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Letters16 October 2018Firearm Involvement in Violent Victimization and Mental Health: An Observational StudyFREERose M.C. Kagawa, PhD, MPH, Magdalena Cerdá, DrPH, MPH, Kara E. Rudolph, PhD, MHS, MPH, Veronica A. Pear, MPH, Katherine M. Keyes, PhD, MPH, and Garen J. Wintemute, MD, MPHRose M.C. Kagawa, PhD, MPHUniversity of California, Davis, Sacramento, California (R.M.K., M.C., K.E.R., V.A.P., G.J.W.), Magdalena Cerdá, DrPH, MPHUniversity of California, Davis, Sacramento, California (R.M.K., M.C., K.E.R., V.A.P., G.J.W.), Kara E. Rudolph, PhD, MHS, MPHUniversity of California, Davis, Sacramento, California (R.M.K., M.C., K.E.R., V.A.P., G.J.W.), Veronica A. Pear, MPHUniversity of California, Davis, Sacramento, California (R.M.K., M.C., K.E.R., V.A.P., G.J.W.), Katherine M. Keyes, PhD, MPHColumbia University, New York, New York (K.M.K.), and Garen J. Wintemute, MD, MPHUniversity of California, Davis, Sacramento, California (R.M.K., M.C., K.E.R., V.A.P., G.J.W.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-0365 Annals Author Insight Video - Rose M.C. Kagawa, PhD, MPH In this video, Rose M.C. Kagawa, MPH, offers additional insight into the article, "Firearm Involvement in Violent Victimization and Mental Health: An Observational Study." SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: In 2015, firearms were involved in more than 250 000 nonfatal victimizations in the United States (1). Physicians are familiar with the physical consequences of firearm violence (2), but less is known about firearm-specific mental health consequences. The perceived level of threat to a person's life during a traumatic event may influence his or her mental health response (3). Because firearms are highly lethal, their presence may exacerbate the mental health effects of violent victimization.Objective: To assess the association between firearm involvement in a violent victimization and the prevalence of severe distress and social functioning problems attributed to the victimization.Methods and Findings: We used cross-sectional data from the National Crime Victimization Survey, a nationally representative sample of households (4). Respondents aged 12 years or older who experienced a personal violent victimization (that is, an attack; a threat of attack; or attempted harm, including unwanted sexual contact) in the 6 months before the interview were eligible for inclusion in the study (n = 8465). We included the first reported victimization for respondents interviewed between 2008 and 2015 (18% of respondents reported more than 1 victimization). When the first incident could not be distinguished, respondents were excluded from the sample (7% [n = 581]).The presence of a weapon was self-reported. Firearm victimization (n = 715), the exposure of interest, was compared with that involving another weapon (n = 1054) and no weapon (n = 5350). Other weapons included rocks, knives, and axes. In 765 cases, the presence or type of weapon could not be determined and these cases were excluded from the study sample.Two outcome measures were used to identify mental health consequences. Respondents reported whether being victimized was distressing (responses ranged from not at all to severely). Severe distress was compared with all other levels of distress. Respondents also reported whether the victimization led to substantial problems in their social life, including their job, schoolwork, and interactions with family or friends.We calculated the prevalence of reported social functioning problems and severe distress among persons whose victimizations involved a firearm, another weapon, and no weapon and compared these proportions. We used survey weights and adjusted SEs to account for the complex survey design and reweighting to adjust for outcome missingness. Analyses were conducted using the svy commands in Stata, version 14.2 (StataCorp).Twenty-six percent of the respondents in the sample reported severe distress as a result of the victimization, and 27% reported having problems at work or school or with friends or family after the incident. Table 1 shows respondent characteristics by victimization type.Table 1. Characteristics of Respondents, by Weapon Presence and Type* Those whose violent victimizations involved firearms were more likely to report severe distress than those whose victimizations involved other weapons (prevalence ratio, 1.27 [95% CI, 1.06 to 1.51]) or did not involve weapons (prevalence ratio, 1.63 [CI, 1.38 to 1.93]) (Table 2). Differences