Guns and mental illness

Jeffrey Swanson and Marvin Swartz

Monday, Oct. 14, 2013 | 2:01 a.m.

DURHAM, N.C. — Whatever went wrong with Virginia’s gun background check system or the Navy security protocols or the neurons in Aaron Alexis’ delusional and angry brain, none of that matters now to the 12 souls who were tragically killed Sept. 16.

They are gone. They don’t care about balancing gun rights and public safety. They don’t care about Thanksgiving this November. They won’t be there.

Heartbroken family members of the victims of the Navy Yard shooting do care, and so should the rest of us. But we should also care about the 85 people who are shot every day in the United States, many by their own hand, according to Centers for Disease Control and Prevention data.

The root causes of our national gun violence epidemic are many and complex, but it seems easier these days to blame one thing: mental illness. After all, what person in their right mind massacres strangers?

Of course we need better mental health care in America. Our public mental health system is fragmented, ineffective, overburdened and underfunded. An estimated 3.5 million people with serious mental illnesses are going without treatment every year. But they are not the nub of the violence problem.

Schizophrenia, bipolar disorder and major depression are miserable diseases that don’t make most people violent; serious mental disorder accounts for about 4-5 percent of violent incidents. Suicide is a different story, as 61 percent of firearm fatalities are suicides and mental illness is a strong contributing factor. Better access to effective treatment, and less access to lethal means, could save thousands of lives each year.

As for mass shooters, it is easy to profile them after the fact and almost impossible to predict them in advance. Most of them are young and male. They tend to be angry and socially isolated. Some of them have delusional beliefs. Some use illicit drugs, drink too much alcohol, play violent video games and are preoccupied with weapons. But this picture also matches the description of tens of thousands of young men who would never perpetrate a mass shooting.

In theory, a more effective way to reduce gun violence in the United States would be to broadly limit legal access to firearms for everyone — whether mentally ill or not. Other high-income countries have taken that approach and tend to have far lower homicide rates than we do. Here, owning a gun for personal protection is an individual right conferred by the Second Amendment.

We have to do something more difficult, which is to try to keep guns out of the hands of certain “dangerous people.” But our existing criteria for prohibiting guns from people with mental illness — being involuntarily committed to psychiatric hospital or “adjudicated as a mental defective” — are too broad and too narrow at the same time.

Given that psychiatrists’ predictions of violence aren’t much better than a coin toss, and we live in a country awash in 310 million firearms, reducing gun violence in the small proportion of mentally ill individuals at risk is a vexing challenge.

But a history of violence is a far better predictor of future violent behavior than is having a mental health diagnosis. Focusing gun prohibition on the clearest indicators of violence risk — for example, expanding the criteria to encompass some violent misdemeanor offenses that currently are not gun-disqualifying — might improve the long odds of deterring a gun purchase by the next Aaron Alexis.

Even that measure is unlikely to work without universal background checks and stricter enforcement of gun trafficking laws. And it wouldn’t stop an angry, depressed, intoxicated or delusional person from using guns he may already have access to. A policy to remove guns, at least temporarily, from people during and immediately after a dangerous mental health crisis — a law like the ones Indiana, Connecticut and California already have in some form — might add another piece to the puzzle.

There are also things that we all could do, over the long term, to address the root causes of violence. We could invest in healthier communities that don’t breed violent behavior. And we could foster neighborhoods with stronger ties between people over the generations and fewer child victims of everyday violence who grow up to be perpetrators. We could also rebuild our fraying mental health care system and make evidence-based treatment available to people who need it, when and where they need it.

If we did all these things, we would live in a far less violent country. If we accept the status quo of political paralysis over gun rights, the toll will continue.

Jeffrey Swanson is professor of psychiatry and behavioral sciences at Duke University Medical Center in North Carolina. Marvin Swartz is professor of psychiatry and behavioral sciences and head of the division of social and community psychiatry at the medical center.