Dr. Forman: Unfortunately, your new book Gun Violence and Mental Illness could not be timelier. Is there one thing that you see the media or politicians consistently getting wrong with respect to mental illness and mass shootings?

Dr. Gold: Well, there are multiple things they get wrong-but my area of expertise is mental health, and from a mental health perspective, they could not be more wrong when they continue to repeat that the problem with gun violence in this country is due to failure to adequately address mental illness. It is true that the mental health system is underfunded and fragmented-especially for people with acute serious mental illness. However, most serious mental illness is only weakly associated with violence of any kind-and with gun violence in particular. Most people with serious mental illness are not violent; most people who are violent do not have serious mental illness. Individuals with mental illness are responsible for about 3% to 5% of all types of violence in the US-when they do become violent, they are most likely to assault family members or commit suicide.

Firearm violence committed by individuals with serious mental illness against strangers is one of the rarest forms of gun violence in the US. Of the approximately 33,000 firearm deaths each year, two-thirds are suicides. Less than 1% of all firearm deaths in the US occur in the context of mass shootings by individuals, with or without mental illness. So unless the media and politicians are talking about suicide deaths by firearms-which they never are-they are simply perpetuating negative stereotypes and stigma associated with mental illness.

The thinking goes like this: only someone who is crazy would commit such a horrible act and kill innocent people. We all know that crazy people are dangerous and violent; therefore, it must be people with mental illness who are behind these horrible acts. However, mass shootings are not invariably associated with people who have acute mental illness or a history of mental illness. Some do, but some don’t.

Improved funding and resources for mental health systems and treatment would of course be welcomed. However, the repeated calls to “improve the mental health system” heard after mass shootings do not result in increased spending or funding. They merely serve as a politically expedient method to avoid talking about instituting sensible firearm regulation.

Moreover, the refrain to keep guns out of the hands of the mentally ill does a disservice to American society:

1. It reinforces the stigma and negative stereotypes associated with mental illness, making it less likely that those who need treatment will receive treatment.

2. It does not result in improved funding of or access to mental health treatment.

3. It allows politicians and media to avoid discussing sensible gun regulations.

4. Because no effective change results, the American people have come to believe that “nothing can be done” to stop the high toll of gun violence, despite the fact that we are the only country in the world with this kind of civilian gun violence problem.

Dr. Forman: Many leaders who oppose increased gun regulation point to improving access to mental health care as the solution to reducing gun violence in America. How much do you think improved access to mental health care can drive down gun violence?

Dr. Gold: Improved access to mental health care would likely have a substantial effect in decreasing suicide rates. Suicide is the 10th leading cause of death in the US, and the 2nd leading cause of death among adolescents and young adults. About 40,000 people commit suicide each year. More than half commit suicide with a firearm. Only 2 interventions have evidence indicating effectiveness in regard to decreasing suicide: mental health treatment is one of them, the other is restriction of lethal means. So yes, mental health treatment is likely to decrease suicide rates overall, including probably some percentage of firearm suicides.

However, if you are talking about firearm homicides-of which there are about 11,000 a year-even with adequate mental health resources and access for everyone in the US, you would not significantly affect rates of gun violence. Most of these by far are variations of interpersonal violence-domestic violence, even “gang” violence, which is often interpersonal. Since mass shootings committed by individuals with or without mental illness typically account for less than 0.5% of all gun deaths per year, improved access to mental health treatment is not an effective intervention.

Dr. Forman: Do you believe it could be an effective way to drive down deaths without any changes in gun regulation?

Dr. Gold: For reasons I’ve cited here, no. Since most gun violence toward others is not committed by individuals with mental illness, improved access to treatment would be ineffective for this type of gun violence. Suicide is a different story-as many as 90% of people who commit suicide have a history of or an active psychiatric diagnosis at the time of death.

Dr. Forman: What policy prescriptions, if any, would you make on a federal level for reducing gun violence in America?

Dr. Gold: Many interventions are possible and supported by evidence already available. We need to look at evidence of dangerousness, ie, risk of violent behavior, with or without mental illness. Mental illness should be taken out of the equation as it is not a productive line of discussion.

