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A Good Idea Shot Down: Taking Guns Away From the Mentally Ill Won't Eliminate Mass Shootings

Published:October 18, 2013DOI:https://doi.org/10.1016/j.mayocp.2013.09.007
      I never did like dead people and I never did like guns. That's why I never let my children play with guns,” says Mommy, the heroine in James McBride's biography of his mother, The Color of Water: A Black Man's Tribute to His White Mother.
      • McBride J.
      The Color of Water: A Black Man's Tribute to His White Mother.
      Mommy could be speaking for most of the American physicians, myself included, whose medical training has rarely incorporated gun safety classes while regularly reinforcing the passive and simplistic dogma that guns are evil and should simply go away.
      • Price J.H.
      • Kinnison A.
      • Dake J.A.
      • Thompson A.J.
      • Price J.A.
      Psychiatrists' practices and perceptions regarding anticipatory guidance on firearms.
      As a result, as Hall and Friedman
      • Hall R.
      • Friedman S.H.
      Guns, schools, and the mentally ill: potential concerns for physicians and mental health professionals.
      assert in this issue of Mayo Clinic Proceedings, we physicians generally do not know enough about firearms to have an informed conversation with our patients, let alone counsel them about gun safety. We also tend to ignore the reality that as long as the Second Amendment is the law of the land, the right to bear arms—and therefore personal gun ownership, whether of long guns for hunting or handguns for personal protection—will be an integral part of the American scene. Hall and Friedman also reference mass shootings in Australia, the United Kingdom, Canada, and Norway to remind readers that “school and mass shooting are not just an American problem”; they occur even in countries with firearm restrictions stronger than those in the United States, a fact often lost in media reports.
      Mommy continues, “But in those days, people used guns to hunt and live. This was the thirties, the depression, and folks were poor and they used guns and fishing rods to survive.”
      • McBride J.
      The Color of Water: A Black Man's Tribute to His White Mother.
      Firearms—then as now—were a basic element of the culture, as they continue to be in vast reaches of the United States, where hunting is experienced as a constitutional birthright, a marker of the seasons, a means of putting food on the table during tough times.
      Raised on Air Force bases and in the suburban Northeast, I grew up in a family devoid of hunters, target shooters, or any other type of gun enthusiasts. Meat came from the supermarket in the form of shrink-wrapped, styrofoam-palleted chunks of domestic farm animal. My grandmother had a vague recollection that her own grandfather from frontier Illinois had shot squirrels and other small game for fricassees or stews. But culinary game was for all intents and purposes merely the stuff of family legend. No one survived in our house on account of a gun. We had no tradition of stocking the larder with deer meat every fall. In short, guns seemed like implements of primitive, long gone “olden days.”
      Then I moved to the rural Midwest myself, a culture in which firearms are as ubiquitous as tractors and motorcycles, other icons of rural culture to which I had been heretofore unexposed. As I began reviewing the Hall and Friedman article, I noted that Hall disclosed that he is a member of the National Rifle Association. I was prepared to distrust the article on general principles, not only because of Hall's affiliation with the National Rifle Association but also for the article's heretical failure to condemn guns as public health menaces. Putting aside my pacifist prejudices and actually reading the piece, however, I readily followed the authors' arguments and found—to my shock and chagrin—that I agreed with them.
      In a carefully reasoned and extensively referenced essay, Hall and Friedman focus on the comparatively narrow issue of recent mass shootings committed by former or current university students, including those in Arizona (Jared Lee Loughner, 2011, 6 dead, 13 wounded, including US Representative Gabrielle Giffords), Colorado (James Eagan Holmes, 2012, 12 dead, more than 50 wounded), and Connecticut (Adam Lanza, 2012, 28 dead, including Lanza's mother and himself). The authors argue that these actions were not and could not have been prevented by more restrictive gun legislation. They further contend that a diagnosis of mental illness, per se, as was ex post facto determined to be the case with the aforementioned 3 university student shooters, does not justify stripping Second Amendment rights from all who carry such a diagnosis, most of whom will never commit violent acts toward others. Their essay also warns psychiatrists specifically—and physicians more broadly—that if they collude with the fallacy that they can predict gun-related tragedies initiated by mentally ill patients, then, as a downstream effect, physicians will (1) take on the role of policemen, responsible for ferreting out potentially dangerous criminals for the state, (2) assume greater legal and professional liability for the violent acts of patients from the target population, and (3) compromise the privacy and dignity of law-abiding citizens who carry a psychiatric diagnosis.
      Just because the general public wants to believe the tautology that heinous crimes must be the province of the mentally ill (because no one in his right mind would perpetrate such acts) does not make it so. In a nationwide Swedish study of 13 years of violent crimes such as homicide, aggravated assault, and robbery, individuals discharged from psychiatric hospitals with severe psychotic or affective diagnoses did have 3.8 times the odds of committing such crimes than did their non–mentally ill countrymen. However, their number relative to the general populace was so low that only 1 in 20 violent crimes could be attributed to them.
      • Fazel S.
      • Grann M.
      The population impact of severe mental illness on violent crime.
      These findings are consistent with earlier American studies, which estimated a 2- to 4-fold increase in the risk of violence by individuals with schizophrenia but only a 3% to 5% population-attributable risk.
      • Appelbaum P.S.
      Public safety, mental disorders, and guns.
      Calling the epidemiology of mass murder “counterintuitive,” Friedman and Michels
      • Friedman R.A.
      • Michels R.
      How should the psychiatric profession respond to the recent mass killings?.
      write that “we must explain an epidemiologic fact that the public likely finds counterintuitive in the wake of a mass killing: Although mass murderers probably have more psychopathology than other killers, the mentally ill as a group pose little risk of violence.” Moreover, Appelbaum
      • Appelbaum P.S.
      Public safety, mental disorders, and guns.
      warns that increased violence may not actually be a result of the mental illness itself but of comorbid substance abuse and sociopathic personality traits. Given these statistics, the American Psychiatric Association has questioned both the “fundamental fairness” of restricting firearm access for the mentally ill and the possibility that such restrictions could further stigmatize an already marginalized group.
      • Price M.
      • Norris D.M.
      Firearm laws: a primer for psychiatrists.
      It is important to remember that Hall and Friedman are not writing about homicides in general but about carefully planned mass killings. Their conclusions should not be extrapolated either to other forms of murder in which there is typically only a single victim or to suicide, a phenomenon that is more than twice as common as homicide in the United States.

