JAMA Summit on Reducing Firearm Violence

 

One of my frequent topics on this blog is firearm violence, the likely causes, and ways to prevent it.    When I saw this topic in my most recent edition of the Journal of the American Medical Association (JAMA) – I could not wait to read it.  Now that I have - it is a different story.  

The paper begins by posting some astonishing numbers of gun violence in the United States.  Since the year 2000, there have been 800,000 firearm deaths and 2 million firearm injuries in the US.  Firearms are the leading cause of death in children in the United States.  There were no references to school or mass shootings even though the United States is the only high-income country with this problem.  No other country comes close.

There is a description of the group who produced this paper.  We learn that it consisted of a multidisciplinary group of 60 thought leaders and they were charged with producing an innovation roadmap to decrease firearms harms by 2040. Their recommendations are summarized in this 12-page document and I do not think it will prove very useful. 

The best part of the document is the table Evidence Base for Interventions That Demonstrate Significant Reductions in Firearm Violence.  For 20 years, the Dickey Amendment restricted research on firearm violence and the prevention of firearm violence largely done by the CDC and NIH.  Starting in 2020 funding for research on firearm violence was resumed at both agencies.  This July, the Trump administration cut $158M in gun violence prevention grants (69 of 145 community violence intervention (CVI) grants.   In October, the Trump administration fired key personnel in the CDC violence prevention program that collected data and produced dashboards based on that data.   They also closed the White House Office of Gun Violence Prevention that had been initiated under the Biden administration.  Despite that active suppression of gun violence research except for the last few years – several effective interventions have been discovered and they are included in the table.  They cut across areas involving licensing, violence prevention programs, disarming potentially violent offenders, changing the violence ecosystem, improving the socioeconomic environment, decreasing the availability of alcohol, and an increased police presence and more efficient and targeted policing.

When I think about the people who told me they were saved by their inability to purchase firearms it generally came down to legal waiting periods and federal firearms checks.  They were people considering firearm violence directed at themselves or another person and the only reason it did not happen was that they were prohibited from purchasing a gun at that instant.  In retrospect they were universally thankful that they could not get the gun and when the impulse passed, they did not purchase one later.  This document does not specially mention either of those interventions.

Despite the table, the document focused on a lot of speculative interventions looking at reducing community violence, improving the socioeconomic status, and changing the ecology of neighborhoods where these kinds of crimes occur.  I have no doubt these strategies will be useful to some degree but cannot help but see that most people in these communities are law abiding and are an unlikely source of gun violence.  That does not mean they are immune to the effects of gun violence because just having a gun in the house increases the chances of gun violence death by suicide or accident.

Treating guns as a commercial product is a suggested strategy.  The argument suggests that manufacturers and sellers assume product liability.  When that happens liability suits or the threat of these suits will change gun manufacturers to make safer products.  They provide examples of successful lawsuits.  We should all take a lesson from mental health care in considering a strategy that depends on civil liability.  The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 was supposed to lead to equal treatment of mental illnesses.  It treats insurance coverage as a commercial product.  It has led to lawsuits that (while successful) have had absolutely no impact on the insurance industry.  Their attitude is “if you think you are being treated unfairly – you will have to sue us and win.”   Their basic rationing practices remain unchanged.

There are frequent mentions of technology and artificial intelligence (AI) in the report.  Smart guns that can only be fired by the owner have been talked about for quite some time – but there are not a lot of products. Analyzing data by AI, even if it appropriately designed to incorporate racial diversity and equity does not seem to be a major innovation. The current data being collected lacks the granularity (see below) to properly study the decision making involved.

The authors make the argument that people seem to ignore the fact that violent crime is significantly decreased over the past decades.  They do not describe how this happens but suggest that countering this fallacy is important. It is a difficult fallacy to counter when a major political party uses this narrative daily to rationalize laws that promote gun extremism and gun permissiveness.  Politics is not mentioned at all in the document even though one political party would find it difficult to function without repeated references to gun access and promoting gun extremism.

