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Insight www.thelancet.com/psychiatry Vol 1 October 2014 335 News Gun violence and mental illness The mass shootings perpetrated by troubled young men across the USA, most recently in Santa Barbara, California in May, 2014, have drawn the scrutiny of both the mental health system and the gun control laws as an anguished nation asks how these tragedies could have been prevented. There are no easy answers. While all the shooters exhibited disturbing behaviour before their attacks, their encounters with the mental health system run the gamut: Elliot Rodger, who fatally stabbed three people and shot and killed three others in the Santa Barbara incident, had been taken to see specialists as early as elementary school, whereas Jared Loughner, who killed nine people in Tucson, Arizona, purportedly began to manifest disturbing behaviour only as he approached legal adulthood, at which point he could no longer be compelled by his parents to get help. Similarly, existing laws should have prevented Seung-Hui Cho from buying the guns he used to kill 32 people at Virginia Tech, Blacksburg, Virginia, in 2007, whereas Rodger legally purchased his weapons in a state with some of the strictest controls in the country. Not surprisingly, in view of the complexity of the issue, a wide range of laws have been proposed to address gun violence and mental illness at the state and federal level, each with passionate supporters and detractors. Two bills currently in the House of Representatives propose to overhaul the administration of mental health services to varying degrees. Perhaps the most controversial proposal would establish or increase funding for existing assisted outpatient treatment programmes (also known as involuntary outpatient commitment programmes), in which the court makes compliance with a treatment plan a condition of remaining in the community. Another controversial component would give family members access to medical records that are at present protected by patient privacy laws. After Adam Lanza shot and killed 20 elementary school students and six adults in Newtown, Connecticut, USA, one parent felt compelled to speak out about her struggle with the mental health system and to become active in efforts to pass legislation to address its problems. Liza Long, whose viral blog post “I am Adam Lanza’s mother” described her efforts to get help for her young son—eventually diagnosed with bipolar disorder—supports the proposed measures, noting that the shortage of care for people with serious mental illness and the very high bar for involuntary admission to a psychiatric facility leaves a parent with few options, with juvenile detention or prison often substituting for medical care. Long is frustrated that the mental health system only garners widespread attention after a violent incident. “If we attacked [mental illness] as a medical problem instead of continuing to focus on it as a behavioural problem or as a societal safety problem, naturally safety would improve,” she said. Joe Bruce, a founding member of the non-profit organisation Treatment Before Tragedy, would also like to see changes to the system. He believes patients’ rights advocates went too far in helping his adult son, diagnosed with paranoid schizophrenia, refuse medication and avoid further treatment in hospital; shortly after Will Bruce was released from a psychiatric facility he killed his mother. “You watch this deterioration begin and there is very little that you can do in terms of early intervention. The biggest barriers to getting any kind of timely treatment are the commitment standards, the involuntary treatment standards.” While individual mental health proposals might be controversial, they do not come close to drawing the amount of attention and lobbying as legislation that would regulate access to firearms. There are an estimated 70 million gun owners in the USA and the National Rifle Association (NRA), the nation’s most powerful gun advocacy group, claims 5 million of these as members. Until recently, there was no comparably equipped organisation on the side of gun control, but billionaire and former Mayor of New York City Michael Bloomberg has changed that by throwing his financial resources into his group Everytown for Gun Safety. At the centre of any debate on gun regulation is interpretation of the Second Amendment to the Constitution, which simply states “A well-regulated militia, being necessary to the security of a free state, the right of the people to keep and bear arms, shall not be infringed”. But access to guns isn’t entirely unfettered. The Gun Control Act of 1968 regulates sales from federally licensed firearms dealers to prohibited individuals, including those who have been adjudicated as a mental defective (a term that is no longer in use but remains in this law) or that have been involuntary committed to a mental institution. In January, 2014, President Obama issued an executive order that would extend the prohibition to involuntarily outpatient commitments; the proposed regulation is currently under review. Background checks for guns purchased from federally licensed dealers were instituted by the Brady Handgun Violence Prevention Act in 1993, which established the National Instant Criminal Background Check System (NICS). NICS, which is maintained by the Federal Bureau of Investigation, is populated with federal and state records of those David Howells/Corbis