      Suicide: Facts at a Glance 2012. Centers for Disease Control and Prevention website. http://www.cdc.gov/violenceprevention/pdf/Suicide-DataSheet-a.pdf. Accessed September 15, 2013.

      FastStats: Assault or Homicide. Centers for Disease Control and Prevention website. http://www.cdc.gov/nchs/fastats/homicide.htm. Accessed September 15, 2013.

      The phenomenon of suicide is exponentially more common than mass murder yet similarly difficult to predict.
      Reducing firearms access has been reported to reduce national rates of suicide. Reisch et al
      • Reisch T.
      • Steffen T.
      • Habenstein A.
      • Tschacher W.
      Change in suicide rates in Switzerland before and after firearm restriction resulting from the 2003 “Army XXI” reform.
      described what happened after the Swiss Army was halved a decade ago and personal gun ownership in that country declined proportionately in men of active duty age (18-43 years) whose only weapons had typically been issued by the army. The suicide rate by firearm for men in this age group decreased to 27%, simply because of disarmament. In an accompanying editorial drawing parallels to the American situation, Mann and Gibbons summarize literature that reports that 37 firearm suicides occur for every 1 self-defense homicide, that inhabitants of homes with guns have 5 times the risk of suicide death than do residents of gun-free homes, and that homes in which fatal suicide attempts have occurred have twice the gun ownership rate of homes in which attempts have not been lethal.
      • Mann J.J.
      • Gibbons R.D.
      Guns and suicide.
      Yet again, we must remind ourselves that Mann and Gibbons are reporting population-level statistics about suicide, with no applicability to isolated, though notorious, mass murders that grab the attention of a modern 24-7 media whose lurid imagery and apocalyptic language whip viewers into frenzies of misdirected terror at the bogeyman of the uncontained mentally ill. Appelbaum
      • Appelbaum P.S.
      Public safety, mental disorders, and guns.
      underscores “the absence of hard data linking serious mental disorders” to “episodes of mass violence” and notes that a seeming overrepresentation of the mentally ill among perpetrators may stem from “bias in the nonsystematic collection of such data.”
      US federal law nonetheless aligns with the terrified. Passed in the same year as the assassinations of both Robert F. Kennedy and Martin Luther King, Jr, the Gun Control Act of 1968 proscribed firearm ownership for substance-addicted and mentally ill persons.
      • Gostin L.O.
      • Record K.L.
      Dangerous people or dangerous weapons: access to firearms for persons with mental illness.
      In 1981, the paranoid schizophrenic John Hinckley grievously wounded then White House Press Secretary James Brady during an assassination attempt on President Ronald Reagan. A dozen years later, the Congress passed the Brady Handgun Violence Prevention Act of 1993, which (1) required federally licensed firearm dealers to institute a 5-day waiting period before turning over a handgun to the purchaser and (2) resulted in the establishment of the National Instant Criminal Background System (NICS) to track those to whom licensed dealers were forbidden to sell guns, including the mentally ill.
      • Price M.
      • Norris D.M.
      Firearm laws: a primer for psychiatrists.
      Despite congressional endorsements of the 1968 and 1993 Acts, the states have generated neither the will nor the way to actualize the federal laws, such as they are. The Supreme Court ruled in 1997 that the Congress could not require the states to report federally forbidden sales to the NICS and, 10 years later, 28 states had opted not to do so.
      • Gostin L.O.
      • Record K.L.
      Dangerous people or dangerous weapons: access to firearms for persons with mental illness.
      As evidence of the failure of the states to comply, the Federal Bureau of Investigation in 2006 reported that data for only 235,000 of a potential 2.7 million individuals with a disqualifying mental health history had been entered into the NICS.
      • Price M.
      • Norris D.M.
      Firearm laws: a primer for psychiatrists.
      Many states have apportioned inadequate funds to gather and transmit the necessary data or have no consistent protocols for ensuring that the data reach where they need to go. Hall and Friedman describe how James Eagan Holmes' psychiatrist had notified campus police of his potential dangerousness a month before the shootings, but the campus police did nothing more than deactivate his student identification card so that he could no longer use it for accessing the campus.
      • Hall R.
      • Friedman S.H.
      Guns, schools, and the mentally ill: potential concerns for physicians and mental health professionals.
      Individual states may even entertain frankly contradictory statutes. Having passed a law in 2011 that potentially bars physicians from asking patients about firearm ownership,
      • Cooke B.K.
      • Goddard E.R.
      • Ginory A.
      • Demery J.A.
      • Werner T.L.
      Firearm inquiries in Florida: “medical privacy” or “medical neglect”?.
      the Florida legislature less than 2 years later entertained a law requiring “mandatory reporting of mental health status for firearm safety” in reaction to a recent barely averted mass shooting at a state university.

