Denial of Suicide Attempt Among Hospitalized Survivors of a Self-Inflicted Gunshot Wound

Frequency calculations showed that 29% (N=37) of patients denied that their injuries from a self-inflicted GSW resulted from a suicide attempt (Table 1). For 43% of these patients, psychiatric consultation determined that the GSW occurred under suspicious circumstances, and the denial of suicidal attempt was coded as a suspected false denial. For patients with complete data, 28% reported prior suicide attempts, 71% had a previously diagnosed psychiatric disorder, and 35% reported lifetime sexual, physical, or verbal abuse. Most injuries from self-inflicted GSWs were suffered to the head (44%), followed by the chest or abdomen (37%) and other body parts (20%). A majority of patients were discharged to inpatient psychiatric care (63%), but many were also discharged to their home (20%) or to other facilities (16%).

Table 2 presents the results of individual logistic regression of denial of suicide attempt on all variables of interest, with pairwise deletion used to handle missing data. Individual logistic regression using the MICE model indicated that patients with psychiatric diagnoses or prior suicide attempts were more likely than those without a similar history to be in the disclosure group (odds ratio [OR]=.40 and .32, respectively; p=.03 for both) (Table 3). Patients discharged to home and patients discharged to other facilities were more likely to be in the denial group (OR=10.86, p<.001, and OR=3.54, p=.02, respectively) compared with patients discharged to a psychiatric inpatient facility. In the multiple logistic regression model, the final model, only discharge location remained a significant predictor of group membership, indicating that patients discharged to home or to other facilities were more likely to be in the denial group compared with patients who were discharged to psychiatric inpatient facilities (OR=10.86, p<.001, and OR=3.54, p=.02, respectively).

Post hoc frequency calculations of raw data split by discharge location were conducted to describe differences between the characteristics of patients discharged to home (N=26) and those discharged to inpatient psychiatric facilities or other locations (N=102). Patients discharged to home were more likely than patients discharged to other locations to be employed (N=14, 61%, versus N=38, 40% [total N=119]), have children in the home (N=10, 40%, versus N=26, 29% [total N=127]), and to have suffered a GSW to the chest or abdomen (N=14, 54%, versus N=33, 23% [total N=128]). Patients discharged to home were less likely than patients discharged to other locations to have a psychiatric medication prescription (N=8, 31%, versus N=57, 56% [total N=128]), a prior psychiatric hospitalization (N=4, 15%, versus N=33, 35% [total N=121]), a prior suicide attempt (N=4, 16%, versus N=30, 31% [total N=123]), treatment in an intensive care unit following the GSW (N=7, 28%, versus N=40, 41% [N=123]), and GSW injuries to the head (N=6, 23%, versus N=50, 49% [total N=128]). Patients discharged to home were less likely than patients discharged to other locations to be unemployed (N=5, 22%, versus N=32, 33% [total N=119]), but the groups were similarly likely to have health insurance (N=10, 62%, versus N=30, 70% [total N=126]).

This study sought to identify characteristics of survivors of self-inflicted GSWs associated with an increased likelihood of denying that one’s injuries resulted from a suicide attempt. These results demonstrate that a substantial portion of survivors of self-inflicted GSWs (29%) asserted—while being assessed in the hospital—that their self-inflicted GSWs resulted from circumstances other than a suicide attempt. Nearly half of the denial group’s evaluations revealed information that suggested a false denial of suicide attempt. These findings are consistent with previous reports stating that approximately 22% of persons who are evaluated by a psychiatric consultation and liaison service following a self-inflicted GSW claim that their self-inflicted GSWs resulted from unintentional injuries (13).

Although it is impossible to definitively determine whether a patient is truthfully or falsely denying suicidal intent, contextual information provided by psychiatric consultations suggests false denial by a number of patients. Direct clinician quotations from medical transcripts suggesting false denial included “[former boyfriend] states he saw her put the gun in her mouth,” “[patient] shot herself in bathtub at husband’s house,” “he shot himself when confronted by police,” and “left voice mails on wife’s phone saying goodbye.” There were also multiple instances in which patients provided two or more conflicting stories about the circumstances of their injury. These injuries may represent undocumented suicide attempts, and they highlight the importance of increased assessment of suicidal intent or ideation and accurate identification of intentional or unintentional injury after patients are admitted to the medical floors of hospitals (4). For many individuals, the brief follow-up provided during the psychiatric consultation may be the only assessment of current and prior suicidal intent that they receive following a traumatic injury. For some patients that may be adequate, but previous research suggests that some individuals with suicidal ideation may be prone to denying ideation when the consequences of disclosure (hospitalization) are more distressing than their current quality of life (9).

Data suggesting that nearly half of the denials of suicidal intent were false negatives are especially concerning when coupled with the finding that patients discharged to home were nearly 11 times more likely to be in the denial group compared with patients discharged to inpatient psychiatric care. Psychiatric consultations include a comprehensive evaluation of the circumstances surrounding potentially intentional self-inflicted injuries, but there are several sources that can hinder collection of these data (for example, family members not being present and severe patient injury). If accurate assessment of suicidal intent is obstructed for any reason, these undocumented GSW suicide attempts may account for the comparatively low number of GSW decedents with prior suicide attempts. Data from survivors of GSW suicide attempts may be less accurate because of increased severity of injury and believability of unintentional injury (due to cleaning or mishandling) compared with other methods of suicide attempt. However, this difference in prevalence of prior suicide attempts is also due to the high lethality of suicide attempts involving a GSW, and the rate of suspected false denials found in this study may not generalize to a sample of suicide decedents, who are not completely analogous to individuals who survived a suicide attempt.

