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Many self-inflicted gunshot wound survivors deny suicide attempt as cause
Study findings indicated that hospitalized patients who did not disclose suicidal intent following a self-inflicted gunshot wound often denied their injuries were due to suicide attempt; however, psychiatric examination revealed that 43% of these patients present under circumstances suspicious of suicide.
“Studying patients who deny that a self-inflicted [gunshot wound] was a suicide attempt may have implications for efforts to reduce suicide risk during and after hospitalization,” Michael Matthew McClay, MS, department of psychological sciences, Western Kentucky University, and colleagues wrote. “It has been suggested that stigma and perceived negative consequences of disclosure may be responsible for patients’ decisions not to disclose suicidal ideation in a primary care setting. Within acute care settings, the desire to avoid inpatient psychiatric hospitalization and documentation in the medical record may be barriers to reporting that a self-inflicted [gunshot wound] was intentional.”
Researchers used electronical medical record data from 128 survivors of self-inflicted gunshot wounds who did or did not disclose suicidal intent following injuries at a trauma center to examine their clinical characteristics and use of services. McClay and colleagues measured frequencies of all variables of interest for those with complete psychiatric consultations. They also used data obtained from interviews with family members of study participants who informed the consulting psychiatrist about the injury and the patients’ state prior to self-inflicted gunshot wound.
Analysis revealed that that 29% of participants denied that their injuries from a self-inflicted gunshot wound resulted from a suicide attempt, 43% of which occurred under questionable circumstances and were coded as a suspected false denial, according to psychiatric consultation. Examination of patients with complete data showed that 28% had attempted suicide before, 71% had a known psychiatric disorder and 35% reported abuse. Most self-inflicted gunshot wound injuries were located on the head (44%), chest or abdomen (37%) and other body parts (20%).
Although 63% of patients were discharged to inpatient psychiatric care, 20% were cleared to return home. Logistic regression analyses indicated that patients who denied suicide attempt were nearly 11 times more likely to be discharged home compared with those discharged to psychiatric inpatient facilities (OR = 10.86; P < .001). Using a multiple regression model, researchers observed no significant associations between denial of suicide attempt and any demographic factor.
“These results indicate that there are significant barriers to treatment for individuals who have made a suicide attempt using a self-inflicted [gunshot wound], and they highlight the need for improving assessment, intervention and psychoeducation for survivors of self-inflicted [gunshot wounds], particularly while they are hospitalized on medical floors,” McClay and colleagues wrote. “Additionally, the results indicate a need for further reflection on ways in which usual care in health systems (such as inpatient hospitalization) may present a barrier for eliciting honest reports from suicide attempt survivors due to a fear of hospitalization.” – by Savannah Demko
Disclosures: The authors report no relevant financial disclosures.
Perspective
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For all of medicine’s talk of differential diagnosis as a process much like detective work, discerning the intention behind firearm injuries comes even closer to the real thing. Patients who survive suicide attempts by firearm may have ample reason to dissemble or deny, as is well discussed in McClay and colleagues’ paper. Additionally, people who unintentionally or negligently discharge firearms resulting in injury may also feel substantial social pressure to obscure facts — either from pride or from fear of legal repercussions.
Physical findings can be inconclusive, histories suggestive but inconclusive, and patients and family members less than cooperative. Hardly the context for clear assessments and easy clinical decisions. Nonetheless, whether the firearm injury is intentional or otherwise, there should be great concern for the risk of future injury or suicide. And, with said ambiguities, intervention may need to be especially nuanced.
The objective findings of McCall and colleagues are illuminative, and their discussion section provides direct and practical guidance for clinicians facing similar conundrums. Their consideration of relative risks of involuntary admission, brief interventions and indicators of concern is thoughtful and useful. Their considerations for future research are thoughtful. Their article serves as a useful reference point for clinicians navigating these challenging presentations and for policy and public health wonks working to better understand firearm injuries and their prevention.