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Special article| Volume 88, ISSUE 11, P1272-1283, November 01, 2013

Guns, Schools, and Mental Illness: Potential Concerns for Physicians and Mental Health Professionals

  • Ryan Chaloner Winton Hall
    Correspondence
    Correspondence: Address to Ryan C. W. Hall, MD, 2500 W Lake Mary Blvd, Ste 219, Lake Mary, FL 32746.
    Affiliations
    Department of Medical Education, University of Central Florida, College of Medicine, Orlando, FL

    Department of Psychiatry University of South Florida, Tampa, FL

    Barry Law School, Orlando, FL
    Search for articles by this author
  • Susan Hatters Friedman
    Affiliations
    Department of Psychiatry and Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH

    Department of Psychological Medicine, University of Auckland School of Medicine, Auckland, New Zealand
    Search for articles by this author
Published:October 18, 2013DOI:https://doi.org/10.1016/j.mayocp.2013.08.016
Guns, Schools, and Mental Illness: Potential Concerns for Physicians and Mental Health Professionals
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      Abstract

      Since the recent shootings in Tucson, Arizona; Aurora, Colorado; and Newtown, Connecticut, there has been an ever-increasing state and national debate regarding gun control. All 3 shootings involved an alleged shooter who attended college, and in hindsight, evidence of a mental illness was potentially present in these individuals while in school. What appears to be different about the current round of debate is that both pro–gun control and anti–gun control advocates are focusing on mentally ill individuals, early detection of mental illness during school years, and the interactions of such individuals with physicians and the mental health system as a way to solve gun violence. This raises multiple questions for our profession about the apparent increase in these types of events, dangerousness in mentally ill individuals, when to intervene (voluntary vs involuntary), and what role physicians should play in the debate and ongoing prevention. As is evident from the historic Tarasoff court case, physicians and mental health professionals often have new regulations/duties, changes in the physician-patient relationship, and increased liability resulting from high-profile events such as these. Given that in many ways the prediction of who will actually commit a violent act is difficult to determine with accuracy, physicians need to be cautious with how the current gun debate evolves not only for ourselves (eg, increased liability, becoming de facto agents of the state) but for our patients as well (eg, increased stigma, erosion of civil liberties, and changes in the physician-patient relationship). We provide examples of potential troublesome legislation and suggestions on what can be done to improve safety for our patients and for the public.

      Abbreviations and Acronyms:

      ADA (Americans with Disabilities Act), APA (American Psychiatric Association), NICS (National Instant Criminal Background Check)
      Over the past several years, there have been multiple high-profile shootings involving people who were either currently attending universities or had withdrawn from school who appear to have had a mental illness (Table 1). For physicians, highly public occurrences of violence inevitably put the focus on the mental health system, our patients, and our practices. This has raised many concerns, ranging from how best to detect and treat individuals prone to such acts to what interventions should be engaged in by states and institutions of higher learning for the protection of students and the population at large.
      • Freedman R.
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      Psychiatrists, mental illness, and violence.
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      Many of these violent acts have involved firearms, which raises the questions of whether more laws are needed or if existing regulations need to be tightened

      Now is the time: the President’s plan to protect our children and our communities by reducing gun violence. The Whitehouse website. www.whitehouse.gov/issues/preventing-gun-violence. Published January 16, 2013. Accessed July 21, 2013.

      , 

      Fisher CE, Lieberman JA. Getting the facts straight about gun violence and mental illness: putting compassion before fear [published online ahead of print July 9, 2013]. Ann Intern Med. http://dx.doi.org/10.7326/0003-4819-159-5-201309030-00679.

      , 
      • Gregory N.
      The link between mental health problems and violent behaviour.
      Nurs Times. 2004; 100: 34-36
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      • Record K.L.
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      A systematic plan for firearms law reform.
      JAMA. 2013; 309: 1231-1232
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      • Swanson J.
      Mental illness and new gun law reforms: the promise and peril of crisis-driven policy.
      JAMA. 2013; 309: 1233-1234
      , 
      • Swanson J.
      Mental illness and gun control—reply [letter].
      JAMA. 2013; 310: 98-99
      , 
      • Frattaroli S.
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      Mental illness and gun control [letter].
      JAMA. 2013; 310: 97-98
      , 

      Letter to Governor Andrew Cuomo from Medical Society of the State of New York and New York State Psychiatric Association, dated February 27, 2013, signed by Robert Hughes, MD, and Glenn Martin, MD. http://polhudson.lohudblogs.com/2013/03/20/mental-health-groups-seek-gun-law-changes-in-budget/. Accessed October 2, 2013.

      , 

      New York State Psychiatric Association. NYSPA issues press release on SAFE Act reporting requirements. New York State Psychiatric Association website. http://www.nyspsych.org/index.php?option=com_content&view=article&id=53:safe-act-press-release&catid=20:site-content. Accessed October 3, 2013.

      (Table 2). In addition, recent proposals have been made to increase screening for mental health problems, increase referrals to mental health services, increase funding for mental health in schools, and increase access to mental health care in general as a way to decrease gun violence.

      Now is the time: the President’s plan to protect our children and our communities by reducing gun violence. The Whitehouse website. www.whitehouse.gov/issues/preventing-gun-violence. Published January 16, 2013. Accessed July 21, 2013.

      Although increases in mental health funding are welcomed, linking it to the recent mass shootings, as was done by a former American Psychiatric Association (APA) president (Figure 1), may be counterproductive by increasing the stigma regarding mental illness and creating the impression that “fixing” the mental health field will de facto prevent or considerably reduce future episodes of violence.

      APA President Dilip Jeste, MD, Video Message #4: Mental Health and Gun Violence. January 2013. American Psychiatric Association website. http://www.psychiatry.org/advocacy-newsroom/newsroom/presidents-video-messages. Accessed July 12, 2013.

      Table 1Individuals Who Have Allegedly Engaged in Serious Violent Acts and Whose Alleged Mental Illness Was “Notable” While They Were “in School”
      • •
        Charles Joseph Whitman—A student at the University of Texas who killed 13 people and wounded 32 others from a bell tower on the campus on August 1, 1966, before being shot by authorities
      • •
        Prosenjit Poddar—Graduate student at the University of California, Berkeley who, in 1969, stabbed and killed Tatiana Tarasoff, which eventually resulted in a “duty to protect” for psychotherapists
      • •
        Wendell Williamson—University of North Carolina law student, who had last seen university psychiatrist Dr Myron B. Liptzin 8 months previously, fired a rifle at people in the streets of downtown Chapel Hill, North Carolina, on January 26, 1995, killing two. He was found not guilty by reason of insanity and sued his former psychiatrist Dr Liptzin for malpractice
      • •
        Seung-Hui Cho—Undergraduate student at Virginia Tech who, on April 16, 2007, shot and killed 32 people and wounded 15 others before committing suicide. This case resulted in national and state gun control laws
      • •
        Jared Lee Loughner—Former Pima Community College student (suspended from class in 2008 and not allowed to return until cleared by a mental health official) killed 6 people and left 14 people injured, including Congresswoman Gabrielle Giffords, on January 8, 2011
      • •
        James Eagan Holmes—Former University of Colorado Anschutz Medical Campus graduate student allegedly killed 12 people and injured 58 others at a movie theater on July 20, 2012
      • •
        Adam Lanza—Former Western Connecticut State University student (last attended in 2009) shot 20 children and 6 adults at Sandy Hook Elementary School on December 14, 2012. Suspected to have a mental illness
      Table 2Summary of Concerns With the 2013 SAFE Act Voiced to Governor Cuomo by the Medical Society of the State of New York and the New York State Psychiatric Association on January 11, 2013 and March 1, 2013
      Data from references

      Letter to Governor Andrew Cuomo from Medical Society of the State of New York and New York State Psychiatric Association, dated February 27, 2013, signed by Robert Hughes, MD, and Glenn Martin, MD. http://polhudson.lohudblogs.com/2013/03/20/mental-health-groups-seek-gun-law-changes-in-budget/. Accessed October 2, 2013.

      and

      New York State Psychiatric Association. NYSPA issues press release on SAFE Act reporting requirements. New York State Psychiatric Association website. http://www.nyspsych.org/index.php?option=com_content&view=article&id=53:safe-act-press-release&catid=20:site-content. Accessed October 3, 2013.

