It’s tempting to say that gun violence is about mental illness. The truth is more complicated.

Editor’s note: The opinions expressed by the authors do not necessarily reflect the views of the AAMC or its members.

The scale of gun violence in the United States lends itself to striking comparisons.

More civilians have been killed in our nation by firearms over the past 50 years than ever Soldiers who died in combat In all our wars combined. More American children and youth He died from a gunshot wound in 2020 more than any other reason. In recent years, our firearm homicide rate has increased 25 times higher from similar countries. And if we wrote on a granite wall the names of all those lost to gun violence in the past two decades, we would need a memorial 12 times bigger than the Vietnam Veterans Memorial.

Absolute numbers are equally realistic.

Since the beginning of the 21st century, an estimated 2.5 million people have been injured in shootings in the United States, and 750,000 of them have died. Although we have become increasingly accustomed to random shootings – a uniquely American nightmare on a recurring basis – the day of any such shooting in 2020 averages 134 else People who died from gunshot wounds. More than half of these deaths were suicides. Others were gang shootings, domestic violence incidents, or arguments worsened between drunken youths. American gun killing rate increase by 33% in 2020.

Each of these data points represents a short life, a heartbreaking story that adds to the dripping, dripping, and continuing dripping of gun violence in America.

Fourteen-year-old Eric died While walking home from school in a crime-ridden neighborhood of San Diego, he is shot and killed by one of five other teens, alleged gang members. Across town in a middle-class suburb, a very drunk man named Daniel Her boyfriend was shot dead from his estranged wife, and then shot himself. at a hospital in Tulsa, A surgeon named Preston He died when a former patient shot him and three other people with an AR-15 rifle. A young veteran of the Iraq war Tony, who has been diagnosed with post-traumatic stress disorder and is reeling from a divorce, called his mother at Christmas to tell her, “Never forget how much I love you” before shooting himself.

“Why would anyone kill all these innocent people?” This is the natural question when we learn of yet another senseless massacre with gunfire against strangers in a public place.

In a diverse country that has more guns than people and the right to bear arms is constitutionally protected, the complex mix of circumstances and cultural forces that fuel gun violence pose daunting challenges to those who hope to understand and address it.

What’s going on?

“Why would anyone kill all these innocent people?” This is the natural question when we learn of yet another senseless massacre with gunfire against strangers in a public place.

The answer we hear most often is “mental illness,” an explanation that fits the popular perception that people with severe mental illnesses are dangerous. But most violence, including fatal and near-fatal violence, is Not causally linked to mental illness.

Mental illness is very common in the United States. in 2020, About 20% of adults in the United States – 53 million people – met the criteria for at least one psychiatric diagnosis in the previous year, and approximately 6% – 14 million individuals – suffer from a serious mental illness such as schizophrenia, bipolar disorder or major depression. Given that many individuals have a mental health diagnosis and that the vast majority of these individuals are never violent, mental illness is too blunt a tool to be used as a useful indicator of risk for violence.

In fact, if serious mental illness suddenly disappeared, violence would decrease by only about 4%. More than 90% of violent incidents, including murder, will still happen.

Even mass shooters, who seem to be more likely to develop mental illness, don’t necessarily suffer from major mental disorders. Arguably one of the best reports on the subject, conducted by the FBI, found this Only 25% of these attackers He was diagnosed with a mental illness. Although accurate data on the status of gun bans for each mass shooter is difficult to obtain, Less than 5% of these individuals He had a record of mental weapon ineligibility court rulings, such as involuntary commitment to a mental health facility.

Meanwhile, “Why did he kill all these people?” It is a question so compelling that it seems to require an answer. If mental illness isn’t usually the cause, then what is? The honest response from science is that we don’t know all that much. Sometimes, there is a kind of alienation and indignant anger directed against the inhuman “other”. in rare cases, Severe psychotic symptoms Such paranoid delusions contribute to it. In addition, Crisis, trauma and great personal loss Common to some attackers, but these factors ultimately reveal little since they are common to many people who have never participated in a mass shooting.

The real story – and the real need – regarding mental illness and violence is suicide. Not only is suicide involved in most gun deaths, but most suicides are causally linked to mental illness.

