Research Essay

518 Suicide and Life-Threatening Behavior 37(5) October 2007  2007 The American Association of Suicidology

Gun Safety Management with Patients at Risk for Suicide Robert I. Simon, MD

Guns in the home are associated with a five-fold increase in suicide. All patients at risk for suicide must be asked if guns are available at home or easily accessible elsewhere, or if they have intent to buy or purchase a gun. Gun safety management requires a collaborative team approach including the clinician, pa- tient, and designated person responsible for removing guns from the home. A call-back to the clinician from the designated person is required confirming that guns have been removed and secured according to plan. The principle of gun safety management applies to outpatients, inpatients, and emergency patients, al- though its implementation varies according to the clinical setting.

Guns in the home are associated with a five- (American Association of Suicidology, 2006). Firearm suicide attempts end in death in ap-fold increase in suicide compared to homes

without guns (National Center for Health proximately 85% of cases (Kellerman & Waecker, 1998).Statistics, 2001). Regions with higher rates of

home gun ownership have higher rates of The method of storage and number of guns influence suicide risk. A higher risk ofsuicide, controlling for other factors associ-

ated with suicide (Barber, 2005). In a study suicide is associated with handguns more than long guns, with unlocked more thanby Wintemute, Parham, Beaumont, Wright,

and Drake (1999), the purchase of a handgun locked guns, and with loaded more than un- loaded guns (Brent, 2001). Total suicide rateswas associated with a significant increase in

the risk of suicide by firearm and by any have a statistical association to household gun prevalence (Markush & Bartolucci, 1984).other method. The increased risk of a firearm

suicide occurred within a week after purchase Persons with guns at home were more likely to have died from a firearm suicide than byof a handgun and remained at increased risk

for suicide by firearm for at least 6 years. suicide from a different method (Dahlberg, Ideda, & Kresnow, 2004).Within the first year of purchase, handguns

accounted for 24.5 percent of all suicide Most suicidal patients at moderate risk for suicide are treated as outpatients (Simon,deaths and 51.9 percent of deaths among

women 21 to 33 years of age (Wintemute et 2004). Carefully selected patients assessed at high risk for suicide also may be treated asal., 1999). In 2003, of the 32,439 suicides in

the United States, 16,750 were by firearms outpatients, although most psychiatric pa- tients at high risk for suicide are hospitalized. Patients evaluated in the emergency depart- ment often are at moderate to high risk forRobert Simon is Clinical Professor of Psy-

chiatry and Director of the Program in Psychiatry suicide. Some of these patients have guns and Law at Georgetown University School of stored at home or elsewhere (e.g., cars, work- Medicine in Washington, DC. place, or with others). All patients at risk for

Address correspondence to Robert I. Si- suicide must be asked about the availabilitymon, MD, 8008 Horseshoe Lane, Potomac, MD and accessibility of guns.20854-3831; E-mail: [email protected]

Simon 519

Impulsivity and guns are a lethal mix- Every psychiatric disorder except men- tal retardation is associated with an increasedture. In a study by Simon et al. (2001), sui-

cide attempters aged 15–34 were asked about risk of suicide (Harris & Barraclough, 1997). Should psychiatric patients be routinelythe time between the decision to complete

suicide and the attempt. Nearly 25% an- asked if they have guns at home? If the an- swer is affirmative, should the patient be in-swered less than 5 minutes. Suicide rehearsal

with a gun reinforces the belief that a firearm formed of research finding an increased risk of suicide when guns are in the home?suicide is quick and easy. The gun is placed

to the head or in the mouth and death is only Should the clinician advise psychiatric pa- tients, regardless of suicide risk, to have gunsa trigger click away. It takes less time to reach

for a loaded gun than most other methods of removed from the home? Should only pa- tients at current low risk for suicide, but withsuicide (e.g., overdose, hanging, carbon mon-

oxide). Within a few minutes, the acute, time a family history of suicide, receive such a rec- ommendation? In answering the above ques-limited impulse to commit suicide may pass. tions, the decision to inform and intervene can only be determined by clinical judgment and discretion applied case by case. Asking

