Physicians urged to broaden suicide prevention by addressing access to guns with patients

Posted By News On September 3, 2008 - 9:30pm

Boston, MA -- In an effort to create safer environments for potentially suicidal individuals, researchers at Harvard School of Public Health demonstrate how physicians can broaden their treatment of such patients to address not only their mental illness but also the patients' access to guns and other lethal means. Such an approach could dramatically reduce suicide fatalities.

The article "Guns and Suicide in the United States," appears as a Perspective in the September 4, 2008 issue of The New England Journal of Medicine (NEJM).

"The temporary nature and fleeting sway of many suicidal crises is evident in the fact that more than 90% of people who survive a suicide attempt do not go on to die by suicide," write the authors. "A suicide attempt with a firearm rarely affords a second chance."

Suicide is the second-leading cause of death among Americans 40 years old or younger according to the most recent statistics available. And among Americans of all ages, more than half of all completed suicides are gun suicides. Additionally, an estimated one-third to four-fifths of all suicide attempts, according to studies, are impulsive--with 24% taking less than 5 minutes between the decision to kill themselves and the actual attempt, while 70% took less than 1 hour. Keeping suicidal individuals away from lethal means during these crisis periods is crucial. Attempts involving drugs or cutting, which account for more than 90% of all suicidal acts, prove fatal far less often than firearms.

The researchers provide a website at the Harvard Injury Control Research Center at HSPH http://www.hsph.harvard.edu/means-matter/index.html that can guide physicians in how to assess a patient's access to lethal means, including how to approach family members about the possible presence of a gun in the home. Given the self-limiting nature of suicidal crises, often caused by an immediate stressor, such as the breakup of a romantic relationship, the loss of a job or a run-in with police, physicians are in the position of being able to help prevent many completed suicides by intervening to get firearms out of their patients' reach during these critical periods. Some tactics may be to suggest to family members that the firearms be moved out of the house temporarily or locked and stored more securely.

"The suicide prevention field is where the motor vehicle safety movement was 50 years ago, and the patient safety movement 20 years ago: The focus of prevention is almost exclusively on the individual," said Matthew Miller, assistant professor of health policy and management and lead author of the NEJM Perspective article. "Psychiatrists, psychologists and other medical professionals tend naturally to focus on the mental health of the individual patient, one patient at a time."

Miller continued: "We are proposing a population-based approach to reducing suicide. This approach recognizes that the physical environment (e.g., the availability of household guns in the U.S., the toxicity of pesticides in Sri Lanka, a frequent method of suicide there) can have a profound effect on the likelihood of completed suicide--and that the physical environment can be modified to save lives. This approach is based on understanding that the number of Americans who die each year can be reduced not only by reducing the rate at which Americans attempt suicide (the traditional target of screening and treatment prevention efforts) but also, and perhaps most dramatically, by making it less likely that suicide attempts prove fatal. One of the best ways to reduce the probability that an impulsive suicidal act proves fatal is to remove firearms from the home."

Miller and co-author David Hemenway, professor of health policy at HSPH, state that the empirical evidence linking suicide risk in the U.S. to the presence of firearms in the home is compelling. They point to at least a dozen U.S. case-control studies that have found that a gun in the home is associated with a greatly increased risk of suicide, typically twice to 10 times that in homes without guns depending on the sample population (e.g. adolescents vs. older adults) and the way in which the firearms were stored. Case-control studies have also found that the higher risk of completed suicide in homes with firearms applies not only to the gun owner but also to the gun owner's spouse and children.

"Too many clinicians seem to believe that anyone who uses a gun to attempt suicide must be serious enough that if a gun were not available, they would find an equally lethal way to kill themselves," said Hemenway. "This belief is invalid. Physicians need to embrace all effective measures that can prevent completed suicide, including means restriction."

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