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Savarino JR, Rubin E, Masiakos PT, McLellan R, Rolle ML, Nanda P, Stapleton CJ, Sacks CA. The Experience of Survivors of Firearm Suicide Attempts: A Retrospective Case Series. ANNALS OF SURGERY OPEN 2024; 5:e418. [PMID: 38911645 PMCID: PMC11191906 DOI: 10.1097/as9.0000000000000418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/11/2024] [Indexed: 06/25/2024] Open
Abstract
Objective We sought to identify people who survived firearm suicide attempts to describe the acute stressors, substance use, and mental health conditions related to the attempt. Background Most firearm deaths in the United States are the result of suicide. Because firearm suicide attempts have a case fatality rate of approximately 90%, little is known about the precipitating factors that lead to firearm suicide attempts. Methods We conducted a retrospective case series of patients admitted to a large hospital system between 2000 and 2019 who survived intentional, self-inflicted gunshot wounds to the head. Through the electronic medical record, we collected information about acute stressors, substance use, and mental health diagnoses before or at the time of the suicide attempt. Results Thirty-four patients were included in the study cohort. Patients were predominantly White (74%) and male (88%), with a mean age of 44 (range, 14-82). Nineteen (56%) patients were acutely intoxicated with alcohol upon hospitalization and 17 (50%) patients had a positive urine drug screen. Acute stressors involving interpersonal relationships (53%), work/school (32%), and legal disputes (18%), among others, were documented in 82% of patients. Most patients (65%) had been diagnosed with depression before their index hospitalization. Most patients were discharged to an acute rehabilitation center (41%) or an inpatient psychiatric facility (41%). Conclusions Acute stress and alcohol intoxication were common in this cohort of patients who attempted suicide using firearms. These data offer an ability to learn from the experience of survivors of firearm suicide attempts, a rare population.
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Affiliation(s)
| | - Emily Rubin
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Peter T. Masiakos
- Pediatric Trauma Service, Department of Surgery, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Rachel McLellan
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Myron L. Rolle
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Pranav Nanda
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christopher J. Stapleton
- Harvard Medical School, Boston, MA
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Chana A. Sacks
- Harvard Medical School, Boston, MA
- Division of General Internal Medicine and Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA
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Bovio NR, Brooks JK, Prahlow JA. Suicide by Gunshot Wound to the Posterior Head and Neck: A Retrospective Case Series and Review of the Literature. Am J Forensic Med Pathol 2024:00000433-990000000-00169. [PMID: 38471138 DOI: 10.1097/paf.0000000000000925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
ABSTRACT Suicide by firearm is a significant public health concern in specific regions of the world. Depending on firearm availability, any type of firearm may be used, including handguns, shotguns, and long rifles. Common entrance wound sites in suicidal gunshot wounds include the head, with classic gunshot wound locations including the temple, the forehead, the submental aspect of the chin, and inside the mouth. Occasionally, suicidal gunshot wounds occur in atypical body locations such as the back of the head and neck. Given their relative rarity, suicidal gunshot wounds in these regions may be mistaken for homicides. In this report, we present 5 cases of suicidal gunshot wounds to the back of the head and/or neck. In our series, we focus on differentiating each case from homicides involving gunshot wounds in similar areas of the head and neck.
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Affiliation(s)
- Nicholas R Bovio
- From the Department of Pathology, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI
| | - Jared K Brooks
- From the Department of Pathology, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI
| | - Joseph A Prahlow
- Department of Pathology, St Louis University School of Medicine, St Louis, MO
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3
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Jasperson RA, Sullivan E, Goldstein EV. Employee attitudes toward suicide prevention and Counseling on Access to Lethal Means: initial findings from an academic medical center implementing the Zero Suicide framework. Front Public Health 2023; 11:1268300. [PMID: 38026388 PMCID: PMC10654743 DOI: 10.3389/fpubh.2023.1268300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/11/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Zero Suicide is a strategic framework designed to transform a healthcare system's suicide prevention activities. In 2020, University of Utah Health launched a Zero Suicide program and Counseling on Access to Lethal Means (CALM) training for its employees. In 2022, the healthcare system surveyed its workforce's attitudes toward suicide prevention and CALM. We sought to evaluate employees' attitudes and behaviors toward suicide prevention and CALM training following the launch of the Zero Suicide program. Methods A Zero Suicide Workforce Survey was administered online through REDCap to all University of Utah Health employees. The analytic sample included 3,345 respondents. We used two-portion z-tests to compare the proportions of respondents who (1) completed CALM training and (2) did not yet complete the CALM training because they felt it was irrelevant to their position by different employee characteristics. Results More than half of the respondents in the analytic sample were directly interacting with patients who may be at risk for suicide (57.6%). About 8.4% of the respondents had completed CALM training. Among those who had not yet completed CALM training, 9.5% indicated they did not think CALM was relevant to their job. Respondents knowledgeable about warning signs for suicide and respondents who were confident in their ability to respond when suspecting elevated suicide risk were significantly more likely to complete CALM training. Discussion This evaluation provides important insights from the workforce of a large academic medical center implementing a Zero Suicide program, including insights on opportunities for improving program implementation and evaluation.
