issue with access to firearms by your outpatients

[Igor4sugry]

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Have been coming to the end of PGY-III outpatient clinic (both in large university hospital and at local VA).
I have struggled with assessing/managing risk of symptomatic (depression/anxiety/mania/hypomania/personality issues/substance use or all of them combined) patient that also report having fire-arms. Patients have access to fire-arms, report they are "secured", nod their heads when advised to remove them. Then there are patients who have history of attempting with fire-arms, yet continue to own them and come to outpatient clinic.
--As providers how much control/influence do we have regarding fire-arms in the home?
--How far do we need to escalate the issue to get the fire-arm out of the home (call family/roommates/police)?
--As I understand in Florida it is not allowed to ask about firearms (then what do psychiatrists do there to assess this risk (particularly the VA)).
--Or do we just leave it at "I recommend that you remove your firearm from the home or at least secure it in a safe, given the risk factors and your symptoms"?

 

[hamstergang]

I don't think we should really be doing much here without the patient's consent. If they have a gun, you should suggest ways to make it safer. If they let you talk to their family about it, great! Family should almost always be involved in many parts of treatment, including doing things at home to keep the patient safer.

But if the patient doesn't want to talk to family or address the issue, then what can you do? Just educate and move on. Having easy access to firearms is but one risk factor for suicide. It should go into your decision making process for your assessment and plan, but that's where I'd leave it.

 

[slappy]

--As I understand in Florida it is not allowed to ask about firearms (then what do psychiatrists do there to assess this risk (particularly the VA)).

They would ask about firearms.

 

[michaelrack]

They would ask about firearms.

Agree, when you are at a VA, you are on Federal territory

 

[splik]

They would ask about firearms.

correct. the law in florida is really for pediatricians and PCPs. physicians are able to ask about firearm ownership when "medically necessary". Even Floridians believe that whenever a psychiatrist asks about gun ownership it is "medically necessary". The law is more of a fight back against the routine asking about firearm ownership in health maintenance visits, not for structured risk assessment.

 

[splik]

I don't think we should really be doing much here without the patient's consent. If they have a gun, you should suggest ways to make it safer. If they let you talk to their family about it, great! Family should almost always be involved in many parts of treatment, including doing things at home to keep the patient safer.

But if the patient doesn't want to talk to family or address the issue, then what can you do? Just educate and move on. Having easy access to firearms is but one risk factor for suicide. It should go into your decision making process for your assessment and plan, but that's where I'd leave it.

are you for real? this is THE most important modifiable risk factor for suicide. There is probably little else that a psychiatrist can do to prevent suicide then actively target means prevention. Despite the strong association between mental illness and suicide there is no evidence that treating mental illness reduces suicide rates. Although lithium and clozapine have important effects in reducing suicide at the population level, the effects at the clinical level are very small. Not even the DBT cultists claim DBT reduces suicide - it has been shown to reduce suicidal behaviors but absolute completed suicide does not have a linear relationship with suicide attempts. Only brief intervention and caring letters have been shown to reduce suicide in terms of clinical interventions. Hospitalization, psychotherapy, pharmacotherapy (with exception of above) do not appear to have important effects at reducing suicide. Means prevention is THE most important factor for reducing suicide. Method substitution is simply a myth in the majority of cases. The more difficult we make it for patients to kill themselves, the less likely they will.

We are supposed to be skilled at exploring resistance. Patients don't want to talk about all sorts of things with us - medication non-adherence, addiction, eating disorder, suicidal thoughts, violent thoughts, unwanted sexual thoughts, etc. This should not stop us from exploring these - we build rapport, with gently explore, we educate, show curiosity, highlight ambivalence, show warmth, and explore resistance, and sometimes confront. If something is as important as this, I just never let up, anything else is colluding with the patient.

