Therapeutic Risk Management and Firearm-related Lethal Means Safety

Impact of a suicide prevention learning module for firearm training courses in Louisiana

BACKGROUND

Firearm suicide is a leading cause of death in the United States. Suicide prevention experts have advocated for upstream interventions that can be implemented prior to the development of suicidal thoughts, particularly those that focus on lethal means safety (LMS; e.g., increasing secure firearm storage). To reach firearm owners with LMS messaging, researchers have developed suicide prevention training content which can be incorporated into firearm training courses. However, no study to date has evaluated impact of such training on firearm course students' subsequent knowledge, attitudes, and openness related to secure firearm storage. Thus, the current study sought to examine both the feasibility and acceptability of a LMS-focused suicide prevention training module among firearm course students, as well as the impact of this module on students' secure firearm storage-related knowledge, attitudes, and openness.

METHODS

Firearm instructors (N = 6) and students in firearm classes (N = 83) were recruited to participate. Students were invited to complete voluntary, anonymous pre- and post-surveys during courses they attended that were led by these instructors. Instructors and students were also invited to complete a brief qualitative interview.

RESULTS

Results indicated that firearm instructors and students in firearm courses found the module feasible and acceptable. Additionally, students' knowledge about the relationship between firearms and suicide, openness to changing firearm storage practices, and endorsement of the importance of discussing firearms and suicide with fellow firearm owners, as well as willingness and confidence to do so, all significantly increased after viewing the module.

CONCLUSIONS

These findings provide strong support for the use of such culturally competent LMS messaging as upstream suicide prevention in settings such as concealed carry courses.

Increasing the Acceptability of Lethal Means Safety Counseling for Firearms: Tips and Scripts

In lethal means safety counseling (LMSC), clinicians encourage patients to limit their access to common and lethal means of suicide, especially firearms. However, previous studies have shown that clinicians may hesitate to deliver this evidence-based intervention, in part because of concerns that patients might not find such discussions acceptable. Based on a published review of 18 qualitative studies examining diverse perspectives on LMSC, we discuss strategies that may help clinicians increase the acceptability of LMSC among their patients and present supporting scripts, rationales, and resources. The studies included in the review examined the perspectives of clinicians, patients, firearm owners, and other relevant groups across a wide range of clinical settings on LMSC for firearms. The authors of these studies recommend that clinicians approach LMSC in a nonjudgmental manner with awareness of their own biases, demonstrate cultural competency by acknowledging the role of firearms in patients' lives, and adapt LMSC to patients' previous experiences with firearms, safety, and injury. Clinicians may also want to contextualize and provide a rationale for LMSC, decide whether or not to directly ask about access to firearms, and recommend a range of storage options tailored to the patient. Free locking devices or discount coupons for purchasing such devices may increase the acceptability and efficacy of these discussions. The strategies recommended in this paper are the first to be based on a comprehensive set of relevant studies. Future research is needed to examine whether these strategies do in fact increase the acceptability of LMSC and promote other outcomes such as increased feasibility and efficacy.

Comorbidity profiles in older patients last seen by mental health prior to suicide attempt

OBJECTIVES

Suicide in late life is a public health concern. Determining profiles of psychiatric/medical comorbidity in those who attempt while engaged in mental health services may assist with prevention. We identified comorbidity profiles and their association with utilization, means, and fatality in a national sample who attempted suicide.

METHODS

Using latent class analysis, all patients aged ≥ 65 from the Department of Veterans Affairs (VA) healthcare services (2012-2018) last seen in mental health prior to suicide attempt were included. Diagnoses and attempt data were obtained from VA and Center for Medicare & Medicaid Services, VA Suicide Prevention Applications Network, and VA National Mortality Data Repository.

RESULTS

2,269 patients were clustered into three profiles, all with high probability of depression. Profiles included minimal comorbidity (50.4%), high medical comorbidity (28.6%), and high (psychiatric/medical) comorbidity (21.0%). Over half (61.7%) attempted suicide within one week of their visit. The class with highest comorbidity had lowest proportion of fatal attempts, while minimal comorbidity class had highest proportion.

CONCLUSIONS

Older patients last seen in mental health prior to suicide attempt were characterized by depression and varying additional comorbidity and attempt-related factors. Findings have implications for risk assessment and intervention in mental health settings, beyond depression.

