Lethal Means Counseling in Emergency Departments

Lethal Means Counseling in Emergency Departments Wikicommons(Kencf0618) MARIAN (EMMY) BETZ, MD, MPH ASSOCIATE PROFESSOR OF EMERGENCY MEDICINE UNIVERSITY OF COLORADO SCHOOL OF MEDICINE Background: Whydo we need to talk about guns? Disclosures Consultant for American Foundation for Suicide Prevention & Suicide Prevention Resource Center Serve on Colorado Suicide Prevention Commission Funding: American Foundation for Suicide Prevention NIMH ED-SAFE trial NIA Beeson K23 Career Development Award San Francisco Public Library Overview of today talk about guns when we Why we need to talk about suicide talk about guns when we Do we Why we need to talk about suicide How talk about guns when we Why we need to talk about suicide historical example o Israeli military: Most suicides by gun, on weekends 2006: Required soldiers to leave weapons on base Suicide rates dropped % Lubin2010, Suic & Life-Threat Behavior. 1

why? why? 1. impulsivity The final decision to attempt suicide often occurs within only minutes 3. lethality 85-90% of people who use a gun to attempt suicide die time between deciding to attempt suicide and taking action The Houston Study: Nearly Lethal Suicide Attempts - N=153 (15-34 year olds) 30% 25% 20% 15% 10% suicide methods in the US Fatal suicides Firearm Suffocation Poisoning Jump Cut Other 5% 0% <5 min 5-20 min 20- min 1-8 >8 hours hours Nonfatal suicide attempts CDC WISQARS; MeansMatter.org Why? 2. prognosis The majority of people with suicidal thoughts or behavior do not later die by suicide where there are more guns, there are more suicides o States with more firearms have higher suicide rates Differences in state suicide rates better explained by levels of household gun ownership than by mental health problems, suicidal ideation, or suicide attempts Miller M et al. Annu Rev Public Health. 2012;33:393-8 o Gun in the home >3x risk of completed suicide (Odds ratio, 3.24) Anglemyer A et al. Ann Intern Med. 2014;1:101-10. o Adults in households with firearms are not more depressed or suicidal yet far more likely to die by suicide Hemenway D. Ann Intern Med. 2014;1(2):134-5. Betz ME et al. Suicide Life Threat Behav. 2011;41:384-91. 2

why ask about guns? o Access to lethal means matters o Large numbers of ED patients evaluated for suicide risk ED visits for mental health reasons rising 39-43% of suicide decedents visit an ED in the year before death Multiple ED visits may indicate elevated suicide risk Emergency Dept Safety and Follow-up Evaluation Study Treatment as usual ED-SAFE provider survey: 8 sites, survey of all ED physicians & nurses Survey Survey Survey EDs determine screening and care Universal suicide screening EDs determine care Intervention ED: Safety form and MD screener Cohort: telephone counseling Kruesi et al, J Am Acad Child Adolesc Psychiatry 1999. 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action Caring for Adult Patients with Suicide Risk: A Consensus-Based Guide for Emergency Departments. why ask about guns? ogoal is to reduce access to lethal means Access to lethal means may affect overall risk assessment Lethal means counseling as part of safety planning for discharged emergency department patients % "I often/almost always ask if there are firearms at home 100 80 20 Suicidal in past month, not now* In ED for overdose, no longer suicidal* Suicidal today, without plan* Suicidal with plan doesn't involve gun* Suicidal with plan, does involve gun* Kruesi et al, J Am Acad Child Adolesc Psychiatry 1999. 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action Caring for Adult Patients with Suicide Risk: A Consensus-Based Guide for Emergency Departments. 0 *P<0.001 under Pearson chi-square test. MD RN Betz et al. Depress Anxiety 2013. "I often/almost always ask if there are firearms at home Current state: Do we talk about guns? % 100 80 Suicidal in past month, not now* In ED for overdose, no longer suicidal* Suicidal today, without plan* Suicidal with plan doesn't involve gun* Suicidal with plan, does involve gun* 20 0 *P<0.001 under Pearson chi-square test. MD RN Betz et al. Depress Anxiety 2013. 3

Percent "I often/almost always ask if there are firearms at home (by study phase) 100 80 47 Barriers to asking o Ignorance, inadequate training o Fear of alienating patient o No time! No resources! o How should we ask? o What if they say yes? 20 0 Phase 1 Phase 2 Phase 3 ED-SAFE cohort: ED patients with SI/attempt in past 2 weeks (N=1358) Research staff asked about firearm access (part of baseline questionnaire) + Research staff reviewed ED record from that same day 11% told research staff they had 1 gun at home (site range: 6-26%) o 25% had unlocked & loaded o 54% had easy access + 50% of charts had documentation of lethal means assessment Barriers to asking o Ignorance, inadequate training o Fear of alienating patient o No time! No resources! o How should we ask? o What if they say yes? Betz et al. Depress Anxiety 2016 epubmarch 17. who did we miss? ED disposition (n=1358) Discharge home Psych admission Other Lethal means assessment in ED medical record (among those discharged; n=337) Yes No Self-reported firearms (among those discharged & with assessment; n=185) 1 firearm at home No firearm at home Recommendations: How should we talk about guns? Betz et al. Depress Anxiety 2016 epubmarch 17. 4

