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      Lethal means access and assessment among suicidal emergency department patients

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          Abstract

          Background

          Reducing access to lethal means (especially firearms) might prevent suicide, but counseling of at-risk individuals about this strategy may not be routine. Among emergency department (ED) patients with suicidal ideation or attempts (SI/SA), we sought to describe home firearm access and examine ED provider assessment of access to lethal means.

          Methods

          This secondary analysis used data from the Emergency Department Safety Assessment and Follow-up Evaluation, a 3-phase, 8-center study of adult ED patients with SI/SA (2010-2013). Research staff surveyed participants about suicide-related factors (including home firearms) and later reviewed the ED chart (including documented assessment of lethal means access).

          Results

          Among 1358 patients with SI/SA, 11% (95%CI 10-13%) reported ≥1 firearm at home; rates varied across sites (range: 6% to 26%) but not over time. On chart review, 50% (95%CI 47-52%) of patients had documentation of lethal means access assessment. Frequency of documented assessment increased over study phases (40% to 60%, p<0.001) but was not associated with state firearm ownership rates. Among the 337 (25%, 95%CI 23-27%) patients discharged to home, 55% (95%CI 49-60%) had no documentation of lethal means assessment; of these, 13% (95%CI 8-19; n=24) actually had ≥1 firearm at home. Among all those reporting ≥1 home firearm to study staff, only half (50%, 95%CI 42-59) had provider documentation of assessment of lethal means access.

          Conclusions

          Among these ED patients with SI/SA, many did not have documented assessment of home access to lethal means, including patients who were discharged home and had ≥1 firearm at home.

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          Most cited references29

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          Gun storage practices and risk of youth suicide and unintentional firearm injuries.

          David Grossman (2005)
          Household firearms are associated with an elevated risk of firearm death to occupants in the home. Many organizations and health authorities advocate locking firearms and ammunition to prevent access to guns by children and adolescents. The association of these firearm storage practices with the reduction of firearm injury risk is unclear. To measure the association of specific household firearm storage practices (locking guns, locking ammunition, keeping guns unloaded) and the risk of unintentional and self-inflicted firearm injuries. Case-control study of firearms in events identified by medical examiner and coroner offices from 37 counties in Washington, Oregon, and Missouri, and 5 trauma centers in Seattle, Spokane, and Tacoma, Wash, and Kansas City, Mo. CASES AND CONTROLS: Case firearms were identified by involvement in an incident in which a child or adolescent younger than 20 years gained access to a firearm and shot himself/herself intentionally or unintentionally or shot another individual unintentionally. Firearm assaults and homicides were excluded. We used records from hospitals and medical examiners to ascertain these incidents. Using random-digit dial telephone sampling, control firearms were identified by identification of eligible households with at least 1 firearm and children living or visiting in the home. Controls were frequency matched by age group and county. The key exposures of interest in this study were: (1) whether the subject firearm was stored in a locked location or with an extrinsic lock; (2) whether the firearm was stored unloaded; (3) whether the firearm was stored both unloaded in a locked location; (4) whether the ammunition for the firearm was stored separately; and (5) whether the ammunition was stored in a locked location. Data regarding the storage status of case and control guns were collected by interview with respondents from the households of case and control firearms. We interviewed 106 respondents with case firearms and 480 with control firearms. Of the shootings associated with the case firearms, 81 were suicide attempts (95% fatal) and 25 were unintentional injuries (52% fatal). After adjustment for potentially confounding variables, guns from case households were less likely to be stored unloaded than control guns (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.16-0.56). Similarly, case guns were less likely to be stored locked (OR, 0.27; 95% CI, 0.17-0.45), stored separately from ammunition (OR, 0.45; 95% CI, 0.34-0.93), or to have ammunition that was locked (OR, 0.39; 95% CI, 0.23-0.66) than were control guns. These findings were consistent for both handguns and long guns and were also similar for both suicide attempts and unintentional injuries. The 4 practices of keeping a gun locked, unloaded, storing ammunition locked, and in a separate location are each associated with a protective effect and suggest a feasible strategy to reduce these types of injuries in homes with children and teenagers where guns are stored.
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            Suicide in the home in relation to gun ownership.