What is missing?  Just about everything I have written about on this blog.  First, guns are a problem and there is no way around it.  I was concerned to see the following sentence in this paper:

“Firearms are not a cause of violence but, because of their high lethality and ability to injure large numbers of people, result in serious harm when combined with violent acts.”

It contrasts with:

“Primordial prevention addresses the most upstream, root-level causes of adverse outcomes—well before they take shape—by changing the structures and systems that give rise to them. This means transforming the fundamental social, environmental, and economic contexts that foster violence. This upstream approach is relevant to all types of firearm harms and applies across urban and rural settings. The current moment demands bold, systems-level interventions that prioritize housing stability, economic opportunity, environmental improvement, and equitable policies.”

In biological systems theory, a firearm is not conceptualized in isolation as an inert object.  Firing a gun is seen as an emergent property of the interaction of multiple subsystems in the individual, the task, the implement used, and the environment.  There are many examples.  You are not brushing your teeth without a toothbrush or walking with a cane without the cane.  The firearm is an integrated component of that system.  To prevent adverse outcomes from that system, all the components including the gun need to be addressed.  It is guns and people that account for the outcome not either in isolation.

Second, there is not a single mention of culture as a significant factor. There is discussion of changing narratives and all the various groups involved but not a single mention of the cultural aspects of gun violence. More specifically there is no mention of how the US has gone from a culture of firearms for hunting and target shooting in the mid-20^th century to the current culture of carrying firearms with minimal regulation like what existed in the mid-19^th century.  That was before towns in the Old West passed ordinances about not carrying firearms in town.  There is clear current evidence that lax firearm regulation correlates with firearm casualties and deaths.

Third, there is a clear gun extremism culture that I have elucidated in this past post.  The elements are clear and this level of gun extremism correlates with increases in mass shootings and school shootings.  Gun extremists typically take and expansionist view of the Second Amendment while ignoring the preamble.  Many are also strict constructionists who ignore gun restrictions that were in place when it was written. 

Politics is a clear factor in gun extremism since it is promoted by the politicians, judges, and operatives of one political party.  It is really a combination of gun extremism and inaction. After every mass or school shooting – nothing ever gets done.  School shooters are a subset of the gun extremist culture and a clear example of how cultural effects can spread to other people.  At the broader political level gun extremism is heritable and passed on from generation to generation.

Fourth, the neuroscience of human decision making and development is ignored, especially the emotional component.  It has been known for some time that human decision making is more than a purely rational process and that an emotional component is essential (5-8).  Since then, the neurobiological substrate has been partially elucidated but research continues to find new components (9).  The basic observation seen on any true crime TV show – the relationship of anger and gun availability to gun violence has not been adequately investigated.  The epidemiological methods use to examine gun violence gather adequate contextual details for accidental injury and death but not homicide (10).  One of the gun extremist myths is that gun owners and carriers have superior ability to control themselves and avoid making mistakes. There is no reason to expect that is true.  Just having more people carrying lethal weapons in public will increase the chances of a violent confrontation.      

Fifth, the authors recommend strategies to decrease alcohol consumption and there is some evidence that younger generations are consuming less alcohol.  At the same time, we have increased cultural permissiveness for other intoxicants that are as likely to be associated (directly or indirectly) with aggression and violence – specifically stimulants, cannabis and cannabis derivatives, synthetic cannabinoids, and opioids.

Sixth, homicide prevention needs to have a similar path toward resolution that suicide prevention currently has.   To put things into perspective, many people with either problem end up on psychiatric units in hospitals.  Most of them are there because of stated suicidal ideation or making a suicide attempt.  The violent people are typically there because of police calls where they had to contain an aggressive person who has a mental illness.  There are no hot lines comparable to suicide hot lines.  There are no homicide prevention programs for the acutely homicidal person. As far as I know there has been no research in this area.  Aggressive and homicidal behavior needs to be identified as a clinical and public health problem that needs to be addressed in a timely manner. 

