When Donald Trump targeted mental illness as the cause of the mass shootings that killed 31 people in El Paso, Texas, and Dayton, Ohio, federal health officials made sure no government experts might contradict him.

A Health and Human Services (HHS) directive on 5 August warned communication staffers not to post anything on social media related to mental health, violence and mass shootings without prior approval.

That alarmed some government mental health experts who said they felt muzzled at a moment many Americans were searching for answers to the US epidemic of mass shootings, said three agency employees.

Many researchers and mental health experts said Trump’s comments contradicted well-established research.

“Mental illness and hatred pull the trigger. Not the gun,” Trump said immediately after the shootings. In the following days, he doubled down on his statement, arguing that America should reopen mental institutions shuttered decades ago as a way to address mass shootings.

While mental illness is sometimes a factor in such shootings, it is rarely a predictor, according to a growing body of research. Most studies of mass shooters have found that no more than a quarter of them have diagnosed mental illness. Researchers have noted more commonly shared attributes include a strong sense of resentment, desire for notoriety, obsession with other shooters, a history of domestic violence, narcissism and access to firearms.

Trump protests: President visits Texas and Ohio after mass shootings Show all 31 1 /31 Trump protests: President visits Texas and Ohio after mass shootings Trump protests: President visits Texas and Ohio after mass shootings Miami Valley Hospital, Dayton Demonstrators chant as they protest the arrival of President Donald Trump outside Miami Valley Hospital after a mass shooting that occurred in the Oregon District AP Trump protests: President visits Texas and Ohio after mass shootings El Paso Trump headed to El Paso, after visiting Dayton, Ohio to offer a message of healing and unity, but he was met by hostility in both places by people who fault his own incendiary words as a contributing cause to the mass shootings AP Trump protests: President visits Texas and Ohio after mass shootings El Paso, University Medical Centre US President Donald Trump greets first responders as he visits El Paso Regional Communications Centre AFP/Getty Trump protests: President visits Texas and Ohio after mass shootings El Paso, University Medical Centre An anti-Trump protestor holds a sign as police are lined up outside University Medical Centre Getty Trump protests: President visits Texas and Ohio after mass shootings El Paso Demonstrators hold a sign as the motorcade carrying President Donald Trump departs a joint operations center after meeting with first responders after the El Paso mass shooting, Wednesday, Aug. 7, 2019, in El Paso, Texas. (AP Photo/Evan Vucci) Evan Vucci AP Trump protests: President visits Texas and Ohio after mass shootings El Paso Anti-Trump protesters hold a banner outside the makeshift memorial to the victims of the WalMart shooting that left a total of 22 people dead, in El Paso, Texas, on August 7, 2019. - President Donald Trump consoled victims of a mass shooting in Ohio on Wednesday but protesters and opponents denounced what they say is his extremist rhetoric on race and immigration. The president's trip to Dayton, where nine people were gunned down over the weekend, was to be followed immediately after by a stop in the border city of El Paso, Texas, where 22 were murdered. (Photo by Mark RALSTON / AFP)MARK RALSTON/AFP/Getty Images MARK RALSTON AFP/Getty Trump protests: President visits Texas and Ohio after mass shootings Miami Valley Hospital, Dayton Demonstrators gather to protest the arrival of President Donald Trump outside Miami Valley Hospital after a mass shooting that occurred in the Oregon District early Sunday morning, Wednesday, Aug. 7, 2019, in Dayton. Twenty-four-year-old Connor Betts opened fire in Dayton early Sunday, killing several people including his sister, before officers fatally shot him. (AP Photo/John Minchillo) John Minchillo AP Trump protests: President visits Texas and Ohio after mass shootings El Paso Democratic presidential candidate Beto ORourke hugs a woman at a makeshift memorial outside Walmart honoring victims of the mass shooting there which left 22 people dead. Getty Trump protests: President visits Texas and Ohio after mass shootings El Paso Anti-Trump protesters hold signs outside the makeshift memorial to the victims of the WalMart shooting that left a total of 22 people dead, in El Paso, Texas, on August 7, 2019. - President Donald Trump consoled victims of a mass shooting in Ohio on Wednesday but protesters and opponents denounced what they say is his extremist rhetoric on race and immigration. The president's trip to Dayton, where nine people were gunned down over the weekend, was to be followed immediately after by a stop in the border city of El Paso, Texas, where 22 were murdered. (Photo by Mark RALSTON / AFP)MARK RALSTON/AFP/Getty Images MARK RALSTON AFP/Getty Trump protests: President visits Texas and Ohio after mass shootings El Paso Marisela Hernandez holds sign to protest the visit of President Donald Trump to the border city after the Aug. 3 mass shooting in El Paso, Texas, Wednesday, Aug. 7, 2019. Aiming to play the traditional role of healer during national tragedy, President Donald Trump paid visits Wednesday to cities reeling from the mass shootings. (AP Photo/Andres Leighton) Andres Leighton AP Trump protests: President visits Texas and Ohio after mass shootings El Paso, University Medical Centre An anti-Trump demonstrator holds up a placard outside the University Medical Center, where U.S. President Donald Trump holds a meeting with first responders in the wake of last weekend's mass shootings at a Walmart store, in El