Jonathan M. Metzl, MD, PhD

New legislation in a number of states requires mental health professionals to assess their patients for the potential to commit gun crimes. For instance, New York state law mandates that mental health professionals report anyone who “is likely to engage in conduct that would result in serious harm to self or others” to the state’s Division of Criminal Justice Services, which then alerts local authorities to revoke the person’s firearms license and confiscate his or her weapons. Similarly, a recently passed bill in Tennessee requires mental health professionals to report “threatening patients” to local law enforcement.

Supporters of these types of laws argue that they provide important tools for law enforcement officials to identify potentially violent persons-and understandably so. US policymakers and the general public look to psychiatry, psychology, neuroscience, and related disciplines as sources of certainty in the face of the often incomprehensible terror and loss that gun violence inevitably produces. And to be sure, persons with mental illness who have shown violent tendencies should not have access to weapons that could be used to harm themselves or others.

[[{"type":"media","view_mode":"media_crop","fid":"33302","attributes":{"alt":"gun violence","class":"media-image media-image-right","id":"media_crop_3111397089833","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3516","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 141px; height: 149px; float: right;","title":"shutterstock.com","typeof":"foaf:Image"}}]]However, the notion that psychiatric attention might prevent gun crime is more complicated than it might seem. New research undertaken by me and my colleague, Professor Ken MacLeish, warns of the potential pitfalls of such laws if they are unaccompanied by other community-based or antistigma interventions.

 We systematically reviewed the key psychiatry, psychol- ogy, public health, and sociology literature that addressed connections between mental illness and gun violence between 1960 and 2014. We also used our own primary source historical research on violence and mental illness, and American gun culture.

Our review critically addresses 4 central assumptions that underlie many US political and popular associations between gun violence and mental illness:

• That mental illness causes gun violence

• That psychiatric diagnosis can predict gun crime before it happens

• That US mass shootings teach us to fear mentally ill loners

• That because of the complex psychiatric histories of mass shooters, gun control “won’t prevent” another Tucson, Aurora, Newtown, or Navy Yard

Each of these statements is certainly true in particular instances. At the same time, our research shows how these seemingly self-evident assumptions are replete with complicated and at times contradictory assumptions. At the aggregate level, the notion that mental illness causes gun violence stereotypes a diverse population of persons with psychiatric conditions and oversimplifies links between violence and mental illness. Moreover, notions of mental illness that emerge in relation to gun violence frequently reflect larger cultural issues that become obscured when mass shootings come to stand for all gun crime and when “mentally ill” ceases to be a medical designation and becomes a sign of violent threat.

Our research also shows how anxieties about insanity and gun violence are imbued with often unspoken anxieties about race, politics, and the unequal distribution of violence in American society. In the current American landscape, these tensions play out most clearly in differing cultural responses to, for instance, high-profile shootings in places like Newtown (where headlines located pathology in the perpetrator’s brain) and New York City (where news commentators wondered whether murderous actions were motivated by “black politics.”

Our analysis suggests that similar, if less overt, tensions suffuse discourses linking guns and mental illness more broadly, in ways that subtly connect “insane” gun crimes with often unspoken assumptions about “white” individualism or “black” communal aggression.

Ultimately, our research challenges psychiatry to think deeply about potentially untenable situations in which mental health practitioners become the persons most empowered to make decisions about gun ownership-and most liable for failures to predict gun violence-if these situations are not accompanied by larger reforms that address the social, structural, and indeed psychological implications of gun violence in the US.

Our findings appear in the February 2015 issue of the 

 By way of a summary, the following 4 assumptions are examined.

Assumption 1: mental illness causes gun violence

The focus on mental illness in the wake of recent mass shootings in the US reflects a decades-long history of psychiatric and legal debates about guns, gun violence, and mental competence. Psychiatric articles in the 1960s deliberated ways to assess whether mental patients were “of sound mind enough” to possess firearms.

