Mass shootings, gun ownership and mental health: What can the data tell us?

Gun Violence and Mental Illness: It’s Time to Change the Status Quo

An Ethical Response to Mass Shootings

(Reprinted with permission from APA Resource Document, June 2018).

Proceedings from the Second Medical Summit on Firearm Injury Prevention, 2022: Creating a Sustainable Healthcare Coalition to Advance a Multidisciplinary Public Health Approach.

Firearm Injury and Mortality Prevention in Pediatric Health-care Settings.

This column describes federal and state laws to restrict access to firearms among people with mental illness. The contribution to public safety of these laws is likely to be small because only 3%-5% of violent acts are attributable to serious mental illness, and most do not involve guns. The categories of persons with mental illnesses targeted by the laws may not be at higher risk of violence than other subgroups in this population. The laws may deter people from seeking treatment for fear of losing the right to possess firearms and may reinforce stereotypes of persons with mental illnesses as dangerous.

Back to table of contents Previous article Next article APA & MeetingsFull AccessHow Can Psychiatrists Contribute to Dialogue on Mental Illness and Violence?Mark MoranMark MoranSearch for more papers by this authorPublished Online:18 Feb 2020https://doi.org/10.1176/appi.pn.2020.2b28AbstractJonathan Metzl, M.D., Ph.D., has examined history to expose the ways that gender, class, race, and societal assumptions are intertwined with—and sometimes obscure—social and public policy issues such as guns and gun violence.Jonathan Metzl, M.D., Ph.D., says that psychiatrists can contribute to the conversation about guns and gun violence by focusing on the meaning of guns to people and how social networks—or their lack—influence gun violence.John Russell/Vanderbilt UniversityMaybe gun violence, including a mass shooting, is a simple thing: guy (or woman) with a gun pulls the trigger. Bang. Or maybe it is the violent intersection of any number of social and political influences: gun laws or the lack of them, socioeconomic status, racial and gender stereotypes, social networks (or their lack), and feelings of community connectedness.Jonathan Metzl, M.D., Ph.D., this year’s Benjamin Rush Award winner, will seek to untangle these social determinants of gun violence and how psychiatrists might usefully address them in the lecture “Mental Illness, Mass Shootings, and the Politics of American Firearms.”He is the Frederick B. Rentschler II Professor of Sociology and Psychiatry and the director of the Center for Medicine, Health, and Society at Vanderbilt University. The Benjamin Rush Award, established in 1967, recognizes an individual renowned for major contributions to the literature on the history of psychiatry.Metzl is the author of the recently published book Dying of Whiteness: How the Politics of Racial Resentment Is Killing America’s Heartland. In the book, Metzl examines how racial and class anxieties and resentments among white working-class Americans are connected to public policies—repeal of gun control laws and curtailments of school, health, and social support programs, including the Affordable Care Act—that have measurably hurt working-class Americans.It’s Metzl’s fourth book. In 2010 he published The Protest Psychosis: How Schizophrenia Became a Black Disease in which he examined how schizophrenia and race became intertwined and African American men came to be overdiagnosed with the disorder.Metzl’s 2003 book, Prozac on the Couch, traces the notion of “pills for everyday worries” from the 1950s to the early 21st century through psychiatric and medical journals, popular magazine articles, pharmaceutical advertisements, and popular autobiographical “Prozac narratives.”His recent work has focused on guns and gun violence, including mass violence, and the ways in which gun violence is falsely conflated with mental illness. In a 2015 article in the American Journal of Public Health, Metzl and co-author Kenneth MacLeish, Ph.D., wrote: “[N]otions of mental illness that emerge in relation to mass shootings frequently reflect larger cultural stereotypes and anxieties about matters such as race/ethnicity, social class, and politics. These issues become obscured when mass shootings come to stand in for all gun crime and when ‘mentally ill’ ceases to be a medical designation and becomes a sign of violent threat.”In comments to Psychiatric News, Metzl said his lecture will address how psychiatrists can meaningfully contribute to discussion and debate about guns. “A host of false assumptions surrounds the narrative that tries to connect mental illness with mass shootings,” he said. “You have to look at mass shootings in the context of gun laws, social networks or the lack of them, gender stereotypes, substance abuse, what guns symbolize for people—all of the other stories that get put on the back burner in the rush to focus on mental illness. These are the kinds of issues psychiatrists can address more meaningfully than trying to make individual-level predictions about who will be violent.” ■The lecture “Mental Illness, Mass Shootings, and the Politics of American Firearms” will be held Tuesday, April 28, from 10 a.m. to 11:30 a.m. The American Journal of Public Health article is posted here. “What Guns Mean: The Symbolic Lives of Firearms” is posted here. ISSUES NewArchived

Meeting the UN Sustainable Development Goals for mental health: why greater prioritization and adequately tracking progress are critical.

