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.

Letter to Gov. Walz About Guns

 

Dear Governor Walz,

 I am a psychiatrist and have practiced for most of my career in Minnesota. Much of that time was spent running an acute care unit at St. Paul-Ramsey and then Regions Hospital.  In acute care psychiatry we spend most of our time addressing psychiatric emergencies involving violence and aggression directed at self and others. The goal is to prevent injuries including suicide and homicide and we do a good job with that.  Addressing any associated firearms is part of that job.

I was driving around yesterday and heard on MPR that you may be planning to introduce legislature to toughen gun laws based on the recent tragic events.  I encourage you to do this and have written extensively about this issue and the surrounding politics.  It is quite unbelievable that nothing is ever done to address the problem solely because we have a political party that supports gun extremism.  I offer some posts off my blog to give you necessary data if you need it.

The first looks at the issue of permissive gun laws and how they affect the gun death rate of children and adolescents.  Firearm deaths are the number one cause of preventable deaths in this age group and the United States is the only high-income country where this is true.  In the study I reviewed, Minnesota is classified as a state with intermediate permissiveness in terms of gun laws.  In states in this category there were 1,424 excess firearm deaths.  States in the most permissive category had 6,029 excess firearm deaths.  I have a table in this post that compares Illinois, Minnesota, and Wisconsin as examples of strict, permissive, and most permissive gun law states:

https://real-psychiatry.blogspot.com/2025/06/pediatric-deaths-from-firearms.html

In a second post I address the issue of likely and unlikely causes of mass shootings.  There is always a lot of excuse making by gun extremists when these events occur.  Recently that has included blaming mental illnesses and even psychiatric treatments.  As an expert in treating aggression and violence I can attest to the fact that psychiatric treatment does not cause aggression.  Beyond that I would invite you to look at the data in this post clearly illustrating that the major variable in mass shootings is gun density.  Countries using the same number of antidepressants or more bracket the US in the first table and neither country has mass shootings and nowhere near the number of gun suicides or homicides. Even considering mental illness as a risk factor, people with that problem do worse in the US due to firearm availability.

 https://real-psychiatry.blogspot.com/2023/03/likely-and-unlikely-causes-of-mass.html

And finally, I have a few posts about gun extremism in the US and how it has evolved over the years.  We have gone from 19^th century local ordinances that require checking your firearms at the city limits to permitless concealed carry of much more deadly modern firearms.  And all of that is since the party pushing this agenda has no functional policies that would appeal to the electorate.  In fact, in one of my posts I point out that the same party that pushes gun extremism has pushed political violence.

Gun Extremism Not Mental Illness:  https://real-psychiatry.blogspot.com/2022/05/gun-extremism-not-mental-illness.html

Mass Shooters - The American Gun Extremist Superman:  https://real-psychiatry.blogspot.com/2024/08/mass-shooters-american-gun-extremist.html

Another Note on Gun Extremism - An Appeal to Grandparents:  https://real-psychiatry.blogspot.com/2023/01/another-note-on-gun-extremism-appeal-to.html

Current Political Violence In The USA:  https://real-psychiatry.blogspot.com/2024/10/current-political-violence-in-usa.html

You can find more posts on my blog by searching guns, firearms, or gun extremism. Good luck with your efforts to make Minnesota a safer place for all of us.

Sincerely,

George Dawson, MD, DFAPA

Additional Information:  I sent similar notes to both US Senators from Minnesota.

Photo Credit:  I took this shot of the crowd at the Minnesota State Fair on August 26, 2025. 

Gun Extremism Not Mental Illness

With the most recent school shooting in Uvalde, Texas the familiar repetition persists. There is public outcry to do something.  Many commentators make the comparison to the Sandy Hook Elementary School shooting a decade ago that produced public outcry but no effective response.  In fact, since Sandy Hook there have been 266 additional incidents of school shootings. Member of the pro-gun party have already spoken out and it is clear that their position of supporting gun ownership at all costs is essentially unchanged. That includes access to military grade weapons and high capacity weapons, with minimum and in many cases no regulations.  We keep hearing about all of the polls of “responsible gun owners” who support more reasonable regulation of firearms and more reasonable firearms – but they are generally drowned out by the aggressive tactics of the gun extremism faction.