caveat o Limited prior empirical work o Much active work in this area please join us! what do patients want? o Patient-centered care Nonjudgmental, respectful, empathetic education o Provider cultural competence already expected (eg., for ethnic heritage, religious beliefs, sexual orientation) o Counseling that is both individualized and routine Becher EC et al. Am J Public Health2000; Betz & Wintemute JAMA. 2015. Olson et al. InjPrev. 2007;Price JH et al. J EmergMed2013;Sege RD et al. Pediatrics2006; VriniotisMet al. Suicide Life Threat Behav. 2015; Wintemuteet al Annals Internal Med2016. Colorado Firearm Safety Coalition basic messages o Reduce firearm access for those at risk of suicide Store firearm outside of home Store inside home (inaccessible to person at risk) (Also option to get rid of firearm permanently) o Ideally, safe storage is a long-term practice But even short-term changes can save lives o This is not about confiscation of firearms! gag laws : you canask 80 Reasons Americans Own Guns (open-ended Gallup survey); Oct 3-6, 2013 o Florida law: health practitioners should refrain from asking about firearms or ammunition and may not intentionally enter information about firearms into medical records o EXCEPTION: A practitioner who in good faith believes that this information is relevant to the patient s medical care or safety, or the safety of others may ask Only information that is not relevant to the patient s medical care or safety, or the safety of others must be kept out of medical records Percent 20 0 Wintemuteet al. Annals Internal Med 2016 (in press). 5

suggested language sample small handgun safes (amazon, 1/2016) o How you raise the issue with a person at risk of suicide can make a difference: A Lots of people have guns at home. What some people in your situation do is store their guns away from home until they re feeling better, or lock them and ask someone they trust to hold onto the keys. If you have guns at home, I m wondering if you ve thought about a strategy like that. versus $22 (key) $~250+ (fingerprint or bracelet) B Do you have guns at home? They should be removed for your safety. ~$100 (combination) suggested language larger safes o What do you think about storing your guns off-site until the situation improves? o Is there someone you d trust to hold onto the keys for a while? NOT give up, dispose of, relinquish your guns o Don t ask the patient change their identity as a gun owner collaborate with him/her in-home safe storage options relevant Colorado laws $5 (cable lock) $10 (trigger lock) o With family? YES o With friends/neighbors? 72 HOURS o At a gun shop? YES* o With police? YES* 6

Colorado: storage with non-family o Universal background check law Background checks required for for gun sales from a federally licensed dealer and also for private sales Must be completed before any transfer (check is on proposed transferee); check often run by a licensed dealer ~$7, takes ~15 minutes o Exception: No background checks required for temporary transfer <72 hours Check on B Colorado: storage with police o Colorado lists police departments as potential repositories for firearms when they are surrendered (e.g., as a result of a domestic violence restraining order) o Police departments are not required to accept firearms Likely agency specific Concerns about liability (proper storage, return to owner) A Check on A B questions about 72 hour window o Can a family member, friend, or other nonowner of a firearm transfer a firearm? o Can the transferee subsequently transfer the firearm to a safer space? o Can the 72-hour transfer be restarted? o What should the transferee do with the firearm if the transferor doesn t claim it after 72 hours? overview of today Why we need to talk about guns when we talk about suicide Do we talk about guns when we talk about suicide? How we need to talk about guns when we talk about suicide Col. Rev. Stat. 18-12-112 2013 Colorado: storage at gun shop o Firearm retailers are not required to accept firearms Concerns about liability (proper storage, return to owner) o Varying views of retailers (support suicide prevention, but may not want to store) In Denver area, most do not offer storage Thank you! MARIAN.BETZ@UCDENVER.EDU 7

Joint Commission NPSG 15 o Identify patients at risk for suicide Applies to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals, including EDs o Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide. o Address the patient s immediate safety needs and most appropriate setting for treatment. o When a patient at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as a crisis hotline) to the patient and his or her family. http://www.jointcommission.org/assets/1/6/npsg_eps_scoring_hap_20110706.pdf 100% 75% 50% 25% 0% Percent of providers reporting they "often" or almost always ask suicidal patients about gun access Suicidal in past month, not now** Phase 1 (n=658) Phase 2 (n=616) Phase 3 (n=610) In the ED for Suicidal today, multi-drug without plan*** ingestion, no longer suicidal*** Suicidal with plan, doesn't involve gun*** Suicidal with plan, does involve gun *p 0.05, **p 0.01, ***p 0.001 under Chi Square for Phase Situational factors Population Suicide Risk Factors Most attempts are within a crisisor psychiatric illness exacerbation Psychiatric illness Substance abuse Gender Age Access to lethal means Marital status Medical conditions Family history of suicide Depression, schizophrenia, panic disorder, personality disorder Drugs or alcohol Female 3x as likely to attempt, but males 3x as likely to complete Older men at highest risk (55-65 years-old) Women younger at attempts (25-35 years old) Presence of a firearm in the home increases suicide risk 5-10x Separated, divorced, widowed Chronic pain, chronic illness Resources o Means Matter Website from the Harvard School of Public Health For providers: information about lethal means counseling For families: safety tips, what to do with guns Plus additional information about the research underpinning a means restriction approach to suicide prevention http://www.hsph.harvard.edu/means-matter/ o National Hotline 1-800-273-TALK (1-800-273-8255) 8