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Insight

www.thelancet.com/psychiatry Vol 1 October 2014 335

NewsGun violence and mental illnessThe mass shootings perpetrated by troubled young men across the USA, most recently in Santa Barbara, California in May, 2014, have drawn the scrutiny of both the mental health system and the gun control laws as an anguished nation asks how these tragedies could have been prevented. There are no easy answers. While all the shooters exhibited disturbing behaviour before their attacks, their encounters with the mental health system run the gamut: Elliot Rodger, who fatally stabbed three people and shot and killed three others in the Santa Barbara incident, had been taken to see specialists as early as elementary school, whereas Jared Loughner, who killed nine people in Tucson, Arizona, purportedly began to manifest disturbing behaviour only as he approached legal adulthood, at which point he could no longer be compelled by his parents to get help. Similarly, existing laws should have prevented Seung-Hui Cho from buying the guns he used to kill 32 people at Virginia Tech, Blacksburg, Virginia, in 2007, whereas Rodger legally purchased his weapons in a state with some of the strictest controls in the country.

Not surprisingly, in view of the complexity of the issue, a wide range of laws have been proposed to address gun violence and mental illness at the state and federal level, each with passionate supporters and detractors. Two bills currently in the House of Representatives propose to overhaul the administration of mental health services to varying degrees. Perhaps the most controversial proposal would establish or increase funding for existing assisted outpatient treatment programmes (also known as involuntary outpatient commitment programmes), in which the court makes compliance with a treatment plan a condition of remaining in the community. Another

controversial component would give family members access to medical records that are at present protected by patient privacy laws.

After Adam Lanza shot and killed 20 elementary school students and six adults in Newtown, Connecticut, USA, one parent felt compelled to speak out about her struggle with the mental health system and to become active in eff orts to pass legislation to address its problems. Liza Long, whose viral blog post “I am Adam Lanza’s mother” described her eff orts to get help for her young son—eventually diagnosed with bipolar disorder—supports the proposed measures, noting that the shortage of care for people with serious mental illness and the very high bar for involuntary admission to a psychiatric facility leaves a parent with few options, with juvenile detention or prison often substituting for medical care. Long is frustrated that the mental health system only garners widespread attention after a violent incident. “If we attacked [mental illness] as a medical problem instead of continuing to focus on it as a behavioural problem or as a societal safety problem, naturally safety would improve,” she said.

Joe Bruce, a founding member of the non-profit organisation Treatment Before Tragedy, would also like to see changes to the system. He believes patients’ rights advocates went too far in helping his adult son, diagnosed with paranoid schizophrenia, refuse medication and avoid further treatment in hospital; shortly after Will Bruce was released from a psychiatric facility he killed his mother. “You watch this deterioration begin and there is very little that you can do in terms of early intervention. The biggest barriers to getting any kind of timely treatment are the commitment standards, the involuntary treatment standards.”

While individual mental health proposals might be controversial, they do not come close to drawing the amount of attention and lobbying as legislation that would regulate access to fi rearms. There are an estimated 70 million gun owners in the USA and the National Rifle Association (NRA), the nation’s most powerful gun advocacy group, claims 5 million of these as members. Until recently, there was no comparably equipped organisation on the side of gun control, but billionaire and former Mayor of New York City Michael Bloomberg has changed that by throwing his fi nancial resources into his group Everytown for Gun Safety.

At the centre of any debate on gun regulation is interpretation of the Second Amendment to the Constitution, which simply states “A well-regulated militia, being necessary to the security of a free state, the right of the people to keep and bear arms, shall not be infringed”. But access to guns isn’t entirely unfettered. The Gun Control Act of 1968 regulates sales from federally licensed fi rearms dealers to prohibited individuals, including those who have been adjudicated as a mental defective (a term that is no longer in use but remains in this law) or that have been involuntary committed to a mental institution. In January, 2014, President Obama issued an executive order that would extend the prohibition to involuntarily outpatient commitments; the proposed regulation is currently under review.

Background checks for guns purchased from federally licensed dealers were instituted by the Brady Handgun Violence Prevention Act in 1993, which established the National Instant Criminal Background Check System (NICS). NICS, which is maintained by the Federal Bureau of Investigation, is populated with federal and state records of those

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Insight

336 www.thelancet.com/psychiatry Vol 1 October 2014

prohibited from purchasing fi rearms. The fl aws of NICS were exposed when it was found that Virginia Tech shooter Seung-Hui Cho’s prohibitory records had not been submitted to the system. The NICS Improvement Amendments Act of 2007 relies on grants to encourage states to submit records because it is illegal for the federal government to require them to do so.

