In lethal means safety counseling (LMSC), clinicians encourage patients to limit their access to common and lethal means of suicide, especially firearms. However, clinicians may hesitate to deliver this evidence-based intervention. By conducting a systematic review of the growing number of qualitative studies examining stakeholder perspectives on LMSC, we identified stakeholder-recommended strategies for clinicians, health system leaders, and researchers to increase LMSC acceptability. We conducted a pre-registered, comprehensive search for studies up to February 2021 using PubMed and PsycInfo. Thematic synthesis, with an inductive and iterative approach, was used to analyze findings. Eighteen studies examined the perspectives of a various stakeholders across multiple clinical settings on LMSC for firearms. Using relevant themes, we describe strategies and present scripts, rationales, and resources that may increase LMSC acceptability. Clinicians may approach LMSC in a nonjudgmental manner with awareness of their own biases, demonstrate cultural competency by acknowledging the role of firearms in patient’s lives, and adapt LMSC to patients’ previous experiences with firearms, safety, and injury. Clinicians can contextualize and provide a rationale for LMSC, decide whether or not to ask about access to firearms, and recommend a range of storage options tailored to the patient. Free locking devices or coupons for purchasing devices may be distributed. These strategies for potentially increasing the acceptability of LMSC for firearms are the first to be based on a comprehensive set of studies generated by diverse stakeholders. Future efforts should focus on testing them empirically and considering them alongside other relevant outcomes (e.g., feasibility, efficacy).
Pharmacogenomic testing has emerged to aid medication selection for patients with major depressive disorder (MDD) by identifying potential gene-drug interactions (GDI). Many pharmacogenomic tests are available with varying levels of supporting evidence, including direct-to-consumer and physician-ordered tests. We retrospectively evaluated the safety of using a physician-ordered combinatorial pharmacogenomic test (GeneSight) to guide medication selection for patients with MDD in a large, randomized, controlled trial (GUIDED).Patients diagnosed with MDD who had an inadequate response to ≥1 psychotropic medication were randomized to treatment as usual (TAU) or combinatorial pharmacogenomic test-guided care (guided-care). All received combinatorial pharmacogenomic testing and medications were categorized by predicted GDI (no, moderate, or significant GDI). Patients and raters were blinded to study arm, and physicians were blinded to test results for patients in TAU, through week 8. Measures included adverse events (AEs, present/absent), worsening suicidal ideation (increase of ≥1 on the corresponding HAM-D17 question), or symptom worsening (HAM-D17 increase of ≥1). These measures were evaluated based on medication changes [add only, drop only, switch (add and drop), any, and none] and study arm, as well as baseline medication GDI.Most patients had a medication change between baseline and week 8 (938/1,166; 80.5%), including 269 (23.1%) who added only, 80 (6.9%) who dropped only, and 589 (50.5%) who switched medications. In the full cohort, changing medications resulted in an increased relative risk (RR) of experiencing AEs at both week 4 and 8 [RR 2.00 (95% CI 1.41-2.83) and RR 2.25 (95% CI 1.39-3.65), respectively]. This was true regardless of arm, with no significant difference observed between guided-care and TAU, though the RRs for guided-care were lower than for TAU. Medication change was not associated with increased suicidal ideation or symptom worsening, regardless of study arm or type of medication change. Special attention was focused on patients who entered the study taking medications identified by pharmacogenomic testing as likely having significant GDI; those who were only taking medications subject to no or moderate GDI at week 8 were significantly less likely to experience AEs than those who were still taking at least one medication subject to significant GDI (RR 0.39, 95% CI 0.15-0.99, p=0.048). No other significant differences in risk were observed at week 8.These data indicate that patient safety in the combinatorial pharmacogenomic test-guided care arm was no worse than TAU in the GUIDED trial. Moreover, combinatorial pharmacogenomic-guided medication selection may reduce some safety concerns. Collectively, these data demonstrate that combinatorial pharmacogenomic testing can be adopted safely into clinical practice without risking symptom degradation among patients.Myriad Neuroscience/Assurex Health.
