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Behavioral Emergencies Update

Volume 1, Issue 1
Spring/Summer 2004
Section on Clinical Emergenices and Crises
American Psychological Assn.
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In this issue...

The President's Column:
Who is teaching our youth?

Letter from the Editor

Ideas for Moving Forward

Assessment of Firearm Access

The Lack of Graduate School Training in Suicide Assessment and Management

APA Program Summary


SECTION VII Members'
APA PROGRAMMING

SECTION VII BOARD MEMBERS

Pre-APA Convention

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ASSESSMENT OF FIREARM ACCESS

Glenn R. Sullivan, MS
Pacific Graduate School of Psychology

     
In the United States, more people die by self-inflicted gunshot than by all other suicide methods combined (Miller, Azrael, & Hemenway, 2002). Whether or not a patient has access to a firearm can determine the outcome of a suicidal crisis. Deficient clinical screening for firearm access increases the risk of suicide completion (Kaplan, Adamek, & Rhodes, 1998).

This article briefly summarizes the results of a recent investigation of psychologists’ firearm assessment practices. Eight hundred members of the APA Practice Directorate were surveyed regarding suicide risk assessment practices, experience with suicidal patients, and personal firearm history. The usable response rate was 51.9% (N=415).

The mean age of respondents was 53.4 years (SD=8.6) and the mean years of postdoctoral experience was 18.6 (SD=8.4). Of the valid respondents, 49.2% were male and 50.8% were female. Almost all respondents held a Ph.D. (79%), or a Psy.D. (19%). Over 65% indicated Private Practice as their Primary Employment Setting. Overall, 78% indicated Private Practice as either their Primary or Secondary Employment Setting. Almost 80% of the respondents indicated that they perform more than half of their clinical work with adult patients.

Firearm Ownership among Psychologists
Current firearm ownership was reported by 19.5% (n=81) of the psychologists participating in this study. Nearly 30% of respondents reported that they had owned a firearm at some point in their life. Male respondents were far more likely than female respondents to own firearms (Male=30%; Female=9%). In addition to the psychologists who personally own firearms, 7.2% of non-owners indicated that firearms were present in their households. Therefore, firearms were present in 26.7% of the homes in this sample. The rate of household firearm ownership for psychologists in this study was only slightly lower than national estimates of household firearm access. The 19.5% firearm ownership rate among psychologists was much lower than the 32% rate found in a survey of psychiatrists (Guglielmo, 2000).

More than one-fifth of the firearm-owning psychologists in this study reported sometimes carrying a concealed firearm. Approximately 12% of the firearm-owning psychologists reported keeping a firearm in their office. While almost two-thirds of respondents indicated that they had personally discharged a firearm at least once, nearly one-fourth of respondents indicated that they had never before handled or touched a firearm.

Compared to non-owners, firearm owners were more likely to be male, to live in a rural area, and to reside in a Southern state. There were no differences between owners and non-owners with regard to age, race/ethnicity, marital status, or whether children under the age of 18 were living in the home. Handguns were the most commonly owned firearm (69% of owners), followed by rifles (58%), and shotguns (56%). Most firearm owners (80%) owned more than one type of firearm. Among firearm owning psychologists, the mean number of firearms owned was 3.9, with a range of 1 to 26.

Most male respondents indicated recreation (i.e. hunting, target shooting, or collecting) as their primary reason for firearm ownership, whereas most female respondents indicated self-defense. A remarkable 22% of respondents indicated “Other” as their Primary Reason for Firearm Ownership. This suggests that firearms are likely to be present in the homes of many people who have no readily apparent reason to own them.

Firearm Access Inquiries
On average, clinicians who currently own firearms (or who had owned them in past) directly inquired about firearm access with firearms from their homes (M=24.8; SD=56.5) as did non-owning clinicians (M=8.3; SD=13.55). With regard to the perceived efficacy of these interventions, firearm owners reported a 70% success rate, compared to 66% reported by non-owners.