It may be countertherapeutic to involuntarily hospitalize patients in psychiatric units if they deny having attempted suicide. Some may argue that even voluntary psychiatric hospitalizations are potentially iatrogenic if a patient does not wish to be admitted or perceives that the “cons” of being hospitalized outweigh the “pros” (19,20). One solution to treatment linkage barriers is the implementation of brief psychological interventions following potentially intentional, traumatic, and self-inflicted injuries. A number of empirically validated brief interventions have demonstrated efficacy to reduce suicidal thoughts and behaviors among survivors of suicide attempts (5), and these interventions can be implemented within the hospital while patients recover from physical injuries. Brief interventions during recovery may also be able to positively affect future disclosure of suicidal ideation or suicidal intent associated with the current injury, given the impact of prior mental health treatment on disclosure of suicidal ideation (9,21). However, future research is needed to determine the efficacy of brief interventions for injury prevention and treatment seeking.

Results indicated that prior psychiatric diagnosis and prior suicide attempt were individually negatively associated with denial of suicide attempt. These individual associations are unsurprising because prior suicide attempts and psychiatric diagnoses are risk factors for suicide attempt (16,22). Results support previous research indicating that patients without prior experience with mental health care are less likely to disclose a suicide attempt (9). Alternatively, it may be that patients who falsely deny that their current injuries are the result of a suicide attempt are also more likely to falsely deny having made a previous suicide attempt and having one or more psychiatric diagnoses. Both of these explanations are concerning and indicate the need for increased intervention and psychoeducation about psychiatric services for survivors of self-inflicted GSWs.

It is worth noting that there was a trend indicating that patients who suffered self-inflicted GSWs to the chest or abdomen were more likely to be in the denial group compared with those with injuries to the head. Although these results were not significant, they are surprising because the head and the chest are similarly lethal locations, and without intent to injure oneself, there are few reasons why a firearm would be pointed directly at the head or chest. Unfortunately, there were not sufficient records on the type of weapon used by each patient to include these data, but future research should include these data because some firearms have a higher likelihood of injuring specific bodily locations in firearm suicides (23).

There were no significant associations between denial of suicide attempt and any demographic factor, despite the association of age and male sex with decreased mental health literacy and increased stigma toward mental illness and suicide (24,25). Specifically, our results did not replicate the findings of Williams et al. (13), who reported an increased likelihood among younger participants to claim that a self-inflicted GSW was an accident. Future research will need to directly incorporate scales assessing suicide stigma and mental health literacy in order to analyze interactions of these variables with demographic factors and denial or disclosure of suicidal intent.

Results of this study indicated that a substantial portion of individuals who survived a self-inflicted GSW were discharged directly to home, some of whom are likely to have falsely denied a suicide attempt. Frequency calculations indicated that patients who were discharged to home were more likely to have motivation to deny a suicide attempt compared with those discharged to a psychiatric inpatient or other facility (such as being employed and having children in the home). However, they were less likely to have prior psychiatric hospitalizations, psychiatric diagnoses, psychiatric medication prescriptions, and prior suicide attempts, indicating a somewhat better clinical picture as well as a potentially long-standing barrier to psychiatric care. Additionally, patients discharged to home were more likely to suffer a GSW to the chest or abdomen and were less likely to suffer a GSW to the head, indicating similar suicidal intent for individuals discharged home and those discharged to a psychiatric inpatient or other facility. Future research should assess the effects of clinical profile and motivation for denial on the likelihood of being discharged to home by employing formal assessment of motivation for denial.

There were a number of limitations of this study. Most important, the design precluded any ability to be certain about the legitimacy of suspected false denial. To determine clinical suspicion, research assistants reviewed brief notes by medical staff. Future research into denial of suicide attempt would benefit from semistructured interviews with patients and their support networks to verify suspicions about false denial of a suicide attempt. Additionally, the rate of intoxication among survivors of self-inflicted GSWs (57%) in this study was higher than the rate reported for suicide decedents (27%) (26). That may be due to the inclusion of individuals whose injuries truly were unintentional, and our sample may differ too much from suicide decedents to provide generalizable results. Additionally, more detailed injury severity data may provide insight into the way injury severity affects discharge. This study’s analyses were limited by reliance on dichotomized, self-reported responses from patients. Future research should use dimensional measurement of lifetime suicidal behaviors and current suicidal intent as well as comprehensive suicide risk factor assessments. Longitudinal designs should be employed to assess future disclosure of previously denied suicidal intent. More diverse samples should be assessed. Females were well represented, but future research will benefit from assessment of greater diversity of racial-ethnic minority groups.

A substantial portion of survivors of self-inflicted GSWs deny that their injuries are the result of a suicide attempt. Psychiatric consultation raised suspicion that more than one-third of these patients were falsely denying that a self-inflicted GSW resulted from a suicide attempt. Patients who denied a suicide attempt were nearly 11 times more likely to be discharged to home than to inpatient care. These results indicate that there are significant barriers to treatment for individuals who have made a suicide attempt using a self-inflicted GSW, and they highlight the need for improving assessment, intervention, and psychoeducation for survivors of self-inflicted GSWs, particularly while they are hospitalized on medical floors. Additionally, the results indicate a need for further reflection on ways in which usual care in health systems (such as inpatient hospitalization) may present a barrier for eliciting honest reports from suicide attempt survivors due to a fear of hospitalization.