Guns, Suicide, COPD and Sleep

Within the past year two tragic events, the shootings in Las Vegas and Florida have renewed the debate about guns. The politics and the money that fuels the political debate have sharply divided politicians. As tragic as these mass shootings are, deaths by suicide far outnumber the loss of live in these shootings. In 2014 suicide was the tenth most common cause of death with 42,826 lives lost (1). Half of the suicides were by firearm (21,386).

The medical profession has traditionally been reluctant to speak about politically sensitive issues such as abortion, sexuality, and guns. However, beginning early in this millennium some medical societies such as the American Academy of Pediatrics, the US Preventative Services Task Force and even the Department of Veterans Affairs were suggesting physicians ask patients about gun behavior, but a few patients complained (2-5). There were some anecdotal reports of patients feeling “pressured” to answer questions about guns (5). One grumbled that it was invasion of privacy. The National Rifle Association also viewed the medical community’s gun-related questions as discriminatory and a form of harassment. In 2011, the Republican-controlled Florida legislature, with the support of the then and still state’s Republican governor, Rick Scott, passed restrictions aimed at limiting physician inquiries about gun ownership and gun habits. Under the law, doctors could lose their licenses or risk large fines for asking patients or their families about gun ownership and gun habits. Fortunately, this law was struck down by the 11th U.S. Circuit Court of Appeals (5). The Court ruled in 10-1 decision that the law violated the First Amendment rights of doctors and did nothing to infringe on the Second Amendment right to bear arms.

Eight health professional organizations and the American Bar Association have released a call for action to reduce firearm-related injury and death in the United States (6). Specific recommendations include the following:

• Criminal background checks should be a universal requirement for all gun purchases or transfers of ownership.
• Opposition to state and federal mandates interfering with physician free speech and the patient–physician relationship, such as laws preventing physicians from discussing a patient's gun ownership.
• All persons who have a mental or substance use disorder should have access to mental health care, as these conditions can play a significant role in firearm-related suicide.
• Recognition that blanket reporting laws requiring healthcare providers to report patients who show signs of potentially causing serious harm to themselves or others may stigmatize persons with mental or substance use disorders and create barriers to treatment. The statement urges that such laws protect confidentiality, do not deter patients from seeking treatment, and allow restoration of firearm purchase or possession in a way that balances the patient's rights with public safety.
• There should be restrictions for civilian use on the manufacture and sale of large-capacity magazines and military-style assault weapons, as private ownership of these represents a grave danger to the public.

Our national professional societies including the American Thoracic Society, the American College of Chest Physicians and the Society of Critical Care Medicine have all endorsed this call for action to gun violence (7).

Editors of the Annals of Internal Medicine have recently urged physicians to sign a formal pledge committing to having conversations with their patients about firearms (8). The Annals campaign began in the wake of the Las Vegas shooting and gained momentum after the February 14 school shooting in Parkland, Florida. So far nearly 1000 physicians have signed the pledge (9).

People who commit firearm violence against themselves or others often have notable risk factors that bring them into contact with physicians. We in the pulmonary, critical care and sleep communities are positioned to prevent some of these deaths. Patients with chronic diseases including COPD and sleep deprivation are known to be at higher risks for suicide (10,11). By inquiring about guns during these patients’ clinic visits, we may be able to identify potential problems and prevent some deaths.