PRINCIPLES OF GUN patients who are not at current risk for sui-

SAFETY MANAGEMENT cide about guns in the home may unduly alarm the patient and disrupt a fledgling

Gun safety management of patients at treatment. Patients at risk for suicide, how- risk for suicide is a complex and difficult ever, require active implementation of a clini- challenge. While total prevention of suicide cal gun safety management plan. by any method is an impossible task, prac- Gun safety management is first and titioners must be proficient in providing foremost a treatment issue, but the clinician competent clinical gun safety management must do more if the patient is at risk for sui- (see Table 1). cide (“Practice Guidelines,” 2003). Suicidal

patients must be asked if they have access to guns. Some patients will volunteer that infor- mation, while others will deny that there areTABLE 1 guns at home, even though guns are easilyPrinciples of Gun Safety Management accessible elsewhere. Thus, it is necessary towith Patients at Risk for Suicide ask the patient, “Do you have guns at home

• Inquire about guns at home or located outside or at any other place?” “Can you get one eas- the home (e.g., car, office, other). Also inquire if ily?” Additionally, the patient must be asked, patient intends to obtain or purchase a gun. “Do you intend to obtain or purchase a

• Designate a willing, responsible person to re- gun?” In the first week following the pur- move and safely secure guns and ammunition chase of a handgun, suicide by firearms outside the home, at a location unknown to the

among purchasers was 57 times higher thanpatient. the adjusted rate for the general population• Have direct contact with or receive a phone call (Wintemute et al., 1999).from the designated person that guns and am-

Patients who have a gun at home usu-munition are properly removed from the home ally have more than one gun. Guns that areor from outside the home and safely secured ac-

cording to the pre-arranged gun safety manage- described as locked up and safely stored may ment plan. E-mail should not be used to com- still be accessible, for example, if the patient municate. has a duplicate key or is able to break into

• Do not discharge inpatients or ED patients as- the place where the guns are stored. The cli- sessed at low to moderate risk of suicide until nician should not rely on “no suicide con- guns and ammunition are properly removed and tracts” given orally or in writing by the pa- secured (outpatients case by case).

tient as part of gun safety management. No

520 Gun Safety Management

evidence exists that such suicide prevention tween clinician, patient, and the designated individual must be documented.contracts reduce or eliminate suicide risk (Si-

mon, 2004; Stanford, Goetz, & Bloom, 1994). The clinician cannot rely on a task- specific therapeutic alliance with the personAll handguns and long guns must be

removed, including ammunition, and stored designated to implement the gun safety plan unless that individual is in conjoint treatmentin a place not accessible to the patient. But

who will do it? The patient may want to give with the patient at risk for suicide. The clini- cian’s task is to determine whether the desig-the guns to a family member or other per-

sons for safekeeping. This option is risky be- nated person understands the gun safety plan and is responsible to carry it out. The deter-cause it places the patient in direct contact

with guns. In some instances, patients have mination is a clinical judgment call. All the clinician can do is to trust his or her assess-brought guns to the clinician for safekeeping.

The risk to the clinician is obvious. The dan- ment. A meeting with the patient, the desig- nated responsible person, and the clinicianger of harm persists when the patient re-

quests that the guns held by the clinician be should be arranged, if possible. All partici- pants are encouraged to ask and answer ques-returned. If the clinician disagrees, a counter-

therapeutic power struggle may develop that tions. A collaborative team approach helps to preserve the therapeutic alliance and givesundermines the treatment. It is not the re-

sponsibility of the clinician to provide safe the clinician the opportunity to meet the des- ignated person. It should be explained thatstorage of patients’ firearms.

