'It's changed how we have these conversations': emergency department clinicians' experiences implementing firearms and other lethal suicide methods counseling for caregivers of adolescents.

Counseling parents to reduce access to firearms and other potentially lethal suicide methods is commonly known as lethal means counseling (LMC). The current study explores the experiences that emergency department-based behavioural health clinicians described having as they provided lethal means counseling to parents of adolescents at risk for suicide. Clinicians were purposively sampled from four hospital networks in Colorado after their hospitals adopted LMC protocols as part of an intervention that also included online training in LMC and provision of free medication and firearm lockboxes. Twenty-three clinicians were interviewed using semi-structured interviews. Data were analysed using a modified grounded theory-based approach. Clinicians felt more comfortable and effective in their abilities to provide LMC after the intervention. Clinicians also described how being able to offer free storage devices helped them engage in LMC. In advising parents to make guns and medications inaccessible to their at-risk child, most clinicians pointed to at least one of three research findings highlighted in the online training: (1) Suicide attempts with guns rarely afford second chances, (2) medication overdoses can kill, (3) suicidal behaviour is always unpredictable and often impulsive. All clinicians described a desire to continue LMC as currently protocolized at their hospital after the study ended.

Are We Missing Something Pertinent? A Bias Analysis of Unmeasured Confounding in the Firearm-Suicide Literature.

Despite the magnitude and consistency of risk estimates in the peer-reviewed literature linking firearm availability and suicide, inferring causality has been questioned on the theoretical basis that existing studies may have failed to account for the possibility that members of households with firearms differ from members of households without firearms in important ways related to suicide risk. The current bias analysis directly addresses this concern by describing the salient characteristics that such an unmeasured confounder would need to possess in order to yield the associations between firearm availability and suicide observed in the literature when, in fact, the causal effect is null. Four US studies, published between 1992 and 2003, met our eligibility criteria. We find that any such unmeasured confounder would need to possess an untenable combination of characteristics, such as being not only 1) as potent a suicide risk factor as the psychiatric disorders most tightly linked to suicide (e.g., major depressive and substance use disorders) but also 2) an order of magnitude more imbalanced across households with versus without firearms than is any known risk factor. No such confounder has been found or even suggested. The current study strongly suggests that unmeasured confounding alone is unlikely to explain the association between firearms and suicide.

Antidepressant class, age, and the risk of deliberate self-harm: a propensity score matched cohort study of SSRI and SNRI users in the USA.

BACKGROUND: The US Food and Drug Administration's meta-analyses of placebo-controlled antidepressant trials found approximately twice the rate of suicidal behaviors among children and adults aged 24 years and younger who were randomized to receive antidepressant medication than among those who were randomized to placebo. Rates of suicidal behavior were similar for subjects aged 25-64 years whether they received antidepressants or placebo, and subjects aged 65 years or older randomized to antidepressants were found to have lower rates of suicidal behavior. The age-stratified FDA meta-analyses did not have adequate power to investigate rates of suicidal behaviors by antidepressant drug class. OBJECTIVE: Our objective was to assess the risk of deliberate self-harm associated with the two most commonly prescribed classes of antidepressant agents. DESIGN: Propensity score matched cohort study of incident users of antidepressant agents. SETTING: Population-based healthcare utilization data of US residents. PATIENTS: US residents aged 10-64 years with a recorded diagnosis of depression who initiated use of selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) between 1 January 1998 and 31 December 2010. MAIN OUTCOME MEASURES: ICD-9 external cause of injury codes E950.x-E958.x (deliberate self-harm). RESULTS: A total of 102,647 patients aged between 10 and 24 years, and 338,021 aged between 25 and 64 years, initiated therapy with antidepressants. Among 10-24 year olds, prior to propensity score matching, 75,675 initiated therapy with SSRIs and 5,344 initiated SNRIs. After matching, there were 5,344 SNRI users and 10,688 SSRI users. Among the older cohort, 36,037 SNRI users were matched to 72,028 SSRI users (from an unmatched cohort of 225,952 SSRI initiators). Regardless of age cohort, patients initiating SSRIs and patients initiating SNRIs had similar rates of deliberate self-harm. Restriction to patients with no antidepressant use in the past 3 years did not alter our findings. CONCLUSIONS: Our findings of similar rates of deliberate self-harm for depressed patients who initiate treatment with either an SSRI or an SNRI suggests that physicians who have decided that their patients would benefit from initiating antidepressant therapy need not weigh differential suicide risk when deciding which class of antidepressant to prescribe.

