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The problem of the suicidal patient in Primary Care
A moral imperative
How to identify suicidal patients
What to do with the hot potato: keep the patient safe
Primary Care Toolkit
Discussions that occur in primary care settings about patients voluntarily limiting access to firearms during periods of suicidal ideation will achieve successful outcomes if culturally appropriate messaging about firearm safety is identified and implemented.
Guns are Pervasive: members of this demographic own multiple firearms, many loaded at all times, often not locked or not stored in secure locations.
Firearm Safety: most frequently cited basis of firearm safety has been explicit training of children and young adults, primarily through instruction from family members, and secondarily through formal firearms safety courses.
Firearm Taboo: highly inappropriate to ask someone where they keep their guns, how many guns they have, and other details of firearm ownership and safety in the home.
The above suggests that traditional, public health driven, firearm safety discourses (e.g. store ammunition separately from weapons, use a gun safe, impersonal physician in-take forms) may be ineffective for at least some portion of the gun-owning population.
Crisis Situations: in discussions of actual and hypothetical mental health crises with the potential for suicide, trust in the person asking the individual to relinquish their firearm is deemed fundamental. A trusted friend or family member can successfully breach the Firearm Taboo.
Trust in Primary Care: extremely important; point blank questions about firearm ownership (including intake checklists) or means restriction from someone who has not established trust are often perceived as threatening and antagonistic; fear of reporting to a government registry, especially among veterans.
Suicide Prevention as an Expression of Cultural Values: optimism about efficacy of making culturally-appropriate resources available in a primary care setting; means restriction would be treated as a basic extension of cultural values that emphasize firearm safety (rather than loss of access) and care for friends and family.
Message testing for patient education material
Links to Firearm Safety Toolkit
Ideation Among Individuals Who Have Purchased Firearms
Participants (N=3,500) were recruited through Qualtrics Panels to participate in an online survey examining methods for self-protection. ANCOVAs were utilized to assess suicidal ideation. Multivariate ANCOVAs were used to examine firearm storage practices and storage changes during COVID-19. Data were collected in late June and early July 2020, and analyses were conducted in July 2020.
Individuals who purchased a firearm during COVID-19 more frequently reported lifetime, past-year, and past-month suicidal ideation than nonfirearm owners and firearm owners who did not make a purchase during COVID-19. COVID-19 purchasers with lifetime ideation were less likely to hide loaded firearms in a closet than those without lifetime ideation. COVID-19 purchasers with past-year or past-month ideation were more likely to use locking devices than COVID-19 purchasers without past-month ideation.
In contrast to firearm owners more generally, COVID-19 firearm purchasers appear far more likely to have experienced suicidal ideation and appear less likely to use certain unsafe firearm storage methods but also report a greater number of storage changes during COVID-19 that made firearms less secure. Future research should seek to further understand those who purchased a firearm during COVID-19 and determine ways to increase secure storage among firearm owners.
In late 2019, coronavirus disease 2019 (COVID-19) emerged. Local and federal governments have enforced social distancing in an effort to slow the spread. Such interventions physically separate people, which is an effective method for preventing the spread of infectious diseases.1, 2, 3 However, some interventions may also lead to unintended consequences such as unemployment and social isolation, which are risk factors for suicide.4,5 Indeed, indicators of poor mental health nationwide have been increasing in severity during the pandemic.6 This has led to concerns regarding increased suicide risk.5,7
Another consequence of the pandemic is increased firearms sales in the U.S. An estimated 2 million firearms were purchased in March 2020,8 and >2.5 million Americans became first-time gun owners during the first 4 months of 2020.9 The increase in firearm purchases is concerning given the association between firearms and suicide.10 Firearm ownership is robustly associated with suicide (e.g., mental illness11). Suicide is 3 times more likely in homes with firearms,12 and the risk is increased for all household members.13 Risk for suicide surges by 100-fold immediately after the purchase of a handgun.14 In addition, unsafe firearm storage (e.g., loaded and unlocked) increases the risk.15,16 Furthermore, in some populations (e.g., service members), suicidal firearm owners are more likely to store firearms unsafely.17,18
Thus far, it is unknown whether those who have and have not purchased a firearm during COVID-19 differ in terms of suicide risk. One study utilizing a convenience sample (N=1,105) from Amazon's Mechanical Turk conducted in the opening week of May 2020 found few demographic differences between individuals who had and those who had not purchased firearms in the initial months of the pandemic. This survey, however, did not assess for suicidal ideation and included purchases that predated the initial surge of COVID-19 cases.19 COVID-19 firearm purchasers may be at particularly heightened risk given their recent purchase and pandemic-related consequences compared with other firearm owners and nonfirearm owners. Furthermore, individuals motivated to purchase firearms during COVID-19 may represent a different group of individuals, perhaps driven by anxiety potentially accompanied by a history of suicidal ideation. In this sense, a cohort effect could exist, resulting in a higher-risk group of individuals driving the firearm purchasing surge, thereby introducing long-term suicide risk into the homes of individuals who otherwise may not have acquired firearms. This study seeks to determine the extent to which those who acquired firearms during COVID-19 differ from those who did not in terms of suicide risk. Exploratory analyses examine whether suicidal ideation is associated with less-safe storage methods more generally and storage changes specifically during COVID-19. Each of these analyses is considered on the basis of lifetime suicidal ideation, past-year suicidal ideation, and past-month suicidal ideation. Given that many of the firearms purchased during COVID-19 will remain in homes after the pandemic, these findings may have implications for firearm safety and suicide prevention efforts beyond the context of the current moment.
