Compliance with recommendations to remove firearms in families participating in a clinical trial for adolescent depression

Systemic therapy in children and adolescents with mental disorders: a systematic review and meta-analysis

BACKGROUND

Systemic therapy (ST) is a psychotherapeutic intervention in complex human systems (both psychological and interpersonal). Cognitive behavioural therapy (CBT) is an established treatment for children and adolescents with mental disorders. As methodologically rigorous systematic reviews on ST in this population are lacking, we conducted a systematic review and meta-analysis to compare the benefit and harm of ST (and ST as an add-on to CBT) with CBT in children and adolescents with mental disorders.

METHODS

We searched MEDLINE, Embase, PsycINFO and other sources for randomised controlled trials in 14 mental disorder classes for the above comparisons in respect of effects on patient-relevant outcomes (search date: 7/2022). Where possible, meta-analyses were performed and results were graded into 3 different evidence categories: "proof", "indication", or "hint" (or none of these categories). PRISMA standards were followed.

RESULTS

Fifteen studies in 5 mental disorder classes with usable data were identified. 2079 patients (mean age: 10 to 19 years) were analysed. 12/15 studies and 29/30 outcomes showed a high risk of bias. In 2 classes, statistically significant and clinically relevant effects in favour of ST were found, supporting the conclusion of a hint of greater benefit of ST for mental and behavioural disorders due to psychoactive substance use and of ST as an add-on to CBT for obsessive-compulsive disorders. In 2 other classes (eating disorders; hyperkinetic disorders), there was no evidence of greater benefit or harm of ST. For affective disorders, a statistically significant effect to the disadvantage of ST was found for 1 outcome, supporting the conclusion of a hint of lesser benefit of ST.

CONCLUSIONS

Our results show a hint of greater benefit of ST (or ST as an add-on to CBT) compared with CBT for 2 mental disorder classes in children and adolescents (mental and behavioural disorders due to psychoactive substance use, obsessive compulsive disorders). Given the importance of CBT as a control intervention, ST can therefore be considered a beneficial treatment option for children and adolescents with certain mental disorders. Limitations include an overall high risk of bias of studies and outcomes and a lack of data for several disorders.

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.

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.

Firearm ownership, attitudes, and safe storage practices among a nationally representative sample of older U.S. adults age 50 to 80

Firearms are a leading cause of injury mortality across the lifespan, with elevated risks for older adult populations. To inform prevention efforts, we conducted a probability-based web survey (12/1/2019-12/23/2019) of 2048 older adults (age 50-80) to characterize national estimates of firearm ownership, safety practices, and attitudes about health screening, counseling, and policy initiatives. Among older U.S. adults, 26.7% [95%CI = 24.8%-28.8%] report owning one or more firearms. The primary motivation for ownership was protection (69.5%), with 90.4% highlighting a fear of criminal assault. 39.4% of firearm owners reported regularly storing firearm(s) unloaded and locked, with 24.2% regularly storing at least one loaded and unlocked. While most firearm owners found healthcare screening (69.2% [95%CI: 64.9-73.1]) and safety counseling (63.2% [95%CI = 58.8-67.3]) acceptable, only 3.7% of older adults reported being asked about firearm safety by a healthcare provider in the past year. Among firearm owners, there was support for state-level policy interventions, including allowing family/police to petition courts to restrict access when someone is a danger to self/others (78.9% [95%CI = 75.1-82.3]), comprehensive background checks (85.0% [95%CI = 81.5-87.9]), restricting access/ownership under domestic violence restraining orders (88.1%; 95%CI = 84.9-90.7], and removing firearms from older adults with dementia/confusion (80.6%; 95%CI = 76.8-84.0]. Healthcare and policy-level interventions maintained higher support among non-owners than owners (p's < 0.001). Overall, data highlights opportunities exist for more robust firearm safety prevention efforts among older adults, particularly healthcare-based counseling and state/federal policies that focus on addressing lethal means access among at-risk individuals.

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.

Emergent Mental Health Visits to a Pediatric Hospital: Impact on Firearm Storage Practices

OBJECTIVE

The aims of this study were to describe firearm storage practices in homes of patients evaluated for mental health (MH) complaints at a tertiary care children's hospital and to describe storage practice changes after treatment.

METHODS

We surveyed families of children with MH complaints presenting to the emergency department or psychiatry unit who stored firearms in their homes between February 12, 2016, and January 14, 2017. Patients and families received standard care, including routine counseling on limiting access to methods of suicide. Participants completed surveys at baseline, 7, and 30 days after discharge. The primary outcome was triple safe firearm storage-storage of firearms unloaded, locked, and with ammunition stored and locked separately.

RESULTS

Ninety-one household members of MH patients who stated they had firearms were enrolled at baseline. Seventy-seven (85%) completed at least 1 follow-up survey, and 63 (69%) completed both. At baseline, 21% (19/91) of participants reported engaging in triple safe firearm storage, 26% had an unlocked firearm, 23% had a loaded firearm, and 65% stored ammunition either unlocked or with their firearm. Triple safe storage rates increased to 31% at both 7 days and 30 days. Ten (17%) of 59 (P < 0.01) participants who did not report triple safe storage at baseline and completed a follow-up survey changed to reporting triple safe storage on follow-up.

CONCLUSIONS

The majority of firearm-storing family members of children with MH complaints do not follow triple safe storage practices. Storage practices modestly improved after an emergent MH visit, but over two thirds of participants reported unsecured or partially secured firearms 7 and 30 days later.