Recent psychopathology, suicidal thoughts and suicide attempts in households with and without firearms: findings from the National Comorbidity Study Replication.

OBJECTIVE: To assess the relationship between firearm ownership and possible psychiatric confounders of the firearm-suicide relationship. METHODS: Multivariate logistic regression was used to estimate the association between living in a home with firearms and 12-month occurrence of major Diagnostic and statistical manual of mental disorders (DSM)-IV disorders and suicidal behaviour among respondents to the National Comorbidity Survey Replication, a household survey of 9282 adults aged 18+. Analyses controlled for sociodemographic characteristics including age, sex, race/ethnicity, educational attainment and poverty. RESULTS: Approximately one in three Americans reported living in a home with firearms. People living in a home with firearms were no more or less likely than people in homes without firearms to have recent (past year) anxiety disorders (OR = 1.0, 95% CI 0.8 to 1.2), mood disorders (OR = 0.9, 95% CI 0.7 to 1.1) or substance dependence and/or abuse (OR = 0.9, 95% CI 0.6 to 1.3). Past year suicidal ideation (OR = 0.8, 95% CI 0.5 to 1.3) and suicide planning (OR = 0.5, 95% CI 0.2 to 1.4) were also not associated with living in households with firearms. Having made a suicide attempt over the previous year was the only outcome more common among participants reporting that they currently lived in a home without [corrected] firearms. CONCLUSIONS: The previously reported association between household firearm ownership and heightened risk of suicide is not explained by a higher risk of psychopathology among gun-owning families. As there are Americans with suicidal ideation and/or significant and recent psychiatric disorders currently living in homes with firearms, future work should focus on understanding the impediments to effectively communicating the suicide risk associated with household firearms.

The US gun stock: results from the 2004 national firearms survey.

OBJECTIVES: To examine the size and composition of the privately held firearm stock in the US; and to describe demographic patterns of firearm ownership and motivations for ownership. DESIGN, SETTING AND PARTICIPANTS: A nationally representative household telephone survey of 2770 adults aged>or=18 years living in the US, conducted in the spring of 2004. MAIN OUTCOME MEASURE: Responses to questions regarding firearm ownership, the number and types of guns owned, and motivations for ownership. RESULTS: 38% of households and 26% of individuals reported owning at least one firearm. This corresponds to 42 million US households with firearms, and 57 million adult gun owners. 64% of gun owners or 16% of American adults reported owning at least one handgun. Long guns represent 60% of the privately held gun stock. Almost half (48%) of all individual gun owners reported owning>or=4 firearms. Men more often reported firearm ownership, with 45% stating that they personally owned at least one firearm, compared with 11% for women. CONCLUSIONS: The US population continues to contain at least one firearm for every adult, and ownership is becoming increasingly concentrated. Long guns are the most prevalent type of gun in the US but handgun ownership is widespread. Ownership demographic patterns support findings of previous studies.

The association between changes in household firearm ownership and rates of suicide in the United States, 1981-2002.

OBJECTIVE: To explore whether recent declines in household firearm prevalence in the United States were associated with changes in rates of suicide for men, women, and children. METHODS: This time series study compares changes in suicide rates to changes in household firearm prevalence, 1981-2002. Multivariate analyses adjust for age, unemployment, per capita alcohol consumption, and poverty. Regional fixed effects controlled for cross sectional, time invariant differences among the four census regions. Standard errors of parameter estimates are adjusted to account for serial autocorrelation of observations over time. RESULTS: Over the 22 year study period household firearm ownership rates declined across all four regions. In multivariate analyses, each 10% decline in household firearm ownership was associated with significant declines in rates of firearm suicide, 4.2% (95% CI 2.3% to 6.1%) and overall suicide, 2.5% (95% CI 1.4% to 3.6%). Changes in non-firearm suicide were not associated with changes in firearm ownership. The magnitude of the association between changes in household firearm ownership and changes in rates of firearm and overall suicide was greatest for children: for each 10% decline in the percentage of households with firearms and children, the rate of firearm suicide among children 0-19 years of age dropped 8.3% (95% CI 6.1% to 10.5%) and the rate of overall suicide dropped 4.1% (2.3% to 5.9%). CONCLUSION: Changes in household firearm ownership over time are associated with significant changes in rates of suicide for men, women, and children. These findings suggest that reducing availability to firearms in the home may save lives, especially among youth.