      SB 1484: Mental Health. Florida Senate website. http://www.flsenate.gov/Session/Bill/2013/1484. Accessed September 15, 2013.

      Dying in committee, this potential legislation begged the question of how physicians could gather the necessary information, given the earlier proscription against asking about gun ownership.
      Even if the states were inclined to follow the Gun Control and Brady Acts to the letter of the law, gaping loopholes would render them toothless at keeping guns away from all “prohibited persons,” particularly those motivated to arm themselves regardless of the law. Unlicensed secondhand dealers at gun shows (the source of weapons used at Columbine High School) are required neither to seek background checks nor to honor a waiting period before turning over a purchased weapon.
      • Gostin L.O.
      • Record K.L.
      Dangerous people or dangerous weapons: access to firearms for persons with mental illness.
      Secondhand guns may routinely change hands without any oversight, as may guns passed between family members and friends. A chilling detail of the Sandy Hook shootings was that the killer needed to go no further than his own home to acquire his weapons: he killed his mother, 26 elementary school students and teachers, and himself with armaments from his gun-enthusiast mother's personal arsenal.
      • Mann J.J.
      • Gibbons R.D.
      Guns and suicide.
      In addition, does anyone in a nation with tens of millions of readily accessible firearms really believe that a determined killer who had taken weeks or months to plan an attack would be thwarted by mere feckless laws?
      • Price M.
      • Norris D.M.
      Firearm laws: a primer for psychiatrists.
      Even as I write, the latest American mass shooting has occurred, this one on a military base in Washington, District of Columbia, a scenario that had happened previously at Fort Hood, Texas (Nidal Hasan, 2009, 13 dead, 31 wounded), and Fairchild Air Force Base, Washington (Dean Mellberg, 1994, 4 dead, 23 wounded). In early reports from the Washington Naval Yard shootings on September 16 of this year, The New York Times observed that “many planets aligned to place” the mass murderer, Aaron Alexis, a Navy veteran, on a balcony inside the military facility with a Remington pump-action shotgun that he used to rain down death on 12 employees and gunshot wounds on 14 others.

      Gabriel T, Goldstein J, Schmidt MS. Suspect's past fell just short of raising alarm. The New York Times website. http://www.nytimes.com/2013/09/18/us/washington-navy-yard-shootings.html?pagewanted=all&_r=0. Accessed September 18, 2013.

      These “planets” orbit around the central themes of this editorial: (1) respect for civil liberties while fighting stigmatization of the mentally ill, (2) failure of state agencies to report outlandish or dangerous behavior to federal authorities, and (3) ready access to firearms as a cherished American right, flamboyantly hideous downsides notwithstanding.
      With regard to the first theme, failure to report, despite clear evidence of severe mental illness—auditory hallucinations and paranoid ideation that compelled Alexis to report to police a month before the shootings that people were following him and using a microwave machine to send vibrations into his body that caused insomnia—and despite his having sought treatment at 2 government-run hospitals for the sleeplessness he believed resulted from the vibrations, his psychiatric symptomatology was not considered egregious enough to trigger court-ordered involuntary psychiatric hospitalization. In a Fox News commentary,

      Krauthammer C. Is the USA a great country anymore? Foxnews website. http://video.foxnews.com/v/2679324742001/is-the-usa-a-great-country-anymore/?playlist_id=940325739001. Accessed September 18, 2013.