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.

Documentation of Screening for Firearm Access by Healthcare Providers in the Veterans Healthcare System: A Retrospective Study

INTRODUCTION

Presence of a firearm is associated with increased risk of violence and suicide. United States military veterans are at disproportionate risk of suicide. Routine healthcare provider screening of firearm access may prompt counseling on safe storage and handling of firearms. The objective of this study was to determine the frequency with which Veterans Health Administration (VHA) healthcare providers document firearm access in electronic health record (EHR) clinical notes, and whether this varied by patient characteristics.

METHODS

The study sample is a post-9-11 cohort of veterans in their first year of VHA care, with at least one outpatient care visit between 2012-2017 (N = 762,953). Demographic data, veteran military service characteristics, and clinical comorbidities were obtained from VHA EHR. We extracted clinical notes for outpatient visits to primary, urgent, or emergency clinics (total 105,316,004). Natural language processing and machine learning (ML) approaches were used to identify documentation of firearm access. A taxonomy of firearm terms was identified and manually annotated with text anchored by these terms, and then trained the ML algorithm. The random-forest algorithm achieved 81.9% accuracy in identifying documentation of firearm access.

RESULTS

The proportion of patients with EHR-documented access to one or more firearms during their first year of care in the VHA was relatively low and varied by patient characteristics. Men had significantly higher documentation of firearms than women (9.8% vs 7.1%; P < .001) and veterans >50 years old had the lowest (6.5%). Among veterans with any firearm term present, only 24.4% were classified as positive for access to a firearm (24.7% of men and 20.9% of women).

CONCLUSION

Natural language processing can identify documentation of access to firearms in clinical notes with acceptable accuracy, but there is a need for investigation into facilitators and barriers for providers and veterans to improve a systemwide process of firearm access screening. Screening, regardless of race/ethnicity, gender, and age, provides additional opportunities to protect veterans from self-harm and violence.

The "Rules of the Road": Ethics, Firearms, and the Physician's "Lane"

Physicians play a critical role in preventing and treating firearm injury, although the scope of that role remains contentious and lacks systematic definition. This piece aims to utilize the fundamental principles of medical ethics to present a framework for physician involvement in firearm violence. Physicians' agency relationship with their patients creates ethical obligations grounded on three principles of medical ethics - patient autonomy, beneficence, and nonmaleficence. Taken together, they suggest that physicians ought to engage in clinical screening and treatment related to firearm violence. The principle of beneficence also applies more generally, but more weakly, to relations between physicians and society, creating nonobligatory moral ideals. Balanced against physicians' primary obligations to patient agency relationships, general beneficence suggests that physicians may engage in public advocacy to address gun violence, although they are not ethically obligated to do so. A fourth foundational principle - justice - requires that clinicians attempt to ensure that the benefits and burdens of healthcare are distributed fairly.

Extreme Risk Protection Orders: An Opportunity to Improve Gun Violence Prevention Training

States are increasingly enacting extreme risk protection order (ERPO) laws, also known as "red flag" or gun violence restraining order laws, as one part of a multidisciplinary approach to address the national gun violence epidemic. Passed into law in more than 10 states and under consideration by legislatures in approximately 30 others, ERPO laws create a legal process to temporarily remove firearms from people who may pose a risk to themselves or others. By enabling family or household members, law enforcement, and, in some cases, health care professionals to petition courts when they are concerned about a potential crisis, these laws can potentially prevent firearm-related violence and save lives. Most states with ERPO laws do not give health care professionals a direct role in filing petitions; still, physicians may serve as a resource for patients or their families by counseling on firearm safety and raising awareness of this legal pathway. In this way, the success of ERPO laws depends, in part, on the ability of physicians to accurately assess risk. However, physicians are often not proficient in making these types of risk assessments, largely because of insufficient training, particularly in the context of firearm-related violence. The authors review the literature on physician skill in violence-related risk assessment, medical education in gun violence prevention, and the capacity for training to improve such risk assessments. The authors then make recommendations for integrating focused gun violence prevention training into undergraduate, graduate, and continuing medical education, reviewing notable examples.

Children Are Different: Liability Issues in Working With Suicidal and Dangerous Youths

While many of the principles of assessing risk to self and others in adults are applicable to risk assessments of children and adolescents, developmental and legal factors regarding youths give rise to some significant differences. This article highlights major differences in assessing and managing risk in working with suicidal and homicidal youths and gives suggestions for reducing clinicians' liability in these challenging cases.

Preventing Firearm-Related Death and Injury

Deaths and injuries from firearms are significant public health problems, and clinicians are in a unique position to identify risk among their patients and discuss the importance of safe firearm practices. Although clinicians may be ill-prepared to engage in such discussions, an adequate body of evidence is available for support, and patients are generally receptive to this type of discussion with their physician. Here, we provide an overview of existing research and recommended strategies for counseling and intervention to reduce firearm-related death and injury.

Master Clinician Review: Saving Holden Caulfield: Suicide Prevention in Children and Adolescents

OBJECTIVE

The rate of adolescent suicide and suicidal behavior has risen dramatically in the past decade. The title of this article comes from the classic coming-of-age novel by J.D. Salinger, The Catcher in the Rye. Its protagonist, Holden Caulfield, is a precocious adolescent who, in the face of his inability to cope with his own self-destructives urges, imagines himself saving "little kids playing some game in this big field of rye." He is standing on the edge of a cliff trying to catch "thousands of little kids" before they fall to their demise. This vignette from The Catcher in the Rye provides a useful metaphor for the relationship between mental health professionals and youth at risk for suicide, and suggests more efficient and effective alternative interventions to prevent youth suicide compared to standing by a cliff.