These are some obvious unaddressed factors in this report.  It is probably easier to consider general solutions than more specific cultural and political ones.  But we can no longer pretend that maintaining and ignoring these cultural factors will lead to any effective changes.  It also requires adequate expertise in data collection, sociocultural changes, and in clinical settings. More discussion in this area will result in people who are more comfortable talking about the problem.   This is a complex problem but it does have solutions.  Considering the biological and sociocultural factors described – it should be apparent that the sociocultural factors are primary. The current administration is doing nothing to address childhood adversity.  The logical place for intervention is changing the sociocultural environment with legal and public health interventions.  It will take more than what is  suggested in this review.   

George Dawson, MD, DFAPA

 

References:

1:  Rivara FP, Richmond TS, Hargarten S, Branas CC, Rowhani-Rahbar A, Webster D, Richardson J Jr, Ayanian JZ, Boggan D, Braga AA, Buggs SAL, Cerdá M, Chen F, Chitkara A, Christakis DA, Crifasi C, Dawson L, deRoon-Cassini TA, Dicker R, Erete S, Galea S, Hemenway D, La Vigne N, Levine AS, Ludwig J, Maani N, McCarthy RL, Patton DU, Quick JD, Ranney ML, Rimanyi E, Ross JS, Sakran JV, Sampson RJ, Song Z, Tucker J, Ulrich MR, Vargas L, Wilcox RB Jr, Wilson N, Zimmerman MA; JAMA Summit on Reducing Firearm Violence and Harms. Toward a Safer World by 2040: The JAMA Summit Report on Reducing Firearm Violence and Harms. JAMA. 2025 Nov 3. doi: 10.1001/jama.2025.18076. Epub ahead of print. PMID: 41182880.

2:  Rostron A. The Dickey Amendment on Federal Funding for Research on Gun Violence: A Legal Dissection. Am J Public Health. 2018 Jul;108(7):865-867. doi: 10.2105/AJPH.2018.304450.

3:  Lin JC, Chang C, McCarthy MS, Baker-Butler A, Tong G, Ranney ML. Trends in Firearm Injury Prevention Research Funding, Clinical Trials, and Publications in the US, 1985-2022. JAMA Surg. 2024;159(4):461–463. doi:10.1001/jamasurg.2023.7461

4:  Zaller N, Brown J, Fischer K, Abaya R, Cardoso LF, Dreier FL. The Critical Role Of Federal Funding In Combating Firearm Violence. Health Affairs Forefront. 2025.  Accessed on November 8, 2025) https://www.healthaffairs.org/content/forefront/critical-role-federal-funding-combating-firearm-violence-public-health-perspective

5:  Bechara A, Damasio H, Damasio AR. Emotion, decision making and the orbitofrontal cortex. Cereb Cortex. 2000 Mar;10(3):295-307. doi: 10.1093/cercor/10.3.295. PMID: 10731224.

6:  Bechara A. The role of emotion in decision-making: evidence from neurological patients with orbitofrontal damage. Brain Cogn. 2004 Jun;55(1):30-40. doi: 10.1016/j.bandc.2003.04.001. PMID: 15134841.

7:  Sanchez EO, Bangasser DA. The effects of early life stress on impulsivity. Neurosci Biobehav Rev. 2022 Jun;137:104638. doi: 10.1016/j.neubiorev.2022.104638. Epub 2022 Mar 24. PMID: 35341796; PMCID: PMC9119952.

8:  Potegal M, Stemmler G. Constructing a neurology of anger. In International handbook of anger: Constituent and concomitant biological, psychological, and social processes 2009 Dec 21 (pp. 39-59). New York, NY: Springer New York.

9: Jung J, You IJ, Shin S. Thalamo-hippocampal pathway determines aggression and self-harm. Sci Adv. 2025 Nov 7;11(45):eady5540. doi: 10.1126/sciadv.ady5540. Epub 2025 Nov 5. PMID: 41191756; PMCID: PMC12588284.

10:  Forsberg K. Surveillance for Violent Deaths—National Violent Death Reporting System, 50 States, the District of Columbia, and Puerto Rico, 2022. MMWR. Surveillance Summaries. 2025;74. https://www.cdc.gov/mmwr/volumes/74/ss/pdfs/ss7405a1-H.pdf

Graphic:  The graphic above is a line drawing of my MRI.  I intend to place it in a larger drawing of all the relevant factors to consider when it comes to gun violence. That is a work in progress and it is an extremely complex drawing.  When I complete it – I will replace the graphic at the top of this post.

