Changes in Firearm and Medication Storage Practices in Homes of Youths at Risk for Suicide: Results of the SAFETY Study, a Clustered, Emergency Department-Based, Multisite, Stepped-Wedge Trial

Improving Identification of Firearm Access in Children With Mental Health Complaints

OBJECTIVE

To determine if electronic medical record (EMR) changes and implementation of a study on firearm storage practices changed identification of firearm exposure in children presenting to a pediatric emergency department (PED) with mental health complaints. We also sought to determine the accuracy of information collected on firearm storage practices.

METHODS

Retrospective study of EMR documentation of firearm exposure in PED patients with mental health complaints from January 20, 2015 until November 20, 2017. EMR changes occurred on January 20, 2016 and the firearms study began on February 13, 2016. The primary outcome was documentation of firearm exposure. Secondary outcomes were documentation of unsafe firearm storage practices. We also examined differences between clinical and research documentation of unsafe firearm storage practices post-intervention. We compared groups using descriptive statistics and chi-squared tests. We used statistical process control to examine the relationship between interventions and changes in outcomes.

RESULTS

5582 encounters were examined. Identification of firearm exposure increased from 11 to 17% postintervention. Identification of unsafe storage practices increased from 1.9% to 4.4% across all encounters. Special cause variation in both metrics occurred concurrently with the interventions. Postintervention, unsafe firearms storage practices in firearm owning families were under-identified (39% identified as not triple-safe in clinical data vs 75% in research data).

CONCLUSIONS

EMR changes and implementation of a firearms study improved identification of firearm exposure and unsafe storage practices in families of PED patients being evaluated for mental health complaints. However, unsafe storage practices continued to be under-identified in firearm-owning families.

A step forward in conceptualizing psychological closeness/distance to suicide methods: A qualitative approach

INTRODUCTION

Suicide is a leading cause of death, making suicide prevention a major public health priority. Increasing understanding of factors influencing suicidal behavior is paramount. Previous research has implicated psychological closeness, characterized by perceptions of how close/distant or attached/detached one feels to a particular object, as a cognitive factor that influences suicidal behavior. However, a better understanding of how psychological closeness to suicide methods is conceptualized by relevant populations is needed to improve its assessment and understand how it may confer risk for suicide.

METHODS

The goal was to refine the conceptualization of psychological closeness to suicide methods by incorporating feedback from relevant populations. We conducted 30 interviews with those primarily identifying as having lived experience of suicide (n = 10), clinicians who work with suicidal patients (n = 11), and suicide researchers (n = 9). A rigorous thematic approach using NVivo software was used to uncover common themes.

RESULTS

Primary themes included familiarity, comfort, and attachment, with one emerging theme of symbolism. We define these themes, provide context to their meaning, and share exemplary quotes across diverse participants.

CONCLUSION

We consider clinical, research, and policy implications from an interdisciplinary lens and discuss the strengths and limitations of this study.

Improving Documentation of Firearm Access During Pediatric Emergency Visits for Suicidal Ideation

BACKGROUND AND OBJECTIVES

Approximately half of youth suicides involve firearms. The promotion of safe firearm storage in the home through lethal means counseling reduces suicide risk. We aimed to increase the documentation of firearm access and storage among children presenting to the emergency department (ED) with suicidal ideation or self-injury to 80% within 13 months.

METHODS

We conducted a multidisciplinary quality improvement initiative to improve the documentation of firearm access and storage among children <18 years old seen in the ED for suicidal ideation or self-injury. The baseline period was February 2020 to September 2021, and interventions occurred through October 2022. Interventions included adding a templated phrase about firearm access to psychiatric social work consult notes and the subsequent modification of the note to include all firearm storage elements (ie, locked, unloaded, separate from ammunition). Statistical process control and run charts were generated monthly to monitor the documentation of firearm access and storage, which was measured through a review of keyword snippets extracted from note text.

RESULTS

We identified 2158 ED encounters for suicidal ideation or self-injury during the baseline and intervention periods. Documentation of firearm access increased from 37.8% to 81.6%, resulting in a centerline shift. Among families who endorsed firearm access, the documentation of firearm storage practices increased from 50.0% to 78.0%, resulting in a centerline shift.

CONCLUSIONS

The modification of note templates facilitated increased documentation of firearm access and storage practices for children with suicidal ideation in the ED. Future studies should assess whether improved documentation is associated with improved storage practices and reductions in firearm suicides after ED encounters.

Patients' Perspectives on Medication-Related Suicide Prevention Interventions Delivered in Emergency Settings

OBJECTIVE

Encouraging patients at risk for suicide to reduce access to potentially lethal medications and drugs is a key component of evidence-based suicide prevention. However, little research has been done to inform interventions for reducing intentional self-harm.

METHODS

Semistructured interviews were conducted with 28 U.S. veterans who sought emergency care from the Veterans Health Administration between 2021 and 2023 to explore veterans' perspectives on medication-related interventions, including opinions on intervention components (e.g., medication return envelopes). Matrix analysis was used to aggregate data into categories, which were predefined by using constructs from the health belief model (e.g., perceived benefits).

RESULTS

The participating veterans generally endorsed interventions as acceptable and were particularly supportive of distributing medication return envelopes. However, they often conceptualized these efforts as steps to prevent unintentional overdose or theft-not necessarily to prevent suicide-and rarely indicated that such interventions were appropriate for themselves. Across the interviews, participants identified important facilitators to care, such as ensuring that interventions were convenient and accounted for the perceived cost of disposing medications. Perspectives on engaging family or friends in interventions were mixed. The importance of the interventions was more readily acknowledged among participants with previous opioid use exposure-perspectives that appeared to stem from lived experiences.