METHOD

These four alternative approaches are described, namely: (1) leading youth away from the cliff (ie, prevention); (2) going to where youth are (ie, improving access to care); (3) working with others to change the rules in the field (ie, changing the way care is delivered); and (4) putting a fence around the cliff (ie, restriction of access to lethal agents). The evidence to support the utility and cost-effectiveness of each of these approaches is reviewed.

CONCLUSION

There are extant, empirically supported, cost-effective approaches to the prevention and management of adolescent suicidal behavior that, if implemented widely, are likely to significantly reverse the decade-long rise in adolescent suicide.

Differences Between New and Long-Standing US Gun Owners: Results From a National Survey

OBJECTIVES

To quantify the proportion of current US gun owners who are new to owning firearms and compare new versus long-standing gun owners with respect to their firearms and firearm-related behaviors.

METHODS

We performed a cross-sectional analysis of a nationally representative probability-based online survey conducted in 2015 in the United States. We defined new gun owners as current firearm owners who acquired all of their firearms within the past 5 years, but who lived in a home without a gun at some time over the past 5 years. We defined long-standing firearm owners as all other current gun owners.

RESULTS

New gun owners represented 10% of all current US adult gun owners. In addition to being younger than long-standing gun owners, new gun owners were more likely to be liberal, own fewer guns, own handguns, own guns only for protection, and store guns in a safe manner.

CONCLUSIONS

Gun ownership is dynamic, with approximately 1 million Americans becoming new gun owners each year. Public Health Implications. Clinical guidelines should be updated to explicitly endorse re-evaluating household firearm status at regular intervals.

Counseling on Access to Lethal Means (CALM): An Evaluation of a Suicide Prevention Means Restriction Training Program for Mental Health Providers

This paper evaluates the effectiveness of the Counseling on Access to Lethal Means (CALM) suicide prevention program. CALM trains mental health providers how to counsel suicidal individuals and those who support them on mean restriction during times of crisis. Pre/post/3-month follow-up assessments measured knowledge of lethal means, confidence and comfort in discussing means restriction (self-efficacy), and future intentions to counsel clients on means restriction. Change in the number of clients receiving lethal means counseling was also assessed. All constructs increased significantly at posttest. Confidence and counseling intentions were sustained at follow-up and significantly more clients received means counseling in the 3 months following the CALM training. Knowledge and comfort levels decreased at follow-up but not to pre-training levels. CALM is effective at increasing mental health professionals' comfort, knowledge, and frequency of talking about means restriction with clients. an effective means restriction training program. A template to assess clients for suicidality and lethal means access and booster sessions are recommended to further sustain effects.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management

OBJECTIVES

To update clinical practice guidelines to assist primary care (PC) clinicians in the management of adolescent depression. This part of the updated guidelines is used to address practice preparation, identification, assessment, and initial management of adolescent depression in PC settings.

METHODS

By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) draft revision and iteration among the steering committee, which included experts, clinicians, and youth and families with lived experience.

RESULTS

Guidelines were updated for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in PC, including the identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The practice preparation, identification, assessment, and initial management section of the guidelines include recommendations for (1) the preparation of the PC practice for improved care of adolescents with depression; (2) annual universal screening of youth 12 and over at health maintenance visits; (3) the identification of depression in youth who are at high risk; (4) systematic assessment procedures by using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria; (5) patient and family psychoeducation; (6) the establishment of relevant links in the community, and (7) the establishment of a safety plan.

CONCLUSIONS

This part of the guidelines is intended to assist PC clinicians in the identification and initial management of adolescents with depression in an era of great clinical need and shortage of mental health specialists, but they cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for depression management in adolescents. Additional research that addresses the identification and initial management of youth with depression in PC is needed, including empirical testing of these guidelines.

Firearm Storage Practices in Households of Adolescents With and Without Mental Illness

PURPOSE

Safe firearm storage practices are associated with a lower risk of self-inflicted injury and death. Whether such practices and relevant beliefs differ between households of adolescents with and without mental illness is unknown.

METHODS

We used survey and administrative data to perform a two-stage cross-sectional study of parents/guardians of adolescents who were 11-17 years, enrolled in a managed care plan in 2004 and living in a household with a firearm. Multivariable Poisson models compared the prevalence of three firearm storage practices between households of adolescents with (depression or bipolar disorder) and without mental illness (no psychiatric or substance use disorder), including whether all firearms were locked, any firearms were loaded, and all firearms were locked and unloaded. We used chi-square tests to compare responses to Likert items assessing beliefs relevant to storage practices between households.

RESULTS

Adolescents with mental illness were present in 141 (50.5%) of 279 study households. Their mean age was 14.5 years, and 54.8% were male. The mean age of parent/guardian respondents was 47.0 years, and 17.9% were male. Respondents from nearly 70% of households reported that all household firearms were stored locked and unloaded. In unadjusted and adjusted analyses, there were no significant differences in the prevalence of three firearm storage practices or in beliefs relevant to those practices between households of adolescents with and without mental illness.