      .
      • •
        “Medical science does not permit even the most experienced clinician to predict with certainty who will commit acts of violence with a weapon or firearm”

        Letter to Governor Andrew Cuomo from Medical Society of the State of New York and New York State Psychiatric Association, dated February 27, 2013, signed by Robert Hughes, MD, and Glenn Martin, MD. http://polhudson.lohudblogs.com/2013/03/20/mental-health-groups-seek-gun-law-changes-in-budget/. Accessed October 2, 2013.

      • •
        Legislation must assure that the circumstances that enable the reporting are well defined
      • •
        Legislation must assure that the professionals reporting are properly qualified and trained to know that a report needs to be made
      • •
        Legislation must assure that the report is made directly to law enforcement so that immediate action can be taken to avert the potential event
      • •
        Legislation must assure that the reporting professional is protected from liability if they have acted without malice or intentional misconduct
      • •
        Legislation must clarify discrepancies between the new law and existing laws (eg, HIPAA) regarding reporting
      • •
        Legislation needs to not be so broad that it leads to reporting of persons who do not pose a serious and imminent threat to society
      HIPAA = Health Insurance Portability and Accountability Act; SAFE = Secure Ammunition and Firearms Enforcement.
      Figure thumbnail gr1
      Figure 1Transcript of Video Message #4 from the American Psychiatric Association's President, Dilip Jeste, MD.

      APA President Dilip Jeste, MD, Video Message #4: Mental Health and Gun Violence. January 2013. American Psychiatric Association website. http://www.psychiatry.org/advocacy-newsroom/newsroom/presidents-video-messages. Accessed July 12, 2013.

      Allegations that the Tucson, Arizona, and Aurora, Colorado, deaths were due to the mental health field being inept have already been made.
      • Grantham D.
      Arizona’s mental health system did not fail: state’s mental health director answers critics, details response to Tucson tragedy.
      Behav Healthc. 2011; 31: 14-16
      , 

      McGhee T. Theater shooting victim's wife sues Holmes' psychiatrist. Denver Post website. http://www.denverpost.com/breakingnews/ci_22378331/theater-shooting-victims-wife-sues-holmes-psychiatrist#ixzz2PpP2KqJD. Posted January 15, 2013. Accessed April 7, 2013.

      In the Tucson case, several people tried to get Jared Loughner into treatment, with his school even making it a requirement for him to have an evaluation to be eligible to return as a student. He simply chose not to follow up, which then raises the question about the need to change civil commitment laws and allow for easier outpatient forced medication to truly reduce dangerousness since most violent acts are perpetrated by people who are not in treatment or are not adherent with medications.

      APA President Dilip Jeste, MD, Video Message #4: Mental Health and Gun Violence. January 2013. American Psychiatric Association website. http://www.psychiatry.org/advocacy-newsroom/newsroom/presidents-video-messages. Accessed July 12, 2013.

      However, such changes often raise concerns about people’s civil liberties, rights to self-determination, and least restrictive/intrusive treatment options. In Aurora, Colorado, James Holmes had been seen by campus mental health professionals, but the event still occurred—raising the question of whether the mental health system failed. This impression is likely to be further enforced when existing lawsuits against Holmes’ psychiatrist for “failing to protect the public” go to court.

      McGhee T. Theater shooting victim's wife sues Holmes' psychiatrist. Denver Post website. http://www.denverpost.com/breakingnews/ci_22378331/theater-shooting-victims-wife-sues-holmes-psychiatrist#ixzz2PpP2KqJD. Posted January 15, 2013. Accessed April 7, 2013.

      However, in many ways, this is an unfair criticism because recently revealed court documents indicate that his psychiatrist had indeed notified campus police 1 month before the shootings as she was legally required to do.

      Aurora Police Department Case No. 2012–28181. Return and inventory for court order for production of records. 9NEWS.COM website. www.9news.com/assetpool/documents/130404065331_12CR1522%20Search%20Warrant%20Google%20Inc%[email protected]. Accessed April 7, 2013.

      The campus police’s response was to deactivate Holmes’ access card for the campus, which illustrates both the practical limitations and some of the peril that physicians actually face when it comes to questions of violence prevention and the practice of medicine. To put it colloquially, a physician’s ability to prevent imminent violence many times depends on “how good their dance partner is” (eg, local law enforcement’s willingness/ability to carry out a civil commitment/warnings, school administration’s willingness to take action, support from family, and the patient’s willingness to engage in treatment).

      Are the Tarasoff Laws Effective?

      The 1969 murder of University of California, Berkeley student Tatiana Tarasoff by graduate student Prosenjit Poddar and the subsequent lawsuit gave rise to a formalized duty for mental health professionals to nonpatients regarding violence risk.

      Tarasoff v Regents of the University of California, 17 Cal. 3d 425, 551 P.2d 334, 131 Cal Rptr 14 (1976).

      , 
      • Herbert P.B.
      • Young K.A.
      Tarasoff at twenty-five.
      J Am Acad Psychiatry Law. 2002; 30: 275-281
      , 
      • Kachigian C.
      • Felthous A.R.
      Court responses to Tarasoff statutes.
      J Am Acad Psychiatry Law. 2004; 32: 263-273
      , 
      • Hall R.C.
      • Resnick P.J.
      Psychotherapy malpractice: new pitfalls.
      J Psychiatr Pract. 2008; 14: 119-121
      The specifics of the case are illustrative when we ponder how risks are considered. Indeed, months before the murder, Poddar had voluntarily informed a university psychologist of his violent thoughts. The psychologist contacted the police, who interviewed but did not detain or commit a “rational-appearing” Poddar. Despite this attempt to intervene, Tatiana Tarasoff was killed months later.

      Tarasoff v Regents of the University of California, 17 Cal. 3d 425, 551 P.2d 334, 131 Cal Rptr 14 (1976).

      The therapist and school settled out of court after the California Supreme Court found there was a “duty to protect.” In its brief to the California Supreme Court, the APA argued that psychiatrists did not have a standard for predicting dangerousness.

      Tarasoff v Regents of the University of California, 17 Cal. 3d 425, 551 P.2d 334, 131 Cal Rptr 14 (1976).

      , 
      • Herbert P.B.
      • Young K.A.
      Tarasoff at twenty-five.
      J Am Acad Psychiatry Law. 2002; 30: 275-281
      , 
      • Kachigian C.
      • Felthous A.R.
      Court responses to Tarasoff statutes.
      J Am Acad Psychiatry Law. 2004; 32: 263-273
      , 

      Barefoot v Estelle, 463 US 880 (1983).

