U.S. Department of Veterans Affairs Public Access Author manuscript Mil Med. Author manuscript; available in PMC 2017 February 14. Published in final edited form as: Mil Med. 2016 October ; 181(10): 1207–1211. doi:10.7205/MILMED-D-15-00552.

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Firearm Ownership Among Military Veterans with PTSD: A Profile of Demographic and Psychosocial Correlates Adrienne J. Heinz1,2, Nicole L. Cohen1, Lori Holleran3, Jennifer A. Alvarez4, and Marcel O. Bonn-Miller1,2,5,6 1

National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, CA, USA

2

Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA 3

Palo Alto University, Palo Alto, CA, USA

4

VA Palo Alto Health Care System, Menlo Park, CA, USA

5

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Center of Excellence in Substance Abuse Treatment and Education, Philadelphia VA Medical Center, Philadelphia, PA, USA

6

Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA

Abstract

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Posttraumatic stress disorder (PTSD), a condition that disproportionately affects military veterans, is associated with heightened rates of aggression and suicide. Although experience with firearms is common among this population, virtually nothing is known regarding who is more likely to own a firearm and whether firearm ownership is differentially associated with psychological and behavioral risk factors among veterans with PTSD. Of 465 veterans (79% male) entering PTSD treatment, 28% owned a firearm (median number of firearms among owners = 3, range 1-40). Firearm owners reported higher income, were less likely to be unemployed, and were more likely to be male, Caucasian, married, and living in permanent housing. Ownership was associated with higher combat exposure and driving aggression, yet lower rates of childhood and military sexual trauma, suicidal ideation, and incarceration. Ownership was not associated with previous suicide attempt, arrest history, number of traumas experienced, PTSD symptoms, or depression. Together, among a sample of treatment-seeking military veterans with PTSD, those who owned a firearm appeared to demonstrate greater stability across a number of domains of functioning. Importantly though, routine firearm safety discussions (e.g., accessibility restrictions; violence risk assessments) and bolstering of anger management skills remain critical when working with this high-risk population.

Keywords Guns; Firearms; Veterans; PTSD; Trauma; Suicide

Corresponding Author: Adrienne J. Heinz, Ph.D., [email protected], Guarantor: Adrienne J. Heinz, PhD.

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Military veterans and individuals with Posttraumatic Stress Disorder (PTSD) are at increased risk for aggressive behavior and suicide, compared to civilians and those without PTSD1-4. Further, compared to other psychiatric populations, veterans with PTSD have been found to possess more firearms and to more frequently engage in potentially dangerous firearm-related behaviors5,6. This is concerning as, compared to civilians, veterans are more likely to complete suicide with a firearm2,7, and access to firearms is associated with higher risk of suicide above and beyond the effect of psychiatric illness8. Veterans with PTSD also demonstrate higher levels of anger, hostility, and aggression than those without PTSD9, which may render firearm possession particularly problematic among this population.

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Although firearm experience and ownership is common among treatment-seeking veterans10,11, very little is known regarding which individual factors are associated with firearm ownership (i.e., demographic characteristics), or whether there are differential associations between ownership and psychological and behavioral risk factors. Such information is critical to better inform screening practices, risk assessment, [suicide] meansrestriction counseling, and institutional policies among a population who may professionally and culturally identify with firearm ownership12. To date, the current study represents the first attempt to offer a comprehensive demographic and psychological profile associated with firearm ownership among veterans with PTSD.

METHODS Participants and Procedure Participants were 465 military veterans entering a residential PTSD treatment facility at a large VA Medical Center. Past month abstinence from alcohol and illicit substances was a requirement of treatment intake, during which time patients also completed the questionnaires described below. Measures

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Demographic Characteristics and Firearm Ownership—Patients completed a demographic questionnaire that assessed age, education, race/ethnicity, household income, employment, housing, marital status, children, military history (era of service, number of deployments), and firearm ownership (number of firearms owned). Trauma—Combat exposure, childhood trauma, number of traumas personally experienced, and PTSD symptom severity were assessed with the Combat Exposure Scale13 Childhood Trauma Questionnaire14, Life Events Checklist15, and the PTSD Checklist16, respectively. Patients also indicated whether they served in a war zone, as well as whether they endured sexual harassment and/or assault while in the military. Legal—Patients were asked whether they had ever been arrested and if so, the number of months they had spent in jail or prison. Depression, Suicide, Driving Aggression—In addition to completing the Beck Depression Inventory17, patients were asked whether they had ever attempted and/or experienced serious thoughts of committing suicide (i.e., suicidal ideation). Patients also Mil Med. Author manuscript; available in PMC 2017 February 14.