CONCLUSIONS

This study contributes important foundational knowledge that can be used to inform research and clinical initiatives aimed at preventing medication- and drug-related suicides.

Engagement with Preventive Health Behaviors and Safe Firearm Storage Practices Using the 2017 Behavioral Risk Factor Surveillance System

PURPOSE

"Behavioral bundling" is a theory that explains how some health behaviors reinforce one another. This study aims to investigate the relationship between preventive health behaviors (PHBs) and safe firearm storage.

DESIGN

This study used a cross-sectional design using 2017 Behavioral Risk Factor Surveillance Survey data.

SETTING

Survey participants resided in California, Idaho, Kansas, Oregon, Texas, and Utah.

SUBJECTS

There were 12,817 people living in households with a firearm included in this study.

MEASURES

We classified individuals' engagement in 5 PHBs: cholesterol screening, influenza immunization, physical activity, primary care, and seatbelt use. We defined safe firearm storage as storing a firearm unloaded, or loaded but locked.

ANALYSIS

Using Poisson regression models, we calculated adjusted prevalence ratios (aPRs) to estimate the association between engagement in the five PHBs with safe firearm storage.

RESULTS

Most firearm owners reported safe firearm storage (80.3%). The prevalence of safe firearm storage was 3% higher for each additional PHB engaged in (aPR = 1.03 [1.01, 1.05]). There was a higher prevalence of safe firearm storage among those who always wore a seatbelt while driving or riding in a car compared to those who did not (aPR = 1.12 [1.05, 1.18]).

CONCLUSION

This study found preliminary evidence to suggest that engagement in seatbelt usage may be bundled with safe firearm storage, though we are not able to determine causality.

"Your son needs help … and we're gonna help him": A qualitative study of the experiences of gun-owning caregivers of adolescents receiving lethal means counseling in the emergency department

Suicide attempts in adolescents are often transient and unpredictable, making preventative approaches crucial in reducing suicide deaths. One important approach is lethal means counseling (LMC), in which clinicians counsel caregivers to reduce access to methods used in suicide, specifically firearms and medications. Research on LMC has increasingly encouraged the use of the shared decision-making (SDM) model, which emphasizes information exchange, collaborative deliberation, and joint planning between caregivers and clinicians. We examine caregivers' experiences with LMC, using the SDM model as our analytic framework. We conducted qualitative interviews with 21 firearm-owning caregivers of adolescents who came to emergency departments (EDs) in Colorado for a behavioral health complaint. The implementation of LMC at these institutions had three central components: training for clinicians, materials (e.g., lockboxes and pamphlets) to support LMC, and the protocolization of LMC at the institution. Our semi-structured, hour-long interviews examined participants' reflections on and reactions to LMC provided in the ED and how that related to changes in their understanding of their medication and gun storage practices. We analyzed interviews using a phenomenological approach, focusing on experiences with LMC and informed by the tenets of the SDM model. Our analysis revealed that caregivers were receptive to the idea of LMC in the pediatric emergency care setting. Caregivers' engagement in LMC was reinforced by experiences with clinicians who sought to understand the circumstances of their household, shared the motivation behind LMC, and facilitated conversation around a shared concern for the child's safety. In contrast, counseling delivered mechanically and without considering the household context was tied to caregivers' confusion and alienation, both for LMC and their consideration of changes to home storage practices. These findings provide insight into adolescent caregivers' experiences with LMC implemented in EDs and how LMC may best be approached.

Utilizing the Electronic Medical Record to Enhance Health Care Provider Delivery of Messages About the Safe Storage of Firearms

The goal of this project was to determine whether screening youth and parents for firearm presence and imbedding those results in the electronic medical record (EMR) increased health care provider (HCP) documentation of firearms and subsequent delivery of a safe storage message. The study took place in a large adolescent medicine practice. Fifty-six dyads (40% of eligible) were randomized to usual care or the intervention, in which screening results for firearms were imbedded in the EMR. Health care providers delivered a safe storage message to 20% of controls and 51.2% in the intervention (P = .04). When HCPs documented the delivery of a safe storage message, 64% of parents recalled hearing it, compared with only 36% when there was no documentation (P = .012). Therefore, we found that incorporating firearm screening into the EMR increases the attention HCPs give to delivering a firearm safe storage message and correlates with parents recalling having heard a safe storage message.

A National Survey of Pediatricians' Experiences and Practices With Suicide Prevention

OBJECTIVE

Describe pediatricians' experiences, attitudes, and practices around suicide prevention within primary care, and examine associations between pediatricians' experiences and practices.

METHODS

The nationally representative Periodic Survey of American Academy of Pediatrics members provided data on pediatricians' patient experience with suicide risk, perceived barriers to screening for suicidal ideation (SI), preparedness to counsel about suicide prevention, interest in learning more about suicide prevention strategies, and frequency of screening for and managing suicidal ideation. Multivariable analyses examined the effect of having a patient die by or attempt suicide on screening practices.

