Case Managers Need to Address Mental Health Effects of Gun Violence
By Melinda Young
In the hospital, there are many missed opportunities to help gun violence victims while they are receiving treatment.
“We see such high rates of psychiatric illness and needs for mental health support as part of the recovery from injury,” says Rafael Tamargo, MD, MBA, fourth-year resident in the department of psychiatry at Western Psychiatric Hospital and the University of Pittsburgh Medical Center. “I see mental health as another facet of the recovery from this injury. A lot of times, people are so ill, or their injuries are so severe, that the next steps are focused on their physical health.”1
But their psychiatric complications make it difficult to recover and participate in physical therapy. It is even more challenging for these patients once they go home. “If you’re feeling depressed and have PTSD symptoms, it makes it scary to leave the house,” Tamargo says. “One of our goals was to address that to facilitate the physical healing.”
For example, case managers and other providers can give gunshot victims psychological first aid, which helps people understand anxiety and PTSD. It tells them how to monitor themselves and where to find community resources for support. These include therapists and mental health clinics.
“We created a pipeline to connect people to peer support,” Tamargo says. (See story on Gunshot Reoccurring Injury Prevention Service in this issue.)
Victims of gun violence are beyond tragic, says Lauren Magee, PhD, an assistant professor in the O’Neill School of Public and Environmental Affairs at Indiana University-Purdue University Indianapolis.
“[The] study takes place in Indianapolis, and we have three victims shot every day,” Magee explains. “These trends have increased since the beginning of COVID.”
Missed Opportunities for Care
Magee and colleagues studied data from before and after the nonfatal shootings that injured the research participants. The goal was to see how the shooting changed their healthcare use.2 They studied a person’s first shooting event because 4% of shooting survivors are shot a second time.
“Survivors were included in the study if they had one or more clinical encounters prior to their injury,” Magee says. “What we found is that 70% of survivors were not connected to any mental healthcare — just clinical care utilization.”
But many survivors were seen for follow-up medical care to treat their physical injuries. These were opportunities for providers to screen and connect them to mental healthcare.
“This is absolutely an unmet need,” Magee says. “There is no standard screening. While some hospital systems have [violence] prevention programs, they’re not specific to mental healthcare.”
Among the gun violence survivors who were connected to mental health services, there was a 5% increase in mental health disorders, including depression, anxiety disorders, and PTSD.
Magee and colleagues found gun violence victims with pre-injury mental health diagnoses were five times more likely to receive a post-injury diagnosis.
The likelihood of a mental health diagnosis also increased among those with Medicaid coverage and those older than age 35 years. The least likely to receive a mental health diagnosis were Black teenage victims.
“We need more trauma-informed services for survivors and families of shooting survivors,” Magee says. “There needs to be more follow-up post-discharge.”
Other research revealed a 13% increase in substance use disorders after their injury. Victims’ employment dropped by 14%, which suggests gun trauma can affect other social determinants of health.3
Tamargo and colleagues found even higher rates of mental health challenges as they performed psychiatric assessments on every gunshot victim who presented to the hospital. It is part of ongoing research.
“We started in September 2021,” Tamargo says. “From that time to June 2022, we interviewed 24 patients who came in after a gunshot injury — largely a young Black male population. We found that 70% met the criteria for some kind of psychiatric diagnosis.”
About 15% met the criteria for two or more diagnoses, which is high. “The types of diagnoses we’re seeing are adjustment disorder, which is physically adjusting to a significant event. [It usually manifests] as anxiety, depression, and sometimes it comes out as changes in behavior,” Tamargo explains. “We saw a fair amount of delirium and a state of confusion people often have while in a hospital, and high rates of substance use disorder.”
Practice Trauma-Informed Care
Case managers could help gun violence victims with mental health screenings and trauma-informed care coordination tactics.
Trauma-informed services follow four Rs:4
- Realize the widespread effect of trauma and identify potential paths for recovery;
- Recognize signs and symptoms of trauma in patients, families, staff, and others;
- Respond by creating trauma-informed policies, procedures, and practices;
- Prevent re-traumatization.
“It’s important to have a credible messenger in the room — maybe someone who has experienced violence,” Magee suggests. “Provide the services they need, and realize that shooting survivors face different barriers than other trauma patients.” For example, young victims of gun violence might be afraid of retaliation in their communities. This creates unique barriers to attending medical appointments because they could be afraid to ride the bus, she adds.
The National Technical Assistance Center for Children’s Mental Health offers a series of videos that describe what trauma-informed care means as an organizational approach. It also includes information for healthcare providers about educating staff on trauma-informed methods.4
“They need follow-up and connection to community-based mental health providers,” Magee says. “Survivors in the urban context may be going back to the same community post-injury, and have more exposure to gun violence, adverse health outcomes, obesity, and smoking.”
Gun trauma continues to cycle through some communities, but addressing it as a social determinant of health can help interrupt the cycle.
“I think the most important message is to keep the possibility of mental illness in mind,” Tamargo says. “It’s such a complicated medical event to recover from a gunshot injury, but properly healing from it and optimally healing really includes addressing mental health concerns.”
Everyone who works with gunshot victims should keep that in mind.
“Exposure to gun violence is like child abuse or intimate partner violence, especially within a community that experiences it daily,” Magee says. “There are communities that experience a level of trauma that is unacceptable. We have to care as a collective to improve the health and well-being of children in this country. It will only get worse if we don’t act.”
- Tamargo R, Moschenross D, Clark T, et al. Consultation-liaison case conference: Psychiatric evaluation and management following gunshot injury. J Acad Consult Liaison Psychiatry 2022;S2667-2960(22)00022-2. doi: 10.1016/j.jaclp.2022.02.009. [Online ahead of print].
- Magee LA, Fortenberry JD, Aalsma MC, et al. Healthcare utilization and mental health outcomes among nonfatal shooting assault victims. Prev Med Rep 2022;27:101824.
- Vella MA, Warshauer A, Tortorello G, et al. Long-term functional, psychological, emotional, and social outcomes in survivors of firearm injuries. JAMA Surg 2020;155:51-59.
- Administration for Children & Families. Resource guide to trauma-informed human services. Jan. 4, 2017.
In the hospital, there are many missed opportunities to help gun violence victims while they are receiving treatment. Case managers and other providers can give gunshot victims psychological first aid, which helps people understand anxiety and PTSD. It tells them how to monitor themselves and where to find community resources for support.
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