Before going any further, I will provide my assessment of gun extremism. It is based on my personal observation about how guns have essentially been radicalized over the past 50 years.  When I was in middle school in the early 1960s living in a small town in northern Wisconsin, gun ownership by adults was common.  That gun ownership was focused on hunting seasons – primarily water fowl and deer hunting.  Middle schoolers took the NRA Hunter safety course in order to be able to handle firearms and hunt. Gun safety was taught primarily with the use of lectures and pamphlets. I can still recall some of the passages in the pamphlet with captions like “alcohol and gunpowder don’t mix” and a page with suggestions about what a safe target was. There was no explanation about why a crow is a safe target. The practical side of the training was with BB guns and then a .22 caliber rifle. Even though the common deer hunting rifles at the time were larger calibers like 30.06 there was no training with those guns. There was a competition series based on accuracy and most people in the class were eventually awarded Distinguished Marksman if they practiced and submitted enough targets. Memberships in the NRA was required and for $18.00/year – you got the National Rifleman magazine sent to your home every month.  The centerfold of that magazine was an array of inexpensive rifles, often “sporterized” surplus rifles from WWII.  They typically held 5 cartridges and could be used for hunting.

But like most kids taking the course. I never went hunting or acquired any additional firearms. My family was not a family of hunters and we did not have a typical cabin in the woods where everybody gathered during hunting season. The course was taught by an instructor who had been doing it for years. His overriding message was that guns had to be taken very seriously. In fact, one of the prerequisites for taking the course was that students had to vow never to “play” at guns again. That involved never pointing a gun at a person, even accidentally on the gun range. He described a number of incidents where people were accidentally shot by relatives to emphasize that point.  We all took it very seriously and there were no close calls in the class. There was no emphasis on “gun rights”, the need for self-protection, or the Second Amendment.  Handguns were not discussed because they were not used for hunting and you had to be 21 years of age to own one.  Gun rights was not an issue in any political campaign.

I don’t want to create the impression that the firearm situation was idyllic during my childhood.  Two classmates died by firearm suicide and one was killed in a hunting accident. I knew all three of them.

That is the backdrop against which gun extremism has evolved and it contains several elements.  First of all, politics. There are obvious contradictions when politicians say it is not a time for politics in the wake of the next mass shooting after they have passed laws that allow people to avoid background checks, carry military grade weapons with high capacity magazines, allow large purchased of ammunition, carry guns without permits, carry guns openly, and not have to “stand down” in confrontations – even when their opponent is not armed. That is all politics and if you are trying to deal with the aftermath pf a shooting – you are dealing with the aftermath of that politics especially if your politics facilitated that.

At a broader political level what has to be considered is how most polls show that Americans favor “common sense” gun laws – but the gun extremists continue to have their way.  In the decade following the Sandy Hook Elementary School Shooting, nothing has been done at the federal level.  Even the most basic fix of eliminating loopholes in the background checks laws has been avoided. Even when a law has been passed in the House (HR8) that makes a few changes – to the background check law there is practically no chance that it will pass in the Senate, even though the Republicans in the Senate represent 44 million fewer people. This situation has been referred to as the tyranny of the minority or a highly motivated smaller group of people dictating in this case the laws of the nation. That tyranny is even more complicated by Republican appointed Supreme Court making decisions on both gun laws and probably abortion consistent with what the minority party wants. Demographically that comes down to white, rural, less college educated voters making the laws that in the case of guns carry out an extremist agenda.

What do I mean about gun extremism?  Basically, all of the interventions over the past two generations that have allowed lax background checks and registration, lowered minimum age to purchase handguns and high-capacity military grade weapons, the increased carrying of weapons (both concealed and open) in many cases without permits, and stand your ground laws that say there is no obligation to retreat in a confrontation – even in the case where one of the parties is unarmed. There is an associated lack of gun safety and that has clearly been a factor in accidental death of adolescents and teenagers, suicides, carrying firearms into schools, and even arming mass shooters. That lack of basic gun safety is a likely contributing factor to firearm deaths being the leading cause of death in children and adolescents (1). And finally, there is a constant stream of pro-gun rhetoric that routinely distorts those facts about gun availability and usefulness.   There is good evidence that this gun extremism began in the 1970 and 1980s and has been unabated since then. 

