0Annals of Internal Medicine
Ideas and Opinions
Getting the Facts Straight About Gun Violence and Mental Illness: Putting Compassion Before Fear
Carl E. Fisher, MD, and Jeffrey A. Lieberman, MD
Discussions about gun policy reflect a growing willingness to treat gun violence as a public health issue. We emphatically support this movement and add our voices to the growing chorus of physicians calling for more stringent gun control.
Mental illness has figured prominently in the public dialogue, and we are concerned about its conflation with gun violence in both the popular press and the academic literature. This rhetoric too often portrays people with mental disorders as more dangerous or a greater part of the problem of gun-related violence than they actually are. Although we support reasonable restrictions on gun access among persons with mental illness, such measures will have only a small impact on gun-related violence. More important, we must provide better services for mentally ill persons, a need that is too easily overlooked when inordinate attention is paid to restricting their access to firearms.
Restricting Access
Although politically motivated funding cuts have restricted research on gun control, evidence indicates that tougher gun laws reduce the rates of gun-related deaths (1), and the presence of guns in the home increases the risk for suicide by firearm (2). Echoing the position taken by the American Psychiatric Association in 1993, we support the renewed calls for strong controls on firearm availability.
However, we believe that the potential danger of people with mental illness has been overstated as a reason to strengthen gun control. This sentiment is reflected in new measures, such as the vague reporting requirements for mental health professionals recently enacted in New York (3). At worst, people with mental illness have been demon-ized as "genuine monsters" who are largely responsible for the problem of gun violence (4), but even well-meaning advocacy groups often cite mental illness as a primary reason to strengthen background checks. The increasing public will to reduce access to firearms (3) should be directed appropriately. The links between mental disorder and violence should not be misrepresented for political ends.
Mental Illness and Violence
The best evidence on mental illness and violence indicates a 2- to 4-fold increase in violence for serious mental illnesses (such as schizophrenia, bipolar disorder, and depression) (5), but people with these conditions represent 3% to 5% of total violence (for example, as measured by records of violent crime) (6). Moreover, it is difficult to
predict which patients will become violent and when— under the best circumstances, even well-trained specialists do not perform much better than chance (7). Furthermore, the focus on violence can obscure the fact that many more firearm deaths are due to suicide than to homicide (8).
On a larger scale, the policies and laws that restrict firearm possession among people with mental disorders also attempt to predict violence risk, but they use broad, blunt criteria, such as a history of involuntary commitment or voluntarily seeking psychiatric treatment, to disqualify people from firearm ownership (9). These criteria often have limited relation to actual risk. Practical risk assessment would look at stronger predictors of violence, such as history of violence or loss of control while intoxicated. Inconsistencies are also prevalent in firearm policies. People who commit violent misdemeanors, such as assault and battery, have a much clearer risk for violent crime but can purchase guns in many jurisdictions.
Like any public health intervention, measures to restrict firearm access among people with mental disorders have disadvantages. Criteria that do not predict actual violence risk may be ineffective and waste resources. Furthermore, an undue focus on all persons with mental illness is discriminatory and stigmatizing and might discourage people with treatable mental disorders from seeking help.
Restricting access to guns is an effective public health measure, and an important component of this policy is to appropriately restrict access to firearms among the subset of people with mental illness who actually exhibit risk factors for dangerousness. But focusing only on restricting access would be a woefully incomplete response to the broader problem and would neglect other opportunities for positive change.
Role of Clinical Care
Given that treatment of mental illness significantly reduces the risk for violence (10), focusing solely on background checks is not enough. Many commentators have pointed to the examples of Seung-Hui Cho (Virginia Tech), Jared Loughner (Tucson), or James Holmes (Aurora, Colorado), all of whom had contacts with mental health professionals before those tragic events, to suggest that background checks could have stopped some mass shootings. However, voluntary treatment should not be (and, thankfully, is often not) a basis for inclusion on gun-restriction databases. Furthermore, many individuals with mental disorders simply lack access to adequate mental health care.
This article was published at www.annals.org on 9 July 2013.