The optimal situation exists when the guns in the home increase the risk of suicide. The designated person should be instructedpatient at risk for suicide acknowledges that

guns are at home and agrees to have the guns to go directly home and immediately remove the guns and ammunition from the home toremoved by a designated, responsible person,

usually a family member, partner, or neigh- safe storage outside the home, at a location unknown to the patient. Loaded guns mustbor. The treatment boundaries are readjusted

to accommodate the designated person. The be disarmed. Instructions on gun safety man- agement must be kept as simple and straight-designated individual must be able to remove

the gun(s) without self-injury and, if unable, forward as possible. The patient’s family or partner is often frightened and easily con-to contact another person or the police to

perform the task. The designated person may fused. For example, asking the designated person to remove the firing pin of a gun oralso require competent assistance in disarm-

ing the gun(s). Many individuals do not know securing the gun in a combination locking safe with the combination reset may over-how to handle firearms or are fearful when

around guns. By a prearranged plan, the des- whelm the designated person and scuttle the safety plan. The designated person must callignated individual will report back to the cli-

nician that all guns have been removed from back once the task is performed expedi- tiously. All other daily tasks and activitiesthe home or from outside the home and

safely secured, so that the guns and ammuni- must be deferred. If the call-back is not re- ceived in a prearranged timely manner, thetion cannot be found by the patient. As tragic

events indicate, simply hiding guns does not patient’s gun safety plan is no longer viable and a fall-back plan should be implemented,suffice. Patients intent on completing suicide

are ingenious at finding guns supposedly se- if possible. Limitations exist, however, on the ability of the clinician to ensure that the pa-cured in the home. Even for guns with trig-

ger locks, or guns stored in lock boxes or gun tient and designated person will comply with a gun safety management plan.safes, the suicidal patient may have a dupli-

cate key, the combination written down, or In a study by Brent, Baugher, Bir- maher, Kolko, and Bridge (2000), the parentsfind some other way of defeating these for-

mal locking devices. The negotiation be- of 106 adolescents with major depression

Simon 521

participated in a randomized psychotherapy axiom, there is no safe gun storage at a sui- cidal patient’s home. Again, the gun safetyclinical trial. Those parents who answered

“yes” to having guns at home were urged to plan should be carefully documented. Eventually, the patient may ask thatremove them after being informed of the sui-

cide risk. Only 27% removed guns by the the guns be returned. When the therapeutic alliance with the patient is present and coop-end of the acute trial. The authors concluded

that families of depressed adolescents were eration by the designated third party exists, an informed decision to return the guns tononcompliant with recommendations to re-

move guns while compliant with other as- the patient is made jointly by the clinician, patient, and the designated person. In the ab-pects of treatment. Although a small scale

study by Kruesi et al. (1999) demonstrated sence of such collaboration, the clinician may have little or no control over the prematurethat parental education on injury prevention

limited access to firearms, larger scale studies release of gun(s) to the patient. If guns have been returned prematurely to a patient whoby Grossman et al. (2000) and Sidman et al.

(2005) found that safety counseling session or remains at substantial risk for suicide, volun- tary or involuntary hospitalization are inter-a multifaceted community education cam-

paign to promote safe firearm storage did not vention options. Patients, however, possess all their civil rights. The gun safety plan, atlead to statistically significant changes in gun

storage practices. These studies underscore its inception, should include a discussion about the clinical criteria that will be consid-the importance of a call-back from the desig-

nated person confirming implementation of ered in the decision to return a gun(s) to a patient.the agreed upon gun safety management plan.

Time and circumstances may not allow for a meeting with a designated person. In such cases, a phone contact with the desig- APPLICATION OF GUN SAFETY

MANAGEMENT PRINCIPLESnated person familiar with the situation should be made, preferably with the patient present, explaining that the gun(s) and am- The application of gun safety manage-

ment principles vary across treatment set-munition must be removed immediately and stored separately in a safe place outside the tings, specific clinical situations, and the

safety requirements of patients at risk for sui-home as discussed above. A “cold call” should be avoided, if possible. Such calls can alarm cide. an unsuspecting recipient, making it difficult for that person to assimilate the clinician’s in- Outpatients structions and to ask questions. It is prefera- ble to have the patient call the designated The opportunities for gun safety man-

agement of suicidal patients in outpatient set-person first. Although telephone contact with a designated person is less than optimal, it tings are limited. Much depends on whether

the patient is a new or is an established pa-may be the only pragmatic alternative. The clinician must be satisfied that the gun safety tient, the presence or absence of a therapeu-

tic alliance with the patient, and the availabil-management plan is clearly understood ei- ther by direct contact or by telephone. E- ity of supportive relationships by responsible

individuals, as well as other protective fac-mail contact with designated persons is insuf- ficient; an actual conversation is necessary to tors. Systematic suicide assessments that con-

sider both risk and protective factors guidediscern nuances and ambiguities and to avoid misunderstandings. Family members may hide the clinician’s decision (Simon, 2006).