RESULTS

A total of 41% responded to the survey with 377 respondents in the analytic sample. A total of 93% of pediatricians had a patient screen positive for SI and 81% had a patient attempt or die by suicide. A total of 61% always screened for SI and 63% reported using a standardized depression screening tool and 9% a suicide-specific tool. Respondents who had a patient attempt or die by suicide were more likely to screen for SI (OR, 2.05, 95% CI, 1.16-3.63) and use a standardized depression screening instrument (OR, 2.34, 95% CI, 1.29-4.24). Patient reluctance to discuss mental health was the most frequently cited barrier (51%) followed by lack of time (49%) and lack of treatment options (43%). Over 90% of respondents assessed for a plan and referred to mental health services when suicidal ideation was identified.

CONCLUSION

Although pediatricians frequently see patients with suicide risk, 39% do not always screen for SI. Educational efforts are needed to improve pediatricians' assessment and management of suicide risk given new guidelines.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) visits of children and youth to emergency departments are increasing in the United States. Reasons for these visits range from suicidal ideation, self-harm, and eating and substance use disorders to behavioral outbursts, aggression, and psychosis. Despite the increase in prevalence of these conditions, the capacity of the health care system to screen, diagnose, and manage these patients continues to decline. Several social determinants also contribute to great disparities in child and adolescent (youth) health, which affect MBH outcomes. In addition, resources and space for emergency physicians, physician assistants, nurse practitioners, and prehospital practitioners to manage these patients remain limited and inconsistent throughout the United States, as is financial compensation and payment for such services. This technical report discusses the role of physicians, physician assistants, and nurse practitioners, and provides guidance for the management of acute MBH emergencies in children and youth. Unintentional ingestions and substance use disorder are not within the scope of this report and are not specifically discussed.

Access to Firearms: Initiation of Firearm Screening Among Psychiatric Patients in a Pediatric Emergency Department

OBJECTIVE

Increase provider screening rates for firearm access among patients presenting to the pediatric emergency department (PED) for a psychiatric chief complaint.

METHODS

In this resident-driven quality improvement project, a retrospective chart review examined firearm access screening rates among patients presenting to the PED with the chief complaint of "psychiatric evaluation." After establishing our baseline screening rate, the first phase of our plan, do, study, act (PDSA) cycle included implementing Be SMART education for pediatric residents. We made Be SMART handouts available in the PED, created electronic medical record (EMR) templates to facilitate documentation, and emailed routine reminders to residents during their PED block. In the second PDSA cycle, the pediatric emergency medicine (PEM) fellows expanded our efforts to increase project awareness from a supervisory role.

RESULTS

The baseline screening rate was 14.7% (50 of 340). After PDSA 1, a center line shift occurred, and screening rates increased to 34.3% (297 of 867). After PDSA 2, screening rates increased to 35.7% (226 of 632). In the intervention phase, providers who received training screened 39.5% (238 of 603) of encounters versus providers who did not receive training screened 30.8% (276 of 896) of encounters. Of all encounters screened, 39.2% (205 of 523) screened positive for in-home firearms.

CONCLUSIONS

We improved firearm access screening rates in the PED using provider education, EMR prompts, and PEM fellow participation. Opportunities remain to promote firearm access screening and secure storage counseling in the PED.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure; challenges with timely access to a mental health professional; the nature of a busy ED environment; and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affect patient care and ED operations. Strategies to improve care for MBH emergencies, including systems-level coordination of care, are therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Screening and Assessing Suicide Risk in Medical Settings: Feasible Strategies for Early Detection

Early detection of risk is a key suicide prevention strategy. Given that most individuals who die by suicide visit a health care provider in the year leading up to their death, medical settings are ideal venues for identifying those at elevated risk and bridging them to life-saving care. Clinicians are presented with an opportunity to engage in proactive suicide prevention efforts through practical and adaptable suicide risk screening, assessment, and management processes. Psychiatrists and mental health clinicians are well positioned to assist nonpsychiatric clinicians on the frontlines of this public health problem. This article discusses the importance of identifying people at elevated suicide risk through screening, differentiates screening from assessment procedures, and presents practical strategies for implementing evidence-based screening and assessment tools into practice as part of a three-tiered clinical pathway. Specifically, this article discusses key components that guide embedding suicide prevention strategies into the workflows of busy medical settings.

Youth Firearm Injury: A Review for Pediatric Critical Care Clinicians

Firearms are now the leading cause of death among youth in the United States, with rates of homicide and suicide rising even more steeply during the SARS-CoV-2 pandemic. These injuries and deaths have wide-ranging consequences for the physical and emotional health of youth and families. While pediatric critical care clinicians must treat the injured survivors, they can also play a role in prevention by understanding the risks and consequences of firearm injuries; taking a trauma-informed approach to the care of injured youth; counseling patients and families on firearm access; and advocating for youth safety policy and programming.

Interactions at the point of firearm purchase and subsequent use of locking devices

BACKGROUND

Firearms account for over 40,000 deaths in the USA each year in addition to thousands of nonfatal injuries. One notable prevention strategy for firearm-related fatalities and nonfatal injuries is safe storage. Safe storage of firearms emphasizes using storage mechanisms that limit ready access of firearms to unauthorized users. Cable locks are one safe storage option that is easy to access and typically free, as they are included in many firearms sales. The present study examined the extent to which firearms retailers notifying purchasers at the point of sale about the included cable locks was associated with subsequent locking device use in two large samples and three subsamples. Exploratory analyses then examined demographic factors associated with frequency of seller notification of locks.