The Editors discuss how physicians, who have long been powerful voices in discussions of issues that threaten public health, should draw on similar motivations and strategies to promote sensible, e...

Mass shootings represent a major public health crisis. There are economic, health, and mental health consequences of these events. A number of causes of mass shootings have been investigated. One cause that has been hypothesized but not yet investigated is violent political rhetoric (VPR). The current study used publicly available data to test for an association between VPR and mass shootings. Independent variables included income inequality, gun ownership, changes in gross domestic product, and a measure of VPR. Lagged values of the dependent variable tested for generalized imitation effects. Results of an analysis of a 54-year time series of mass shootings showed positive associations between mass shootings and VPR and income inequality. Results also showed a negative association between changes in gross domestic product and mass shootings. There was no evidence of a relationship between mass shootings and either gun ownership or generalized imitation. Implications of these results for future research, as well as for social workers and social services in health and mental health settings, are considered, including the creation and implementation of social services and programs designed to create empathy for targets of VPR and to reduce the use of VPR.

#IAmNotDangerous and the politics of stigma

Using Mental Illness as a Scapegoat for Mass Shootings: The Perils of Being a Bystander in a World of Misinformation—A Psychologist's Perspective

Back to table of contents Previous article Next article Government & LegalFull AccessCongress Passes First Significant Gun Safety Bill in DecadesKatie O'ConnorKatie O'ConnorSearch for more papers by this authorPublished Online:20 Jul 2022https://doi.org/10.1176/appi.pn.2022.08.8.45AbstractThe Bipartisan Safer Communities Act provides funding for community-based violence prevention initiatives and state grants to create and implement red flag laws. Advocates say it is a small step in the right direction, but much more action is required to stymie gun violence.Every day, an average of 64 Americans die by firearm suicide, according to the Educational Fund to Stop Gun Violence. As of July 17, there have been 354 mass shootings in the United States this year, according to the Gun Violence Archive.Most Americans, including many gun owners, support basic measures to prevent gun violence, says Marc Manseau, M.D., M.P.H. These include universal background checks, safe storage requirements, and an assault weapons ban.Advocates have been vocal about the need to pass gun safety policies for decades, yet few such policies have been enacted, and gun violence has become a commonplace aspect of American life. In June, following several tragic mass shootings, including the shooting at Robb Elementary School in Uvalde, Texas, Congress passed the Bipartisan Safer Communities Act. President Joe Biden signed it into law on June 25.The legislation is the first significant federal legislative action to address gun violence prevention since the Brady Handgun Violence Prevention Act was passed in 1994, said Marc Manseau, M.D., M.P.H., co-founder of Psychiatrists for Gun Violence Prevention and a clinical assistant professor in the Department of Psychiatry at NYU Grossman School of Medicine.“It is a small step in the right direction and therefore a victory,” he said. “However, we must recognize that this is a small step, indeed, and we therefore mustn’t be lulled into complacency and inaction simply because it passed,” he continued.In a news release, APA outlined the major provisions included in the package for which it advocated, including the following:$750 million in grants for states to create, implement, and improve extreme risk protection orders (ERPOs), also known as red flag laws.Additional background checks for gun purchasers who are under age 21, including consideration of juvenile criminal records.$250 million in funding for community-based violence prevention initiatives.“This is a noteworthy, major piece of bipartisan legislation,” said Rebecca Capasso, M.D., membership coordinator for Psychiatrists for Gun Violence Prevention and a clinical assistant professor in the Department of Psychiatry at NYU Grossman School of Medicine. “I don’t think there’s any way forward in this country without compromising and working together across the political aisle.”The package also includes numerous provisions that support mental health programs. In the release, APA emphasized that it is inaccurate to link mental illness with violence.There is a lot of hesitancy among some psychiatrists to talk with their patients about guns, says Rebecca Capasso, M.D. “In training, we should be talking about how to speak to patients about this and encourage safe storage if they own guns.”“I’m very concerned that the legislation expands access to mental health care because that promotes the false narrative that attributes gun violence to people with mental illness,” Capasso said. “We know that to be patently false” (“Mental Illness Too Often Wrongly Associated With Gun Violence”).Capasso explained that the impulse to connect gun violence with mental illness may be rooted in the discomfort people feel with the complexity of violence. “People end up going to the very simplistic answer of ‘This person must be mentally unwell,’ rather than grappling with the multiple factors, including access to guns, that better explain why violence occurs,” she said.The mental health provisions included in the Bipartisan Safer Communities Act include the following:Almost $8 billion for the Medicaid Certified Community Behavioral Health Clinics program.$150 million to states to support the implementation of the National Suicide Prevention Lifeline’s new three-digit dialing code, 988, to improve crisis response and prevention programs.$500 million to the School-Based Mental Health Services program under Medicaid to increase the number of qualified mental health professionals in schools.$250 million to states through the Community Mental Health Services Block Grant.$80 million for the Pediatric Mental Health Care Access grant program.$60 million for mental health training for primary care clinicians.Assistance to states on how to increase access to telehealth services, among other items.The law’s mental health funding is potentially lifesaving, said APA President Rebecca Brendel, M.D., J.D., in the news release, as more than half of gun deaths are suicides.“We view this as the first step in a process that needs to continue,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., said in the release.Manseau noted the recent Supreme Court decision in New York State Rifle & Pistol Association v. Bruen, which struck down a New York law that limited when someone could carry a gun outside of the home. “It is very clear that we have a lot more work to do,” he said.“The fact of the matter is we have more guns per capita than most other countries in the world, except war-torn countries like Yemen, and that’s going to cause the U.S. to have far higher rates of gun violence, including suicide and homicide, than almost any other country,” Manseau said. “Until we grapple with that fact and the politics surrounding it, we are not going to solve our gun violence problem.” ■ResourcesAPA Statement on the Bipartisan Safer Communities ActThe Bipartisan Safer Communities Act ISSUES NewArchived