Efforts to expand the background check system, which does not cover some sales at gun shows or on the internet, have failed as lawmakers from states with a strong gun culture fear they will lose re-election if they support any gun control legislation. Most notably, the Manchin-Toomey amendment, which specifically addressed many of the gun lobby’s concerns about background checks, failed despite closely following the tragedy in Newtown, Connecticut. Lobbyists asserted that it would allow the federal government to infringe on the 2nd Amendment rights of private citizens.

The firearm industry’s trade association, the National Shooting Sports Foundation (NSSF), and the NRA advocate instead to ensure that every state sends its records to NICS, which in some cases require a change to state laws that prohibit the release of mental health information. “The system is only as good as the records in it,” said Michael Bazinet, spokesperson for the NSSF.

Prohibition of the sale of semi-automatic weapons and large capacity magazines has also met with defeat at the federal level. A federal assault weapon ban enacted in 1994 expired after 10 years and was not renewed after strong lobbying against it. However, seven states, including California and Connecticut, have enacted their own bans.

In addition to such general gun-control provisions, lawmakers are looking for ways to specifically prohibit those in crisis from accessing guns. Congressman Mike Thompson of California, Chairman of the Gun Violence Prevention Task

Force, acknowledges that individuals with mental illness are more likely to be the victims of gun violence than the perpetrators but says “you can’t dismiss the fact that some people who have a dangerous mental illness can create problems and we’ve seen it happen. I think to ignore that would be foolish.”

He points to the case of Elliot Rodger, whose parents notified the police of their concerns about his threatening behaviour before his rampage. “The police went to the perpetrator’s home…but they didn’t take his guns away—they didn’t even know if he had guns. They had no incentive to find out because there is no provision in the law that allows those guns to be removed from a potential perpetrator’s possession.”

In addition to broadly strengthening mental health services, Thompson’s bill would give federal grants to states that create crisis intervention laws that allow such removals and that would temporarily prohibit the purchase and possession of a gun after an involuntary admission to an emergency psychiatric institution.

Although the bill establishes a process for restoration of the firearms after some time, the NRA is strongly opposed to it. “Not only is it unjustified and expansive in its prohibitions, it exploits and stigmatizes stereotypes of the mentally ill, most of whom do not pose an elevated risk of harm,” reads an NRA letter to its members regarding the bill. Catherine Mortensen, spokesperson for the NRA, elaborated, “Something really terrible can happen to someone and, because they might not react well, we want to ensure that just that one-time reaction doesn’t keep them from ever having access to a fi rearm.”

Josh Horwitz of the Coalition to Prevent Gun Violence sees an evidence-based approach as a way to avoid unnecessarily targeting individual groups while creating effective laws. He convened the Consortium for Risk-Based Firearm Policy, a group composed mainly of mental health and law professors from several universities, to examine what is known about gun violence and mental health. Their fi ndings support the current prohibitions and the proposed extension to involuntary outpatient commitment. They would add temporary restrictions to gun access after an involuntary admission to hospital for a mental health crisis.

The group also strongly recommends creating a gun violence restraining order (GVRO) similar to those available for domestic violence. “If your spouse is threatening you, you can get a domestic violence restraining order—you can get them removed from the house and you can get the fi rearms removed. If your spouse is being violent to themselves, or threatening someone else, or your son is doing that, there is nothing you can do until a crime is committed,” Horwitz explained. A GVRO bill is under ongoing consideration in the California state legislature.

Ultimately, though, the evidence showed that past acts of violence are the best predictor of future violence. “It doesn’t really matter whether you are committing violent misdemeanors because you are a criminal or prone to criminal behavior, because you are mentally ill, or because you are drunk. Once you have exhibited those types of behaviours you’ve increased the risk factor [for gun violence]”, Horwitz said. “If you care about the risk of violence, if you care about the small amount that is attributable to mental illness, you must care about the larger amount that is attributable to other types of behaviours. And then you should make sure that you’re addressing the whole problem.”

Jamie Kass

“If you care about the risk of violence, if you care about the small amount that is attributable to mental illness, you must care about the larger amount that is attributable to other types of behaviours.”