Medication Checklist

 

I just completed a modification of my Medication Checklist that I have been using for the past 20 years.  The intent of the checklist was to provide an easy way for patients I was seeing to recall any medications they had been treated with in the past. There was no attempt to classify the medications in a more precise manner.  I found it was successful for its intended purpose and allowed for a discussion of other potentially useful medications as well as the limitations of this kind of classification.  As an example, there are overlap categories between antipsychotic medications and mood stabilizers as well as anxiolytics and antidepressants.

My last update was 5 years ago.  Since then, there have been 24 additions, but very few in terms of new medications.  Most of the changes have all been changes in drug formulations (sustained release, combination medications, a new transdermal patch, and longer acting injectable medications.  I included one GLP-1A agonist – tirzepatide (Zepbound, Mounjaro) because it has a new indication for obstructive sleep apnea and sleep medicine is a growing subspeciality in psychiatry. 

I included a new category of Agitation, because dexmedetomidine has that indication.  The only other medications typically in that class are antipsychotics and mood stabilizers but it is far from inclusive.  In acute care psychiatry, most of the medication used to treat this problem are not FDA approved but are from the same classes as the approved drugs.  The only exception are benzodiazepine drugs that are often combined with antipsychotics. 

The time domain for this list is about 40 years. That means there are several older medications on the list that are no longer manufactured or prescribed. It is useful to retain them because many people coming in for new assessments may have been exposed to them over the years. 

Gepirone is an interesting addition.  I posted previously about how azapirones (buspirone and gepirone) seemed to be neglected compounds in psychiatry. Despite buspirone having an anxiety disorder only indication, gepirone was approved for depression in 2023. The current package insert says it is indicated for depression only.  It is a once-a-day dosing but it has a QTc prolongation warning and may require more intensive medical monitoring for that reason.

Viloxazine is a selective norepinephrine reuptake inhibitor (SNRI) that is structurally dissimilar to atomoxetine – an earlier SNRI used to treat Attention Deficit-Hyperactivity Disorder.  

The most significant new medication is likely to be Xanomeline trospium chloride (Cobenfy).  It is a new antipsychotic medication with a novel mechanism of action. Xanomeline is a CNS M1 and M4 muscarinic acetylcholine receptors agonist.  Trospium is a muscarinic acetylcholine receptor antagonist primarily in the peripheral tissues making it a first in class medication.   

The medication sheet contains several medications that are used to treat symptoms and medication wide effects.  There is a total of 142 medications (not counting various reformulations of the same compound). 

I am currently working on reclassifying the medication on this sheet by two different systems – the Anatomical Therapeutic Chemical (ATC) classification system based on more formal indications and the Neuroscience-based Nomenclature (NbN) based on purported mechanisms of action.  At some point I will also try to put them all on a timeline based on when they were FDA approved.

In the meantime, the list can be accessed and printed out.  It is setup to fit on both sides of a standard piece of paper.  During an interview if a person has a difficult time recalling medications – I will show them the list and point out the section that is most likely relevant.  I never include it in the medical record, but use it as part of my notes to record the clinical encounter or check pharmacy records.    

Let me know what you think and if I missed anything.

 

George Dawson, MD, DFAPA

 

The Medication Checklist can be downloaded at this link.

How To Stop Burning Witches...

 

I was hoping for a timely post for Halloween but just missed the deadline. Witches are considered an icon of the season, although I have not seen a lot of those costumes recently. I came across an important book that analyzed the witchmongering movement in 15^th to 18^th century.   Witchmongering was term was coined by Reginald Scott in 1584 in his book The Discoverie of Witchcraft.  He used it to describe people promoting the ideas and superstitions about witchcraft – specifically those who profited from spreading these ideas.  His book discusses the idea that witches have connections to the devil and Scott’s position was that this was all imaginary.  He studied magic and concluded that the belief in witchcraft was rooted in illusions, imposters, or inaccurate conclusions due to mental disorders.  He sought to prevent marginalized individuals from being attacked as witches.