 Following the 1999 mass shooting at Columbine High School, psychiatrist Peter Breggin decried the toxic combination of mental illness, guns, and psychotropic medications that contributed to the perpetrators’ actions. After the 2012 shooting at Sandy Hook Elementary School in Newtown, psychiatrist E. Fuller Torrey claimed that “about half of . . . mass killings are being done by people with severe mental illness, mostly schizophrenia, and if they were being treated they would have been preventable.”

Yet surprisingly little population-level evidence supports the notion that individuals with mental illness are more likely than anyone else to commit gun crimes. According to psychiatrist Paul Appelbaum,

 fewer than 3% to 5% of American crimes involve people with mental illness, and the percentages of crimes that involve guns are lower than the national average for persons without a diagnosis of mental illness. Databases that track gun homicides, such as the National Center for Health Statistics, similarly show that fewer than 5% of the 120,000 gun-related killings in the US between 2001 and 2010 were perpetrated by people with mental illness.

Moreover, a growing body of research suggests that mass shootings represent anecdotal distortions of, rather than representations of, the actions of “mentally ill” people as an aggregate group. By most estimates, there were fewer than 100 mass shootings reported in the US-defined as crimes “when four or more people are shot in an event, or related series of events”-between 1982 and 2012.

 Rates of reported mass shootings rose in 2013 and 2014.

Scholars who study violence prevention contend that mass shootings occur far too infrequently to allow for statistical modeling and predictability-factors that lie at the heart of effective public health interventions. Psychologist Jeffrey Swanson

 argues that mass shootings denote “rare acts of violence” that have little predictive or preventive validity in relation to the bigger picture of the 32,000 fatalities and 74,000 injuries caused on average by gun violence and gun suicide each year in the US.

Links between mental illness and other types of violence are similarly contentious among researchers who study such trends. Study findings suggest that subgroups of persons with severe or untreated mental illness might be at increased risk for violence during periods surrounding psychotic episodes or psychiatric hospitalizations.

 At the same time, a number of seminal studies asserting links between violence and mental illness have been critiqued for overstating connections between serious mental illness and violent acts.

Media reports often assume a binary between mild and severe mental illness, and they connect the latter form to unpredictability and lack of self-control. However, this distinction is called into question by mental health research. To be sure, a number of the most common psychiatric diagnoses, including depressive, anxiety, and attention-deficit disorders, have no correlation with violence whatsoever. Community studies find that serious mental illness without substance abuse is also “statistically unrelated” to community violence. At the aggregate level, the vast majority of people with psychiatric disorders do not commit violent acts-only about 4% of violence in the US is attributable to persons with mental illness.

This is not to suggest that researchers know nothing about predictive factors for gun violence. However, credible studies suggest that a number of risk factors more strongly correlate with gun violence than mental illness alone. For instance, alcohol and drug use increase the risk of violent crime by as much as 7-fold, even among persons with no history of mental illness-a concerning statistic in the face of recent legislation that allows persons in certain states to bring loaded handguns into bars and nightclubs. According to Van Dorn and colleagues,

 male sex and a history of childhood abuse and binge drinking are all predictive risk factors for serious violence. Belying Lott’s

 argument that “more guns” lead to “less crime,” Miller and colleagues

 found that homicide was more common in areas in which household firearms ownership was higher. The rate of interpersonal conflicts resolved by fatal shootings jumped by 200% after Florida passed “stand your ground” in 2005.

 The availability of guns is also considered a more predictive factor than is psychiatric diagnosis in many of the 19,000 completed suicides by gun each year in the US.

Some persons with mental illness undoubtedly commit violent acts. Yet growing evidence suggests that mass shootings on which gun legislation is often based represent statistical aberrations that reveal more about particularly horrible instances than they do about population-level events. To use Swanson’s

 phrasing, basing gun-crime prevention efforts on the mental health histories of mass shooters risks building “common evidence” from “uncommon things.” This type of approach loses the opportunity to build common evidence from common things-such as the types of evidence that clinicians of many medical specialties might catalogue, in alliance with communities, about substance abuse, domestic violence, availability of firearms, suicidality, social networks, economic stress, and other factors.

