The Intersection of Mental Illness and Gun Violence: Examining the Evidence to Guide Sound Public Policy
■ The pervasive narrative linking mental illness to gun violence is harmful to individuals, families, and communities.
■ The widespread belief that mental illness drives mass shootings and interpersonal gun violence more broadly has shaped 50 years of gun control policy.
■ Family health professionals must actively engage in research, education, and outreach to shape effective policies around gun violence and mental health.
Gun Violence and the Perceived Link to Mental Illness
Gun ownership, gun control, and gun violence have long been contentious topics in national policy discourse. In its most recent report, the Small Arms Survey estimates that individuals in the United States own more than 393 million guns, representing nearly half of the world’s privately owned guns (Karp, 2018). In other words, there are more guns in the United States than there are residents, who numbered 325.7 million in 2017. The public health impact of resulting gun violence is staggering. The Centers for Disease Control and Prevention (CDC, 2017) reported that there were nearly 39,000 firearm-related fatalities in this country in 2016. Approximately 59% of those fatalities were due to suicide, and 37% to homicide. Each day in the United States, an average of 96 people are killed and more than 200 injured by guns (CDC, 2017).
Mass shootings account for approximately 1% of all firearm-related deaths in the United States—far fewer than suicide, intimate partner violence (IPV), and other gun-related violent crime—but they garner far more news coverage (Rozel & Mulvey, 2017). An increasingly common narrative emerging from these widely publicized tragedies is that individuals with mental illness are violent and that mass shootings and other acts of gun violence are the result of mental illness (Rozel & Mulvey, 2017). Much of the public has embraced this narrative. According to 2013 polling data collected in the aftermath of the 2012 Sandy Hook Elementary School shooting, people were more likely to blame the mental health system than easy access to guns for mass shootings; moreover, the majority of people surveyed supported increased spending on mental health screening and treatment as a gun violence prevention strategy (Swanson, McGinty, Fazel, & Mays, 2015). Public perception of a link between mental illness and gun violence is problematic for numerous reasons. It reinforces stigma around mental illness and potentially deters people from seeking treatment (Chappell, 2014; Swanson et al., 2015). Furthermore, this narrative distracts policymakers and the general public from responding in an empirically grounded way to the complex—and distinct—public health problems of gun violence and mental illness.
A wealth of evidence reveals that the vast majority of people with serious mental illness will never behave violently toward others (Swanson et al., 2015). When a person with mental illness does commit an act of violence, it can often be explained by the same risk factors that predict violence by people without mental illness. Among the most significant risk factors for interpersonal gun violence are socioeconomic disadvantage, abuse of illicit drugs or alcohol, and a history of trauma and/or violent victimization (Swanson et al., 2015).
Whereas mental illness only weakly predicts violence toward others, numerous studies have demonstrated a substantially higher risk of suicide among individuals with mental illness (Swanson et al., 2015). Notably, studies also show that access to firearms strongly contributes to suicide risk (Baumann & Teasdale, 2017): Individuals who commit suicide are more likely to have had access to guns in the home. Still, the narrative linking mental illness and gun violence remains narrowly focused on mass shootings while paying insufficient attention to gun-involved suicide.
Gun violence in any form affects families in a multitude of ways, each important to address. From our perspective as family health professionals, we must also consider the impact on families of the pervasive narrative linking mental illness to gun violence. For example, families convinced of the narrative may believe that it is unnecessary to practice safe firearm storage in the absence of a known mental illness in their family. As the narrative perpetuates untrue stereotypes against persons with mental illness, families in which mental illness is present may experience increased stigma and may avoid treatment out of fear that their rights and privacy will be violated. Given the evidence that serious mental illness in and of itself is not a predictor of future interpersonal violence (Price & Norris, 2010), family health professionals must advocate for policies that promote the safety and well-being of families and communities without reinforcing or exacerbating stigma related to mental health problems (Swanson et al., 2015).
Current Policy Landscape
Despite the lack of evidence, the widespread belief that mental illness drives mass shootings and interpersonal gun violence more broadly has shaped 50 years of gun control policy in the United States (Swanson et al., 2015). Since the 1968 passage of the Gun Control Act, a key component of federal policy has been to identify categories of individuals prohibited from purchasing guns. One such category is individuals with severe mental illness, generally defined in federal regulations as people who have been either involuntarily committed to the hospital or legally declared incompetent to stand trial or manage their affairs as a result of mental illness (Rozel & Mulvey, 2017). The 1993 Brady Handgun Violence Prevention Act and subsequent policies in the 2000s led to the creation and expansion of a national electronic registry, which relies on states to report their criminal justice and mental health records.
Various states have implemented additional policies addressing gun violence by persons with mental illness. For example, California and Florida have expanded gun ownership prohibitions against individuals who have been admitted to psychiatric hospitals (Swanson et al., 2015). New York went a step further when it passed the Secure Ammunition and Firearms Enforcement (SAFE) Act of 2013, which mandated that mental health professionals report to police the names of patients posing a “substantial risk” of violence. Police could then crossreference names with those in the state’s handgun permit registry and remove handguns from reported patients (Swanson et al., 2015).