Underestimates of unintentional firearm fatalities: comparing Supplementary Homicide Report data with the National Vital Statistics System.

OBJECTIVE: A growing body of evidence suggests that the nation's vital statistics system undercounts unintentional firearm deaths that are not self inflicted. This issue was examined by comparing how unintentional firearm injuries identified in police Supplementary Homicide Report (SHR) data were coded in the National Vital Statistics System. METHODS: National Vital Statistics System data are based on death certificates and divide firearm fatalities into six subcategories: homicide, suicide, accident, legal intervention, war operations, and undetermined. SHRs are completed by local police departments as part of the FBI's Uniform Crime Reports program. The SHR divides homicides into two categories: "murder and non-negligent manslaughter" (type A) and "negligent manslaughter" (type B). Type B shooting deaths are those that are inflicted by another person and that a police investigation determined were inflicted unintentionally, as in a child killing a playmate after mistaking a gun for a toy. In 1997, the SHR classified 168 shooting victims this way. Using probabilistic matching, 140 of these victims were linked to their death certificate records. RESULTS: Among the 140 linked cases, 75% were recorded on the death certificate as homicides and only 23% as accidents. CONCLUSION: Official data from the National Vital Statistics System almost certainly undercount firearm accidents when the victim is shot by another person.

Firearm availability and unintentional firearm deaths.

BACKGROUND: Between 1979 and 1997, almost 30,000 Americans died from unintentional firearm injuries, half of whom were under 25 years of age and 4,600 of whom were less than 15 years old. PURPOSE: To explore the association between state firearm levels and rates of unintentional firearm deaths by age group, accounting for several potential confounders. METHODS: The study used a proxy for firearm availability and pooled cross-sectional time-series data on unintentional firearm deaths for the 50 United States from 1979 to 1997. Negative binomial models were used to estimate the association between firearm availability and unintentional firearm deaths. RESULTS: A statistically significant and robust association exists between gun availability and unintentional firearm deaths for the US as a whole and within each age group. Multivariate analysis found that, compared to states with the lowest gun levels, states with the highest gun levels had, on average, 9 times the rate of unintentional firearm deaths. These results hold among men and women, for Whites and African Americans. CONCLUSION: Of the almost 30,000 people who died in unintentional firearm deaths over the 19-year study period, a disproportionately high number died in states where guns are more prevalent. The results suggest that the increased risk of unintentional violent death among all age groups is not entirely explained by a state's level of poverty, urbanization, or regional location.

National attitudes concerning gun carrying in the United States.

OBJECTIVES: To determine public attitudes in the United States concerning gun carrying. SETTING: In the past 15 years, many state legislatures have passed laws making it easier for United States citizens to carry concealed firearms, not only on the street but into various locations, including churches and government buildings. METHODS: National random digit dial telephone surveys conducted in 1996 and 1999 asked questions concerning the public's feelings of safety as more people in their community carry firearms, and whether, in the language of the question, respondents believe "regular" citizens should be allowed to carry guns into public or government buildings. RESULTS: Americans feel less safe rather than more safe as more people in their community begin to carry guns. By margins of at least nine to one, Americans do not believe that "regular" citizens should be allowed to bring their guns into restaurants, college campuses, sports stadiums, bars, hospitals, or government buildings. CONCLUSIONS: The public believes that increased gun carrying by others reduces rather than increases their safety. Overwhelmingly, the public believes that in many venues gun carrying should be prohibited.

Community firearms, community fear.

To examine how perceptions of safety are influenced as more people in a community acquire firearms, we conducted a nationally representative random-digit-dial survey of 2,500 adults and asked whether respondents would feel more safe, less safe, or equally safe if more people in their community were to acquire guns. We used multivariable logistic regression to explore correlates of perceived safety while taking into account various confounders. Fifty percent of respondents reported that they would feel less safe if more people in their community were to own guns; 14% reported they would feel more safe. Women and minorities were more likely than were men and Whites to feel less safe as others acquire guns, with Odds ratios of 1.7 and 1.5, respectively. Our findings suggest that most Americans are not impervious to the psychological effects of guns in their community, and that, by a margin or more than 3 to 1, more guns make others in the community feel less safe rather than more safe.