Since the school shooting in Uvalde, gun extremists jumped to the defense of permissive to non-existent gun laws.  They offered alternate explanations for the school shooting. Governor Abbot of Texas suggested the shooter had a “mental health challenge” since anyone who shoots someone does.  That is clearly not true.  Recent evidence from high profile media cases where a homicide occurred during a fight over a firearm are cases in point. The vast majority of homicides by firearms does not involve mental illness of any kind.  In carefully selected samples – probably biased because they are selected based on forensic criteria – only 10-25% of the sample is described as having a mental illness diagnosis (2,3).

If mental illness is not an explanation for a mass shooter or mass school shooter behavior what is more likely? Given the fact that this behavior has been going on for at least 2-3 generations at this point it likely represents a subcultural phenomenon.  Subcultures are cultural groups within a larger culture that hold beliefs at variance with the larger culture.  American culture in general is steeped in violence and crime largely through entertainment and news media outlets. There are well known violent subcultures in the United States including organized crime, gangs, domestic terrorists, and various hate groups that perpetrate violence against specific people.  These other crimes are frequently seen in the news. It is easy to ascribe some of the behaviors of these groups to individual psychopathology. You can see these efforts in many true crime television shows. Crime dramas are likely to emphasize profiling as a way that the crimes are solved. Practically all of these cases lack features that are typically seen with individual psychopathology. Instead, we hear about a profile of social factors and circumstances that are cited as motivations for the violence and aggression. Those factors are also not uniform explanations for all of the violence and aggression seen across all categories and typically are collected long after the commission of the crime and by people who seemingly have unlimited time to do that task.  A good example was a forensic psychiatrist giving a profile of the Uvalde, Texas shooter describing him as a marginalized loner who had been bullied in the past and pointing out that many shooters have this profile but only a small number of people with the profile ever engage in firearm violence.

I think it is highly likely that the mass shooter and mass school shooter have become a meme that is passed in this subculture of primarily men or boys who feel that they have been victimized and they begin to see this as acceptable payback for their perceived victimization.  It is subculturally acceptable even though it produces outrage and is completely unacceptable in the larger culture and that is why the questions about “motivation” always go unanswered. Firearms and secrecy are obviously a big part of this meme and the way it is typically enacted. Gun extremism makes it much easier to enact.  In analyzing these situations, the usual starting point is where the individual perpetrator has gone wrong.  From the perspective of an alienated subculture these people and those who identify with them consider what they are doing to be correct for various reasons and more importantly widely accepted in that subculture (7). There are many reports that these subcultures are reinforced and more accessible through social media sites where manifestos, threats, time lines, and in some cases photos and recordings of the violence are posted.

In addition to the subcultural effects, important developmental effects are seldom considered.  In the past 20 years development and brain maturation has been the object of increasing neuroscience scrutiny and in addition to structural brain changes – correlations with culture, socioeconomic class, and social network/peer environment have also been investigated. In an excellent review of this topic Foulkes and Blakemore (3) point out that averaging of large samples has been used so far to get to statistical significance – but they discuss the benefits of looking beyond the averages at the total variation of normal brain development. They illustrate significant variation in the brain volume of subcortical grey matter structures over the course of ages 7 to 23.3.  I think it is generally accepted that brain maturation by these indices is not complete until mid-20s for most people, but the graphs also suggest that there may be quite a lot of variation even at that point. Beyond that they discuss several aspects of cognition and social cognition that develop in the transition from adolescence to adulthood including reasoning, risk perception, risk taking, the varied effects of social exclusion, and the use of others’ perceptions in decision making. They demonstrate what appear to be specific cultural, socioeconomic and peer effects and discuss the neuroscience correlates where they are known.  An analysis of mass shooters at this level of detail may provide better answers in terms of prevention.

What can be done to interrupt this cycle of school and mass shooter violence? Plenty can be done.  A basic time-tested public health intervention is to remove the means for perpetrating the violence and injury. This has worked in the case of suicide prevention by specific methods as well as preventing gun violence.  In a previous post, I pointed out that Tombstone had an ordinance in 1881 forbidding the carrying of deadly weapons within the city. This was a time commonly referred to as the Wild West (1865-1895).  This period is typically idealized by movies like Gunfight at the OK Corral. That was a 30 second gunfight between three Earp brothers and Doc Holiday and 5 cowboys that occurred in 1881.  One of the precipitants of that gunfight was violation of the city ordinance about carrying deadly weapons. Contrary to most accounts – both Wyatt Earp and Doc Holliday were arrested and charged with murder.  They were released after a three-day probable cause hearing. Even during America’s Wild West days, people knew that removing deadly weapons would lead to less violence.