1) The evidence indicates that times of risk/crisis can be identified. For example, women are often killed by firearms in the context of domestic violence. Right now, individuals under a permanent, but not temporary domestic violence restraining order are prohibited from having firearms, which has been effective in decreasing the homicide rates in these situations. However, the time of highest risk of harm for women is when they attempt to leave a relationship. When they first apply for the restraining order, they get a temporary order (the permanent order comes later). Why not extend firearm prohibition to temporary as well as permanent restraining orders?

Another example is the case of felons who are categorically prohibited to own firearms, even though not all of them have committed violent crimes. It is the history of violence, not the conviction, that is highly associated with risk of future firearm violence. Why not tailor firearm prohibitions to anyone convicted of a violent felony or misdemeanor-particularly if it involves use of a firearm.

2) Public education programs and legal interventions to separate individuals from firearms at times of crisis are needed, along the lines of “friends don’t let friends drive drunk.” Family members and friends are often aware when someone they care about is going into a crisis. We need to educate people to ask and offer to hold firearms for their loved ones until the crisis passes (as we do when an individual may be suicidal).

3) Legislation based on the model of domestic violence would allow family members to petition the courts for a firearm restraining order at times of crisis, when law enforcement can be authorized to temporarily separate an individual from firearms. Such a law went into effect for the first time in California on January 1, 2016.

Dr. Forman: What are the top facts you think every psychiatrist should know about the connection between mental illness and gun violence?

Dr. Gold: These are my recommendations:

1) Always ask patients whether there are firearms in the home, not just whether they are firearm owners. Evidence shows increased risk of suicide and homicide in homes where there are firearms, regardless of who owns them.

2) If there are firearms in the home and children/teenagers, it is mandatory that guns are safely stored. Guns should be kept unloaded and locked, separately from ammunition, which should also be locked.

3) There is no such thing as safe storage of a firearm in a home where someone is in crisis with, for example, depression, psychosis, or substance abuse; is distraught over the loss of a relationship or job; has a recent diagnosis of serious medical illness; or has dementia. People with family members who fall into these categories, especially if one of them is a teenager or young adult, should not keep guns in the home.

Dr. Forman: Do you think suicide is a below-the-radar gun-related tragedy? Do you believe there are any policy changes that would reduce suicide rates?

Dr. Gold: Why does suicide go below the radar? Many people feel it shouldn’t count because it is self- inflicted. Also, it is highly stigmatized; many people are ashamed to acknowledge or admit that there might be an issue in the family. We need to recognize that there are many different types of gun violence, and suicide is one of those types. Interventions to decrease the morbidity and mortality of gun violence must include evidence-based policy that addresses suicide risk as well as homicide.

More on Gun Violence

Mounties, Cowboys, Avengers-and the Cultural Script of Gun Violence

James L. Knoll IV, MD and Ronald W. Pies, MD

The Seven Myths of Mass Murder

J. Reid Meloy, PhD

Gun Violence, Stigma, and Mental Illness: Clinical Implications

Jonathan M. Metzl, MD, PhD

[[{"type":"media","view_mode":"media_crop","fid":"51298","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_6995954752670","media_crop_h":"306","media_crop_image_style":"-1","media_crop_instance":"6326","media_crop_rotate":"0","media_crop_scale_h":"200","media_crop_scale_w":"119","media_crop_w":"182","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":" ","typeof":"foaf:Image"}}]]Liza H. Gold, MD, is an internationally renowned leader in forensic psychiatry. In addition to her book Gun Violence and Mental Illness, Dr. Gold is a co-editor with Robert I. Simon, MD, of the American Psychiatric Publishing Textbook of Forensic Psychiatry. She has been honored numerous times for her work, including the American Academy of Psychiatry and the Law’s (AAPL) Seymour Halleck Award for distinguished contributions to the field of forensic psychiatry. Her books Sexual Harassment: Psychiatric Assessment in Employment Litigation and Evaluating Mental Health Disability in the Workplace are essential for anyone who works in these fields and have both been honored by the American Psychiatric Association and the AAPL with the Manfred Guttmacher Award. Her expert opinion has been sought by sources including ABC, PBS, CNN, and NPR. As psychiatrists who practice in an era with gross distortions about the connection between mental illness and gun violence, it is incumbent on us to contribute to public discourse with sound information and guidance. It is very fortunate that Dr. Gold has given us a book that will help us to do so.