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Clinical Approaches to the Prevention of Firearm-Related Injury

Author/s: 
Patrick M Carter, Rebecca M Cunningham

Firearm-related injuries are an urgent health crisis in the United States, with firearm-related deaths surpassing deaths from motor vehicle crashes in 2017.1 In contrast to other conditions for which clinicians have evidence-based solutions to reduce harm, the 25-year gap in federal research funding2,3 halted substantial advances in the science of firearm-related injury prevention. Yet renewed funding and emerging science continue to highlight the critical role clinicians have in prevention efforts.2,3 Similar to other complex health issues, firearm-related injury is heterogeneous, with multiple causes (Figure 1). Each of these causes has entry points within clinical encounters that represent opportunities to interact, interrupt, and prevent negative outcomes.

The lack of research has resulted in a generation of clinicians currently lacking the training necessary to implement the solutions generated by recent science. As a result, despite clinicians recognizing the need for prevention and agreeing that prevention of firearm-related injury is within their scope of practice,13 few deliver evidence-based interventions even though their patients find such measures acceptable within the context of clinical care.14 This lack of training is compounded by a shortage of adequate health care infrastructure necessary to support the integration of useful approaches into practice. Clinicians note multiple barriers, including a lack of knowledge, guidelines, time, clinical support, and reimbursement, as well as a fear of offending patients or encountering legal trouble.15-17

Clinicians routinely provide harm-reduction measures and anticipatory guidance for a range of complex health issues (e.g., substance use and vaccination), capitalizing on available evidence, their relationships with patients, and their community standing to promote health and safety. Although gaps exist, there remain opportunities to improve the current standard of care for the prevention of firearm-related injury. In this article, we review clinical approaches to prevention, ranging from ones implemented within individual clinical encounters to ones advanced by health care leaders within the systems and communities they serve.

Keywords 
Physician's Role Firearms gun safety safety suicide counseling

Screening for Depression and Suicide Risk in Adults US Preventive Services Task Force Recommendation Statement

Author/s: 
US Preventive Services Task Force, Barry, M. J., Nicholson, W. K., Silverstein, M., Chelmow, D., Coker, T. R., Davidson, K. W., Davis, E. M., Donahue, K. E., Jaén, C. R., Li, L., Ogedegbe, G., Pbert, L., Rao, G., Ruiz, J. M., Stevermer, J. J., Tsevat, J., Underwood, S. M., Wong, J. B.

IMPORTANCE Major depressive disorder (MDD), a common mental disorder in the US, may
have substantial impact on the lives of affected individuals. If left untreated, MDD can
interfere with daily functioning and can also be associated with an increased risk of
cardiovascular events, exacerbation of comorbid conditions, or increased mortality.

OBJECTIVE The US Preventive Services Task Force (USPSTF) commissioned a systematic
review to evaluate benefits and harms of screening, accuracy of screening, and benefits and
harms of treatment of MDD and suicide risk in asymptomatic adults that would be applicable
to primary care settings.

POPULATION Asymptomatic adults 19 years or older, including pregnant and postpartum
persons. Older adults are defined as those 65 years or older.

EVIDENCE ASSESSMENT The USPSTF concludes with moderate certainty that screening for
MDD in adults, including pregnant and postpartum persons and older adults, has a moderate
net benefit. The USPSTF concludes that the evidence is insufficient on the benefit and harms
of screening for suicide risk in adults, including pregnant and postpartum persons and older
adults.

RECOMMENDATION The USPSTF recommends screening for depression in the adult
population, including pregnant and postpartum persons and older adults. (B
recommendation) The USPSTF concludes that the current evidence is insufficient to assess
the balance of benefits and harms of screening for suicide risk in the adult population,
including pregnant and postpartum persons and older adults. (I statement)

Keywords 
risk assessment depression suicide screening Adults

Understanding Suicide Risk And Prevention

Author/s: 
Miller, Benjamin F., Coffey, M. J.

