Removing the tools

Article in review: Bandealy, A., Herrra, N, Weissman, M. & Scheidt, P (2020). Use of lethal means restriction counseling for suicide prevention in pediatric primary care. Preventive Medicine., DOI: 10.1016/j.ypmed.2019.105855

Summary: The essential aspects of suicide prevention strategies is more than just delivering therapy. We need to actively understand not only what is occurring in a person’s life to bring them to a point where they think suicide is the answer but to buy them time to create, find or eliminate whatever they need, to find the life they want to live. This can take time, and hence creating a safe environment is an essential aspect of suicide prevention. This research notes that means restriction counselling requires greater emphasis and importance in our interactions, particularly with young people.

___________________________________________________________________

Each year in the United States, 3000 young people aged between 10-19 years died by suicide. In nearly half of all of these cases, suicide was conducted through the use of firearms. For those living in homes with firearms, there is a five-fold increase in the risk of suicide.

Lethal means restriction (LMR) is a method of suicide prevention whereby access to means is removed or restricted. This includes public safety and design measures, such as barriers to bridges and buildings that prevent jumping. It also includes individualised measures such as removing from the home any firearms, medications, alcohol, ropes, or sharp objects that could be used in a suicide attempt. Suicide crisis is often surprisingly short, less than one hour in many cases. And 90% of those who make a suicide attempt will not go on to die by suicide. LMR strategies are useful methods that can prevent suicide attempts during a crisis episode by removing tools and means for suicide.

Suicide prevention through LMR

Counselling patients and parents about the safe storage of firearms and medicines are recognised to be an effective suicide prevention method. Parents who receive lethal means restriction advice and counselling are nearly four times more likely to restrict access to lethal means risks in the home.

Most adolescents have seen their primary physician within the year proceeding a suicide attempt, and around half have seen them within the preceding month. Physicians are well connected and well placed to provide LMR counselling to patients and their families.

A study by Bandealy, Herrera, Weissman, and Scheidt (2020) has intended to research the extent to which lethal means restriction counselling is occurring in primary health services, and identify any factors associated with a higher likelihood of counselling. An anonymous survey was undertaken by 167 primary care pediatricians in Washington DC.

Findings

Lethal means restriction counselling is typically provided in a five-minute counselling encounter between a physician and a suicidal adolescent, and their parents or families.

The study found that when treating a young person at risk of suicide, most physicians did routinely screen to identify if there were firearms in the home, as well as employing lethal means restriction counselling. However, physicians do not consistently provide this LMR counselling. The rate of provision LMR counselling was higher for physicians who had received specific lethal means restriction training, and amongst those who had been in practice for five or more years.

When LMR is known to be a preventative strategy, this study sought to identify why it was not consistently provided across all cases.

Reasons given for not providing lethal means restriction counselling included:

• Time (71%)
• Attitudes of patient and family (46%)
• Insufficient staff resources (27%)
• Political pressure, referring to the impact of ‘gag’ laws (10%)

The finding that 71% of physicians think that time is the biggest barrier may indicate a belief that lethal means restriction counselling is an intervention that is too time-consuming to routinely deliver. The research suggests the following strategies to improve the overall rate of provision of lethal means restriction counselling

• Integration of social workers or other professionals to conduct the LMR counseling
• The provision of training about how best to screen for firearms and deliver lethal means restriction advice
• Training about how to best approach the topic with families
• Role play with physicians to boost their confidence in discussing difficult topics
• The inclusion of LMR counselling as a standard part of medical education

We know that lethal means restriction can reduce the rate of suicide in adolescents. We must support physicians to encourage patients and families to remove and restrict lethal means in the homes of at risk adolescents.