Self-reported Access to Firearms Among Patients Receiving Care for Mental Health and Substance Use

Abstract

Importance: Firearms are the most common method of suicide, one of the "diseases of despair" driving increased mortality in the US over the past decade. However, routine standardized questions about firearm access are uncommon, particularly among adult populations, who are more often asked at the discretion of health care clinicians. Because standard questions are rare, patterns of patient-reported access are unknown.

Objective: To evaluate whether and how patients self-report firearm access information on a routine mental health monitoring questionnaire and additionally to examine sociodemographic and clinical associations of reported access.

Design setting and participants: Cross-sectional study of patients receiving care for mental health and/or substance use in primary care or outpatient mental health specialty clinics of Kaiser Permanente Washington, an integrated health insurance provider and care delivery system.

Main outcomes and measures: Electronic health records were used to identify patients who completed a standardized self-reported mental health monitoring questionnaire after a single question about firearm access was added from January 1, 2016, through December 31, 2019. Primary analyses evaluated response (answered vs not answered) and reported access (yes vs no) among those who answered, separately for patients seen in primary care and mental health. These analyses also evaluated associations between patient characteristics and reported firearm access. Data analysis took place from February 2020 through May 2021.

Results: Among patients (n = 128 802) who completed a mental health monitoring questionnaire during the study period, 74.4% (n = 95 875) saw a primary care clinician and 39.3% (n = 50 631) saw a mental health specialty clinician. The primary care and mental health samples were predominantly female (63.1% and 64.9%, respectively) and White (75.7% and 77.0%), with a mean age of 42.8 and 51.1 years. In primary care, 83.4% of patients answered the question about firearm access, and 20.9% of patients who responded to the firearm question reported having access. In mental health, 91.8% of patients answered the question, and 15.3% reported having access.

Conclusions and relevance: In this cross-sectional study of adult patients receiving care for mental health and substance use, most patients answered a question about firearm access on a standardized mental health questionnaire. These findings provide a critical foundation to help advance understanding of the utility of standardized firearm access assessment and to inform development of practice guidelines and recommendations. Responses to standard firearm access questions used in combination with dialogue and decision-making resources about firearm access and storage may improve suicide prevention practices and outcomes.

Figure 1.. Analytic Sample

Adult outpatient visits with documentation of a mental health monitoring questionnaire during the study period of January 1, 2016, through December 31, 2019. ^aPatient visits outside primary care (PC) and outpatient mental health (MH) were excluded, including urgent care (UC) visits and hospitalizations, and other specialty care visits, because this questionnaire was rarely completed in those settings (<1% of all questionnaires). ^bIncludes 17 704 patients with at least 1 visit to both the PC and MH specialty settings during the study period.

Figure 2.. Responses to the Firearm Access Question Among Patients With More Than 1 Visit to an Outpatient Mental Health and/or Primary Care Clinician During the Study Period

Proportions of patients with 2 or more visits during the study period (n = 60 514) who always, sometimes, or never (1) answered the firearm access question and (2) among those who answered at least twice (n = 54 915), always, sometimes, or never reported firearm access.