CONCLUSIONS

These findings add to a growing body of evidence suggesting that firearm storage practices do not differ based on household mental health risk factors for self-harm.

Pediatric Firearm-Related Injuries in the United States

Pediatric firearm-related deaths and injuries are a national public health crisis. In this Special Review Article, we characterize the epidemiology of firearm-related injuries in the United States and discuss public health programs, the role of pediatricians, and legislative efforts to address this health crisis. Firearm-related injuries are leading causes of unintentional injury deaths in children and adolescents. Children are more likely to be victims of unintentional injuries, the majority of which occur in the home, and adolescents are more likely to suffer from intentional injuries due to either assault or suicide attempts. Guns are present in 18% to 64% of US households, with significant variability by geographic region. Almost 40% of parents erroneously believe their children are unaware of the storage location of household guns, and 22% of parents wrongly believe that their children have never handled household guns. Public health interventions to increase firearm safety have demonstrated varying results, but the most effective programs have provided free gun safety devices to families. Pediatricians should continue working to reduce gun violence by asking patients and their families about firearm access, encouraging safe storage, and supporting firearm-related injury prevention research. Pediatricians should also play a role in educating trainees about gun violence. From a legislative perspective, universal background checks have been shown to decrease firearm homicides across all ages, and child safety laws have been shown to decrease unintentional firearm deaths and suicide deaths in youth. A collective, data-driven public health approach is crucial to halt the epidemic of pediatric firearm-related injury.

The Link Between Mental Illness and Firearm Violence: Implications for Social Policy and Clinical Practice

The United States has substantially higher levels of firearm violence than most other developed countries. Firearm violence is a significant and preventable public health crisis. Mental illness is a weak risk factor for violence despite popular misconceptions reflected in the media and policy. That said, mental health professionals play a critical role in assessing their patients for violence risk, counseling about firearm safety, and guiding the creation of rational and evidence-based public policy that can be effective in mitigating violence risk without unnecessarily stigmatizing people with mental illness. This article summarizes existing evidence about the interplay among mental illness, violence, and firearms, with particular attention paid to the role of active symptoms, addiction, victimization, and psychosocial risk factors. The social and legal context of firearm ownership is discussed as a preface to exploring practical, evidence-driven, and behaviorally informed policy recommendations for mitigating firearm violence risk.

A Consensus-Driven Agenda for Emergency Medicine Firearm Injury Prevention Research

STUDY OBJECTIVE

To identify critical emergency medicine-focused firearm injury research questions and develop an evidence-based research agenda.

METHODS

National content experts were recruited to a technical advisory group for the American College of Emergency Physicians Research Committee. Nominal group technique was used to identify research questions by consensus. The technical advisory group decided to focus on 5 widely accepted categorizations of firearm injury. Subgroups conducted literature reviews on each topic and developed preliminary lists of emergency medicine-relevant research questions. In-person meetings and conference calls were held to iteratively refine the extensive list of research questions, following nominal group technique guidelines. Feedback from external stakeholders was reviewed and integrated.

RESULTS

Fifty-nine final emergency medicine-relevant research questions were identified, including questions that cut across all firearm injury topics and questions specific to self-directed violence (suicide and attempted suicide), intimate partner violence, peer (nonpartner) violence, mass violence, and unintentional ("accidental") injury. Some questions could be addressed through research conducted in emergency departments; others would require work in other settings.

CONCLUSION

The technical advisory group identified key emergency medicine-relevant firearm injury research questions. Emergency medicine-specific data are limited for most of these questions. Funders and researchers should consider increasing their attention to firearm injury prevention and control, particularly to the questions identified here and in other recently developed research agendas.

The American College of Preventive Medicine Policy Recommendations on Reducing and Preventing Firearm-Related Injuries and Deaths

The American College of Preventive Medicine Policy Committee makes policy guidelines and recommendations on preventive medicine and public health topics for public health decision makers. After a review of the current evidence available in 2016, the College is providing a consensus-based set of policy recommendations designed to reduce firearm-related morbidity and mortality in the U.S. These guidelines address seven general areas pertaining to the public health threat posed by firearms: gun sales and background checks, assault weapons and high-capacity weapons, mental health, research funding, gun storage laws, and physician counseling.

Effectiveness of Interventions to Promote Safe Firearm Storage

Despite supportive evidence for an association between safe firearm storage and lower risk of firearm injury, the effectiveness of interventions that promote such practices remains unclear. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, we conducted a systematic review of randomized and quasi-experimental controlled studies of safe firearm storage interventions using a prespecified search of 9 electronic databases with no restrictions on language, year, or location from inception through May 27, 2015. Study selection and data extraction were independently performed by 2 investigators. The Cochrane Collaboration's domain-specific tool for assessing risk of bias was used to evaluate the quality of included studies. Seven clinic- and community-based studies published in 2000-2012 using counseling with or without safety device provision met the inclusion criteria. All 3 studies that provided a safety device significantly improved firearm storage practices, while 3 of 4 studies that provided no safety device failed to show an effect. Heterogeneity of studies precluded conducting a meta-analysis. We discuss methodological considerations, gaps in the literature, and recommendations for conducting future studies. Although additional studies are needed, the totality of evidence suggests that counseling augmented by device provision can effectively encourage individuals to store their firearms safely.