The ideal would be for patients who are suicidal or violent to not have firearms, but the reality is in many cases this is not going to happen. This doesn't matter in a proper structured risk management plan. What you would do is explore all the steps you can get the patient to take to increase the time between the suicidal/homicidal impulse. For example, keeping it unloaded, taking magazine out, putting a gun lock on, putting it in a locked box, putting the key in a completely different place, hiding the key away, locking the key away, putting the locked box in a cabinet that is also locked, putting a bunch of things on top of or around the locked box so it takes time to retrieve it etc etc... The more time there is between the suicidal impulse and retrieving the gun, the less likely the patient is to harm himself. The data is quite clear that suicides are often impulsive and the more complicated you make it, the less likely your patient will be to end their life. This is why restricting quantity of acetaminophen or aspirin sold has been a v effective means prevention intervention even though there is nothing to stop someone going to multiple stores and buying more in the places where this is enacted. The point is there is something stopping the patient - the effort, the fact the impulse dies down, the chance for ambivalence to kick in etc etc....

If your patient who is known to be suicidal kills himself with his gun and you haven't documented efforts to discuss a plan to make access more difficult, good luck defending yourself. "I tried to talk to him about it, and he wasn't interested" is not a legitimate defense.

 

[hamstergang]

are you for real?

Yes, but I just don't explain myself very much when posting from my phone just before I go to sleep.

What I was trying to emphasize is that it would be inappropriate to involve anyone other than the patient without their consent. Of course you do what you can to make the patient safer wrt guns, but it stays between the two of you.

 

[whopper]

http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String &URL=0700-0799/0790/Sections/0790.338.html\

--As I understand in Florida it is not allowed to ask about firearms (then what do psychiatrists do there to assess this risk (particularly the VA)).

Do you see a provision where psychiatrists are exempt from the law? I don't. I included what I believe is the Florida law in the above link.

Laws are supposed to be followed to the letter of the law, not based off of media buzz. The NRA among other right-wing groups portrayed this AS IF it only referred to pediatricians and PCPs. Hence the false perception that it does not apply to psychiatry. Several pediatricians even went forward and stated they backed the law completely ignoring that it applies to all physicians (and ignoring the data that some parents leave guns dangerously unattended-loaded and in easy access and kids shoot themselves). It would only not apply to psychiatry if the wording specifically mentioned psychiatrists were exempt or it only is for PCPs and pediatricians. It doesn't.

I have several right-wing friends that are NRA members and many of them (blindly) backed this law but when I presented them with the scenario of someone psychotic or demented having a gun they all agreed a doc should ask about it in that scenario. When I told them the law applied to all physicians some of them agreed the law should be re-written, others went into the typical extremist "I can't hear you" mentality.

A health care practitioner licensed under chapter 456 or a health care facility licensed under chapter 395 may not intentionally enter any disclosed information concerning firearm ownership into the patient’s medical record if the practitioner knows that such information is not relevant to the patient’s medical care or safety, or the safety of others.

Now are VAs exempt? I don't know. I don't practice in Florida and I'm sure any doc in the VA there have the answer to this. The law specifically states this law applies to any licensed health care practitioner under chapter 456. That likely does include VA physicians but I'm not going to go into the minutiae given that I don't work in Florida, anyone from Fl could easily answer this question for me, and I don't want my kids growing up with a personality disorder cause I spent more time on the forum instead of with them. Anyone could look up chapter 456 on their own and see if VA physicians fall into it's jurisdiction.

Typically when a case like this happens for a forensic psychiatrist where the question/case on hand is not fully known the psychiatrist asks the lawyer to look it up for him/her. While we do get legal training we don't know laws as well as most lawyers, and its' their job to further clarify the specifics.

Possession of a firearm should be included in any evaluation of safety but because of the Fl laws you can't put that into the equation. I've mentioned this before. If someone with mental illness ends up shooting themselves or others and this could've been prevented had you known about the patient owning a gun you could use this same law as a defense stating that your hands were tied by the law.

An irony is Fl is a retirement locus with several who will get dementia. Now you can't ask the guy who's in the early phase of dementia and still independent if he owns a gun that will most definitely lose his independence in the coming months. I've already had this scenario happen to me several times while running a geriatric psych unit and gun ownership was a significant factor in my decision in holding a patient and formulating their discharge plan.

 

[whopper]

If the APA advisor stated it I'd believe him.

But here's a problem. Pediatricians-at least their professional society does see it as medically relevant for the same reason psychiatrists do. Due to circumstances of the mind, the child (or psychiatric patient) can be dangerous with a gun. So while it does state we can ask if we think it's relevant....

