? Health Care System Research Network Conference April 9, 2019 Julie Richards, PhDc, MPH

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1 What Will Happen If I Say Yes? Perspectives Among Adults With Depressive Symptoms On Routine Questions About Firearms Access In Primary Care? Health Care System Research Network Conference April 9, 2019 Julie Richards, PhDc, MPH 1

2 Funding KP Washington Health Research Institute Development Fund Awards 1/1/ /31/2018 Acknowledgments Collaborators: David Grossman Sarah Hohl Amy Lee Evette Ludman Casey Luce Chester Pabiniak Rob Penfold Courtney Segal Greg Simon Ursula Whiteside Emily Williams 2

3 Disclosures I have no financial conflicts of interest. Advisor for NowMattersNow.org I have family members and friends who have died by suicide and I care about prevention. 3

4 Research question Background Methods Results Clinical Implications Future Directions Outline 4

5 Research Question How do patients perceive standard questions about firearm access? Pictures from: Guns in America: The Search for Common Ground Begins with Listening to Everyone, November 5,

6 Background Firearms most common method of suicide deaths Highly lethal (85%-95%) Safe storage interventions may be effective Providers usually do not ask patients about firearms No clinical guidelines Proposed and enacted laws KPWA routinely collects patient-reported firearm access information in the EHR 6

7 Objective To describe primary care patient perspectives about being asked a standard question about firearm access in context of routine MH care. Part of broader project Semi-structured interviews Stratified sampling by frequency of self-harm reported on the PHQ-9 ninth question 7

8 Patient Sample Identification KP Washington adult primary care patients Sample N=100 PHQ-2+ & assessed with PHQ-9 Answered PHQ-9 Q9 in different ways Demographic diversity (age, sex, race/ethnicity) Excluded minors and SPOT trial enrollees Goal interview participants 8

9 Recruitment Advance letter Phone follow-up Oral consent Phone interview ~15 minutes in length $50 incentive Audio-recorded 9

10 Interview 3 Interviewers Build rapport General -> Specific questions Probes about the firearm access question Some people are asked about access to a gun. Do you remember this question? [ Do you have access to guns? Yes/No] (If yes) Can you tell me about your experience answering that question? (Yes or No) Do you think this is an appropriate question for your health care provider to ask? 10

11 Qualitative Analysis Demographic & patient-reported characteristics (Screening Qx sampling -> EHR) Transcribed audio-recordings Atlas.ti Deductive and inductive content analysis 2 Coders (10 interviews coded by both) 11

12 Targeted Qualitative Analysis Data specific to perceptions of firearm access warranted targeted analysis 4 team members (2 new team members) Affinity diagram organize themes Full team review 12

13 Results 37 participants interviewed Interview average duration= 15.4 minutes (range 5-29) 13

14 N % Female RESULTS 25 68% Age Category % % % > % Race/Ethnicity White 28 76% Black 3 8% Asian 2 5% Hispanic 2 5% Am Indian 1 3% Unknown 1 3% Did Not Answer 2 5% PHQ-9 Score (Mean, SD) PHQ-9 Q9 Never (0) 9 24% Several Days (1) 8 22% More than half the days (2) 11 30% Nearly Every Day (3) 9 24% Received C-SSRS 14 38% 14

15 Results Participant sample N=37 N Received the Firearm Qx 16 No Access 9 Yes Access 3 Did not respond 4 15

16 Results Participant sample N=37 PHQ-9 Q9=0 PHQ-9 Q9=1-3 N Received the Firearm Qx 16 No Access Yes Access Did not respond

17 Privacy Concerns Big Brother Surveillance Fear of Denied Rights Concerns about Disclosure Other Lethal Means Suggestions for Connecting Qx to Suicide Capacity for Suicide Perspectives on the Firearm Access Question Depression & Suicidal Thoughts Men Veterans Yes Alcohol & Drug Use Appropriate? Suicide Private Decision Means Substitution No Firearm Ownership Demographics Suggestive 17

18 Privacy Concerns Big Brother Surveillance Fear of Denied Rights Concerns about Disclosure Other Lethal Means Suggestions for Connecting Qx to Suicide Capacity for Suicide Perspectives on the Firearm Access Question Depression & Suicidal Thoughts Men Veterans Yes Alcohol & Drug Use Appropriate? Suicide Private Decision Means Substitution No Firearm Ownership Demographics Suggestive 18