It is ironic, but hardly surprising, that Florida, a state known for a series of gun-rights laws and its “Stand Your Ground” self-defense law (5), is the site of the latest mass shooting. The shooter, Nikolas Cruz, by all descriptions could have readily been recognized as a potential threat. Perhaps if he had been identified and an intervention performed before the Florida law banning physicians from discussing guns when the he was 12, a tragedy could have been avoided. As Florida Sen. Marco Rubio recently found out, the times may be changing (12). Politicians should keep their politics out of the clinic, hospital and physician-patient relationship. Those who do not, and especially those who by their actions put our patients in peril, do so at their own political risk.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Centers for Disease Control and Prevention. Suicide and self-inflicted injury. March 17, 2017. Available at: https://www.cdc.gov/nchs/fastats/suicide.htm (accessed 3/2/18).
2. American Academy of Pediatrics. Gun violence prevention. Available at: https://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/pages/aapfederalgunviolencepreventionrecommendationstowhitehouse.aspx (accessed 3/2/18).
3. United States Preventive Services Task Force. Guide to clinical preventive services. Available at: https://www.ataamerica.com/arc1/users/pdfforms/Guide%20to%20Clinical%20Preventive%20Services.pdf (accessed 3/2/18).
4. Department of Veterans Affairs. Firearms and dementia. August 2017. Available at: https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2731 (accessed 3/2/18).
5. Alvarez L. Florida doctors may discuss guns with patients, court rules. NY Times. February 16, 2017. Available at: https://www.nytimes.com/2017/02/16/us/florida-doctors-discuss-guns-with-patients-court.html (accessed 3/2/18).
6. Weinberger SE, Hoyt DB, Lawrence HC 3rd, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015 Apr 7;162(7):513-6. [CrossRef] [PubMed]
7. American College of Physicians. More than two dozen organizations join call by internists and others for policies to reduce firearm injuries and deaths in U.S. ACP Newsroom. May 1, 2015. Available at: https://www.acponline.org/acp-newsroom/more-than-two-dozen-organizations-join-call-by-internists-and-others-for-policies-to-reduce-firearm (accessed 3/2/18).
8. Wintemute GJ. What you can do to stop firearm violence. Ann Intern Med. 2017 Dec 19;167(12):886-7. [CrossRef] [PubMed]
9. Frellick M. More than 1000 doctors pledge to talk to patients about guns. Medscape. March 1, 2018. Available at: https://www.medscape.com/viewarticle/893307?nlid=121033_4502&src=wnl_dne_180302_mscpedit&uac=9273DT&impID=1572032&faf=1 (accessed 3/2/18).
10. Goodwin RD. Is COPD associated with suicide behavior? J Psychiatr Res. 2011 Sep;45(9):1269-71. [CrossRef] [PubMed]
11. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Washington (DC): National Academies Press (US); 2006. [CrossRef] [PubMed]
12. Associated Press. Sen. Marco Rubio changes stance on high-capacity magazines after Florida school shooting. Time. February 22, 2018. Available at: http://time.com/5171653/marco-rubio-large-capacity-magazine-parkland-shooting/ (accessed 3/2/18).

Cite as: Robbins RA. Guns, suicide, COPD and sleep. Southwest J Pulm Crit Care. 2018;16(3):138-40. doi: https://doi.org/10.13175/swjpcc039-18 PDF

Guns and Sleep

Gun deaths are a problem in America. Irrespective of one’s position on gun control, the statistics do not lie. According to the Centers for Disease Control and Prevention (CDC), there were 11,208 deaths caused by firearms in 2013 (1). The recent high profile cases in Cincinnati, OH, Lafayette, LA and Memphis, TN further highlight the issue. Obviously, each case of death by a firearm had its own set of underlying factors that contributed to the final fatal outcome, but one wonders whether sleep deprivation can be implicated in some of them.

Sleep duration in adults over the past approximately 30 years has been declining in the United States (2). A variety of reasons can be cited as underlying causes such as greater use of artificial lighting, an expanding 24 hour non-stop society, promotion of a work ethic that values “burning the midnight oil”, and use of electronic devices before bedtime (especially those that emit blue wavelength light). In addition, both legal and illegal drugs have important impacts on sleep quality and quantity. For example, amphetamines can cause insomnia and by extension a reduction in sleep time (3), and perhaps more importantly, caffeine will have the same effect if used to excess (4). The most recent recommendation from the American Academy of Sleep Medicine is for adults to sleep at least 7 hours per night (5). However, recent CDC data indicate that 29.2% of adults sleep less than 6 hours per night and are thus chronically sleep deprived (2).

