial model, counties in states with AWB were associated with a 41% lower incidence of MS fatalities (OR=0.58, 95% CI 0.37 to 0.97, p=0.02).

Conclusions

Counties located in states with AWB were associated with fewer MS fatalities between 2014 and 2022.