Self-reported Access to Firearms Among Patients Receiving Care for Mental Health and Substance Use

Abstract

IMPORTANCE Firearms are the most common method of suicide, one of the "diseases of despair" driving increased mortality in the US over the past decade. However, routine standardized questions about firearm access are uncommon, particularly among adult populations, who are more often asked at the discretion of health care clinicians. Because standard questions are rare, patterns of patient-reported access are unknown. OBJECTIVE To evaluate whether and how patients self-report firearm access information on a routine mental health monitoring questionnaire and additionally to examine sociodemographic and clinical associations of reported access. DESIGN, SETTING, AND PARTICIPANTSCross-sectional study of patients receiving care for mental health and/or substance use in primary care or outpatient mental health specialty clinics of Kaiser Permanente Washington, an integrated health insurance provider and care delivery system. MAIN OUTCOMES AND MEASURESElectronic health records were used to identify patients who completed a standardized self-reported mental health monitoring questionnaire after a single question about firearm access was added from January 1, 2016, through December 31, 2019. Primary analyses evaluated response (answered vs not answered) and reported access (yes vs no) among those who answered, separately for patients seen in primary care and mental health. These analyses also evaluated associations between patient characteristics and reported firearm access. Data analysis took place from February 2020 through May 2021.RESULTS Among patients (n = 128 802) who completed a mental health monitoring questionnaire during the study period, 74.4% (n = 95 875) saw a primary care clinician and 39.3% (n = 50 631) saw a mental health specialty clinician. The primary care and mental health samples were predominantly female (63.1% and 64.9%, respectively) and White (75.7% and 77.0%), with a mean age of 42.8 and 51.1 years. In primary care, 83.4% of patients answered the question about firearm access, and 20.9% of patients who responded to the firearm question reported having access. In mental health, 91.8% of patients answered the question, and 15.3% reported having access. CONCLUSIONS AND RELEVANCEIn this cross-sectional study of adult patients receiving care for mental health and substance use, most patients answered a question about firearm access on a standardized mental health questionnaire. These findings provide a critical foundation to help advance understanding of the utility of standardized firearm access assessment and to inform development of practice guidelines and recommendations. Responses to standard firearm access questions used in combination with dialogue and decision-making resources about firearm access and storage may improve suicide prevention practices and outcomes.

Determining subgroups that exist among US firearm owners

“…The high ranking of law enforcement and veterans as a credible source is consistent with previous studies, while the rankings of family, AFSP, and physicians were more surprising. However, research suggests that a majority of patients in primary care (83%) and mental health settings (92%) answer standard questions about firearms on a mental health questionnaire (Richards et al, 2021); suggesting the majority of patients are open to answering questions regarding firearm ownership. Additionally, the high ranking of physicians may be due to the fact that in certain regions, patients assume their physicians own firearms, which leads them to view their providers as credible to discuss safe firearm storage for suicide prevention.…”

Patient-Reported Firearm Access Prior to Suicide Death

“…Most patients who died by firearm suicide answered the firearm access question when they received it, confirming our prior finding that patients will answer this standardized firearm access question. 5 However, more than half of those who answered the question and who subsequently died by firearm suicide reported no firearm access. A study limitation is that we cannot determine whether these individuals acquired access after answering the question or answered no despite having access.…”

“…Between January 1, 2016, and December 31, 2019, the MH monitoring questionnaire was routinely used and recorded in the electronic health record for all MH specialty encounters, urgent care encounters per provider discretion, and primary care encounters following MH integration for all patients with an active MH or substance use disorder (SUD) diagnosis. 5 We report the proportions of patients who (1) had MH or SUD diagnoses, (2) received the firearm question, (3) answered the question, and (4) reported access. We stratified findings by firearm and other suicide methods, because opportunities for suicide prevention may differ between these groups.…”

Patient and Clinician Perspectives of a Standardized Question About Firearm Access to Support Suicide Prevention

“…Therefore, this qualitative study aimed to purposefully sample (1) patients with recent experiences answering a firearm question on a routine mental health monitoring questionnaire implemented by a large regional health care system 40 and (2) clinicians responsible for engaging patients at risk of suicide in risk mitigation and follow-up care. Semistructured interviews were designed to elicit multidimensional practice barriers and facilitators for purposes of informing and improving the routine use of standard questions about firearms during mental health care encounters.…”