Symptoms of sleep deprivation include longer reaction times, lapses in attention or concentration, poor short term memory, errors of omission and sleepiness. However, sleep deprivation also leads to confusion, stress, irritability and impulsivity. Importantly, decision making and the ability to formulate reasonable moral judgments are impaired. All of these negative impacts of sleep deprivation can lead to high-risk behavior. Thus, can it be posited that in some cases, sleep deprivation, perhaps fueled by the legal or illegal use of stimulant compounds, leads to impaired judgment and increased impulsivity, poor decisions and fatal shootings?

Several years ago, I was asked to be a defense expert in a case where a jilted wife fatally shot her husband’s lover. After learning about her husband’s affair, the wife had become distraught and unable to sleep for ~2 days. She then sought out the victim and shot her. Her sleep deprivation was used as a mitigating factor to reduce the charge from 1^st to 2^nd degree homicide. Although not a shooting, more recently, a Florida man was acquitted of the murder by suffocation of his father because he was sleep deprived after consuming a large amount of Red Bull (80 mg caffeine per 8.46 fluid ounces). Cases such as these have led to speculation that sleep deprivation may be an effective defense where the fatal act could plausibly be explained by a change in mood or cognitive impairment.

The potential impact of sleep deprivation is likely not limited to citizens accused of fatal shooting, but law enforcement officers as well. Police officers frequently work overnight or rotating shifts, and many accept overtime duty as well. A recent survey of 4957 police officers found that >40% screened positive for at least one sleep disorder with 28.5% being excessively sleepy, suggesting an element of sleep deprivation (5). Most troubling was that those who were identified as having a sleep disorder had a 51% greater likelihood of making an error or safety violation and a 63% greater chance of exhibiting other adverse work-related outcomes including uncontrolled anger toward suspects. Could some of the recently publicized adverse interactions between police officers and citizens be partially explained by lack of sleep?

Although a possible causal link between gun violence and sleep deprivation is speculative, there is no doubt that insufficient sleep is becoming endemic in our society and has significant personal and public health consequences. There should be a concerted effort on the part of public health officials, public and private institutions and individuals to reverse this trend by publicizing the adverse impact of insufficient sleep, undertaking policy measures to promote adequate sleep and set themselves as examples of healthy sleepers.

Stuart F. Quan, MD

Gerald E. McGinnis Professor of Sleep Medicine

Harvard Medical School

Brigham and Women's Hospital

Boston, MA

References

1. Centers for Disease Control. Fast stats. Available at: http://www.cdc.gov/nchs/fastats/homicide.htm (accessed 8/6/15). 
2. Ford ES, Cunningham TJ, Croft JB. Trends in self-reported sleep duration among US adults from 1985 to 2012. Sleep. 2015;38(5):829-32. [CrossRef] [PubMed]
3. Coghill DR, Caballero B, Sorooshian S, Civil R. A systematic review of the safety of lisdexamfetamine dimesylate. CNS Drugs. 2014;28(6):497-511. [CrossRef] [PubMed]
4. Drake C, Roehrs T, Shambroom J, Roth T. Caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. J Clin Sleep Med. 2013 Nov 15;9(11):1195-200. [CrossRef] [PubMed]
5. Watson NF, Badr MS, Belenky G, et al. Joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society on the recommended amount of sleep for a healthy adult: methodology and discussion. J Clin Sleep Med. 2015;11(6):591-2. [CrossRef] [PubMed]
6. Rajaratnam SM, Barger LK, Lockley SW, Shea SA, Wang W, Landrigan CP, O'Brien CS, Qadri S, Sullivan JP, Cade BE, Epstein LJ, White DP, Czeisler CA. Harvard work hours, health and safety group. JAMA. 2011;306(23):2567-78. [CrossRef] [PubMed]

Reference as: Quan SF. Guns and sleep. Southwest J Pulm Crit Care. 2015;11(2):68-9. doi: http://dx.doi.org/10.13175/swjpcc107-15 PDF