METHODS

Sample 1 included 1203 firearm owners and sample 2 included 1556 firearm owners. Subsamples were drawn from sample 2 to examine if there were differences by state. The three subsamples included firearm owners from Minnesota (n = 515), Mississippi (535), and New Jersey (506). Logistic regressions were used to examine the association between frequency of sellers notifying buyers of locks and subsequent locking device use. Linear regressions were used to examine what demographic factors were associated with greater frequency of seller notification of locking devices.

RESULTS

Results indicated a general trend such that more frequent notification of cable locks at the point of purchase was associated with greater likelihood of using locking devices to secure firearms. At the subsample level, these findings were most consistent for Mississippi relative to Minnesota and New Jersey. Exploratory analyses generally indicated those who were younger and those living in more densely populated areas were more likely to be notified about cable locks at the point of purchase.

CONCLUSIONS

These findings suggest that interactions about cable locks at the point of firearm purchase has an impact on firearm storage behaviors. Such results indicate that encouraging firearm retailers to have these discussions with those purchasing firearms might be an important strategy for preventing firearm-related fatalities and nonfatal injuries.

A Web-Based Decision Aid for Caregivers of Persons With Dementia With Firearm Access (Safe at Home Study): Protocol for a Randomized Controlled Trial

BACKGROUND

Firearm safety among individuals with Alzheimer disease and related dementias (ADRD) is an underdiscussed and underresearched concern in the United States, especially given the growing population of community-dwelling adults with ADRD. The "Safety in Dementia" (SiD) web-based decision aid was developed to support caregivers in addressing firearm access; the efficacy of SiD is unknown.

OBJECTIVE

Through the SiD decision aid, the Safe at Home (S@H) study aims to support caregivers in making decisions about home safety that align with their goals and values, and behaviors regarding firearm access for persons with ADRD and firearm access.

METHODS

The S@H study is a 2-armed randomized controlled trial to test the effect of the SiD decision aid on caregivers of community-dwelling adults with ADRD who have firearm access. S@H aims to recruit 500 ADRD caregivers (age ≥18 years, fluent in English or Spanish, and in the United States) through online or social media advertisements and through relevant organizations. Participants are randomized to view SiD or a control website at their own pace; all participants complete web-based questionnaires at baseline, 2 weeks, 2 months, and 6 months. The primary outcome is immediate preparation for decision-making; secondary outcomes include longitudinal decision outcomes and self-reported modifications to firearm access. The relative reach and effectiveness of each recruitment method (online/social media and through relevant organizations) will be assessed by examining differences in caregiver participation, retention rates, and relative cost.

RESULTS

The study enrollment began in May 2022. As of December 2022, a total of 117 participants had enrolled.

CONCLUSIONS

The S@H study is the first randomized trial of a firearm safety decision aid for ADRD caregivers. The results from this study will inform how best to support caregivers in decision-making regarding firearm safety. Further, results may guide approaches for recruiting caregivers and for dissemination of resources.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05173922; https://clinicaltrials.gov/ct2/show/NCT05173922.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43702.

An intervention to improve safe firearm storage for adolescents presenting with suicide ideation or attempt in a pediatric emergency department

BACKGROUND

Firearm injuries are the second leading cause of death in American youth aged 15 to 24, and over half of these deaths are suicides. Self-harm deaths in Wisconsin among adolescents have increased by 34% since 2006. Each year, our pediatric emergency department (ED) staff care for over 1100 children and adolescents who present with suicidal ideation or self-harming behaviors. We implemented an ED-based program aimed at improving the education given to families on reducing self-directed violence and providing firearm storage devices to families with the goal of reducing access to lethal means.

PROGRAM DESCRIPTION

Our program takes place in the pediatric ED of an academic children's hospital and seeks to assist families of all patients who present with suicidal ideation or suicide attempt (SI/SA). In collaboration with our social workers, we reviewed their processes for interviewing and counseling families of patients who present with SI/SA. Social workers previously used a hospital-wide patient and family education sheet for safety planning that included information about safely storing medications and community mental health services. We teamed with our hospital's health literacy and education committees and revised the teaching sheet to include more in-depth information about safe firearm storage. For families who were interested, we developed a process to provide up to two firearm lockboxes equipped with a combination lock. Working with risk management, the parent injury prevention product liability form was updated to include firearm lockboxes.

CONCLUSION

We implemented a safe firearm storage program including development of a patient and family education sheet and provision of firearm lockboxes to families. Next steps under consideration include providing lockboxes for safe medication storage and establishing a follow-up system to assess proper use of firearm lockboxes and family and social worker satisfaction.

Identifying and Managing Suicidality in Children and Adolescents with Chronic Pain: Evidence-Based Treatment Strategies

Children and adolescents with chronic pain are at an increased risk of suicidality. This narrative review article aims to inform clinical practice in the assessment and management of suicidality in youth with chronic pain. The article begins with a survey of the background and prevalence of youth with chronic pain. A review of the current evidence behind the increased risk of suicidality in youth with chronic pain follows. Contextualization of this data with general tenets of child and adolescent suicide risk and risk assessment is provided. Suicidology theory including the interpersonal theory of suicide is overviewed to help clinicians to conceptualize the reviewed data. Guiding parameters for the suicide risk assessment and management planning is presented. Concluding recommendations are made to guide clinical practice in the assessment and management of suicidality in youth with chronic pain.

Reducing access to means for suicidal youth presenting to emergency services: A test of medication lock bag distribution

OBJECTIVE

Emergency departments (ED) provide psychiatric assessments to approximately 4000 youth annually. While most are discharged home, they are not without risk. To improve safety, this study examined the distribution of medication lock bags (MLB) to caregivers of youth discharged following an emergency evaluation.

