Perlis and colleagues1 describe the convergence of firearm ownership and symptoms consistent with a clinically significant depressive condition among respondents to a carefully crafted and demographically weighted internet survey. As part of an effort to examine the consequences of COVID-19, the authors used the 9-Item Patient Health Questionnaire (PHQ-9) depression screening scale as well as a dichotomous yes or no question regarding gun ownership. Additionally, they inquired about recency of purchase, future plans for acquiring guns, and reasons for obtaining them.
Of the 24 770 respondents, 6929 (28.0%) were positive, with a PHQ-9 score 10 or greater, of whom nearly a third owned a gun—of which more than 35% had purchased their firearm during the pandemic. However, depressive symptoms were not preferentially associated with ownership. Among persons with depression, those who owned guns were significantly more likely to be younger, male, and White; to have higher income; to be rural dwelling and living in the southern United States; and to express an affiliation with the Republican party. Most respondents indicated that their purchases were for protection against crime, although persons with depression noted this relatively less often, while more frequently affirming gun acquisition due to COVID-19 and for protection against someone known to them. Other common reasons included hunting and target shooting as well as concerns regarding protection against the government, the election, and the lockdown. Participants with depression had purchased their guns more recently; of those who were not owners, there was greater expressed interest in a near future purchase as compared with respondents who did not own a firearm and did not have depression. While the authors conducted others analyses, their major conclusion suggested that “our results may facilitate focused interventions to diminish suicide risk and increase firearm safety among individuals with 2 major suicide risk factors.”1
Suicide Prevention—Writ Large
It is useful to place suggestions for preventing suicide, attempted suicide, and risk-related outcomes, such as drug-related fatalities (ie, “self-injury mortality”2), into a broader public health context.3 We know that large scale public health efforts to restrict access to lethal methods of suicide have the greatest potential population impact by fundamentally impeding the ability of persons to select a more lethal option for suicide.3 However, results can be ambiguous. National bans of highly hazardous pesticides can lead to declines in suicide,4 yet a major community-based, cluster-randomized trial regarding the effectiveness of lockable household pesticide storage containers found no effect.5 Australia enacted firearm laws during the mid-1990s and early 2000s, which appeared to be associated with a decline in suicide rates during the early 2000s, only to see a relatively steady rise during the second decade of this century.6 Prevention initiatives that depend on one-on-one clinical interactions and efforts to educate individuals tend to be less potent in their overall effects as compared with broadly reaching public health programs.3 But the vast majority of efforts in the United States have focused almost exclusively on identifying individuals with apparently elevated risks for suicide, and there are scant data to suggest that these have had demonstrable effects.3
Firearms and Home Safety Screening
Prevention of suicide in the United States cannot be based on a full-scale banning of firearms—given the second amendment to the US Constitution—even as the use of guns for self-inflicted death is the most common method used in our country, as noted by Perlis et al.1 Nonetheless, different states have taken steps to limit access to firearms for persons with mental disorders. New York passed the Safe Act in 2013, which, in addition to specific limitations related to military style weapons, requires mental health professional to report any patients who the clinician believes is likely to harm themselves or others. These reports are sent to the local director of community services, a county level position, who reviews them and decides whether to pass the information to state criminal justice authorities. Another approach now used in multiple states involves Extreme Risk Protection Orders (ERPOs), where it is possible to initiate a judicial intervention for gun removal.7 Although measures such as these do offer tools for focused interventions regarding persons who are greatly distressed and deemed in imminent danger, they do not address the much larger challenge of preventing persons from becoming suicidal, nor do they foster conversations that build a culture of safety in homes and among those who lives are distressed.
Nonlegislated approaches also are part of efforts to reduce the nation’s suicide rate by 20% percent by 2025. The American Foundation for Suicide Prevention together with key partners has sought to “educate the range, retail, and broader firearms-owning communities on how to spot suicide risk.”8 In a related vein, the Suicide Prevention Resource Center developed Counseling on Access to Lethal Means (CALM), which is being used in some emergency department settings. These and similar strategies remain to be evaluated for wide uptake, use, and impact.
Suicide prevention is possible systemically, as exemplified by the US Air Force, which started its efforts in in 1996 and continued for more than a decade,9 and observed internationally (eg, Denmark, Finland). Such efforts involve a broadly based alignment of collective values that lead to concerted actions, which are embedded in a mosaic of activities that include communities, governmental and nongovernmental institutions, and health systems. Ultimately, these efforts require fostering and widely disseminating a culture of collective and individual safety. The results of the study by Perlis et al1 underscore that we must be especially vigilant and inquiring when, as clinicians, we encounter persons suffering depressive conditions—ie, be willing to ask about guns at home as much as we must discern whether they are experiencing suicidal thoughts and formulating suicidal plans. At the same time, all members of households would benefit from safe firearm storage, given findings that parents of at-risk children do not preferentially store weapons in a safety-enhanced fashion.10 Another potential challenge arises when people purchase guns for self-protection with an expectation of immediate availability.
Mindful of such obstacles and the great proliferation of firearms in our country, it is timely now to rethink how we ask persons seeking care about the safety of their homes. Many clinicians when screening for domestic violence inquire routinely at the beginning of appointments whether home is a safe place. Why not conduct a routine, universal home safety check—eg, ask about smoke alarms, stored medications and cabinet safety locks for children, family violence, drug misuse by family members, slippery rugs, and guns. We surely must address the signal apparent when our patients have depression. Building a universal approach to inquiring about home safety could be an element of a more complete mosaic of activities that health systems and clinicians can lead at this time, when suicide, drug-related fatalities, homicides, and other risk-related forms of premature mortality are leading to decreasing life expectancy in the United States.
Published: March 21, 2022. doi:10.1001/jamanetworkopen.2022.3252
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Caine ED. JAMA Network Open.
Corresponding Author: Eric D. Caine, MD, University of Rochester Medical Center, 300 Crittenden Blvd, Rochester, NY 14642 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
Caine ED. Guns, Depression, and Suicide Prevention: Is It Time for Universal Home Safety Screening? JAMA Netw Open. 2022;5(3):e223252. doi:10.1001/jamanetworkopen.2022.3252
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