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Affiliation(s)
- Rachael A. Jasperson
- Zero Suicide Program, University of Utah Health, Salt Lake City, UT, United States
| | - Emily Sullivan
- Zero Suicide Program, University of Utah Health, Salt Lake City, UT, United States
- Hunstman Mental Health Institute, University of Utah, Salt Lake City, UT, United States
| | - Evan V. Goldstein
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
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Goldstein EV, Brenes F, Wilson FA. Critical gaps in understanding firearm suicide in Hispanic communities: demographics, mental health, and access to care. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad016. [PMID: 38770408 PMCID: PMC11103729 DOI: 10.1093/haschl/qxad016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/28/2023] [Accepted: 05/09/2023] [Indexed: 05/22/2024]
Abstract
Suicide rates increased by 26.7% among Hispanics from 2015 to 2020, driven at least in part by highly lethal firearm suicide deaths. However, there are critical gaps in characterizing firearm suicide risks and prevention opportunities in Hispanic communities. We examined Hispanic adult firearm suicide decedents reported through the National Violent Death Reporting System from 2013-2019, focusing on demographic characteristics, firearm choices, suicidal thoughts/behaviors, mental health, and mental health treatment, compared with non-Hispanic adult firearm suicide decedents. Only 13.8% of Hispanic firearm suicide decedents were known to be undergoing treatment for a mental health or substance use problem prior to death, compared to 18.8% of non-Hispanic firearm suicide decedents. On average, Hispanic firearm suicide decedents were significantly less likely than non-Hispanic firearm suicide decedents known to have been treated for a mental health or substance use problem. These results may underscore the critical need for public health agencies and policymakers to promote initiatives integrating mental health screening into medical care, reducing mental health stigma among Hispanics, and expanding mental health treatment capacity in Hispanic communities.
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Affiliation(s)
- Evan V Goldstein
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
| | - Francisco Brenes
- Nicole Wertheim College of Nursing and Health Sciences, Florida International University, Miami, FL 33199, United States
| | - Fernando A Wilson
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
- Department of Economics, University of Utah, Salt Lake City, UT 84112, United States
- Matheson Center for Health Care Studies, University of Utah, Salt Lake City, UT 84112, United States
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5
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Hoffmann JA, Attridge MM, Carroll MS, Simon NJE, Beck AF, Alpern ER. Association of Youth Suicides and County-Level Mental Health Professional Shortage Areas in the US. JAMA Pediatr 2023; 177:71-80. [PMID: 36409484 PMCID: PMC9679958 DOI: 10.1001/jamapediatrics.2022.4419] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/26/2022] [Indexed: 11/23/2022]
Abstract
Importance Suicide is the second leading cause of death among US adolescents. Workforce shortages of mental health professionals in the US are widespread, but the association between mental health workforce shortages and youth suicides is not well understood. Objective To assess the association between youth suicide rates and mental health professional workforce shortages at the county level, adjusting for county demographic and socioeconomic characteristics. Design, Setting, and Participants This retrospective cross-sectional study included all US counties and used data of all US youlth suicides from January 2015, through December 31, 2016. Data were analyzed from July 1, 2021, through December 20, 2021. Exposures County health-professional shortage area designation for mental health, assigned by the US Health Resources and Services Administration based on mental health professionals relative to the population, level of need for mental health services, and service availability in contiguous areas. Designated shortage areas receive a score from 0 to 25, with higher scores indicating greater workforce shortages. Main Outcomes and Measures Suicides by youth aged 5 to 19 years from 2015 to 2016 were identified from the US Centers for Disease Control and Prevention's Compressed Mortality File. A multivariable negative binomial regression model was used to analyze the association between youth suicide rates and mental health workforce shortage designation, adjusting for the presence of a children's mental health hospital and county-level markers of health insurance coverage, education, unemployment, income, poverty, urbanicity, racial and ethnic composition, and year. Similar models were performed for the subgroups of (1) firearm suicides and (2) counties assigned a numeric shortage score. Results During the study period, there were 5034 youth suicides (72.8% male and 68.2% non-Hispanic White) with an annual suicide rate of 3.99 per 100 000 youths. Of 3133 US counties, 2117 (67.6%) were designated as mental health workforce shortage areas. After adjusting for county characteristics, mental health workforce shortage designation was associated with an increased youth suicide rate (adjusted incidence rate ratio [aIRR], 1.16; 95% CI, 1.07-1.26) and an increased youth firearm suicide rate (aIRR, 1.27; 95% CI, 1.13-1.42). For counties with an assigned numeric workforce shortage score, the adjusted youth suicide rate increased 4% for every 1-point increase in the score (aIRR, 1.04; 95% CI, 1.02-1.06). Conclusions and Relevance In this cross-sectional study, US county mental health professional workforce shortages were associated with increased youth suicide rates. These findings may inform suicide prevention efforts.
