Written by Marc W. Manseau, MD, MPH, NPA Gun Violence Prevention Taskforce Member

September is Suicide Prevention Awareness Month. But as physicians, what should we be aware of, and how should we educate our patients about suicide? Like all manifestations of human psychology and behavior, suicide is the (catastrophic) result of an extremely complex and mostly opaque series of processes. As such, while I maintain hope that technology will one day prevail, there is currently no screening tool, blood test, or imaging study that can predict suicide with any reasonable degree of accuracy. This certainly does not mean we should refrain from asking about suicidal thoughts and risk factors. There are evidence-based screening tools available, and we can save some lives by using them in clinical settings. However, short the equivalent of a colonoscopy or Pap smear for suicide, we cannot currently expect to reach a public health solution through clinical means.
And suicide is certainly a public health crisis worthy of our serious attention. Suicide is the tenth leading cause of death in the United States, and the second leading cause of death for adolescents and youth. Even more alarming, increasing suicide seems to be one of several major contributors (in addition to accidental drug overdose deaths) to recently rising mortality in the United States, both overall and in particular among white, middle aged adults. Drug poisoning-related deaths are finally getting the public health and policy attention that they very much deserve and need, but what about suicide?
Without an obviously effective clinical prevention approach available, what would a public health approach to suicide prevention look like? Public education – including for both clinicians and their patients – would be a good start. In June 2015, I wrote a blog post in this space about addressing lethal means of suicide, where I argued that all physicians should ask their patients about both suicidal thoughts and access to suicide methods that would be highly likely to cause death. If we are unable to accurately screen for and predict who will attempt suicide, maybe we can at least educate the public about which environmental characteristics are most dangerous to someone who is struggling with mental illness, addiction, and/or an acute crisis. Then, family and community members – who are likely to know when someone is in danger sooner and more intimately than a clinician – can try to keep at-risk people safe until they are able to secure mental health care or other assistance. This reasoning leads us straight to the politically and culturally charged topic of guns in the United States. With about half of suicides committed with firearms, and with nine out of ten suicide attempts by gun resulting in death, the topic of guns is simply unavoidable if we wish to mitigate our national epidemic of suicide.
So what are the risks in terms of suicide of gun ownership and access in the United States? How should we educate the public and our patients about these risks? Our understanding is unfortunately limited by gun-lobby-promoted restrictions on federally supported gun violence prevention research, but we still know enough to save lives. Most people who survive a suicide attempt do not eventually die by suicide. Presumably, they are able to get the help they need to prevent future death by suicide. Therefore, when first attempts are highly likely to be lethal (eg., by gun shot), there is no opportunity for secondary prevention. Reducing access to guns in general, and especially for those at risk of suicide, presents opportunities for universal and selective primary prevention. For instance, we know that states with higher gun ownership rates have higher suicide rates, the difference in which is completely explained by gun-related suicides (suicide rates by other means are roughly equivalent across high- and low-gun-ownership states). We also know that having a gun in the home more than triples the risk of suicide. For adolescents, the risk of gun access is even higher, even when known mental illness is controlled for. Homes with guns have a risk of adolescent suicide that is almost ten times higher than the risk in homes without guns, and the risk of suicide increases proportionally with both the number and accessibility of firearms in the home.
Talking about guns is difficult in the United States, and some states have even attempted to prevent physicians from doing so with their patients. Firearms seem to immediately incite political differences and intercultural resentments; they have become a flashpoint in our increasingly polarized society. However, until we find a way to objectively identify and treat the premorbid lesion for suicide, a public health approach is all we have. Since access to guns is central to any public health approach to suicide prevention, we owe it to our patients, our communities, and our profession to continue having difficult conversations about guns.
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Suicide: Facts at a Glance 2015 – Centers for Disease Control https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf
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