Although state-level policies such as SAFE have not yet been adequately studied, there is scant evidence that placing mental health restrictions on guns effectively identifies individuals with mental illness who pose a significant risk of gun violence or deters those individuals from accessing guns (Swanson et al., 2015). A plausible reason for this is that most people who are at risk of violence have no record in the judicial or mental health systems that would disqualify them from owning a gun (Swanson et al., 2015). Even among those with legal disqualifications, there are avenues by which they may access guns (e.g., purchasing a gun online or at a gun show). Moreover, a large proportion of individuals in the United States live in households with guns, making it possible for them to engage in gun violence without having to purchase their own firearms (Rozel & Mulvey, 2017).
To address the intersection of mental health and gun violence, policymakers must develop policies that are evidence based rather than crisis driven. We agree with the numerous researchers, practitioners, and advocates who have called for robust research funding on gun violence causes, consequences, and prevention (e.g., Consortium for Risk-Based Firearm Policy, 2013; National Physicians Alliance and Law Center to Prevent Gun Violence, 2013).
On the basis of available evidence, we also support the adoption of state- and federallevel policies that restrict the purchase or possession of guns by individuals whose behaviors represent identifiable risk factors for violence (Consortium for Risk-Based Firearm Policy, 2013). For example, people subject to a restraining order for domestic violence, those with more than one conviction for driving under the influence of drugs or alcohol, or those convicted of a violent misdemeanor are more likely than others to pose a danger to themselves or others. Focusing on risk factors like IPV and substance abuse would enable policymakers and law enforcement to develop more effective criteria and processes for restricting access to or removing firearms from at-risk individuals. Furthermore, states should consider and evaluate gun violence restraining order laws, which allow family members and intimate partners to petition the court to temporarily remove guns from an individual with significant risk factors for causing harm to self or others (Frattaroli, McGinty, Barnhorst, & Greenberg, 2015).
Implications for Family Professionals
Family health professionals must actively engage in shaping policies and practices that acknowledge the complex realities and risks of firearm access and ownership in the United States (Rozel & Mulvey, 2017). Although evidence from other countries suggests that broadly restricting access to guns effectively reduces all forms of gun violence, such policy options are constrained in this nation by the constitutionally protected individual right to own firearms (Swanson et al., 2015). Thus, it is vital that we consider strategies for reducing the negative consequences of high rates of gun ownership. One strategy would be to develop and test trainings and resources for health professionals that are related to gun safety counseling, risk assessment, and violence management (Rozel & Mulvey, 2017). Family health professionals are well positioned to inform and implement evidence-based standards of care related to assessing families’ risk factors and promoting safer gun practices. It is incumbent upon us to educate families, communities, and policymakers that gun violence and mental illness are complex problems, each requiring a range of thoughtful responses. They are distinct problems that “intersect at their edges” (Swanson et al., 2015, p. 374). Policies based on a narrative that conflates the two will almost certainly fail to meaningfully reduce gun violence.
Baumann, M. L., & Teasdale, B. (2017). Severe mental illness and firearm access: Is violence really the danger? International Journal of Law and Psychiatry, 56, 44–49.
Brady Handgun Violence Prevention Act of 1994. Pub. L. No. 103-159, 18 U.S.C. § 921–922 (1994).
Centers for Disease Control and Prevention. (2017). Fatal injury reports, injury prevention & control: Data & statistics. Retrieved from https://webappa.cdc.gov/sasweb/ncipc/mortrate.html
Chappell, D. (2014). Firearms regulation, violence and the mentally ill: A contemporary Antipodean appraisal. International Journal of Law and Psychiatry, 37, 399–408.
Consortium for Risk-Based Firearm Policy. (2013). Guns, public health, and mental illness: An evidence-based approach for federal policy. Retrieved from www.jhsph.edu/research/centers-and-institutes/johns-hopkins-center-for-gun-policy-and-research/publications/GPHMI-Federal.pdf
Frattaroli, S., McGinty, E. E., Barnhorst, A., & Greenberg, S. (2015). Gun violence restraining orders: Alternative or adjunct to mental health-based restrictions on firearms? Behavioral Sciences and the Law, 33(2–3), 290–307.
Gun Control Act of 1968. Pub. L. No. 90-618, 18 U.S.C. ch. 44 § 921 (1968).
Karp, A. (2018). Estimating global civilian-held firearms numbers: Small Arms Survey. Retrieved from www.smallarmssurvey.org/fileadmin/docs/T-Briefing-Papers/SAS-BP-Civilian-Firearms-Numbers.pdf
National Physicians Alliance and Law Center to Prevent Gun Violence. (2013). Gun safety & public health: Policy recommendations for a more secure America. Retrieved from http://lawcenter.giffords.org/wp-content/uploads/2013/09/gunsafety-and-publichealth.pdf
New York Secure Ammunition and Firearms Enforcement Act of 2013. New York Senate Bill 2230 (2013).
Price, M., & Norris, D. (2010). Firearms laws: A primer for psychiatrists. Harvard Review of Psychiatry, 18(4), 326–335.
Rozel, J. S., & Mulvey, E. P. (2017). The link between mental illness and firearm violence: Implications for social policy and clinical practice. Annual Review of Clinical Psychology, 13, 445–469.
Swanson, J. W., McGinty, E. E., Fazel, S., & Mays, V. M. (2015). Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Annals of Epidemiology, 25(5), 366–376.