Given these realities, wrongly placing mental illness at the center of the American gun violence narrative impedes solutions to each of these public health problems, which only converge on their edges.

Associating mental illness with violence reinforces stigma and undue fear of people with mental illnesses – people who need support to recover from serious brain-related conditions. In addition, some mental health advocates may be tempted to focus on violence in seeking critical funding for services, but doing so can lead to lopsided priorities, wrong resources, and wrong coercive interventions against people with mental illnesses.

The real story – and the real need – regarding mental illness and violence is suicide. Not only are most gun deaths suicides, but most suicides are Causally linked to mental illness.

Even when we look at suicide, the relationship between mental illness and risk is complex and nuanced. For example, there are significant gender differences in the role of both mental illness and firearms in suicide. Extensive research on suicide risk factors It indicates that mental illness is involved in about 7 out of 10 suicides among women, but only about half of men who die by suicide. Socioeconomic stressors are stronger determinants of suicide among men, who are also more likely than women to use a firearm to commit suicide.

Despite these complexities, it is clear that people who may be suicidal should not obtain firearms when they are most at risk. Suicide is often a fleeting impulse—many people who took large amounts of pills and survived later say they regret their suicidal act—and firearms offer little chance of survival.

What can we do?

To help address the risk of gun-related suicide, providers need the training, skills, and resources to systematically screen patients for depression and discuss firearm safety when clinically indicated. On an institutional level, hospitals and health care systems should also include policies and guidelines to facilitate universal screening for depression and to educate patients about firearm safety. For example, electronic health records can prompt doctors to examine patients and conduct firearms conversations.

Medical schools globally should teach future physicians the skills to discuss firearm safety. In fact, subject matter experts have been developed consensus guidelines To educate all medical professionals about gun injury and its prevention, And many institutions have it Strong efforts related to firearms. Part of this education should include discussing firearms with patients in ways that respect their values ​​and consider their cultural experiences. Ample guidance is available in this area, eg Use of jargon It is likely to resonate with different types of patients.

Clinicians should also learn ways to temporarily limit access to firearms when patients present a danger to themselves or others. Depending on the state, options for restricting access include extreme risk protection orders (ERPOs)—also known as red flag laws—in which family members and law enforcement officials may ask a judge to ask someone to temporarily give up their firearms. In addition, many states allow individuals who are concerned that they may harm themselves in the future Register voluntarily In a background check database that prevents them from purchasing a firearm without a waiting period.

In 19 states and the District of Columbia, doctors can also contact law enforcement to ask a judge to issue a restraining order to temporarily separate firearms from people at high risk of harm to themselves or others. in four states, authorized physicians To petition a court directly for an ERPO In compliance with HIPAA privacy rules And with some legal immunity. These orders are time-limited, carry no criminal penalties, and do not create a criminal record. They also provide due process protections, respect and uphold the Second Amendment The majority of Americansincluding the majority of gun owners.

We will never solve gun violence in America with “mental health reform.” This is a simplistic idea that focuses on a serious but different public health problem.

Indeed, the causes of gun violence in the United States are numerous and complex—and so are the solutions. But if we follow proven measures designed to prevent access to firearms among those most at risk of violence at the most dangerous times, we will move significantly in the right direction. If health care providers use their influence to advocate for evidence-based gun safety policies and practices; If we systematically implement firearm safety conversations into clinical care; And if we teach these skills to our future service providers, we will save many more lives than if we just acted heroically to treat yet another tragic shooting victim.

John Rozel, MD, MSL, is the medical director of crisis resolution at UPMC Western Psychiatric Hospital in Pittsburgh, and a psychiatrist at University of Pittsburgh, and Assistant Professor of Psychiatry and Assistant Professor of Law at the University of Pittsburgh. He divides his time between emergency psychiatry and violence prevention.

Jeffrey Swanson, PhD, is a professor of psychiatry and behavioral sciences at Duke University School of Medicine in Durham, North Carolina, and a faculty member of the Firearms Law Center at Duke Law School. He is a sociologist who collaborates across disciplines to build evidence for policies, laws, and interventions to improve outcomes for people with mental illness and prevent gun-related violence and suicide.

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