Assumption 2: psychiatric diagnosis can predict gun crime before it happens

Legislation in a number of states mandates that psychiatrists assess their patients for the potential to commit violent gun crime. History suggests, however, that psychiatrists are inefficient gatekeepers in this regard. Data that support the predictive value of psychiatric diagnosis in matters of gun violence are thin at best. Psychiatric diagnosis is largely an observational tool, not an extrapolative one. Largely for this reason, research dating back to the 1970s suggests that psychiatrists using clinical judgment have difficulty in predicting which patients will commit a violent crime.

The lack of prognostic specificity is in large part a matter of simple math. Psychiatric diagnosis is in and of itself not predictive of violence, and the overwhelming majority of psychiatric patients do not commit crimes.

In this sense, population-based literature on guns and mental illness suggests that legislatures risk drawing the wrong lessons from gun crimes and mass shootings if their responses focus on asking psychiatrists to predict future events. Although rooted in valid concerns about public safety, legislation that expands mental health criteria for revoking gun rights puts psychiatrists in potentially untenable positions, not because they are poor judges of character, but because the urgent political and social conditions psychiatrists are asked to diagnose are at times at odds with the capabilities of their diagnostic tools and prognostic technologies.

Assumption 3: look out for dangerous loners

Mass shootings in the US are often framed as the work of loners-unstable, angry white men who never should have had access to firearms.

 “Gunman a Loner Who Felt No Pain” read a headline in the wake of the Newtown shooting. And to be sure, a number of other recent shooters undoubtedly led troubled, solitary lives.

It is important to note, however, that the seemingly self-evident images of the mentally disturbed, gun-obsessed, white male loner are relatively recent phenomena. In the 1960s and 1970s, by contrast, many of the men labeled as violent and mentally ill were also, it turned out, African American. And, when the potential assailants were black, American psychiatric and popular culture frequently blamed “black culture” or black activist politics-not individual, lone shooters-for the threats such men were imagined to pose.

For instance, anxieties about race and politics shaped many 1960s-era American political associations between schizophrenia and gun violence. FBI profilers spuriously gave diagnoses of militant forms of schizophrenia to many “pro-gun” black political leaders as a way of highlighting the insanity of their political activism. According to declassified documents, the FBI diagnosed “pre-psychotic paranoid schizophrenia” in Malcolm X while highlighting his attempts to obtain firearms and his “plots” to overthrow the government.

 The FBI also gave Robert Williams, the head of the Monroe, North Carolina, chapter of the NAACP, the diagnosis of “schizophrenic, armed, and dangerous” during his flight from trumped-up gun charges in the early 1960s.20 Malcolm X, Robert Williams, and other leaders of African American political groups were far from schizophrenic. But fears about their political sentiments, guns, and sanity mobilized substantial response.

During this era, US psychiatry also spoke out in favor of gun control-articles in the 

 urged psychiatrists to address “the urgent social issue” of firearms in response to “the threat of civil disorder”-while Congress began serious debate about gun control legislation leading to the Gun Control Act of 1968.

Recent history suggests that cultural politics underlie anxieties about whether guns and mental illness represent individual or communal etiologies. In the 1960s and 1970s, widespread concerns about black “cultural” and political violence fomented calls for widespread reforms in gun ownership. As this played out, politicians, FBI profilers, and psychiatric authors argued for the right to use mental health criteria to limit gun access. However, in the present day, the actions of “lone” white male shooters go hand in hand with calls to expand gun rights, or limit gun rights only for the severely mentally ill. Indeed it would seem political suicide for a legislator or doctor to hint at restricting the gun rights of white Americans, private citizens, or men, although these groups are frequently linked to high-profile mass shootings.

