Gun Policy and Serious Mental Illness: Priorities for Future Research and Policy
Abstract
Objective
In response to recent mass shootings, policy makers have proposed multiple policies to prevent persons with serious mental illness from having guns. The political debate about these proposals is often uninformed by research. To address this gap, this review article summarizes the research related to gun restriction policies that focus on serious mental illness.
Methods
Gun restriction policies were identified by researching the THOMAS legislative database, state legislative databases, prior review articles, and the news media. PubMed, PsycINFO, and Web of Science databases were searched for publications between 1970 and 2013 that addressed the relationship between serious mental illness and violence, the effectiveness of gun policies focused on serious mental illness, the potential for such policies to exacerbate negative public attitudes, and the potential for gun restriction policies to deter mental health treatment seeking.
Results
Limited research suggests that federal law restricting gun possession by persons with serious mental illness may prevent gun violence from this population. Promotion of policies to prevent persons with serious mental illness from having guns does not seem to exacerbate negative public attitudes toward this group. Little is known about how restricting gun possession among persons with serious mental illness affects suicide risk or mental health treatment seeking.
Conclusions
Future studies should examine how gun restriction policies for serious mental illness affect suicide, how such policies are implemented by states, how persons with serious mental illness perceive policies that restrict their possession of guns, and how gun restriction policies influence mental health treatment seeking among persons with serious mental illness.
In recent years, a series of high-profile mass shootings have drawn public attention to an apparent link between serious mental illness and gun violence. Most persons with serious mental illness—which includes schizophrenia and bipolar disorder (1)—are not violent (2–5). However, several mass shooters—in the incidents at Virginia Tech University; in Aurora, Colorado; and in Tucson, Arizona—appear to have had serious mental illness (6–8), potentially reinforcing an already widely held connection in Americans’ minds between serious mental illness and violence. Most recently, in December 2012, Adam Lanza fatally shot his mother, 20 children, and six adults at Sandy Hook Elementary School in Newtown, Connecticut. Despite little evidence to suggest that Lanza had a mental illness, the news media and policy makers were quick to suggest the presence of an undiagnosed mental health condition (9–11). In response to these mass shootings, policy makers at the state and federal levels have proposed multiple policies to prevent persons with serious mental illness from having guns.
Policies to restrict access to firearms among persons with serious mental illness are popular among politicians and the American public. When asked about gun policy in the second presidential debate in 2012, President Obama consistently focused his responses on preventing persons with serious mental illness from having guns (12). A national survey conducted in January 2013 found that majorities of Americans—including gun owners, members of the National Rifle Association, and Republicans—supported policies to restrict gun possession by people with serious mental illness (13).
Despite their popularity, such gun restriction policies have generated controversy in the public health community (14–19). Research suggests a complex relationship between serious mental illness and violence, and little is known about whether gun restriction policies that focus on serious mental illness are effective in reducing gun violence by this group. Furthermore, although many violence prevention experts view gun restrictions in cases of serious mental illness as part of an incremental approach to reducing gun violence, many mental health experts fear that such policies could have unintended consequences for persons with serious mental illness, in two areas. First, some experts have expressed concern that such policies could exacerbate the public misperception that persons with serious mental illness are likely to be violent, thereby strengthening negative public attitudes toward an already stigmatized group (15,20,21). Second, they have asserted that these policies may have a chilling effect on treatment seeking, reasoning that persons with serious mental illness may be less likely to seek treatment if health care providers have the ability to restrict patients’ firearm rights (18,19).
These considerations play central roles in the ongoing political debates surrounding gun restriction policies for persons with serious mental illness. These debates are often uninformed by research, perhaps in part because the relevant research, stemming from both the mental health and violence prevention fields, is difficult to access and interpret. To address this gap, we provide a review of the available evidence related to the history and current context of gun restriction policies for persons with serious mental illness. We begin by providing an overview of gun restriction policies in the United States, including those currently under consideration at the state and federal levels, that pertain to persons with serious mental illness. We then summarize the evidence concerning the relationship between serious mental illness and violence, the effectiveness of policies restricting firearm possession among persons with serious mental illness, the potential for such policies to exacerbate negative attitudes about this population, and the influence of gun restriction policies on mental health treatment seeking. We conclude by identifying areas for future research.
Methods
We begin by providing overviews of federal and state gun restriction policies currently in place that address the population with serious mental illness. We then illustrate common types of proposed gun restriction policies for persons with serious mental illness currently under consideration at the state and federal levels. Information about gun restriction policies that apply to this population was collected from the THOMAS legislative database, which is the Library of Congress online database of all legislation in the current U.S. Congress; state legislative databases (available in some but not all states), which include legislation under consideration by state legislatures; prior review articles (22–25); and the news media.
In the second section of this review, we summarize the evidence regarding the relationship between serious mental illness and violence, the effectiveness of gun restriction policies for persons with serious mental illness, the potential for such policies to exacerbate negative attitudes about persons with serious mental illness, and the potential for gun restriction policies to have a chilling effect on treatment seeking among persons with serious mental illness. To identify the relevant literature related to each of these three issues, we searched the PubMed, PsycINFO, and Web of Science databases. Studies were identified with the following search terms: “mental illness” or “mental health condition” or “mental health disorder” or “psychiatric illness” or “psychiatric condition” or “psychiatric disorder” or “behavioral health condition” or “behavioral health disorder” AND “gun” or “firearm” or “violence” or “homicide” or “assault” or “gun policy” or “firearm policy” or “gun control policy” or “firearm control policy” or “public attitudes” or “stigma” or “treatment seeking” or “therapeutic alliance.” On the basis of results of this search, we included 34 articles, published between 1970 and 2013, in our review of the literature related to the effectiveness and consequences of policies restricting gun access by persons with serious mental illness. We conclude our brief review of the evidence related to such policies by identifying gaps in the literature and suggesting areas for future research.