METHOD

The objective was to evaluate caregiver attitudes and behaviors related to the bag and perceptions of whether the MLB enhanced their youth's safety. MLB distribution was limited to patients who had presented with recent or current non-suicidal self-injurious behavior, suicidal ideation, or a suicide attempt.

RESULTS

Caregivers were contacted for a phone survey and asked components of their MLB experience. Of the 119 caregivers offered the MLB, 114 accepted and 5 declined. Results indicate that caregivers found the most positive aspects of the bag to include the "Bag is Secure" (39%) and "Safety of Child and Family" (31%). Parents found the most negative aspects of using the bag to be "Nothing" (30%) and "Size" (21%).

CONCLUSION

These results suggest most caregivers will accept and use MLBs when it is provided during a psychiatric ED evaluation. Further, data suggests caregivers find the bag to be easy to use and that it provides them with a sense of safety/security.

Who owned the gun in firearm suicides of men, women, and youth in five US states?

One way to reduce firearm suicide is to keep household guns away from a person at risk for suicide. To learn who owned (and presumably controlled access to) the guns used in suicide and which broad gun type they were, we examined National Violent Death Reporting System (NVDRS) data from 2015 to 2017 for five US states that supplied information on gun owner in over 80% of firearm suicides (AK, IA, NH, UT, WI). For adult males, 88% used their own gun; for women, 52% used their own gun and 32% used their partner's gun; for youth ages 18-20, 42% used their own gun, 43% used a family member's, and 8% used a friend's; for children, 19% used their own gun (usually a long gun) and 79% used a family member's gun. Almost 3/4 of firearm suicides involved a handgun, ranging from 62% for youth to 92% for women. In times of suicide risk, interventions for a youth should address not only the parents' guns, but those of other family members and the youth's own rifle or shotgun. For a woman, interventions need to address her own and her partner's guns. For a man, locking guns alone will confer little protection if he controls the keys or combination. Storing firearms-or a critical component-away from home or having someone else control the locks may be safer. Five NVDRS states provided useful data on who owned the gun used in firearm suicides. More NVDRS states should follow suit.

Firearm-Related Injuries and Deaths in Children and Youth: Injury Prevention and Harm Reduction

Firearms are the leading cause of death in children and youth 0 to 24 years of age in the United States. They are also an important cause of injury with long-term physical and mental health consequences. A multipronged approach with layers of protection focused on harm reduction, which has been successful in decreasing motor vehicle-related injuries, is essential to decrease firearm injuries and deaths in children and youth. Interventions should be focused on the individual, household, community, and policy level. Strategies for harm reduction for pediatric firearm injuries include providing anticipatory guidance regarding the increased risk of firearm injuries and deaths with firearms in the home as well as the principles of safer firearm storage. In addition, lethal means counseling for patients and families with individuals at risk for self-harm and suicide is important. Community-level interventions include hospital and community-based violence intervention programs. The implementation of safety regulations for firearms as well as enacting legislation are also essential for firearm injury prevention. Increased funding for data infrastructure and research is also crucial to better understand risks and protective factors for firearm violence, which can then inform effective prevention interventions. To reverse this trend of increasing firearm violence, it is imperative for the wider community of clinicians, public health advocates, community stakeholders, researchers, funders, and policy makers to collaboratively address the growing public health crisis of firearm injuries in US youth.

Firearm-Related Injuries and Deaths in Children and Youth

Firearms are the leading cause of death in children and youth 0 to 24 years of age in the United States. In 2020, firearms resulted in 10,197 deaths (fatality rate 9.91/100,000 youth 0-24 years old). Firearms are the leading mechanism of death in pediatric suicides and homicides. Increased access to firearms is associated with increased rates of firearm deaths. Substantial disparities in firearm injuries and deaths exist by age, gender, race, ethnicity, and sexual orientation and gender identity and for deaths related to legal intervention. Barriers to firearm access can decrease the risk to youth for firearm suicide, homicide, or unintentional shooting injury and death. Given the high lethality of firearms and the impulsivity associated with suicidal ideation, removing firearms from the home or securely storing them-referred to as lethal means restriction of firearms-is critical, especially for youth at risk for suicide. Primary care-, emergency department-, mental health-, hospital-, and community-based intervention programs can effectively screen and intervene for individuals at risk for harming themselves or others. The delivery of anticipatory guidance coupled with safety equipment provision improves firearm safer storage. Strong state-level firearm legislation is associated with decreased rates of firearm injuries and death. This includes legislation focused on comprehensive firearm licensing strategies and extreme risk protection order laws. A firm commitment to confront this public health crisis with a multipronged approach engaging all stakeholders, including individuals, families, clinicians, health systems, communities, public health advocates, firearm owners and nonowners, and policy makers, is essential to address the worsening firearm crisis facing US youth today.

