Experts Discuss Efforts Required to Reduce Gun Violence

Firearm injuries and deaths cost the United States $229 billion per year in medical treatment, legal fees, emergency services, security, law enforcement, mental health services, and lost income, said Georges Benjamin, M.D., executive director of the American Public Health Association.

As he spoke in February at the Washington Psychiatric Society’s Presidential Symposium on Violence Risk Reduction at St. Elizabeths Hospital, there had already been 22 mass shootings (defined as four or more dead) in the country that month—and that was with three days still left to go.

“We have more guns than people in the U.S. (357 million guns versus 317 million people), but the percentage of households with guns has dropped from about 50 percent in 1975 to 32 percent in 2014,” he said. “The protective value of a gun in the house is overestimated. Without minimizing criminal activity, homicide is usually committed using a handgun, by someone who knows the victim, by someone of the same race, during an argument or fight, aided by the use of drugs or alcohol.”

Benjamin suggested three ways to reduce gun violence: make guns safer with technological checks on misuse; make people safer with their guns by improving gun safety practices; and creating a safer environment with guns. The latter includes universal background checks, permitting product safety oversight (now banned by law), and counseling for victims to break cycles of violence. He also called for restarting federal research on firearms injuries and violence, which has been effectively blocked by Congressional mandate.

Physicians could play a more active role in reducing gun violence by discussing firearms in the same way they discuss other risk factors for injury, said Benjamin. “Too many doctors don’t ask if there is a gun in the home or if it is stored safely.”

Two-thirds of gun deaths are suicides, a fact that presents a logical place for clinicians to intervene to reduce gun deaths, said forensic psychiatrist Liza Gold, M.D., a clinical professor of psychiatry at Georgetown University School of Medicine.

“Suicide risk assessment is a process, not an event,” said Gold. “The problem is that there are no standardized assessment models or tools.”

APA last issued such a model in 2003, but it needs updating now, she said.

A systematic suicide risk assessment should combine semistructured tools, clinical interviews, and patient self-report, as well as information from family members, other treating clinicians, and psychiatric records.

“We cannot predict who will die by suicide, but we can mitigate risk,” she said. Suicide attempts are often impulsive, arising in moments of crisis, and depend on the immediate availability of lethal means, so reducing access to lethal means has the potential to cut suicide rates.

“Access to firearms increases risk of suicide for all members of the household, independent of psychopathology,” said Gold. Thus, when talking to patients, the discussion should focus not on politics or rights, but on reducing risks of injury or death for the patient and all the members of the patient’s household.

Two special subpopulations that have great familiarity with guns are military service members and veterans, said Elspeth Cameron Ritchie, M.D., M.P.H., a retired Army psychiatrist and the chief of mental health at the community-based outpatient clinics at the Washington, D.C., Veterans Affairs.

Suicides among members of the Armed Forces increased markedly beginning in 2005, two years into the war in Iraq, from about 11 per 100,000 to a peak of about 27 per 100,000 in 2012; it dropped below 22 per 100,000 in 2013.

Violence against others by returned service members has also been a source of concern, said Ritchie. In one well-known series of events in 2002 at Fort Bragg, N.C., two returning soldiers murdered their wives, and there were two cases of murder-suicides. Army investigators noted certain common elements: a rapid return from the war zone, marital infidelity, easy access to a gun in the home, and stigma against seeking mental health care.

In this case and others, the antimalarial drug mefloquine also has been hypothesized as a possible risk factor for violence and suicide among some service members, and it has been largely phased out by the Department of Defense, said Ritchie.

Overlapping risk factors characterize both suicides and homicides among military personnel, said Ritchie: perpetrators are mainly young and male; many experience pain from injuries or have been diagnosed with a traumatic brain injury or PTSD; relationship problems are a recurring theme, as are misuse of alcohol and the ready availability of weapons. Stigma—whether from a soldier’s commanders, military peers, or self—is common.

“Multiple individual, unit, and community factors appear to increase risk of suicidal or violent behavior,” said Ritchie.

The Army is attempting to reduce population-based risk by decreasing stigma, substance abuse, family problems, and untreated behavioral health issues, she said.

Overall, reducing violence in any segment of American society must be a joint effort, said Benjamin.

“We have to figure out how we address these barriers and work in a more collaborative way, not just with the health system but across the social services system and the criminal justice system,” he said. ■