Results
U.S. gun restriction policies for serious mental illness
Federal policies.
Although federal gun restrictions in cases of serious mental illness have existed since 1968, they were not implemented until the 1990s (22). The 1968 Gun Control Act made it a criminal offense for licensed gun dealers to sell a gun to persons “adjudicated mentally defective” or “committed to any mental institution” (26). However, licensed gun dealers had no way to identify persons prohibited from having a gun because of these (outdated and widely considered offensive) criteria until 1993, when Congress passed the Brady Handgun Violence Prevention Act (22,24). The Brady Act required the Federal Bureau of Investigation to create a background check system for gun sales (the National Instant Criminal Background Check System, or the NICS), which became operational for all firearm sales in 1998 (24). Identifying information for individuals who are prohibited from purchasing a firearm under federal law is entered into this system, which licensed gun dealers then check at point of sale—either by phone or electronically—to identify illegal purchases (24). Given the broad language related to serious mental illness in the 1968 Gun Control Act, in 1997 the Bureau of Alcohol, Tobacco and Firearms (ATF) issued regulations to define which persons with serious mental illness should be reported to the NICS (22). Under ATF regulations still in effect today, persons involuntarily committed to inpatient psychiatric care, persons found incompetent to stand trial or acquitted because of serious mental illness, and persons placed under legal conservatorship because of serious mental illness are prohibited from purchasing guns by federal law (22).
In 2007, nearly ten years after implementation of the background check system for gun sales, a majority of states did not report mental health records to the NICS (27). Reporting by states is voluntary, and in 2007 many states lacked the data systems necessary to connect information from mental health agencies, court systems, law enforcement, and the federal government (27). After the Virginia Tech mass shooting in 2007, Congress passed the NICS Improvement Act, which gave some states funding to develop the necessary data systems to transmit records to the NICS (27). Although state reporting of mental health records to the NICS has improved since 2007, the most recent available data (2011) suggest that 17 states have submitted fewer than ten records and four states have submitted none (27).
In addition to lack of technical infrastructure, several states have cited concerns about data confidentiality as the reason for not reporting mental health records to NICS (27). Although names of persons prohibited from purchasing a gun because of serious mental illness are reported to the NICS, no diagnosis or other medical information is transmitted (27). The legal barriers to such reporting under the Health Insurance Portability and Accountability Act (HIPAA), which protects disclosure of confidential health information (28), are unclear. Although no private medical information is transmitted to the NICS, health care providers and facilities must access private health information in order to prepare and submit records to the NICS.
In January 2013, President Obama ordered his administration to gather information about the scope of the problem regarding confidentiality of mental health records, with the ultimate goal of remedying “unnecessary legal barriers that prevent states from reporting information about those [with serious mental illness] prohibited from having guns” to the NICS (29). In April 2013 the Congressional Research Service (CRS) released a report concluding that if state law requires health care providers or agencies to report mental health records to the NICS, the HIPAA privacy rule does not prohibit disclosure (30). If, however, state law does not mandate reporting of mental health records to the NICS, the CRS concluded that health care providers “do not appear to have permission under the [HIPAA] privacy rule to use or disclose protected health information for the purpose of preparing and reporting mental health records to the NICS” (30).
State policies.
Policies to prevent persons with serious mental illness from having guns vary by state. Some state gun restrictions in regard to serious mental illness mirror federal law and prohibit gun ownership on the basis of involuntary commitment and adjudication of mental incompetence (22). However, involuntary commitment laws vary by state; a person involuntarily committed to inpatient psychiatric care in one state might not meet legal criteria for involuntary commitment in another state (31). In addition, some states have gun restriction laws that are stricter than federal law for cases of serious mental illness (22). For example, Virginia prohibits persons who have been involuntarily committed to either inpatient or outpatient care from having guns, and Maryland prohibits gun ownership among persons who have been either involuntarily or voluntarily hospitalized for serious mental illness for more than 30 days (22). These variations in state laws create variation in the types of records reported to the NICS for gun sales. For example, Virginia reports both inpatient and outpatient involuntary psychiatric commitments to the NICS, whereas other states report only inpatient commitments (27,32).
In practice, most gun restriction policies that concern serious mental illness prevent only the sale of guns from a licensed dealer. Several state policies also provide mechanisms for removal of guns from the possession of persons with serious mental illness. For example, Indiana passed a law in 2005 that allows police to seize guns without a warrant if they believe a person is dangerous as a result of serious mental illness or other reasons (33). In California, when a person is newly prohibited from having a gun because of serious mental illness, the person’s name is checked against a database of handgun and assault weapon owners (34). If the individual owns a gun, police can seize the firearm (34). In an example of what may be the most expansive firearms restrictions for people with serious mental illness, New York passed a law in January 2013 to require medical providers to report patients whom they believe are likely to harm themselves or others to law enforcement authorities, who could then seize the individual’s guns (35).