Clinician Attitudes, Screening Practices, and Interventions to Reduce Firearm-Related Injury

Firearm injury is a leading cause of injury-related morbidity and mortality in the United States. We sought to systematically identify and summarize existing literature on clinical firearm injury prevention screening and interventions. We conducted a systematic search of PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsycInfo, and ClinicalTrials.gov for English-language original research (published 1992-2014) on clinical screening methods, patient-level firearm interventions, or patient/provider attitudes on the same. Unrelated studies were excluded through title, abstract, and full-text review, and the remaining articles underwent data abstraction and quality scoring. Of a total of 3,260 unique titles identified, 72 were included in the final review. Fifty-three articles examined clinician attitudes/practice patterns; prior training, experience, and expectations correlated with clinicians' regularity of firearm screening. Twelve articles assessed patient interventions, of which 6 were randomized controlled trials. Seven articles described patient attitudes; all were of low methodological quality. According to these articles, providers rarely screen or counsel their patients-even high-risk patients-about firearm safety. Health-care-based interventions may increase rates of safe storage of firearms for pediatric patients, suicidal patients, and other high-risk groups. Some studies show that training clinicians can increase rates of effective firearm safety screening and counseling. Patients and families are, for the most part, accepting of such screening and counseling. However, the current literature is, by and large, not high quality. Rigorous, large-scale, adequately funded studies are needed.

Lethal Means Counseling for Parents of Youth Seeking Emergency Care for Suicidality

INTRODUCTION

A youth's emergency department (ED) visit for suicidal behaviors or ideation provides an opportunity to counsel families about securing medications and firearms (i.e., lethal means counseling).

METHODS

In this quality improvement project drawing on the Counseling on Access to Lethal Means (CALM) model, we trained 16 psychiatric emergency clinicians to provide lethal means counseling with parents of patients under age 18 receiving care for suicidality and discharged home from a large children's hospital. Through chart reviews and follow-up interviews of parents who received the counseling, we examined what parents recalled, their reactions to the counseling session, and actions taken after discharge.

RESULTS

Between March and July 2014, staff counseled 209 of the 236 (89%) parents of eligible patients. We conducted follow-up interviews with 114 parents, or 55% of those receiving the intervention; 48% of those eligible. Parents had favorable impressions of the counseling and good recall of the main messages. Among the parents contacted at follow up, 76% reported all medications in the home were locked as compared to fewer than 10% at the time of the visit. All who had indicated there were guns in the home at the time of the visit reported at follow up that all were currently locked, compared to 67% reporting this at the time of the visit.

CONCLUSION

Though a small project in just one hospital, our findings demonstrate the feasibility of adding a counseling protocol to the discharge process within a pediatric psychiatric emergency service. Our positive findings suggest that further study, including a randomized control trial in more facilities, is warranted.

Reducing a suicidal person's access to lethal means of suicide: a research agenda

Reducing the availability of highly lethal and commonly used suicide methods has been associated with declines in suicide rates of as much as 30%-50% in other countries. The theory and evidence underlying means restriction is outlined. Most evidence of its efficacy comes from population-level interventions and natural experiments. In the U.S., where 51% of suicides are completed with firearms and household firearm ownership is common and likely to remain so, reducing a suicidal person's access to firearms will usually be accomplished not by fiat or other legislative initiative but rather by appealing to individual decision, for example, by counseling at-risk people and their families to temporarily store household firearms away from home or otherwise making household firearms inaccessible to the at-risk person until they have recovered. Providers, gatekeepers, and gun owner groups are important partners in this work. Research is needed in a number of areas: communications research to identify effective messages and messengers for "lethal means counseling," clinical trials to identify effective interventions, translational research to ensure broad uptake of these interventions across clinical and community settings, and foundational research to better understand method choice and substitution. Approaches to suicide methods other than firearms are discussed. Means restriction is one of the few empirically based strategies to substantially reduce the number of suicide deaths.

Health problems and male firearm suicide

Drawing on constructs of masculinity as it relates to both gun ownership and men's health, we use a rich data set, the New Jersey Violent Death Reporting System as well as hospital discharge data, to analyze 3,413 completed male suicides between the years of 2003 and 2009. We test the hypotheses that the use of firearms is more common when physical health problems are cited as suicide circumstances, and that suicide decedents who use firearms have poorer physical health than those who used other methods. Results show that firearms are disproportionately used in male suicides when physical health is listed as a circumstance. Additionally, among suicide decedents with a hospitalization during the 3 years prior to death, those who used firearms were in poorer health than those who used other methods. These findings have implications for prevention efforts, because restricting access to lethal means is an important aspect of suicide prevention.

Training mental healthcare providers to reduce at-risk patients' access to lethal means of suicide: evaluation of the CALM Project

The objective of this study was to evaluate the "CALM" (Counseling on Access to Lethal Means) training, in which community-based mental health care providers were trained to work with at-risk clients and their families to assess and reduce access to lethal means of suicide, including firearms. In 2006, CALM trainers conducted workshops in 7 community-based mental health care centers in New Hampshire towns. Participants completed a post-test immediately after the workshop and a follow-up questionnaire approximately 6 weeks later. At follow-up, 65% reported that they had counseled clients' parents about access to lethal means (n = 111). Findings also indicate that the workshop influenced participants' attitudes, beliefs, and skills regarding conducting lethal means counseling.

Suicide and firearm means restriction: can training make a difference?

