Better Resident Training About State Gun Laws and Mental Health Needed

Gun violence and proposals for restrictive gun legislation continue to be a prominent topic in the media and the field of psychiatry. Public discourse and the significant media attention paid to high-profile cases of violence would lead one to believe that mental illness is responsible for the majority of these violent acts. The shooter in the October 25, 2023, shooting in Lewiston, Maine, for instance, reportedly may have been committed to mental health treatment in the months leading up to the attack, which was specifically highlighted by news coverage of the event.

Available research indicates that serious mental illness is not a major risk factor for gun violence, however. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), only about 3% to 5% of violent acts in the U.S. are perpetrated by people with serious mental illness. A 2015 study by Jeffrey Swanson, Ph.D., and colleagues in the Annals of Epidemiology identified prior violence, early trauma, and substance use as more likely indicators of violence than psychotic symptoms. Yet, in the field of psychiatry, the majority of states have involuntary hold and civil commitment laws that include gun-disqualifying clauses, with possible permanent restriction to own firearms. While it should be noted that access to firearms definitively increases an individual’s likelihood of death by suicide, under most state laws, firearm restriction is based purely on the presence of, rather than the reasons for, an involuntary hold/civil commitment. This raises many questions: What is the evidence behind these laws, how are they enforced, and why are they specifically directed at individuals placed on civil commitments and involuntary holds?

As residents training in different states and geographic regions with contrasting political leanings, civil commitment protocols, and firearm restriction policies, we have both encountered challenges in witnessing these state gun-disqualifying policies enacted and the uncertain impact on our patients. First, while federal law restricts gun ownership after an involuntary commitment, each of our states varies in how this occurs and how these laws are enforced.

In South Carolina, patients lose firearm access with involuntary commitment, but they may petition the court upon expiration of a commitment order and have their rights restored if justified by an evaluation conducted by a psychiatrist or the Department of Mental Health. In Washington, patients are prohibited from possessing or controlling firearms for six months following an initial involuntary hold. If detained by the court for longer periods, patients may lose permanent firearm access, including possession, control, and purchasing rights. Additional state-specific complexities, such as Voluntary Waivers and Extreme Risk Protection Orders (ERPOs, also known as red-flag laws), can complicate the public understanding of gun restriction and cause confusion on the role of health care professionals.

With so many questions, one would expect more formal training on this topic. However, to our knowledge, the Accreditation Council for Graduate Medical Education (ACGME) does not require residency programs to provide education on gun laws pertaining to people with mental illness. There have been several publications highlighting the need for resident-level teaching on this topic given significant knowledge gaps among practicing psychiatrists—most notably a March 2023 article by Joseph R. Simpson, M.D., in the Journal of the American Academy of Psychiatry and the Law titled “Education About Mental Health Firearm Laws Should Be Required in Psychiatry Residency Programs.”

Some of the challenges we have each faced during our training include notifying patients about gun restrictions, confusion about the laws among health care staff, misunderstandings about who will remove the weapons (if anyone), and fears about the underlying socioeconomic and racial inequities that may also be perpetuated through these policies. We have also felt conflicted in many instances, feeling responsible for the safety of patients while desiring to maintain their autonomy and civil rights in a largely paternalistic system.

As psychiatrists, we have a role in reducing stigma toward people with mental illness while also advocating for common-sense programs and policies regarding firearm access. It is apparent that there is unclear evidence for the varying statewide policies, and more research is needed on gun-disqualifying commitment laws and the identification of other risk factors for violent crime aside from mental illness.

Given public and professional misconceptions about this issue, we advocate for ACGME-mandated education. Our hope for the future of psychiatry and APA is to reduce public bias associating violence with mental illness and to foster knowledge within the medical community. ■