Notwithstanding this provision, a health care practitioner or health care facility that in good faith believes that this information is relevant to the patient’s medical care or safety, or the safety of others, may make such a verbal or written inquiry

The American Academy of Pediatrics has stated they do believe asking for a gun pretty much as a standard question is relevant, but the law in question is supposed to prevent this, and that's what all the talking heads and local politicians were arguing it's about-getting pediatricians to stop asking.

Another problem is we see patients all the time where we do not think there is a significant risk at that moment, but things change. E.g. I see a guy for depression, I get him better and he continues to see me for maintenance treatment. I have him for 5 years. During those 5 years he buys a gun and never tells me. Now he finds out his wife is cheating on him and he is now very very angry and makes statements suggesting he could get violent (e.g. "That bastard effing my wife I hope he dies"). During those 5 years time, especially if I saw no signs of significant problems I might've never asked the guy if he had a gun. Now that I find it relevant to ask him, should I given that a lot of pediatricians think it's relevant and in good faith but aren't supposed to do so?

If I were in Fl and I didn't know the answer to this I'd just call my hospital legal dept. IF I did private practice, I'd ask my local APA branch.

But I will say this...
The way I'm reading the law, as a layman, I do think we can ask because in good faith any psychiatric evaluation as a standard, has the questions if the person is suicidal or homicidal, and along those same lines we ask if there's a gun available.

 

[slappy]

The way I'm reading the law, as a layman, I do think we can ask because in good faith any psychiatric evaluation as a standard, has the questions if the person is suicidal or homicidal, and along those same lines we ask if there's a gun available.

Yes. And it is indeed clearly spelled out in the law.

The American Academy of Pediatrics has stated they do believe asking for a gun pretty much as a standard question is relevant, but the law in question is supposed to prevent this, and that's what all the talking heads and local politicians were arguing it's about-getting pediatricians to stop asking.

I think the law was lobbied for by the supersmart people at National Rogues(sp?) Association (NRA) to prevent doctors from starting a string of evidence documenting people's firearms, and passing them on to the government. It's every bit as stupid as it sounds.

 

[smalltownpsych]

Yes, but I just don't explain myself very much when posting from my phone just before I go to sleep.

What I was trying to emphasize is that it would be inappropriate to involve anyone other than the patient without their consent. Of course you do what you can to make the patient safer wrt guns, but it stays between the two of you.

Actually if they are at risk for suicide, then you can break confidentiality and sometimes should. Think of the liability if patient goes home and kills wife and kids when you wouldn't talk to her about the guns in the home. I had a case like that two weeks ago and I was able to get the guy to agree to let his wife take guns to friends house for safekeeping but mainly because I told him otherwise I will lock you up.

 

[erg923]

--As providers how much control/influence do we have regarding fire-arms in the home?
--How far do we need to escalate the issue to get the fire-arm out of the home (call family/roommates/police)?
--As I understand in Florida it is not allowed to ask about firearms (then what do psychiatrists do there to assess this risk (particularly the VA)).
--Or do we just leave it at "I recommend that you remove your firearm from the home or at least secure it in a safe, given the risk factors and your symptoms"?

Control?! I hope none.

Due diligence for means prevention of course. But you need to be real careful about infringing on rights and privacy here.

 

[hamstergang]

Actually if they are at risk for suicide, then you can break confidentiality and sometimes should. Think of the liability if patient goes home and kills wife and kids when you wouldn't talk to her about the guns in the home.

Well as you alude to, if you're really concerned about this, you hospitalize the patient. I don't think breaking confidentiality to tell the family about the gun is allowed, but maybe I'm wrong?

 

[smalltownpsych]

Well as you alude to, if you're really concerned about this, you hospitalize the patient. I don't think breaking confidentiality to tell the family about the gun is allowed, but maybe I'm wrong?

I was under the impression from my memory of law and ethics class, that involving family members could be an effective safety plan and didn't always need to have consent. I rarely if ever have done it, except of course with kids, but that is another issue. In fact, I use consent exception as a means to encourage patient to enlist support. In other words, "I think we should call your wife or parent and talk to them about this. Remember when we were talking about limitations of confidentiality and exceptions?" If others disagree, I would appreciate feedback. Also, I don't always want to involuntarily hospitalize if we can come up with an effective safety plan that includes immediate decrease in risk as well as the potential to decrease future risk such as a willingness to engage in treatment.