      They further argued that creating a duty for psychiatrists to a third party would lead to risks that outweighed the benefits. Subsequent legislation has sought to limit this duty and liability in many jurisdictions, due to what seemed to be an ever-expanding third-party population—such as victims in car accidents, unidentifiable victims of shootings, and victims of actions that occurred months after the patient dropped out of treatment.
      • Herbert P.B.
      • Young K.A.
      Tarasoff at twenty-five.
      J Am Acad Psychiatry Law. 2002; 30: 275-281
      , 
      • Kachigian C.
      • Felthous A.R.
      Court responses to Tarasoff statutes.
      J Am Acad Psychiatry Law. 2004; 32: 263-273
      , 
      • Hall R.C.
      • Resnick P.J.
      Psychotherapy malpractice: new pitfalls.
      J Psychiatr Pract. 2008; 14: 119-121
      Even though the effects of the Tarasoff case have been limited by subsequent legislation, many physicians still find it hard to maintain a balance between the very real concern about malpractice suits, maintaining the physician-patient relationship, and when to violate confidentiality. Further, police departments across the United States have varying experience with Tarasoff warnings, which results in unpredictable outcomes.
      • Huber M.G.
      • Balon R.
      • Labbate L.A.
      • Brandt-Youtz S.
      • Hammer J.H.
      • Mufti R.
      A survey of police officers’ experience with Tarasoff warnings in two states.
      Psychiatr Serv. 2000; 51: 807-808
      Although contacting the police may discharge one’s duty to protect or warn in certain states, it may not be the most effective way to actually accomplish the goal, as seen in both the Aurora and the original Tarasoff case (Table 3). It is important to remember this as a profession because it highlights the fact that even after 35 years of increased reporting requirements, 35 years of additional regulations/laws, and more than 35 years of medical advances (eg, new medications, new violence risk assessment research), the violence, even with the willing help of physicians, could not be stopped in these cases.
      Table 3Similarities Between the Tarasoff Case and the Aurora, Colorado, Shootings
      • •
        Both perpetrators were graduate students
      • •
        Both apparently sought treatment voluntarily (there is some question with Holmes because some information is not public before his trial)
      • •
        Neither had a clear history of violence or mental health problems before college
      • •
        In both cases, the treating mental health professional warned campus police
      • •
        In both cases, the campus police took action short of hospitalization
      • •
        In both cases, violence occurred after the last contact with a mental health professional beyond what most would consider a reliable window for prediction of imminent violence

      Current Gun Laws and Restrictions on Mentally Ill Individuals

      The Brady Handgun Violence Prevention Act of 1993 mandated both background checks and a waiting period for purchasing handguns.
      • Price M.
      • Norris D.M.
      National Instant Criminal Background Check Improvement Act: implications for persons with mental illness.
      J Am Acad Psychiatry Law. 2008; 36: 123-130
      , 
      • Price M.
      • Norris D.M.
      Firearm laws: a primer for psychiatrists.
      Harv Rev Psychiatry. 2010; 18: 326-335
      , 
      • Appelbaum P.S.
      • Swanson J.W.
      Gun laws and mental illness: how sensible are the current restrictions?.
      Psychiatr Serv. 2010; 61: 652-654
      , 
      • Gostin L.O.
      • Record K.L.
      Dangerous people or dangerous weapons: access to firearms for persons with mental illness.
      JAMA. 2011; 305: 2108-2109
      , 
      • Simpson J.R.
      Bad risk? an overview of laws prohibiting possession of firearms by individuals with a history of treatment for mental illness.
      J Am Acad Psychiatry Law. 2007; 35: 330-338
      This Act was prompted by the disabling shooting of White House Press Secretary James Brady by John Hinckley in his attempted assassination of President Ronald Reagan in 1981. However, legislation limiting individuals committed to mental hospitals from owning a gun actually dates back to the Omnibus Crime Control and Safe Streets Act and the Gun Control Act of 1968.
      • Price M.
      • Norris D.M.
      National Instant Criminal Background Check Improvement Act: implications for persons with mental illness.
      J Am Acad Psychiatry Law. 2008; 36: 123-130
      , 
      • Price M.
      • Norris D.M.
      Firearm laws: a primer for psychiatrists.
      Harv Rev Psychiatry. 2010; 18: 326-335
      , 
      • Appelbaum P.S.
      • Swanson J.W.
      Gun laws and mental illness: how sensible are the current restrictions?.
      Psychiatr Serv. 2010; 61: 652-654
      , 
      • Gostin L.O.
      • Record K.L.
      Dangerous people or dangerous weapons: access to firearms for persons with mental illness.
      JAMA. 2011; 305: 2108-2109
      , 
      • Simpson J.R.
      Bad risk? an overview of laws prohibiting possession of firearms by individuals with a history of treatment for mental illness.
      J Am Acad Psychiatry Law. 2007; 35: 330-338
      The National Instant Criminal Background Check System (NICS), which ensued as a result of the Brady Bill, is a computerized system run by the Federal Bureau of Investigation that maintains the eligibility data for purchase of firearms.
      • Gostin L.O.
      • Record K.L.
      Dangerous people or dangerous weapons: access to firearms for persons with mental illness.
      JAMA. 2011; 305: 2108-2109
      However, not all gun sales are required to be submitted to the NICS as the law is currently worded. A notorious loophole is that unlicensed secondhand dealers can sell at gun shows without performing background checks. Also, private gun sales/transfers (from one private owner to another) are not regulated by federal restrictions and include up to 40% of sales.
      • Appelbaum P.S.
      • Swanson J.W.
      Gun laws and mental illness: how sensible are the current restrictions?.
      Psychiatr Serv. 2010; 61: 652-654
      By 2008, after the Virginia Tech shootings, the Brady Act was amended to encourage improved state reporting of those who were disqualified from purchasing firearms (eg, felons, individuals adjudicated mentally ill).
      • Appelbaum P.S.
      • Swanson J.W.
      Gun laws and mental illness: how sensible are the current restrictions?.
      Psychiatr Serv. 2010; 61: 652-654
      Although some states have followed through with this amendment, many states have not, citing budgetary difficulties and concerns of privacy and inability to safeguard the data.
      • Sterzer J.
      The good, the bad and the ugly: a 50-state survey exploring federal and state firearm regulations related to mental health.
      J Leg Med. 2012; 33: 171-191
      Even if the Brady law is fully implemented and expanded, questions remain regarding whether it would have been able to prevent school shootings like the ones that have occurred. Many times, individuals already own guns by the time they would meet criteria to be added to this list, and the waiting period does not seem to be a deterrent or obstacle because most school-based or mass shootings are planned in advance.
      • Preti A.
      School shooting as a culturally enforced way of expressing suicidal hostile intentions.
      J Am Acad Psychiatry Law. 2008; 36: 544-550
      Furthermore, shootings such as those at Columbine High School in Littleton, Colorado, and Sandy Hook Elementary School in Newtown, Connecticut, would not have been prevented because the individuals obtained the guns from family and friends.
      • Preti A.
      School shooting as a culturally enforced way of expressing suicidal hostile intentions.
      J Am Acad Psychiatry Law. 2008; 36: 544-550
      Although some states, including California, are trying to confiscate guns from people added to the list, the funding for such endeavors is often limited, resulting in large case backlogs.

      Calif. agents detail risks of seizing guns from felons, mentally ill. CBS SF Bay Area website. http://sanfrancisco.cbslocal.com/2013/05/04/calif-agents-detail-risks-of-seizing-guns-from-felons-mentally-ill/. Published May 4, 2013. Accessed July 12, 2013.

      Although more funding has recently been allotted to the California program after the Sandy Hook tragedy, the program that had been in existence for 10 years only had roughly 30 officers for the entire state in 2012, with only 10% completion of targeted confiscations.

      Calif. agents detail risks of seizing guns from felons, mentally ill. CBS SF Bay Area website. http://sanfrancisco.cbslocal.com/2013/05/04/calif-agents-detail-risks-of-seizing-guns-from-felons-mentally-ill/. Published May 4, 2013. Accessed July 12, 2013.

      The question is then raised, even if additional reporting from physicians occurs, would the other needed support mechanisms be funded and staffed to a level that would make a major impact on public safety? This is important for physicians to consider when trying to weigh the risks and benefits of proposed legislation, especially in a state such as California where there is a duty to protect after the Tarasoff case. What further steps a physician should take (or possibly be mandated to take) if local law enforcement is unable to follow up should also be considered.
      Even though mass shootings by mentally ill individuals are relatively rare events (ie, most gun violence occurs in the commission of more standard crimes), some politicians are actually calling for every physician to report patients to the databases—in some cases on the basis of a potential diagnosis, need for long-term medication, or mere belief of potential dangerousness at some unspecified time in the future

      Mental health, SB 1484 (Fla 2013).

