"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.

Suicide attempts in adolescents are often transient and unpredictable, making preventative approaches crucial in reducing suicide deaths. One important approach is lethal means counseling (LMC), in which clinicians counsel caregivers to reduce access to methods used in suicide, specifically firearms and medications. Research on LMC has increasingly encouraged the use of the shared decision-making (SDM) model, which emphasizes information exchange, collaborative deliberation, and joint planning between caregivers and clinicians. We examine caregivers' experiences with LMC, using the SDM model as our analytic framework. We conducted qualitative interviews with 21 firearm-owning caregivers of adolescents who came to emergency departments (EDs) in Colorado for a behavioral health complaint. The implementation of LMC at these institutions had three central components: training for clinicians, materials (e.g., lockboxes and pamphlets) to support LMC, and the protocolization of LMC at the institution. Our semi-structured, hour-long interviews examined participants' reflections on and reactions to LMC provided in the ED and how that related to changes in their understanding of their medication and gun storage practices. We analyzed interviews using a phenomenological approach, focusing on experiences with LMC and informed by the tenets of the SDM model. Our analysis revealed that caregivers were receptive to the idea of LMC in the pediatric emergency care setting. Caregivers' engagement in LMC was reinforced by experiences with clinicians who sought to understand the circumstances of their household, shared the motivation behind LMC, and facilitated conversation around a shared concern for the child's safety. In contrast, counseling delivered mechanically and without considering the household context was tied to caregivers' confusion and alienation, both for LMC and their consideration of changes to home storage practices. These findings provide insight into adolescent caregivers' experiences with LMC implemented in EDs and how LMC may best be approached.

Serotonin-norepinephrine reuptake inhibitor and selective serotonin reuptake inhibitor use and risk of fractures: a new-user cohort study among US adults aged 50 years and older.

BACKGROUND: Antidepressants may increase the risk of fractures by disrupting sensory-motor function, thereby increasing the risk of falls, and by decreasing bone mineral density and consequently increasing the fall- or impact-related risk of fracture. Selective serotonin reuptake inhibitor (SSRI) antidepressants appear to increase fracture risk relative to no treatment, while less is known about the effect of serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants, despite SNRIs being prescribed with increasing frequency. No prior study has directly examined how fracture risk differs among patients initiating SNRIs versus those initiating SSRIs. OBJECTIVE: The objective of this study was to assess the effect of SNRI versus SSRI initiation on fracture rates. DATA SOURCE: Data were derived from a PharMetrics claims database, 1998-2010, which is comprised of commercial health plan information obtained from managed care plans throughout the US. METHODS: We constructed a cohort of patients aged 50 years or older initiating either of the two drug classes (SSRI, N = 335,146; SNRI, N = 61,612). Standardized mortality weighting and Cox proportional hazards regression were used to estimate hazard ratios (HRs) for fractures by antidepressant class. RESULTS: In weighted analyses, the fracture rates were approximately equal in SNRI and SSRI initiators: HRs for the first 1- and 5-year periods following initiation were 1.11 [95 % confidence interval (CI) 0.92-1.36] and 1.06 (95 % CI 0.90-1.26), respectively. For the subgroup of patients with depression who initiated on either SNRIs or SSRIs, those initiating SNRIs had a modestly, but not significantly, elevated fracture risk compared with those who initiated on SSRIs [HR 1.31 (95 % CI 0.95-1.79)]. CONCLUSIONS: We found no evidence that initiating SNRIs rather than SSRIs materially influenced fracture risk among a cohort of middle-aged and older adults.

History of military service and the risk of suicidal ideation: findings from the 2008 national survey on drug use and health.

Studies of completed suicide by history of military service have produced inconsistent findings; no representative population-based study has compared the risk of nonfatal suicidal behavior among veterans with risk among nonveterans. The objective of this study was to examine whether male veterans of the U.S. military are at heightened risk of suicidal ideation, compared with males who never served in the U.S. military. A total of 17,641 adult men completed the 2008 National Survey on Drug Use and Health (NSDUH). Subjects provided information about history of ever having served in the U.S. armed forces, past suicidal ideation, alcohol and drug abuse and dependence, measures of psychological distress, and sociodemographic data. Overall, men who had ever served in the armed forces were no more likely than men who had never served to report having seriously considered suicide over the prior 12 months. Military status was not differentially associated with other known suicide risk factors assessed by NSDUH, including psychiatric disorders. Our findings suggest that evidence-based suicide prevention strategies applicable to the general population should be employed to reduce suicide risk among the veteran population as well.

Batterers' use of guns to threaten intimate partners.

OBJECTIVES: To present the prevalence of gun ownership among batterers and describe their self-reported use of guns to threaten intimate partners. METHODS: We used multivariate methods to analyze data from 8529 men enrolled in Massachusetts certified batterer intervention programs between 1999 and 2003. RESULTS: Seven percent of the sample reported owning guns during the past 3 years. Recent gun owners were 7.8 times more likely than non-gun-owners to have threatened their partners with guns. Gun owners and non-gun-owners were equally likely to have threatened their partners with knives. Batterers reported using guns to threaten their partners in 4 ways, including 1) threatening to shoot them; 2) cleaning, holding, or loading a gun during an argument; 3) threatening to shoot a pet or person the victim cared about; and 4) shooting a gun during an argument with a victim. Identified risk markers for threatening an intimate partner with a gun included substance abuse, homicidal behavior, making knife threats, and gun ownership in the 3 years preceding assessment. CONCLUSION: Among batterers, owning a gun is highly correlated with using a gun to threaten an intimate partner. Legal restrictions that prohibit batterers from owning and possessing firearms should be enforced consistently. Detailed contextual information about the circumstances in which batterers use guns to threaten intimate partners and potential protective and risk factors relevant to firearm use by batterers should be explored.