The Firearm Suicide Crisis: Physicians Can Make a Difference

How Can Physicians Reduce Firearm Suicide Risk?

The primary care practice environment already provides motivation for physicians to address firearm suicide through improved screening and prevention efforts. For example, the US Preventive Services Task Force (USPSTF) recommends screening all adults for depression and women of reproductive age for intimate partner violence, both known risk factors for suicide.¹⁵ Billing codes also allow primary care physicians to earn compensation for depression and suicide screening, while new physician payment methods, such as the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APM), provide further financial incentives to do so.¹⁶ Although firearm suicide is not exclusively driven by mental illness, a renewed focus on depression and suicide risk screening—especially among adolescents—may help clinicians uncover behavioral risk factors among the slight majority of people who complete suicide with unrecognized mental health conditions.⁹ Enhanced screening efforts are critical for preventing additional attempts at suicide and the successful completion of suicide by firearm, as firearms are 2.6 times more lethal than suffocation, the next deadliest method of suicide.¹⁷ While a non-fatal attempt at suicide can act as a red flag to help prevent a future attempt, firearm suicide has an alarming 80% to 90% fatality rate.¹⁸

To that end, many physicians do not routinely screen or counsel their patients about firearm safety.¹⁹ Lack of time, inadequate training, lack of understanding regarding the availability of screening tools, and related factors present barriers for fulfilling this function. Even if additional screening happens, it is often difficult to navigate local mental health treatment systems or to identify appropriate community-based mental health resources. However, there are steps that can be taken. First, primary care practices can employ other members of the clinical team in the medical home or practice to screen patients about their access to firearms and their firearm storage practices. Second, clinicians can incorporate questions about firearm availability directly into existing screening tools, such as the Patient Health Questionnaire (PHQ-9) for depression. Third, primary care practices can enhance pre-visit planning services by using online portal-based questionnaires to more efficiently screen patients for firearm availability, firearm storage practices, and related risk factors without increasing office encounter times.²⁰ Professional organizations, such as the American Academy of Family Physicians (AAFP), the American Academy of Pediatricians (AAP), or similar associations offering continuing medical education (CME) could also actively promote the incorporation of these actionable steps into primary care practice. While many patients may benefit from these process enhancements, a renewed effort at the individual practice level will be critical for patients with children and patients who screen positive for depression, domestic violence, or suicide risk.

The Medical Community Advocating for Policy Change

The medical profession also wields considerable advocacy power, and there is a long history of physicians collectively influencing policy making and public health practice.²¹ Key historic examples of improving the public’s health include the physician community’s role in advocating for stricter state-level drunk-driving legislation and for stricter tobacco advertising policies.²² Because the AAFP, the AAP, and the AMA all formally denounce gun violence,^23-25 we believe the broader physician community can harness the momentum of the #ThisIsOurLane movement²⁶ and can collectively influence the political discourse on firearms. Acting together, physicians can support the adoption of firearm safety and control policies at the state level that are shown to be effective for preventing firearm suicide, such as stricter background checks with mandatory waiting period requirements and child-access prevention laws.^27,28

Specific advocacy steps can be taken. First, the collective medical profession can help present the facts about firearm suicide; set aside discomfort with approaching sensitive political and mental health– related issues at the community level; and mobi-lize grassroots outreach and voter support for the evidence-based policy interventions.²⁹ Second, the literature suggests medical associations like the AAFP and AAP can effectively communicate important public policy matters—such as the suicide-related consequences of firearm safety initiatives—to state legislatures and facilitate the adoption of policies across state lines.³⁰ Third, primary care physician coalitions are equipped to help the greater public health community identify alternative funding sources for conducting meaningful research on firearm suicide because of their designated roles in delivering preventive care.

To date, the literature on how different firearm control policies affect suicide is limited.²⁸ The Dickey Amendment to the Omnibus Reconciliation Act of 1996 and subsequent policies have severely limited federal funding for gun violence research, impeding the public health community’s ability to fully explore the relationship between firearms and suicide.³¹ While private foundations offer funding opportunities, seeking and securing funding can be challenging. Finally, the physician community can also advocate against proposed or pending “physician gag laws,” where states attempt to regulate conversations between physicians and their patients and prevent physicians from inquiring about firearm ownership. Despite the 2017 ruling issued by the US Court of Appeals for the Eleventh Circuit, other physician gag laws exist or have been proposed in different jurisdictions, further demonstrating the need for ongoing physician advocacy.³²

Conclusion: Wide Public Support for Action

A call to action is imperative. The United States has so far failed to make meaningful and appropriate policy changes at the federal level to promote gun safety and limit gun availability to advance the goal of reducing firearm suicide and firearm deaths more generally. Recent national survey data indicate broad public support, among both gun owners and non-gun owners, for regulatory action to promote gun safety and restrict access to certain weapons.³³ To be sure, no single solution exists. As in the past, however, the medical community now has an opportunity to meaningfully wield its professional authority, both collectively and as individual physicians, to improve screening efforts and to promote evidence-based firearm safety initiatives toward the end of reducing the suicide epidemic plaguing our families and communities.