The long-awaited update to the VA/DoD Clinical Practice Guideline (CPG) for the Assessment and Management of Patients at Risk for Suicide was released in August and included the newest, evidence-based recommendations for managing one of our most critical patient populations. These updates provide us, as clinicians, an opportunity to review and renew our practice to ensure we are offering our very best to those trusting themselves to our care. This guideline includes a review of and recommendations for 1) screening and evaluation, 2) risk management and treatment, and 3) other management modalities. With suicide by firearm being the most lethal means as well as the most commonly used method by military service members (2017 DoDSER), it should not be a surprise firearms are addressed within each category of care.
Screening and Evaluation. The strongest evidence for action within this category is a comprehensive evaluation looking at a combination of risk factors and symptoms with attention to the availability of lethal means. There is weak evidence (note that weak in the context of CPGs does not imply poor – it means that there is evidence that this approach is effective, though the research is either nascent or simply not as strong as the “strong” findings) supporting screening tools for suicide risk and weak evidence against the use of any single instrument or method. This guideline highlights the importance of asking specific questions related to past suicide attempts, suicidal ideation, prior psychiatric hospitalizations, and access to lethal means.
Risk Management and Treatment. This section considered a variety of intervention and management tools for suicide risk including multiple psychotherapy treatments, technological tools, and pharmacotherapy options. The intervention with the strongest evidence for management and treatment of suicide risk was cognitive behavioral therapy with a direct focus on suicide prevention. Support for dialectical behavior therapy, problem solving therapy, and crisis response/safety planning (which include plans for means restriction) were also highlighted.
Other Management Modalities. In reviewing population health and suicide risk, the new guideline identified weak evidence for reducing access to lethal means. Insufficient evidence was available to recommend any other population or community-based initiatives.
The updated guideline highlights the importance of means safety at all steps of managing suicide risk. In considering suicide from a public health intervention perspective, these guidelines suggest assessing for availability of firearms and potentially limiting access to lethal means in secondary and tertiary prevention and weak support for means restriction as a primary prevention tool. Specifically, means restriction is most effective with those identified as either at risk or within an at risk group, as opposed to the broader population. For those of us embedded in the populations we serve, all three levels of intervention are important to us in providing outreach to the unit, command guidance for at risk groups, and individual patient care. Indeed, tertiary intervention, including evaluating means risk with an at-risk patient, is an important tool for clinicians to be comfortable employing, regardless of setting.
It’s important to note that means restriction is for individuals who are actively at risk for suicide. This is NOT an attempt to limit population access to firearms nor permanently restrict a service member’s access to firearms. Rather, the recommendations below include identifying a plan to return the weapon when risk decreases, likely increasing compliance and safety during the risk period.
Removal of firearms from at-risk patients has been demonstrated to reduce suicide attempts and likelihood of death by suicide. Further, temporarily limiting access to firearms has not been linked to an increase in suicides by other methods; rather, the temporary removal of firearms may create the time and space for your patient to consider healthy alternatives and receive targeted intervention. Although there have been changes to the CPG, the steps to take with a patient to implement means safety have not changed significantly. Read on for steps to take with your military patients.
Recommendations for Means Safety:
How do I actually limit access to firearms with military personnel?
Step 1: Know whether or not your patient has access to firearms. If there are safety concerns, health care professionals are specifically authorized to inquire about currently owned firearms and plans to acquire firearms and other weapons per Section 1057 of the 2013 National Defense Authorization Act(link is external) and a 2014 memorandum from the Undersecretary of Defense(link is external).
Questions to ask your service member patient include: Do you use a firearm in line with your duties? How many private weapons do you have? Where are they kept? Who has access? If secured, how are they secured? Do you have a gunlock or weapon safe? Do you store ammunition with your weapon(s)? Do you live in military or private housing?
Notably, firearm ownership may be an important component of many service members’ personal and professional identities. This conversation should be undertaken with this cultural awareness. As with many topics in mental health, the more comfortable you are as a provider in having the discussion, the more valuable the discussion will become.
Step 2: Temporary restriction of access to service weapons for active-duty personnel. This step is fairly straightforward. If a safety concern exists, the command can and should be notified, and access will be restricted. The command can restrict access to service weapons in line with general duties as well as training environments (e.g. range, field training, deployment build ups). However, in 2017, 90 percent of military suicides by firearm were completed using a personal firearm – not a service weapon (2017 DoDSER).
Step 3: Temporarily limiting access to personal weapons for active-duty members. Explain the recommendation and ask the service member to temporarily give up access to their weapons. If introduced as temporary and as a safety precaution, you may find most service members will be receptive. A plan should be established to verify restriction of means, and equally as important – how and when the service member will get their weapons back (see Step 5). Effective plans can include a partner locking away firearms, transfer of firearms to a relative’s home, and preferably, command involvement to store firearms in the command or installation armory.
Additionally, means restriction should not be considered an all-or-nothing proposition (i.e., complete access versus zero access). If a service member usually keeps his or her firearm loaded on a nightstand with the safety disengaged, a compromise might be keeping it unloaded and secured in a personal safe. Even this moderate delay in access could decrease the likelihood of suicide behavior. Removing all access is preferable for safety, but delaying access should be a consideration when exploring options with a service member.
Step 4a: High-risk service member refuses clinical requests for means restriction and lives on a military installation. On all military installations, the commander has the ability to restrict or remove firearms. Notifying the command can lead to removal of personal firearms by the command if warranted. These firearms will be stored in the command or installation armory until they are returned.
Step 4b: High-risk service member refuses clinical requests for limiting access and lives in private housing. This step will vary based on the state in which you currently reside. Each state has different laws regarding safety and access to firearms. It is best to familiarize yourself with your local options before you find yourself needing to use them. Regardless of which state you live in, the command retains the authority to require the service member to move onto the installation. See Step 4a if this option is used to limit access to firearms.
Note: Engaging authorities (civilian or military) to forcibly remove access to firearms likely will have an immediate, adverse impact on the therapeutic relationship. These steps should be considered, based on clinical judgment, for high-risk situations with the understanding that repairing the therapeutic relationship may be significantly challenging following this intervention. Suicide risk and access to firearms is obviously a very complicated situation.
Step 5: Return of weapons. This step is often the most overlooked step in the process of limiting access to firearms – how is access to the firearm(s) returned to the service member? Whether a family member, partner, friend, or command is involved in the plan to temporarily limit access, you as the provider are the common denominator. You made the recommendation to restrict means and therefore the responsibility for planning the return also falls with you. A plan to return means, in which you are directly and collaboratively involved, is necessary to avoid potentially dangerous consequences for the service member as well as significant guilt and emotional consequences for the individual who returned the weapon (in the case of an adverse event). Established and agreed upon safety benchmarks between you and the service member will ensure this process is not overlooked and will be completed safely. Additionally, collaborative planning for the return of personal weapons likely will improve the therapeutic relationship and reduce the possibility that they may acquire another firearm without your knowledge.
These steps are meant as a guideline. They are not the only options, but they provide a framework from which to consider your plan for safe and legal means restriction. Good clinical judgment, peer consultation, and consultation with your local judge advocate general (JAG) should always be used in complex situations. Good cultural competence regarding firearms is also highly encouraged – it’s not a topic you want to learn on the job when a patient’s safety is in question.