In many ways American streets are less protected from gun violence than they were in Tombstone in 1881.  All 50 states allow people to carry handguns.  Twenty-four states require no permit to carry a firearm.  Federal law requires a handgun holder to be 18 years of age and 21 years of age to purchase a handgun. There are currently 21 million concealed carry permit holders in the US.   There is no minimum age for possessing a rifle or a shotgun.  There was a ten-year ban on assault rifles at the federal level from 1994-2004.  The ban grandfathered in all assault weapons before 1994 and there were also many other qualifications that decreased the overall impact of the bill.  Despite these limitations the ban may have decreased the frequency of mass shootings when it was in effect. (6).  Considering that there are 258.3 million Americans over the age of 18, the manufacture and importation of firearms is brisk to say the least as well as the concentration of handguns. (Click to expand the graphic)

Concluding this post, the most clearcut path to reducing gun violence of all kinds is to improve gun regulation.  The evidence is clearly there in terms of reductions in suicides, homicides and accidental deaths. The idea that gun regulation has no effect on gun deaths or that the Second Amendment is a sacred clause that mandates gun extremism is pure misinformation.  Even as I typed this post today, the Prime Minister of Canada announced stricter handgun regulations in the interest of safety.  There is absolutely no reason that high-capacity military grade weapons are necessary in society and there are many groups of responsible gun owners who openly acknowledge that fact.

Gun extremists’ additional rhetoric about how mental illness is the real problem rather than gun access is also incorrect.  Mental illness is not defined by homicide, but by constellations of findings and associated disability. There are general developmental, socioeconomic, cultural and subcultural trends associated with violence and aggression – but none are precise enough to allow for predictions of who will likely perpetrate mass homicide.  It will take continued large longitudinal studies to examine all of these factors close enough to produce an effective population wide intervention. One of my suggestions since I started writing this blog is explicit homicide prevention.  You won’t be able to find that is a book or research paper – it is based on my experience in acute care psychiatry. In that context, I encountered many people with acute homicidal thinking who ended up on my inpatient unit.  Irrespective of any psychiatric diagnosis, we were able to help them resolve that crisis.  Before the rationed mental health system takes on another significant task, it has to be adequately funded.  And beyond the mental health system – social services are required to address many of the factors associated with violence and aggression.

George Dawson, MD, DFAPA

 

 

References:

 

1:  Goldstick JE, Cunningham RM, Carter PM. Current Causes of Death in Children and Adolescents in the United States. N Engl J Med. 2022 May 19;386(20):1955-1956. doi: 10.1056/NEJMc2201761. Epub 2022 Apr 20. PMID: 35443104.

2:  Stone MH. Mass murder, mental illness, and men. Violence and Gender. 2015 Mar 1;2(1): 51-86.

3:  Hall RCW, Friedman SH, Sorrentino R, Lapchenko M, Marcus A, Ellis R. The myth of school shooters and psychotropic medications. Behav Sci Law. 2019 Sep;37(5):540-558. doi: 10.1002/bsl.2429. Epub 2019 Sep 12. PMID: 31513302.

4:  Firearms Commerce Report in the United States: Accessed 05.29.2022:  https://www.atf.gov/firearms/docs/report/2021-firearms-commerce-report/download

5:  Foulkes L, Blakemore SJ. Studying individual differences in human adolescent brain development. Nature Neuroscience. 2018 Mar;21(3):315-23.

6:   DiMaggio C, Avraham J, Berry C, Bukur M, Feldman J, Klein M, Shah N, Tandon M, Frangos S. Changes in US mass shooting deaths associated with the 1994-2004 federal assault weapons ban: Analysis of open-source data. J Trauma Acute Care Surg. 2019 Jan;86(1):11-19. doi: 10.1097/TA.0000000000002060. PMID: 30188421.