      (Figure 2). Physicians need to be careful as the Brady Bill is expanded that we neither ask for nor receive too much power because of the potential effect it could have on the physician-patient relationship and our role in society in general. If an individual is placed on that list, it effectively removes their Second Amendment rights for future gun purchases. Currently, people are placed on that list after judicial court rulings, either to the standard of beyond a reasonable doubt (eg, convicted of a felony) or a court determination of mental unsoundness (eg, guilty but mentally ill; incompetent to stand trial; in need of guardianship, which require various standards of proof but at a minimum of preponderance of the evidence, more likely than not). Conversely, if physicians were placing people on the list, they would likely use the much lower standard of reasonable suspicion (the same standard used to report child abuse and often described as below a 50% level of certainty), which could violate constitutional law. In addition, if physicians directly reported to the NICS or other state database, there would be no judicial oversight as there is with removal of other rights for the mentally ill, such as termination of parental rights, which could result in a due process challenge against the law because of the removal of the checks and balances that a judge and/or hearing provides.
      Figure thumbnail gr2
      Figure 2Proposed 2013 Florida State Senate Bill Number 1484.

      Mental health, SB 1484 (Fla 2013).

      In addition, physicians need to pay close attention to the wording used in any bills that require background checks on transferors of firearms. Currently, many physicians treating suicidal patients often ask them to remove firearms from their homes. Depending on how legislation is written, our patients may actually need to have a background check performed before and after they transfer their weapons to a friend, family member, or physician for safekeeping. Although many would argue that once a patient is suicidal, they should never have a gun again, this may be a step too far for the suicidal patient to agree to, whereas the notion of a temporary transfer is agreeable and improves immediate safety.
      • Walters H.
      • Kulkarni M.
      • Forman J.
      • Roeder K.
      • Travis J.
      • Valenstein M.
      Feasibility and acceptability of interventions to delay gun access in VA mental health settings.
      Gen Hosp Psychiatry. 2012; 34: 692-698
      Many in the United States point to the stricter laws in other countries as a model for future US laws. For example, an Australian study examined legislative reform after 2 mass shootings—in 1988 and 1996—and firearm-related deaths, finding that firearm amnesty, buy-backs/confiscation, and strong regulatory reforms were followed by a downward trend in suicide by firearm and firearm deaths overall.
      • Ozanne-Smith J.
      • Ashby K.
      • Newstead S.
      • Stathakis V.Z.
      • Clapperton A.
      Firearm related deaths: the impact of regulatory reform.
      Inj Prev. 2004; 10: 280-286
      However, even in countries with strong firearm restrictions, mass shootings can still occur—like the 2012 Quebec election shooting, the 2011 Norway shooting at a summer camp by Anders Behring Breivik, and the 1996 Scottish Dunblane shooting in which 16 children were killed. School and mass shootings are not just an American problem; 3 school shootings occurred in Canada and 4 school shootings occurred in Europe between 1999 and 2008 (ie, between the times of the Columbine and Virginia Tech events).
      • Preti A.
      School shooting as a culturally enforced way of expressing suicidal hostile intentions.
      J Am Acad Psychiatry Law. 2008; 36: 544-550
      Even if stronger gun laws are in place in the United States, the chance for future episodes of mass violence in or out of schools unfortunately cannot be eliminated.

      Increased Rate of Occurrence in Schools?

      Although there is a history of school-based firearm violence dating back to the 1800s, there has been increasing recent awareness, especially when such acts are committed by people with a mental illness.
      • Preti A.
      School shooting as a culturally enforced way of expressing suicidal hostile intentions.
      J Am Acad Psychiatry Law. 2008; 36: 544-550
      , 

      Serious case of shooting—navigation. The New York Times. Nov 3, 1853.

      There are likely many factors causing this increased awareness. The first is that individuals with mental illness, especially psychotic illness, are attending college at a higher rate than ever before.

      Clemetson L. Off to college alone, shadowed by mental illness. The New York Times website. www.nytimes.com/2006/12/08/health/08Kids.html?pagewanted=all. Published December 8, 2006. Accessed July 11, 2013

      , 

      Gabriel T. Mental health needs seen growing at colleges. The New York Times website. www.nytimes.com/2010/12/20/health/20campus.html?pagewanted=all. Published December 19, 2010. Accessed July 12, 2013.

      , 
      • Gruttadaro D.
      • Crudo D.
      College Students Speak: A Survey Report on Mental Health.
      National Alliance on Mental Illness (NAMI), Arlington, VA2012
      www.nami.org/Content/NavigationMenu/Find_Support/NAMI_on_Campus1/collegereport.pdf
      This is due to better treatments, passage of laws such as the Americans with Disabilities Act (ADA), and decreases in stigma. In addition, the college years are often a time when mental illness presents for the first time. Individuals who have a mental illness or have development of one while attending university may be at greater risk for having decompensation—due to stress (eg, academic and social problems), being away from their family, increased use of substances (eg, alcohol), and having limited supervision or accountability.
      There are also concerns of a copycat or Werther effect (a term coined by sociologist David Phillips in 1974
      • Phillips D.P.
      The influence of suggestion on suicide: substantive and theoretical implications of the Werther effect.
      Am Sociol Rev. 1974; 39: 340-354
      ) in which individuals, usually adolescents and younger adults, act out situations they have seen in media and the news.

      Obmascik M, Robinson M, Olinger D. Officials say girlfriend bought guns. Denver Post website. http://extras.denverpost.com/news/shot0427a.htm. Published April 27, 1999. Accessed April 7, 2013.

      , 
      • Phillips D.P.
      The influence of suggestion on suicide: substantive and theoretical implications of the Werther effect.
      Am Sociol Rev. 1974; 39: 340-354
      , 
      • Day T.R.
      • Hall R.C.W.
      Déjà vu: from comic books to video games; legislative reliance on “soft science” to protect against uncertain societal harm linked to violence v. the First Amendment.
      Oregon Law Rev. 2010; 89: 415-452
      , 
      • Hall R.C.W.
      • Day T.
      • Hall R.C.W.
      A plea for caution: violent video games, the Supreme Court, and the role of science.
      Mayo Clin Proc. 2011; 86: 315-321
      For example, 20-year-old Blaec Lammers, who had a history of being civilly committed, was arrested for planning a movie theater shooting spree months after the Aurora movie theater shootings.

      Hollingsworth H. Blaec Lammers, ‘Twilight’ movie shooting suspect, planned ’09 killing, authorities say. 11/20/12. Huffington Post website. www.huffingtonpost.com/2012/11/20/blaec-lammers-twilight-movie-shooting_n_2168537.html. Published November 20, 2012. Accessed December 8, 2012.

      His planned attack was thought to be directly inspired by James Holmes’ actions in Aurora.

      Hollingsworth H. Blaec Lammers, ‘Twilight’ movie shooting suspect, planned ’09 killing, authorities say. 11/20/12. Huffington Post website. www.huffingtonpost.com/2012/11/20/blaec-lammers-twilight-movie-shooting_n_2168537.html. Published November 20, 2012. Accessed December 8, 2012.

      Why past episodes such as the University of Texas clock tower shootings in 1966 did not spur the same level of copycat behavior may indicate a magnifying influence of our current 24-hour news cycle.
      • Day T.R.
      • Hall R.C.W.
      Déjà vu: from comic books to video games; legislative reliance on “soft science” to protect against uncertain societal harm linked to violence v. the First Amendment.
      Oregon Law Rev. 2010; 89: 415-452
      However, one needs to be careful about blaming the media. There will always be susceptible individuals, and it is impossible to predict which story will trigger a reaction.
      • Day T.R.
      • Hall R.C.W.
      Déjà vu: from comic books to video games; legislative reliance on “soft science” to protect against uncertain societal harm linked to violence v. the First Amendment.
      Oregon Law Rev. 2010; 89: 415-452
      , 
      • Hall R.C.W.
      • Day T.
      • Hall R.C.W.
      A plea for caution: violent video games, the Supreme Court, and the role of science.
      Mayo Clin Proc. 2011; 86: 315-321
      For example, some have written about how the book Catcher in the Rye incites assassination and antisocial behavior, since Lee Harvey Oswald (suspected of shooting and killing President John F. Kennedy), John Hinckley (shot President Ronald Reagan), and David Mark Chapman (shot and killed John Lennon) all owned a copy.