Let's Talk About Firearms: Perspectives of Older Veterans and VA Clinicians on Universal and Dementia-Specific Firearm Safety Discussions

OBJECTIVES

Veterans experience high rates of fatal and non-fatal firearm injuries. This risk may be compounded among Veterans who are rural-residing, aging, and/or experiencing cognitive decline or dementia. Firearm safety discussions are not broadly implemented across Department of Veterans Affairs (VA) healthcare settings due, in part, to concerns of causing Veterans to disengage from care. This study examines perceptions about firearm safety discussions to inform healthcare-based harm-reduction efforts.

METHODS

We conducted interviews with 34 Veterans (median age 70) and 22 clinicians from four VA facilities that treat high rates of rural patients with firearm-related injuries.

RESULTS

Most Veterans accepted the idea of universal firearm safety discussions at the VA. Some reported they might not be forthright in such discussions, but raising the topic would not stop them from engaging with VA care. Veterans and clinicians unanimously endorsed firearm safety discussions for older patients experiencing cognitive decline or dementia.

CONCLUSIONS

VA patients and clinicians are amenable to firearm safety discussions during healthcare visits and especially endorse the need for such discussions among high-risk populations.

CLINICAL IMPLICATIONS

Universal firearm safety discussions could be incorporated into standard VA practice, particularly for Veterans experiencing cognitive decline or dementia, without risking Veteran disengagement from care.

Lethal Means Counseling for Suicidal Firearm Owners

The death of a patient by suicide is one of the professional events most feared by psychotherapists and firearms are the most commonly used means of suicide. However, as the number of firearm owners within the United States has increased in recent years, so has the risk of firearm-related suicides. Suicidal patients with easy access to their firearms may give in to the wish to die and end their life with little opportunity for reflection or forethought. Furthermore, because the topic of gun control has become so polarized, patients may not always be open to discussing barriers between themselves and their firearms. Nonetheless, psychotherapists using non-judgmental, respectful, and collaborative lethal means counseling can substantially reduce patient suicides.

Lithium Use for Suicide Prevention, Revisited

The literature on lithium's role in suicide prevention is rife with competing interpretations and diverging opinions, in part stemming from the complexity of the underlying literature base. Conclusions that lithium unequivocally offers suicide prevention benefits do not appear warranted based on the strength of existing studies. Given the evidence along with the indisputable risks associated with lithium (especially in overdose), and the need for sustained therapeutic dosing to achieve any theoretical antisuicide benefit, it seems evident that any potential role for lithium in suicide prevention is far narrower than originally hypothesized. As such, the goal of this article is to provide an evidence-informed, therapeutic risk management approach to clinical decision-making concerning the use of lithium for suicide prevention to ensure that such prescribing is done in a patient-centered fashion that mitigates, to the extent possible, the potential risks of lithium use. This includes a review of potential justifications for not employing lithium for suicide prevention, given the recommendations in the existing guidelines. Clinicians should approach this clinical decision in an individualized fashion with full consideration of the potential risks associated with lithium use and availability, as well as potential alternative treatment options. An individualized risk/benefit analysis must also take into consideration the presence of comorbid conditions; the acuity of suicide risk, and any history of self-directed violence, with special attention to suicide attempts via overdose; treatment adherence, past and present; the presence and/or strength of a therapeutic relationship; and other viable treatment options.

Firearm Injury Prevention and Extreme Risk Protection Orders

Extreme risk protection orders (ERPOs) represent a potential mechanism to facilitate firearm-related lethal means safety. ERPOs are a legal mechanism that enables law enforcement to temporarily remove firearms from, and prevent firearm purchase by, an individual who presents a significant danger to self or others, as determined by a court of law. While few jurisdictions currently allow mental health professionals to initiate ERPO petitions, it nonetheless seems important that clinicians be familiar with ERPOs, as clinicians may still serve an important role in disseminating information and facilitating judicious petitions. However, ERPO laws remain quite new, and the implications for mental health professionals when participating (directly or indirectly) in ERPOs remain unclear. This column introduces readers to ERPOs and offers resources to learn more about how ERPOs work across various jurisdictions.