Lethal means safety counseling


Key points
  • Suicide attempts using firearms are much more likely to result in death than attempts using other methods, with a lethality rate of approximately 90%.
  • Firearms are the weapon used in more than two-thirds of all homicides in the United States and have a lethality rate of approximately 85%
  • In 2020, 53% of all U.S. suicide deaths involved firearms, while 27% involved hanging or suffocation, 12% involved overdose or poisoning, and 8% involved other means.
  • Nearly 7 out of every 10 veteran deaths by suicide are the result of firearm injuries.
  • Over 80% of youth firearm suicides involved a gun belonging to a family member.

This evidence further supports the importance of Lethal Means Safety Counseling (LMSC), which aims to reduce access to lethal means during times of crisis and prevent suicide and other forms of violence.



Lethal Means Safety (LMS) refers to reducing access to potentially fatal items to lower a person’s risk of suicide, homicide, and unintentional injury or death. LMS Counseling (LMSC) is a patient-centered, clinical counseling strategy that seeks to reduce lethal means of access for at-risk individuals. 

LMSC involves conversations around secure storage behaviors that align evidence-based recommendations with individuals’ preferences and values. This practice aims to prevent injury and death by increasing the time and space required to access a lethal method. LMSC has strong, preventive outcomes in a wide-ranging set of factors, especially self-inflicted firearm death.2 However, it remains underused in clinical practice. 

Risk factors for those with an elevated risk of firearm injury or death include: 

  • Youth: Children and adolescents are at a higher risk of unintentional firearm injury due to their natural curiosity and lack of firearm experience, and adolescents are at risk of suicide. Additionally, firearm injury is a leading cause of death among youth in the United States.
  • Suicidality: Individuals with suicidal thoughts or behaviors – whether from an underlying mental health condition, life circumstances, or both – are at increased risk of death by suicide.
  • Domestic violence: Domestic violence victims are at a higher risk of homicide death when a firearm is present, regardless of whether that firearm belongs to the victim or the abuser. 
  • Cognitive impairment: Individuals with impaired thinking or memory are at increased risk of suicide and accidental harm toward others. Cognitive impairment can be long-term (e.g., from dementia or traumatic brain injury) or short-term (e.g., from intoxication with alcohol or drugs).

Is lethal means safety counseling effective?

In a 2016 review of seven studies conducted in clinics and communities, researchers looked at using LMSC to promote secure firearm storage. Some studies also provided a safety device, such as a gun lock, to help with secure storage.3 The studies that provided both a safety device and counseling showed significant improvement in secure storage practices.3 It is important to note that locked firearm storage is associated with a lower risk of firearm injury, but it has not been directly linked to injury outcomes. More studies are needed to determine if interventions like LMSC prevent firearm injuries.


LMSC in a clinical setting

Firearm access is an important risk factor for suicide, homicide, and unintentional firearm injury. Certain storage practices, such as storing firearms that are unlocked or loaded with ammunition, are associated with increased injury risk.9 Using LMSC in clinical practice can reduce the risk of firearm injury and death. Importantly, LMSC often focuses on temporary changes in firearm access or storage until the person has received treatment or the crisis has ended.

Specialized training for providers, protocols, and resources may help increase the adoption of LMSC in clinical care. By addressing the gaps identified and fostering a culture of open dialogue and proactive intervention, Colorado can take significant steps toward reducing suicide rates and promoting mental well-being in the community. Counseling on Access to Lethal Means (CALM) is a free, self-paced, online course for health care and social services providers from the American Academy of Pediatrics that covers how to address reducing access to firearms and other lethal methods in situations of suicide risk.

The BulletPoints Project also offers guidelines for clinical providers on how to counsel patients about firearm safety in various situations. The BulletPoints Project developed the 3A's Framework (Approach, Assess, Act) to guide clinicians in discussing firearm injury prevention with patients.

The guidelines include recommendations such as addressing firearm ownership in the context of overall health, conducting a risk assessment, and discussing secure firearm storage practices. Other recommendations include addressing the risks of unintentional and intentional firearm injuries and deaths, exploring the patient's attitudes and beliefs about firearm ownership, and providing resources to help patients make informed decisions. 