      Is Catcher in the Rye an assassination trigger? WordPress.com website. http://atomicpoet.wordpress.com/2012/01/31/is-catcher-in-the-rye-an-assassination-trigger/. Accessed April 8, 2013.

      , 

      Turner A. ‘Catcher in the Rye’ author leaves behind tales of teen angst. PBS NewsHour website. www.pbs.org/newshour/extra/features/arts/jan-june10/salinger_01-29.html. Posted January 29, 2010. Accessed April 8, 2013.

      Granted, this list does seem to suggest a common thread with hindsight, but it must be remembered that over 65 million copies of Catcher in the Rye have been sold, and most people who have read it have not engaged in assassinations.
      The Werther effect extends beyond just guns and even the United States media markets. Many in North America may not be aware that there has been a rash of deadly knife attacks in China.

      Yan H. China releases footage of elementary school knife attack. CNN website. www.cnn.com/2012/12/24/world/asia/china-school-knife-attack. Updated December 24, 2012. Accessed April 8, 2013.

      , 

      China school attacks in 2010. CNN website. www.cnn.com/2010/WORLD/asiapcf/05/12/china.school.attack.timeline/. Published May 12, 2010. Accessed April 8, 2013.

      , 

      FlorCruz J. Execution does not stop Chinese knife attacks. CNN website. www.cnn.com/2010/WORLD/asiapcf/05/02/china.attacks/. Published May 3, 2010. Accessed April 8, 2013.

      , 

      22 Stabbed students receive treatment in central China. Xinhuanet website. http://news.xinhuanet.com/english/photo/2012-12/15/c_132042958.htm. Published December 15, 2012. Accessed July 12, 2013.

      , 

      School attacks in China (2010-12). Wikipedia website. http://en.wikipedia.org/wiki/School_attacks_in_China_(2010%E2%80%9312). Updated August 21, 2013. Accessed July 12, 2013.

      In 2010, 3 separate school knife attacks resulted in 68 primary school–aged children being stabbed.

      China school attacks in 2010. CNN website. www.cnn.com/2010/WORLD/asiapcf/05/12/china.school.attack.timeline/. Published May 12, 2010. Accessed April 8, 2013.

      The government of China went so far as having people register in order to buy butcher knives, executed the individual involved in the first event, and trained school personnel in how to detain a knife-wielding individual with long metal Y-shaped “forks.”

      Yan H. China releases footage of elementary school knife attack. CNN website. www.cnn.com/2012/12/24/world/asia/china-school-knife-attack. Updated December 24, 2012. Accessed April 8, 2013.

      , 

      FlorCruz J. Execution does not stop Chinese knife attacks. CNN website. www.cnn.com/2010/WORLD/asiapcf/05/02/china.attacks/. Published May 3, 2010. Accessed April 8, 2013.

      Unfortunately, these knife control measures did not prevent a 2012 school knife attack (on the same day as the Newtown, Connecticut, shootings) in which 22 children were stabbed and school personnel had only brooms to try to stop the attacker.

      Yan H. China releases footage of elementary school knife attack. CNN website. www.cnn.com/2012/12/24/world/asia/china-school-knife-attack. Updated December 24, 2012. Accessed April 8, 2013.

      Fortunately, none of the schoolchildren died from this attack, although it is estimated that at least 25 schoolchildren have died in previous attacks.

      China school attacks in 2010. CNN website. www.cnn.com/2010/WORLD/asiapcf/05/12/china.school.attack.timeline/. Published May 12, 2010. Accessed April 8, 2013.

      , 

      22 Stabbed students receive treatment in central China. Xinhuanet website. http://news.xinhuanet.com/english/photo/2012-12/15/c_132042958.htm. Published December 15, 2012. Accessed July 12, 2013.

      , 

      School attacks in China (2010-12). Wikipedia website. http://en.wikipedia.org/wiki/School_attacks_in_China_(2010%E2%80%9312). Updated August 21, 2013. Accessed July 12, 2013.

      In absolute numbers, the Werther effect is usually small; however, when it does occur, it can have a substantial impact, as seen by the steps China took to protect its schoolchildren from future knife attacks.
      Since it appears that acts such as these can occur with guns or knives and across different cultures, the question then becomes: why schools? Schools may just be targets of opportunity, because almost every community has one and almost everyone has had some experience of being a student. Schools symbolically hold value as symbols of hope, achievement, and betterment while at the same time being the place where many have their first negative encounters with authority or failure academically or socially. Since communities often cherish schools, they also may be the easiest way to make others suffer the pain, hurt, or anxiety that the mass shooter wants to inflict. This was evident with the Washington, DC, sniper case in which the police officer in charge, Chief Charles Moose, made the following statement after a child was shot at a school: “All of our victims have been innocent and defenseless, but now we're stepping over the line,… Shooting a kid—it's getting to be really, really personal now.”

      School shooting linked to sniper attacks. ABC News website. http://abcnews.go.com/US/story?id=91160&page=1. Accessed April 7, 2013.

      What Are the Potential Effects on Our Patients, Other Students, and Institutions of Higher Learning?

      Important concerns for physicians, mental health practitioners, their patients, and institutions of learning include how to ensure that the stigma of these actions does not prevent otherwise “safe” students from receiving treatment and to prevent patients/students from having their civil liberties violated (eg, confidentiality, overly intrusive screening).
      • Cole T.B.
      Efforts to prevent gun sales to mentally ill may deter patients from seeking help.
      JAMA. 2007; 298: 503-504
      Institutions of higher learning are potentially liable for suit if a shooting incident occurs, as well as being susceptible to lawsuits under the ADA if termination of a student’s status occurs without sufficient justification. The ADA does have specific exceptions for violence and risk toward others, but the threshold to legally prove that someone is a threat may be difficult to determine before an incident or be based on nonspecific and nonthreatening risk factors, such as isolation or social awkwardness.
      This problem was highlighted in a recent university case in which a student with no known history of mental illness, no known disruptive behaviors on campus, and no known academic problems committed suicide after his alleged plan for a mass shooting was interrupted by his roommate walking in on him minutes before he planned to act.

      Ordway D-M, Hudak S. James Seevakumaran ends checklist with: ‘Give them hell.’ Orlando Sentinel website. http://articles.orlandosentinel.com/2013-03-19/community/os-ucf-death-james-seevakumaran-20130319_1_fire-alarm-dorm-room-ucf-police. Published March 19, 2013. Accessed July 11, 2013.

      The person had smuggled 2 firearms and 4 bombs into his room without his roommates’ knowledge despite the university having a policy of no firearms allowed in the dormitories. A resident advisor who knew the individual made the statement that[the student] was a good person; I know that in my heart.… He was a bit socially awkward, but I would never have guessed something like this, and he never gave me any indication or reached out to me for help.

      Ordway D-M, Hudak S. James Seevakumaran ends checklist with: ‘Give them hell.’ Orlando Sentinel website. http://articles.orlandosentinel.com/2013-03-19/community/os-ucf-death-james-seevakumaran-20130319_1_fire-alarm-dorm-room-ucf-police. Published March 19, 2013. Accessed July 11, 2013.

      The only potential warning signs that could have been identifiable before the suicide/mass shooting plan were that the student had not paid for the semester (suggesting possible financial problems) and that he was described by some as a loner with a possible temper issue.

      Ordway D-M, Hudak S. James Seevakumaran ends checklist with: ‘Give them hell.’ Orlando Sentinel website. http://articles.orlandosentinel.com/2013-03-19/community/os-ucf-death-james-seevakumaran-20130319_1_fire-alarm-dorm-room-ucf-police. Published March 19, 2013. Accessed July 11, 2013.