Participants were 3,500 U.S. residents (51.5% female, mean age=46.09 years, 66.5% White) recruited using Qualtrics Panel, an online survey platform that maintains a database of millions of U.S. residents who have previously volunteered to participate in survey-based studies. Quota sampling was utilized to enroll a sample demographically matched to 2010 Census distributions for age, sex, race/ethnicity, income, and education. Panel members were invited to participate in the survey through e-mail invitation, which included a link that redirected them to the study's page. The landing page included information about the study's design, purpose, risks, and benefits. Consent to participate was provided by checking a box indicating consent. After completing the survey, participants were compensated in the form and amount agreed on when they joined the panel. Participants were eligible if they were aged =18 years. The study procedures were reviewed and approved by the necessary review boards.
Demographic information was collected using items assessing age, sex, race, ethnicity, highest educational attainment, and annual household income. Firearm ownership was assessed using a single item asking: Do you currently own a firearm? Acquisition of a firearm during COVID-19 was assessed using an item asking: Have you purchased a firearm during the COVID-19 pandemic? Firearm storage was assessed using an item asking: Which of the following storage procedures do you use for the firearms currently located in or around your home? (select all that are used), with the following answers: gun safe; gun cabinet; locking device (e.g., cable lock, trigger lock); hard cases (e.g., pelican case); hide in closet or drawer, unloaded; hide in a closet or drawer, loaded; and other safety procedure. Reasons for acquiring firearms during COVID-19 were assessed using an item asking: What were your reasons for acquiring a firearm during the COVID-19 pandemic? (choose all that apply). Firearm storage changes during COVID-19 were assessed using an item asking: Have you recently changed your firearm(s) storage practices because of the COVID-19 pandemic? If participants endorsed making changes owing to COVID-19, they were then asked: How has your firearm(s) storage practices changed since COVID-19? (choose all that apply). To determine the level of change, this item was summed such that there was a more secure variable and less secure variable. Possible storage change options included unloaded =1 firearm, loaded =1 firearm, removed locking device from =1 firearm, placed a locking device on =1 firearm, removed =1 firearm from a safe/lock box, placed =1 firearm in a safe/lock box, stored =1 firearm outside the home, stored =1 firearm inside the home, and other. Other was not included in the total. These changes represent an overall number of types of storage changes made across all of an individual's firearms and, as such, cannot be said to represent the storage practice of each individual firearm. Instead, these change variables represent the extent to which individuals made adjustments to storage practices overall during this timeframe and the extent to which such changes involved rendering firearms more or less secure.
Suicidal ideation was assessed with the self-report version of the Self-Injurious Thoughts and Behaviors Interview-Revised.20 This tool assesses for suicidal ideation by asking participants to identify which of 8 different suicide-related thoughts they have experienced in their lifetime, the past year, and the past month. For this study, an individual was considered to have suicidal ideation for a given timeframe if they endorsed any of the 8 suicide-related thoughts during that timeframe.
Between-group differences in reports of experiencing lifetime, past-year, and past-month suicidal ideation were examined using logistic regression. Age, sex, education, and annual household income served as covariates. Differences in general firearm storage practices were considered using chi-square analyses. Changes in storage practices specifically during COVID-19 were examined using a series of multivariate ANCOVAs.
The COVID-19 pandemic has seen a surge in firearm sales across the U.S. and has raised concerns about long- and short-term increases in suicide.5,6 Developing a clear understanding of the extent to which COVID-19 firearm purchasers differ from other firearm ownersand nonfirearm ownerswith respect to suicide risk could inform data-driven steps toward reducing risk. Given the limited time that has transpired since the initial surge of COVID-19, this understanding is currently lacking.
