Andrew Anglemyer, PhD, MPH; Tara Horvath, MA; George Rutherford, MD
Grant Support: None.
Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1301.
Requests for Single Reprints: Andrew Anglemyer, PhD, MPH, University of California, San Francisco, UCSF Box 1224, 50 Beale Street, Suite 1200, San Francisco, CA 94143; e-mail, Andrew.Anglemyer@ucsf.edu.
Current Author Addresses: Drs. Anglemyer and Rutherford and Ms. Horvath: University of California, San Francisco, UCSF Box 1224, 50 Beale Street, Suite 1200, San Francisco, CA 94143.
Author Contributions: Conception and design: A. Anglemyer, G. Rutherford.
Analysis and interpretation of the data: A. Anglemyer, G. Rutherford.
Drafting of the article: A. Anglemyer, T. Horvath.
Critical revision of the article for important intellectual content: A. Anglemyer, G. Rutherford.
Final approval of the article: A. Anglemyer, T. Horvath, G. Rutherford.
Provision of study materials or patients: A. Anglemyer.
Statistical expertise: A. Anglemyer.
Administrative, technical, or logistic support: A. Anglemyer, T. Horvath, G. Rutherford.
Collection and assembly of data: A. Anglemyer, T. Horvath.
This article has been corrected. The original version (PDF) is appended to this article as a Supplement.
Research suggests that access to firearms in the home increases the risk for violent death.
To understand current estimates of the association between firearm availability and suicide or homicide.
PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and Web of Science were searched without limitations and a gray-literature search was performed on 23 August 2013.
All study types that assessed firearm access and outcomes between participants with and without firearm access. There were no restrictions on age, sex, or country.
Two authors independently extracted data into a standardized, prepiloted data extraction form.
Odds ratios (ORs) and 95% CIs were calculated, although published adjusted estimates were preferentially used. Summary effects were estimated using random- and fixed-effects models. Potential methodological reasons for differences in effects through subgroup analyses were explored. Data were pooled from 16 observational studies that assessed the odds of suicide or homicide, yielding pooled ORs of 3.24 (95% CI, 2.41 to 4.40) and 2.00 (CI, 1.56 to 3.02), respectively. When only studies that used interviews to determine firearm accessibility were considered, the pooled OR for suicide was 3.14 (CI, 2.29 to 4.43).
Firearm accessibility was determined by survey interviews in most studies; misclassification of accessibility may have occurred. Heterogeneous populations of varying risks were synthesized to estimate pooled odds of death.
Access to firearms is associated with risk for completed suicide and being the victim of homicide.
Appendix Table 1. Search Strategy
Table 1. Summary of Critical Appraisal of Included Studies Using the Newcastle–Ottawa Scale for Assessing the Quality of Observational Studies*
Appendix Table 2. Detailed Risk of Bias Results Using the Newcastle–Ottawa Scale for Assessing Quality for Observational Studies
Summary of evidence search and selection.
Table 2. Characteristics of Included Studies of Suicide and Homicide Victimization
Odds of suicide and homicide in the context of firearm access.
Horizontal lines indicate 95% CIs, squares reflect point estimates, and the size of the squares is proportional to the study's weight. The diamonds reflect the pooled estimate across all studies, and the solid vertical lines reflect the null hypothesis.
Meta-analyses estimating the odds of suicide and homicide between subgroups.
Horizontal lines indicate 95% CIs, squares reflect point estimates, the diamonds reflect the pooled estimate across all studies, and the solid vertical lines reflect the null hypothesis. The τ estimate was not reported in fixed-effects models. NA = not applicable.
* The τ estimate is on the log odds ratio scale.
† Fixed-effects models.
‡ No meta-analysis was performed.