Asking an outpatient to stay in thea gun in a place that they think is safe but can be easily found by the patient who is de- waiting area while guns are being removed

from the home and secured elsewhere maytermined to attempt suicide. As a clinical

522 Gun Safety Management

be workable on a case-by-case basis. It may, confidential information disclosed by the pa- tient” (Section 4, annotation 8). Mentalhowever, be unnecessary, impractical, and

countertherapeutic. Patients are free to leave health clinicians of other disciplines should consult their professional organization guide-at any time. Clinicians cannot restrict an out-

patient’s freedom of movement unless the pa- lines regarding managing the tension be- tween maintaining patient confidentialitytient is petitioned for involuntary hospitaliza-

tion. If it is necessary to compel the patient versus disclosure in emergency situations. Under the Health Insurance Portability andto wait until guns are removed from the

home, hospitalization should be considered. Accountability Act of 1996 (HIPPA), it is permissible for covered providers to discloseThe patient at risk for suicide who lives alone

and isolated from others may not be able to information in emergencies without the pa- tient’s authorization, within certain guide-identify a designated person for gun removal.

Hospitalization may be required while the lines (Vanderpool, 2002). In an emergency, consent for treatment is also implied (Simongun(s) are removed by other means.

Even with the most cooperative pa- & Goetz, 1999). Federal and state statutes and courts define medical emergency along atient, the clinician cannot provide suicide

proof gun safety management. There are too narrow to expansive spectrum (Currier, Al- len, Serper, Trenton, & Copersino, 2002).many suicide risk variables beyond the clini-

cian’s control. For example, between sessions, When confronted with a choice be- tween maintaining patient confidentiality anda stable therapeutic alliance may be under-

mined by an unexpected surge in the severity disclosing information critical to the suicidal patient’s safety, the clinician should err on theof the patient’s illness or by unanticipated

traumatic events. Individuals entrusted with side of life and disclose. Moreover, it is better to be sued for breach of confidentiality thanthe responsibility for removing and securing

guns may fail to follow the safety plan. If a to lose a patient to suicide. patient who is assessed at moderate to high risk of suicide refuses to cooperate with the Inpatients clinician in securing guns at home, then vol- untary or, if necessary, involuntary hospital- Most patients admitted to a pscyhiatric

unit have severe psychiatric disorders and areization may be required for the patient’s safety. Patients intent on completing suicide at high suicide risk. The hospital length of

stay is usually very brief, often 5 or 6 days orregard the clinician as their enemy (Resnick, 2002); therefore, hidden guns may not be less. At the time of discharge, inpatients are

often discharged at some level of reduceddisclosed. All the clinician can do is to imple- ment a reasonable gun safety management suicide risk. Inpatient treatment is designed

to stabilize the patient. Post discharge plan-plan to reduce the risk of a firearm suicide. A patient at risk for suicide may refuse ning addresses the patient’s need for further

treatment and safety management.authorization for the clinician to speak with others for the purpose of securing guns. The The inpatient gun safety management

team includes the physiciatrist, patient, clini-patient may not want family members or a partner to know that he or she is suicidal and cal staff, and a designated responsible person

(e.g., family member, partner, other). Thehas guns hidden at home. The clinician must determine whether the situation is an emer- designated person should be the main con-

tact person throughout the patient’s hospital-gency, necessitating a breach of confidential- ity. In this regard, The Principles of Medical ization to prevent miscommunications that

can develop when the psychiatrist must re-Ethics with Annotations Especially Applicable to Psychiatry (American Psychiatric Association, spond to multiple family members.