A conceptual framework for the revision of the ICD‐10 classification of mental and behavioural disorders

Among people with diabetes, co-occurring mental health (MH) or substance use (SU) disorders increase the risk of medical complications. Identifying how to effectively promote long-term medical benefits for at-risk populations, such as people with MH or SU disorders, is essential. Knowing more about how health care accessed before the onset of diabetes is associated with health benefits after the onset of diabetes could inform treatment planning and population health management. To analyze how preexisting MH or SU disorders and primary care utilization before a new diabetes diagnosis are associated with the long-term severity of diabetes complications. This cohort study analyzed medical record data from US Department of Veterans Affairs health care systems nationwide and used mixed-effects regressions to test associations between prediabetes patient or health care factors and longitudinal progression of diabetes complication severity from 2006 to 2015. Participants included patients who received a new diabetes diagnosis in 2008 and who were aged 18 to 85 years at the time of their diagnosis. Data analysis was conducted from March to August 2017. Patients were assigned to groups on the basis of a 2-year look-back period for MH or SU disorders status (MH disorder only, SU disorder only, MH and SU disorder, or no MH or SU disorder diagnoses) and on the basis of the amount of primary care utilization before diabetes was diagnosed. Nine-year trajectories of Diabetes Complication Severity Index (DCSI) scores. Among 122 992 patients with newly diagnosed diabetes, the mean (SD) age was 62.3 (11.1) years, 118 810 (96.6%) were male, and 28 633 (23.3%) had preexisting MH or SU disorders diagnoses. From the onset of diabetes to 7 years later, patients' mean estimated DCSI scores increased from 0.84 (95% CI, 0.82-0.87) to 1.42 (95% CI, 1.36-1.47). Controlling for sociodemographic characteristics and medical comorbidities, SU disorders only (decrease in DCSI score, -0.09; 95% CI, -0.13 to -0.04; P < .001) or both MH and SU disorders (decrease in DCSI score, -0.13; 95% CI, -0.16 to -0.09; P < .001), but not MH disorders only, were associated with lower DCSI scores at the time of the onset of diabetes compared with no MH or SU disorders. More than 90% of patients with MH or SU disorders had primary care visits before diabetes was newly diagnosed, compared with approximately 58% of patients without MH or SU disorders. Patients who had primary care visits before the onset of diabetes had lower baseline DCSI scores, compared with patients who did not have primary care visits (decrease in DCSI score, -0.41 [95% CI, -0.43 to -0.39] for 1-2 visits, -0.50 [95% CI, -0.52 to -0.48] for 3-4 visits, -0.39 [95% CI, -0.41 to -0.37] for 5-8 visits, and -0.15 [95% CI, -0.17 to -0.12] for ≥9 visits; P < .001 for all). Patients with MH or SU disorders had lower overall, but more rapidly progressing, mean DCSI scores through year 7 after the onset of diabetes (MH disorder only, 0.006 [95% CI, 0.005-0.008], P < .001; SU disorder only, 0.005 [95% CI, 0.001-0.008], P = .004; or both MH and SU disorders, 0.008 [95% CI, 0.006-0.011], P < .001), compared with patients without MH or SU disorders. Access to and engagement in integrated health care may be associated with modest, albeit impermanent, long-term health benefits for patients with MH and/or SU disorders with newly diagnosed diabetes.