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Christopher Barsotti MD FAAEM
Dartmouth-Hitchcock Putnam Physicians, Southwestern Vermont Medical Center
January 25, 2014
Firearm Screening and Individual Risk
The article by Anglemyer, et al., summarizes and affirms the association between elevated rates of homicide/suicide and the presence of firearms, but beyond estimating the role of impulsivity, more specific causalities of gun violent acts remain obscure. From other studies we recognize that certain populations are at greater risk: individuals with alcohol and other drug abuse (1), previous domestic violent conduct (2), etc. Hemenway’s editorial calling for individual-level studies of perpetrators would certainly move us towards a better understanding of firearm risk by those with access to guns. Indeed, firearm exposure is intrinsically relevant to the risk stratification of patients susceptible to perpetrating an act of self-directed or interpersonal violence. Patients’ cognitions about firearms, as well as their behavior with them, have immediate clinical application. Firearm avoidance by patients presenting with suicidal ideation may indicate healthy insight by that individual regarding his/her impulsivity, and thus firearm avoidance may be evidence of good judgment. It is certainly plausible that such behavior may be perceived as protective. Conversely, whether and how a patient handles a firearm conveys essential information about the gravity of suicidal ideation: as in one recent case of mine, the patient unlocked and loaded only one of his two handguns – and subsequently consumed an excessive quantity of alcohol in order to impair further his impulse control. Despite being the first medical professionals to assess acutely decompensated suicidal patients, the majority of emergency physicians do not screen for firearms (3). There are substantial barriers to firearm screening in clinical practice, as well as risks that might be encountered by physicians who attempt to use such information to reduce possible harm. Although firearm exposure may elevate the clinical estimation of risk for harm in certain presentations, physicians may not disclose such protected health information unless a “serious and imminent” threat against an identifiable party is known (4). Additionally, outpatient management may be more problematic for patients whose firearm exposure cannot be managed. We do need more research on individual-level perpetrators of gun violence, but what physicians also need right now are clear guidelines on how, when and to whom we should direct questions about firearm access. How should we interpret the information we receive? How and when is it appropriate to intervene? Without adequate legal support and professional guidelines, firearm screening will remain captive to the politics of gun control, and dangerous individuals will remain unrecognized, untreated and at high risk. References:1. Rivara F, Mueller B, Somes G, et al. Alcohol and illicit drug abuse and the risk of violent death in the home. JAMA. 1997;278:569-575. 2. Bailey J, Kellermann A, Somes G, et al. Risk factors for violent death of women in the home. Arch Intern Med. 1997;157:777-82 3. Betz M, Miller M, Barber C, et al. Lethal means restriction for suicide prevention: Beliefs and behaviors of emergency department providers. Depress Anxiety. 2013;30:1013-20.4. HHS Regulations, Uses and Disclosures for Which an Authorization or Opportunity to Agree or Object is Not Required: Uses and Disclosures to Avert a Serious Threat to Health or Safety - § 164.512 (j)(i)(A).
Robert B. Sklaroff, M.D.
Nazareth Hospital, Philadelphia, PA
February 4, 2014
Potential Politicization of Gun Control Controversy
TO THE EDITOR:Because Public Health research predictably guides generation of Public Policy, it is necessary to scrutinize the political science underlying the paired gun-control review (1) and editorial (2); challenges are detected to fundamental standards that may compromise an otherwise sound meta-analysis of available literature. The last sentences of each are revelatory, for the former finds “restricting [access to a firearm in the home] may effectively prevent injury” and the latter concludes “obtaining a firearm not only endangers those living in the home, but also imposes substantial costs on the community.” Notwithstanding unaddressed Second Amendment constraints, the authors of both unabashedly campaign to restrict the right to bear arms, thereby ignoring—for example—the human compulsion to manifest reasonable self-defense.The intuitive deduction, that availability of a firearm will increase the risk that momentary depression will yield suicide, is consistent with modern lay culture—recalling the 1945 movie “Spellbound”—and medical scholarship—recalling an essay published last year in this journal (3). Yet, it is undermined by the editorialist, who has argued that the widespread ownership of firearms in private hands in the U.S. promotes the spread of the "disease" of gun violence (4). He invoked a generalized reference to his book when claiming “There is no association between gun ownership levels and suicide by means other than guns. These studies have controlled for…depression [and] suicidal ideation.” If true, this assertion would undermine efforts to include scrutiny of mental health data during any mandated background-checks; alas, it is untrue, for a profile has been generated of psychiatric patients at high risk for suicide (5). This latter citation was among the articles cited in the review (#26), prompting confusion when noting it was among three articles cited in the online Appendix—which purports to show “the disposition of studies excluded after full-text review”—along with two others (#32 and #60) “because the study populations were contained in previously published data included in this review.” Noting there are 59 published references and 97 online references, merely counting the number of citations associated with a particular reason for exclusion yields the observation that there is an admixture of articles that were included and articles that were excluded (i.e., some were among the first #1-59 and at least one was among the latter #60-97). The authors should have provided a cross-walk “pairing” of how one set of data was subsuming another set of myriad peer-reviewed studies, precluding concern that any undue selectivity existed.Therefore, author-bias—seeking the ability to generate the above preordained outcome—could have clouded how subsidiary observations were drawn regarding, for example, the allegation of enhanced risk of being killed by a household member. And, overall, adopting a purely academic approach could have yielded insights, for example, as to the type of mental health diagnoses that might predispose to criminal gun-use; indeed, this entire body of work could then have been compared/contrasted with lethal violence committed via non-household, unregistered firearms, yielding far more useful insights as to what societal interventions might be optimal. References 1. Andrew Anglemyer, Tara Horvath, George Rutherford; The Accessibility of Firearms and Risk for Suicide and Homicide Victimization Among Household Members - A Systematic Review and Meta-analysis. Ann. Intern. Med. 2014 Jan;160(2):101-110. 2. David Hemenway; Guns, Suicide, and Homicide: Individual-Level Versus Population-Level Studies. Ann. Intern. Med. 2014 Jan;160(2):134-135. 3. Carl E. Fisher, Jeffrey A. Lieberman; Getting the Facts Straight About Gun Violence and Mental Illness: Putting Compassion Before Fear. Ann. Intern. Med. 2013 Sep;159(6):423-424.4. Wheeler, Timothy J. (September 2005). "Private Guns, Public Health". The Freeman. In http://en.wikipedia.org/wiki/Private_Guns,_Public_Health#cite_ref-free_1-0.5. Brent DA, Perper JA, Moritz G, Baugher M, Schweers J, Roth C. Firearms and adolescent suicide. A community case-control study. Am J Dis Child. 1993; 147:1066-71.
