Gunshot injuries worsen mental health and jack up medical bills, new study finds

A new study from Harvard Medical School looks at the long-term costs of gun violence. What researchers found: the roughly 85,000 survivors of non-fatal gunshots each year were far more likely to develop substance abuse and mental health disorders. Their healthcare costs, too, increased significantly, costing the survivors thousands of dollars in medical bills. And it’s not just those who were shot: their families were more likely to develop psychiatric disorders, too.

Dr. Zirui Song, the study’s lead author, an associate professor of health care policy at Harvard Medical School and a physician at Mass General, spoke with host Arun Rath on GBH’s All Things Considered Monday to talk about what his findings mean. What follows is a lightly edited interview.

Arun Rath: Dr. Song, thanks for joining us.

Dr. Zirui Song: Thank you for having me.

Rath: So let's talk about the findings now. The study goes beyond just the survivors, but let's start off with the survivors. So an individual who is survived a gunshot, they're discharged from the hospital. They've ostensibly recovered. But what do they face? What are they at greater risk for?

Song: In this work, we found that in the first year, after a non-fatal firearm injury, on average survivors incurred a roughly 400 percent increase in health care spending, and notably, there was roughly 4,000 percent increase in health care spending in the month immediately after firearm injury. That increase in health care spending is comprised of increases in not only hospitalizations, but also follow-up readmissions, outpatient visits, imaging labs, tests, prescription drugs and every category of health care spending that we looked at.

Rath: And do we have a sense of how much of that is medical care related to the direct trauma of the injury and how much is from other effects?

Song: To try to get at that, we used a methodological strategy where we matched every survivor to five similar control individuals who looked like survivors on their observable attributes, but differed in that they did not incur a non-fatal firearm injury. Relative to this population of control individuals, the firearm survivors appear to have this 400 percent increase in health care spending attributable to the non-fatal firearm injury.

Rath: So that's pretty significant, it would seem — not having an eye for statistics — but what does that get across to you as a researcher?

Song: Well, it certainly struck us as being clinically meaningful. Obviously, increases of any magnitude can be framed in different ways relative to a benchmark that a person has in mind. But a 50 percent increase in psychiatric diagnoses, an 85 percent increase in substance use disorders, including both alcohol use disorder and opioid use disorder, suggest to us that the impact of firearm injuries ripple beyond the extent to which we've understood them so far.

And again, as you noted earlier, not only through survivors but also through their family members who similarly incurred a 12 percent increase in mental health disorders.

Rath: So knowing all of this now, what are the recommendations that would come out of the study, both in terms of how doctors at an individual level might treat people are who victims of gun trauma or even more broadly in terms of the macro level, in terms of spending and resources?

Song: One of the first things to notice is that, although increasingly our nation pays attention to the number of firearm deaths sustained, for example, each year — that being roughly 40,000 — there are more than twice as many individuals in the United States each year who sustain a firearm injury but managed to survive. And among those more than half as many people — roughly 85,000 estimated people in the U.S. each year — health care spending increases out of pocket spending, increases for health care, worsening health status both mental and physical and detrimental effects on the mental health of family members are all part of the ripple effects of firearm violence that we, as a public, as clinicians and colleagues, as policymakers, may benefit from knowing.

Such evidence could inform future efforts or policies to both help patients clinically at the individual level and inform discussions at a policy level about the firearm epidemic more broadly. For example, at the individual level, clinicians may benefit from knowing this information so that there may be better screening for the mental health needs — in addition to the physical health needs — of firearms survivors. So, for example, if clinicians know that or anticipate that firearm survivors on average have a 50 percent increase in mental health disorders and an 85 percent increase in substance use disorders, including opioid use disorders, that may change how we do follow-up screening for mental health needs, how frequently we check in with patients on a follow-up basis, what other specialists we bring in to help co-manage a patient such as psychotherapists or psychiatrists and how we might prescribe opioids as a way to treat pain more generally. Because, of course, coming out of a firearm injury, we expect that patients are in pain and the way we prescribe medications to treat pain may now have a greater effect. Or at least lead us to it to understand that there may be a greater effect on opioid use disorders than we've known in the past.

Rath: Looking at this at the overall study, obviously there's a horrendous human toll which is right there in the numbers. In terms of the economic toll, what does it tell you about how much we are spending on gun violence and how much we should be spending?

Song: Using our findings, if we apply a rough estimate of the $30,000 per year or so in the first year, immediately after firearm injury and direct health care spending to the roughly 85,000 Americans each year who sustain a non-fatal firearm injury, that comes out to roughly $2.5 billion annually in direct health care spending attributable to firearm injuries of the non-fatal type alone.

$2.5 billion is a substantial amount, which you might imagine could be devoted to other needs in health care as well as other needs societally if these firearm injuries did not occur.

They're, obviously also, dollars spent in good need for patients who are in need, especially in that first month after firearm injury, so it's not a judgment on the value of that health care spending per se, but it certainly gives us a magnitude of the economic implications of non-fatal firearm injuries applied across the population, which again has been less of a focus in our discussion of the firearm epidemic more broadly. Most of the coverage of the firearm pandemic has focused on deaths.

Rath: And also one could say we also have until now have a data to talk about it.

Song: I think the the screening part for a patient's needs is quite important and something that's not been focused on so much, given that we as a public have heard so much about deaths from firearms. You know, we almost intuitively, I think, are led to believe that those who did not die are in some ways “okay” and we sort of tend to forget about them. And this study sort of flips that notion on its head and says, you know, for our neighbors and friends and colleagues and people — we know for members of the public who don't die from a firearm injury — there are actually ways that clinicians should think about those folks in the long run.

Rath: Dr. Song, this is fascinating and very sobering. Thank you so much for being with us.

Song: Thank you very much for your interest in this work. We really appreciate it, and it's an honor to be with you.

Rath: That's Dr. Zirui Song, associate professor of health care policy at Harvard Medical School and a physician at Mass General. This is GBH’s All Things Considered.