The duration of gun restrictions in cases of serious mental illness varies by state. Whereas some states permanently restrict firearm rights among persons meeting disqualifying mental health criteria, others have time-limited restrictions. In California, for example, persons determined in an emergency mental health evaluation to be a danger to self or others are prohibited from having a gun for five years (36). States also vary in terms of whether they have a policy to allow persons with serious mental illness to restore their legal firearm rights after being prohibited from having a gun (37). Although the details of these restoration policies vary by state, there are two main models in place. Some states, such as New York, have physicians certify that an individual’s firearm rights can be restored (22). Other states, such as Virginia, restore firearm rights through judicial proceedings that do not require physician certification (22,37). Some states also employ a hybrid of these models, where persons petition a court to have their firearm rights restored but must meet specific criteria similar to those used in the physician certification process. For example, Washington State requires evidence that an individual “no longer presents a substantial danger to himself or herself, or the public” (38), “has successfully managed the condition related to the commitment” (38), and has met several additional criteria before firearm rights are restored (38).
To be eligible for federal funding to help build the data systems necessary to report mental health records to the NICS under the 2007 NICS Improvement Act, states must have a firearm restoration policy in place (37). To date, over 20 states have policies to restore firearm rights to persons prohibited from having a gun due to serious mental illness (37).
Proposed policies.
Recent mass shootings have prompted policy makers to propose additional gun restriction policies in regard to serious mental illness. At the federal level, legislation to restrict firearm rights among persons required by a court to receive counseling or medication for mental illness has been introduced twice, in 2011 (39,40) and 2013 (41). In addition, current bills under consideration by the U.S. Congress propose to cut federal funding to states that fail to report mental health records to the NICS (42), to fund state programs to remove guns from the possession of persons prohibited from owning guns due to serious mental illness (43), and to permanently prohibit gun ownership among anyone who has ever been determined by a judge to be a danger to others as a result of serious mental illness (44).
States are also currently considering a wide array of gun restriction policy proposals that stipulate serious mental illness. Although most proposals involve improving reporting of mental health records to the NICS (45–47), others aim to expand state-level gun restriction policies in regard to serious mental illness. For example, Hawaii, Virginia, Maryland, and Tennessee considered legislation in 2013 to require health care providers and other professionals to report persons who make credible threats to themselves or others to law enforcement, which could then seize an individual’s guns (47,48). If passed, a New Jersey bill would require mental health screening by a licensed professional in order for individuals to purchase a firearm (49). Minnesota is considering legislation to create a system to allow persons to temporarily surrender their firearms if they have voluntarily requested to be prohibited from possessing guns for a specified period due to serious mental illness or other reasons (50). Although some or all of these proposals may never become law, the scope and variety of the gun restriction policies currently under consideration for cases of serious mental illness provide important context for the often heated political debates around the effectiveness and likely consequences of such policies.
Summary of research evidence
Relationship between serious mental illness and violence.
Despite the proliferation of serious mental illness–related gun restriction policy proposals in response to recent mass shootings, few studies have examined the effectiveness and potential unintended consequences of these policies. Most persons with serious mental illness are not violent, and only about 4% of all violence in the United States is attributable to mental illness (5). In community populations, the prevalence of violence among persons with serious mental illness is similar to the prevalence of violence among persons without serious mental illness (2%−4% in a given year) (2). However, absolute risk of perpetrating violence is heightened among persons receiving inpatient treatment for serious mental illness (51) and persons with untreated psychoses (52), and research consistently shows that risk of committing violence is heightened among persons with serious mental illness with comorbid factors such as substance use and history of abuse or trauma (2,3). These risk factors for violence are more prevalent among persons with serious mental illness than the overall population: a 2009 study using a national sample found that 46% of persons with schizophrenia had a lifetime history of a comorbid substance use disorder (2), compared with about 15% of the overall U.S. population (53).
Effectiveness of gun restriction policies for serious mental illness.
Existing risk assessment tools are reasonably accurate at predicting which persons with serious mental illness are unlikely to be violent but are poor at accurately predicting whether individuals are likely to perpetrate violence (54). Inability to accurately predict future violence makes it difficult to target policy interventions to the small subgroup of persons with serious mental illness who are at heightened risk of violence (55). A 2008 review concluded that using available tools, communities would need to detain “large numbers of patients who are potential offenders in order to prevent the actual offending of a few” (55).
Although some mental health experts have expressed skepticism regarding the effectiveness of gun restriction policies with a focus on serious mental illness (15), the difficulty of predicting violence by individuals with serious mental illness does not necessarily mean that gun restriction policies cannot prevent gun violence from this population. Until recently, no research existed to inform this question. In 2013, however, Swanson and colleagues (56) published findings from a study suggesting that current federal gun restrictions in cases of serious mental illness may reduce risk of violence from this population. In 2007, Connecticut began reporting to the NICS persons involuntarily committed to inpatient psychiatric care, persons found incompetent to stand trial or acquitted because of serious mental illness, and persons placed under conservatorship because of serious mental illness. To test the effects of the policy on violent crime, the authors assembled two cohorts of people with serious mental illness by using administrative records from Connecticut’s mental health and criminal justice agencies for the period 2002–2009 (56). The first cohort included persons with a diagnosis of schizophrenia, bipolar disorder, or major depressive disorder who had been prohibited from buying a gun under federal gun restriction policy because of serious mental illness. The second cohort included persons with the same diagnoses who had a voluntary psychiatric hospitalization during the study period but who were not prohibited from buying a gun for any reason.