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Affiliation(s)
- Jennifer A. Hoffmann
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Megan M. Attridge
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael S. Carroll
- Smith Child Health Outcomes Research and Evaluation Center, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Norma-Jean E. Simon
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew F. Beck
- Divisions of General and Community Pediatrics and Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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6
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Affiliation(s)
- Aaron E Carroll
- Indiana University, Bloomington.,Center for Pediatric and Adolescent Comparative Effectiveness Research, Indiana University School of Medicine, Indianapolis.,Web and Social Media Editor, JAMA Pediatrics
| | - Denise Hayes
- Denise Hayes & Associates Counseling and Consulting, LLC, Indianapolis, Indiana.,Indiana University School of Public Health, Bloomington
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7
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Prater LC, Ellyson AM, Shawon RA, Lyons VH, Cheung A, Rivara F, Rowhani-Rahbar A, Zatzick D. Suicide, Firearms, and Terminal Illness: A Latent Class Analysis Using Data From the National Violent Death Reporting System. Psychiatr Serv 2022:appips202100733. [PMID: 36475825 DOI: 10.1176/appi.ps.202100733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Firearms are highly lethal when used for suicide and are used more frequently as a suicide method by persons of older age. Individuals with terminal illness are at high risk for suicide, yet little research has explored how firearms may be used for self-harm in this population. The authors sought to understand the patterns of psychiatric diagnoses, substance use disorders diagnoses, and suicide mechanisms for individuals with terminal illness who died by suicide as well as their demographic and circumstantial characteristics. METHODS A latent class analysis using data from the National Violent Death Reporting System was undertaken to better understand typologies of individuals with terminal illness who died by suicide in 2003-2018 (N=3,072). To develop the classes, the authors considered diagnoses of mental illness and of alcohol or substance use disorders, suicidal thoughts and behaviors, and mechanism of suicide (firearm or no firearm). Demographic and circumstantial variables were examined across classes. RESULTS The analysis revealed four classes of persons with terminal illness who died from suicide: depression and nonfirearm methods (N=375, 12%), suicidal intent and firearm use (N=922, 30%), alcohol or substance use disorder and nonfirearm methods (N=70, 2%), and firearm use only (N=1,705, 56%). CONCLUSIONS Firearm access is an important consideration for terminally ill persons at risk for suicide. Screening for psychiatric and substance use disorders may not identify terminally ill persons who are at increased suicide risk because of the presence of a firearm in the home. This population may benefit from tailored interventions in specialty care settings to address firearm safety.
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Affiliation(s)
- Laura C Prater
- Departments of Psychiatry and Behavioral Health (Prater, Zatzick), Pediatrics (Ellyson, Rivara), and Epidemiology (Shawon, Cheung, Rowhani-Rahbar), University of Washington, Seattle; Firearm Injury and Policy Research Program, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle (Prater, Ellyson, Rivara); Social Development Research Group, School of Social Work, University of Washington, Seattle (Lyons)
| | - Alice M Ellyson
- Departments of Psychiatry and Behavioral Health (Prater, Zatzick), Pediatrics (Ellyson, Rivara), and Epidemiology (Shawon, Cheung, Rowhani-Rahbar), University of Washington, Seattle; Firearm Injury and Policy Research Program, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle (Prater, Ellyson, Rivara); Social Development Research Group, School of Social Work, University of Washington, Seattle (Lyons)
| | - Riffat Ara Shawon
- Departments of Psychiatry and Behavioral Health (Prater, Zatzick), Pediatrics (Ellyson, Rivara), and Epidemiology (Shawon, Cheung, Rowhani-Rahbar), University of Washington, Seattle; Firearm Injury and Policy Research Program, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle (Prater, Ellyson, Rivara); Social Development Research Group, School of Social Work, University of Washington, Seattle (Lyons)
| | - Vivian H Lyons