      , 

      Couwels J, Ford D. Former university student found dead in dorm planned larger attack. CNN website. www.cnn.com/2013/03/18/us/florida-ucf-body-found. Updated March 18, 2013. Accessed March 18, 2013.

      However, neither of these are necessarily rare in college-aged males. In a review of school shootings, Petri
      • Preti A.
      School shooting as a culturally enforced way of expressing suicidal hostile intentions.
      J Am Acad Psychiatry Law. 2008; 36: 544-550
      noted that roughly half the events studied had some potential action that warned about upcoming violence; however, this also means that for the other half, the individual seemed no different than usual or looked like an average if not normal student.
      A University spokesman later made a statement regarding the financial situation of the student who had planned the mass shooting there:We want to give students every opportunity to get their education. Some students have a hard time making payments on time, so we have been compassionate about that in the past and certainly in this case. [But] what took place is going to make us evaluate if that's the right policy.

      UCF attack plotter could've been evicted in September: university looks into dorm eviction process among students. WESH.com website. www.wesh.com/news/central-florida/orange-county/UCF-attack-plotter-could-ve-been-evicted-in-September/-/12978032/19421874/-/5e26lvz/-/index.html#ixzz2YlZyJ3rW. Updated March 22, 2013. Accessed July 11, 2013.

      This highlights a concern that these events will result in schools and universities changing policies designed to give people the opportunity to complete school to potentially rigid policies with less flexibility, which could disproportionately affect students with mental illness.
      Unfortunately, after an event like this is discovered, there is often a hindsight bias or “20-20 hindsight.” Even physicians are susceptible to hindsight in our assessments of risk and must proceed with caution.
      • LeBourgeois III, H.W.
      • Pinals D.A.
      • Williams V.
      • Appelbaum P.S.
      Hindsight bias among psychiatrists.
      J Am Acad Psychiatry Law. 2007; 35: 67-73
      The scepter of mental illness may be raised because of tautologous logic such as “someone who was not mentally ill would not do something like this.” Although there is sometimes truth to this belief, caution is needed that mental illness not become the excuse for all violent crimes or shootings. Both authors of this article are forensic psychiatrists who have evaluated many people who have committed murder and other horrific crimes but were not mentally ill per se (eg, acts occurred due to intoxication, revenge, to send a message, or while engaging in “normal” criminal behavior such as a robbery). However, if every act of violence, especially involving a current or former student, is labeled as an act of mental illness, it may become difficult for nonviolent conscientious students with mental illness to obtain an education. As implied in the quote from the University spokesman, schools will start to become “less compassionate” toward students with difficulties and/or mental illness. Ironically, obtaining an education may actually be the best factor to help ensure economic stability, access to care, and insight into need to continue with treatment—which is best for the individual and the community.

      Mental health, SB 1484 (Fla 2013).

      Are Individuals With Mental Illness More Dangerous Than Those Without Mental Illness?

      Mental illness, in and of itself, is often cited as a risk factor for gun violence, by both gun control advocates and gun rights advocates. Although physicians are aware of the statistics that having a gun in the home leads to a higher risk of suicide, we may not realize what such statistics could imply about our patient population (Table 4). Physicians are forced to consider the question of whether our patients with mental illness are truly more likely to commit acts of violence. To date, the medical literature is split on this notion in general and even, to some degree, on the question of gun access and suicide (eg, whether a truly causal relationship exists or just observational data, with the National Academy of Sciences reporting that methodological limitations prevent credible demonstration that the association is causal
      • Price M.
      • Norris D.M.
      National Instant Criminal Background Check Improvement Act: implications for persons with mental illness.
      J Am Acad Psychiatry Law. 2008; 36: 123-130
      ).
      • Casiano H.
      • Belik S.L.
      • Cox B.J.
      • Waldman J.C.
      • Sareen J.
      Mental disorder and threats made by noninstitutionalized people with weapons in the National Comorbidity Survey Replication.
      J Nerv Ment Dis. 2008; 196: 437-445
      , 
      • Miller M.
      • Barber C.
      • Azrael D.
      • Hemenway D.
      • Molnar B.E.
      Recent psychopathology, suicidal thoughts and suicide attempts in households with and without firearms: findings from the National Comorbidity Study Replication [published correction appears in Inj Prev. 2009;15(4):288].
      Inj Prev. 2009; 15: 183-187
      , 
      • Weiner J.
      • Wiebe D.J.
      • Richmond T.S.
      • et al.
      Reducing firearm violence: a research agenda.
      Inj Prev. 2007; 13: 80-84
      In addition, we need to be careful how we use the term mental illness since definitions vary from state to state when it comes to legal implications.
      • Sterzer J.
      The good, the bad and the ugly: a 50-state survey exploring federal and state firearm regulations related to mental health.
      J Leg Med. 2012; 33: 171-191
      , 
      • Norris D.M.
      • Price M.
      • Gutheil T.
      • Reid W.H.
      Firearm laws, patients, and the roles of psychiatrists.
      Am J Psychiatry. 2006; 163: 1392-1396
      The condition that may most commonly come to mind when the public refers to mental illness and guns is schizophrenia, but as evident from a study by Casiano et al,
      • Casiano H.
      • Belik S.L.
      • Cox B.J.
      • Waldman J.C.
      • Sareen J.
      Mental disorder and threats made by noninstitutionalized people with weapons in the National Comorbidity Survey Replication.
      J Nerv Ment Dis. 2008; 196: 437-445
      the mental illnesses actually most likely to result in increased threatening behavior with a gun are bipolar disorder type 1 (adjusted odds ratio, 8.46; 95% CI, 4.01-17.88) and drug dependence (adjusted odds ratio, 5.59; 95% CI, 3.53-8.85), both potentially fluctuating, unpredictable states.
      Table 4Data on Mental Illness, Firearms, and Violent Acts
      Data from references
      • Price M.
      • Norris D.M.
      Firearm laws: a primer for psychiatrists.
      Harv Rev Psychiatry. 2010; 18: 326-335
      ,
      • Gostin L.O.
      • Record K.L.
      Dangerous people or dangerous weapons: access to firearms for persons with mental illness.
      JAMA. 2011; 305: 2108-2109
      ,
      • Walters H.
      • Kulkarni M.
      • Forman J.
      • Roeder K.
      • Travis J.
      • Valenstein M.
      Feasibility and acceptability of interventions to delay gun access in VA mental health settings.
      Gen Hosp Psychiatry. 2012; 34: 692-698
      , and
      • Price J.H.
      • Mrdjenovich A.J.
      • Dake J.A.
      Prevalence of state firearm mortality and mental health care resources.
      J Community Health. 2009; 34: 383-391
      ,
      • Monahan J.
      • Bonnie R.J.
      • Davis S.M.
      • Flynn C.
      Interventions by Virginia’s colleges to respond to student mental health crises.
      Psychiatr Serv. 2011; 62: 1439-1442
      ,
      • Appelbaum P.S.
      Violence and mental disorders: data and public policy [editorial].
      Am J Psychiatry. 2006; 163: 1319-1321
      ,

      Guns. Gallup.com website. www.gallup.com/poll/1645/guns.aspx. Updated September 3, 2013. Accessed July 13, 2013.

      .
      • •
        37% of the US population own guns
      • •
        For veterans, the gun ownership rate is 42%
      • •
        Homicide is more common in areas where homes have firearms
      • •
        52% of US suicides are completed with firearms
      • •
        67% of all US homicides are completed with firearms
      • •
        3%-5% of serious violent acts are directly attributed to mental illness
      • •
        Most of these violent acts do not involve firearms
      • •
        Most patients with mental illness have nothing to do with firearm deaths
      • •
        A survey of Virginia colleges after the Virginia Tech shootings in 2007 found that 4-year colleges occasionally utilized various protective interventions in response to mental health crises, although the number affected was usually small
      • •
        The Second Amendment gives citizens the right to bear arms, although the Supreme Court has ruled that limits can be placed on those adjudicated mentally ill
      Those trying to destigmatize the perception of mental illness will point to studies such as the MacArthur Foundation study that find no significant increased risk of violence between mentally ill individuals taking medication and those without illness.
      • Monahan J.
      • Steadman H.J.
      • Silver E.
      • et al.
      Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence.
      Oxford University Press, New York, NY2001
      Yet at the same time, widely used and well-referenced risk assessment instruments (such as the Historical, Clinical, and Risk Management [HCR-20] scale) consider a history of mental illness as a risk factor.