The clinical team, as part of the initial2001) states, “A psychiatrist at times may find it necessary, in order to protect the patient or screening, must ask the patient if there are

guns at home or easily accessible elsewhere.community from imminent danger, to reveal

Simon 523

The patient may admit to possessing guns likely want their guns impounded by the po- lice, prompting them to find another optionand disclose their location. Other patients

may only partially disclose the location of for gun removal. Legislative remedies may also be helpful. State laws should be con-guns at home or deny accessibility to guns.

With the patient’s written permission, a per- sulted to determine limitations or facilitation of the clinician’s gun safety management planson who lives with the patient should also be

asked to verify the presence and location of (Norris, Price, Gutheil, & Reid, 2006). Gun safety management requires thatguns disclosed by the patient as well as the

possible possession and location of other fire- before the patient is discharged, the guns at home or stored elsewhere must continue toarms. The psychiatrist should meet with the

designated responsible person in the pres- be secured. Recently discharged psychiatric patients are at increased risk of suicide, espe-ence of the patient, where the gun safety plan

can be explained, agreed on, and docu- cially within the week following discharge (Currier et al., 2002). If guns are kept withmented. The patient’s cooperation is essen-

tial to gun safety management. the patient’s friends or acquaintances, they must be informed explicitly not to allow theIn contrast to the outpatient settings,

the use of the telephone in determining a patient to retrieve the guns. It is critical that the responsible party call the psychiatrist ordesignated person’s ability to competently ex-

ecute the gun removal plan can be more clinical staff to verify that the gun(s) is safely secured before the patient is discharged. Theproblematic. The mental stability of the des-

ignated person may be difficult to determine. call-back allows the clinician to determine whether the gun removal plan was properlySome family members or partners may be

more mentally disordered than the patient. If performed (e.g., where the guns are stored). If no call is received from the responsiblethe patient does not grant permission to con-

tact family members or partners to imple- party within the agreed on time, the patient’s discharge should be delayed until the gunsment a gun safety plan, the patient’s discharge

should be delayed while other treatment and can be secured. A follow-up call by the psy- chiatrist or clinical staff may be made to thesafety options are pursued.

An inpatient at risk for suicide who designated person responsible for removing the guns. The clinical staff, however, cannotlives alone and isolated from others may have

guns at home but no person to designate for be expected to track down persons who fail to call back as previously agreed.gun removal. Upon reflection, the patient

may be able to think of someone who could Delays in patient discharges can be les- sened when the safety management plan isact as a designated person. If no family or

friend can be found, the patient should be activated on the first day of admission. Trying to remove guns and receiving a verificationencouraged to call the local police precinct

to have the guns impounded. The patient’s call at the last minute may lead to a delay in discharge, patient regression, and the denialrefusal to cooperate is a contraindication for

discharge until the gun safety issue is re- of insurance coverage for additional unau- thorized hospital days. Worse, it may abortsolved. The staff will need to provide the po-

lice with a legitimate reason to enter the pa- the safety plan if the patient insists on dis- charge and the responsible person cannot betient’s home. The police option will require

the active participation of the staff by provid- located to secure the firearms. Any delays or complications regarding gun removal musting the patient’s house key and informing the

police of the location of the guns. The police halt the patient’s discharge until the problems are resolved.will call back confirming that the guns were

removed. The patient must be told that the An inpatient’s gun removal plan may fail for a variety of reasons. The person re-police may not return the guns, depending

on the jurisdiction. Patients who are gun en- sponsible for securing guns may give an affir- mative call back that the guns have beenthusiasts, sportsmen, and hunters, will not