Along with physician education in depression recognition and treatment, restricting lethal methods is an effective suicide prevention strategy. The present study surveyed a random sample (N = 697) of Ohio licensed social workers regarding client firearm assessment and safety counseling. Analyses sought to determine what independent factors would predict the probability that a social worker would hold positive attitudes regarding firearm risk assessment and counseling. Findings indicated that prior training and reporting from an urban area significantly increased the odds (p < .05) of registering more positive attitudes toward firearm assessment and safety counseling by 91.1% and 44.7%, respectively. Training mental health professionals in firearm assessment and safety counseling is an important aspect in addressing the reduction of suicide by this means.

Lethal means reduction: what have we learned?

PURPOSE OF REVIEW

Suicide is an important global public health problem. Across nations, suicide rates are linked to the availability of lethal means. Three methods dominate country-specific suicide rates: firearms, pesticides, and hanging. There is increasing international support for reducing the availability of lethal means to prevent suicide. This article reviews evidence regarding lethal means reduction as a suicide-prevention strategy.

RECENT FINDINGS

Most evidence in support of means reduction comes from ecological studies examining the association between population-level decreases in the availability of a given lethal means of suicide and method-specific suicide rates. Substantial declines in method-specific suicide rates were shown following reductions in availability of lethal means through initiatives such as the passage of firearm control laws, detoxification of domestic gas, modification of drug packaging and toxicity, and installation of barriers at jump sites. The vast majority of the evidence for the effectiveness of lethal means reduction relates to reducing the availability of firearms and pesticides.

SUMMARY

Implementing means reduction at both the population and individual levels poses many challenges, particularly when political issues arise during regulation of firearms or pesticides. Nevertheless, evidence strongly suggests that means reduction is effective and should be an important part of a suicide-prevention strategy.

Suicidality in Pediatric Bipolar Disorder

This article describes what is known about the epidemiology of suicidal ideation and behavior in pediatric bipolar disorder. Risk factors associated with suicidality in this population are reviewed in detail. Clinical recommendations for assessment, management and treatment are provided based on the literature to date.

Storage of household firearms: an examination of the attitudes and beliefs of married women with children

Although safe firearm storage is a promising injury prevention strategy, many parents do not keep their firearms unloaded and locked up. Using the theory of planned behavior as a guiding conceptual framework, this study examines factors associated with safe storage among married women with children and who have firearms in their homes. Data come from a national telephone survey (n=185). We examined beliefs about defensive firearm use, subjective norms, perceived behavioral control and firearm storage practices. A Wilcoxon-Mann-Whitney test was conducted to assess associations between psychosocial factors and firearm storage practices. Women were highly motivated to keep firearms stored safely. Those reporting safe storage practices had more favorable attitudes, more supportive subjective norms and higher perceptions of behavioral control than those without safe storage. One-fourth believed a firearm would prevent a family member from being hurt in case of a break-in, 58% believed a firearm could scare off a burglar. Some 63% said they leave decisions about firearm storage to their husbands. Women were highly motivated to store firearms safely as evidenced by favorable attitudes, supportive subjective norms and high perceptions of behavioral control. This was especially true for those reporting safer storage practices.

Mental health and firearms in community-based surveys: implications for suicide prevention

Suicide rates are higher among those who own a handgun and among those who [corrected] live in a household with a hand gun. This article examines the association between [corrected] gun ownership and mental health, another risk factor for suicide. Data from the General Social Survey, a series of surveys of U.S. adults, are analyzed to compare general emotional and mental health, sadness and depression, functional mental health, and mental health help seeking among gun owners, persons who do not own but live in a household with a gun, and those who do not own a gun. After taking into account a few basic demographic characteristics associated with both variables, there appears to be no association between mental health and gun ownership. Nor is there any association between mental health and living in a household with a firearm. Findings suggest that the high risk of suicide among those who own or live in a household with a gun is not related to poor mental health. Implications for prevention are discussed.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management

OBJECTIVES

To develop clinical practice guidelines to assist primary care clinicians in the management of adolescent depression. This first part of the guidelines addresses identification, assessment, and initial management of adolescent depression in primary care settings.

METHODS

By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 5 phases, as informed by (1) current scientific evidence (published and unpublished), (2) a series of focus groups, (3) a formal survey, (4) an expert consensus workshop, and (5) draft revision and iteration among members of the steering committee.

RESULTS

Guidelines were developed for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in primary care, including identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The identification, assessment, and initial management section of the guidelines includes recommendations for (1) identification of depression in youth at high risk, (2) systematic assessment procedures using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, (3) patient and family psychoeducation, (4) establishing relevant links in the community, and (5) the establishment of a safety plan.

CONCLUSIONS

This part of the guidelines is intended to assist primary care clinicians in the identification and initial management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists but cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for adolescent depression management. Additional research that addresses the identification and initial management of depressed youth in primary care is needed, including empirical testing of these guidelines.

Family therapy for depression

BACKGROUND

People with depression often experience interpersonal problems. Family therapy for depression is a widely used intervention, but it is unclear whether this is an effective therapy for the treatment of depression.

OBJECTIVES

To assess the efficacy of family therapy for depression.

SEARCH STRATEGY

The following electronic databases were searched using a specific search strategy: CCDANCTR-Studies and CCDANCTR-References searched on 21/10/2005, The Cochrane Central Register of Controlled Trials, Medline (1966 to January 2005), EMBASE (1980 to January 2005), Psycinfo (1974 to January 2005). Reference lists of articles were also searched. Handsearches of relevant journals and bibliographies were conducted and first authors of included studies and experts in the field were contacted for further information.

