Abstract and Introduction
Abstract
The purpose of this study was to investigate the current perceptions and practices of discussing firearm risk management with patients diagnosed with selected mental health problems. A three-wave survey was mailed to a national random sample of clinical psychologists and 339 responded (62%). The majority (78.5%) believed firearm safety issues were greater among those with mental health problems. However, the majority of clinical psychologists did not have a routine system for identifying patients with access to firearms (78.2%). Additionally, the majority (78.8%) reported they did not routinely chart or keep a record of whether patients owned or had access to firearms. About one-half (51.6%) of the clinical psychologists reported they would initiate firearm safety counseling if the patients were assessed as at risk for self-harm or harm to others. Almost half (46%) of clinical psychologists reported not receiving any information on firearm safety issues. Thus, the findings of this study suggest that a more formal role regarding anticipatory guidance on firearms is needed in the professional training of clinical psychologists.
Introduction
In 2003, firearms were responsible for 30,136 deaths. The majority of these deaths were suicides, accounting for 16,907 (57%) of these deaths. Suicide was the 11th leading cause of death in the United States. Firearms are the most common method (57%) of completed suicides. Firearms are used three times more often than hanging, which is the second most common method of completed suicides. A positive association has been demonstrated between suicide and firearm ownership, as well as homicide and firearm ownership. Firearms are used in 67% of homicides. Storing firearms locked and unloaded decreases the risk of firearm suicide. However, keeping a firearm in the home regardless of storage method increases the risk of suicide and homicide.
Several factors are linked to increased suicide rates. These include gender, availability of firearms in the home, carrying weapons and psychiatric disorders. A firearm in the home increased the risk of completed suicide by firearms among both sexes (odds ratio, OR = 31.1).
Depression, bipolar disorder, schizophrenia, personality disorders, and affective disorders are associated with repeated suicide attempts and suicide ideation. Schizophrenic patients have a significantly greater risk of suicide than the general population (OR = 9.9). Patients with mental health disorders and co-morbid alcoholism are at greatest risk of suicide. Alcohol consumption increases the risk of dying by suicide for men (OR = 3.18) and women (OR = 2.81). A variety of studies have explored various groups of physicians' and their perceived roles in reducing firearm injuries and premature mortality in patients. Most of these studies of physicians focused on primary care providers, including family physicians, internists, and pediatricians. A recent national study of psychiatrists and their practices and perceptions regarding anticipatory guidance on firearms found psychiatrists perceived firearm safety issues as especially important, yet only 27% had a routine system for identifying patients who owned firearms. In addition, 45% had never thought seriously about discussing firearm safety issues with patients.
The American Psychological Association and the International Association for Suicide Prevention both have published guidelines on suicide risk assessment. However, no published studies could be found regarding firearm counseling practices of clinical psychologists. This is especially noteworthy since approximately 90% of suicides are among individuals with a mental health problem. In a previous study on preventive medical services, only 6% of psychiatric patients reported being asked about firearm ownership. A study of counselors found that 23% had a patient under their care commit suicide. Restriction of access to firearms, especially during a mental crisis, could decrease the number of firearm related suicides. A recent review of suicide prevention strategies for physicians concluded there were only two solutions that had substantial scientific merit in the literature for reducing suicides: (1) physician education in depression recognition and treatment, and (2) restricting access to lethal means (namely firearms).
During patient treatment, clinical psychologists are in a unique position to counsel patients on firearm safety and could decrease the likelihood of a firearm suicide by helping limit access to firearms during critical periods. In essence, it would seem that both psychologists and psychiatrists have a "duty to treat" patients regarding the risks of firearms, whether stored at home or carried on them. Preliminary evidence indicates that firearm risk management with mental health patients can help reduce the potential for firearm violence.
To date, no studies have been published regarding firearm counseling practices of clinical psychologists. Yet, restriction of access to firearms, especially during a mental crisis, could decrease the number of firearm related suicides and homicides.
The purpose of this study was to investigate clinical psychologists' firearm risk management activities with patients. More specifically, answers to the following questions were sought: Do the majority of clinical psychologists discuss firearm safety issues with clients? Do clinical psychologists perceive patients with mental health problems to be at a greater risk from firearm injury/death than the general population and if so, which mental health problems create greater risk? What topics do clinical psychologists cover during firearm safety counseling? What are the barriers perceived by clinical psychologists to firearm safety counseling? What are clinical psychologists' efficacy and outcome expectations in applying the "5As" (Ask, Advise, Assess, Assist and Arrange) in firearm safety counseling? Where have clinical psychologists obtained the majority of their training on anticipatory guidance on firearms?