Affecting children’s knowledge about rational use of medicines using read-along videos of pictorial storybooks

Although efforts have been taken to educate the public about medication from a very young age, there are very limited availability and accessibility of education material for children. The aim of this study is to assess the impact of read-along videos of pictorial storybooks on children’s knowledge about rational use of medicines. This study compared pre and post knowledge scores in a nonrandomized, one-group pre-test-post-test experimental design. Pre-recorded read-along storytelling videos were used as intervention covering two topics on rational use of medicine -medicine storage and antibiotic resistance. The questionnaire and intervention videos were distributed using Google Forms to children aged six and seven in Malaysia via online social media platforms. 521 children completed the study. The mean baseline knowledge score for medication storage was 4.89 (SD = 1.12) pre-test and 5.44 (SD = 0.78) post-test while for antibiotic resistance the mean was 3.616 (SD = 1.340) pre-test and 4.820 (SD = 1.134) post-test. A Wilcoxon signed-rank test showed statistically significant changes on medication storage (Z = −10.21, p < 0.001) and antibiotic resistance (Z = −14.869, p < 0.001) related knowledge among children. Pictorial storybook read-along video interventions were shown to be effective in improving children’s knowledge on rational use of medicine. Education and awareness on the use of antibiotics should be prioritized.

Reducing Firearm Injury and Death in the United States

Firearms injury is a major cause of American morbidity and mortality. Although the firearm is a common vector, the intentions with which it is used represent a wide array of social ills-suicide, community violence, domestic violence, mass shootings, legal intervention, and unintended injury. The political and social underpinnings of this epidemic are inseparable from its prevention measures. Surgeons have an important role in firearm policy, research, prehospital and hospital advances, trauma survivor networks, and hospital-based violence prevention programs. It is only through interdisciplinary, multilevel, evidence-based prevention measures that the tides will turn on American firearm injury.

Youth gun carrying and household firearm ownership in 22 US states

Youth gun carrying is associated with a range of adverse outcomes, including increased risks for homicide, suicide, school disciplinary problems, and criminal legal involvement. In this study we examined the association between state-level household firearm ownership rates and the odds of past-year gun carrying among high-school-aged youth. Using survey-weighted multivariable logistic regression models, results showed that each 1% point increase in state-level gun ownership was associated with a 2.7% (95% confidence interval [CI] = [1.1%, 4.2%], p = 0.001) increased odds of youth gun carrying, controlling for histories of school-based victimization, physical fighting, and substance use. Among a subset of weapon-carrying youth, state-level firearm availability was a significant factor in determining whether the weapon carried was a gun or a less lethal (i.e., nonfirearm) weapon (odds ratio = 1.021, 95% CI = [1.005, 1.038], p = 0.01). These findings show that firearm availability confers additional risk for youth gun carrying beyond the psychosocial risks emphasized in prior research and efforts to restrict youth access to firearms might be particularly important, especially in communities with high levels of household gun ownership.

Selection and Use of Firearm and Medication Locking Devices in a Lethal Means Counseling Intervention

Background: While some suicide prevention initiatives distribute locking devices for firearms and medication, little evidence exists to guide the selection of devices. Aims: This study aimed to describe safety standards for locking devices and compare parental acceptance rates for different types of devices. Method: As part of the larger SAFETY Study, behavioral health clinicians provided free locking devices to parents whose child was evaluated in the emergency department (ED) for a suicide-related or behavioral health-related problem. For logistical reasons, we changed the specific devices offered midstudy. Data on device use came from follow-up interviews with 226 parents. Results: Few effective standards exist for locking devices for home use; we could easily break into some. At follow-up, twice as many gun-owning parents were using ED-provided handgun lockboxes as cable locks (28% vs. 14%, p = .02). Overall, 55% of parents reported using an ED-provided medication lockbox, with more using the drawer-sized lockbox than the larger, steel toolbox (60% vs. 42%, p < .01). Limitations: Storage outcomes are from parents' self-report and from one state only. Conclusion: Parents appeared to prefer some devices over others. Our findings suggest the need for (a) effective safety standards, (b) affordable devices meeting these standards, and (c) further research on consumer preferences to ensure use.

The Recent Rise of Suicide Mortality in the United States

Suicide is a major public health concern in the United States. Between 2000 and 2018, US suicide rates increased by 35%, contributing to the stagnation and subsequent decrease in US life expectancy. During 2019, suicide declined modestly, mostly owing to slight reductions in suicides among Whites. Suicide rates, however, continued to increase or remained stable among all other racial/ethnic groups, and little is known about recent suicide trends among other vulnerable groups. This article (a) summarizes US suicide mortality trends over the twentieth and early twenty-first centuries, (b) reviews potential group-level causes of increased suicide risk among subpopulations characterized by markers of vulnerability to suicide, and (c) advocates for combining recent advances in population-based suicide prevention with a socially conscious perspective that captures the social, economic, and political contexts in which suicide risk unfolds over the life course of vulnerable individuals.

Motivating Behavior Change in Parents for Suicide Prevention in the Midwest, USA

Safe storage of lethal means is an evidence-based approach to suicide prevention that is underutilized. This naturalistic study investigated whether a presentation on parenting teenagers that includes education about safe storage of firearms and medications, paired with tools to enact change, can impact storage practices. Ten community presentations for parents were given between November 2018 and September 2019 in the Midwest region of the United States. Multiple topics pertinent to parenting adolescents were included with an emphasis on safe storage of firearms and medications to reduce suicide risk. Toolkits including medication storage boxes and cable gun locks were offered to help parents enact recommended changes. Surveys were completed prior to the presentation (T1), immediately following the presentation (T2), and 2 weeks after the presentation (T3). Five-hundred eighty-one parents comprised the initial study sample, of whom 410 (70.6%) completed the primary study endpoint. Generalized linear mixed models with and without worst-case imputation were used to evaluate changes in safe storage practices. Results suggested the odds of storing firearms in the safest manner possible increased 5.9 times (95% CI 2.6-13.5, p < 0.001) without imputation and increased 2.0 times (95% CI 1.1-3.4, p = 0.02) with the worst-case imputation. Among participants with unlocked medications at baseline, 56.5% reported they had disposed of old medications and 53.0% reported locking up bottles of medication by the primary study endpoint. This study provides preliminary evidence that safe storage education paired with tools for behavior change motivates parents to enact safe storage measures.

