Rising Rates of Adolescent Firearm Suicide and the Clinician's Role in Addressing Firearms.

Suicide is a leading cause of death of 10- to 19-year-olds in the United States.1 Firearms were used in 48% of suicides of 15- to 19-year-olds and in 38% of suicides of 10- to 14-year-olds in 2020.1 During the COVID-19 pandemic, gun sales surged, leading to increases in household firearm ownership,2 a known risk factor for suicide.3 There are many ways in which adolescents access firearms. Most commonly, adolescents encounter firearms owned by an adult in the home. One study showed that one-third of adolescents reported they could access a loaded household gun in less than 5 minutes, even in households where parents did not believe that their child could access a household firearm.4 Another study found that 39% of parents who reported that their children did not know the location of household guns, and 22% of parents who reported that their children had never handled a household gun, were contradicted by their children's reports.5Adolescents can legally own rifles or shotguns if gifted to them by a parent. Federal law (18 U.S.C. 922) prohibits possession of handguns by minors less than 18 years of age; however, there are no federal minimum age requirements for possession of long guns (shotguns, rifles).Social media contributes to adolescent gun culture. TikTok users have created and viewed popular videos about guns,6 including videos with instructions on building guns from hardware store materials or via 3D printing. Adolescents can purchase kits online to assemble fully functional handguns. No federal restrictions or background check requirements exist on who can purchase "ghost gun" kits.7Child and adolescent mental health providers often assess suicide risk with a screening tool such as the Columbia-Suicide Severity Rating Scale, with a clinical assessment, or with a combination of both. Either way, the assessment should include asking about access to lethal means, including firearms. Many adolescent suicide attempts are impulsive; completed suicides may be prevented if access to firearms is limited during periods of crisis.8 However, many clinicians do not talk about firearms with patients even when clinically relevant.9 This may be due to assumptions that adolescents do not have access to firearms, or to lack of comfort with this topic. One study surveying medical residents reported the most common barriers to providing firearm counseling were not knowing how to ask about firearm access and not knowing how to respond to patients' answers about firearm access.9Once identifying an adolescent at risk for suicide, clinicians can intervene by providing evidenced-based interventions tailored to each situation. In this article, we present steps adapted from the BulletPoints Project for clinicians to intervene with adolescents at risk for firearm suicide.

Talking about firearm injury prevention with patients: a survey of medical residents.

BACKGROUND: Firearm injury and death are significant public health problems in the U.S. and physicians are uniquely situated to help prevent them. However, there is little formal training in medical education on identifying risk for firearm injury and discussing safe firearm practices with patients. This study assesses prior education, barriers to counseling, and needs for improved training on firearm safety counseling in medical education to inform the development of future education on clinical strategies for firearm injury prevention. METHOD: A 2018 survey administered to 218 residents and fellows at a large, academic medical center asked about medical training on firearm injury prevention, frequency of asking patients about firearm access, and perceived barriers. RESULTS: The most common barriers cited were not knowing what to do with patients' answers about access to firearms (72.1%), not having enough time (66.2%), not feeling comfortable identifying patients at-risk for firearm injury (49.2%), and not knowing how to ask patients about firearm access (48.6%). Prior education on firearm injury prevention was more strongly associated with asking than was personal exposure to firearms: 51.5% of respondents who had prior medical education reported asking compared with who had not received such education (31.8%, p=0.004). More than 90% of respondents were interested in further education about interventions, what questions to ask, and legal mechanisms to separate dangerous people from their firearms. CONCLUSIONS: Education on assessing risk for firearm-related harm and, when indicated, counseling on safe firearm practices may increase the likelihood clinicians practice this behavior, though additional barriers exist.

Consensus-Driven Priorities for Firearm Injury Education Among Medical Professionals.

