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Mental Health Reform Will Not Reduce US Gun Violence, Experts Say

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JAMA

January 12, 2016

Charleston, South Carolina. Lafayette, Louisiana. Roseburg, Oregon. Colorado Springs, Colorado. Although these towns have little in common, they will be forever linked. In each of them in 2015, an individual with a gun opened fire in public places where people gather: a church, a movie theater, a college campus, and a health clinic.

Because the perpetrators of these and other widely publicized mass shootings are often described in news coverage as mentally ill outcasts, many people and their representatives in Congress view improving mental health services as the key to reducing gun violence.

But while few people would disagree with the need for mental health reform, scientists who study gun violence say it won’t make much of a dent in the number of homicides and attempted homicides committed with firearms. That’s because although mass shooters are likely to be mentally ill (but not necessarily diagnosed), high-profile mass shootings represent only a small fraction of US gun violence, the vast majority of which is committed by people who are not mentally ill. In addition, most people with mental illness are not violent; they are far more likely to be the victims than the perpetrators of shootings.

 

Rita Rubin, MA

People should realize that “even though it feels that mass shootings happen all the time, they’re still extremely rare,” said Jeffrey Swanson, PhD, a professor of psychiatry and behavioral sciences at Duke University.

Through early December 2015, about 450 individuals died in mass shootings in the United States last year, according to Mass Shooting Tracker, a crowd-sourced website that defines a mass shooting as one in which at least 4 people have been shot but not necessarily killed (http://bit.ly/1MuHpVL). Compare that with 11 208, the number of people killed in homicides committed with firearms in 2013, the most recent year for which the Centers for Disease Control and Prevention (CDC) has US data (http://1.usa.gov/1GEJ0TN).

“The link between guns and mental illness is a link that needs to be debunked, because at least 95% of violent acts are committed by persons without serious mental disorders,” said American Psychiatric Association President Renée Binder, MD, founding director of the psychiatry and law program and forensic fellowship at the University of California, San Francisco.

Only mass shooters might be more likely to be mentally ill, psychiatrist Jonathan Metzl, MD, PhD, noted in a recent article (Metzl JM and MacLeish KT. Am J Public Health. 2015;105[2]:240-249). Reports suggest that up to 60% of the perpetrators of US mass shootings since 1970 displayed such symptoms as acute paranoia, delusions, and depression beforehand, according to Metzl.

But the typical description of a mass shooter, “a young, alienated, isolated, troubled young man who might be somewhat delusional,” matches tens of thousands of other men who would never kill anyone, Swanson said.

“People refer to that as a needle-in-a-haystack problem,” said Binder, citing a meta-analysis of studies from Australia, Denmark, Finland, Germany, and the United Kingdom that estimated the annual risk of a person with schizophrenia killing a stranger to be 1 in 70 000 patients, assuming that 0.5% of the population has the illness (Nielssen O et al. Schizophr Bull. 2011;37[3]:572-579).

And it’s virtually impossible to dig out those needles, said Metzl, director of the Center for Medicine, Health, and Society at Vanderbilt.

“There’s no real psychiatric diagnosis that psychiatrists can use to predict which patient is going to commit a violent act and which isn’t,” he said. By blaming gun violence on mental illness, Metzl said, “we lose the sense of the larger contextual factors that surround the violence,” such as drinking, arguing with a spouse or neighbor, having access to firearms, and having a history of violence, all of which are statistically correlated with gun violence but not linked to mental health disorders.

Despite the evidence that most gun violence is committed by people who are not mentally ill, recent mass shootings have spurred a drive in Congress to overhaul the US mental health system for the first time since 1963, when President John F. Kennedy signed into law the Community Mental Health Act (http://1.usa.gov/1la9RlV), which led to the deinstitutionalization of people with mental illness.

Neither mental health reform bill currently in Congress mentions firearms, but the legislation’s sponsors have spoken of a connection.

When Rep Tim Murphy, PhD (D, Pa), first introduced the Helping Families in Mental Health Crisis Act in December 2013, he opened his speech with a mention of Sandy Hook Elementary, the Newtown, Connecticut, school where Adam Lanza fatally shot 20 children and 6 staff members a year earlier (http://1.usa.gov/1WYObdm). “If we want to prevent the Newtowns, Tucsons, Auroras, Pittsburghs, and Columbines, we have to do something comprehensive, research-based, and we have to do it now,” Murphy, a psychologist, said, referring to towns in which high-profile mass shootings have occurred.

And when Sen Bill Cassidy, MD (R, La), and Sen Chris Murphy (D, Conn) talk about the Mental Health Reform Act they introduced last August, they can’t avoid bringing up recent mass shootings.

The act “attempts to address the root cause of mass violence, which is recognized but untreated mental illness,” Cassidy, a gastroenterologist, said in a speech on the Senate floor October 21 (http://bit.ly/1HdMPUX).

He and Murphy introduced their legislation less than 2 weeks after 59-year-old John Houser opened fire July 23 in a Lafayette, Louisiana, movie theater, killing 2 people and wounding 9 before killing himself. Houser’s family had asked a judge to have a doctor evaluate him because he was a danger to himself and others, but he was never hospitalized against his will, a move that would have prevented him from legally buying a gun (http://reut.rs/1Pr0TeX). The discussion about mental health reform “right now, frankly, is being driven by tragedy,” Cassidy said in his October 21 speech.