As expected, COVID-19 firearm purchasers reported lifetime, past-year, and past-month suicidal ideation with far greater frequency than both firearm owners who have not purchased firearms during COVID-19 and nonfirearm owners. These findings indicate that individuals already at risk for death by suicide are introducing a pronounced risk factor for suicide into their homes during a time of extended social isolation, economic uncertainty, and general upheaval. This combination of factors does not guarantee an increase in suicide rates but represents an unusually large surge in the risk made more troubling by the fact that firearms purchased during COVID-19 may remain in the homes beyond the pandemic.14 Firearm owners who have not purchased firearms during COVID-19 did not differ from nonfirearm owners with respect to suicidal ideation, which is consistent with previous research and highlights that COVID-19 firearm purchasers may represent a distinctly high-risk group.21 It may be that anxiety is driving the firearm purchasing surge, consistent with the finding that protection at or away from home were the most common reasons endorsed for purchasing a firearm during COVID-19. This also aligns with previous research.19 That same anxiety could partially explain the elevated frequency of suicidal ideation and indicate that demographic patterns of firearm purchasing have been different during COVID-19. Such interpretations need to be considered within the context of a notable limitation, however. The data did not allow confident identification of which COVID-19 firearm purchasers represented first-time firearm owners. The difference between purchasing a firearm for the first time and purchasing it for the fifth time, for example, may be quite meaningful. First-time buyers are likely less familiar with safe firearm storage methods. Furthermore, it may be that the motives for purchasing firearms during the pandemic differ between first-time buyers and individuals who have purchased firearms in the past, meaning that important subgroups would exist within the groups considered in these analyses.
The findings regarding storage practices were somewhat mixed. In contrast to research indicating that those at elevated risk for suicide are more likely to store their firearms unsafely,15,16 COVID-19 firearm purchasers who endorsed lifetime or recent suicidal ideation were more likely to utilize a number of specific storage practices that may mitigate suicide risk. Those with lifetime suicidal ideation were less likely to store firearms hidden in a drawer or closet and loaded, and those with past-year or past-month suicidal ideation were more likely to utilize locking devices.
In contrast to findings examining specific storage methods overall, the results recorded when participants were asked specifically about changes made during COVID-19 were complicated. COVID-19 firearm purchasers who endorsed lifetime or past-year suicidal ideation endorsed making a greater number of firearm storage changes that increased ready access to firearms as well as changes that made firearms less readily accessible. In addition, those with past-month suicidal ideation endorsed having made a greater number of firearm storage changes during COVID-19 that rendered firearms more readily accessible than did COVID-19 firearm purchasers who endorsed no past-month suicidal ideation. This may indicate that individuals who purchased firearms during COVID-19 and who are at a higher risk for suicide are more volatile with respect to their storage practices. For some, this may represent a lack of experience and an effort to develop a comfort level with a storage system. For others, this might represent fluctuating levels of anxiety regarding COVID-19 and their need for ready access for protection. Without an understanding of the entire profile of changes made by specific individuals, these findings are difficult to interpret. If the same individual did not only make storage changes that rendered a firearm more accessible but also changes that made that same (or another) firearm less accessible, the overall shift in the level of security would be unclear.
This work had several limitations. First, although the sample was large and matched to the 2010 Census data, quota sampling was used rather than probability-based sampling. Furthermore, the sample of COVID-19 firearm purchasers was small. In addition, although participants were asked why they acquired firearms during COVID-19, it is not definitively clear that their motivations were driven by the pandemic and fundamentally different from what their motivations would have been outside the current context. Protection at or away from home is consistently the most frequently endorsed reason for firearm ownership,22 including both in data that predate COVID-19 and data that partially overlap with COVID-19.19 Economic uncertainty, fears of societal breakdown, and a general sense of threat during uncertain times may influence protective firearm ownership23; however, the extent to which such motivations are COVID-19 specific rather than simply amplified by current events is unclear. Finally, the data did not allow examination of the impact of the racial justice movement taking place during 2020 and, in this sense, was limited in its ability to fully understand the context underlying the firearm purchasing surge. Relatedly, the data could not address the potential impact of the pending Presidential election or recent surges in interpersonal gun violence across the U.S. Nonetheless, the comparison of COVID-19 firearm purchasers with other firearm owners and the general population allowed a novel examination of a timely problem. The use of self-report and cross-sectional data also represents limitations. Finally, the response rate for the survey was unknown, which limits the understanding of the impact of selection bias.
Despite these limitations, these data
offer substantial value. Understanding suicide risk among
individuals driving the surge in firearm sales is vital for
the U.S. to develop a national strategy for combating any
potential surge in suicide attempts among firearm owners.
The data indicate that these individuals may be more likely
to be suicidal than other firearm owners, thereby raising
questions about the generalizability of previous research on
firearm owners to the current cohort. Indeed, these findings
highlight the importance of implementing more rapid data
collection and reporting of suicide deaths in the U.S. The
current lag in reporting of suicide data precludes a truly
effective public health response to this potential risk. A
sharp increase in suicide deaths is not an inevitable result
of a surge in firearm purchasing, but a sharp increase in
firearm acquisitions among suicidal individuals would
increase that risk.