in the prevalence of reported social functioning problems were not statistically significant. The findings remained consistent in models adjusted for the variables in Table 1 (data not shown).Table 2. Percentage of Respondents With Severe Distress and Social Functioning Problems, by the Presence of a Firearm During the Victimization* Discussion: Our findings suggest that firearm victimization is associated with increased levels of distress, greater than the effects of victimization itself. These findings may be explained by the fear of death being increased in situations involving more lethal weapons (3). However, the presence of a firearm did not seem to affect respondents' social functioning, perhaps because we used the first reported violent victimization. Cumulative exposures have documented associations with substantial mental health risk (5).We present novel findings for a general population experiencing violent victimization. However, this study has some limitations. These include a cross-sectional design and reliance on self-reported measures of weapon exposure during the victimization and of mental health, which were sometimes not reported. In addition, we cannot determine whether responses to the mental health questions applied to the time of the event or a time during the 6 months after the event.These findings suggest that firearm violence has unique negative effects on mental health in addition to well-understood effects on physical health and that patients victimized with a firearm may require special attention. They also highlight the emotional costs that might be avoided by investing in efforts to prevent firearm violence.References1. Truman J, Morgan R. Criminal victimization, 2015. Washington, DC: U.S. Department of Justice; 2016. Google Scholar2. Gani F, Sakran JV, Canner JK. Emergency department visits for firearm-related injuries in the United States, 2006-14. Health Aff (Millwood). 2017;36:1729-38. [PMID: 28971917] doi:10.1377/hlthaff.2017.0625 CrossrefMedlineGoogle Scholar3. Yelland C, Robinson P, Lock C, La Greca AM, Kokegei B, Ridgway V, et al. Bushfire impact on youth. J Trauma Stress. 2010;23:274-7. [PMID: 20419736] doi:10.1002/jts.20521 CrossrefMedlineGoogle Scholar4. Bureau of Justice Statistics. National crime victimization survey, 2008-2015. Washington, DC: U.S. Department of Justice; 2016. Google Scholar5. Turner HA, Finkelhor D, Ormrod R. The effect of lifetime victimization on the mental health of children and adolescents. Soc Sci Med. 2006;62:13-27. [PMID: 16002198] CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: University of California, Davis, Sacramento, California (R.M.K., M.C., K.E.R., V.A.P., G.J.W.)Columbia University, New York, New York (K.M.K.)Financial Support: From the Robertson Fellowship in Violence Prevention Research and the Heising Simons Foundation (grant 2016-219).Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-0365.Reproducible Research Statement:Study protocol and statistical code: Not available. Data set: Available at www.icpsr.umich.edu.This article was published at Annals.org on 19 June 2018. PreviousarticleNextarticle Advertisement Annals Author Insight Video - Rose M.C. Kagawa, PhD, MPH In this video, Rose M.C. Kagawa, MPH, offers additional insight into the article, "Firearm Involvement in Violent Victimization and Mental Health: An Observational Study." FiguresReferencesRelatedDetails Metrics Cited byInequities in Community Exposure to Deadly Gun Violence by Race/Ethnicity, Poverty, and Neighborhood Disadvantage among Youth in Large US CitiesGun Violence EpidemiologyExposure to Violence, Firearm Involvement, and Socioemotional Consequences Among California AdultsGun violence against unhoused and unstably housed women: A cross-sectional study that highlights links to childhood violenceGun Violence Exposure and Experiences of Depression Among MothersEmotional and physical symptoms after gun victimization in the United States, 2009–2019Risk factors for assaultive reinjury and death following a nonfatal firearm assault injury: A population-based retrospective cohort studyDistress level and daily functioning problems attributed to firearm victimization: sociodemographic-specific responses 16 October 2018Volume 169, Issue 8Page: 584-585KeywordsCrimeDisclosureEmotionsFearFellowshipsFirearm injuriesObservational studiesPsychiatry and mental healthRisk management ePublished: 19 June 2018 Issue Published: 16 October 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. 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