Why Asking About Firearms Can’t Be Optional in Emergency Behavioral Health Care

By: Sara Gotheridge, MD, Chief Medical Officer at Array Behavioral Care

If you’re serious about suicide prevention, you have to start with one question: Does this patient have access to a firearm?

Firearms account for more than half of suicide deaths in the U.S., and attempts involving a firearm are far more likely to result in death than other methods.^1,2,3 That makes firearm access one of the most important and actionable risk factors health systems can assess.

Yet in many healthcare settings, this question is often not asked consistently, not documented clearly, or quietly ignored when the answer isn’t known.

At Array, we take a different approach. We require clinicians to ask and document firearm access every time: yes, no, or unknown. This ensures one of the most important drivers of suicide risk is always addressed.

And we don’t stop there. We also give clinicians a structured way to respond when the answer isn’t clear.

Most systems treat “unknown” like a gap. We treat it like a signal.

The combination of consistently capturing firearm access and knowing how to act when it’s uncertain is what sets our acute care model apart.

Firearm access is one of them.

Research consistently shows:

• More than half of suicide deaths involve firearms^1,4
• Firearm attempts are far more likely to be fatal than other methods.^2,3 Reducing access during high-risk moments saves lives^3,5

Because of this, asking about firearm access should be standard practice. It should not be optional or inconsistent. At Array, it is standard. Every evaluation requires a clear answer:

No skipping. No assumptions.

This simple step ensures that one of the most important risk factors in suicide prevention is never overlooked.

In many organizations, when firearm access isn’t known, one of two things happens:

• The field is left blank
• Or worse, it’s treated as “no” by default

Both approaches create risk.

They create a false sense of safety and can lead to underestimating a patient’s true risk.

But in real-world emergency care, “unknown” is common.

Patients may be:

• Medically unstable
• Intoxicated or disoriented
• Unable or unwilling to provide reliable information

So the question isn’t whether uncertainty exists.

It’s what you do with it that matters.

At Array, our acute care model is built on a simple idea:

If something is important, you have to capture it. If you capture it, you have to use it.

That’s why “unknown” is not treated as a data problem.

It’s treated as real clinical information.

When clinicians select “unknown,” they’re not skipping the question. They’re documenting a real limit in what can be known at that moment.

And when you look at the data, that distinction becomes critical.

Because we require structured documentation, we’ve built one of the largest real-world datasets in acute behavioral health that is drawn from tens of thousands of encounters across emergency and acute care settings.

We looked at how clinicians actually document firearm access (“yes,” “no,” or “unknown”) and asked a question the literature rarely does:

Are these three categories really interchangeable?

They aren’t.

Patients whose firearm access is documented as “unknown” are substantially more likely to show other signs of acute risk than patients with confirmed access or no access:

• 36% show signs of psychosis
• 24% show signs of agitation
• Psychosis rates are nearly 10 percentage points higher in the “unknown” vs. the “yes” group

The takeaway is simple:

When firearm access is unknown, patients tend to be more unstable and more complex.

In other words, “unknown” behaves more like a red flag than a “no.”

This is exactly the kind of insight that only large-scale, real-world clinical data can reveal. Few organizations have visibility into care at this level, which is why it matters that this data is being brought forward.

When uncertainty is ignored or oversimplified, it creates real problems:

• Clinicians carry more cognitive burden
• Decisions become less consistent
• Risk can be underestimated

Research on clinical decision-making shows that missing or ambiguous information increases variability and raises the risk of error when left unstructured.^6,7,8

But when uncertainty is structured and visible, it becomes something clinicians can use.

That’s what our acute care model is designed to do:

• Requires clear documentation of firearm access
• Makes uncertainty explicit
• Incorporates it into clinical decision-making
• Supports more consistent and defensible outcomes

This doesn’t replace clinical judgment. It strengthens it.

For healthcare organizations, this isn’t just documentation. It’s care design.

Getting firearm access right, and handling uncertainty correctly, directly impacts:

• Patient safety
• Quality and consistency of care
• Risk management
• Medical-legal defensibility

Organizations don’t fail because uncertainty exists.

They fail when they don’t design systems to handle it.⁶

If you want to reduce suicide risk, you have to start by asking about firearm access every time.

And if you want to make better decisions, you can’t ignore when the answer is unknown.

At Array, we do both:

Because in emergency behavioral health care, the most important decisions are often made without perfect information.

And the organizations that deliver the safest care aren’t the ones that avoid uncertainty.

They’re the ones designed to handle it.