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rated the overall frequency of aggressive driving (which could include verbal outbursts/ gesturing, tail-gating/chasing/cutting-off drivers, driving intoxicated, intentionally hitting another object) on a 7-point rating scale (1 = never/rarely, 7 = very frequently).

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Pearson chi-square tests, with 2-sided tests of significance, and t-tests were conducted to determine whether demographic characteristics and behavioral and psychological risk factors differed as a function of firearm ownership. Spearman correlations were performed instead of t-tests in the event that continuous variables were not normally distributed and skewness and kurtosis could not be corrected with a transformation. See Tables 1 and 2.

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Twenty-eight percent of patients reported firearm ownership (median firearms among owners = 3, range 1-40). Firearm owners reported higher income, were less likely to be unemployed, and were more likely to be male, Caucasian, married, and living in permanent housing. Education, age, having children, era of service, and depression severity were not associated with ownership. Firearm owners had greater combat exposure, were more likely to serve in a war zone, and had a higher number of deployments. In terms of legal history, history of arrest did not differ as a function of firearm ownership, though time spent in jail or prison was inversely associated with ownership. Number of traumatic events experienced and PTSD symptom severity did not differ as a function of firearm ownership, though firearm owners had significantly lower levels of childhood trauma and were less likely to report sexual assault or harassment during their military service. Finally, history of a suicide attempt did not differ between groups, though firearm owners were less likely to have suicidal ideation than non-owners.

DISCUSSION

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Among a sample of treatment-seeking military veterans with PTSD, those who owned a firearm appeared to demonstrate greater stability across a number of domains of functioning. Rate of ownership (28%) in the current sample was similar to that reported in a large national sample (n = 4,000, one-third owned a firearm)18, though significantly lower than reported among outpatient veteran samples (n=208, 52.6% owned a firearm)11. Consistent with previous research, ownership was not associated with PTSD symptom severity11 and counter to anecdoctal evidence, firearm ownership was not associated with hypervigalience symptoms. In fact, firearm ownership was associated with significantly lower levels of childhood and military sexual trauma. The current findings may reflect the restrictive requirements for obtaining a license to own a firearm, whereby individuals in the sample who have been convicted of a felony or placed on a psychiatric hold may have had their right to own a firearm limited or revoked. Of note though, firearm ownership was not associated with having a previous suicide attempt (p = .054) or a history of arrest, but was associated with spending less time in jail/prison. Underreporting of firearm ownership among this subset of individuals is thus a possible limitation. The lower prevalence of suicidal ideation observed among firearm owners may reflect (1) increased clinician awareness of the risk that firearm ownership poses among veterans with

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PTSD, (2) a subsequent focus on firearm means-restrictions counseling (e.g., restricting access to firearms)19 for veterans at higher risk for suicide, or (3) protective factors associated with firearm ownership in the current sample (i.e., marriage, stable housing, employment). The greater frequency of aggressive driving observed among firearm owners warrants concern, and suggests that bolstering anger management skills to curtail anti-social behavior is an important treatment target. Given that firearm ownership was associated with greater combat exposure, veterans with PTSD and combat experience may benefit from additional clinical screening around firearm ownership and keeping practices.

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Adjunctive qualitative research efforts may help yield a better understanding of the role of firearm possession in the veteran subculture (e.g., protective purposes, recreational uses) and potential cultural, legal, and practical barriers to implementing firearm safety measures12. Although the current study offers an important first step with descriptive analyses, future studies should prospectively examine these demographic and psychological associations, with particular focus on the relations between firearm ownership and impulsivity, interpersonal aggression, and suicidal ideation. An emphasis on firearm ownership and suicide is especially important as the observed lifetime rate of suicidal ideation in the current sample was 5.9 times higher than the general population20. Identifying individual risk factors for suicide, means restriction counseling, and reducing stigma often associated with suicide ideation are known to be efficacious suicide prevention techniques for this high risk population (for further information on suicide prevention strategies see 21,22,23).