The guidelines emphasize the importance of cultural competence and sensitivity when discussing firearm safety with patients, recognizing that cultural values and beliefs may impact a patient's attitudes toward firearm ownership and storage. Additionally, the project offers resources to help clinicians communicate effectively with patients and families about firearm safety, including sample scripts and other educational materials. 

Other organizations have also created learning materials, toolkits, and other resources on how to implement LMSC in clinical settings. For more information, see “Resources for Clinicians.”


In Colorado 
  • LMSC plays an important role in firearm injury prevention in Colorado. A recent study examined the attitudes and behaviors of emergency department (ED) and behavioral health (BH) providers regarding the screening and counseling of patients with suicide risk in Colorado. The study found that there were notable gaps in the delivery of lethal means safety counseling in the ED. Only 35% of ED providers felt confident in their ability to counsel patients about lethal means safety, while a much higher portion of BH providers (81%) expressed confidence in this area. 
  • In addition to efforts within clinical settings, the Colorado Office of Suicide Prevention has also implemented the Colorado Gun Shop Project—an initiative that involves collaboration between firearm retailers, range owners, and firearm safety course instructors to reduce firearm suicide attempts and deaths. 
  • The Gun Shop Project works in collaboration with firearm owners and the firearm owning community to promote LMS and general suicide prevention awareness, including identifying signs of suicidal behavior. Through this partnership, gun shop retailers, range owners, and firearm safety course instructors receive training and resources to recognize warning signs of suicide and respond appropriately. By actively participating in suicide prevention efforts, these stakeholders play a crucial role in sharing suicide prevention resources with community members, safeguarding individuals in crisis, and preventing access to firearms during vulnerable moments.

Learn more about lethal means safety:


  1. Khazanov GK, Keddem S, Hoskins K, et al. Stakeholder perceptions of lethal means safety counseling: A qualitative systematic review. Front Psychiatry. Published October 20, 2022. doi:10.3389/fpsyt.2022.993415.
  2. Kellermann AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun ownership. N Engl J Med. Published August 13, 1992. doi:10.1056/NEJM19920813327070.
  3. Diurba S, Johnson RL, Siry BJ, et al. Lethal Means Assessment and Counseling in the Emergency Department: Differences by Provider Type and Personal Home Firearms. Suicide Life Threat Behav. Published October 2020. doi:10.1111/sltb.12649.
  4. Suicide. National Institute of Mental Health (NIMH).
  5. Conner A, Azrael D, Miller M. Suicide Case-Fatality Rates in the United States, 2007 to 2014: A Nationwide Population-Based Study. Ann Intern Med. Published December 17, 2019. doi:10.7326/M19-1324.
  6. Braga AA, Griffiths E, Sheppard K, et al. Firearm Instrumentality: Do Guns Make Violent Situations More Lethal? Annu Rev Criminal. Published January 2021. 4(1), 147–164. doi:10.1146/annurev-criminol-061020-021528.
  7. Kegler SR, Simon TR, Zwald ML, et al. Vital Signs: Changes in Firearm Homicide and Suicide Rates - United States, 2019-2020. MMWR Morb Mortal Wkly Rep. 2022;71(19):656-663. Published 2022 May 13. doi:10.15585/mmwr.mm7119e1Lethal
  8. Means Safety & Suicide Prevention. Veterans Health Administration, REACH: Keep it Secure. Updated November 1, 2022. Accessed March 10, 2023.   
  9. Gun Safety and Injury Prevention. American Academy of Pediatrics. Updated July 27, 2022. Accessed March 9, 2023.
  10. Lee LK, Fleegler MK, Doh KF, et al. Firearm-Related Injuries and Deaths in Children and Youth. Pediatrics. Published December 2022. doi:10.1542/peds.2022-060071.
  11. Simonetti JA, Azrael D, Zhang W, Miller M. Perspectives on clinician-delivered firearm safety counseling during routine care: Results of a national survey. Prev Med. Published May 2022. doi:10.1016/j.ypmed.2022.107039.