- Departments of Psychiatry and Behavioral Health (Prater, Zatzick), Pediatrics (Ellyson, Rivara), and Epidemiology (Shawon, Cheung, Rowhani-Rahbar), University of Washington, Seattle; Firearm Injury and Policy Research Program, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle (Prater, Ellyson, Rivara); Social Development Research Group, School of Social Work, University of Washington, Seattle (Lyons)
| | - Angel Cheung
- Departments of Psychiatry and Behavioral Health (Prater, Zatzick), Pediatrics (Ellyson, Rivara), and Epidemiology (Shawon, Cheung, Rowhani-Rahbar), University of Washington, Seattle; Firearm Injury and Policy Research Program, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle (Prater, Ellyson, Rivara); Social Development Research Group, School of Social Work, University of Washington, Seattle (Lyons)
| | - Frederick Rivara
- Departments of Psychiatry and Behavioral Health (Prater, Zatzick), Pediatrics (Ellyson, Rivara), and Epidemiology (Shawon, Cheung, Rowhani-Rahbar), University of Washington, Seattle; Firearm Injury and Policy Research Program, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle (Prater, Ellyson, Rivara); Social Development Research Group, School of Social Work, University of Washington, Seattle (Lyons)
| | - Ali Rowhani-Rahbar
- Departments of Psychiatry and Behavioral Health (Prater, Zatzick), Pediatrics (Ellyson, Rivara), and Epidemiology (Shawon, Cheung, Rowhani-Rahbar), University of Washington, Seattle; Firearm Injury and Policy Research Program, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle (Prater, Ellyson, Rivara); Social Development Research Group, School of Social Work, University of Washington, Seattle (Lyons)
| | - Douglas Zatzick
- Departments of Psychiatry and Behavioral Health (Prater, Zatzick), Pediatrics (Ellyson, Rivara), and Epidemiology (Shawon, Cheung, Rowhani-Rahbar), University of Washington, Seattle; Firearm Injury and Policy Research Program, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle (Prater, Ellyson, Rivara); Social Development Research Group, School of Social Work, University of Washington, Seattle (Lyons)
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8
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Goldstein EV, Prater LC. Examining the policy effects of Arizona's 2016 pre-emption law on firearm suicide rates in the greater Tucson area: an observational study. BMJ Open 2022; 12:e058196. [PMID: 35534056 PMCID: PMC9086613 DOI: 10.1136/bmjopen-2021-058196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE In 2016, Arizona enacted SB 1487 to nullify Tucson's ordinance permitting the municipality to destroy confiscated and forfeited firearms and instead require the firearms to be resold to the public through an auctioneer. Our objective was to examine whether firearm suicide rates increased in Pima County (greater Tucson area) relative to other Arizona counties following the enactment of Arizona's 2016 pre-emption law. DESIGN An observational study of a natural policy experiment. We used a difference-in-differences approach to estimate the effects of Arizona enacting SB 1487 on firearm suicide rates in Pima County. Our statistical analyses adjusted for county-level differences in population demographics (age, gender and race) and unemployment rates, as well as a proxy for firearm availability and mental health professional shortage area status. SETTING 9 Arizona counties from 2014 to 2019. PARTICIPANTS A policy group was constructed using Pima County (Tucson area) observations. A comparison group was created using data from eight other Arizona counties. 54 county-year observations were analysed. INTERVENTION SB 1487, which pre-empted Tucson law and allowed firearms that were seized/surrendered to law enforcement to be recirculated instead of destroyed. OUTCOMES AND MEASURES Annual rates of firearm and non-firearm suicides per 100 000 persons extracted from the Centers for Disease Control and Prevention WONDER system. RESULTS Over the study period, comparison group counties had an average of 14.87 firearm suicides per 100 000 persons per year, compared with 11.56 firearm suicides per 100 000 persons per year in Pima County. A 1.13 increase in Pima County's firearm suicides per 100 000 persons coincided with the enactment of Arizona's 2016 pre-emption law, relative to comparison group counties over the same period. CONCLUSIONS SB 1487 was associated with higher firearm suicide rates in Pima County relative to other areas not targeted by the law, assuming fewer firearms were destroyed and more firearms re-entered the greater Tucson area through 2019.