Paso, Texas, U.S., August 7, 2019. REUTERS/Jose Luis Gonzalez JOSE LUIS GONZALEZ Reuters Trump protests: President visits Texas and Ohio after mass shootings El Paso, University Medical Centre President Trump and First Lady Melania Trump greet PFC Glendon Oakley (second right), who saved several lives during the mass shooting in Texas AFP/Getty Trump protests: President visits Texas and Ohio after mass shootings Miami Valley Hospital, Dayton Demonstrators chant as they protest the arrival of President Donald Trump outside Miami Valley Hospital after a mass shooting that occurred in the Oregon District early Sunday morning, Wednesday, Aug. 7, 2019, in Dayton. (AP Photo/John Minchillo) John Minchillo AP Trump protests: President visits Texas and Ohio after mass shootings El Paso, University Medical Centre An anti-Trump demonstrator holds up a placard as police block the area outside the University Medical Center, where U.S. President Donald Trump holds a meeting with first responders in the wake of last weekend's mass shootings at a Walmart store, in El Paso, Texas, U.S., August 7, 2019. REUTERS/Jose Luis Gonzalez JOSE LUIS GONZALEZ Reuters/Amanda Voisard Trump protests: President visits Texas and Ohio after mass shootings El Paso Beto ORourke consoles a man at the makeshift memorial outside Walmart Getty Trump protests: President visits Texas and Ohio after mass shootings El Paso, University Medical Centre An anti-Trump demonstrator yells near police outside the University Medical Centre Reuters Trump protests: President visits Texas and Ohio after mass shootings El Paso TOPSHOT - El Paso residents protest against the visit of US President Donald Trump to the city after the Walmart shooting that left a total of 22 people dead, in El Paso, Texas, on August 7, 2019. - President Donald Trump consoled victims of a mass shooting in Ohio on Wednesday but protesters and opponents denounced what they say is his extremist rhetoric on race and immigration. The president's trip to Dayton, where nine people were gunned down over the weekend, was to be followed immediately after by a stop in the border city of El Paso, Texas, where 22 were murdered. (Photo by Mark RALSTON / AFP)MARK RALSTON/AFP/Getty Images MARK RALSTON AFP/Getty Images Trump protests: President visits Texas and Ohio after mass shootings Dayton President Donald Trump and First Lady Melania Trump arrive at Wright-Patterson Air Force Base AP Trump protests: President visits Texas and Ohio after mass shootings El Paso Makeshift memorial for victims of the shooting that left a total of 22 people dead at the Cielo Vista Mall Walmart AFP/Getty Images Trump protests: President visits Texas and Ohio after mass shootings Miami Valley Hospital, Dayton Demonstrators gather to protest the arrival of President Donald Trump outside Miami Valley Hospital after a mass shooting that occurred in the Oregon District early Sunday morning, Wednesday, Aug. 7, 2019, in Dayton. (AP Photo/John Minchillo) John Minchillo AP Trump protests: President visits Texas and Ohio after mass shootings President Trump greets Dayton Mayor Nan Whaley as he arrives at Wright-Patterson Air Force Base AFP/Getty Trump protests: President visits Texas and Ohio after mass shootings Miami Valley Hospital, Dayton Demonstrators gather to protest the arrival of President Donald Trump outside Miami Valley Hospital after a mass shooting that occurred in the Oregon District early Sunday morning, Wednesday, Aug. 7, 2019, in Dayton, Ohio. Twenty-four-year-old Connor Betts opened fire in Dayton early Sunday, killing several people including his sister, before officers fatally shot him. (AP Photo/John Minchillo) John Minchillo AP Trump protests: President visits Texas and Ohio after mass shootings Dayton Damon Smith presents a message to President Donald Trump beside a makeshift memorial in Dayton AP Trump protests: President visits Texas and Ohio after mass shootings Miami Valley Hospital, Dayton Demonstrators gather in front of an inflatable "Baby Trump" to protest the presidents arrival AP Trump protests: President visits Texas and Ohio after mass shootings Miami Valley Hospital, Dayton Demonstrators gather to protest the arrival of President Donald Trump outside Miami Valley Hospital after a mass shooting that occurred in the Oregon District early Sunday morning, Wednesday, Aug. 7, 2019, in Dayton. President Donald Trump is headed to Dayton and El Paso, Texas on Wednesday to offer a message of healing and unity, but he will be met by unusual hostility in both places by people who fault his own incendiary words as a contributing cause to the mass shootings . (AP Photo/John Minchillo) John Minchillo AP Trump protests: President visits Texas and Ohio after mass shootings El Paso A photo of victim Javier Amir Rodriguez, a 15-year-old sophomore Getty Trump protests: President visits Texas and Ohio after mass shootings Dayton Demonstrators protest the visit of US President Donald Trump to the site of the mass shooting in Dayton, Ohio, on August 7, 2019. - Nine people were killed on August 4 in the city's popular Oregon District. (Photo by Megan JELINGER / AFP)MEGAN JELINGER/AFP/Getty Images MEGAN JELINGER AFP/Getty Trump protests: President visits Texas and Ohio after mass shootings El Paso A message is left for Donald Trump AFP/Getty Trump protests: President visits Texas and Ohio after mass shootings El Paso Signs and flags adorn the makeshift memorial for victims of the shooting that left a total of 22 people dead at the Cielo Vista Mall Walmart, in El Paso, Texas, on August 7, 2019. (Photo by Mark RALSTON / AFP)MARK RALSTON/AFP/Getty Images MARK RALSTON AFP/Getty Trump protests: President visits Texas and Ohio after mass shootings El Paso People hug at the makeshift memorial AFP/Getty Trump protests: President visits Texas and Ohio after mass shootings El Paso People pray at the makeshift memorial AFP/Getty