Swanson and colleagues (56) found that in Connecticut implementation of federal gun restriction policy for serious mental illness was associated with reduced risk of arrest for violent crime in the cohort prohibited from having a gun because of serious mental illness. As expected, implementation of the policy had no effect on risk of arrest for violent crime in the second cohort of persons with serious mental illness, who were legally allowed to buy a gun (56). This finding suggests that implementation of current federal gun restriction policy may reduce violent offending by persons prohibited from having guns due to serious mental illness. However, only a small proportion of people with serious mental illness in the Connecticut cohort (7%) were prohibited from having a gun under federal gun restriction policy, and the effect of the policy on overall violent crime among the cohort with serious mental illness was minimal (56). Ninety-six percent of violent crime during the study period was committed by individuals who did not meet federal criteria for gun restriction as a result of serious mental illness (56).
Swanson and colleagues’ (56) findings should be interpreted in the context of several important limitations. The authors measured the effects of federal gun restriction policy for serious mental illness on overall violent crime, rather than specific gun-related crime, by persons with serious mental illness. Importantly, study results suggested that implementation of federal gun restriction policy in cases of serious mental illness reduced risk of violence among persons prohibited from having a gun solely due to serious mental illness. In contrast, among individuals prohibited from owning a gun in Connecticut because of both serious mental illness and a criminal disqualification (such as a felony conviction), risk of arrest for violent crime increased after implementation of federal gun restriction policy (56).
In conclusion, although one study suggests that implementation of federal gun restriction policy in cases of serious mental illness may prevent violent crime among persons with serious mental illness (56), the study had important limitations, and additional studies are needed. Effects of federal gun restriction policy in regard to serious mental illness may differ across states because of variation in involuntary commitment criteria, differences in public mental health systems, and presence or absence of other gun policies.
Negative public attitudes about persons with serious mental illness.
In addition to questioning the effectiveness of serious mental illness–related gun restriction policies, experts, advocates, and policy makers have expressed concern that such policies could strengthen negative public attitudes toward persons with serious mental illness by implicitly suggesting that this population is a threat to public safety (15). Negative public attitudes about persons with serious mental illness are pervasive and persistent in the United States. A national survey conducted in January 2013 found that 46% of Americans thought that people with serious mental illness are far more likely to be dangerous than the general population, and only 29% and 33% were willing, respectively, to have a person with serious mental illness as a work colleague or neighbor (13). Furthermore, whereas negative public attitudes toward common conditions such as anxiety and depression appear to have declined in recent years (57), negative public attitudes about serious conditions such as schizophrenia and bipolar disorder have remained steady (58) or, by some measures, increased (59). One study found that 31% of Americans viewed persons with psychosis as violent or frightening in 1996, compared with 13% in 1950 (59). In addition, results of a 2005 study showed that persons with serious mental illness, family members of persons with serious mental illness, and mental health clinicians held negative attitudes similar to those held by the general public (60).
Limited research exists regarding whether gun restriction policies in the case of serious mental illness contribute to these negative attitudes. A 2013 experimental study found that news media messages about gun restriction policies focusing on persons with serious mental illness did not exacerbate negative public attitudes toward persons with serious mental illness (61). Respondents in a nationally representative online survey panel were randomly assigned to a control group or to a group that read either a one-paragraph news story describing a mass shooting by a person with mental illness or a two-paragraph news story describing the same mass shooting by a person with mental illness as well as legislation to “require states to enter people with serious mental illness into a background check system used by gun dealers to identify people prohibited from buying guns, or face a penalty.” The control group did not read any news story (61). The study found that the news story describing the details of mass shooting events strengthened negative public attitudes about persons with serious mental illness compared with the control group, but the additional message about gun restriction policy as it pertains to serious mental illness did not exacerbate widely held negative attitudes (61).
Treatment seeking.
More than half of Americans with serious mental illness do not receive treatment in a given year, presenting a significant public health problem (62,63). Multiple factors appear to contribute to poor rates of treatment among persons with serious mental illness. In a national study, Kessler and colleagues (64) found that 55% of untreated persons with serious mental illness did not perceive a need for treatment. Among persons who perceived a need for care, reasons for failure to seek treatment included desire to solve the problem on their own (72%), thinking the problem would get better by itself (61%), high cost of treatment (44%), uncertainty about where to go for help (41%), and concern about what others might think (14%) (64). Mental health experts have identified stigma as a potentially important barrier to treatment seeking, but the research evidence is mixed. Some studies have shown that persons who perceive strong negative public attitudes about serious mental illness have poor treatment adherence and retention (65,66), but other studies show no link between negative public attitudes and treatment outcomes in college-age populations (67,68). In contrast, a recent review showed that negative personal attitudes—“personal stigma” or “self-stigma”—consistently deter mental health treatment seeking (68).
In the ongoing debate concerning gun restriction policy proposals related to serious mental illness, mental health experts and clinicians have expressed concern that such restrictions could have a chilling effect on treatment seeking in an already undertreated population with serious mental illness (18,19,35). Experts have worried that this population may be less likely to seek mental health treatment, and less likely to engage in meaningful therapeutic relationships during treatment, if health care providers have the ability to restrict patients’ firearm rights (18). Our search, however, identified no studies examining the effects of gun restriction policies on mental health treatment seeking.