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The current study consisted of treatment seeking veterans and thus may not be representative of the larger population of veterans with PTSD. There is some evidence to suggest that veterans with PTSD within the VA health care system utilize more health services compared to those without PTSD24 and this is also observed in other civilian populations25. Less is known regarding whether there are differences in demographic and psychosocial characteristics among veterans with PTSD who elect to seek treatment versus those who do not (e.g.26). Additional research is needed to replicate and expand these findings in other clinical populations, including veterans from different geographical areas and those who are not currently treatment seeking. In addition, future research should extend to include firearm possession as well as keeping behaviors (i.e., storage and safety practices). In summary, institutional violence risk assessment training27, firearm accessibility restriction interventions (e.g., storage outside the home; separating ammunition from the firearm), and firearm safety discussions (e.g., use of gun locks) remain critical when working with this vulnerable, high-risk population.

Acknowledgements There are no acknowledgements. Funding Sources: This work was supported by a Rehabilitation Research and Development (RR&D) Career Development Award – 2 awarded to Dr. Heinz. The expressed views do not necessarily represent those of the Department of Veterans Affairs.

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21. Bryan CJ, Stone SL, Rudd MD. A practical, evidence-based approach for means-restriction counseling with suicidal patients. Prof Psychol: Res Pr. 2011; 42(5):339. 22. Bagley SC, Munjas B, Shekeile P. A systematic review of suicide prevention programs for military or veterans. Suicide Life Threat Behav. 2010; 40(3):257–265. [PubMed: 20560747] 23. Office of the Surgeon General (US). National Action Alliance for Suicide Prevention (US). 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action: A Report of the US Surgeon General and of the National Action Alliance for Suicide Prevention. US Department of Health & Human Services; Washington, DC: 2012. 24. Schnurr PP, Friedman MJ, Sengupta A, Jankowski MK, Holmes T. PTSD and utilization of medical treatment services among male Vietnam veterans. J Nerv Ment Dis. 2000; 188(8):496– 504. [PubMed: 10972568] 25. Elhai JD, North TC, Frueh BC. Health service use predictors among trauma survivors: a critical review. Psychol Serv. 2005; 2(1):3. 26. Elhai JD, Reeves AN, Frueh BC. Predictors of Mental Health and Medical Service Use in Veterans Presenting With Combat-Related Posttraumatic Stress Disorder. Psychol Serv. 2004; 1(2):111. 27. Elbogen EB, Fuller S, Johnson SC, Brooks S, Kinneer P, Calhoun PS, et al. Improving risk assessment of violence among military veterans: An evidence-based approach for clinical decision-making. Clin Psychol Review. 2010; 30(6):595–607.

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Table 1

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Demographic characteristics as a function of firearm ownership Total n

M(SD)

Owner M(SD) n = 131, (28%)

Non-Owner n = 334, (72%)

t/ρ

Age^

463

44.72(14.60)

46.86(15.43)

44.27(14.26)

.05

Years of Education

460

13.72(2.05)

13.74(1.95)

13.71(2.09)

−.12

Total

n (%)

Owner

Non-owner

χ2/ρ

Male

364 (79%)

112 (31%)

252 (69%)

5.87*

Female

98 (21%)

18 (18%)

80 (82%)

Married (R)

161 (35%)

63 (49%)

98 (30%)

14.75**

Divorced or Separated

181 (40%)

Never Married or Partnered

108 (24%)

Widowed

7 (1%) 329 (72%)

100 (77%)

229 (70%)

2.46

Caucasian (R)

255 (56%)

89 (69%)

166 (51%)

12.47**

Hispanic/Latino

87 (19%)

African American

57 (13%)

Asian or Pacific Islander

23 (5%)

American Indian

14 (3%)

51 (39%)

170 (52%)

5.92*

3.62(1.77)

3.11(1.82)

.13**

108 (84%)

234 (72%)

7.06**

64 (49%)

153 (46%)

.26

Gender

462

Marital Status

458

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Have Children

459

Race

456

Other

20 (4%)

Employment Status

458

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Unemployed (R)

221 (48%)

Employed

84 (18%)

Disabled

87 (19%)

Retired or Full-time Student

66 (15%)

Household Income^ (1-6)

449

50k (5-6)

127 (28%)

Housing Situation

455

Live in Apartment/House (R)

342 (75%)