524 Gun Safety Management

moved according to plan but delay securing EDs. Some EDs have metal detection secu- rity systems for the protection of the ED staffthe guns. The designated person may be-

come distracted or change his or her mind and the patients. As noted in the study by Wintemute et al. (1999), the recent purchaseabout gun safety, disbelieving that the patient

would attempt suicide based on the patient’s of a handgun by a suicidal patient is an indi- cator of high risk, especially in women agesdisavowal of suicide. Family, partners, or a

friend’s denial of the patient’s suicide intent is 21 to 33. When a suicidal patient is admitted to the ED, the patient is initially examineda major factor in non-adherence to safe gun

removal from the home. The patient’s or by a physician. Once the patient is medically cleared, a crisis counselor usually evaluatesfamily member’s car may not be checked for

guns. The person may or may not know that the patient. The task of the crisis counselor is to quickly gather as much information asthere is a gun at the patient’s place of em-

ployment. Because of ambivalence, exhaus- possible to make an appropriate disposition. If the patient has been previously admitted totion, or frustration with a seriously ill suicidal

patient, family members may not diligently the ED or to the inpatient unit, the patient’s records should be requested and reviewed.follow the original plan and may carelessly

store guns where the patient can find them. The clinician should attempt to contact the treating therapists, if the patient is in currentMoreover, the patient may undermine a gun

safety plan by withholding information about treatment. Since patients are often admitted late at night or in the early morning hours,the existence of others guns. Some family

members have lied about removal of guns in information gathering may be limited. Most patients will provide names and phone num-order to have the patient discharged. The cli-

nician is not a detective. Affirmation of ad- bers for the crisis counselor to contact. The patient’s history, including the presence andherence to the gun safety plan by a desig-

nated person is, of necessity, taken at face location of guns in the home, should be veri- fied with the contact person. The ED is avalue.

Despite the many potential pitfalls, cli- prime venue for suicide prevention, given the sheer number of patients at risk for suicidenicians must perform adequate suicide risk

assessments and implement a gun safety plan who come through its doors. When a patient at risk for suicide inprior to discharge. Gun safety management is

an essential component in the patient’s post- the ED is admitted to an inpatient unit, gun safety management is transferred to the inpa-discharge treatment plan. As discussed above,

the outpatient clinicians must decide, based tient clinical staff. If it is determined that the patient’s risk of suicide can be managed as anon systematic suicide risk assessment, when it

is safe to return guns to the patient. A contin- outpatient and guns are accessible at home, the team safety plan described above shoulduation of the gun safety management plan is

an integral part of a careful hand off of the be implemented and documented. Patients at risk for suicide who are referred for outpa-patient from inpatient to outpatient treat-

ment. tient treatment the next day or next few days must have guns removed from the home and safely secured before discharge from the ED.

Emergency Patients If a responsible party is not available to se- cure the guns or if a reasonable doubt exists that the gun safety plan can be effectively im-Patients at high risk for suicide by fire-

arms are routinely evaluated in an emergency plemented, the patient should be admitted to the inpatient unit for further evaluation anddepartment (ED). Every psychiatric patient

admitted to the ED must be asked about a treatment. Merely asking and documenting that there is no suicidal ideation or homicidalsuicide plan by firearms, the accessibility of

firearms, or the intent to obtain firearms. ideation, or that there is a contract for safety, before sending the patient home is unaccept-Suicidal patients have brought guns into

Simon 525

able. Systematic suicide risk assessment that CONCLUSION informs treatment and safety management is required (Simon, 2006). The safety management plan proposed

here is only one method of reducing gun sui-If the patient requires constant 24- hour surveillance following discharge from cides. Other viable approaches to gun safety

management will depend on the clinician’sthe ED, the patient should be admitted to the inpatient unit. The patient’s family or training and clinical experience, and the

unique treatment and safety managementpartner should not be burdened with the im- possible task of providing constant one-to- needs of the individual patient. Whichever

method of gun safety management is adopted,one supervision of the patient. Exceptions to constant supervision are invariably made by it should employ a team approach with prear-

ranged call-back verification from the re-family members. For example, it is rare that the patient will be followed into a bathroom. sponsible, designated person confirming that

the patient’s guns have been disarmed and re-Distractions also occur because of the activi- ties of daily living. Family members assume moved from the home and are safely secured.

The essence of gun safety management isthat the patient wants help. They deny or downplay that the patient is determined to verification. die and is looking for a gun or other means to complete suicide.

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