Mass shootings such as the Sept. 6 attack at the Fifth Third Center don’t neatly boil down just to who has access to guns. Preventing such horrors isn't as simple as who has access to mental health care, or who is mentally ill.

Those brushes paint too broadly over the root causes for mass shootings, experts say. They believe we need to focus on a key point: Mass shootings are spreading and metastasizing out of the nation’s suicide epidemic.

Criminologists and psychologists who spoke with The Enquirer believe mass shootings could be prevented with more effort to intercede in suicide, which causes about 45,000 deaths a year across the country. But progress will come, they said, when the gun-rights community participates in suicide-prevention efforts.

Suicides account for about two-thirds of all gun deaths. In the United States, the No. 1 method of suicide is with a gun. Suicide is more common in households with firearms.

“There is a connection,” said Julie Cerel, a University of Kentucky psychologist and president of the American Association of Suicidology. “It has a lot to do with our national struggle with firearms and how this is an integral part of who we are as a country.”

Nation faces surge in suicides

In June, the U.S. Centers for Disease Control and Prevention reported that the rate of suicide has risen nearly 30 percent since 1999. Every state, including Ohio and Kentucky, reported major increases.

Though mass shootings are rare compared to suicide, a 2014 FBI report found that half of “active shooters” since 2000 had expressed suicidal intent within the year before committing a mass shooting.

The mood disorder of depression, which can lead to suicide, is called mental illness, but depressed people usually don't display more severe symptoms such as delusions or hallucinations. The American Psychiatric Association says one in five Americans experiences mental illness.

The strength of the connection between suicide and mass shootings, though, is limited by lack of data, said experts on mass shootings who spoke with The Enquirer. The 2014 FBI report on active shootings found that only about 25 percent of people who commit mass shootings were ever diagnosed with a mental illness.

Yet, said psychologist Michael Anestis of the University of Southern Mississippi, “People who are inflicting these tragedies are already suicidal or primarily suicidal. They also have this sense of: 'I need to do this to make the world more just.' ”

Despair mixed with rage

What mutates the despair of a lone potential suicide into a mass shooting is rage, said criminologist Sarah Daly of St. Vincent College in Latrobe, Pennsylvania, who has written about mass shootings.

“With mass shooters, what we tend to see is this idea of what researchers have called aggrieved entitlement,” she said. “They are not just sad, but they are very, very angry. … People ask: Why don’t they just kill themselves? Part of it is that there’s infamy, through news coverage. This is a final active of revenge before they commit suicide. It’s about who inflicted that pain on them, and what brought about this sadness.”

The 2014 FBI report on 160 "active shooters" situations between 2000 and 2013 found that 54 shooters died by suicide at the scene.

Said UK's Cerel: “Men who perpetrate this kind of violence don’t see it as weakness or mental illness. There is this perception that they have been wronged by the world, and they’re going to do something to right it or to bring glory to themselves even after they end their lives.”

Lonely, angry, depressed

Mass shooters "are lonely and angry and depressed, which is different. They’re not mentally ill," Anestis said. "They’re seeing the world through a lens that isn’t accurate.”

Daly said simply attributing a mass shooting to “mental illness” pushes the problem onto a system already woefully stretched helping an anxious, sleep-deprived, stressed-out population. “It’s a huge burden, and it’s not one that the mental health community should bear alone. This is cultural. This is societal. This is legal.”

Adam Lankford, a University of Alabama criminologist, said blaming mass shootings on “mental illness” obscures the fact that people with mentally illness are far more likely to be crime victims than perpetrators. The blame also hardens the discrimination of mental illness.

“Most of these mass shooters do struggle with mental health problems, but that doesn’t mean they’re criminally insane or necessarily psychotic,” Lankford said. “And often, mental health problems are not properly diagnosed or diagnosed at all.”

Raising a 'red-flag order'

There are few limitations on the legal purchase of a gun in the United States. Prohibitions include a record of certain felonies, a court finding of mental defectiveness or an involuntary committal to mental health hospitalization.

Experts said basing new prohibitions on gun purchases on "mental health" would likely trigger legal issues. Where to draw a new line? When someone undergoes therapy? Or gets a prescription for a psychoactive drug? Or agrees to a hospital stay?

They also point out that current prohibitions haven’t prevented or stemmed mass shootings. The 2014 FBI report found that at least half the guns used in active shootings were legally purchased. The gun in the Downtown shooting was legally purchased.

Instead, experts say society needs another tool between a gun and suicidal thoughts. One proposal under discussion in Ohio is a device now permitted in at least five states called the “extreme risk protection order,” or a “red-flag order.”

Under such a law, police could go to a judge for the power to remove guns temporarily from a person who is communicating threats. That person can later petition a judge to get back weapons.

Alabama's Lankford said getting guns away from someone dealing with suicidal thoughts could add a measure of safety without infringing on the gun owner’s constitutional rights.

“The FBI has found that in about 56 percent of mass shootings, they found ‘leakage,’ meaning that the shooter told someone what he was considering,” Lankford said. “If the line (for possessing a gun) is that someone who openly admits to having thoughts of killing others, that should be the line we can all agree on. But we’re not even at that point in this country. You can admit those things, and still get firearms.”

But gun-rights advocates oppose red-flag orders as pre-emptive and unconstitutional. After the Sept. 6 attack in Cincinnati, an official of the Buckeye Firearms Association wrote an essay on the Greenville, Darke County-based group's website that the only thing that would have stopped the shooter was "a good guy with a gun."

Association secretary Chad H. Baus said a version of a “red-flag orders” that Ohio Gov. John Kasich has proposed would have overridden gun rights of all felons, even of nonviolent crimes.

“There are already plenty of laws in place to deal with people who are suffering mental health issues that could cause them to commit violence, and which still respect our constitutional rights,” said Baus. “Those who suggest that yet another gun-control law is all that is needed for our government bureaucracy to finally act properly and efficiently are misguided, at best.”

‘Create a culture of safety’

A better approach, the experts said, is a widespread cultural shift that would mean getting gun advocates on board with suicide prevention – just as the culture changed over drunken driving.

“We have a hard time in this nation having a pragmatic conversation about firearms,” said Anestis of Southern Mississippi, so the gun-rights community has to participate in creating a solution. “We have to work to create a culture of safety. We did that with drunken driving. We did that with mandatory seat belts. We did that with texting and driving. … We have to work with gun owners. You’re not going to solve the problem of guns unless you work with gun owners.”

The Buckeye Firearms Association is taking that step. The group is working with Franklin County Local Outreach to Suicide Survivors to develop safety materials for gun owners that would go into gun stores, said LOSS Executive Director Denise Meine-Graham.

The materials, entitled, "Do You Have Your Buddy's Back?" encourage gun owners to help other find mental health care if they are feeling the need. Meine-Graham said her organization reached out to the firearms group to get a better understanding of how best to reach out.

"We're not anti-gun," Meine-Graham said. "This has nothing to do with anti-gun. It has to do with suicide prevention." The result, she said, is a "gun-friendly" approach to help people in need.