Transitional housing

51 (11%)

Shelter or homeless

30 (7%)

Hospital, Jail or Prison

15 (3%)

Other

17 (4%)

Era of Service Iraq/Afganistan (R)

462 217 (47%)

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Total n

M(SD)

Owner M(SD) n = 131, (28%)

Non-Owner n = 334, (72%)

t/ρ

Age^

463

44.72(14.60)

46.86(15.43)

44.27(14.26)

.05

Years of Education

460

13.72(2.05)

13.74(1.95)

13.71(2.09)

−.12

Total

n (%)

Owner

Non-owner

χ2/ρ

Gulf war

72 (16%)

Vietnam war

145 (31%)

Peace-keeping or other

40 (7%)

*

p < .05.

** p < .01. ^

Spearman rho correlation (ρ) is provided because of non-normal distribution. R = reference group.

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p < .05.

*

Emotional neglect

Emotional abuse



438

Sexual abuse^

437

435

444

Physical neglect^



445

Physical abuse^

409

Childhood Trauma Questionnaire^

465

PTSD Checklist Total

465

373

Life Events Checklist

465

393

Beck Depression Inventory

Cluster D -- Hypervigilance

433

Combat Exposure Scale^

Cluster C – Avoidance/numbing

453

Aggressive Driving Frequency^

465

444

Number of Tours^

Cluster B -- Intrusions

449

Months in jail/prison^

Total n

458

459

Sexually Harassed in Military

Served in a War Zone

456

Ever arrested

462

444

Suicide Attempt

Sexually Assaulted in Military

463

Suicidal Ideation

Total n

.91, (5-25)

.87, (5-25)

.96, (5-25)

.72, (5-25)

.84, (5-25)

.94, (25-125)

.81, (5-25)

.81, (7-35)

.87, (5-25)

.91, (17-85)

.66, (1-17)

.90, (0-63)

.88, (0-44)

−, (1-7)

α, (possible range)

11.81(5.50)

11.29(5.86)

7.76(5.63)

8.42(3.66)

9.90(5.0)

48.89(20.46)

20.05(3.84)

27.30(5.33)

18.40(4.45)

65.75(11.81)

7.99(3.03)

31.68(11.13)

19.53(20.46)

3.04(2.09)

1.45(1.08)

4.64(16.36)

M(SD)

368 (80%)

101 (22%)

115 (25%)

265 (58%)

175 (39%)

289 (62%)

n (%)

10.94(4.70)

10.17(4.96)

6.83(4.67)

7.81(3.17)

9.17(4.54)

48.08(16.37)

20.05(3.64)

27.0(5.74)

17.94(4.13)

64.98(11.51)

8.41(3.02)

32.27(11.37)

22.60(11.83)

3.37(2.11)

1.55(.98)

1.34(6.85)

Owner

115 (89%)

20 (15%)

22 (17%)

65 (51%)

41 (32%)

72 (55%)

Owner n(%)

12.17(5.76)

11.74(6.14)

8.14(5.95)

8.66(3.82)

10.20(5.15)

50.46(21.76)

20.05(3.92)

27.42(5.16)

18.58(4.57)

66.05(11.92)

7.83(3.03)

31.45(11.05)

18.32(13.05)

2.90(2.07)

1.41(1.11)

5.93(18.66)

Non-Owner

253 (77%)

81 (24%)

93 (28%)

200 (61%)

134 (42%)

217 (65%)

Non-owner n(%)

Trauma history and psychosocial behavioral risk factors as a function of firearm ownership 2

2.30*

2.78**

−.10*

−.10*

−.08

−.09

.01

.77

1.41

.88

−1.68

−.66

.15**

.10*

.09*

−.17**

t/ρ

7.57**

4.44*

6.37*

3.93

3.79

4.33*

χ

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Table 2 Heinz et al. Page 9

Spearman rho (ρ) correlation is provided because of non-normal distribution. α = internal consistency

^

Levene’s test of equality of variances was significant and results reflect that equal variances are not assumed.

p < .01.

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**

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Mil Med. Author manuscript; available in PMC 2017 February 14.

Firearm Ownership Among Military Veterans With PTSD: A Profile of Demographic and Psychosocial Correlates.

Post-traumatic stress disorder (PTSD), a condition that disproportionately affects military veterans, is associated with heightened rates of aggressio...
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