Mental Illness and Gun Violence: Disrupting the Narrative

Mental illness is associated with a statistically significant increased risk of violence, but most people with mental illness are never violent. In the longitudinal National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; wave 1, 2001–2002; wave 2, 2004–2005), the 12-month prevalence of any violent behavior was .8% among people with no mental illness, 1.7% among people with any mental illness, and 2.9% among people with serious mental illness. All of these estimates excluded individuals with a substance use disorder, which increases risk of violence among people with and without mental illness: in the NESARC, 2.9% of people with a substance use disorder alone and 10.0% of people with serious mental illness plus a substance use disorder had any violent behavior in the past 12 months. The estimated one-year population-attributable risk of interpersonal violence associated with mental illness is 4%, meaning that approximately 96% of all gun violence incidents in the United States are caused by factors other than mental illness (1).

Much of the public dialogue about mental illness and gun violence has been prompted by mass shootings. High-quality research quantifying the relationship between mental illness and mass shootings specifically is not available because of the statistically rare nature of such events, but the evidence clearly suggests that many mass shootings—as with other types of gun violence—are driven by factors with stronger and more direct links to violence than mental illness (1).

As noted above, substance use—particularly alcohol use—is linked with violence, as are anger, impulsivity, and experience of traumatic life events. Poverty, low education attainment, and issues stemming from systemic discrimination, such as racial residential segregation, also contribute to gun violence in the United States (1). Access to guns is a key risk factor that interacts with all of these other factors to produce gun violence.

Counter to the evidence above, mental illness is frequently framed as a cause of gun violence. Let’s consider four likely drivers.

It is important to disrupt, as opposed to counter, the pervasive narrative about mental illness as a cause of gun violence. Attempts to counter powerful though atypical examples of scenarios in which mental illness led to gun violence—for example, the mass shooting in Tucson—with complex and unintuitive facts about the true epidemiologic relationship of mental illness and violence are unlikely to change attitudes of the general public, although such messages may be more effective with policy makers and others interested in gaining deeper understanding of the issue (4). Messages that oversimplify in an attempt to destigmatize—“people with mental illness are no more violent than people without mental illness”—are easily dismissed by audiences who have internalized prominent examples of scenarios in which the symptoms of mental illness led to violent behavior.

Disrupting the narrative by reframing the causes of gun violence is a more promising approach. The youth movement arising from the February 2018 mass shooting in Parkland has focused on easy access to firearms, as opposed to mental illness. We should avoid repositioning the blame for gun violence on other stigmatized conditions such as substance use disorder, but a focus on dangerous behavior holds promise. This is the approach taken by the Consortium for Risk-Based Firearm Policy, a group focused on developing policies to keep guns out of the hands of people who meet evidence-based indicators of dangerous behavior known to increase risk of future violent acts (4). In addition to alignment with the research evidence, this framing appears to resonate with a range of stakeholders. Mental health consumer groups have supported the consortium’s approach in multiple states, and the NRA endorsed the consortium’s gun violence restraining order (GVRO) policy in March 2018. The GVRO policy creates a civil restraining-order process allowing courts to temporarily remove firearms from individuals exhibiting dangerous behavior.

Should we disrupt the mental illness and violence narrative, or is drawing attention to mental illness as a cause of violence, although misleading and stigmatizing, the best way to increase investment in the public mental health system? In a recent study, our team found that nonstigmatizing messages emphasizing barriers to treatment and stigmatizing violence-focused messages were equally effective in increasing the public’s willingness to pay additional taxes to improve the public mental health system (5). Policy leaders interested in increasing investment in mental health services therefore have an effective, nonstigmatizing alternative to violence-focused messages, supporting disruption of the mental illness and violence narrative.