 

[hamstergang]

Also, I don't always want to involuntarily hospitalize if we can come up with an effective safety plan that includes immediate decrease in risk as well as the potential to decrease future risk such as a willingness to engage in treatment.

Of course, but if the patient agrees to the plan to discuss the gun with family then it has nothing to do with this thread. I'm talking solely about when you can't convince the patient to go along a plan that addresses the gun issue.

 

[smalltownpsych]

Of course, but if the patient agrees to the plan to discuss the gun with family then it has nothing to do with this thread. I'm talking solely about when you can't convince the patient to go along a plan that addresses the gun issue.

So then we hospitalize. As I think about it a little more, I wouldn't want to break confidentiality with a patient who is at risk and has access to weaponry then send him home to deal with that family. 😱
To get back to the OP, I guess it really all boils down to thinking each individual case through and consulting and document, document, document.
Nonetheless, option four,

Or do we just leave it at "I recommend that you remove your firearm from the home or at least secure it in a safe, given the risk factors and your symptoms"?

may or may not be a good plan depending on what those risk factors and symptoms are. If I was a non-psych person, I think I would try to get someone else who is more qualified to do a risk assessment at this point, just like I wouldn't want to tell a patient with chest pain that it is probably indigestion. I would have thought that some basic suicide risk assessment training is part of medicine so rely on that training. For myself, if a patient stated that they are having suicidal thoughts and they have a gun at home and are unwilling to cooperate with a safety plan, then they aren't going home that day.

 

[DJspreadsheet]

So then we hospitalize. As I think about it a little more, I wouldn't want to break confidentiality with a patient who is at risk and has access to weaponry then send him home to deal with that family. 😱
To get back to the OP, I guess it really all boils down to thinking each individual case through and consulting and document, document, document.
Nonetheless, option four, may or may not be a good plan depending on what those risk factors and symptoms are. If I was a non-psych person, I think I would try to get someone else who is more qualified to do a risk assessment at this point, just like I wouldn't want to tell a patient with chest pain that it is probably indigestion. I would have thought that some basic suicide risk assessment training is part of medicine so rely on that training. For myself, if a patient stated that they are having suicidal thoughts and they have a gun at home and are unwilling to cooperate with a safety plan, then they aren't going home that day.

The whole gun issue is a bright example of how we think we're actually doing something wherein fact we are not. I'm pretty sure that our question of "do you have access to firearms" doesn't have the most veracious response validity. Do you want to be hospitalized? Say yes! Do you want to actually kill yourself? Say no! Do you prefer not to have some unknown party if you have a gun? Say no! Do you have a car that you could drive into a tree? Oh wait...

 

[whopper]

National Rogues(sp?) Association (NRA) .

Got a laugh from that. Some of my closest friends are NRA members and gun-owners. I actually toy with the idea of buying a gun at least monthly but due to procrastination and having a bunch of other things more immediate, I haven't bought one yet.

But I must admit the NRA just sometimes do some very out-there crazy things. They lobbied to prevent the government from further researching and utilizing data on firearms. I'm not talking about fighting ant-gun legislation, I'm talking blocking further attempts to gain knowledge on firearms and their impact on our culture-good or bad. I figure if you really believe in philosophy you ought to encourage more research and stand your ground when the chips fall where they may, or at least utilize the new data to come up with a better philosophy.

And if I buy I gun I do not think I will join the NRA. Anyone willing to put money in Sarah Palin's pocket isn't someone I want to support. I'm not trying to get anti-right here, just anti-Palin.

 

[smalltownpsych]

The whole gun issue is a bright example of how we think we're actually doing something wherein fact we are not. I'm pretty sure that our question of "do you have access to firearms" doesn't have the most veracious response validity. Do you want to be hospitalized? Say yes! Do you want to actually kill yourself? Say no! Do you prefer not to have some unknown party if you have a gun? Say no! Do you have a car that you could drive into a tree? Oh wait...

When asked by a trained clinician of someone in distress that you develop rapport with, you would be surprised at how open patients are. We don't just walk in and ask questions in a vacuum, that's one reason why a self-report measure is a weak tool for this, as well. Being able to get the key information to save lives is what we do. The EM docs that call us in know this and are amazed that we find out what is really going on when they could get almost nothing out of the patient. Throughout training that's how we compete too. I imagine in other areas of medicine it is the same with how well or quickly you can do a procedure. For psych, it's how much rapport you can develop as measured by getting the true story and getting the patient on board with treatment plan.