      Charles Krauthammer, a news analyst, physician, and psychiatrist, pointed out that increased civil liberties for the mentally ill in recent decades have resulted in decreased psychiatric commitments, even for an individual such as Alexis, who was floridly psychotic. In the absence of psychiatric commitment, there was no legal obligation to report his strange behavior to the NICS.
      With regard to the second theme, despite police in 2 states having investigated Alexis for bizarre shooting incidents

      Gabriel T, Goldstein J, Schmidt MS. Suspect's past fell just short of raising alarm. The New York Times website. http://www.nytimes.com/2013/09/18/us/washington-navy-yard-shootings.html?pagewanted=all&_r=0. Accessed September 18, 2013.

      —the first for having fired a gun through his apartment ceiling for unclear reasons and the second for having shot out a car's tires in anger at the driver—neither incident resulted in a report that reached a national database. In the road rage incident, a clerical error was cited to explain why the report was not filed. It is not hard to imagine that inadequate motivation and funding factored into the shoddy reporting up the chain of oversight for these events.
      Finally, when Alexis showed up in a Virginia gun store 2 days before the shootings, he was not permitted by Virginia state law to buy an AR-15 “black rifle” on the basis of the technicality that he was not a state resident. He was, however, allowed to purchase the shotgun he used in the killings because a federal background check revealed nothing about either a history of mental illness or the gun incidents described previously because they had never been entered into the NICS.

      Schmidt MS. State law prevented sale of assault rifle to suspect last week, officials say. The New York Times website. http://www.nytimes.com/2013/09/18/us/state-law-stopped-gunman-from-buying-rifle-officials-say.html. Accessed September 18, 2013.

      One could argue that the same American constitutional ideal that seeks to limit state impingement on individual rights both protects the mentally ill such as Alexis from being easily institutionalized and allows them to purchase firearms with comparative ease. It is also clear that the preventive measures that should have come into play to prevent Alexis from purchasing a gun–that is, measures that are obvious when viewed retrospectively–had little chance of playing out prospectively, given the severely flawed system of governmental oversight, accounting, and execution. And I wonder, if the government cannot properly intervene in such a clear case as that of Alexis, who had military security clearance and entered a “secure” military base carrying unauthorized guns, what chance is there it can intervene in other scenarios involving more “remote” areas of US geography, oversight, and culture (regardless of how one defines remote).
      Although Hall and Friedman have not persuaded me to like guns, they have resoundingly dispelled any lingering belief I might have entertained that laws designed to keep firearms from the mentally ill can prevent horrific school shootings such as those in Arizona, Colorado, and Connecticut or killings on military bases such as the recent Washington Naval Yard massacre. They have convinced me that firearms are here to stay and that wishing them away serves neither my patients nor myself. They have reminded me that the technology does not exist to predict which of my patients could “go postal.” And they have reinforced my commitment to ask all my patients whether they have access to firearms and, when they do, to get them to agree to store their guns safely, up to and including temporarily transferring them out of the home if they or their loved ones are in danger of using them for ill against themselves or others.
      In the final paragraph of their article, Hall and Friedman suggest that 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 communication with their patients….
      • Hall R.
      • Friedman S.H.
      Guns, schools, and the mentally ill: potential concerns for physicians and mental health professionals.
      Regardless of whether I fancy firearms, they have persuaded me to give their suggestion serious consideration.

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      1. Suicide: Facts at a Glance 2012. Centers for Disease Control and Prevention website. http://www.cdc.gov/violenceprevention/pdf/Suicide-DataSheet-a.pdf. Accessed September 15, 2013.

      2. FastStats: Assault or Homicide. Centers for Disease Control and Prevention website. http://www.cdc.gov/nchs/fastats/homicide.htm. Accessed September 15, 2013.

        • Reisch T.
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      3. SB 1484: Mental Health. Florida Senate website. http://www.flsenate.gov/Session/Bill/2013/1484. Accessed September 15, 2013.

      4. Gabriel T, Goldstein J, Schmidt MS. Suspect's past fell just short of raising alarm. The New York Times website. http://www.nytimes.com/2013/09/18/us/washington-navy-yard-shootings.html?pagewanted=all&_r=0. Accessed September 18, 2013.

      5. Krauthammer C. Is the USA a great country anymore? Foxnews website. http://video.foxnews.com/v/2679324742001/is-the-usa-a-great-country-anymore/?playlist_id=940325739001. Accessed September 18, 2013.

      6. Schmidt MS. State law prevented sale of assault rifle to suspect last week, officials say. The New York Times website. http://www.nytimes.com/2013/09/18/us/state-law-stopped-gunman-from-buying-rifle-officials-say.html. Accessed September 18, 2013.