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Commentary: Navy Yard, guns, and mental illness.

Whatever went wrong with Virginia's gun background check system or the Navy security protocols or the neurons in Aaron Alexis's delusional and angry brain, none of that matters now to the 12 souls who were tragically killed on Sept. 16, 2013. 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 other people who were shot to death the same day in the United States--and the 85 who are shot every day, many by their own hand--according to Centers for Disease Control and Prevention data.

Why is this happening?

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?

According to a national poll conducted earlier this year by Johns Hopkins Bloomberg School of Public Health, a majority of adults in the United States support increasing government spending on mental health screening and treatment as a strategy to reduce gun violence (N. Engl. J. Med. 2013;368:1077-81); National Rifle Association members and gun-control advocates agree on very little, but there is that.

Of course we need better mental health care in America. The public mental health system is a disaster in most states--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.

Mental disorders are responsible for about 4%-5% of violent incidents in the United States. If we cured schizophrenia, bipolar disorder, and major depression overnight, 95% of violent acts toward others would still occur. A person with mental illness is far more likely to be a victim of violence rather than a perpetrator.

When we include suicide as part of the gun violence epidemic, mental illness is a much stronger causal factor. Suicides account for 61% of all firearm fatalities in the United States--19,393 of the 31,672 gun deaths reported by the CDC in 2010. Suicide is the third-leading cause of death in Americans aged 15-24 years, perhaps not coincidentally the age group when young people go off to college, join the military, and experience a first episode of major mental illness if it's bound to happen.

More than half of suicides involve guns, and most victims had identified mental health problems and a history of some treatment. "How did they get a gun?" is an important question to answer. "Where was the treatment, and why did it fail?" might be even more important.

Suicide attempts with a gun almost invariably succeed, because they are almost always aimed at the brain at dose range, and there is seldom anyone around to call 911. In contrast, most victims of other-directed firearm violence survive. They are often disadvantaged young people left to struggle with lifelong disabilities in places where hope runs thin. The burden of their care and lost productivity are a big part of the $170 billion price tag for gun violence in America.

How about profiling mass shooters--can we thwart the next mass shooting? Profiling multiple-casualty killers is not difficult. Predicting them in advance is almost impossible. 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. Should we round up all the angry young men who fit this description? Lock them up and treat them?

The problem with that strategy is that the description also applies to tens of thousands of young men in America who would never perpetrate a mass shooting in a million years.

Could the problem have something to do with unregulated guns? The average crime rate in the United States over the past 50 years is very similar to that of Canada, the United Kingdom, and most Western European countries. But our homicide rate is several times higher than the average homicide rate in those countries. We don't have an exceptional crime problem in America. We do have an exceptional murder problem. The reason for that, in part, is that we have approximately 310 million firearms in private hands in the United States. Lots of people in other countries get angry and hurt each other and commit crimes, too. But here, we do it with guns; more people die.

We have tried sensible gun control in the United States, and there is evidence that it can work. In 1975, the District of Columbia enacted the Firearms Control Regulations Act, which effectively banned handguns in the district. Colin Loftin, PhD., and his colleagues published a study in 1991 showing that the law resulted in a dramatic decline in gun homicides and suicides; it saved an estimated 47 lives each year in the District of Columbia during the period it remained in effect (N. Engl. J. Med. 1991;325:1615-20).

The irony in Dr. Loftin's study is that it validated the public safety benefit of the very law that the US. Supreme Court struck down as unconstitutional in District of Columbia v. Heller. The court's decision in Heller, expanded to the states in McDonald v. Chicago, affirmed that the Second Amendment confers an individual right to possess firearms for personal protection. Never mind the scientific evidence for how dangerous this might be.

After Heller, we can't broadly limit legal access to guns here, as other countries have done. We have to do something more difficult, which is to try to keep guns out of the hands of certain "dangerous people." But we often don't know who the dangerous people are (until it's too late), and the people that we might assume to be dangerous (say, because they have a mental illness) mostly are not. Our existing federal prohibitions, inherited from the Gun Control Act of 1968, are both overinclusive and underinclusive. As a result, people who are dangerous can slip through the cracks, while people who are not dangerous can be unfairly subjected to stigma.

Given that psychiatrists' predictions of violence aren't much better than a coin toss, and we live in a country awash in firearms, reducing gun violence in the tiny proportion of mentally ill individuals at risk is a vexing challenge. A policy to seize guns, at least temporarily, from people during and immediately following a dangerous mental health crisis--a law like the ones Indiana, Connecticut, and California already have in some form--might be a place to start.

By itself, such a law may have only a marginal effect. But it could make a difference in combination with other sensible measures that would be permissible under the Second Amendment--policies such as requiring universal background checks, beefing up enforcement and lowering evidentiary standards for prosecuting illegal gun transfers, banning assault weapons and high capacity ammunition magazines, and maybe requiring personalized gun technology to ensure that a gun could be operated only by its licensed owner.

That firearms have become a symbolic issue in a paralyzed political debate over individual rights and government intrusion is enough to make a public health--minded researcher or clinician, on a bad day, lose hope for evidence-based policy. A good day will be one with more reasonable conversation about firearms, fewer people with untreated mental illness, and nobody dead from a gunshot in America.

We do need to improve mental health care in this country; we need more effective treatments and better access to services for people with serious mental illnesses. That said, people with mental illness are really not the source of our social problem of gun violence. Mass shooters with mental health problems get a huge amount of media attention, but they do not represent most people treated by psychiatrists. They're also atypical of most people who commit violent crimes. We need to think more broadly about mental illness and violence in society as two separate public health problems that overlap at the moment of such tragedies.

Caption: Two police officers guard the front entrance to the Washington Navy Yard after a government contractor went on a rampage and killed 12 people. The U.S. homicide rate surpasses the rate found in Canada or the United Kingdom.

Caption: DR. SWANSON

Caption: DR. SWARTZ


Dr. Swanson is professor of psychiatry and behavioral sciences at Duke University Medical Center, Durham, N.C. He is principal investigator of a multisite study on firearms laws, mental illness, and prevention of violence, cosponsored by the National Science Foundation and the Robert Wood Johnson Foundation's Program on Public Health Law Research. Dr: Swartz is professor of psychiatry and behavioral sciences and head of the division of social and community psychiatry at Duke University Medical Center. His current research focuses on the effectiveness of firearms laws, involuntary outpatient commitment, psychiatric advance directives, and antipsychotic medications. Scan the QR code to read more commentaries at
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Title Annotation:OPINION
Author:Swanson, Jeffrey; Swartz, Marvin
Publication:Clinical Psychiatry News
Date:Oct 1, 2013
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