19 Privacy Concerns Big Brother Surveillance Fear of Denied Rights Concerns about Disclosure Other Lethal Means Suggestions for Connecting Qx to Suicide Capacity for Suicide Perspectives on the Firearm Access Question Depression & Suicidal Thoughts Men Veterans Yes Alcohol & Drug Use Appropriate? Suicide Private Decision Means Substitution No Firearm Ownership Demographics Suggestive 19

20 Privacy Concerns Big Brother Surveillance Fear of Denied Rights Concerns about Disclosure Other Lethal Means Suggestions for Connecting Qx to Suicide Capacity for Suicide Perspectives on the Firearm Access Question Depression & Suicidal Thoughts Men Veterans Yes Alcohol & Drug Use Appropriate? Suicide Private Decision Means Substitution No Firearm Ownership Demographics Suggestive 20

21 Theme 1: Concerns about disclosing access to firearms related to privacy, autonomy and firearm ownership rights When you just see it on this form, and you don't know what they're going to do about how you answer this form, for someone who is concerned about the government infringing on their rights, it gives you the feeling of, Maybe I should just answer no (P20). Privacy Concerns Big Brother Surveillance Fear of Denied Rights Concerns about Disclosure But just because you struggle with depression, I don't believe you should not be allowed to have a gun, because while depression might be something you struggle with, it is not who you are though they have days where they want to give up on life, they're also at the same time spending every minute of every day trying to beat their depression; trying to focus on their survival. So I think that's important (P25). 21

22 Theme 2: Suggestions for connecting questions about firearms and other lethal means to suicide risk Women, I think, particularly say, Of course not [no firearm], while their purses are stuffed with sedatives and morphine derivatives and those things, which they might be planning to use when they get home (P28). Technically, anybody has access to a gun Would you shoot yourself? is how I always interpreted that question (P29). Other Lethal Means Suggestions for Connecting Qx to Suicide Capacity for Suicide I don t know any of my veteran friends who don t have guns. And I know at least more than half of them have put the gun to their head and almost pulled the trigger. So, I feel like if there was some way to pardon me for being blunt but have you ever held a gun in your hand and turned it towards your face? Or something to where the sincerity of that action is actually being verbalized (P17). 22

23 Theme 3. Varying perspectives on the appropriateness of the firearm question, informed by beliefs and experiences Appropriate? Suicide Private Decision Means Substitution No Firearm Ownership Demographics Suggestive I would say no. For me, I m an Asian, I have a kid, all that. I have a high education. I don t know if it s useful for me to answer this question at all (P13). I feel like if a person really has their mind set on killing themselves, it doesn't matter whether they have a gun or not. They will find a way (P25). Well, if someone really wants to end their life, that s a private decision (P31). It s a little bit like giving you an idea of how to do this, and a little suggestive, you know. Oh, that s right, I ve got a gun (P31). 23

24 Theme 3: Varying perspectives on the appropriateness of the firearm question, informed by beliefs and experiences I think it s an important question I mean I purposely, no matter how afraid I would be or I mean I have kids. And I wanna protect them. I wanna protect my house, but there was no way I would ever buy a gun. Just because I know if I ever got really, really depressed, I d use it (P18). Depression & Suicidal Thoughts Men Veterans Yes Alcohol & Drug Use Appropriate? She [PC social worker] said, The Second Amendment is just fine if that's why you have the gun but you've got to realize that the failure rate with a gun is so small. So is there anything you can do to at least remove it from your immediate access? and so forth. And I made an agreement with her too, Yeah, I can give it to this relative located 20 miles away from my house, We made this verbal agreement that I would make it inoperable for a while, at least so that if I had any thoughts of using it, there'd be a few-hour cool down period before I could ever get access to it (P20). 24

25 Strengths & Limitations All participants had some depressive symptoms and many had experienced suicidal ideation recently Strength= unique insight Limitation=not typical PC population Less than half (16 of 37) participant had received the firearm qx (at their most recent visit) Did not systematically assess firearm access 25

26 Clinical Implications Context may be helpful for patients answering firearm access Firearms are highly lethal Preference for means Suicidal crises often time limited Women also die by firearm suicide Benefits of disclosure = lethal means counseling Non-judgement Resources 26

27 Future Directions Statistical analyses of patient reported access to firearms Qualitative analyses Why some patients do not answer this question? How do providers use this information? Implementation and evaluation of firearm access decision aid 27

28 Thank you! Questions? (P.S. Reference list available upon request) 28

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