Written by Marc W. Manseau, M.D., M.P.H.
On June 17, 2015 – more than halfway through Gun Violence Awareness Month – the United States was once again thrust into an excruciating abyss of soul searching, in the aftermath of the act of mass shooting terrorism at the Emanuel African Methodist Episcopal Church in Charleston, South Carolina. President Obama’s somewhat resigned tone on that dark evening reflected the nation’s weariness, as the United States was forced once again to confront our collective stain of gun violence with the recognition that we have been unable to take any corrective measures on the national level. And with each act of mass shooting, we are reminded of the daily scourge of gun-related deaths and injuries in the United States that occur well outside the fevered media attention surrounding a mass shooting event. While less terrifying to the public, gun-related accidental injuries, suicides, and homicides unrelated to mass shootings account for more than ninety-nine percent of firearm deaths in the United States. And while critical public discourse is necessary for healing in the aftermath of a horrific event, we will need to break this recent endless cycle of intense mourning followed by stagnated inaction in order to address gun violence in the United States.
Before the Charleston shooting, Dr. Jerry Walden wrote a piece for the NPA blog on Gun Violence Awareness Day (June 2, 2015) highlighting the importance of the ASK Campaign, designed to prevent firearm-related accidental injuries to children. Given the great success of other primary care and pediatrics-based patient educational interventions aimed at preventing injuries and accidental death, it is vital that physicians spread the word about the ASK Campaign, and fight to protect our freedom and responsibility to speak openly with our patients about the risk of gun-related injuries. I now draw attention to the most common but also most often neglected cause of gun violence-related death in the United States: suicide.
According to the Centers for Disease Control and Prevention, there were over 41,000 suicides in 2013 in the United States, making suicide the tenth leading cause of death. More than half of these deaths were caused by a firearm, and about two thirds of gun-related deaths in the United States are suicides. The situation is even direr for adolescents, as suicide is the third leading cause of death for people between the ages of fifteen and nineteen years old. Some may assume that the decision to take one’s life is carefully thought out, arrived at only after all other perceived options have been exhausted. However, we know that suicide is most often an impulsive act, fueled by a combination of acute crisis and alcohol or drugs. People who survive a suicide attempt are often likely to get the help they need afterwards, thus preventing their eventual death by suicide. Therefore, the lethality of the means of a suicide attempt is paramount, and guns are extremely lethal. For instance, whereas almost ninety percent of suicide attempts with guns end in death, only two percent of overdose attempts are fatal. Given this context, it is not surprising that gun access at home is a major risk factor for suicide. Having a gun within easy reach can very quickly turn a manageable crisis into an irreversible tragedy.
So, what role can physicians play in preventing suicide? The fact that almost half of people who die by suicide visit their primary care physician within the month prior suggests that doctors have a large role to play. However, unfortunately, the technology and research related to suicide prevention is far behind other areas. We know that individual clinicians – even psychiatrists – are unable to predict who will die by suicide with much greater accuracy than the average non-clinician. On an individual event basis, you cannot prevent what you cannot predict. This leaves addressing access to highly lethal means of suicide amongst those at elevated risk as our most potentially powerful tool. There is indirect evidence that “means restriction” works for suicide. Studies on barriers to prevent people from jumping off of bridges show sustained, community-wide reductions in suicide rates – once impulsive acts are thwarted, most would-be suicide victims do not simply find other places from which to jump. It stands to reason that removing guns from crises could work in much the same way.
We urgently need an ASK Campaign for suicide prevention, on a scale equal to or larger than the campaign for pediatric injury prevention. A clinical intervention sometimes referred to as “Lethal Means Counseling” holds great promise as a model. If a patient is at risk for suicide, due to reported thoughts of suicide, worsening mental illness symptoms, escalating substance use, or a personal crisis, the doctor first assesses whether the patient has access to firearms. It is important to try to speak with both the patient as well as the patient’s support system, such as family members. If the patient indeed has access to guns, the physician then works with the patient’s support system to temporarily restrict access to them, preferably through removal to a family member’s home or to local law enforcement, but at a minimum by ensuring that they are locked and stored separately from ammunition.
Psychiatrists and allied mental health professionals are working hard every day to treat the mental illnesses that often underlie suicide, but they cannot do it alone. In order to prevent one of our society’s top killers, we need help from all physicians. Until suicide prevention research progresses much further, restricting access to lethal means holds the greatest potential to save lives. In the United States, lethal means is largely synonymous with firearms, and therefore our success will be predicated on the ability of all physicians to speak openly with our patients without intimidation from the gun industry lobby.
To find gun violence prevention information, helpful resources, and action opportunities, please visit http://npalliance.org/gun-violence-prevention.
Bennewith O, Nowers M, Gunnell D: Effect of barriers on the Clifton Suspension Bridge, England, on local patterns of suicide: implications for prevention. Br J Psychiatry 2007; 190:266–267.