      Douglas KS, Guy LS, Reeves KA, Weir J. HCR-20 violence risk assessment scheme: overview and annotated bibliography (current up to November 24, 2008). University of Massachusetts Medical School website. http://escholarship.umassmed.edu/cgi/viewcontent.cgi?article=1362&context=psych_cmhsr. Accessed July 14, 2013.

      , 
      • Douglas K.S.
      • Ogloff J.R.
      • Nicholls T.L.
      • Grant I.
      Assessing risk for violence among psychiatric patients: the HCR-20 violence risk assessment scheme and the Psychopathy Checklist: Screening Version.
      J Consult Clin Psychol. 1999; 67: 917-930
      What further complicates the debate is that both may be correct. On the population level, individuals with mental illness may not be considerably more likely to commit a violent crime than those without mental illness, but on the individual level, once an individual has been identified (eg, committed a crime, made a threat, disruptive behavior), symptoms of mental illness can be an important factor.
      The MacArthur study of mental illness and violence risk, a well-designed prospective longitudinal study, sought to overcome the methodological problems of other violence risk studies and thus included a range of potential risk factors (eg, demographic characteristics, personality factors, violence history, mental disorder and symptoms, and social support) and careful definitions of violence, (eg, including self-report as well as collateral information about violence), studied a large segment of the population, and was conducted at 3 American sites.
      • Monahan J.
      • Steadman H.J.
      • Silver E.
      • et al.
      Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence.
      Oxford University Press, New York, NY2001
      Patients were initially interviewed while psychiatrically hospitalized and had a diagnosis of affective or thought disorder, substance abuse, or personality disorder. They were also interviewed 10 and 20 weeks later. Psychopathy, prior violence, socioeconomic disadvantage, substance abuse, and anger were associated with violence, as were persistent thoughts of violence. A diagnosis of major mental disorder was correlated with a lower violence risk. Delusions and hallucinations were not associated with violence; however, a paranoid attitude or command hallucinations of violence increased the likelihood of violence. It must be remembered that this study, arguably the most comprehensive of its kind, only included violence occurring within 20 weeks after hospital discharge.
      Much uncertainty remains regarding our ability to predict violence. For example, misunderstandings are rife on the topic of violent fantasies. Little research has addressed this issue. Some assert that violent fantasies are warning signs of risk.
      • Gellerman D.M.
      • Suddath R.
      Violent fantasy, dangerousness, and the duty to warn and protect.
      J Am Acad Psychiatry Law. 2005; 33: 484-495
      However, others theorize that the most gentle among us may harbor violent fantasies, which may be a safe way of dealing with angry emotions as illustrated in the title of Dr Robert Simon’s book, Bad Men Do What Good Men Dream.
      • Day T.R.
      • Hall R.C.W.
      Déjà vu: from comic books to video games; legislative reliance on “soft science” to protect against uncertain societal harm linked to violence v. the First Amendment.
      Oregon Law Rev. 2010; 89: 415-452
      , 
      • Hall R.C.W.
      • Day T.
      • Hall R.C.W.
      A plea for caution: violent video games, the Supreme Court, and the role of science.
      Mayo Clin Proc. 2011; 86: 315-321
      , 
      • Simon R.I.
      Bad Men Do What Good Men Dream: A Forensic Psychiatrist Illuminates the Darker Side of Human Behavior.
      1st ed rev. American Psychiatric Publishing Inc, Washington, DC2008
      To date, there is no community study adequately addressing whether violent fantasies truly predict future dangerousness.
      • Gellerman D.M.
      • Suddath R.
      Violent fantasy, dangerousness, and the duty to warn and protect.
      J Am Acad Psychiatry Law. 2005; 33: 484-495
      In one study, 73% of male undergraduates and 66% of female undergraduates reported having at least one homicidal fantasy in their lifetime, suggesting that violent fantasies may be quite common but rarely acted on.
      • Kenrick D.T.
      • Sheets V.
      Homicidal fantasies.
      Ethology Sociobiol. 1993; 14: 231-246
      Many of those who have perpetrated mass gun violence—such as Jared Lee Loughner and James Eagan Holmes—displayed symptoms of a mental illness that affected their ability to participate in formal education for months to years before actually engaging in their acts of violence. In addition, acts such as these have a low base rate and therefore have the potential for high false-positives in terms of risk assessment, especially long term.
      • Freedman R.
      • Ross R.
      • Michels R.
      • et al.
      Psychiatrists, mental illness, and violence.
      Am J Psychiatry. 2007; 164: 1315-1317
      Only limited research has explored links between policies on gun ownership, violence, and mental illness. Price et al
      • Price J.H.
      • Mrdjenovich A.J.
      • Dake J.A.
      Prevalence of state firearm mortality and mental health care resources.
      J Community Health. 2009; 34: 383-391
      found that mental health resources within a state have little association with firearm death rates; however, education expenditures were more related. Recently, Sen and Panjamapirom
      • Sen B.
      • Panjamapirom A.
      State background checks for gun purchase and firearm deaths: an exploratory study.
      Prev Med. 2012; 55: 346-350
      found that states with background checks for gun purchases that include mental illness and fugitive status have lower rates of firearm suicide deaths than states checking only for criminal history, but checking for mental illness did not independently affect homicide rates. Although criminals often have a history of violence and mental illness (it is generally estimated that half of the prison population meets diagnostic criteria for at least one mental illness using a broad defination of “mental illness”), those with mental illness who have not committed a crime are often nonviolent.
      • Monahan J.
      • Steadman H.J.
      • Silver E.
      • et al.
      Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence.
      Oxford University Press, New York, NY2001
      Despite this fact and a dearth of research, the general public supports that access to firearms should be limited among those with mental illness, whether they have a criminal background or not, as a way to lower homicide rates.

      Guns. Gallup.com website. www.gallup.com/poll/1645/guns.aspx. Updated September 3, 2013. Accessed July 13, 2013.

      Do Physicians Ask About Guns? The Elephant in the Room?

      Surprisingly, another topic that has not been well studied is whether physicians ask their patients about firearm access. For a period of time, there was actually a presumptive ban on federally funded gun violence research. In 1996, Congress enacted a law banning Centers for Disease Control and Prevention funding for any research to “advocate or promote gun control.”
      • Weiner J.
      • Wiebe D.J.
      • Richmond T.S.
      • et al.
      Reducing firearm violence: a research agenda.
      Inj Prev. 2007; 13: 80-84
      , 

      Lowes R. Florida appeals defeat of gag law on physician gun queries. Medscape Medical News website. http://www.medscape.com/viewarticle/768470. Published August 1, 2012. Accessed April 9, 2013.

      This topic has been further complicated by proposed gun rights legislation prohibiting physicians from asking patients about firearms that was put forth in many states to address perceived antigun “discrimination” and “harassment” carried out by physicians.

      Lowes R. Florida appeals defeat of gag law on physician gun queries. Medscape Medical News website. http://www.medscape.com/viewarticle/768470. Published August 1, 2012. Accessed April 9, 2013.

      Such legislation was even enacted into law in Florida.

      Lowes R. Florida appeals defeat of gag law on physician gun queries. Medscape Medical News website. http://www.medscape.com/viewarticle/768470. Published August 1, 2012. Accessed April 9, 2013.