PURPOSE: Firearm injury is a leading cause of morbidity and mortality in the United States. However, many medical professionals currently receive minimal or no education on firearm injury or its prevention. The authors sought to convene a diverse group of national experts in firearm injury epidemiology, injury prevention, and medical education to develop consensus on priorities to inform the creation of learning objectives and curricula for firearm injury education for medical professionals. METHOD: In 2019, the authors convened an advisory group that was geographically, demographically, and professionally diverse, composed of 33 clinicians, researchers, and educators from across the United States. They used the nominal group technique to achieve consensus on priorities for health professions education on firearm injury. The process involved an initial idea-generating phase, followed by a round-robin sharing of ideas and further idea generation, facilitated discussion and clarification, and the ranking of ideas to generate a prioritized list. RESULTS: This report provides the first national consensus guidelines on firearm injury education for medical professionals. These priorities include a set of crosscutting, basic, and advanced learning objectives applicable to all contexts of firearm injury and all medical disciplines, specialties, and levels of training. They focus on 7 contextual categories that had previously been identified in the literature: 1 category of general priorities applicable to all contexts and 6 categories of specific contexts, including intimate partner violence, mass violence, officer-involved shootings, peer (nonpartner) violence, suicide, and unintentional injury. CONCLUSIONS: Robust, data- and consensus-driven priorities for health professions education on firearm injury create a pathway to clinician competence and self-efficacy. With an improved foundation for curriculum development and educational program-building, clinicians will be better informed to engage in a host of firearm injury prevention initiatives both at the bedside and in their communities.

Clinical strategies for reducing firearm suicide.

Suicide is complex, with psychiatric, cultural, and socioeconomic roots. Though mental illnesses like depression contribute to risk for suicide, access to lethal means such as firearms is considered a key risk factor for suicide, and half of suicides in the USA are by firearm. When a person at risk of suicide has access to firearms, clinicians have a range of options for intervention. Depending on the patient, the situation, and the access to firearms, counseling on storage practices, temporary transfer of firearms, or further intervention may be appropriate. In the USA, ownership of and access to firearms are common and discussing added risk of access to firearms for those at risk of suicide is not universally practiced. Given the burden of suicide (particularly by firearm) in the USA, the prevalence of firearm access, and the lethality of suicide attempts with firearms, we present the existing evidence on the burden of firearm suicide and what clinicians can do to reduce their patients' risk. Specifically, we review firearm ownership in the USA, firearm injury epidemiology, risk factors for firearm-related harm, and available interventions to reduce patients' risk of firearm injury and death.

Evaluating threats of mass shootings in the psychiatric setting.

Psychiatrists may encounter patients at risk of perpetrating mass shootings or other mass violence in various settings. Most people who threaten or perpetrate mass violence are not driven by psychiatric symptoms; however, psychiatrists may be called upon to evaluate the role of mental illness plays in the risk or threat, and to treat psychiatric symptoms when present. Regardless of whether psychiatric treatment is likely to reduce symptoms or the potential for violence, the psychiatrist should collaborate closely with law enforcement, potential targets, and other agencies involved to mitigate risk. Such communications are governed by various privacy laws and duties to third parties. Additional measures, like protective orders, may be a means of restricting the subject's access to firearms.

Suicide prevention efforts in the United States and their effectiveness.

PURPOSE OF REVIEW: Suicide is a serious public health problem in the United States, and suicide rates have been increasing for more than a decade. Rural areas are more impacted than urban areas, reinforcing that social, cultural, and economic factors contribute to risk. This article reviews recent work about these contributors to suicide and how they may inform prevention efforts. RECENT FINDINGS: Current research has shown that suicide is more than a mental health problem with a psychiatric or medical solution. Universal screening and referral by gatekeepers target a large group with a low baseline risk, and there are few treatments proven to reduce death by suicide, as well as a severe shortage of mental health providers in the United States to provide them. Instead, suicide prevention polices can target various other factors that contribute to elevated suicide risk at the population level, including reducing socioeconomic deprivation and access to firearms, both of which are often higher in rural areas. Internet-based interventions also hold promise as they are highly scalable, accessible almost anywhere, and often anonymous. SUMMARY: Understanding factors that increase suicide risk guide development of evidence-based policies targeted at high-risk groups. Population-level interventions should be developed in collaboration with the target audience for cultural appropriateness.