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Affiliation(s)
- Evan V Goldstein
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Laura C Prater
- Department of Psychiatry and Behavioral Health Sciences, School of Medicine, University of Washington, Seattle, Washington, USA
- Firearm Injury Prevention and Research Program, Harborview Injury Prevention and Research Center, Seattle, Washington, USA
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Prabhakar D, Peterson EL, Hu Y, Chawa S, Rossom RC, Lynch FL, Lu CY, Waitzfelder BE, Owen-Smith AA, Williams LK, Beck A, Simon GE, Ahmedani BK. Serious Suicide Attempts and Risk of Suicide Death. CRISIS 2021; 42:343-350. [PMID: 33151092 PMCID: PMC8096861 DOI: 10.1027/0227-5910/a000729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background: In the US, more than one million people attempt suicide each year. History of suicide attempt is a significant risk factor for death by suicide; however, there is a paucity of data from the US general population on this relationship. Aim: The objective of this study was to examine suicide attempts needing medical attention as a risk for suicide death. Method: We conducted a case-control study involving eight US healthcare systems. A total of 2,674 individuals who died by suicide from 2000 to 2013 were matched to 267,400 individuals by year and location. Results: Prior suicide attempt associated with a medical visit increases risk for suicide death by 39.1 times, particularly for women (OR = 79.2). However, only 11.3% of suicide deaths were associated with an attempt that required medical attention. The association was the strongest for children 10-14 years old (OR = 98.0). Most suicide attempts were recorded during the 20-week period prior to death. Limitations: Our study is limited to suicide attempts for which individuals sought medical care. Conclusion: In the US, prior suicide attempt is associated with an increased risk of suicide death; the risk is high especially during the period immediately following a nonlethal attempt.
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Affiliation(s)
- Deepak Prabhakar
- Sheppard Pratt Health System, 6501 North Charles Street, Baltimore, MD, 21204
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Zuriaga A, Kaplan MS, Choi NG, Hodkinson A, Storman D, Brudasca NI, Hirani SP, Brini S. Association of mental disorders with firearm suicides: A systematic review with meta-analyses of observational studies in the United States. J Affect Disord 2021; 291:384-399. [PMID: 34098496 DOI: 10.1016/j.jad.2021.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/26/2021] [Accepted: 05/05/2021] [Indexed: 11/30/2022]
Abstract
In the United States (US), 61% of all suicide cases may involve firearms, and some evidence suggests that mental disorders may play a role in suicide by firearm. We performed the first systematic review and meta-analyses to investigate: (i) whether mental disorders are associated with suicide by firearm, and (ii) whether the risk of using a firearm compared with alternative means is associated with higher levels of suicide in individuals with a mental disorder METHODS AND FINDINGS: We searched twelve databases from inception to the 24th of May 2020. We retrieved 22 observational studies conducted in the US. Random-effects meta-analyses showed individuals who had a diagnosis of a mental disorder had lower odds (odds ratios (OR)= 0.50, 95% CI: 0.36 to 0.69; I2=100 (95% CI: 87 to 100%), of dying by suicide with a firearm than those who did not have a diagnosis of a mental disorder. Secondary analysis showed that decedents who had a mental health diagnosis resulted in lower odds of dying by suicide by using firearms than using other means LIMITATIONS: Risk of bias revealed a heterogeneous and poor definition of mental disorders as well as lack of control for potential demographic confounding factors. In the meta-analyses, studies were combined in the same analytic sample as 77% of these studies did not specify the type of mental disorder CONCLUSION: While our results seem to suggest that having a mental disorder may not be consistently associated with the odds of dying by suicide using a firearm, the presence of substantial heterogeneity and high risk of bias precludes any firm conclusions.
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Affiliation(s)
- Ana Zuriaga
- Division of Health Services Research and Management, School of Health Sciences, City, University of London, London, United Kingdom.
| | - Mark S Kaplan
- Luskin School of Public Affairs, University of California, Los Angeles, United States
| | - Namkee G Choi
- Steve Hicks School of Social Work, University of Texas at Austin, United States
| | - Alexander Hodkinson
- National Institute for Health Research, School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, United Kingdom
| | - Dawid Storman
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland; Systematic Reviews Unit, Jagiellonian University Medical College, Krakow, Poland
| | - Nicoleta I Brudasca
- Division of Health Services Research and Management, School of Health Sciences, City, University of London, London, United Kingdom
| | - Shashivadan P Hirani
- Division of Health Services Research and Management, School of Health Sciences, City, University of London, London, United Kingdom
| | - Stefano Brini
- Division of Health Services Research and Management, School of Health Sciences, City, University of London, London, United Kingdom
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11
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Lethal means counseling for suicide prevention: Views of emergency department clinicians. Gen Hosp Psychiatry 2021; 71:95-101. [PMID: 33971519 PMCID: PMC8249328 DOI: 10.1016/j.genhosppsych.2021.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Lethal means safety - counseling and guidance about reducing access to home firearms and medications - is recommended for emergency department patients at risk of suicide. Decision aids are tools that can facilitate potentially difficult decisions by incorporating personal preferences and values. The present study evaluates clinician perceptions about the implementation and utility of "Lock to Live," a lethal means safety decision aid. METHOD One-on-one qualitative interviews were conducted with clinicians (n = 15) at three large emergency departments. Interviewees were asked to evaluate the "Lock to Live" decision tool and its potential implementation and utilization in the emergency department. Interviews were recorded and transcribed. Data were coded via thematic analysis; two coders developed a shared codebook iteratively with high interrater reliability. RESULTS Perspectives on the tool fell into three domains: (1) patients (use with patients and families), (2) clinicians, and (3) emergency department system. Interviewees noted that the tool had numerous potential benefits but that its uptake and effectiveness would depend on clinicians' perceptions on its utility, time constraints, and integration into workflow. Addressable concerns related to relationship to other resources, fit within emergency department workflow, and clarification about which emergency department clinician types should use the tool. CONCLUSIONS "Lock to Live" represents a promising new tool for use in suicide prevention as an aid to lethal means counseling. This qualitative study provides insights into the importance of considering the clinical environment when designing and implementing interventions.