Are household firearms stored safely? It depends on whom you ask.

OBJECTIVE: To determine gun storage practices in gun-owning households with children. DESIGN: National random digit-dial telephone survey of 2521 households conducted in March 1999 through July 1999. This study uses a subsample of 434 households with children <18 years old in which a respondent reported either: 1) personally owning a gun, or 2) living in a gun-owning household but not owning a gun themselves. Respondents were asked whether any household gun was currently stored loaded, and, if yes, whether any gun was currently stored loaded and unlocked. RESULTS: Twenty-one percent of gun owners compared with 7% of non-owners reported that a household gun was stored loaded, while 9% and 2%, respectively, reported that a household gun was stored loaded and unlocked. Non-gun owners were significantly more likely than were gun owners to be female (87% vs 22%) and to report that they lived in a house with only 1 gun (70% vs 57%) and no handguns (51% vs 31%). Based on the reports of actual gun owners (n = 252), households with children <13 years old were significantly less likely to store a gun loaded and unlocked (multivariate odds ratio:.1; 95% confidence interval:.0,.4) than were households with teenagers only. CONCLUSIONS: We find that among gun-owning households with children, non-gun owners report significantly lower rates of guns stored loaded and unlocked than do gun owners. These findings are consistent with recent studies that have found that married men are far more likely to report household gun ownership than are married women, and that gun users are far more likely to report that a gun is stored loaded or loaded and unlocked than are never users. Our findings suggest that non-gun owners, the vast majority of whom are women (87%), may be unaware that guns in their homes are stored in a manner that experts agree is unsafe. Our findings reinforce the importance of many pediatricians' current efforts to offer anticipatory guidance about firearms to gun-owning families, and, in addition, suggest that this guidance can be adapted depending on whether the physician is speaking with a gun-owning or non-gun-owning parent. In particular, because gun owners (mostly fathers) are less likely to bring children to the pediatrician's office than are non-owners (mostly mothers), physicians should take advantage of any opportunities that they have to address gun-related issues with parents who personally own guns. More commonly, physicians can encourage non-gun owners to participate more fully in household decision-making about gun storage by letting them know not only about recommended storage practices, but also that many non-owners may not know how guns are actually stored in their own homes. firearm, storage, children, survey.

'In the safety of your own home': results from a national survey on gun use at home.

In the US, guns, particularly handguns, are typically brought into the home for protection. The wisdom of having a firearm in the home, however, is disputed. While guns appear to be a risk factor for family homicide, suicide and unintentional firearm fatality, no evidence has been available about gun use at home to intimidate family members and little about gun use to thwart crimes by intruders, or about the use of other weapons in home self-defense. Over the past decade, various private surveys have asked questions about the respondent's use of guns in self-defense. None, however, has asked detailed questions about the use of guns to threaten or intimidate the respondent. This study presents results from a national random digit dial telephone survey of 1906 US adults conducted in the spring of 1996. Respondents were asked about hostile gun displays and use of guns and other weapons in self-defense at home in the past five years. The objective of the survey was to assess the relative frequency and characteristics of weapons-related events at home. Thirteen respondents reported that a gun was displayed against them at home, two reported using a gun in self-defense at home, and 24 reported using another weapon (e.g. knife, baseball bat) in home self-defense. While we do not always know whose weapon was used in these incidents, most gun brandishings were by male intimates against women. A gun in the home can be used against family members or intruders and can be used not only to kill and wound, but to intimidate and frighten. This small study provides some evidence that guns may be used at least as often by family members to frighten intimates as to thwart crime, and that other weapons are far more commonly used against intruders than are guns.

The relative frequency of offensive and defensive gun uses: results from a national survey.

Some controversy exists about the relative frequency of criminal and self-defense gun use in the United States. Using data from a national random-digit-dial telephone survey of over 1,900 adults conducted in 1996, we find that criminal gun use is far more common than self-defense gun use. This result is consistent with findings from other private surveys and the National Crime Victimization Surveys. In this survey, all reported cases of criminal gun use and many cases of self-defense gun use appear to be socially undesirable. There are many instances of gun use, often for intimidation, that are not reported to the police and may not appear in official crime statistics.

Gun use in the United States: results from two national surveys.