The psychological study of resilience has increasingly underscored the need for children and families to access material and psychological resources to positively adapt to significant stress. Redistributive policies-policies that downwardly reallocate society's social and economic resources-can offer economically disadvantaged families sustained access to these resources and mitigate the harmful impacts of adversity. This conceptual article builds upon and integrates insights from psychological and policy research to develop a unifying multilevel resilience framework, which we call the Social Determinants of Resilience. We examine four U.S. redistributive policies that have been extensively studied for their effects on child and family outcomes as case studies: (1) Medicaid expansion; (2) the Earned Income Tax Credit; (3) childcare subsidies; and (4) Temporary Assistance for Needy Families. Informed by a scoping review of each policy, we propose that redistributive policies promote children's resilience through three mechanisms by (1) increasing families' resource and service access; (2) reducing family stress; and (3) enhancing adaptive cognitions, emotions, behaviors, and interpersonal processes that protect against the development of psychopathology and promote positive mental health outcomes. Highlighting current evidence for these resilience mechanisms as well as gaps in knowledge, we conclude by setting a multidisciplinary research agenda that can leverage this conceptual framework to advance the science on how redistributive policies enable children and families to thrive. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
Importance Firearm injury and poisoning, often by drug or medication overdose, account for most suicides among the general population and US veterans. In the Veterans Health Administration, the largest integrated health care system in the US, firearm and opioid access is assessed among patients at risk for suicide who complete suicide safety plans. Objective To describe self-reported, clinician-documented access to firearms and opioids, firearm storage practices, distribution of firearm cable locks and naloxone, and counseling on firearm storage and overdose among veterans at elevated risk for suicide who completed suicide safety plans. Design, Setting, and Participants This cross-sectional study used electronic health record data from the Veterans Health Administration from December 2021 to February 2023. Participants were veterans identified as having elevated suicide risk through routine screening with the Columbia Suicide Severity Rating Scale Screener who completed a safety plan within 30 days. Data were analyzed from March 2023 to March 2024. Exposure Completion of a safety plan, a brief, evidence-based intervention to help prevent or de-escalate suicidal crises. Main Outcomes and Measures Firearm and opioid access, as well as firearm storage information, were assessed via the lethal means component of the standardized safety plan note template. Results Among 38 454 veterans identified (32 310 [84.0%] male; 15 206 participants [39.5%] aged ≥55 years; 26 960 participants [70.1%] living in urban areas), 9969 (25.9%) were Black and 23 714 (61.7%) were White and 3426 (8.9%) were Hispanic/Latine and 28 892 (75.1%) were not Hispanic/Latine. A total of 10 855 (28.2%) reported access to firearms. Approximately one-third of veterans reported storing at least 1 firearm in each of the following ways: unlocked and loaded (insecure), outside of the home or locked and unloaded (secure), or locked and loaded. Younger and middle-aged veterans, White veterans, veterans who were not Hispanic/Latine, male veterans, and rural veterans were more likely to report firearm access. A total of 2021 veterans (5.3%) reported access to opioids; older veterans, White veterans, veterans who were not Hispanic/Latine, and rural veterans were more likely to report opioid access. Clinicians reported discussing firearm storage with 10 655 veterans (98.2%) and overdose with 1589 veterans (78.6%). Only 1837 veterans (16.9%) offered firearm cable locks and 536 veterans (26.5%) of veterans offered naloxone were documented as accepting them. Conclusions and Relevance In this cross-sectional study of electronic health record data, the prevalence of reported access to firearms was lower than expected, suggesting underreporting or underdocumentation, or a lower true prevalence among this at-risk population. Completion of a note template may have encouraged routine discussion of firearm storage and overdose risk, but acceptance of gunlocks and naloxone was low. These findings suggest that White veterans, veterans who were not Hispanic/Latine, and rural veterans may be at particular risk of harm by firearms and opioids.
Freely available and asynchronous implementation supports can reduce the resource burden of evidence-based practice training to facilitate uptake. Freely available web-based training videos have proliferated, yet there have been no efforts to quantify their breadth, depth, and content for suicide prevention.
Abstract Background In the US, over 50% of suicide deaths are by firearm injury. Studies have found that limiting access to firearms, including storing them temporarily outside of the home or locking and unloading them securely at home, helps prevent suicide. Family members and other loved ones are in a unique position to encourage secure firearm storage. This paper describes the development of a workshop to empower loved ones of individuals at risk for suicide to discuss secure firearm storage in New York State. Methods Using a multistakeholder engagement framework, we partnered with New York State county-level suicide prevention coalitions, local firearms experts, and other stakeholders to develop a 90-min workshop addressing secure firearm storage for suicide prevention. Pilot workshops were co-facilitated by a suicide prevention coalition member and a local firearms expert. Feedback gathered via surveys from workshop attendees and interviews with workshop co-facilitators were used to revise workshop content and inform dissemination. Following pilot workshops, a 1-day training event was held for potential future facilitators, and survey data were collected to assess trainee experiences and interest in facilitating future workshops. Data analysis included rapid qualitative analysis of interviews and statistical analysis of survey responses about acceptability of workshop. Results Four pilot workshops included a total of 23 attendees. Pilot workshop attendees endorsed willingness and confidence to discuss secure firearm storage with a family member or loved one. The training event included 42 attendees, of which 26 indicated interest in facilitating a workshop within the next year. Co-facilitators agreed on several key themes, including the importance of having a “trusted messenger” deliver the firearms portion of the workshop, keeping the conversation focused on firearm safety for suicide prevention, and developing interventions that reflect firearm owning community’s culture. Conclusions Consistent with a public health approach to suicide prevention, this study leveraged a multistakeholder engagement framework to develop a community-based workshop empowering loved ones of individuals at risk for suicide to discuss secure firearm storage. The workshop will be disseminated across New York State. We noted positive and collaborative relationships across stakeholder groups, and willingness to facilitate the workshop among both suicide prevention and firearm stakeholders.
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