Andrew Anglemeyer, PhD
University of California, San Francisco
February 20, 2014
In Dr Sklaroff’s commentary, he refers to our systematic review and meta-analysis (1) as a “gun-control review” and suggests that the “preordained outcome” was due to “author-bias” (2). Clearly this is a contentious topic for many, but our scholarly endeavor was not clouded by any personal or political leaning. We are not “unabashedly campaigning to restrict the right to bear arms” (2), as Dr Sklaroff suggests--our review underscores the importance of firearm safety, particularly in high-risk situations (e.g., depressed family member or violent relationship). Dr Sklaroff’s suggestion that the exclusion of some studies and not others somehow creates “author bias” is incorrect. We correctly listed reference 26 (3) as an excluded study to avoid double counting because its data were included in references 6 (4) and 16 (5), both of which were correctly included and correctly cited. References 32 (6) and 60 (7) were both excluded for similar reasons. All of the studies excluded because some or all of their data were previously published found higher odds of death among cases with firearm exposure. By excluding these data, we actually reduced the risk of artificially deflated variance in our pooled estimates (and subsequently the quality of evidence could have been stronger had we included them)--the opposite of "author-bias". In fact, had we incorrectly included these data, we would have obtained an estimate of suicide that was 5% greater with a margin of error 10% smaller than we obtained in our review. For the homicide outcome, we would have obtained an estimate 12% greater with a margin of error 9% smaller than we obtained in our review. Further, as we state in our response to the editorial (8), had we included population-level data, as opposed to only individual-level data, we would have likely found even stronger evidence. Lastly, the truncating of references in the print edition is a journal-specific issue, not an attempt to hide from the readership specific references. All 97 references are available in the online version of our review. Respectfully,Andrew Anglemyer, PhDUniversity of California, San FranciscoSan Francisco, CaliforniaReferences1. Anglemyer A, Horvath T, and Rutherford G. The Accessibility of Firearms and Risk for Suicide and Homicide Victimization Among Household Members. A Systematic Review and Meta-Analysis. Ann Intern Med 2014; 160: 101-10.2. Sklaroff Robert (February 4, 2013). “Potential Politicization of Gun Control Controversy”. In http://annals.org/article.aspx?articleid=1814426.3. Brent DA, Baugher M, Bridge J, Chen T, Chiappetta L. Age- and sex- related risk factors for adolescent suicide. J Am Acad Child Adolesc Psychiatry. 1999;38:1497-505. 4. Brent DA, Perper JA, Moritz G, Baugher M, Schweers J, Roth C. Firearms and adolescent suicide. A community case-control study. Am J Dis Child. 1993; 147:1066-71. 5. Brent DA, Perper JA, Goldstein CE, Kolko DJ, Allan MJ, Allman CJ, et al. Risk factors for adolescent suicide. A comparison of adolescent suicide victims with suicidal inpatients. Arch Gen Psychiatry. 1988;45:581-8. 6. Brent DA, Perper J, Moritz G, Baugher M, Allman C. Suicide in adoles- cents with no apparent psychopathology. J Am Acad Child Adolesc Psychiatry. 1993;32:494-500. 7. Bailey JE, Kellermann AL, Somes GW, Banton JG, Rivara FP, Rushforth NP. Risk factors for violent death of women in the home. Arch Intern Med. 1997;157:777-82.8. Anglemyer A (January 28, 2013). “Comment”. In http://annals.org/article.aspx?articleid=1814430.
Anglemyer A, Horvath T, Rutherford G. The Accessibility of Firearms and Risk for Suicide and Homicide Victimization Among Household Members: A Systematic Review and Meta-analysis. Ann Intern Med. 2014;160:101-110. doi: 10.7326/M13-1301
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