Training Physicians About Suicide

This commentary presents the overwhelming evidence that the availability of lethal means increases the suicide rate and argues that physicians need to take an active role in reducing access for potentially suicidal individuals.

Miller, Matthew; Hemenway, David. Guns and suicide in the United States. The New England Journal of Medicine. 2008; 359:989-991.

In one Boston emergency department (ED), ED physicians and nurses believe they should counsel suicidal patients on lethal means restriction, but they often don’t. Psychiatrists working at the ED were much more likely to ask about firearms.

Betz, Marian E; Barber, Catherine; Miller, Matthew. Lethal means restriction as suicide prevention: Variation in belief and practices among providers in an urban ED. Injury Prevention. 2010; 16:278-81.

Physicians and nurses at 8 emergency departments (n = 631) were surveyed about their practices and beliefs concerning means restriction and whether they asked their patients about guns. The proportion of providers who reported that they “almost always” ask suicidal patients about firearm access varied across five patient scenarios: 64% would ask a suicidal patient whose suicide plan involved firearms and 21% would ask a suicidal patient who did not have a specific plan. Less than half believed that most suicides are preventable; two-thirds of nurses thought that most or all firearm suicide decedents would have died by another method if the firearm had not been available.

Many ED nurses and physicians do not understand the importance of the availability of lethal means in determining whether or not a suicide attempt ends in death. The Means Matter Campaign needs to continue educating these professionals.

Betz, Marian E; Miller, Matthew; Barber, Catherine et al. Lethal means restriction for suicide prevention: Beliefs and behaviors of emergency department providers. Depression and Anxiety. 2013; 10:2013-20.

The Counseling on Access to Lethal Means (CALM) workshops were effective in improving mental health care providers’ attitudes, beliefs and skills regarding lethal means counseling.

Johnson, Rene M; Frank, Elaine; Ciocca, Mark; Barber, Catherine. Training mental health providers to reduce at-risk patients’ access to lethal means of suicide: Evaluation of the CALM project. Archives of Suicide Research. 2011 15(3): 259-264.

This article describes Harvard Injury Control Research Center’s (HICRC) National Center for Suicide Prevention Training, which uses the public health approach and includes training on means restriction.

Stone, Deborah; Barber, Catherine, Posner, Marc. Improving public health practice in suicide prevention through online training: A case example. In: Sher, Leo & Vilens, Alexander, eds. Internet and Suicide. New York: Nova Science, 2009.

This essay summarizes the evidence concerning guns and suicide for a leading psychiatry textbook on violence and mental illness. It is part of our ongoing work to educate medical professionals to become knowledgeable about and advocates for the Means Matter approach to suicide prevention.

Miller M, Barber C, Azrael D. Firearms and suicide in the U.S. In: Gold LH, Simon RI eds. Gun Violence and Mental Illness. Arlington, VA: American Psychiatric Publishing. 2015.

This study evaluated, via self-report, an intervention to change provider attitudes and practices related to suicide risk assessment at emergency departments (EDs). Clinicians were trained in conducting universal risk assessment, but there was not training on lethal means counseling. There was a large increase in the percentage of providers reporting universal screening and secondary assessment of suicide risk. The proportion of nurses reporting asking suicidal patients about firearm access increased (the proportion of doctors asking did not change). Still, the numbers asking remained low relative to ideal practice.

Getting more providers to ask about firearms should help reduce suicides. The findings support the feasibility of implementing universal screening for suicide in EDs and points to the need for specific training in lethal means counseling.

Betz ME, Arias AA, Miller M, Barber C, et al. Change in emergency department providers’ beliefs and practices after new protocols for suicidal patients. Psychiatric Services. 2015; 66:625-31.

Sixteen psychiatric emergency clinicians were trained via an online course written by HICRC to provide lethal means counseling with parents of patients under 18 years receiving care for suicidality. Interviews with 114 families found that parents had favorable impressions of the counseling and good recall of the main messages. Everyone who reported there were guns in the home at the time of the visit reported at follow-up that all were currently locked, compared to 67% reporting this at the time of the visit.

The project demonstrates the feasibility of a Means Matter intervention for families with at-risk children.

Runyan C, Becker A, Brandspigel S, Barber C, Trudeau A, Novins D. Lethal means counseling for parents of youth seeking emergency care for suicidality. Western Journal of Emergency Medicine. 2016; 17:8-14.

In a study of eight emergency departments, half of patients treated for suicide ideation or attempts, who had firearms in the home, had not been assessed for access to lethal means.

This study demonstrates the importance of training in lethal means counseling since lethal means assessment in emergency departments is still not the norm.