Given that we found no studies directly examining the potential chilling effects of gun restriction policies on mental health treatment seeking, we considered relevant examples of chilling effects in other contexts. Immigration policies, for example, have been shown to prevent undocumented immigrants from seeking health care (69,70), but few examples related to mental health or violence prevention exist. Like gun restriction policies that cover serious mental illness, the Tarasoff duty-to-warn laws passed by many states in the 1970s—which require mental health professionals to warn potential victims when a patient expresses a credible threat (71)—prompted concerns related to treatment seeking (72). Mental health experts worried that duty-to-warn laws would discourage patients from seeking treatment, potentially increasing rates of violence by deterring from care patients at high risk of committing violence (72,73). A 2011 white paper by Edwards (74) suggests that states’ implementation of mandatory duty-to-warn laws was associated with a small increase in homicides in those states, but our search found no studies in the peer-reviewed literature examining the effects of duty-to-warn laws on either mental health treatment seeking or violent crime.
Priorities for future research
Despite the proliferation of gun restriction policy proposals after the Sandy Hook Elementary School shooting in December 2012, we are faced with critical gaps in the research around these policies as they concern serious mental illness. The limited existing literature regarding the effectiveness of gun restriction policies targeting serious mental illness, the potential for such policies to exacerbate negative attitudes about persons with serious mental illness, and the potential for gun restriction policies to inhibit mental health treatment seeking among those with serious mental illness suggest a need for future research. Five key gaps in the existing literature should be addressed. To date, little is known about how implementation of federal gun restriction policy for serious mental illness affects violence by persons with serious mental illness in states with different policy, political, and demographic contexts; the effects of gun restriction policies on suicide; how to best implement gun restriction policies in cases of serious mental illness; attitudes about gun restriction policies in the population with serious mental illness; and the effects of gun restriction policies on mental health treatment seeking.
Although recent findings by Swanson and colleagues (56) indicate that federal gun restrictions in cases of serious mental illness appear to prevent arrests for violent crime in Connecticut, it is unclear how implementation might affect violence from this population in other states. State variation in factors such as criteria used for involuntary commitment, demographic characteristics, prevalence of gun ownership, gun policies, and availability of mental health services may influence the effects of federal gun restriction policy pertaining to serious mental illness. Future research should evaluate the effects of implementation of federal gun restriction policy in diverse states across the nation.
To date, no studies have examined how gun restriction policies for serious mental illness affect suicide. According to the Centers for Disease Control and Prevention Web-Based Injury Statistics Query and Reporting System database, 60% of all gun deaths in the United States are suicides, and although most suicide attempts do not involve guns, they are used in half of suicide fatalities (75,76). Firearm availability is associated with heightened risk of suicide (77–79), and suicide is the tenth leading cause of death in the United States and the second leading cause among young adults ages 25–34 (76). Studies show a consistent link between mental illness and risk of suicide (80–82), and depression is the mental health condition most strongly associated with suicide risk (80). Given that depression rarely leads to involuntary commitment to psychiatric care, however, it is unclear how existing federal gun restriction policy for serious mental illness might affect suicide (56). Innovative state-level gun restriction policies could also affect suicide: an evaluation of Indiana’s law allowing police to seize weapons without a warrant if they believe an individual is dangerous because of serious mental illness or other reasons found that weapons were most commonly seized in cases related to suicide (33).
Although it is critically important not to criminalize suicide, carefully implemented gun restriction policies—for example, with voluntary components, with time-limited restrictions, and integrated with existing initiatives such as crisis response programs—have the potential to reduce suicides. Suicide rates have remained high in recent years (76), and the Surgeon General has identified suicide as a public health priority (83). Future research should consider how existing state and federal gun restriction policies focusing on serious mental illness may affect suicide.
Little is known about implementation of state gun restriction policies for cases of serious mental illness. One exception is Parker’s 2010 study (33) of implementation of Indiana’s law allowing police to seize firearms from dangerous persons without a warrant. Parker found that after two years of implementation of this law, suicide was the leading reason for gun confiscation (56% in 2006 and 71% in 2007) and that serious mental illness was a factor in only 10% of cases. In contrast, little is known about how other states, California for example, implement laws that allow or require law enforcement to seize the guns of persons with serious mental illness. How often are guns seized under each type of serious mental illness restriction? What is the process for seizing guns? What are the boundaries of legal authority to search for and seize guns of individuals prohibited from possessing guns due to serious mental illness? Answers to these questions are critical to understanding both the effectiveness and unintended consequences of proposed policies.
Stigma, in particular, can be both exacerbated and mitigated by the details of policy implementation. For example, having a trained crisis response team call ahead and subsequently arrive in an unmarked car to seize firearms may be less stigmatizing than having local police arrive unannounced, with their lights flashing, for the same purpose. While multiple state and federal policies to seize firearms from persons prohibited from having a gun due to serious mental illness are currently under consideration, implementation of such policies is an important area for future research.
Research studying the implementation of gun restriction policies in the case of serious mental illness should be accompanied by studies examining the attitudes of persons with serious mental illness toward such policies. To our knowledge, only one relevant study exists. A 2012 study examined veterans’ support for several gun restriction proposals as a means to prevent suicide (84). Study results suggested that veterans were potentially willing to support a policy that would temporarily remove guns during periods of high risk of suicide (84). However, veterans’ tentative support for such a policy was contingent on characteristics of implementation, including having a trusted clinician make the determination of suicide risk (84). Although many veterans supported the idea of temporary gun removal to prevent suicide, they questioned where guns would be stored, who would have access, and how difficult it would be to have firearms returned (84). These findings suggest that implementation may play a critical role in whether persons with serious mental illness support gun restriction policies that pertain to them; this is an area that warrants future research. In addition, although one study suggests that gun restriction policies in the case of serious mental illness do not exacerbate negative public attitudes toward persons in that population (61), it is unclear how such policies influence the attitudes of the persons with serious mental illness. With literature showing that self-stigma is adversely related to treatment seeking (68), understanding how persons with serious mental illness perceive gun restriction policies that pertain to their condition is an important area for research.
