The federal response to the Virginia Tech tragedy was to pass the NICS Improvement Act, which will have significant impact on persons with mental illness. It provides states with significant financial incentives to release to the Attorney General all relevant records on individuals who are prohibited by federal law from possessing firearms. The records covered include automated information needed by the NICS to identify felony convictions, felony indictments, fugitives from justice, drug arrests and convictions, prohibiting mental health adjudications and commitments, domestic violence protection orders, and misdemeanor crimes of domestic violence.12
Several states currently have specific laws addressing firearm access of individuals with mental illness and/or substance abuse and clearly define the roles of health care professionals.13-15 Connecticut laws permit legal authorities to confiscate fire-arms of individuals adjudicated to be a danger to themselves or others.
In California, persons who are admitted to a psychiatric hospital (public or private) and who are designated a danger to themselves or others must be reported to the local law enforcement agency by an attending health care professional. The reports are used to build a data bank of persons with mental illnesses and substance abuse. The legal authorities of the state are notified by the medical facility.
In Washington State, a new law broadens the firearms prohibition to include adults and youths who have 14-day commitments. Prior law mandated that the firearm prohibition only include persons who received 90-day or 180-day involuntary treatment for mental illnesses.16,17
As the public calls for increased control in matters of firearm licensure to persons with mental illnesses and to substance abusers, other states may implement similar laws and obligations for mental health professionals.
Certain provisions exist that allow persons with mental illnesses some recourse after their names are placed in a national mental health database. The federal Gun Control Act requires all federal agencies that impose mental health adjudications or commitments to provide a process for “relief from disabilities.” It prevents reporting of mental adjudications or commitments by federal agencies when those adjudications or commitments have been removed. The law further requires removal of expired, incorrect, or otherwise irrelevant records, and it provides persons with mental illness an opportunity to appeal when there has been an inappropriate commitment or finding of incompetence by a federal agency.
Firearms as instruments for suicide
Persons with mental illnesses and/or substance abuse disorders are frequently perceived by the public to be dangerous, and their inclusion in the NICS data bank is controversial. The vast majority of violent events are not perpetrated by persons with mental illness. However, there is a well-documented correlation of violence for individuals with substance abuse disorders.18,19 Thus, it is unclear whether a database of mentally ill persons is a deterrent. It is estimated that more than 40% of American households have a firearm. A recent manufacturing report from the Bureau of Alcohol(Drug information on alcohol), Tobacco, and Firearms evidences the growing firearms industry in this country (Table 2).
Access to firearms is an important factor for clinicians to consider in any risk assessment of suicidal patients. Miller and Hemenway20 report that “in 2005, an average of 46 Americans a day committed suicide with a firearm, accounting for 53% of all completed suicides.” Ilgen and colleagues21 used data from the National Comorbidity Survey to report on new research linking violence and mental illness. The results of their examination of the relationship between mental disorders, past suicidality, gun access, and safety practices show that persons with lifetime mental disorders were as likely as those without a mental disorder to have access to a gun, carry a gun, or store a gun in an unsafe manner. However, individuals with prior suicide attempts were less likely to have access to a firearm.
All discussions with the patient and his or her family regarding firearms should be documented. When clinicians are doing a psychiatric examination of suicidal patients, they should inquire about the availability of firearms in the household. If a firearm is available, concerns about safety should be raised with the family and police. This is particularly true when children and adolescents reside in the household.