 

[keifernny2]

This brings some interesting thoughts about federal property vs. non-fed.

In NY, with the SAFE act that has stirred up so much controversy (somewhat unnecessarily), I don't generally ask my VA patients about firearms. (Though I do ask all other patients about them). I can (and do) make suggestions that if VA patients "were" to have a firearm, that can increase suicide risk. I generally assume that all veterans have firearms. If I were to have a real concern that a veteran may use a firearm for suicide then I would generally hospitalize them (voluntarily or not).

Veterans will often not be aware, though, that if they are picked up by the local sheriff, and taken to the nearest ED (non-VA), that they are not on Federal property anymore, and the local ED psychiatrist will often report them to the SAFE act registry if they are threatening harm or delusional.

 

[DD214_DOC]

Seriously, where do we draw the line with respect to autonomy and parentalism? Discuss it with them, offer options if they're interested, even hospitalize if you need to, but invoking third parties to confiscate someone's personal property is a bit much. We can also stop kidding ourselves -- our ability to assess imminent risk of self harm is no better than anyone else's; we just have some snazzy medico-legal stuff to write in a chart to CYA

 

[NontradCA]

.

 

[smalltownpsych]

Seriously, where do we draw the line with respect to autonomy and parentalism? Discuss it with them, offer options if they're interested, even hospitalize if you need to, but invoking third parties to confiscate someone's personal property is a bit much. We can also stop kidding ourselves -- our ability to assess imminent risk of self harm is no better than anyone else's; we just have some snazzy medico-legal stuff to write in a chart to CYA

Confiscate? Part of a safety plan is frequently having the patient give firearms to someone else to hold on to. If they are willing to do that then that would sound like a reasonable mitigating factor to justify not hospitalizing. Where I work we tend to assume they have firearms cause about 95 percent do. Patients usually come up with a friend or family member to hold on to the weapons until they feel more stable. We also have one of the highest suicide rates in the country. Probably not a coincidence.

 

[thoffen]

It is not parentalism to discuss firearm safety as it relates to mental illness. It is unethical not to when it relates to your risk formulation. What we cannot do is drive to someone's home and take away their gun. We can hospitalize based on legally defined standards. We can involve family in efforts to manage risk if permission is given. There is no autonomy conflict. If the patient says no and is not committable it is up to them to implement change, just the same as it would be for substance abuse. And just as for substance abuse, it is our duty to weigh risk and engage in education and motivational interviewing.

RE: everything else on this subject, I defer to splik's responses above.

 

[whopper]

One thing I miss about Cincinnati is if we had an issue like this where even when reading the law literally we still didn't know what the answer was, our city and county's mental health health board lawyer was a phone call away. If he didn't know (and he almost always knew), he'd call a local judge to get the answer, and if the judge didn't know the judge literally called the governor's office if it were an emergency.

I've had that happen a few times and it wasn't like I'd get the answer 5 months later. I'm talking same day usually.

In Missouri, the state mental health legal infrastructure is in no way on the same order at Ohio. Ohio was state of the art minus an outpatient commitment program that NY has.

I wrote about this case before but I one-time had a guy with schizoaffective disorder that almost always stopped his meds and would be back in the hospital within a few weeks due to violence related to psychosis. I had him, stabilized him on the unit but he put down a payment for a gun, and I was not going to discharge him. (A-Patient always stopped his meds and became violent within weeks of discharge + B-Patient plans on buying a Desert Eagle Gun led me to believe that C-patient will be violent with a gun in just a few weeks).

I refused to discharge him despite that he was taking his meds, had capacity, and swore he wouldn't be violent. Ohio law has in it's writing that you must keep someone even if if in the present they are safe and clear if in the imminent future they could be dangerous due to mental illness. No one dared to clarify how long "imminent" was-an hour? A day? A week, a month?

I told the court that since no one has defined it, and that a month IMHO could be interpreted as imminent and I did believe the patient was going to shoot someone within a few weeks due to psychosis, I wasn't discharging him.

It got to the point where a judge called the governor's office over this. We discharged the guy after the governor's office told us a few weeks was past imminent. Even the judge wasn't sure on that one.