Legislators and gun safety advocates often focus on how guns are purchased. But many lives could be saved, especially among children, if they looked more at how they are stored.
In the last decade, guns killed more than 14,000 American children. A startling number of those deaths more than a third were classified as suicides, and around 6 percent as accidents. Many more children were injured.
Nearly everyone agrees that children should not be able to buy guns, and no state lets them do so on their own. When children die by suicide in this way, its a result of being able to get hold of a gun that someone else already obtained often legally.
How guns are stored matters. A study published Monday in JAMA Pediatrics has found that even a modest increase in owners who lock up their guns would pay off in an outsize drop in gun deaths.
Dr. Michael Monuteaux, an assistant professor of pediatrics at Harvard Medical School and an author of the study, said, We need to communicate to parents that storing guns in a way that makes them inaccessible to children can reduce the number of children who die year after year, especially from suicide.
In 2010, researchers examined who owned the firearms used in youth suicides. In cases where this could be determined, three-quarters of the time the owner was a parent, and for a further 7 percent it was some other relative.
In a 2005 study published in JAMA, researchers found that keeping guns locked and unloaded, and keeping ammunition locked and separate from guns, were significantly associated with lower levels of suicides and accidents among adolescents in gun-owning households. This held true for both handguns and long guns.
But such safety practices arent common. If a recent New York bill is signed into law, it will make the state one of just a handful with comprehensive gun storage laws to protect children.
Last year, a study based on a national survey in 2015 found that about one in three of all households in the United States owned at least one gun. Of those households with both guns and children at home, more than 20 percent reported storing them both loaded and unlocked the least-safe way. An additional 50 percent stored them either loaded or unlocked.
This meant that about 7 percent of all children in the United States lived in a house in which at least one gun was stored in an unsafe manner. This was about twice the number reported in the previous national survey, published in 2002. Other research suggests that many people in gun-owning households, typically not the primary owner of the gun, think they are safely stored when they are not.
Critics of gun-storage laws say homeowners need to be able to act quickly if a criminal tries to enter a home. Its not easy to measure how often guns are used in self-defense when someone attempts a break-in, but research suggests its a rare occurrence.
Suicides are less rare than self-defense shootings and, along with accidents, they are more likely in children who have parents who abuse alcohol. Studies have also found that children living with an adult who misuses alcohol were more likely to live in a house with a gun stored unsafely, and that heavy alcohol use was most common in those who store guns loaded and unlocked.
We know from prior studies that children who live with alcohol-misusing adults are at a greater risk of suicide attempt, bullying victimization and perpetration, and unintentional injuries, said Dr. Ali Rowhani-Rahbar, an associate professor of epidemiology at the University of Washingtons School of Public Health.
Critics also say safe storage laws are hard to enforce because of privacy concerns. As a model from Mondays study in JAMA Pediatrics shows, though, even a modest intervention that motivates households to safely store guns could reduce youth firearm deaths by 6 percent to 32 percent.
Possible safety measures
Last year, in the journal Injury Prevention, Dr. Rowhani-Rahbar and other researchers reported on the results of two community-based firearm safety events in Washington State. They found that presenting people with information and offering to sell them trigger guards or lockboxes resulted in an increase of about 14 percent of households that stored all guns locked and 9 percent more that stored them unloaded.
In 2017, the Government Accountability Office reviewed 16 public or nonprofit programs that aimed to improve the storage of guns. It also reviewed studies of these programs. It found that distributing locks led to more safely stored guns. Few of these evaluations were rigorous, however. (Gun research, as with most things related to guns, is a politically divisive issue, and for many years research funding has been very low relative to other major causes of death.)
Policy can make a difference, too. In 2004, a study examined how laws that focused on the sale of guns affected the suicide rates of children, compared with laws mandating safe storage of firearms. They found that between 1976 and 2001, minimum-age purchase laws and possession-age laws had no effect on adolescent suicide rates. Laws preventing childrens access to guns, on the other hand, were associated with significant reductions of suicides by guns, even when reductions were not seen in suicides by other methods.
About two-thirds of gun deaths in the United States are suicides, and given political stalemates over gun rights, it seems an area in which policymakers could be more productive. Safer storage of guns, especially in households with children, might make more of a difference than many legislative and advocacy efforts that get more attention.
Aaron E. Carroll is a professor of
pediatrics at Indiana University School of Medicine who
blogs on health research and policy at The Incidental
Economist and makes videos at Healthcare Triage. He is the
author of The Bad Food Bible: How and Why to Eat