Finally, to our knowledge no studies exist to inform the question of whether gun restriction policies have a chilling effect on treatment seeking by persons with serious mental illness. This issue plays a central role in political debates about gun restrictions in the case of serious mental illness, but to date no research exists to inform those debates. The potential for gun restriction policies or other reporting requirements to inhibit mental health treatment seeking should be a priority for future research.
Conclusions
Multiple state and federal gun restriction policies that pertain to serious mental illness have been proposed in response to recent mass shootings, but research related to such policies is limited. Although limited evidence suggests that current federal gun restriction policy may prevent violent crime among persons with serious mental illness, little is known about the potential for such policies to prevent suicide, how policy initiatives are implemented by states, and how persons with serious mental illness perceive these gun restriction policies. Future research should prioritize study of how such gun restriction policies influence mental health treatment seeking.
Acknowledgments and disclosures
The authors gratefully acknowledge the prior contributions to the literature on mental illness and violence by Jeffrey Swanson, Ph.D., M.A., whose work has informed much of the evidence reviewed in this article.
Dr. Webster served as an expert witness for the cities of Chicago, San Francisco, and the District of Columbia in cases in which there were legal challenges against the gun laws of those cities. He also served on behalf of lawsuits brought by police officers in Milwaukee against a gun dealer. The other authors report no competing interests.
References
1.
Forensic Populations and the Department of Health and Mental Hygiene: Report to the General Assembly, April 2007. Rockville, Md, Substance Abuse and Mental Health Services Administration, Department of Health and Mental Hygiene and the Judiciary, 2008
2.
Elbogen EB, Johnson SC: The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry 66:152–161, 2009
3.
Fazel S, Långström N, Hjern A, et al.: Schizophrenia, substance abuse, and violent crime. JAMA 301:2016–2023, 2009
4.
Steadman HJ, Mulvey EP, Monahan J, et al.: Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Archives of General Psychiatry 55:393–401, 1998
5.
Swanson JW, Holzer CE, Ganju VK, et al.: Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area Surveys. Hospital and Community Psychiatry 41:761–770, 1990
6.
Friedman E: Va Tech shooter Seung-Hui Cho’s mental health records released. ABC News, Aug 19, 2009. Available at abcnews.go.com/US/seung-hui-chos-mental-health-records-released/story?id=8278195#.UKUxeWd418c
7.
Martinez M, Rowlands T: Judge rules Loughner not competent to stand trial. CNN, May 25, 2011. Available at articles.cnn.com/2011-05-25/justice/arizona.loughner.competency_1_jared-lee-loughner-mental-illness-giffords?_s=PM:CRIME
8.
Sallinger R: James Holmes saw three mental health professionals before shooting. CBS News, Aug 21, 2012. Available at www.cbsnews.com/8301-201_162-57497820/james-holmes-saw-three-mental-health-professionals-before-shooting
9.
Kellerman GR: Diagnosing Adam Lanza. The Atlantic, Dec 16, 2012. Available at www.theatlantic.com/health/archive/2012/12/diagnosing-adam-lanza/266322
10.
Estes AC: Revelations about Adam Lanza’s mental health still don’t explain the violence. The Atlantic Wire, Feb 19, 2013. Available at www.theatlanticwire.com/national/2013/02/revelations-about-adam-lanzas-mental-health-still-dont-explain-violence/62317
11.
Volsky I: Congresswoman attributes Adam Lanza’s killing spree to unprecedented levels of violent games, music. Thinkprogress.org, Feb 28, 2013. Available at thinkprogress.org/politics/2013/02/28/1651951/congresswoman-attributes-adam-lanzas-killing-spree-to-unprecedented-levels-of-violent-games-music/?mobile=nc
12.
Transcript of second Presidential debate. Fox News, Oct 16, 2012. Available at www.foxnews.com/politics/2012/10/16/transcript-second-presidential-debate
13.
Barry CL, McGinty EE, Vernick JS, et al.: After Newtown: public opinion on gun policy and mental illness. New England Journal of Medicine 368:1077–1081, 2013
14.
Appelbaum PS, Swanson JW: Gun laws and mental illness: how sensible are the current restrictions? Psychiatric Services 61:652–654, 2010
15.
Gostin LO, Record KL: Dangerous people or dangerous weapons: access to firearms for persons with mental illness. JAMA 305:2108–2109, 2011
16.
Swanson J, Gilbert AR: Mental illness and firearm violence: comment on “Dangerous people or dangerous weapons: access to firearms for persons with mental illness.” JAMA 306:930–931, 2011
17.
Gostin LO, Record KL: Reply to comment on “Dangerous people or dangerous weapons: access to firearms for persons with mental illness.” JAMA 306:931, 2011
18.
Swanson J: Mental illness and new gun law reforms: the promise and peril of crisis-driven policy. JAMA 309:1233–1234, 2013
19.
Cole TB: Efforts to prevent gun sales to mentally ill may deter patients from seeking help. JAMA 298:503–504, 2007
20.
Appelbaum PS: “One madman keeping loaded guns”: misconceptions of mental illness and their legal consequences. Psychiatric Services 55:1105–1106, 2004
21.