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.

'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.

Impact of a Firearm Safety Device Distribution Intervention on Storage Practices After an Emergent Mental Health Visit

OBJECTIVE

To determine if providing firearm storage devices with training during clinical care improves safe storage practices in household members of children who present to a pediatric hospital with an emergent mental health complaint.

METHODS

Prospective, pre-post study. Enrollment occurred in the emergency department or the inpatient psychiatric unit. Participants in the observation phase received usual care. Participants in the intervention phase were randomized to be offered a firearm storage device at either no or low ($5) cost and trained in its use. We surveyed participants at enrollment, 7, & 30 days post visit. Our primary outcome was triple-safe storage (TSS) - storing firearms unloaded, locked, and with ammunition stored and locked separately.

RESULTS

About 256 participants enrolled. In the observation phase TSS increased from 21% (95% confidence interval [CI] 14%-30%) at baseline to 31% (95% CI 21%-42%) at 7 and 31% (95% CI 21%-43%) at 30 days. In the intervention phase, TSS increased from 32% (95% CI 25%-39%) at baseline to 56% (95% CI 48%-64%) at 7 and 56% (95% CI 47%-64%) at 30 days. Among those not practicing TSS at baseline, 7-day TSS was higher in the intervention (38%) versus the observation phase (14%, P = .001).

CONCLUSIONS

Distribution and training in the use of firearm storage devices increased TSS in the study population, improves pediatric safety and should be part of the routine care of these high-risk patients.

Editorial: Household Firearms, Child Access Prevention Laws, and Adolescent Suicide

In the United States, suicide is the second leading cause of death among adolescents aged 14-18 years, and the rate of suicide increased 61% from 2009 to 2018.¹ During that period, 15,951 14- to 18-year-olds died by suicide, with 6,794 deaths (42.6%) occurring with a firearm.¹ Most firearm suicide deaths in adolescents occur in the home with a firearm owned by the parent.² An aspirational goal of the National Strategy for Suicide Prevention is to reduce access to lethal means that people use to attempt suicide. The American Foundation for Suicide Prevention has identified firearms as one of 4 critical areas to address in Project 2025, the nationwide initiative to reduce the suicide rate 20% by 2025.³.

Firearms storage safety discussions in VA primary care: Staff perspectives

OBJECTIVE

To describe VHA primary care clinician and staff perspectives on conducting firearms storage safety (FSS) discussions in primary care, and to identify key approaches for primary care teams to facilitate FSS conversations.

METHOD

Qualitative analysis of transcripts and notes from focus groups with VA primary care staff and individual semi-structured interviews with primary care clinicians. One hundred-seven VHA primary care team members participated in one of four focus groups or individual semi-structured interviews (n = 5).

RESULTS

FSS discussions are perceived as within the purview of primary care. Primary care staff also outlined five tools and processes needed to meaningfully implement FSS discussions in primary care: training on firearms and firearms culture; examining personal attitudes toward firearms; developing supplemental materials to normalize and support FSS discussions; increasing knowledge of firearms laws and regulations; and providing scripts to facilitate conversations.

CONCLUSIONS

Conducting FSS discussions in primary care settings is perceived as an acceptable practice, yet care teams identified barriers and suggestions for overcoming implementation challenges.

Adolescent Suicide, Household Firearm Ownership, and the Effects of Child Access Prevention Laws

OBJECTIVE

This study has 3 objectives: to examine the association between state-level firearm ownership and suicide among adolescents of high school age; to compare the strength of the firearm ownership-suicide association among adolescents relative to adults; and to evaluate the relationship between 11 child access prevention (CAP) laws and suicide.

METHOD

Using an ecological time series cross-sectional design, we modeled suicide rates from January 1, 1991, to December 31, 2017, as a function of household firearm ownership and states' implementation of CAP provisions using fixed effect negative binomial models.

RESULTS

There were 37,652 suicides among adolescents between the ages of 14 and 18 years during the study period, and more than half of all suicides (51.5%, n = 19,402) involved firearms. Each 10 percentage-point increase in states' firearm ownership was associated with a 39.3% (35.1%-43.5%) increase in firearm suicide, which in turn contributed a 6.8% (2.5%-11.1%) increase in all-cause suicide. The association between firearm ownership and suicide was approximately 2 times stronger among adolescents relative to adults. Policies mandating locks and safe storage were associated with a 13.1% (2.7%-22.3%) reduction in adolescent firearm suicide and an unexplained 8.7% (1.2%-15.7%) reduction in non-firearm suicide. CAP provisions were associated with reduced firearm suicide across the lifespan, but effects were stronger among adolescents.

CONCLUSION

There is an increased risk of adolescent suicide associated with household firearm ownership, and safe storage provisions are associated with decreased adolescent firearm suicide.

Lethal Means Counseling for Suicidal Adults in the Emergency Department: A Qualitative Study

Introduction

Lethal means counseling (to reduce access to firearms or other suicide methods) is a recommended critical yet challenging component of care of suicidal patients. Questions remain about communication strategies for those in acute crisis.

