As the American Medical Association (1) emphasized, guns are the means of a number of injuries and deaths. According to 2007 data (2), firearm suicides account for approximately 50% of all suicides in the United States alone, and firearm homicides account for approximately 69% of all homicides. Firearms are present in around 35% of all U.S. households (3). The presence of a firearm in the home is a risk factor for suicide (4–8) and homicide (6, 7), although this is not explained by elevated levels of psychopathology in those households (3, 9).

Moreover, media portrayals of mental illness are frequently characterized by crime and violence (10, 11), and occasions of mass murder by firearms, although uncommon, can attract widespread and negative media coverage (12, 13). Preventing any one such occasion should contribute greatly to limiting stigmatizing depictions. One perspective is that many family practitioners and psychiatrists focus almost exclusively on trying to reduce the number of suicides by recognizing and treating mental disorders, while not doing enough to restrict access to lethal means (14). Evidence suggests that restricting access to lethal methods, at least by legislative initiatives, decreases suicides by those methods (15, 16).

In this issue, Price et al. (17) report on a survey of U.S. psychiatric residency program directors. They found that only 13% of respondents had been training residents in firearm injury prevention. The majority of program directors thought that this training would benefit residents by increasing the safety of practicing psychiatrists and by reducing firearm mortalities. The most important barrier to providing firearm injury prevention training, however, was viewed as a lack of standardized teaching material. Thus, the authors called on the American Association of Directors of Psychiatric Residency Training and APA, in conjunction with the American Association of Suicidology, to develop curricular guidelines to help to reduce morbidity and mortality associated with firearms.

One purpose of our editorial is to review educational or teaching programs on addressing the accessibility and safety of firearms. We will also discuss some of the topics that might be incorporated into the curriculum on the prevention of injuries and death by firearms. This editorial does not focus on legislative efforts to restrict ownership of firearms or legislative initiatives to redesign weapons in order to increase their safety. Instead, our focus primarily concerns training residents for managing the clinical circumstances related to patients’ access to firearms.

Model Teaching Programs

We searched for model teaching programs in education journals on PubMed (Academic Medicine, Academic Psychiatry, British Journal of Medical Education, BMC Education, Journal of Medical Education, Medical Education, and Teaching and Learning in Medicine) using the terms guns or firearms. No articles were found. We also found no relevant articles by hand-searching the indexes of Academic Psychiatry for the period from 1989 to 2001 (before the incorporation of Academic Psychiatry into PubMed). We also searched the ERIC database using combinations of the terms guns, firearms, medical education, or training, finding no articles pertaining to the training of residents or physicians. We did find one editorial that promoted training for medical students on this topic (18).

One study (19) suggested possible benefits that might accrue from providing information on firearm safety to psychiatrists. In this study, psychiatrists in Ohio were asked whether they had received information on firearms. Only a minority reported having received information, with the most common sources being professional journals and professional meetings. Respondents who had received information on firearm safety were substantially more likely to counsel patients regarding firearms than those who had not. Furthermore, psychiatrists who had more confidence in their ability to communicate on topics such as the dangers of having firearms and proper storage of firearms and to provide safety recommendations were more likely to counsel patients (19).

Developing the Curriculum

History Taking

Residents should receive training on how to ask about access to guns and about gun safety. The manner in which firearms are stored is an important topic of inquiry in that locking and unloading firearms (20, 21), along with locking ammunition and placing it in a separate location (21), are important safety practices. It should be appreciated, for example, that some patients may not affirm that they have access to a firearm when they are only asked about the presence of a firearm in a household (22). It should also be appreciated that different members of firearm-owning households may have different understandings on how firearms are stored. In firearm-owning households with children, nonfirearm owners, the vast majority of whom are women, may be unaware that firearms in the home are stored in a manner that experts would agree is unsafe (23).

Training on how to ask about gun safety should take account of individual (19) and institutional factors, if known, that serve as barriers to inquiry. Asking about access to firearms will likely occur in conjunction with assessment of risk for suicidal and homicidal behaviors. Residents should be trained on how to facilitate patients’ disclosure of sensitive information by the use of specific validity techniques (24). The assessment of risk for suicide or homicide includes an assessment of clinical and statistical risk factors as well as the use of specific techniques for exploring suicidal and homicidal ideation (24). It is important to help psychiatrists to practice routine screening in the context of assessing risk for suicide and homicide; the proportion of hospitalized psychiatric patients who acknowledged having firearms was significantly larger when routine inquiry was established (25). Moreover, in another study, only a very small percentage of patients who were receiving care for psychiatric and substance use disorders at a university medical center reported having been screened for gun ownership (26).