SELECTION CRITERIA

Included studies were randomised controlled and controlled clinical trials comparing family therapy with no intervention or an alternative intervention in which depression symptomatology was a main outcome measure.

DATA COLLECTION AND ANALYSIS

Methodological quality was independently assessed by two review authors using the Maastricht-Amsterdam Criteria List. The qualitative and quantitative characteristics of the selected trials were independently extracted by three review authors using a standardised data extraction form. Levels of evidence were used to determine the strength of the evidence available. It was not possible to perform meta-analyses because of the heterogeneity of the selected studies.

MAIN RESULTS

Three high-quality and three low-quality studies, involving 519 people with depression, were identified. The studies were very heterogeneous in terms of interventions, participants, and measuring instruments. Despite fairly good methodological quality and positive findings of some studies, evidence for the effectiveness of family therapy for depression did not exceed level 3 (limited or conflicting evidence), except for moderate evidence (level 2), based on the non-combined findings from three studies, indicating that family therapy is more effective than no treatment or waiting list condition on decreasing depression, and on increasing family functioning.

AUTHORS' CONCLUSIONS

The current evidence base is too heterogeneous and sparse to draw conclusions on the overall effectiveness of family therapy in the treatment of depression. At this point, use of psychological interventions for the treatment of depression for which there is already an evidence-base would seem to be preferable to family therapy. Further high quality trials examining the effectiveness and comparative effectiveness of explicitly defined forms of family therapy are required.

Management of the depressed, suicidal child or adolescent

Two prominent risk factors for completed suicide and suicidal behavior in adolescents are previous suicide attempts and a diagnosis of a depressive episode. Adolescents with different degrees of suicidal risk and severity are referred or admitted to various clinical settings. Research has yet to identify clearly the treatment of choice for suicidal patients. Regardless, clinical interventions should be based on a thorough suicide risk assessment. Treatment strategies should be multidimensional, targeting suicidal behavior and the underlying psychiatric illness or other personality and environmental risk factors. Because adolescents are referred from one clinical setting to another, continuity of care must be one of mental health practitioners' major concerns. Lack of continuity of care places patients at an elevated risk for additional suicide attempts.

Adolescent suicide and suicidal behavior

This review examines the descriptive epidemiology, and risk and protective factors for youth suicide and suicidal behavior. A model of youth suicidal behavior is articulated, whereby suicidal behavior ensues as a result of an interaction of socio-cultural, developmental, psychiatric, psychological, and family-environmental factors. On the basis of this review, clinical and public health approaches to the reduction in youth suicide and recommendations for further research will be discussed.

Preventing suicidal behaviour in a general hospital psychiatric service: priorities for programming

PURPOSE

General hospital psychiatric services are able to provide leadership and coordinate the development of suicide prevention programs for individuals serviced in general hospital settings. We completed this literature review to suggest priorities for programming.

METHODS

Our procedure was to update the review by Gunnell and Frankel that guided priorities for Health of the Nation, the national suicide prevention strategy in the UK. We completed a search, using the terms suicide prevention and control, of all English-language research and clinical trials conducted between January 1, 1994, and May 1, 2004.

RESULTS

We identified 82 papers. Of these, 48 were excluded and the remaining 34 were grouped by secondary care setting categories. We found no articles on screening tools for predicting risk of suicide, 16 articles on interventions for individuals with suicidal behaviour, 14 articles on the treatment of major psychiatric disorders, 1 article and 1 published abstract on discharge from hospital, and 2 articles on reducing access to means.

CONCLUSIONS

Based on a review of each category, we make several program and policy recommendations, including regularly updating clinical assessment skills, using guidelines for assessment of patients following a suicide attempt, assessing the risk of suicide 24 to 48 hours before discharge from hospital, and incorporating education about reducing access to means into routine psychiatric care.

Safer storage of firearms at home and risk of suicide: a study of protective factors in a nationally representative sample

OBJECTIVE

To estimate the protective effect of storing firearms locked or unloaded, or both, on the risk of suicide by firearms among people with relatively low intention to die.

DESIGN AND SETTING

Cross sectional survey. The 1993 National Mortality Followback Survey of 22 957 deaths in the United States, representing 2.2 million people, conducted by the National Center for Health Statistics.

PARTICIPANTS

Decedent's next of kin answered questions regarding various aspects of decedent's life to supplement information from death certificates.

MAIN RESULTS

Compared with decedents who stored their firearm unlocked or loaded, those who stored their firearms locked or unloaded, or both, were less likely to commit suicide by firearms (locked: OR = 0.39, 95% CI = 0.24 to 0.66; unloaded OR = 0.30, 95% CI = 0.18 to 0.49).

CONCLUSIONS

This study further supports the utility of devices and practices intended to reduce the likelihood of unauthorised or impulsive use of firearms.

Firearm ownership and storage practices, U.S. households, 1992-2002. A systematic review

BACKGROUND

Because the presence and improper storage of household firearms are risk factors for injury, it is important to understand the prevalence of ownership and storage practices within households to help guide intervention development. This systematic review of published articles (1992 to 2002) provides prevalence estimates of firearm ownership and storage practices in U.S. households.

METHODS

A search of bibliographic databases (MedLine, CINAHL, PsycInfo, Sociological Abstracts) was completed in January 2003.