Access to firearms: When and how do mental health clients become prohibited from owning guns?

Psychologists and other mental health clinicians are often called upon to assess violence and suicide risk. Access to firearms has important implications for client safety, but most psychologists report receiving little or no training on discussing firearms with clients in the context of delivering psychological services such as screening, assessment, or psychotherapy. Understanding the extent to which firearm legislation limits legal firearm ownership among people with mental illness can help clinicians identify and respond to situations in which people at high risk for violence may legally own or acquire a firearm. In this article, we discuss three clinical cases and review firearm legislation as it pertains to people with mental illness. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

How Should Physicians Make Decisions about Mandatory Reporting When a Patient Might Become Violent?

Mandatory reporting of persons believed to be at imminent risk for committing violence or attempting suicide can pose an ethical dilemma for physicians, who might find themselves struggling to balance various conflicting interests. Legal statutes dictate general scenarios that require mandatory reporting to supersede confidentiality requirements, but physicians must use clinical judgment to determine whether and when a particular case meets the requirement. In situations in which it is not clear whether reporting is legally required, the situation should be analyzed for its benefit to the patient and to public safety. Access to firearms can complicate these situations, as firearms are a well-established risk factor for violence and suicide yet also a sensitive topic about which physicians and patients might have strong personal beliefs.

Gun Violence Restraining Orders: Alternative or Adjunct to Mental Health-Based Restrictions on Firearms?

The gun violence restraining order (GVRO) is a new tool for preventing gun violence. Unlike traditional approaches to prohibiting gun purchase and possession, which rely on a high threshold (adjudication by criminal justice or mental health systems) before intervening, the GVRO allows family members and intimate partners who observe a relative's dangerous behavior and believe it may be a precursor to violence to request a GVRO through the civil justice system. Once issued by the court, a GVRO authorizes law enforcement to remove any guns in the respondent's possession and prohibits the respondent from purchasing new guns. In September 2014, California's governor signed AB1014 into law, making California the first U.S. state to enact a GVRO law. This article describes the GVRO and the rationale behind the concept, considers case examples to assess the potential impact of the GVRO as a strategy for preventing gun violence, and reviews the content of the California law.

California Firearms Law and Mental Illness.

California provides numerous pathways by which people with mental illness can qualify for a state-level firearm prohibition. The state's involuntary detention for psychiatric treatment, or "5150" (CA W&I Code 5150) process, is often cited as one potential mechanism for reducing violence by dangerous people, though its use is limited to people whose dangerousness is due to a mental illness. Additionally, California has taken legislative steps to prohibit firearm ownership among other people who have an increased risk of violence, regardless of whether or not mental illness is a factor. This article compares the California firearm ownership disqualification system for mental illness with the federal system and those of other states, examines the strengths and weaknesses of this system, and reviews alternatives.

A case of alcohol withdrawal requiring 1,600 mg of lorazepam in 24 hours.

Alcohol withdrawal continues to present significant morbidity and mortality in hospitalized medical/surgical patients. The authors present a case of a patient with delirium tremens requiring up to 1,600 mg/day of lorazepam and discuss alternative treatments for alcohol withdrawal.

Development of a hospice formulary for psychotropic medications.

OBJECTIVE: The authors describe the concept of hospice formulary as is utilized at the hospice service of a university medical center. METHOD: A periodic review of hospice formulary, focusing on psychotropic medications and delirium prevention, was accomplished in 2006. This effort represents a multidisciplinary effort among hospice nursing, internal medicine, and psychiatry. RESULTS: An updated formulary adopting contemporary psychopharmacologic best practices was produced and implemented along with targeted in-service training to nurse clinicians. SIGNIFICANCE OF RESULTS: The modern hospice formulary offers opportunities to offer state-of-the-art psychopharmacological care and minimization of delirium through judicious use of psychopharmacological treatments for the psychiatric comorbidities common in terminally ill patients.