Appelbaum PS: Violence and mental disorders: data and public policy. American Journal of Psychiatry 163:1319–1321, 2006
22.
Simpson JR: Bad risk? An overview of laws prohibiting possession of firearms by individuals with a history of treatment for mental illness. Journal of the American Academy of Psychiatry and the Law 35:330–338, 2007
23.
Norris DM, Price M, Gutheil T, et al.: Firearm laws, patients, and the roles of psychiatrists. American Journal of Psychiatry 163:1392–1396, 2006
24.
Price M, Norris DM: National Instant Criminal Background Check Improvement Act: implications for persons with mental illness. Journal of the American Academy of Psychiatry and the Law 36:123–130, 2008
25.
Price M, Norris DM: Firearm laws: a primer for psychiatrists. Harvard Review of Psychiatry 18:326–335, 2010
26.
Public Law 90-618, The Gun Control Act of 1968. 90th US Congress, 1968
27.
Fatal Gaps: How Missing Records in the Federal Background Check System Put Guns in the Hands of Killers. Mayors Against Illegal Guns, Nov 2011. Available at www.mayorsagainstillegalguns.org/downloads/pdf/maig_mimeo_revb.pdf
28.
Health Information Privacy. Rockville, Md, US Department of Health and Human Services, 2013. Available at www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
29.
Now Is the Time: The President’s Plan to Protect Our Children and Our Communities by Reducing Gun Violence. Washington, DC, White House Press Office, Jan 16, 2013. Available at www.whitehouse.gov/sites/default/files/docs/wh_now_is_the_time_full.pdf
30.
Liu E, Bagalman E, Chu V, et al: Submission of Mental Health Records to NICS and the HIPAA Privacy Rule. Congressional Research Service Report 7-5700, R43040. Washington, DC, Congressional Research Service, April 15, 2013. Available at www.fas.org/sgp/crs/misc/R43040.pdf
31.
Roman MW: Involuntary treatment laws: one of the “talking points” after the Tucson shootings. Issues in Mental Health Nursing 32:336–337, 2011
32.
Mental Health Reporting Policy Summary. San Francisco, Law Center to Prevent Gun Violence, May 21, 2012. Available at smartgunlaws.org/mental-health-reporting-policy-summary
33.
Parker GF: Application of a firearm seizure law aimed at dangerous persons: outcomes from the first two years. Psychiatric Services 61:478–482, 2010
34.
Richman J: Bill would help states copy California program to take guns from criminals. Contra Costa Times, Feb 28, 2013. Available at www.contracostatimes.com/breaking-news/ci_22683129/bill-would-help-states-copy-california-program-take
35.
Ritter M, Tanner L: Mental health experts worry New York gun laws may discourage proper treatment. New York Times, Jan 15, 2013. Available at www.huffingtonpost.com/2013/01/15/mental-health-experts-new-york-gun-law_n_2480508.html
36.
Mental Health–Related Prohibited Categories in California. San Francisco, Law Center to Prevent Gun Violence, Jan 2, 2012. Available at smartgunlaws.org/mental-health-related-prohibited-categories-in-california
37.
Luo M: Some with histories of mental illness petition to get their gun rights back. New York Times, July 2, 2011. Available at www.nytimes.com/2011/07/03/us/03guns.html?pagewanted=all&_r=0
38.
Restoration of possession rights. Revised Code of Washington State 9.41.047. 1994
39.
Fix Gun Checks Act of 2011, S436 112th Cong, 1st Sess (2011)
40.
Fix Gun Checks Act of 2011, HR 1781 112th Cong, 1st Sess (2011)
41.
Fix Gun Checks Act of 2013, HR 137 113th Congress, 1st Sess (2013)
42.
Strengthening Background Checks Act of 2013, HR 329 113th Congress, 1st Sess (2013)
43.
Armed Prohibited Persons Act of 2013, HR 848 113th Congress, 1st Sess (2013)
44.
An act to amend Sections 8104 and 8105 of the Welfare and Institutions Code, relating to firearms, SB 127 113th Congress, 1st Sess (2013)
45.
An act relating to reporting dangerous and mentally ill persons to the National Instant Criminal Background Check System, S94 Vermont, 2013
46.
Louisiana HB No 21, 2013
47.
Identifying mental illness only small part in gun debate. USA Today, March 25, 2013. Available at www.usatoday.com/story/news/nation/2013/03/03/mental-illness-gun-control/1928953
48.
Sher A: Tennessee Senate targets mental health on gun control. Times Free Press, March 22, 2013. Available at www.timesfreepress.com/news/2013/mar/22/tennessee-senate-targets-mental-health-on-gun
49.
An act adding mental health screening as qualification to purchase a firearm and amending NJS 2C: 58-3, New Jersey Assembly No 3667
50.
HF 184, State of Minnesota House of Representatives. A bill for an act relating to public safety; firearms; requiring the Commissioner of Human Services to create and maintain a centralized register of individuals who voluntarily wish to be ineligible to purchase firearms for a self-determined period of time
51.
Choe JY, Teplin LA, Abram KM: Perpetration of violence, violent victimization, and severe mental illness: balancing public health concerns. Psychiatric Services 59:153–164, 2008
52.
Large MM, Nielssen O: Violence in first-episode psychosis: a systematic review and meta-analysis. Schizophrenia Research 125:209–220, 2011
53.