His cosponsor, Murphy, who represents the state in which Newtown is located, acknowledged, “I don’t know that correcting the mental health system alone would have changed what happened in Newtown, but I know that if we fix our mental health system, we will have a downward pressure on the episodes of mass violence that happen in this country.”

The House and Senate bills, which are similar, would reduce mental health care coverage gaps in Medicare and Medicaid (Blair TR and Espinoza RT. JAMA. 2015;314[21]:2231-2232). They would eliminate the 190-day lifetime cap on Medicare coverage of psychiatric hospital inpatient stays, limit states’ ability to exclude medications for major psychiatric disorders from Medicaid formularies, and loosen limitations under Medicaid for inpatient care for patients 22 to 64 years old.

Changes proposed in the bills go beyond Medicare and Medicaid. They would modify the Health Insurance Portability and Accountability Act to allow physicians to share information about the care of mentally ill patients with their families, increase funding for outpatient treatment, and designate an assistant secretary for mental health and substance abuse within the US Department of Health and Human Services.

“Both bills will improve our nation’s mental health system by focusing on outcomes, breaking down barriers for individuals and families to access services and supports, and expanding the availability of evidence-based practices,” the National Alliance on Mental Illness said in a statement (http://bit.ly/1OoMFf0).

At the markup of the House bill on November 4, Democrats on the Energy and Commerce Health Subcommittee introduced a substitute bill that they say would better serve the needs of people with mental illness, particularly by providing funding for behavioral health programs, among other investments (http://1.usa.gov/1HA7aUV).

While the American Psychiatric Association has endorsed mental health reform, Binder is blunt about how the proposed legislation has little to do with people shooting other people and everything to do with the large number of people with mental illness who are homeless or incarcerated in the United States because they cannot get care.

As Swanson said, “we have more people with really serious disabling mental health disorders in jail than in the largest asylums in the middle of the 20th century

Little research has focused on identifying what will work to reduce gun violence. In the United States, Congress all but shut down federally funded gun research in 1996 when it cut $2.6 million, the amount the CDC had spent the previous year on gun research, from the CDC’s budget (Kuehn BM. JAMA. 2013;310[1]:21).

After Newtown, though, President Obama issued executive orders to bolster firearm research, spurring the CDC to commission the Institute of Medicine to develop a research agenda. In a June 2013 report, the institute identified 5 high-priority areas: the characteristics of gun violence, risk and protective factors, prevention and other interventions, gun safety technology, and the influence of video games and other media (http://bit.ly/1MgtXRr).

As far as Metzl is concerned, looking to mental health reform to lower the US rate of gun homicides sidesteps the real issue. “We have a major problem with gun violence in this country,” he said. “When we say it’s all a problem of mental illness, that’s really a diversionary tactic” to shift discussion away from the need for stronger gun control laws.

A recent observational study found that US high school–aged adolescents were less likely to have carried a gun in states with more restrictive overall gun control policies (Xuan Z and Hemenway D. JAMA Pediatr. 2015;169[11]:1024-1031). And an earlier study found that firearm homicides are lower in states that require retailers to check for restraining orders and fugitive status in the background of people who want to buy a gun (Sen B and Panjamapirom A. Prev Med. 2012;55[4]:346-350).

Unlike the United States, other high-income countries have restricted gun access in response to mass shootings. While there is a dearth of evidence of a causal relationship, homicide rates dropped precipitously after those countries made it more difficult for people to obtain firearms.

Australia is a prime example. In 1996, after a 28-year-old gunman armed with a semiautomatic rifle shot and killed 35 people and wounded 18 others in and around Port Arthur, a tourist area in Tasmania, that country’s federal government and states and territories implemented the National Firearms Agreement (http://1.usa.gov/YMvaOu). The agreement banned certain semiautomatic and self-loading rifles and shotguns, standardized license and permit criteria, and tightened the sale of firearms and ammunition (http://bit.ly/1QRJH3a). Firearms license applicants have to take a safety course and show a “genuine reason”—self-defense doesn’t count—for owning a gun. More than 700 000 prohibited weapons were surrendered in a national buy-back program in 1996 and 1997.

Since the 1996 gun law reforms, there have been no mass killings with guns in Australia (http://on.cfr.org/1GsTpkl), and the country has seen accelerated declines in firearm deaths, according to a recent article (Chapman S et al. Inj Prev. 2015;21[5]355-362). “Removing large numbers of rapid-firing firearms from civilians may be an effective way of reducing mass shootings, firearm homicides, and firearm suicides,” the authors concluded.

Between 2007 and 2012, the average annual rate of homicides by firearms per 100 000 population was 3.1 in the United States—about 15 times greater than the 0.2 rate in Australia, according to the Small Arms Survey, a Geneva, Switzerland, center that provides evidence-based information on small arms and armed violence to governments, policy makers, and researchers (http://bit.ly/1EAJtU9).

Whether anything comes of mental health reform on the national level remains to be seen, said Daniel Webster, ScD, MPH, director of the Center for Gun Policy and Research at the Johns Hopkins Bloomberg School of Public Health. And although suicide, which represents about two-thirds of US gun deaths, “is intertwined with mental illness,” Swanson wrote recently, “the most important modifiable risk factor is access to firearms,” not sweeping mental health reform (Swanson JW et al. JAMA. 2015;314[21]:2229-2230).

“We’re not going to live in a world where we don’t have people inclined to harm others and themselves,” Swanson said. “But we should not live in a world where they have such easy access to this incredible killing technology.”

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