Estimates of Patient Ownership
The base rate for patient firearm ownership estimated by current or former firearm owners (M=24.1%; SD=22.3) was almost twice as high as the estimate by non-owners (M=12.5%; SD=16.9). The estimate of patient household firearm access by firearm-owners (M=33.5%; SD=26.5) was nearly 67% greater than the estimate by non-owners (M=20.1%; SD=21.4). Published rates of firearm ownership in clinical populations range from 27.9% in a sample of older adults receiving primary care treatment (Oslin et al., 2004) to 60.4% in families of patients diagnosed with dementia (Spangenberg, Wagner, Hendrix, & Bachman, 1999).

Suicidal Ideation Inquiries
More than half of respondents (n=230; 55.4%) reported inquiring directly about current suicidal ideation during the first session with all of their last 10 patients. However, 20.7% (n=86) reported performing this basic suicide risk assessment with fewer than half of their last 10 patients. Almost 3% (n=11) reported that they did not assess for current suicidal ideation during the first session with any of their last 10 patients. Clinicians who were less likely to inquire about suicidal ideation tended to be more experienced, to have never lost a patient to suicide, and to be in private practice. Current or former firearm owners reported inquiring about current suicidal ideation and past suicide attempts more frequently than did non-owners.

More than half of respondents (n=217; 52.3%) reported inquiring directly about past suicide attempts with all of their last 10 patients. However, 22.2% (n=92) reported that they had inquired about past suicide attempts with fewer than half of their last 10 patients. Almost 5% (n=19) reported that they had asked none of their last 10 patients about past suicide attempts.

More than half of respondents (n=216; 52.0%) reported assessing family history of suicide with all of their last 10 patients. However, 24.1% (n=100) reported that they had assessed family suicide history with fewer than half of their last 10 patients. Over 8% (n=34) reported that they had asked none of their last 10 patients about family suicide history.

Prevalence of Suicidal Patients
In a typical month, the average respondent reported treating 5.4 patients “for whom suicide is an issue” (SD=5.2; Mode=2; Median=4.0). Only 5.1% of respondents reported seeing no patients in a typical month for whom suicide is an issue. In fact, 43.9% of respondents reported treating five or more such patients each month. A majority of clinicians (n=237; 57.1%) reported having treated 15 or more patients who required voluntary or involuntary hospitalization. Only 3.4% (n=27) reported never having treated a patient who required voluntary or involuntary hospitalization.

An overwhelming majority (n=388; 93.5%) of the psychologists in this study reported that at least one patient under their care had attempted suicide. Nearly 36% (n=148) reported having lost a patient under their care to suicide. Over 34% (n=142) reported that a patient under their care had attempted suicide with a firearm. Almost 15% (n=62) reported having lost a patient under their care to suicide-by-firearm.

Firearm Access:
Eighty percent of the psychologists participating in this study agreed that the presence of a firearm is a major risk factor for completed suicide. Over two-thirds of respondents considered themselves competent to discuss firearms with their patients. Almost 60% of respondents agreed that additional laws restricting access to firearms could reduce suicide rates. Almost half agreed that psychologists have a duty to counsel patients regarding safe firearm storage practices.

However, only 32% of respondents agreed that psychologists should assess for firearm access with all of their patients, and just 22% agreed that psychologists should counsel patients to remove firearms from their homes. Only 17% agreed that psychologists have a duty to report violations of firearms laws.

REFERENCES
Guglielmo, W. (2000). How many doctors own guns? Medical Economics, 19, 151-152.
Kaplan, M.S., Adamek, M.E., & Rhoades, J.A. (1998). Prevention of elderly suicide: Physicians’ assessment of firearm availability. American Journal of Preventive Medicine, 15(1), 60-64.

Miller, M., Azrael, D., & Hemenway, D. (2002). Household firearm ownership and suicide rates in the United States. Epidemiology, 13(5), 514-524.

Oslin, D.W., Zubritsky, C., Brown, G., Mullahy, M., Puliafico, & Ten Have, T. (2004). Managing suicide risk in late life: Access to firearms as a public health risk. American Journal of Geriatric Psychiatry, 12(1), 30-36.

Spangenberg, K.B., Wagner, M.T., Hendrix, S., & Bachman, D.L. (1999). Firearm presence in households of patients with Alzheimer’s disease and dementia. Journal of the American Geriatric Society, 47, 1183-1186.