Kessler RC, Berglund P, Demler O, et al.: Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62:593–602, 2005
54.
Fazel S, Singh JP, Doll H, et al.: Use of risk assessment instruments to predict violence and antisocial behaviour in 73 samples involving 24,827 people: systematic review and meta-analysis. BMJ 345:e4692, July 2012
55.
Buchanan A: Risk of violence by psychiatric patients: beyond the “actuarial versus clinical” assessment debate. Psychiatric Services 59:184–190, 2008
56.
Swanson J, Robertson AG, Frisman LK, et al.: Preventing gun violence involving people with serious mental illness; in Reducing Gun Violence in America: Informing Policy With Evidence and Analysis. Edited by, Webster DW, Vernick JS. Baltimore, Johns Hopkins University Press, 2013
57.
Mojtabai R: Americans’ attitudes toward mental health treatment seeking: 1990–2003. Psychiatric Services 58:642–651, 2007
58.
Pescosolido BA, Martin JK, Long JS, et al.: “A disease like any other”? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. American Journal of Psychiatry 167:1321–1330, 2010
59.
Phelan JC, Link BG, Stueve A, et al.: Public conceptions of mental illness in 1950 and 1996: what is mental illness and is it to be feared? Journal of Health and Social Behavior 41:188–207, 2000
60.
Van Dorn RA, Swanson JW, Elbogen EB, et al.: A comparison of stigmatizing attitudes toward persons with schizophrenia in four stakeholder groups: perceived likelihood of violence and desire for social distance. Psychiatry: Interpersonal and Biological Processes 68:152–163, 2005
61.
McGinty EE, Webster DW, Barry CL: Effects of news media messages about mass shootings on attitudes toward persons with serious mental illness and public support for gun policies. American Journal of Psychiatry 170:494–501, 2013
62.
Wang PS, Demler O, Kessler RC: Adequacy of treatment for serious mental illness in the United States. American Journal of Public Health 92:92–98, 2002
63.
Wang PS, Lane M, Olfson M, et al.: Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Archives of General Psychiatry 62:629–640, 2005
64.
Kessler RC, Berglund PA, Bruce ML, et al.: The prevalence and correlates of untreated serious mental illness. Health Services Research 36:987–1007, 2001
65.
Sirey JA, Bruce ML, Alexopoulos GS, et al.: Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression. American Journal of Psychiatry 158:479–481, 2001
66.
Sirey JA, Bruce ML, Alexopoulos GS, et al.: Stigma as a barrier to recovery: perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence. Psychiatric Services 52:1615–1620, 2001
67.
Golberstein E, Eisenberg D, Gollust SE: Perceived stigma and mental health care seeking. Psychiatric Services 59:392–399, 2008
68.
Eisenberg D, Downs MF, Golberstein E, et al.: Stigma and help seeking for mental health among college students. Medical Care Research and Review 66:522–541, 2009
69.
Berk ML, Schur CL, Chavez LR, et al.: Health care use among undocumented Latino immigrants. Health Affairs 19(4):51–64, 2000
70.
Okie S: Immigrants and health care: at the intersection of two broken systems. New England Journal of Medicine 357:525–529, 2007
71.
Edwards G: Database of State Tarasoff Laws. Feb 11, 2010. Available at ssrn.com/abstract=1551505
72.
Wise TP: Where the public peril begins: a survey of psychotherapists to determine the effects of Tarasoff. Stanford Law Review 31:165–190, 1978
73.
Weinstock R, Weinstock D: Clinical flexibility and confidentiality: effects of reporting laws. Psychiatric Quarterly 60:195–214, 1989
74.
Edwards GS: Doing their duty: an empirical analysis of the unintended effect of Tarasoff v Regents on homicidal activity. Jan 29, 2010. Available at ssrn.com/abstract=1544574
75.
Miller M: Preventing suicide by preventing lethal injury: the need to act on what we already know. American Journal of Public Health 102(suppl 1):e1–e3, 2012
76.
Suicide: Facts at a Glance. Atlanta, Ga, Centers for Disease Control and Prevention, 2012. Available at www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.PDF
77.
Miller M, Azrael D, Hemenway D: Household firearm ownership and suicide rates in the United States. Epidemiology 13:517–524, 2002
78.
Miller M, Hemenway D: The relationship between firearms and suicide: a review of the literature. Aggression and Violent Behavior 4:59–75, 1998
79.
Miller M, Hemenway D: Guns and suicide in the United States. New England Journal of Medicine 359:989–991, 2008
80.
Rihmer Z: Suicide risk in mood disorders. Current Opinion in Psychiatry 20:17–22, 2007
81.
Rihmer Z, Kiss K: Bipolar disorders and suicidal behaviour. Bipolar Disorders 4(suppl 1):21–25, 2002
82.
Nock MK, Borges G, Bromet EJ, et al.: Suicide and suicidal behavior. Epidemiologic Reviews 30:133–154, 2008
83.
2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. Rockville, Md, US Surgeon General and the National Action Alliance for Suicide Prevention, 2012. Available at www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full-report.pdf
84.
Walters H, Kulkarni M, Forman J, et al.: Feasibility and acceptability of interventions to delay gun access in VA mental health settings. General Hospital Psychiatry 34:692–698, 2012
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Cover: A ‘Bear’ Chance, by Philip Russell Goodwin, 1907. Oil on canvas. Minneapolis Institute of Arts, gift of the National Biscuit Company; the Bridgeman Art Library, New York.
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Published online: 15 October 2014
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