© 2013 American College of Physicians 423
Ideas and Opinions Gun Violence and Mental Illness
Mental health treatment should be promoted as an end in itself. Public opinion polls support expanding such treatment to reduce violence (3). It is tempting to capitalize on this sentiment to call for increased funding, but there are ample reasons to advocate for better mental health services. State funding cuts are limiting access to needed public services, and criminalization of people with mental illness is a worsening public health crisis—persons with serious mental illness are more likely to be placed in jails and prisons than hospitals. The chilling fact that gun-related suicides far outnumber gun-related homicides shows how the effects of mental disorders on persons with these conditions can be overlooked when fear dominates the discussion.
Ultimately, providing much-needed mental health treatment may have some impact on reducing the small subset of violence attributable to mental illness, and any effect on a problem as devastating as gun violence is helpful. But it would be misguided to provide treatment to people with mental illness simply because of the fear that they may become violent. We should be careful that calls for increased funding for mental health treatment do not reinforce the false proposition that the problem of violence is largely a problem of untreated mental illness. We urge physicians to thoughtfully consider the facts when discussing the role of mental illness in gun violence and, beyond the issue of gun violence, to advocate for mental health care as a meaningful goal in itself, putting compassion before fear.
From Columbia University College of Physicians and Surgeons, New York, New York.
Disclaimer: The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the American Psychiatric Association, New York State Psychiatric Institute, or of any other agency or organization.
Acknowledgment: The authors thank Marc Manseau for helpful comments on this topic.
Potential Conflicts of Interest: Disclosures can be viewed at www .acponline.org/authors/icmje/ ConflictOflnterestForms.do?msNum = M13 -0717.
Requests for Single Reprints: Jeffrey A. Lieberman, MD, Department of Psychiatry, Columbia University, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032; e-mail, jlieberman @nyspi.columbia.edu.
Current author addresses and author contributions are available at www .annals.org.
Ann Intern Med. 2013;159:423-424.
References
1. Violence Policy Center. States with higher gun ownership and weak gun laws lead nation in gun death [news release]. Washington, DC: Violence Policy Center; 24 October 2011. Accessed at www.vpc.org/press/1110gundeath.htm on 10 May 2013.
2. Wintemute GJ, Parham CA, Beaumont JJ, Wright M, Drake C. Mortality among recent purchasers of handguns. N Engl J Med. 1999;341:1583-9. [PMID: 10564689]
3. Barry CL, McGinty EE, Vernick JS, Webster DW. After Newtown—public opinion on gun policy and mental illness. N Engl J Med. 2013;368:1077-81. [PMID: 23356490]
4. Remarks from the NRA press conference on Sandy Hook school shooting, delivered on Dec. 21, 2012 (Transcript). The Washington Post. 21 December
2012. Accessed at http://articles.washingtonpost.com/2012-12-21/politics /36018141_1_mayhem-with-minimum-risk-nra-wayne-lapierre on 13 March
5. Swanson JW. Mental disorder, substance abuse, and community violence: an epidemiological approach. In: Monahan J, Steadman HJ, eds. Violence and Mental Disorder: Developments in Risk Assessment. Chicago: Univ Chicago Pr; 1994:101-36.
6. Fazel S, Grann M. The population impact of severe mental illness on violent crime. Am J Psychiatry. 2006;163:1397-403. [PMID: 16877653]
7. Swanson JW. Explaining rare acts of violence: the limits of evidence from population research. Psychiatr Serv. 2011;62:1369-71. [PMID: 22211218]
8. Centers for Disease Control and Prevention. FastStats A to Z. Accessed at www.cdc.gov/nchs/fastats on 16 June 2013.
9. Va. Code Ann. § 37.2-818 (2008).
10. Appelbaum PS, Swanson JW. Law & psychiatry: gun laws and mental illness: how sensible are the current restrictions? Psychiatr Serv. 2010;61:652-4. [PMID: 20591996]
4241 17 September 2013 | Annals of Internal Medicine | Volume 159 • Number 6 www.annals.org
Annals of Internal Medicine
Current Author Addresses: Drs. Fisher and Lieberman: New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032.
Author Contributions: Conception and design: C.E. Fisher, J.A. Lieberman.
Drafting of the article: C.E. Fisher, J.A. Lieberman.
Critical revision of the article for important intellectual content: C.E.
Fisher.
Final approval of the article: J.A. Lieberman.
www.annals.org