Assumption 4: gun control “won’t prevent” another Tucson, Aurora, Newtown, or Navy Yard

The mantra that gun control “would not have prevented Newtown” is frequently cited by opponents of such efforts. This contention generally assumes that because none of the recent mass shooters in Tucson, Aurora, Newtown, or Isla Vista used weapons purchased through unregulated private sale or gun shows, gun control in itself would be ineffective in stopping gun crime, and that gun purchase restrictions or background checks are in any case rendered moot when shooters have mental illness.

No one wants another tragedy like Newtown-on this point all sides of the gun debate agree. Moreover, it is widely acknowledged by persons on all sides of that debate that there is no guarantee that the types of restrictions voted down by the US Senate in April 2013, based largely on background checks, would prevent the next mass crime. Yet, as discussed above, many scholars who study violence prevention hold that mass shootings occur too infrequently to allow for statistical modeling, and as such serve as poor jumping off points for effective public health interventions.

The focus on individual crimes or the psychologies of individual shooters obfuscates attention to community-level everyday violence and the widespread symptoms produced by living in an environment engulfed by fear of guns and shootings. Far from the national glare, this everyday violence disproportionally affects lower-income areas and communities of color, and is held to be the cause of widespread anxiety disorders and traumatic stress symptoms as a result.

Given this terrain, it is increasingly the case that when violence prevention experts talk about ebbing gun crime linked to mental illness, they do not mean that mental health practitioners will avert the next random act of violence such as Newtown, although of course stopping mass crime remains a vital goal. Instead, they contend that the insanity of urban gun violence all too often reflects the larger madness of not investing more resources to support social and economic infrastructures and support systems.

Questioning the associations between guns and mental illness in no way detracts from the dire need to stem gun crime. Yet as the fractious US debate about gun rights plays out in ever-more divisive ways, it seems incumbent to find common ground 

 assumptions about whether particular assailants meet criteria for specific mental illnesses, or whether mental health experts can predict violence before it occurs. Of course, understanding a person’s mental state is vital to understanding his actions. At the same time, our research suggests that focusing legislative policy and popular discourse so centrally on mental illness is rife with potential problems if, as seems increasingly the case, those policies are not embedded in larger societal strategies and structural-level interventions.

Research also suggests that agendas that hold mental health workers accountable for identifying dangerous assailants puts these workers in potentially untenable positions because the legal duties they are asked to perform misalign with the predictive value of their expertise. In this sense, instead of accepting the expanded authority provided by current gun legislation, mental health workers and organizations might be bet-ter served by identifying and promoting areas of common cause between clinic and community, or between the social/community and psychological/individual dimensions of gun violence.

Connections between loaded handguns and alcohol; the mental health effects of gun violence in low-income communities; or the relationships between gun violence and family, social, or socioeconomic net- works are but a few of the topics in which mental health expertise might productively join community and legislative discourses to promote more effective medical and moral arguments for sensible gun policy than currently arise amongst the partisan rancor.

Put another way, perhaps psychiatric expertise might be put to better use by enhancing understanding of the complex anxieties, social and economic formations, and blind assumptions that make people fear each other in the first place. Psychiatry could help society interrogate what guns mean to everyday people, and why people feel they need guns or reject guns out of hand. By addressing gun discord as symptomatic of deeper concerns, psychiatry could, ideally, promote more meaningful public conversations about the impact of guns on civic life. And, it could join with public health researchers, community activists, law enforcement officers, or business leaders to identify, promote meaningful conversation about, and empathically address the underlying structural and infrastructural issues that foster real or imagined notions of mortal fear in our minds, our streets, and our society.

Dr Metzl is Frederick B. Rentschler II Professor of Sociology and Medicine, Health, and Society; Director of the Center for Medicine, Health, and Society; and Professor of Psychiatry at Vanderbilt University in Nashville, Tenn. He reports no conflicts of interest concerning the subject matter of this article.

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This review critically addresses 4 central assumptions that underlie many US political and popular associations between gun violence and mental illness.

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