Type of study: Retrospective observational cohort study without controls

The finding: Nearly one-third of patients admitted with a self-inflicted gunshot wound (GSW) denied that the injury was a suicide attempt although just under half of those individuals were assessed by psychiatric consultation to likely be false denials. This is sobering as patients discharged to home were 11 times more likely to be in the denial group. Patients with known psychiatric diagnoses or previous suicide attempts were more likely to be in the group that acknowledged the GSW was a suicide attempt. Overall, 63% of the total study group was discharged to inpatient psychiatric care, 20% to home, and 16% to other facilities; patients discharged home or to other facilities were more likely to be in the denial group. These patients were also more likely to be employed, have children in the home, and have suffered a GSW to the chest or abdomen (as opposed to the head or elsewhere); they were less likely to have been prescribed a psychiatric medication, to have had a prior suicide attempt or psychiatric hospitalization, or to have required ICU level care following the GSW. Interestingly, the rate of alcohol intoxication among survivors of self-inflicted GSW (57%) in this study is more than double the rate reported for suicide decedents (27%) in an earlier study.

Strength and weaknesses: Recognizing the sobering statistics regarding suicide (>44,000 annual deaths by suicide in the U.S. with GSWs accounting for ~50% of these), it is heartening to see a study of this patient population, despite the fact that it did not yield any particular demographic associations or specific clues as to risk factors for denial although, drawing on other studies, the authors speculate that stigma and perceived negative consequences of disclosure (perhaps most notably further hospitalization) may have motivated denial. The study was somewhat hampered by the limitations of retrospective archeologic chart digging, whereby further detail to clarify the strength of the suspicion of false denial and relevant factors such as the severity of the injury were not accessible. We can hope the authors might choose to eventually publish a follow-up with 5-year outcome data.

Relevance: Hospital consultation psychiatrists regularly encounter patients with self-inflicted GSWs, a significant proportion of whom report mishandling or gun-cleaning mishaps as the proximate cause. Although this study does not provide us with a scanning device to divine the truth, it does underscore the frequency of highly suspicious circumstances and also reminds us that it may be worthwhile, in such individuals, to nonetheless proceed with a brief psychological intervention while the patient is a medical/surgical inpatient. The authors reference two additional resources for such intervention:

Jobes DA, Au JS, Siegelman A: Psychological approaches to suicide treatment and prevention. Curr Treat Options Psych 2015; 2(4):363-370

O’Connor SS, Comtois KA, Wang J, et al: The development and implementation of a brief intervention for medically admitted suicide attempt survivors. Gen Hosp Psychiatry 2015; 37(5):427-433