      Although there are some exemptions for emergency department physicians and mental health professionals, it has had a chilling effect in the state. The Florida law is currently being challenged in the courts, and it is unclear what the ultimate outcome will be.
      A recent Veterans Administration study found that this population of psychiatric patients (who have a higher suicide risk, as well as increased access and knowledge about firearms) perceived that access to firearms was only discussed in suicide/homicide risk assessments—and then only if the patients themselves expressed that their thoughts involved guns.
      • Walters H.
      • Kulkarni M.
      • Forman J.
      • Roeder K.
      • Travis J.
      • Valenstein M.
      Feasibility and acceptability of interventions to delay gun access in VA mental health settings.
      Gen Hosp Psychiatry. 2012; 34: 692-698
      However, these patients expressed that they believed physicians and mental health professionals should routinely discuss firearms.
      • Walters H.
      • Kulkarni M.
      • Forman J.
      • Roeder K.
      • Travis J.
      • Valenstein M.
      Feasibility and acceptability of interventions to delay gun access in VA mental health settings.
      Gen Hosp Psychiatry. 2012; 34: 692-698
      In addition to physicians not commonly asking about guns or educating patients about guns, many do not know enough about guns and gun safety to be able to do so in an educated manner.
      • Kaplan M.S.
      • Adamek M.E.
      • Rhoades J.A.
      Prevention of elderly suicide: physicians’ assessment of firearm availability.
      Am J Prev Med. 1998; 15: 60-64
      , 
      • Price J.H.
      • Kinnison A.
      • Dake J.A.
      • Thompson A.J.
      • Price J.A.
      Psychiatrists’ practices and perceptions regarding anticipatory guidance on firearms.
      Am J Prev Med. 2007; 33: 370-373
      Studies have found as few as 10% of mental health personnel know enough about guns to be able to understand what a patient owns, the potential risks associated with any particular type of firearm, or even how to counsel patients and families about gun safety.
      • Kaplan M.S.
      • Adamek M.E.
      • Rhoades J.A.
      Prevention of elderly suicide: physicians’ assessment of firearm availability.
      Am J Prev Med. 1998; 15: 60-64
      , 
      • Price J.
      • Mrdjenovich A.J.
      • Thompson A.
      • Dake J.A.
      College counselors’ perceptions and practices regarding anticipatory guidance on firearms.
      J Am Coll Health. 2009; 58: 133-139
      , 
      • Traylor A.
      • Price J.H.
      • Telljohann S.K.
      • King K.
      • Thompson A.
      Clinical psychologists' firearm risk management perceptions and practices.
      J Community Health. 2010; 35: 60-67
      , 
      • Khubchandani J.
      • Wiblishauser M.
      • Price J.H.
      • Thompson A.
      Graduate psychiatric nurse's training on firearm injury prevention.
      Arch Psychiatr Nurs. 2011; 25: 245-252
      In a survey study of psychiatrists by Price et al,
      • Price J.H.
      • Kinnison A.
      • Dake J.A.
      • Thompson A.J.
      • Price J.A.
      Psychiatrists’ practices and perceptions regarding anticipatory guidance on firearms.
      Am J Prev Med. 2007; 33: 370-373
      it was found that 45% had not “seriously thought” about discussing firearm safety with their patients, in part because 22% reported no personal knowledge of firearms, 54% reported not receiving information about firearm safety at any time (eg, in residency training), and only roughly a quarter had received information from professional journals or meetings (eg, had participated in continuing medical education courses on the topic). However, psychiatrists who had received information on firearm safety were 13 times more likely to counsel patients about firearms. Although the authors know of physicians who say that the only gun safety they need to know for any situation is “do not own a gun” or “no one should own one,” this view in the long run will be counterproductive to physician-patient communication. This approach shuts down communication and the opportunity for patient education before a real discussion can even begin.

      Conclusion

      In the not too distant past of the 1980s, the APA submitted an amicus brief in the case of Barefoot v Estelle that resulted in the United States Supreme Court stating, “Neither petitioner nor the APA suggests that psychiatrists are always wrong with respect to future dangerousness, only most of the time.”

      Barefoot v Estelle, 463 US 880 (1983).

      Physicians also needs to remember that:Violence is a complex, multicausal phenomenon, and [physicians] are not experts on all of its aspects. Our focus is on the individual factors that contribute to violence, especially among people with mental illnesses. The work of other disciplines, including sociology and criminology, has taught us that many other variables predict violence—often more strongly than the factors that [physicians] consider.
      • Freedman R.
      • Ross R.
      • Michels R.
      • et al.
      Psychiatrists, mental illness, and violence.
      Am J Psychiatry. 2007; 164: 1315-1317
      If physicians choose to put themselves in the position of being a potential solution to the problem of gun violence during the current national debate, we should make sure that we have the tools, system resources (eg, adequate police funding and training, greater treatment resources such as hospital beds), and legal justification (eg, clear indication of how not to violate civil rights and liberties and clear and nonconflicting laws) to back up the promise.

      Fisher CE, Lieberman JA. Getting the facts straight about gun violence and mental illness: putting compassion before fear [published online ahead of print July 9, 2013]. Ann Intern Med. http://dx.doi.org/10.7326/0003-4819-159-5-201309030-00679.

      , 
      • Gregory N.
      The link between mental health problems and violent behaviour.
      Nurs Times. 2004; 100: 34-36
      , 
      • Record K.L.
      • Gostin L.O.
      A systematic plan for firearms law reform.
      JAMA. 2013; 309: 1231-1232
      , 
      • Swanson J.
      Mental illness and new gun law reforms: the promise and peril of crisis-driven policy.
      JAMA. 2013; 309: 1233-1234
      , 
      • Swanson J.
      Mental illness and gun control—reply [letter].
      JAMA. 2013; 310: 98-99
      , 
      • Frattaroli S.
      • McGinty E.E.
      Mental illness and gun control [letter].
      JAMA. 2013; 310: 97-98
      , 

      Letter to Governor Andrew Cuomo from Medical Society of the State of New York and New York State Psychiatric Association, dated February 27, 2013, signed by Robert Hughes, MD, and Glenn Martin, MD. http://polhudson.lohudblogs.com/2013/03/20/mental-health-groups-seek-gun-law-changes-in-budget/. Accessed October 2, 2013.

      , 

      New York State Psychiatric Association. NYSPA issues press release on SAFE Act reporting requirements. New York State Psychiatric Association website. http://www.nyspsych.org/index.php?option=com_content&view=article&id=53:safe-act-press-release&catid=20:site-content. Accessed October 3, 2013.

      Otherwise, we just increase our own risk for liability. Particularly, physicians need to work with state legislators (see Table 2) to ensure that laws are crafted to not violate patient confidentiality, are written in a way that is applicable to the principles of medicine, do not turn physicians into “policemen” or agents of the state, and do not place physicians in the position of having to choose between our patients and the general public (as some could argue happened with the proposed Florida bill described in Figure 2).
      In addition, physicians can take steps to improve both our patients’ health and public safety by engaging in conversations with our patients about firearms and furthering our own knowledge on the topic (eg, attending continuing medical education courses on the topic, reading articles on the topic). We may not always be able to affect what our patients do or what laws are passed, but we can make a conscious effort to learn about the topic. Even if an individual’s personal belief is that “no one should own a gun,” they may consider taking a gun safety class themselves. This allows them to have firsthand knowledge, to have a better understanding of the potential dangers, and potentially to better communicate with their patients, beyond just mortality statistics and what not to do.

      Supplemental Online Material

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      Article Info

      Publication History

      Published online: October 18, 2013

      Footnotes

      See editorial comment, page 1191

      Potential Competing Interests: Dr Hall is a member of the National Rifle Association of America (NRA) but received no support or information in writing this article. He has received an honorarium from the National District Attorneys Association for being a presenter at Kid Safe programs related to pedophilia and computer crime.

      Identification

      DOI: https://doi.org/10.1016/j.mayocp.2013.08.016

      Copyright

      © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

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