background why do we lethal means counseling …...why we need to talk about guns when we talk about...
TRANSCRIPT
5/24/2016
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Lethal Means Counseling in Emergency Departments
MARIAN (EMMY) BETZ, MD, MPH
ASSOCIATE PROFESSOR OF EMERGENCY MEDICINE
UNIVERSITY OF COLORADO SCHOOL OF MEDICINE
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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
Overview of today
� Why we need to talk about suicide
� Why we need to talk about suicide
� Why we need to talk about suicide
talk about guns when we
How talk about guns when we
talk about guns when weDo we
Background:Why do we need to talk about guns?
San Francisco Public Library
historical example
o Israeli military: • Most suicides by gun, on weekends
• 2006: Required soldiers to leave weapons on base
�Suicide rates dropped 40%
Lubin 2010, Suic & Life-Threat Behavior.
[email protected] (May 2016)
5/24/2016
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why?
1. impulsivityThe final decision to
attempt suicide often occurs within only
minutes
time between deciding to attempt suicide and taking action
0%
5%
10%
15%
20%
25%
30%
<5min
5-20min
20-60min
1-8hours
>8hours
The Houston Study: Nearly Lethal Suicide Attempts - N=153 (15-34 year olds)
Why?
2. prognosisThe majority of people with suicidal thoughts or behavior do not later die by suicide
why?
3. lethality 85-90% of people who use a gun to
attempt suicide die
Fatal suicides
suicide methods in the US
Firearm
Suffocation
Poisoning
JumpCut
Other
Nonfatal suicide attempts
CDC WISQARS; MeansMatter.org
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;33:393-408
o Gun in the home � >3x risk of completed suicide (Odds ratio, 3.24)
Anglemyer A et al. Ann Intern Med. 2014;160:101-10.
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;160(2):134-5.Betz ME et al. Suicide Life Threat Behav. 2011;41:384-91.
[email protected] (May 2016)
5/24/2016
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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
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
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.
Current state:Do we talk
about guns?
Emergency Dept Safety and
Follow-up Evaluation Study
Treatment as usual
• EDs determine screening and care
Universal suicide screening
• EDs determine care
Intervention
• ED: Safety form and MD screener
• Cohort: telephone counseling
Survey Survey Survey
ED-SAFE provider survey: 8 sites, survey of all ED physicians & nurses
0
20
40
60
80
100
%
MD RNBetz et al. Depress Anxiety 2013. *P<0.001 under Pearson chi-square test.
"I often/almost always ask if there are firearms at home”
Suicidal in past month, not now*
Suicidal with plandoesn't involve gun*
In ED for overdose,no longer suicidal*
Suicidal today,without plan*
Suicidal with plan,does involve gun*
0
20
40
60
80
100
%
MD RNBetz et al. Depress Anxiety 2013. *P<0.001 under Pearson chi-square test.
"I often/almost always ask if there are firearms at home”
Suicidal in past month, not now*
Suicidal with plandoesn't involve gun*
In ED for overdose,no longer suicidal*
Suicidal today,without plan*
Suicidal with plan,does involve gun*
[email protected] (May 2016)
5/24/2016
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"I often/almost always ask if there are firearms at home” (by study phase)
4047
60
0
20
40
60
80
100
Phase 1 Phase 2 Phase 3
Pe
rcent
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%)
o25% had unlocked & loaded
o54% had easy access
+50% of charts had documentation of lethal means assessment
Betz et al. Depress Anxiety 2016 epub March 17.
who did we miss?ED disposition
(n=1358) Lethal means assessmentin ED medical record
(among those discharged; n=337)
Self-reported firearms(among those discharged
& with assessment; n=185)
Other
Discharge home
Psych admission Yes No
≥1 firearm at home
No firearm at home
Discharge home
Psych admission
YesNo
≥1 fire
arm at h
om
e
No
firearm
at ho
me
Betz et al. Depress Anxiety 2016 epub March 17.
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?
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?
Recommendations:How should we talk about guns?
[email protected] (May 2016)
5/24/2016
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caveat
oLimited prior empirical work
oMuch active work in this area – please join us!
Colorado Firearm Safety Coalition
“gag laws”: you can ask
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
Wintemute et al. Annals Internal Med 2016 (in press).
what do patients want?
o “Patient-centered care”• Nonjudgmental, respectful, empathetic
education
oProvider “cultural competence” already expected (eg., for ethnic heritage, religious beliefs, sexual orientation)
oCounseling that is both individualized and routine
Becher EC et al. Am J Public Health 2000; Betz & Wintemute JAMA. 2015. Olson et al. Inj Prev. 2007; Price JH
et al. J Emerg Med 2013; Sege RD et al. Pediatrics 2006; Vriniotis M et al. Suicide Life Threat Behav. 2015;
Wintemute et al Annals Internal Med 2016.
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!
0
20
40
60
80
Pe
rce
nt
Reasons Americans Own Guns
(open-ended Gallup survey); Oct 3-6, 2013
[email protected] (May 2016)
5/24/2016
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suggested language
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
• B―Do you have guns at home? They should be removed for your safety.
suggested language
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, relinquishyour guns
o Don’t ask the patient change their identity as a gun owner – collaborate with him/her
in-home safe storage options
$5
(cable lock)
$10
(trigger lock)
sample small handgun safes (amazon, 1/2016)
$22
(key)$~250+
(fingerprint or bracelet)
~$100
(combination)
larger safes
relevant Colorado laws
o With family? YES
o With friends/neighbors? 72 HOURS
o At a gun shop? YES*
o With police? YES*
[email protected] (May 2016)
5/24/2016
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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
A B
Check on B
Check on A
questions about 72 hour window
o Can a family member, friend, or other non-owner 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?
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
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)
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 gunswhen we talk about suicide
Thank you!
[email protected]@[email protected]@UCDENVER.EDU
[email protected] (May 2016)
5/24/2016
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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
Population Suicide Risk FactorsSituational factors Most attempts are within a crisis or psychiatric illness
exacerbation
Psychiatric illness Depression, schizophrenia, panic disorder, personality
disorder
Substance abuse Drugs or alcohol
Gender Female 3x as likely to attempt, but males 3x as likely to
complete
Age Older men at highest risk (55-65 years-old)
Women younger at attempts (25-35 years old)
Access to lethal means Presence of a firearm in the home increases suicide risk
5-10x
Marital status Separated, divorced, widowed
Medical conditions Chronic pain, chronic illness
Family history of suicide
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)
0%
25%
50%
75%
100%
Suicidal in past
month, not
now**
In the ED for
multi-drug
ingestion, no
longer suicidal***
Suicidal today,
without plan***
Suicidal with
plan, doesn't
involve gun***
Suicidal with
plan, does involve
gun
Percent of providers reporting they "often" or “almost
always“ ask suicidal patients about gun access
Phase 1 (n=658) Phase 2 (n=616) Phase 3 (n=610)
*p≤0.05, **p≤0.01, ***p≤0.001 under Chi Square for Phase 1 versus Phase 3
[email protected] (May 2016)