Rhetoric, Reactivity, and Evidence-Based Policy in the Wake of Shootings

The burden of gun violence on society is staggering.
The burden of gun violence on society is staggering.

Gun violence imposes a significant burden on public health in the United States.  Neither mental illness nor mass shootings account for more than a small fraction of this burden.  Nonetheless, the issues seem to be perpetually conflated. 

There is a cynical, predictable pattern in media coverage and public discourse that follows mass shootings.1  Misinformation abounds.  The mentally ill are vilified.  Serious discussion about gun policy waxes, wanes, and more often than not, fades away over time.  Assurances by policy makers that they do not intend to stigmatize mental illness are often followed by suggestions that more funding for mental health services is necessary to fix America's problem with gun violence.  If this problem were really so simple, then we would not be facing–and failing to correct–this same issue time and time again.

In the days following the Colorado Springs Planned Parenthood shooting on November 27th, House Speaker Paul Ryan said, “One common denominator in these tragedies is mental illness,” a claim he reiterated the day after the December 2nd San Bernadino shooting.2,3  To date, there has been no credible evidence that the shooters in either of these incidents had significant psychiatric illness or overt symptoms.  Alas, Mr Ryan's views are hardly unique: a recent survey found that more than two-thirds of Americans felt that mass shootings were a result of mental health issues, and studies conducted in the wake of the Newtown, Connecticut shooting indicated more than half of Americans believed people with severe mental illness were more dangerous than the general population.4,5 

The reality is far, far different.  Caveats need to be made: classifying any series of rare events begs any number of measurement errors and these recent shootings are anomalous in many ways.  That said, there is clear evidence that mental illness does not play an outsized role in mass shootings.  In a systematic study of a century of mass murders, psychiatric illness was identified in only 25% of offenders.6  In review of 25 years of school shooters, the typical assailant was a socially mainstream student with an A or B average, minimal disciplinary history, and a less than 20% likelihood of a psychiatric diagnosis.7   An oft-cited database of mass shootings from Mother Jones shows clear evidence of mental illness in a minority of shooters over the past 30 years.8  The idea that mass shootings are meaningfully linked to mental illness is grossly inconsistent with the evidence.  

It is also worth noting that the Colorado Springs and San Bernardino shootings are only 2 of the more than 49,000 incidents of gun violence in the United States this year to date.9  Mass shootings account for less than 1% of gun violence incidents, a ratio that has remained generally consistent over the past century.10  The burden of gun violence is not measured in mass shootings, but rather in the quotidian toll of domestic violence, drug crime, bar fights, and myriad other disputes.  Our best estimates are that mental illness contributes to 3% to 10% of all violence.11,12  More concerning, and often lost in the debate, is that there are approximately twice as many firearm suicides than homicides and most of those are unambiguously tied to mental illness.13 

This is not to minimize the burden of violence due to mass shootings or mental illness.  Rather, it is to point out that mental illness is a weak risk factor for violence, interventions targeting mental illness will have limited impact on curtailing violence, and driving policy to address mass shooting events is dangerously neglectful of the much larger concerns of general gun violence and suicide.   The field of psychiatry can contribute positively to the policy discussion around violence in America and has an important role to play.  Psychiatry will also need to push this discussion further to meaningfully address the factors that lie within the domain of mental illness. 

John S. Rozel, MD, MSL, is medical director of the re:solve Crisis Network of Western Psychiatric Institute and Clinic of the University of Pittsburgh Medical Center.

References

  1. King S. Guns. Bangor, ME; Philtrum Press; 2013.
  2. Flores R. Paul Ryan pushes mental health bill after San Bernardino shooting. http://www.cbsnews.com/news/paul-ryan-pushes-mental-health-bill-after-san-bernardino-shooting/. Published December 3, 2015. Accessed December 9, 2015.
  3. Huetteman E, Pérez-peña R. Paul Ryan pushes changes in mental health care after Colorado shooting. The New York Times. http://www.nytimes.com/2015/12/02/us/obama-repeats-call-for-stricter-gun-laws-after-colorado-shooting.html. Published December 1, 2015. Accessed December 2, 2015.
  4. Craighill PM, Clement S. What Americans blame most for mass shootings (Hint: it's not gun laws). The Washington Post. https://www.washingtonpost.com/news/the-fix/wp/2015/10/26/gun-control-americans-overwhelmingly-blame-mental-health-failures-for-mass-shootings/. Published October 26, 2015. Accessed December 9, 2015.
  5. Barry CL, McGinty EE, Vernick JS, Webster DW. After Newtown: public opinion on gun policy and mental illness. New Engl J Med. 2013;368(12):1077-1081. doi:10.1056/NEJMp1300512.
  6. Stone MH. Mass murder, mental illness, and men. Violence Gender. 2015;2(1):51-86. doi:10.1089/vio.2015.0006.
  7. Vossekuil B, Fein RA, Reddy M, Borum R, Modzeleski W. The Final Report and Findings of the Safe School Initiative: Implications for the Prevention of School Attacks in the United States. Washington, DC: U.S. Department of Education, Office of Elementary and Secondary Education, Safe and Drug-Free Schools Program and US Secret Service, National Threat Assessment Center; 2002:63.
  8. Follman M, Aronsen G, Pan D. A guide to mass shootings in America. Mother Jones. http://www.motherjones.com/politics/2012/07/mass-shootings-map. Published December 3, 2015. Accessed December 9, 2015.
  9. Gun Violence Archive. http://www.gunviolencearchive.org/. Accessed December 9, 2015.
  10. Duwe G. The patterns and prevalence of mass murder in twentieth-century America. Justice Quarterly. 2004;21(4):729-761.
  11. Stuart HL, Arboleda-Florez JE. A public health perspective on violent offenses among persons with mental illness. Psychiatric Services. 2001;52(5):654-659.
  12. Choe JY, Teplin LA, Abram KM. Perpetration of violence, violent victimization, and severe mental illness: balancing public health concerns. Psychiatric Services. 2008;59(2):153-164. doi:10.1176/ps.2008.59.2.153.
  13. Brady Center to Prevent Gun Violence. The Truth about Suicide & Guns. Washington, DC: Brady Campaign; 2015. http://www.bradycampaign.org/sites/default/files/TruthAboutSuicideGuns.pdf . Accessed September 19, 2015.
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