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12
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Lemle RB. Veterans, Firearms, and Suicide: Safe Storage Prevention Policy and the PREVENTS Roadmap. Fed Pract 2020; 37:426-433. [PMID: 33029068 PMCID: PMC7535955 DOI: 10.12788/fp.0041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND US veterans die by suicide at a higher rate than that of the civilian population and are more likely to use a firearm as their method. Systemic efforts to address the use of firearms in suicide had been largely evaded. In June 2020, the White House published the Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS) task force report, which verified the link between, and the need to address, at-risk veterans and their access to firearms. This paper reviews the literature on the intersection of veterans, firearms, and suicide, then explores existing VA prevention initiatives aimed at reducing at-risk veterans' access to lethal means and offers policy recommendations to expand efforts in the context of the PREVENTS Roadmap. OBSERVATIONS The PREVENTS report recommends widespread distribution of safety education materials that encourage at-risk individuals to temporarily transfer or store their guns safely and the expansion of free or affordable options for storing weapons. Recommended policy actions to accomplish this goal include delaying access to firearms for at-risk veterans, facilitating temporary storage out of the home, improving in-home safe storage options, requiring that health care providers who care for high-risk veterans are trained in lethal means safety counseling, and creating campaigns to shift cultural norms for firearms' storage during crises. CONCLUSIONS Suicide prevention requires a multimodal approach, and attention to firearms access must become a more salient component. The high rate of veteran suicides involving firearms requires far-reaching interventions at societal, institutional, community, family, and individual levels.
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Affiliation(s)
- Russell B Lemle
- is Senior Policy Analyst, Veterans Healthcare Policy Institute and a Clinical Professor in the Department of Psychiatry, University of California, San Francisco
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Ammerman BA, Reger MA. Evaluation of Prevention Efforts and Risk Factors Among Veteran Suicide Decedents Who Died by Firearm. Suicide Life Threat Behav 2020; 50:679-687. [PMID: 32017233 DOI: 10.1111/sltb.12618] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 11/08/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Veterans die by suicide at a higher rate than the U.S. population, and veterans more frequently use a firearm as the suicide method. Consequently, firearm accessibility and storage represent important prevention considerations. This project aimed to explore the implementation of suicide prevention efforts among veterans who went on to die by suicide, with and without the use of a firearm, and to identify factors that differentiated veteran suicide decedents to help inform suicide prevention efforts. METHODS Data from the Veteran Health Administration Behavior Health Autopsy Program was analyzed for 97 veteran suicide decedents. RESULTS Results demonstrated that veterans who used a firearm for suicide were less likely to have engaged in suicide prevention efforts overall and were less likely to have received lethal means safety counseling / safety planning. Veterans who died by firearm had lower levels of notable risk factors (e.g., prior suicide attempt, no-shows for appointments), however were more likely to have a documented unsecured firearm in their home. CONCLUSION These findings support the benefit of broadening the reach of suicide prevention efforts, especially for high-risk veterans with access to firearms.
