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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

Is Keeping Firearms Out of the Hands of Mentally Ill People the Answer to Gun Violence?

The cultural divide over firearms in the United States is cavernous and appears unbridgeable. There seems to be no common ground, but increasingly there is one shared position: improving identification of mentally ill individuals while restricting their access to firearms.

Lawrence Gostin, JD

The public overwhelmingly supports limiting firearm access to persons with mental illness, which is consistent with the National Rifle Association’s position that “guns don’t kill people; people kill people.” The problem is that focusing solely or primarily on persons with mental illness will not quell firearm violence. (In the case of suicide attempts—a major factor in gun injuries and deaths—the link with mental illness, particularly depression, is stronger. But even here firearm restrictions have a powerful effect in reducing harms to vulnerable individuals [see box on Guns, Suicides and Mental Illness].)

The Gun Control Act of 1968 prohibits selling firearms to individuals involuntarily committed to a mental institution. The National Instant Criminal Background Check System (NICS), however, is badly flawed because states never enter many prohibited persons into the database. Obama Administration initiatives—a grant program and rule changes—seek to make it easier for states to enter information into the database, but this hasn’t resulted in significant improvements.Meanwhile, those who are in the system can easily avoid background checks, such as by purchasing firearms at a gun show—a notorious loophole. States can also issue “Brady permits,” allowing licensed sellers to waive background checks.

Guns, Suicides, and Mental Illness

There are nearly 20 000 suicide deaths by gun in the United States each year, representing about half of all US suicides. Although mass shootings often focus attention on the link between guns, homicide, and mental illness, the link between guns, suicide, and mental illness is far tighter, because depression (particularly when untreated) is a major risk for suicide.Yet a targeted approach to restricting gun ownership involves familiar problems: identification and stigmatization of those potentially at risk, as well as the prevalence of depression. And even keeping people with depression from owning guns will mean little if someone else in their household owns a gun.

By contrast, broader gun control measures, including to limit gun ownership, can have a major and immediate effect on reducing suicide. When Washington, DC, enacted the strong gun control legislation that the Supreme Court would ultimately overturn, gun suicides decreased 23%—without an attendant increase in other methods of suicide and without any change in suicide levels in surrounding areas. Meanwhile, US states with higher levels of gun ownership have higher levels of suicide.

In the wake of the Isla Vista shootings on May 23 and other mass killings, Congress and state legislatures circulated bills designed to keep firearms out of the hands of severely mentally ill individuals. House Democrats, for example, proposed on May 6 a major expansion of the number of mentally ill patients who would be barred from purchasing firearms. A bipartisan proposal last December powerfully incentivizes states to reform their standards for committing severely mentally ill persons to hospitals or outpatient treatment, while also authorizing court-ordered therapy and medication. California lawmakers are proposing a “gun violence restraining order” that would allow families to petition a court to bar a mentally unstable person from possessing firearms.

Historically, society has stereotyped persons with mental illness as dangerous, believing that restraining their liberty or rights would solve social problems. But the evidence does not support this position. Focusing on persons with mental illness allows politicians to claim they are acting in response to firearm violence, while neglecting the principal reason the United States has vastly greater gun deaths than any other developed country. The singular difference between the United States and the rest of the world is simply the number of firearms circulating in society.

What has long been understood in public health is that changing behavior is notoriously difficult. What is far more effective is to change the environment. In this case, limiting access to firearms would prevent many gun injuries and deaths—not just in mass shootings but also, more importantly, on the streets in every major city in the United States. (Mass killings account for only about 0.15% of all homicides but are given disproportionate attention in the media).

Although most mass killers are mentally ill, only a small minority of persons with mental illness is violent. Overall, only about 4% to 5% of overall violent crime can be attributed to persons with mental illness. At the same time, it is exceedingly difficult to predict violence based on a psychiatric diagnosis: psychiatrists’ predictions of violence are no better than chance. It is true that mental illness can be a risk factor for violence, but often only with comorbidities, such as alcohol or drug abuse. The latter are far more powerful predictors of violence than the diagnosis of mental illness. Still more powerful is a history of violence, particularly threatening or using a lethal weapon such as a firearm.

These data suggest that the legislative response to the Isla Vista murders deals with the problem of gun violence only at the margins. At the same time, the response reinforces deep and historical stereotypes of persons with mental illness as irrational and dangerous. At present, federal law restricts firearm access to persons involuntarily committed to a mental institution. This makes most sense, as civil commitment standards incorporate danger to self or others. Widening the net to voluntary admission or to outpatient treatment would not only be overinclusive but also would discourage persons with emotional problems to seek diagnosis and treatment. This would be the wrong result for individuals, their families, and society as a whole.

It is unlikely that it will be possible to stop all or most mass killings; there are too many isolated and angry people and too much access to the means of death. However, there are evidence-based courses of action fully available if the political will could be summoned.

First, and most simply, Congress could fix the badly broken system of reporting to the NICS, giving states more powerful incentives to comply. That would at least offer mental health and law enforcement professionals a reliable method of restricting gun access to those who are civilly committed. Closing the gun show loophole is also essential because legal norms should not be so easily skirted. It is only common sense that if lawmakers create a rule—in this case, banning gun access to civilly committed individuals—it should be enforced fairly and consistently.

Second, Congress could require national background checks for all firearm purchases, an approach that has overwhelming public support. It appears reasonable to make sure that everyone who buys a firearm should be checked to ensure he or she is fit to use the weapon responsibly. This does not interfere with the right of responsible individuals to bear firearms.

Third, restricting firearm access should focus on conduct demonstrating an elevated risk of dangerousness. This would include a history of violence, especially using a firearm. For example, individuals convicted of misdemeanors involving violence should be included within the category of those unable to own a firearm. This behavioral criterion is the best predictor of violent behavior and does not stereotype individuals or drive mentally ill persons underground.

There is a certain simplistic comfort to conflating guns, violence, and mental illness. However, although it may make policy makers feel better, it is unlikely to get to the core of the problem. The only way to meaningfully reduce violence is to prevent truly dangerous people from purchasing firearms and to enact reasonable limits on the means needed for lethal behavior.

About the author: Lawrence O. Gostin, JD, is University Professor and Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, and Director of the World Health Organization Collaborating Center on Public Health Law and Human Rights. His most recent book is Global Health Law (Harvard University Press).