Betz ME, Miller M, Barber C, Betty B, Miller I, Camargo CA, Bourdreaux ED. Lethal means access and assessment among suicidal emergency department patients. Depression and Anxiety. 2016; 33(6):502

This commentary describes effective ways physicians and others who see people in crisis can reduce suicide. Many major successes in suicide prevention focused on reducing access to the lethal means of suicide rather than on solving mental health problems. In the United States, while 1% of suicide attempts are with guns, half of completed suicides are gun suicides. The commentary provides information on how physicians and others can help change social norms and reduce suicide by communicating this message: putting time and distance between a suicidal person and a gun can save a life.

Barber, Catherine; Hemenway, David; Miller, Matthew. How physicians can reduce suicide–without changing anyone’s mental health” American Journal of Medicine (‘the green journal”) 2016; 129(10):1016-7.

11. Betz ME, Knoepke CE, Siry B, Clement A, Azrael D, Ernestus S, Mattlock DD. ‘Lock to Live’: development of a firearm storage decision aid to enhance lethal means counselling and prevent suicide. Injury Prevention. 2019; 25(Suppl1): i18-i24.

12. Pallin R, Siry B, Azrael D, Knoepke CE, Matlock DD, Clement A, Ranney ML, Wintemute GJ, Betz ME. ‘Hey, let me hold your guns for a while’: a qualitative study of messaging for firearm suicide prevention. Behavioral Sciences and the Law. 2019; 37:259-269.

13. Valenstein M, Walters H, Pfeiffer P, Ganoczy D, Ilgen M, Miller M, Fiorella M, Bossarte R. Possession of household firearms and firearm-related discussions with clinicians among Veteran receiving VA mental health care. Archives of Suicide Research. 2020; 24(Sup 1): 260-279.

14. Betz ME, Knoepke CE, Simpson S, Siry BJ, Clement A, Saunders T, Johnson R, Azrael D, Boudreaux ED, Omeragic F, Adams LM, Amond S, Juarez-Colunga E, Matlock DD. An interactive web-based lethal means safety decision aid for suicidal adults (Lock to Live): pilot randomized control trial. Journal of Medical Internet Research. 2020; 22:e16253.

15. Hoops K, Fahimi J, Studenmund C, Barber C……..Ranney ML. Consensus-driven priorities for firearm injury education among medical professionals. Academic Medicine. 2022; 97:93-104.

This article provides information for others who will try to use the ED to reduce suicide.

Runyan CW, Brandspigel S, Barber CW, Betz M, Azrael D, Miller M. Lessons learned in conducting youth suicide prevention research in emergency departments. Injury Prevention. 2020: 26:159-163.

A survey of ED behavioral health clinicians who provided lethal means counseling to parents of adolescents at risk for suicide felt more comfortable when they were able to offer free firearm storage devices, and when they could cite research findings that suicide attempts with guns rarely afforded second chances, and that suicidal behavior is often impulsive and always unpredictable.

Salhi C, Berrigan J, Azrael D, Beatriz E, Barber C, Runyan C, Miller M. ‘It’s changed how we have these conversations’: emergency department clinicians’ experiences implementing firearms and other lethal suicide methods counseling for caregivers of adolescents. International Review of Psychiatry. 2021; 33:617-625.

Salhi C, Beatriz E, Berrigan J, Azrael D, Houston A, Tunyan C, Barber C, Betz M, Miller M. ‘Your son needs help…and we’re gonna help him.’: A qualitative study of the experiences of gun-owning caregivers of adolescents receiving lethal means counseling in the emergency department. Social Science and Medicine. 2023; 335:116218,

Medical providers at four Colorado hospitals were surveyed about their attitudes and behaviors related to lethal means screening and counseling of patients with suicide risk. Fewer than 35%of ED providers, compared to 81% of behavioral health providers, felt confidence in their ability to counsel patients about guns.

Diurba S, Johnson RL, Siry BJ, Knoepke CE, Suresh K, Simpson SA, Azrael D, Ranney ML, Wintemute GJ, Betz ME. Lethan means assessment and counseling in the emergency department: differences by provider type and personal home firearms. Suicide and Life Threatening Behavior. 2020; 50:1054-1064.

Our 2019 national survey asked a nationally random sample of adults living in homes with guns if their clinician had ever discussed firearm safety with them. Only 7.5% said yes; 12% of parents with children and 5% of adults without children in the home.

Conner A, Azrael D, Miller M. Firearm safety discussions between clinicians and US adults living in household with firearms: results from a 2019 national survey. Annals of Internal Medicine. 2021; 174:725-728.