An ED-based RCT of Lethal Means Counseling for Parents of At-Risk Youth

Suicide is the second leading cause of death for U.S. youth 10-17 years of age. Nationally,
51% of all suicides, and 40% of 10-17 year-olds' suicides, are completed with a firearm. In
Colorado, which has the 6th highest adolescent suicide rate in the nation, more youth more
youth die by suicide than in motor vehicle crashes. Every U.S. study that has addressed the
relationship between access to firearms and suicide has found that such access increases risk
of suicide, not only for the gun owner, but for all household members. Indeed, the relative
risk of suicide associated with household firearms is highest for children and young adults,
and elevated further in those households in which guns are stored loaded and unlocked.

Some of the largest reductions in national suicide rates have occurred when access to a
commonly used and highly lethal suicide method was reduced. Consequently, reducing a suicidal
person's access to lethal means of suicide ("means restriction") is a vital component of any
effective national strategy for reducing suicide rates. Reducing access to firearms is
particularly important given their greater lethality compared with other methods commonly
used in US suicides and the very short deliberation period preceding nearly half of suicide
attempts. Nonetheless, means restriction interventions remain uncommon. The CDC's recently
released Research Priorities for the National Center for Injury Prevention and Control,
acknowledges this gap and calls for evaluation of the feasibility, scalability, and economic
efficiency of means restriction strategies.

A recent study estimated that over 40% of youth suicide victims were seen in the ED in the
year preceding their death. EDs have been identified by the National Action Alliance for
Suicide Prevention as one of two key arenas for improved services to reduce the proportion of
at-risk youth who progress to suicide, yet LMC in emergency departments remains uncommon: ED
clinicians often do not offer any lethal means counseling to at-risk patients and their
families, and many do not counsel on reducing access to firearms in particular. For example,
Grossman and colleagues reported that although 80% of emergency nurses in Illinois had recent
experience with suicidal adolescents, only 28% provided LMC to parents. A record review found
that psychiatric residents at a psychiatric emergency department assessed firearm access in
only 3% of pediatric patients.

ED-based lethal means counseling with parents of youth is a promising approach, but no RCTs
have been conducted: Previous studies on LMC point to the need for fully powered RCTs in this
area. A prospective follow-up study at a hospital ED where staff were instructed to deliver
LMC messages to parents of all at-risk youth found that parents exposed to LMC were more
likely to reduce the youth's access to lethal means than parents who were not exposed (75%
vs. 48% for prescription drugs and 63% vs. 0% for firearms), but the number of gun- owning
households (n=15) was very small. Promising evidence also comes from the pilot investigation
that members of the study team conducted at Children's Hospital Colorado.

Our research team, which includes experts in suicide prevention, LMC, evaluation science,
qualitative research, adolescent mental health, and emergency medicine, is well-suited to
rigorously evaluate the study aims using a mixed-methods approach. Our five hospital sites
will collaborate with study personnel to: a) establish IRB procedures and approvals, b)
develop a system (in nearly all sites via the electronic medical record) to flag eligible
patients, document provision of intervention services, and provide parent contact information
to the study team, c) require the clinicians who will provide LMC to take the online training
during their sites' two-week phase-in period, d) host an in-person training with a study
investigator at a staff meeting during the phase-in period, and e) implement the new lethal
means counseling protocol on their start date. A lead ED clinician at each site will be the
point of contact to help manage logistics and access medical record information for the study
in accordance with HIPAA regulations. The Colorado-based project coordinator (Brandspigel)
will work with hospitals to develop site-specific consent and data transfer processes.

Inclusion Criteria:

- Age limits pertain to the patient seen at the ED for a psychiatric or substance abuse
crisis. It is their parents/guardians who receive the intervention. Parents must speak
either English or Spanish and have a working telephone number or email address.

Exclusion Criteria:

- A patient in institutional care would be excluded. Parents/guardians who were not at
the ED with their child are excluded.