“To say that scientists and experts who know the data and facts best are not allowed to speak - that’s very concerning,” said Dominic Sisti, a University of Pennsylvania professor who studies ethics in mental health and psychiatry. “It’s especially alarming that they’re doing this at a critical moment when what we need most is research and evidence-based facts about mental illness.”

An HHS employee who spoke on the condition of anonymity to relate internal discussions said he had “no doubt this was meant to prevent anybody from making any statements that might contradict the president.”

“We understand we’re not supposed to contradict the president, but it’s not typical” for the administration to require that all social media posts be cleared by senior officials, he added.

On 5 August, Trump was scheduled to speak after the weekend shootings. That morning, some HHS employees, including those at the National Institutes of Health (NIH), received an email asking those who contribute to official social media accounts to hold off on posts until “we get the green light from HHS,” which was expected after the president spoke, according to a copy of the email obtained by The Washington Post.

Later that afternoon, some employees received another email from Renate Myles, an NIH spokeswoman. Social media posts could resume, the note said, but employees were asked to “please send any posts related to mental health, violence or other topics associated with mass shootings for review before posting.”

The second directive applied most directly to the National Institutes of Mental Health, where nearly all of the agency’s social media activities relate to mental health. It remains unclear how many people received that instruction, which was lifted by week’s end.

“It’s the department’s long-standing practice to not get ahead of the president’s remarks,” said HHS spokeswoman Caitlin Oakley. “This allows the president to share his message first with the nation. Any suggestions that this was a formal policy put in place related to social media, or meant to stymie work on this issue, are factually inaccurate. These were staff-level discussions seeking to be sensitive and respectful to the victims and their families affected by tragedies of that weekend.”

By contrast, two former senior health officials in the Obama administration said they did not recall ever receiving such a directive after a mass shooting.

In the days and months following the mass shooting that killed 20 first graders and six staff members at Sandy Hook Elementary School in Newtown, Connecticut, the National Institutes of Mental Health (NIMH) spoke extensively about mental illness and violence. “The conversation has evolved, recognising that violence most often associated with mental illness is suicide, and that most violence is unrelated to mental illness,” the NIMH director said at a meeting three months later. NIMH also hosted a special panel discussion, “How Sandy Hook is Changing the Conversation,” during which mental health experts worked to dispel stereotypes that link mental illness to violence.

After this month’s shootings, however, NIMH and its director were largely silent on the shooting. The only mention on the official NIMH Twitter account was a retweet of the NIH account, directing those struggling with grief and emotional distress to the Substance Abuse and Mental Health Services Administration for counselling and support.

“There is this climate of concern whether you can make a statement based on facts,” said a National Institutes of Health employee. “I see people struggling with how to interpret it. What are we allowed to do?”

Trump’s comments after the shootings sparked widespread concern among mental health experts and advocates.

“Research has shown that only a very small percentage of violent acts are committed by people who are diagnosed with, or in treatment for, mental illness,” Rosie Phillips Davis, president of the American Psychological Association, said in a statement.

Mental health advocates also worry that blaming the mentally ill for mass shootings will spread fear and keep people from seeking help.

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In a 2018 report on 63 shooters, the FBI found that 25 percent had been diagnosed with a mental illness. Of those, three had been diagnosed with a psychotic disorder. In a 2015 study that examined 226 men who committed or tried to commit mass killings, 22 per cent could be considered mentally ill. Researchers also point out that other countries have similar rates of mental illness but only a fraction of the United States’s fatalities from shootings. The key factor that sets the United States apart from the rest of the world, epidemiologists say, is the easy availability of guns.

Trump’s latest argument – that reopening mental asylums would help stop mass shootings – has similarly drawn concern. In a June study, Sisti of the University of Pennsylvania and fellow researcher Isabel Perera looked at other countries that shut down their psychiatric institutions as America did, and compared their rates of mass shootings. They found no relationship between deinstitutionalisation and mass shootings.

“Mental illness as an explanation for mass shootings is a trope, a distraction,” Sisti said.