Despite Scott’s rational approach, witchmongering was actively debated for at least another century.  Thomas Ady wrote A Candle in the Dark in 1656 and took a similar position.  Popular opinion about the existence of witches and their presence began to wane around 1700, but witchcraft laws and executions persisted much longer. In Great Britain the Witchcraft Act was repealed in 1736.  By the late 18^th century most witchcraft prosecutions and punishments were banned in Europe. The last witchcraft trial in the US was in 1878.  There is a detailed history of both witch hunts and executions of witches resulting in the deaths of tens of thousands of women.  Even though most people do not know the details of this dark practice – the concept witch hunt is used rhetorically these days to indicate an unfair investigation.  

There are various ways to analyze the history of witchmongering. Social scientists have looked at anthropological and sociopolitical analyses. Rhetoric seems like a powerful approach to me because humans seem to use the same patterns over time to make irrational decisions.  Rhetoric is a component of cultural inheritance.  In the case of witches – anxiety provoking events like crop failures, illnesses, economic and political instability, religious and sexist biases could lead to accusations of witchcraft.  But once the precedent was set behaviors, social factors, and personality factors could also be included as well as accusations of supernatural phenomenon like sorcery and causing people to disappear.  There is no doubt that some had mental illnesses but that is not currently considered to be a major factor in the women who were persecuted.

Ady describes a common scenario in his era. The poor and disabled went door to door in those days asking for relief. Many were elderly, malnourished, and disabled. If they were denied assistance by the landowner and his crops or cattle failed or one of his family fell ill – that person could be blamed for witchcraft as a source for these problems.  They could be subjected to false tests or torture and sentenced to death as a witch.  

Once these negative qualities were specified as evidence, the sequence of events proceeded in the same manner that can easily be observed in modern American politics.  If enough people are anxious about some matter, it is easy enough to incite them.  Just claim that you are the only person who can solve that problem and find a group that is the modern equivalent of witches to blame.  In recent months we have seen documented and undocumented immigrants, women, non-white minorities, university professors, public health officials, public sector employees, the disabled, the economically disadvantaged, the food insecure, members of the previous administration, and just about anyone who is a critic of the current administration. Scapegoating a small segment of the LGBTQ community may have been the deciding factor in that last Presidential election and it continues to be an issue.

Ady’s book is a tour de force against witchcraft.  He begins his three part treatise by directly confronting popular notions of witchcraft with the Biblical moral code of the day.  He lists 16 – “where is it written” or “it is written” clauses in his introductory “A Dilemma that Cannot bee answered By Witchmongers.”  In the subsequent text he elaborates on how references to witches have been misinterpreted to fuel witch misinformation.  An excerpt of the Dilemma is reproduced below.  Note that the original spellings are preserved:

 

 

At the end of this this volume he gives two excellent counterfactuals to falsify witch mongering. It is clear from these examples that any misfortune can be erroneously ascribed to witches and therefore witch mongering and everything that involves adds no explanatory power.  That is made much worse by the fact that this non-explanation resulted in the deaths of thousands.    

 

 Moral reasoning and rationalism was used to discredit witch mongering but they were not the sole factors.  Johann Weyer (1515-1588) was a Dutch physician who argued that witches were mentally ill suffering from melancholia.  He thought that any confessions of witchcraft were based on delusional thinking.  He published numerous works on witchcraft and magic. 

Medicine, science, and rational thought were not enough to immediately correct the practice of persecuting women as witches.  Pseudoscience and various “tests” were used to prove that a woman was a witch.  Many of these tests defy reason like the pseudoscience of the current era.  For example, one test of a witch was to bind them, throw them into a body of water and see if they float.  Certain marks on the skin were taken to be the marks of a witch.  That included puncture marks inflicted with needles by others – if the puncture wound did not bleed it was considered evidence of a witch. Ady provided counterarguments about why these were inadequate tests.  Needless to say there were no control groups. 