            Arthur Kellermann, Frederick Rivara, Grant R. Somes … (1992)
            It has been suggested that limiting access to firearms could prevent many suicides, but this belief is controversial. To assess the strength of the association between the availability of firearms and suicide, we studied all suicides that took place in the homes of victims in Shelby County, Tennessee, and King County, Washington, over a 32-month period. For each suicide victim (case subject), we obtained data from police or the medical examiner and interviewed a proxy. Their answers were compared with those of control subjects from the same neighborhood, matched with the victim according to sex, race, and age range. Crude and adjusted odds ratios were calculated with matched-pairs methods. During the study period, 803 suicides occurred in the two counties, 565 of which (70 percent) took place in the home of the victim. Fifty-eight percent (326) of these suicides were committed with a firearm. After excluding 11 case subjects for various reasons, we were able to interview 80 percent (442) of the proxies for the case subjects. Matching controls were identified for 99 percent of these subjects, producing 438 matched pairs. Univariate analyses revealed that the case subjects were more likely than the controls to have lived alone, taken prescribed psychotropic medication, been arrested, abused drugs or alcohol, or not graduated from high school. After we controlled for these characteristics through conditional logistic regression, the presence of one or more guns in the home was found to be associated with an increased risk of suicide (adjusted odds ratio, 4.8; 95 percent confidence interval, 2.7 to 8.5). Ready availability of firearms is associated with an increased risk of suicide in the home. Owners of firearms should weigh their reasons for keeping a gun in the home against the possibility that it might someday be used in a suicide.
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              Household firearm ownership and rates of suicide across the 50 United States.

              Ethan Lippmann, David Hemenway, Deborah Azrael … (2007)
              The current investigation explores the association between rates of household firearm ownership and suicide across the 50 states. Prior ecologic research on the relationship between firearm prevalence and suicide has been criticized for using problematic proxy-based, rather than survey-based, estimates of firearm prevalence and for failing to control for potential psychological risk factors for suicide. We address these two criticisms by using recently available state-level survey-based estimates of household firearm ownership, serious mental illness, and alcohol/illicit substance use and dependence. Negative binomial regression was used to assess the relationship between household firearm ownership rates and rates of firearm, nonfirearm, and overall suicide for both sexes and for four age groups. Analyses controlled for rates of poverty, urbanization, unemployment, mental illness, and drug and alcohol dependence and abuse. US residents of all ages and both sexes are more likely to die from suicide when they live in areas where more households contain firearms. A positive and significant association exists between levels of household firearm ownership and rates of firearm and overall suicide; rates of nonfirearm suicide were not associated with levels of household firearm ownership. Household firearm ownership levels are strongly associated with higher rates of suicide, consistent with the hypothesis that the availability of lethal means increases the rate of completed suicide.
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                Author and article information

                Journal
                Journal ID (nlm-journal-id): 9708816
                Journal ID (pubmed-jr-id): 20612
                Journal ID (nlm-ta): Depress Anxiety
                Journal ID (iso-abbrev): Depress Anxiety
                Title: Depression and anxiety
                ISSN (Print): 1091-4269
                ISSN (Electronic): 1520-6394
                Publication date Nihms-submitted: 3 March 2016
                Publication date (Electronic): 17 March 2016
                Publication date (Print): June 2016
                Publication date PMC-release: 01 June 2017
                Volume: 33
                Issue: 6
                Pages: 502-511
                Affiliations
                [1 ]Department of Emergency Medicine, University of Colorado School of Medicine; Aurora, CO
                [2 ]Harvard Injury Control Research Center, Harvard School of Public Health, Boston, MA
                [3 ]Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO
                [4 ]Butler Hospital, Providence, RI
                [5 ]Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
                [6 ]Departments of Emergency Medicine, Psychiatry, and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
                Author notes
                Contact for correspondence: Marian E. Betz, MD, MPH (Corresponding author), Department of Emergency Medicine, University of Colorado School of Medicine, 12401 E. 17th Ave B-215; Aurora, CO 80045, marian.betz@ 123456ucdenver.edu ; Telephone: (720) 848-6770; Fax: (720) 848-7374
                Article
                Accession ID: PMC4800489 Pmcid ID: PMC4800489 Pmc-uid ID: 4800489 Manuscript ID: nihpa764496
                DOI: 10.1002/da.22486
                PMC ID: 4800489
                PubMed ID: 26989850
                SO-VID: 7ef9950c-0b00-4c8a-b798-68740f427c70
                History
                Categories
                Subject: Article

                Keywords: Epidemiology,Suicide/Self Harm,treatment,Assessment/Diagnosis,Clinical Trials,Depression
                Data availability:
                Keywords: Epidemiology, Suicide/Self Harm, treatment, Assessment/Diagnosis, Clinical Trials, Depression

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