KEY POINTS:

  • Suicide rates have been rising during the past several years, but suicide is preventable.
  • There are many known risk factors for suicide, but the predictive utility of any single risk factor is low, requiring a focus on population-level rather than individual-level prevention.
  • There are proven processes for identifying suicide risk and intervening in health care, criminal justice, and education settings.
  • There is also a need for an enhanced data infrastructure to support suicide and self-harm surveillance systems.
  • Additional policy intervention is needed to scale and spread successful prevention approaches and to identify others. For example, policies should support removal of lethal means, increased funding for help lines and school-based programs, and integration of mental health care into routine health care.

 

Keywords 
suicide Suicide Prevention mental health public health

Health Policy Brief: Understanding Suicide Risk and Prevention

Author/s: 
Miller, Benjamin F., Coffery, M. J.
  • Suicide rates have been rising during the past several years, but suicide is preventable.
  • There are many known risk factors for suicide, but the predictive utility of any single risk factor is low, requiring a focus on population-level rather than individual-level prevention.
  • There are proven processes for identifying suicide risk and intervening in health care, criminal justice, and education settings.
  • There is also a need for an enhanced data infrastructure to support suicide and self-harm surveillance systems.
  • Additional policy intervention is needed to scale and spread successful prevention approaches and to identify others. For example, policies should support removal of lethal means, increased funding for help lines and school-based programs, and integration of mental health care into routine health care.
Keywords 
mental health suicide public health Suicide Prevention Health Policy brief

Assessment and Management of Patients at Risk for Suicide: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines.

Author/s: 
Sall, J., Brenner, J., Bell, A.M.M., Colston, M.J.

These guidelines produced by the VA apply equally well to all adults.  James W. Mold, MD, MPH

Keywords 
suicide veterans guidelines risk management

Associations between gabapentinoids and suicidal behaviour, unintentional overdoses, injuries, road traffic incidents, and violent crime: population based cohort study in Sweden

Author/s: 
Molero, Y., Larsson H., D'Onofrio B.M., Sharp D.J., Fazel S.

Abstract

OBJECTIVE:

To examine associations between gabapentinoids and adverse outcomes related to coordination disturbances (head or body injuries, or both and road traffic incidents or offences), mental health (suicidal behaviour, unintentional overdoses), and criminality.

DESIGN:

Population based cohort study.

SETTING:

High quality prescription, patient, death, and crime registers, Sweden.

PARTICIPANTS:

191 973 people from the Swedish Prescribed Drug Register who collected prescriptions for gabapentinoids (pregabalin or gabapentin) during 2006 to 2013.

MAIN OUTCOME MEASURES:

Primary outcomes were suicidal behaviour, unintentional overdoses, head/body injuries, road traffic incidentsand offences, and arrests for violent crime. Stratified Cox proportional hazards regression was conducted comparing treatment periods with non-treatment periods within an individual. Participants served as their own control, thus accounting for time invariant factors (eg, genetic and historical factors), and reducing confounding by indication. Additional adjustments were made by age, sex, comorbidities, substance use, and use of other antiepileptics.

RESULTS:

During the study period, 10 026 (5.2%) participants were treated for suicidal behaviour or died from suicide, 17 144 (8.9%) experienced an unintentional overdose, 12 070 (6.3%) had a road traffic incident or offence, 70 522 (36.7%) presented with head/body injuries, and 7984 (4.1%) were arrested for a violent crime. In within-individual analyses, gabapentinoid treatment was associated with increased hazards of suicidal behaviour and deaths from suicide (age adjusted hazard ratio 1.26, 95% confidence interval 1.20 to 1.32), unintentional overdoses (1.24, 1.19 to 1.28), head/body injuries (1.22, 1.19 to 1.25), and road traffic incidents and offences (1.13, 1.06 to 1.20). Associations with arrests for violent crime were less clear (1.04, 0.98 to 1.11). When the drugs were examined separately, pregabalin was associated with increased hazards of all outcomes, whereas gabapentin was associated with decreased or no statistically significant hazards. When stratifying on age, increased hazards of all outcomes were associated with participants aged 15 to 24 years.

CONCLUSIONS:

This study suggests that gabapentinoids are associated with an increased risk of suicidal behaviour, unintentionaloverdoses, head/body injuries, and road traffic incidents and offences. Pregabalin was associated with higher hazards of these outcomes than gabapentin.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Keywords 
Lyrica suicide motor vehicle accidents
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