Methods

This qualitative study was an analysis of semi-structured interviews with English-speaking, community-dwelling adults with a history of lived-experience of suicidal ideation or attempts in themselves or a family member. We used a mixed inductive and deductive approach to identify descriptive themes related to communication and decision-making.

Results

Among 27 participants, 14 (52%) had personal and 23 (85%) had family experience with suicide ideation or attempts. Emergent themes fell into two domains: (1) communication in a state of high emotionality; and (2) specific challenges in communication: initiating, maintaining engagement, considering context.

Conclusion

Engaging suicidal individuals in lethal means counseling may be more effective when messaging and approaches consider their emotional state and communication challenges.

Perceived Access to Handguns Among Colorado High School Students

OBJECTIVES

Access to firearms among youth can increase the risk of suicide or other injury. In this study, we sought to estimate the population prevalence of adolescent perception of firearm access by demographic, geographic, and other individual health characteristics.

METHODS

The 2019 Healthy Kids Colorado Survey was an anonymous survey administered to a representative sample of high school students in Colorado. The survey was used to assess health behaviors and risk and protective factors. Analysis was conducted with weights to the state population of public high school students.

RESULTS

In total, 46 537 high school students responded (71% student response rate; 83% school response rate). One in 5 students said it was "sort of easy" (11.1%) or "very easy" (8.8%) to access a handgun, with higher prevalence among male and older-aged youth and differences in racial and/or ethnicity groups. There were geographic differences such that students in schools in more rural areas were more likely to report perceived easy access. Students who had felt sad or hopeless, attempted suicide, or been in a fight were more likely to say they had access to a handgun.

CONCLUSIONS

A relatively high proportion of youth have easy access to a firearm, with differences across age, sex, race and/or ethnicity, and geography. This highlights the need for efforts to address ways to reduce firearm access for youth, including secure storage at home, for the prevention of youth firearm suicide and other firearm injuries.

An examination of preferred messengers on firearm safety for suicide prevention

This study sought to determine differences in preferred messengers on the topic of safe firearm storage and suicide prevention between firearm owners and non-firearm owners, and among firearm owners of different racial groups and sexes. Participants were 6200 United States residents recruited via Qualtrics Panels to complete an online survey. Data were collected during March 2020. The total sample and all subsamples ranked law enforcement, current military personnel, and military veterans as the top three most credible sources to discuss firearm safety for suicide prevention. Significant differences existed among the mean ranking of sources between firearm owners and non-firearm owners as well as between several subgroups of firearm owners. The identical ranking of the top three sources indicates that these groups agree on the relative credibility of multiple sources, although the average level of credibility for particular sources may vary. These findings highlight that the effectiveness of messaging on safe firearm storage may hinge on the identity of the individual delivering the message and provide an initial roadmap for how to consider packaging specific messages.

Parent and Adolescent Reports of Adolescent Access to Household Firearms in the United States

IMPORTANCE

Adolescent access to firearms increases their risk of firearm injury.

OBJECTIVE

To examine adolescent firearm access in homes with guns, how storage may modify access, and discordance between parent and adolescent report of access.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used data on parents and their adolescent children from a nationally representative online survey of adults in gun-owning households, conducted from June 30 to August 11, 2019. Individuals who owned firearms and parents of adolescents were oversampled. All parents living with a child aged 13 to 17 years were invited to have their child participate in a separate survey. Respondents with more than 1 adolescent living with them were asked to choose the child with the most recent birthday. Analyses were conducted from June 1, 2020, to January 4, 2021.

MAIN OUTCOMES AND MEASURES

Firearm access was assessed by asking adolescents how long it would take to access a loaded gun in their home. Parents were asked whether their child could independently access a household firearm. Individuals who owned guns reported firearm storage practices. Study-specific poststratification weights adjusted for survey nonresponse and undercoverage or overcoverage resulting from the study-specific sample design and for benchmark demographic distributions.

RESULTS

Of 6721 adults invited to participate, 4030 completed the survey. Of these, 280 had a firearm in their homes and had a child aged 13 to 17 years who participated in the survey. The mean (SD) age of parents was 45.2 (7.2) years; of children, 15.0 (1.4) years. The sample included 159 male adolescents (weighted percentage, 60.8%; 95% CI, 53.8%-67.8%) and 129 male adults (weighted percentage, 48.3%; 95% CI, 40.9%-55.6%). In 33.9% (95% CI, 26.7%-41.2%) of households, an adolescent reported that they could access a loaded firearm in less than 5 minutes. In homes where all guns were locked, 23.7% (95% CI, 12.3%-35.1%) of adolescents reported that they could access a loaded firearm in less than 5 minutes. Overall, 70.4% (95% CI, 63.7%-77.1%) of parents reported that their child could not access a household firearm. In households where parents said their child could not access a firearm, 21.8% (95% CI 13.8%-29.7%) of their children indicated that they could access a firearm within 5 minutes and 14.9% (95% CI, 8.9%-20.9%) indicated that they could access a firearm in more than 5 minutes but less than 1 hour.

CONCLUSIONS AND RELEVANCE

In this study, many adolescents reported having ready access to loaded guns in their homes, even when all household firearms were locked. Many adolescents who reported having access to household firearms lived with parents who knew their children had access, but others lived with parents who did not know. These finding should inform prevention efforts aimed at reducing adolescent access to household firearms.