RESULTS

Although all were cross-sectional, the 42 articles included in this review varied in type; there were seven national and five state prevalence studies, as well as studies using clinic-based convenience samples (n =14) and samples of professionals (n =10). Published studies indicate that firearms are present in about one third of U.S. households. Handguns in particular are present in more than half of U.S. households with firearms, or about 19% of all U.S. households. The prevalence of firearms and handguns in households with young people was similar to the prevalence overall. Firearm ownership was highest in the South.

CONCLUSIONS

Although the methodologic rigor of published articles varies substantially, the literature clearly establishes that firearms are common in U.S. households, even in the homes of medical professionals and those with children.

Adolescent Suicide Myths in the United States

Abstract: In the United States, teen suicide rates tripled over several decades, but have declined slightly since the mid-1990s. Suicide, by its nature, is a complex problem. Many myths have developed about individuals who complete suicide, suicide risk factors, current prevention programs, and the treatment of at-risk youth. The purpose of this article is to address these myths, to separate fact from fiction, and offer recommendations for future suicide prevention programs. Myth #1: Suicide attempters and completers are similar. Myth #2: Current prevention programs work. Myth #3: Teenagers have the highest suicide rate. Myth #4: Suicide is caused by family and social stress. Myth #5: Suicide is not inherited genetically. Myth #6: Teen suicide represents treatment failure. Psychiatric illnesses are often viewed differently from other medical problems. Research should precede any public health effort, so that suicide prevention programs can be designed, implemented, and evaluated appropriately. Too often suicide prevention programs do not use evidence-based research or practice methodologies. More funding is warranted to continue evidence-based studies. We propose that suicide be studied like any medical illness, and that future prevention efforts are evidence-based, with appropriate outcome measures.

Unintentional and undetermined firearm related deaths: a preventable death analysis for three safety devices

OBJECTIVE

To determine the proportion of unintentional and undetermined firearm related deaths preventable by three safety devices: personalization devices, loaded chamber indicators (LCIs), and magazine safeties. A personalized gun will operate only for an authorized user, a LCI indicates when the gun contains ammunition, and a magazine safety prevents the gun from firing when the ammunition magazine is removed.

DESIGN

Information about all unintentional and undetermined firearm deaths from 1991-98 was obtained from the Office of the Chief Medical Examiner for Maryland, and from the Wisconsin Firearm Injury Reporting System for Milwaukee. Data regarding the victim, shooter, weapon, and circumstances were abstracted. Coding rules to classify each death as preventable, possibly preventable, or not preventable by each of the three safety devices were also applied.

RESULTS

There were a total of 117 firearm related deaths in our sample, 95 (81%) involving handguns. Forty three deaths (37%) were classified as preventable by a personalized gun, 23 (20%) by a LCI, and five (4%) by a magazine safety. Overall, 52 deaths (44%) were preventable by at least one safety device. Deaths involving children 0-17 (relative risk (RR) 3.3, 95% confidence interval (CI) 2.1 to 5.1) and handguns (RR 8.1, 95% CI 1.2 to 53.5) were more likely to be preventable. Projecting the findings to the entire United States, an estimated 442 deaths might have been prevented in 2000 had all guns been equipped with these safety devices.

CONCLUSION

Incorporating safety devices into firearms is an important injury intervention, with the potential to save hundreds of lives each year.

Depression in children and adolescents with epilepsy

Depression in children and adolescents with epilepsy is a common but often unrecognized disorder. Both epilepsy and depression are characterized by a chronic course and poor long-term psychosocial outcome. The risk of suicide is even greater in depressed youth with epilepsy than in the general youth population. Educating parents about mood disorders may allow them to be more receptive to psychiatric treatment for their child or themselves. Epidemiological and clinical data on depression in children/adolescents with epilepsy are presented. Seizure-related and general risk factors for the development of depression in youth with epilepsy are reviewed. General guidelines for diagnosis and treatment of depression in children and adolescents are discussed. The early identification and treatment of childhood-onset depression is an important clinical task for all pediatric specialists. Safe and effective multimodal treatment approaches are available.

Review of evaluations of educational approaches to promote safe storage of firearms

OBJECTIVE

To systematically review evaluation studies of educational interventions promoting safe firearm storage.

METHODS

Medline, ERIC, PsycINFO, Criminal Justice Periodicals Index, Cumulative Index of Nursing and Allied Health Literature, and Sociofile were searched. The references from each potentially eligible study were checked, and experts in the field were contacted for additional reports. In addition, an internet search was performed to identify programs not published in the conventional literature. Sources relevant to safe firearm storage promotion were selected and evaluated.

RESULTS

Seven studies met inclusion criteria: adult subjects, program description was included, and firearm storage outcomes were measured. One was a randomized controlled trial and the other six were one group pre-test and/or post-test. The studies were classified into the following categories based on the intervention strategies used: (1). counseling and firearm safety materials (n=3); (2). counseling/educational message (n=3); and (3). firearm safety materials distribution (n=1). The outcomes were safe firearms storage (firearms locked up and unloaded or removal from home) after intervention. Four studies, three using counseling and materials distribution, reported improved storage after the interventions.

CONCLUSIONS

It is not yet clear what types of interventions, or which specific intervention components, prompt gun owners to securely store their weapons. Increased understanding of gun storage behaviors and stronger evaluation designs will aid further understanding of this important issue.