A Pediatricians’ Role in Preventing Suicide by Firearms
Tim Fuller, DO, FAAP
BeHiP Medical Director
At the close of the 2022 school year, as many families were eagerly anticipating high school graduations and summer vacations without COVID restrictions, a new fear emerged. Suddenly our hearts were dimmed by the news of multiple mass shootings. Many involved children. Media outrage ensued, followed by a bipartisan legislative response. Discussions confirmed the declaration made by the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association in October 202114. We have a mental health crisis. With the unfortunate lack of mental health access, we as pediatricians, as well as other primary care providers once again find ourselves on the front lines of this battle.
While the terror of an unpredictable, senseless, act of extreme violence such as a mass shooting draws the focus of the media and legislators, the biggest threat from gun violence remains suicide. When we break down the data surrounding gun violence, the link between suicide and gun violence becomes undeniable. According to CDC data published by PEW Research Center6 in Feb 2022, deaths due to gun violence peaked in 2020, at the height of the COVID pandemic. Of the 45,222 people who died as a result of gun violence that year, 54% were the result of suicide, 43% homicide, and only 3% other. So far this year the numbers have not looked good either. According to CDC data published by gunviolencearchive.org4 as of June 22 the US has lost 20,736 people to gun violence this year. Of those, 11, 418 were the result of suicide, with 278 deaths from mass shootings
So, who is a greatest risk of suicide by gun violence? The highest risk group traditionally has been older, white men, usually from rural areas. This number has held fairly steady over the past ten years. However, data from the CDC WONDER database published by the Trace7, a non-profit journalism outlet devoted to gun related news, reveal an increasing number of suicides in younger people of color. While there is no distinct single cause for suicidality, marginalizing influences such as racism, lack of community resource, food insecurity, parental unemployment, and lack of mental health services may be associated with higher trajectories of perceived stress12.
Cultural barriers to engaging in mental health care is another contributing factor. Individuals who already feel marginalized because of their race often do not want to accept the cultural stigma of receiving mental health treatment. The highest rate of rise in suicide deaths by guns was in Asian and Pacific Islanders ages 10 to 197, a group that seeks mental health treatment less frequently than any other group1. Data from the American Psychological Foundation5 published by the TRACE7 reveals only 3% of practicing psychologists are Black, 4 % are Asian, and 7 % are Latino. This emphasizes the need for culturally competent professionals.
An increase in gun ownership may also contribute to increased access by children. In a study published in JAMA Psychiatry in 2021 examining the precipitating circumstances of suicide in children aged 5 -11 years old8 guns were found to be the second leading method of suicide (18.7%) behind strangulation (78.4%). In every case in which the details of gun access were noted, the child obtained a firearm stored unsafely in the home. In an eight center study of 1358 patient with suicidal ideation/suicidal attempts, in which 337 patient were discharged to home from the emergency room, 55% of those discharged did not have documentation of a screening for access to weapons or other lethal items at home. It was found later that 13 % of these patients actually had at least one firearm at home13.
Clinicians should be culturally sensitive when discussing gun ownership. For those who live in unsafe areas, or may have strong personal beliefs surrounding gun ownership, conversations around firearms in the home may be divisive. There should, however, be opportunities to discuss gun safety
Dr. Amy Barnhorst, a psychiatrist at the University of California, Davis directs a program called the BulletPoints Project, an initiative directed toward giving clinicians the knowledge and tools to reduce the risk of firearm injury and death in their patients. The BulletPoints website3 offers clinical scenarios, interventions, and evidence-based counseling strategies. While some of the interventions are based on local California law, most of the information is universally relevant. Her program centers around the framework of “the 3 A’s” (Approach, Assess, and Act), with “Approach” being centered around the context of risk reduction. “Assess” focuses on determining if it is clinically relevant to ask about access to firearms, and willingness to work together at reducing risk. Finally, “Act” identifies actions clinicians can take to prevent firearm injury based on the level and type of risk. You can access the BulletPoints Project at www.bulletpointsproject.org.
