Paul Nestadt is co-director of the Johns Hopkins Anxiety Disorders Clinic and an assistant professor of psychiatry and behavioral sciences at the Johns Hopkins School of Medicine. The views expressed here are his own.
Suicide rates have been climbing for 20 years, and suicide has become the second leading cause of death for Americans under 40. And now, isolation and economic disruption from the coronavirus pandemic are exacerbating the risk factors. For many families affected by suicide, the biggest shock is that their lost loved one was even at risk. Suicidal thoughts are often hidden from friends and family, and depression can go unnoticed until it is too late. Without treatment, pathological anguish can worsen quickly and unexpectedly, leading to impulsive suicidal acts, usually attempted within an hour of the sudden urge.
Fortunately, most suicide attempts are survived. This is because when an individual attempts suicide using the most common methods — poisoning and cutting — they die less than 2 percent of the time. Research has shown that the vast majority of attempt survivors receive treatment and do not go on to die by suicide in a subsequent attempt. However, if the impulse comes when a gun is available, the death rate jumps to 90 percent. This is why, although only 5 percent of suicide attempters use a gun, firearms account for over half of all suicide deaths. As our country reckons with firearm violence as a public health emergency, we must remember that the majority of gun deaths are self-inflicted. At the same time, this year we have seen record numbers of gun sales. By the end of September, it was reported that the year-to-date sales had already surpassed sales for all of 2019.
Because firearm suicides are often a function of weapon access, public health experts have increasingly focused on lethal means counseling to prevent suicide. In my experience as a clinician, most patients are open to the idea of voluntarily, temporarily setting aside their firearm when a trusted doctor explains the risk of suicide during a depressive episode. I’ve had success with family meetings and interventions, during which I guided patients to safely store their weapon at a local gun shop or range or with a close friend until the crisis passes. However, for the minority of patients who are at significant risk of hurting themselves or others but are unwilling to set aside their firearms, a legal tool called an Extreme Risk Protection Order (ERPO) can be lifesaving. Research has shown that for every 10 to 20 firearms temporarily removed through an ERPO, one suicide is prevented.
An ERPO is a legal instrument that allows families or police to petition a judge for the temporary removal of an at-risk person’s firearms during a crisis until the danger passes or treatment is begun. If a gun is unavailable, the chance of surviving suicidal impulses improves dramatically. Maryland’s ERPO law has allowed me to keep my patients safe and minimize their time in the hospital. My experience mirrors new recommendations being released this week by a consortium of experts in public law, health, behavioral health, medicine and criminology who have looked at ERPO laws nationwide and suggest that more states reduce barriers to filing, support broader implementation, and allow clinicians — medical professionals — to initiate ERPOs.
Though 19 states plus D.C. now have ERPO laws on the books, Maryland is one of the few states to include clinicians as ERPO petitioners. This is a missed opportunity for other states. Clinicians are reliable experts with a sworn duty to save lives. We are uniquely positioned to recognize worsening risk of suicide and step in to prioritize safety. These petitions are most appropriately begun as a medical intervention, especially in communities of color where police-initiated protection orders may be viewed with suspicion and families may be reluctant to involve law enforcement.
As with most medical interventions, ERPOs do have drawbacks. Many clinicians fear that invoking the law may hurt the therapeutic alliance or that the power to disarm may prevent an honest disclosure of suicidal thoughts. However, these are not new concerns. Emergency hospitalization has been a cornerstone of safe treatment. In cases of imminent risk, these hospitalizations may be enacted against the will of the patient. By definition, an ERPO is a last-ditch emergency measure used only in cases of extreme risk when attempts to transfer or safely store the gun fail. In many cases, ERPOs may prevent much more restrictive acts of involuntary hospitalization or may facilitate faster hospital release into a safe home.
It is concerning that the covid-19 pandemic, in addition to escalating hopelessness and grief, has driven record-breaking gun sales across the country. The mental health impact of this plague cannot be underestimated, and in some vulnerable homes, these new guns may be sparks near the gasoline. I encourage lawmakers across the country to consider ERPO laws as an effective way to prevent firearm suicide. Physicians need access to these evidence-based tools as we continually battle the rising tide of suicide in America.
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