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Affiliation(s)
| | - Mark A Reger
- VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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Simonetti JA, Piegari R, Maynard C, Brenner LA, Mori A, Post EP, Nelson K, Trivedi R. Characteristics and Injury Mechanisms of Veteran Primary Care Suicide Decedents with and without Diagnosed Mental Illness. J Gen Intern Med 2020:10.1007/s11606-020-05787-1. [PMID: 32219647 DOI: 10.1007/s11606-020-05787-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/09/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND In the United States, suicide rates are increasing among nearly all age groups. Primary care is a critical setting for suicide prevention, where interventions often rely on identifying mental health conditions as indicators of elevated suicide risk. OBJECTIVE Quantify the proportion of suicide decedents within primary care who had no antecedent mental health or substance use diagnosis. DESIGN Retrospective cohort study. PARTICIPANTS Veterans who received Veterans Health Administration (VHA) primary care any time from 2000 to 2014 and died by suicide before 2015 (n = 27,741). MAIN MEASURES We categorized decedents by whether they had any mental health or substance use diagnosis (yes/no) using ICD-9 codes available from VHA records. We compared sociodemographic, clinical, and suicide mechanism characteristics between groups using chi-square, Student's T, or Wilcoxon tests. RESULTS Forty-five percent of decedents had no mental health or substance use diagnosis. Decedents without such a diagnosis were older (68 vs. 57 years, p < 0.001), and more likely to be male (98.3% vs. 95.8%, p < 0.001), non-Hispanic White (90.6% vs. 87.9%, p < 0.001), married/partnered (50.4% vs. 36.6%, p < 0.001), and without military service-connected disability benefits (72.6% vs. 56.9%, p < 0.001). They were also more likely to die from firearm injury (78.9% vs. 60.7%, p < 0.001). There were statistically significant differences in physical health between groups, but the magnitudes of those differences were small. Decedents without a mental health or substance use diagnosis had significantly shorter durations of enrollment in VHA healthcare, less healthcare utilization in their last year of life, and had little utilization aside from primary care visits. CONCLUSIONS AND RELEVANCE From 2000 to 2014, of nearly thirty thousand VHA primary care patients who died by suicide, almost half had no antecedent mental health or substance use diagnosis. Within VHA primary care settings, suicide risk screening for those with and without such a diagnosis is indicated.
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Affiliation(s)
- Joseph A Simonetti
- Rocky Mountain Mental Illness Research, Education and Clinical Center, Rocky Mountain Regional VA Medical Center, G3-189, 1700 N Wheeling St, Aurora, CO, 80045, USA.
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Health Administration, Washington, D.C., USA.
- Division of Hospital Medicine, University of Colorado Anschutz School of Medicine, Aurora, CO, USA.
| | - Rebecca Piegari
- Department of Veterans Affairs, Clinical Systems Development and Evaluation, Veterans Health Administration, Washington, D.C., USA
| | - Charles Maynard
- VHA Primary Care Analytics Team, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Lisa A Brenner
- Rocky Mountain Mental Illness Research, Education and Clinical Center, Rocky Mountain Regional VA Medical Center, G3-189, 1700 N Wheeling St, Aurora, CO, 80045, USA
- Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, University of Colorado Anschutz School of Medicine, Aurora, CO, USA
| | - Alaina Mori
- VHA Primary Care Analytics Team, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Edward P Post
- VA HSR&D Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Karin Nelson
- VHA Primary Care Analytics Team, VA Puget Sound Healthcare System, Seattle, WA, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- General Medicine Service, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Ranak Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Sciences, Division of Public Mental Health and Population Sciences, Stanford University, Palo Alto, CA, USA
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15
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Mortality Among Veterans with Major Mental Illnesses Seen in Primary Care: Results of a National Study of Veteran Deaths. J Gen Intern Med 2020; 35:112-118. [PMID: 31667746 PMCID: PMC6957595 DOI: 10.1007/s11606-019-05307-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 03/12/2019] [Accepted: 06/28/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Premature mortality observed among the mentally ill is largely attributable to chronic illnesses. Veterans seen within Veterans Affairs (VA) have a higher prevalence of mental illness than the general population but there is limited investigation into the common causes of death of Veterans with mental illnesses. OBJECTIVE To characterize the life expectancy of mentally ill Veterans seen in VA primary care, and to determine the most death rates of combinations of mental illnesses. DESIGN Retrospective cohort study of decedents. SETTING/PARTICIPANTS Veterans seen in VA primary care clinics between 2000 and 2011 were included. Records from the VA Corporate Data Warehouse (CDW) were merged with death information from the National Death Index. MAIN MEASURES Mental illnesses were determined using ICD9 codes. Direct standardization methods were used to calculate age-adjusted gender and cause-specific death rates per 1000 deaths for patients with and without depression, anxiety, post-traumatic stress disorder (PTSD), substance use disorder (SUD), serious mental illness (SMI), and combinations of those diagnoses. KEY RESULTS Of the 1,763,982 death records for Veterans with 1 + primary care visit, 556,489 had at least one mental illness. Heart disease and cancer were the two leading causes of death among Veterans with or without a mental illness, accounting for approximately 1 in 4 deaths. Those with SUD (n = 204,950) had the lowest mean age at time of death (64 ± 12 years). Among men, the death rates were as follows: SUD (55.9/1000); anxiety (49.1/1000); depression (45.1/1000); SMI (40.3/1000); and PTSD (26.2/1000). Among women, death rates were as follows: SUD (55.8/1000); anxiety (36.7/1000); depression (45.1/1000); SMI (32.6/1000); and PTSD (23.1/1000 deaths). Compared to men (10.8/1000) and women (8.7/1000) without a mental illness, these rates were multiple-fold higher in men and in women with a mental illness. A greater number of mental illness diagnoses was associated with higher death rates among men and women (p < 0.0001). CONCLUSIONS Veterans with mental illnesses, particularly those with SUD, and those with multiple diagnoses, had shorter life expectancy than those without a mental illness. Future studies should examine both patient and systemic sources of disparities in providing chronic illness care to Veterans with a mental illness.