Remember that when dealing with mental health problems, one of the biggest challenges is identifying the problem. Without the use of screening tools, most mental illness will most likely continue to be missed. Routine use of screening tools and early identification of concerns continue to be vital to the management of mental health issues. In some instances, you may only have one opportunity to address the problem. If you miss it, they may never be back.
Concerning the risk of suicidality in general, there are a few more resources beyond the PHQ -9. The National Institute of Mental Health has an Ask Suicide-Screening Questions (ASQ) Toolkit available2. The screener consists of four brief suicide screening question and only takes 20 seconds to administer. The website includes video instructions on how to use the tool kit as well as how to manage patients at risk for suicide. You can find the ASQ tool kit at www.nimh.nih.gov.
Making the decision to send a depressed patient home vs sending them for inpatient care can sometimes be difficult. The “SAD- PERSONS” scale9 can help guide planning with regards to the disposition of a depressed patient. It may be accessed at www.med.unc.edu as well as other sources.
The REACH institute also has some great resources for assessment and management. Their “Treatment of Maladaptive Aggression in Youth” (T-MAY) handbook11 contains helpful aids and tools for screening for overt aggression, ADHD with comorbid aggression, and anxiety/depression with comorbid aggression. The handbook also contains algorithms and templates for creating short, intermediate, and long-term treatment plans. You can access T-MAY at www.ahrq.gov.
Finally, if you do not have a safety plan in place, you may access a six-step safety plan QUICK GUIDE10 at www.esc14.net.
And above all, make sure that you are taking care of your own mental health as well. Stay safe! And keep changing the world, one person at a time!
Dr. Tim Fuller, BeHiP Co-Medical Director, has been involved with BeHiP since the launch of the foster care learning collaborative pilot project in Upper East Tennessee. He has been in private practice in Greeneville, TN for the past 20 years. Dr. Fuller serves as the executive officer of the 31st medical company in the TN State Guard. Dr. Fuller is also a clinical adjunct professor at Debusk College of Osteopathic Medicine at Lincoln Memorial University.
1. Asian American and Pacific Islander, National Alliance on Mental Illness, https://www.nami.org, accessed 22 June 2022.
2. Ask Suicide-Screener Questions (ASQ) Toolkit, National Institute of Mental Health , NIH, https://www.nimh.nih.gov, Accessed 22 June 2022.
3. The BulletPoints Project, https://www.bulletpointsproject.org, accessed 22 June 22, 2022.
4. Charts and Maps, Gun Violence Archives 2022, https://www.gunviolencearchives.org, Accessed 22 June 2022
5. CWS Data Tool: Demographics of the U.S. Psychological Workforce, American Psychological Association, https://www.APA.org. Accessed 22 June 2022
6. Gramlich, John, What the Data Says About Gun Violence in the U.S., PEW Research Center, 3 Feb 2022, https://www.pewreearch.org
7. Moscia, Jennifer, Pierce, Olga, Youth Gun Suicide is Rising, Particularly Among Children of Color, 24 Feb 2022, The Trace, https://www.thetrace.org
8. Ruch, Donna A., PhD, Heck, Kendra, M., MPH, Sheftall, Arielle H. PhD, et al, Characteristics and Precipitating Circumstances od Suicide Among Children Aged 5 to 11 Years in the United States 2013-2017. JAMA Psychiatry, 27 July 2021.
9. SAD PERSONS Scale, https://www.med.unc.edu, accessed 22 June 2022
10. Safety Plane QUICK GUIDE, https://www.esq14.net, accessed 22 June 2022
11. Treatment of Maladaptive Aggression in Youth, New York State Office of Mental Health , https://www.ahrq.gov, accessed 22 June 2022.
12. Xiao, Yunyu PhD, Yip, Paul Siu-Fui, PhD, Pathak, Jyotishman, PhD, Association of Social Determinants of Health and Vaccinations with Child Mental Health During the COVID-19 Pandemic in the US, JAMA Psychiatry, 2022, 79 (6), 610-622, 27 April 2022.
13. Betz, Marian E, et al. Lethal Means Access and Assessment Among Suicidal Emergency Department Patients, Depress Anxiety, 2016, June.
14. https:// www.aap.org/en/advocacy/child-and-adolescent-heathy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health