Presence of Certain Social Determinants Can Signal Suicide Risk by Firearm Among Children, Teens

Geographic location, socioeconomic status, sexual orientation, and ease of access to firearms are among the social determinants of health that influence suicide risk among children and adolescents, said psychiatrists at a session today.

“We need to acknowledge the severity and magnitude of the problem of gun violence in America,” said Rahn Bailey, M.D., chair of the Department of Psychiatry at Louisiana State University Health Sciences Center. “I believe it has created a larger role for psychiatrists to try to modify and eliminate this problem.”

The session was a clinical presentation focusing on two case vignettes and was geared especially toward trainees and early career child and adult psychiatrists to evaluate risk for suicide among children and teens.

Bailey was joined by Brian Levins, M.D., a first-year child and adolescent psychiatry fellow at Cincinnati Children's Hospital Medical Center, and Brian P. Kurtz, M.D., director of the child and adolescent psychiatry residency program at Cincinnati Children’s Medical Center. The session was chaired by Jordan Wong, M.D., M.P.H., a third-year resident at Columbia University/New York Presbyterian/New York State Psychiatric Institute.

In the first case vignette, Levins described a 17-year-old girl named “Tay” who presented with a gunshot wound to the foot. She was despondent and tearful and reported that the wound was self-inflicted while sitting in her bedroom closet. She said she was upset over a recent argument with her best friend. She adamantly refused to disclose the source of the firearm.

Levins said Tay lived with her mother and younger sister. Her psychiatric history included a diagnosis of attention-deficit/hyperactivity disorder at age 7, previously treated with methylphenidate. She entered a partial hospitalization program at age 13 for suicidal ideation and self-cutting, but she discontinued medications and outpatient follow-up at age 14. She had no prior attempts to end her own life.

“When the patient was 14 years old, she lost her older brother to gun violence and began using cannabis during her freshman year of high school,” Levins said. The girl repeated the ninth grade due to poor academic performance.

The second vignette described “Jacob,” a 15-year-old presenting for a well-child visit. When interviewed separately, Jacob reported feeling overwhelmed and experiencing grief over the loss of his best friend to suicide two months previously. He was feeling pressure to maintain straight As, as a star athlete, and reported increased lethargy due to lack of sleep for the past few weeks.

Jacob said he had panic attacks the previous two Sundays before church and disclosed that he and another male peer had had a sexual encounter recently. He had been previously diagnosed with generalized anxiety disorder and major depressive disorder and was currently taking fluoxetine and hydroxyzine. He had one previous psychiatric hospitalization after a suicide attempt two years ago.

Jacob lived on a farm with his biological mother and father, grandmother, and two older brothers. Per family tradition, the boys had received their own rifles for their 15th birthdays.

Kurtz outlined the social determinants of suicidal thinking and behavior and said both cases illustrate examples of red flags for mental health professionals evaluating children and adolescents. These include past suicide attempt, psychiatric illness, history of trauma, and ease of access to firearms. He described the overlapping interpersonal factors that indicate a very high risk for suicide: a sense of thwarted belonging, perceived burdensomeness, and “capability” for suicide.

Bailey focused on public policy and broad population initiatives. “Gun violence and firearm suicide are public health problems requiring efforts that address large populations of people. In the past we have tried singular approaches that have failed substantially.”

Bailey said there has been an overall “militarization” of society—beginning with the police. “This has had an impact on everyone—everyone needs to get a gun, those who have one need to get a bigger one, and those with one gun need to get more,” he said. “Life in this kind of environment has a profound effect on children. You don’t have to be a child who has shot a gun or been shot to hear the sounds outside, to know that everyone around you has burglar bars on their windows—children hear and see these things, and it has an immeasurably adverse impact on their development.” ■