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Variation in patterns of health care before suicide: A population case-control study. Prev Med 2019; 127:105796. [PMID: 31400374 PMCID: PMC6744956 DOI: 10.1016/j.ypmed.2019.105796] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 07/29/2019] [Accepted: 08/07/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND The United States has experienced a significant rise in suicide. As decision makers identify how to address this national concern, healthcare systems have been identified as an optimal location for prevention. OBJECTIVE To compare variation in patterns of healthcare use, by health setting, between individuals who died by suicide and the general population. DESIGN Case-Control Study. SETTING Eight healthcare systems across the United States. PARTICIPANTS 2674 individuals who died by suicide between 2000 and 2013 along with 267,400 individuals matched on time-period of health plan membership and health system affiliation. MEASUREMENTS Healthcare use in the emergency room, inpatient hospital, primary care, and outpatient specialty setting measured using electronic health record data during the 7-, 30-, 60-, 90-, 180-, and 365-day time periods before suicide and matched index date for controls. RESULTS Healthcare use was more common across all healthcare settings for individuals who died by suicide. Nearly 30% of individuals had a healthcare visit in the 7-days before suicide (6.5% emergency, 16.3% outpatient specialty, and 9.5% primary care), over half within 30 days, and >90% within 365 days. Those who died by suicide averaged 16.7 healthcare visits during the year. The relative risk of suicide was greatest for individuals who received care in the inpatient setting (aOR = 6.23). There was both a large relative risk (aOR = 3.08) and absolute utilization rate (43.8%) in the emergency room before suicide. LIMITATIONS Participant race/ethnicity was not available. The sample did not include uninsured individuals. CONCLUSIONS This study provides important data about how care utilization differs for those who die by suicide compared to the general population and can inform decision makers on targeting of suicide prevention activities within health systems.
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Baiden P, Tadeo SK, Graaf G, Respress BN. Examining the Association between Weapon Carrying on School Property and Suicide Attempt among Adolescents in the United States. SOCIAL WORK IN PUBLIC HEALTH 2019; 34:570-582. [PMID: 31264533 DOI: 10.1080/19371918.2019.1635945] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Suicidal behaviors among adolescents in the United States are the second leading cause of death and has been steadily increasing over the years. Although access to and possession of a weapon may facilitate the transition from suicidal ideation to a suicide attempt, few studies have examined the association between weapon carrying and suicide attempts among adolescents. The objective of this study was to examine the association between weapon carrying on school property and suicide attempt among adolescents. Data for this study came from the 2017 Youth Risk Behavior Surveillance System. A sample of 14,547 adolescents aged 14-18 years old (50.5% female) was analyzed using logistic regression. Of the 14,547 adolescents, 4% carried a weapon on school property, and 7.7% attempted suicide during the past 12 months. In the multivariate logistic regression, adolescents who reported carrying a weapon on school property had more than double the odds of attempting suicide when compared to their counterparts who did not carry a weapon on school property. Other significant predictors of suicide attempt include sexual minority, history of forced sexual intercourse, school bullying and cyberbullying victimization, feeling sad or hopeless, and substance use. Examining the association between weapon carrying and suicide attempt among adolescents would contribute to early identification of adolescents who are likely to engage in suicidal behaviors.
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Affiliation(s)
- Philip Baiden
- School of Social Work, The University of Texas at Arlington , Arlington , TX , USA
| | - Savarra K Tadeo
- School of Social Work, The University of Texas at Arlington , Arlington , TX , USA
| | - Genevieve Graaf
- School of Social Work, The University of Texas at Arlington , Arlington , TX , USA
| | - Brandon N Respress
- College of Nursing and Health Innovation, The University of Texas at Arlington , Arlington , TX , USA
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Laine C, Taichman DB. The Health Care Professional's Pledge: Protecting Our Patients From Firearm Injury. Ann Intern Med 2017; 167:892-893. [PMID: 29049687 DOI: 10.7326/m17-2714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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