OBJECTIVES: To determine the relative incidence of gun victimization versus self defense gun use by civilians in the United States, and the circumstances and probable legality of the self defense uses. METHODS: National random digit dial telephone surveys of the adult population were conducted in 1996 and 1999. The Harvard surveys appear unique among private surveys in two respects: asking (1) open ended questions about defensive gun use incidents and (2) detailed questions about both gun victimization and self defense gun use. Five criminal court judges were asked to assess whether the self reported defensive gun uses were likely to have been legal. RESULTS: Even after excluding many reported firearm victimizations, far more survey respondents report having been threatened or intimidated with a gun than having used a gun to protect themselves. A majority of the reported self defense gun uses were rated as probably illegal by a majority of judges. This was so even under the assumption that the respondent had a permit to own and carry the gun, and that the respondent had described the event honestly. CONCLUSIONS: Guns are used to threaten and intimidate far more often than they are used in self defense. Most self reported self defense gun uses may well be illegal and against the interests of society.

Firearm training and storage.

OBJECTIVE: To determine the extent of firearm training among gun owners, how gun owners currently store their weapons, and the relationship between gun training and gun storage. DESIGN AND SETTING: A national random telephone survey of gun owners conducted from May through June 1994. PARTICIPANTS: A total of 800 adult gun owners residing in the United States. MAIN OUTCOME MEASURES: Number of gun owners who received firearm training and number who store a firearm loaded and unlocked. Logistic regression analyses were conducted to examine factors associated with firearm training and gun storage practices. RESULTS: A total of 451 (56%) of gun owners have received firearm training. A total of 170 (21%) of gun owners keep a firearm both loaded and unlocked in the home. Factors associated with an increased likelihood of storing guns loaded and unlocked included owning a gun for protection (odds ratio [OR], 2.40; 95% confidence interval [CI], 1.62 to 3.54), owning a handgun (OR, 3.31; 95% CI, 1.85 to 5.95), and having received firearm training (OR, 1.71; 95% CI, 1.10 to 2.67). Length of firearm training and how recently training was received have little effect on storage practices. CONCLUSION: It has been suggested that many homicide, suicide, and accidental firearm injuries might be prevented if ready access to lethal weapons was reduced, in part through appropriate storage of guns. Although increased training has been advocated as the prime method to improve gun storage practices, our results cast doubt on whether firearm training, at least as currently provided, will substantially reduce the inappropriate storage of firearms.

Risk factors for hip fracture in US men aged 40 through 75 years.

Relatively few studies have examined risk factors for hip fracture among men. This study analyzes data from the Health Professionals Follow-up Study, a prospective study of approximately 50,000 men who were between the ages of 40 and 75 years in 1986. Body mass index, smoking status, and alcohol consumption were not associated with hip fracture in this population. However, age and height were related to hip fracture. Men who were 65 and older had a significantly higher risk of sustaining a hip fracture than younger adults. Men 6 feet or taller were more than twice as likely to sustain a hip fracture as those under 5 feet, 9 inches.

Risk factors for wrist fracture: effect of age, cigarettes, alcohol, body height, relative weight, and handedness on the risk for distal forearm fractures in men.

Fractures of the distal forearm (wrist) are among the most common of all fractures. While evidence exists concerning risk factors for wrist fracture among women, little is known about risk factors among men. This study examines the relation of lifestyle characteristics (cigarette smoking, alcohol consumption, relative weight) as well as body height and handedness to the risk for fracture in a male population that has been followed up for 6 years. The 51,529 men, who were between the ages of 40 and 75 years in 1986, were participants in the Health Professionals Follow-up Study, a national prospective cohort study. In 271,552 person-years of follow-up, 271 respondents reported a wrist fracture. The risk for wrist fracture in this population did not vary with age. Cigarette smoking, alcohol consumption, body height, and relative weight also were not related to risk for wrist fracture. Handedness, which was divided into four mutually exclusive categories (right-handed, left-handed, forced to change, and ambidextrous), was significantly associated with wrist fracture. Left-handers had a multivariate relative risk for wrist fracture 1.56 times that of right-handers (95% confidence interval 1.02-2.37), and men who reported they had been forced to change from left-handed to right-handed had a multivariate relative risk 2.47 times greater than right-handers (95 percent confidence interval 1.21-5.04).