Despite Weyer’s direct observations there are competing theories that social and cultural factors were important.  It is likely that both played a part, with psychiatric etiologies as suggested by Weyer playing the minor part.  If you are identified as a physician who works with a particular problem – it is likely that selection bias is operating in the clinical population that you see and treat.  Cultural symbols are often incorporated into psychotic symptoms.  In 40 years of practice – I saw a handful of people who believed they were Christ-like and many more who believed they were the Antichrist. During the time of Satanic Ritualistic Abuse (SRA) I saw many people who were not delusional but believed that they had witnessed homicidal rituals by satanists.  Those are all modern examples of observations that were not accurate and could be scientifically disproven.

If we agree that witch accusations and persecutions were psychiatric, social, and cultural in origins are there some common factors that might account for these patterns?  Anti-intellectualism is a complex societal problem that has been examined by Hofstader, Pigliucci, and others (3-5).  Hofstader traced some of it back to right wing politics and religion in the 1950s where it still resides today.  Hofstader described 3 forms (antirationalism, anti-elitism, unreflective instrumentalism) to which Rigney added unreflective hedonism and Pigliucci added academic post modernism as a fifth (4).  Pigliucci also added a qualifier that post modernism may be an intellectual anti-science field.   

The refutation of witchmongering is an important lesson for people in modern times. Reasoning and moral reasoning based on Christian principles and local laws eventually carried the day – but it took a long time. Science through early observations of mental illness were a small part of the story.  The most significant aspects of this historical period is focused on cultural inheritance and rhetoric.  Neither of those dimensions is necessarily predicated on the truth.  The commonest ignored pattern is the use of a scapegoat to avoid the reality of the situation or in the worst case divert attention to an emotional topic that is really all part of the scapegoating.

We typically see these issues categorized as hot button issues or culture wars.  They are responsible for large scale irrational decision making about guns, abortion, welfare, religion in schools, banned books, restricted access to voting, racism, misogyny, the medically uninsured, and corporate welfare.  They are currently responsible for the dismantling of basic research, health care, food subsidies, public health, foreign aid, the Department of Justice, the Department of Defense, and the layoffs and firings of 200,000 federal employees.  There is an estimated large death and morbidity toll associated with those decisions.

While we are no longer naming witches and prosecuting them – a lot of the thinking behind that process has been passed along as cultural inheritance and the associated rhetoric.  A significant number of Americans react to it in expected ways.  Recognizing the pattern of scapegoating and the associated emotions is a critical first step.  The second is to figure out what science is and what it is not.  Science is definitely not doing your own research unless you have been trained in the scientific method or (ideally) are a scientist.  The ultimate ability is to be able to use reason, moral reason, and science to make the best possible decisions.

That is the best way to avoid more witchmongering.      

 

George Dawson, MD, DFAPA   

 

 

 

Graphic Attribution:

“The Witches' Ride' William Holbrook Beard (1870), Public domain, via Wikimedia Commons

 

References:

1;  The National Archives - UK.  Early Modern witch trials.  https://www.nationalarchives.gov.uk/education/resources/early-modern-witch-trials/

2:  Schoeneman TJ. Criticisms of the psychopathological interpretation of witch hunts: a review. Am J Psychiatry. 1982 Aug;139(8):1028-32. doi: 10.1176/ajp.139.8.1028. PMID: 7046480.

3:  Hofstadter, R. Anti-intellectualism in American life. Vol. 713. Vintage, 1966.

4:  Rigney D.  Rethinking Hofstadter: three kinds of anti-intellectualism. Sociological Inquiry.  1999.  61(4): 434-451.

5:  Pigliucci M.  Denying evolution – Creationism, science and the nature of science.  Sinauer Associates, Sunderland MA, 2002.   

6:  Ady T.  A Candle in the Dark or A Treatise Concerning the Nature of Witches and Witchcraft: Being Advice to Judges, Sheriffes, Justices of the Peace, and Grand Jury-men, what to do, before they pass Sentence on such as are arraigned for their Lives as Witches.  1656.  Theophania Publishing.