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WV Behavioral Health Providers Association Statement on Mental Health and Gun Violence

Although it is common for there to be a discourse related to the causal impact of mental illness after media reports of gun violence, particularly those involving mass shootings, the relationship is not that clear.  Questions often arise as to what can be done to better predict and prevent such atrocities.  While public perception may suggest that a large percentage of mass shootings are carried out by individuals who are mentally ill, the link between mental illness and gun violence is complex (1).

In reality, there is little population-level evidence to support the assertion that individuals diagnosed with mental illness are any more likely to commit a gun crime than the general population.  A number of the most common psychiatric diagnoses, including depressive, anxiety, and attention-deficit disorders, have no correlation with violence (2).  Some studies have also shown that serious mental illness without substance abuse is also statistically unrelated to community violence (3).  It is more likely that mass shootings represent anecdotal distortions rather than representations of the violent tendencies of those with mental illness.  Consider the following statistics.

• Less than 3-5{e1be1af54d26799a927a8d0af76a8bbbfd7aef18e4219abc8118a5384db66cb5} of U.S. crimes involve people diagnosed with mental illness.(4)

• Of the 120,000 gun-related killings between 2001 and 2010, fewer than 5{e1be1af54d26799a927a8d0af76a8bbbfd7aef18e4219abc8118a5384db66cb5} were carried out by people diagnosed with a mental illness. (5)

• Only about 4{e1be1af54d26799a927a8d0af76a8bbbfd7aef18e4219abc8118a5384db66cb5} of overall violence in the U.S. can be attributed to people diagnosed with mental illness. (6,7)

• People diagnosed with mental illness are from 65 to 130{e1be1af54d26799a927a8d0af76a8bbbfd7aef18e4219abc8118a5384db66cb5} more likely to be victims of violence that the general public (8).

• 85{e1be1af54d26799a927a8d0af76a8bbbfd7aef18e4219abc8118a5384db66cb5} of shootings occur within social networks (9).

• A 2013 NY City Police Department report indicated a person was more likely to die in a plane crash, drown in a bathtub, or perish in an earthquake than be murdered by a stranger with mental illness (10).

Given this information, we know that it is not helpful to draw broad generalizations related to people diagnosed with mental illness and gun violence.  In particular, mass shootings represent statistical aberrations that reveal very little about population-level events.  There are, however some specific risk factors that correlate with gun violence.  Alcohol and drug use increase the risk of violent crime as much as 7-fold (11).  A history of childhood abuse, binge drinking, and male gender are predictive

risk factors for serious violence (12).  Given this information, we should focus more on assessing and intervening based on specific correlates with violent behavior rather than broad generalizations of “dangerousness” relative to those diagnosed with mental illness.

It should be noted that the specific risk factors may be different for different types of violence, settings, and populations (13).  However, there are some primary predictors of violence that have been identified among people with mental illness (14). These include:

• History of past violence
• Drug and alcohol abuse
• Failure to take prescribed medication

Other indicators of potential violence in those with a diagnosis of mental illness include:

• Antisocial Personality Disorder
• Neurological impairment
• Paranoid delusions
• Command hallucinations

The primary concern in minimizing the likelihood that a violent act may be carried out by an individual diagnosed with mental illness is access to and engagement in adequate assessment and treatment services.  It is estimated that 4 million Americans experience symptoms related to schizophrenia and bipolar disorder, and about 50{e1be1af54d26799a927a8d0af76a8bbbfd7aef18e4219abc8118a5384db66cb5} (~2 million) of these individuals are not receiving treatment (14).

A critical component of the assessment process includes a violence risk assessment and if warranted, an individualized safety plan.  The violence risk assessment should include assessment of ideation, plan, intent, access to means, history of violent behavior, current level of substance use, level of social support, feelings of hopelessness, level of impulse control, and history of treatment compliance.

Rather than a generic “contract for safety”, mental health professionals should assist in the development of an individualized safety plan.  This plan should indicate specific warning signs a crisis may be developing, individualized coping methods, list of available social supports, steps taken to limit access to means and make the environment safe, and emergency contact procedures.

Beyond the initial assessment phase the information presented also highlights the importance of engaging those with severe and persistent mental illness in treatment, not only for the psychiatric disorders, but also for substance use issues.  Evidenced-based programs such as Assertive Community Treatment (ACT) and intensive case management have the ability to target many of the primary risk factors outlined.

References:

1. Metzl J and MacLeish K.  Mental Illness, Mass Shootings, and the Politics of American Firearms
2.  Johns Hopkins Center for Gun Policy and Research. Guns, public health and mental illness: an evidence-based approach for state policy (2013)
3. Elbogen EB, Johnson SC.  The intricate link between violence and mental disorder: results from the National Epidemiological Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2009; 66(2): 152-161.
4. Appelbaum PS. Violence and mental disorders: data and public policy. Am J Psychiatry. 2006; 163(8): 1319-1321.
5. National Center for Health Statistics
6. Fazel S, Grann M. The population impact of severe mental illness on violent crime. Am J Psychiatry. 2006; 163(8): 1397-1403.
7. Friedman R. A misguided focus on mental illness in gun control debate. New York Times, Dec. 17, 2012.
8. Brekke JS, Prindle C, Bae SW, Long JD. Risks for individuals with schizophrenia who are living in the community. Psychiatr Serv. 2001; 52(10): 1368-1366.
9. Papachristos AV, Braga AA, Hureau, DM. Social networks and the risk of gunshot injury. J Urban Health. 1012; 89(6): 992-1003.
10. Hamilton B. Odds that you’ll be killed by a stranger in NYC on the decline. New York Post. January 5, 2014.
11. Monahan J, Steadman H, Silver E, et al. Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence. New York, NY: Oxford University Press; 2001.
12. Van Dorn R, Volavka J, Johnson N. Mental disorder and violence: is there a relationship beyond substance use? Soc Psychiatry Psychiatr Epidemiol. 2012; 47(3): 487-503.
13. Pueyo AA, Illescas SR. Dangerousness and violence risk assessment. Papeles del Psicologo. 2007; 28(3): 157-173.
14. Predictor of violence among mentally ill: Lack of treatment or failure to accept treatment. Mentalillnesspolicy.org.

http://www.transformingstigma.com/

(Photo caption: Senator Jay Rockefeller accepts an award for his work on behalf of children from Mark Drennan of the West Virginia Behavioral Healthcare Providers Association, and Lisa Jones of ResCare, at the Alliance for Children’s annual meeting and senior leader’s conference at the Stonewall Resort in Roanoke, Virginia.)

Last week, Karen Yost and I were nominated by Delegate Perdue to serve on the West Virginia work team  for the National Governors Association Three Branch Institute on Child Social and Emotional Wellbeing.  http://www.nga.org/cms/home/news-room/news-releases/2013-news-releases/col2-content/states-to-improve-social-well-be.html

The goal of this team is to develop a plan to promote and measure the well-being of children in foster care.  The first meeting is August 29, 2013 at 4pm.