This training shares many common elements with training residents on how and when to ask patients about sexual and physical abuse. In one model program, which trains clinical staff to routinely, confidently, and sensitively inquire about sexual abuse and to sensitively manage disclosure, trainees are presented an initial summary of the related evidence base, hear service users’ personal accounts, and participate in several supervised role plays (27). Policy and guideline development are important for providing a supportive culture for this type of work (27).

We can also learn from the teaching of sexual history taking to inform ourselves about other possible methods for teaching as well as on how to evaluate the curriculum. Teaching of history-taking skills can occur by lectures (28, 29), readings (28, 30), workshops (29, 31, 32), small-group discussions (28), observation of sexual history-taking (28), instructor visits to clinical sites (30), specific skills training (28, 29, 33), and role plays (34). Assessment methods include evaluation of knowledge, attitudes, and skills by self-report or observation. Observed frequencies of assessments and counsel on firearm safety could occur by observed structured standardized examinations or by the use of simulated patients.

Other Topics

Wider considerations in training include a study of the epidemiology of suicide and homicide and of the use of firearms in these events. The efficacy of preventive intervention programs could also be reviewed. This could include a study of the efficacy of legislative efforts to reduce access to firearms, as well as advocacy on behalf of such efforts.

Residents might also benefit from information on local law in relation to requirements for the storage and safety of weapons, especially when children are in the household. Considerations in the management of ethical issues that can arise when suicidal or homicidal patients are reluctant to relinquish their firearms include the seriousness, predictability, and imminence of risk and the availability of resources including family members and mental health outreach services to assist in this process of education. Involvement of family members or the police should occur in accordance with standards of confidentiality. APA, for example, states that patient confidentiality is protected with extreme care; confidential information can only be released with the authorization of the patient or under proper legal compulsion (35).

Training in firearm safety also relates to the teaching of techniques that assist individuals with mental disorders and their primary caretakers to manage major mental disorders and to use psychosocial strategies for stress reduction (36, 37). These strategies include early warning signs management, problem-solving and communication skills training, and medication management that might reduce the likelihood of violence in the family settings where these interventions are applied. Anger management is a specific target of these interventions (37).

Integration of Teaching with Clinical Services

Clinical services share the responsibility to address patients’ access to firearms and gun safety and to provide training on these topics. Residents’ training could be linked to the training of social workers, nurses, and other mental health professionals at clinical sites. Clinical sites of interest include child and adolescent services because firearm ownership poses a hazard to these groups (21, 23). Inquiry could be promoted by standardized initial assessments and admission procedures. Affirmation of access to a firearm should evoke further questioning about safety and perhaps team discussions and clearly communicated recommendations to have the firearm removed. Any specific recommendations and interventions should be reflected in the medical record. The Harvard Injury Control Center incorporates information and suggestions for working with patients to restrict access to lethal means at least until the patient is no longer feeling suicidal (38).

There is one important assumption that underlies these recommendations: preventing access to firearms in individual clinical circumstances, as opposed to restriction of means at population levels (15, 16), will, in turn, reduce the risk of firearm injuries or death. Suicide and homicide are low base-rate phenomena, however. It might also be inferred that because firearms are so prevalent and accessible, efforts by mental health professionals to restrict access are likely futile. Moreover, ownership of firearms is a constitutional right, even though rage at the widespread accessibility of firearms (39) is a very understandable response when a person becomes injured. Restriction of access to one method might alternatively be replaced by another potentially lethal and widely available method, such as carbon monoxide poisoning or hanging. In a similar manner, promotion of poisoning and suffocation by a plastic bag by the best-selling book Final Exit was followed by an increase in rate of use of those methods in the United States in the year the book was published (40). The total number of suicides that year, however, did not increase in comparison to the year before the publication of Final Exit (40). These nomothetic considerations should not dampen a determination to prevent individual suicides or homicides, however, for the obvious reason that each suicide or homicide is critically important and irreversible.

It would appear to be a relatively straightforward matter to teach and to implement a recommendation to identify every patient who has access to firearms. This may not be the case. A curriculum concerned with addressing firearm access and safety shares many common elements with other sensitive and challenging topic areas. We have indicated the importance of integrating a curriculum on firearm safety into the wider curricula, including interview and communication skills training, training on the comprehensive assessment and management of mental disorders and suicidal behaviors, forensic psychiatry, ethics, public health, and epidemiology. The relevant skills should be taught in an articulated fashion (41) over the levels of postgraduate education.

The limited research available suggests that psychiatrists tend not to routinely inquire about patients’ access to firearms (19, 26). We have now also learned that the majority of psychiatric residency training directors do not provide training on firearm injury prevention (17). These results should spur us to develop and evaluate the curricula, in collaboration with the clinical services, to ensure that patients are routinely asked about access to firearms as a starting point to addressing safety. Price et al. (17) have set the profession an interesting challenge suggesting that lives are at stake should we fail to respond. Let us see if we can effectively meet this challenge.

Disclosures of editors are published in each January issue.