7: Simon Cottee (2021) Incel (E)motives: Resentment, Shame and Revenge, Studies in Conflict & Terrorism, 44:2, 93-114, DOI: 10.1080/1057610X.2020.1822589

8: 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. PMID: 29874513; PMCID: PMC5993413

9:  Loftin C, McDowall D, Wiersema B, Cottey TJ. Effects of restrictive licensing of handguns on homicide and suicide in the District of Columbia. N Engl J Med. 1991 Dec 5;325(23):1615-20. doi: 10.1056/NEJM199112053252305. PMID: 1669841.

Graphics Credit:

Photo by Ed Colon, MD

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Racism and gun violence both exist in an overtly gun extremist society: They cannot be explained away by mental illness.

I suppose I should have not been very shocked that a Wall Street Journal editorial this morning (1) chose to double down on both gun rights and the myth that racism is not a problem and had nothing to do with the recent mass shooting – while scapegoating both mental illness and the rationed system of mental health care that we have in this country.  For good measure he added another conservative agenda item - that there was also blame for the public health officials like Dr. Fauci for mismanaging the pandemic.  This post is to straighten all of that out.

Let me preface these remarks by saying that I have no information about the most recent mass shooting other than what is reported in the media.  The author of the editorial does not seem to either. What I do have is 22 years of experience in acute care psychiatry and involuntary care. That’s right – for 22 years I was one of the guys you would have to see if you were admitted to my hospital on a legal hold for behavior that involved threatening or harming other people or yourself.  That included all kinds of violence - homicide, suicide attempts and severe self injury, and violent confrontations/shoot outs with the police.  I had to evaluate the situation with the considerable assistance from my colleagues and decide if that person could be released or needed to be held for further assessment and treatment. People (including psychiatrists) like to summarize that situation by saying: “Nobody can predict future dangerousness” and that is certainly true. But we do pretty well in the short term (hours to days).  We also do well coming up with a plan to prevent future violence.

The details about the most recent mass shooting are still being reported at this time, but so far include interviews with the families of the victims, police reports, videos, and excerpts from a manifesto written by the perpetrator.  According to reports that manifesto discussed Replacement Theory as a potential motive for the mass shooting.  Replacement Theory is a white nationalist, far right ideology that claims non-whites are a threat to the white majority in several countries including the US. A corollary is that the Democrats are trying to get aligned with more non-white voters to develop more political power. This is the rationale currently given in the media for the actions of the mass shooter who scouted neighborhoods and said very explicitly in documents that his intent was to murder as many black people as possible. He had no difficulty obtaining firearms legally – even though he was detained and sent for an emergency evaluation a little less than a year earlier for stating “murder-suicide” in response to an online question about what he planned to do upon retirement.  Those details and his response talking about how he got out of it and continued to plan to kill people are at this link.  

As a psychiatrist and member of the American Psychiatric Association, I can’t speculate on the diagnosis of anyone who I have not personally assessed and if I did do an assessment – I would need a release from the person to discuss any details.  The editorialist is under no constraints speculating that “signals were missed” and that “psychotic young males whose outlet is killing” is not the object of his column.  Instead, he makes the claim that he is really concerned about the post pandemic mental illness and addiction trends in this country. He is apparently not consulting the correct sources about what has happened in this country in terms of mental health care before the pandemic.

I will start with his anchor point in the 1970s.  At about that time Len Stein, MD and coworkers invented Assertive Community Treatment and a number of additional innovative approaches that were focused on keeping people with severe mental illnesses in their own homes.  Dr. Stein was one of my mentors and in seminars he would show what Wisconsin state hospital wards used to look like. About a hundred patients in one large room with their cots edge-to-edge and all wearing hospital pajamas. By the time I was working with him in the 1980s, those folks were living independently supported by case management teams and psychiatrists. Dr. Stein and his colleagues also ran a community mental health center that included crisis intervention services and outreach. That model of community mental health and crisis intervention is still practiced and has been covered in the New England Journal of Medicine.  Psychiatric residents are still trained in community mental health settings and many prefer to practice there.  Counties are not as enthusiastic and have shut down many if not most community mental health centers.

Community psychiatry is an obvious 50-year-old solution but it has to be funded. The same is true of affordable housing.  In some cases that housing needs to be supervised and also a sober environment. Both community psychiatry and affordable housing are casualties of business rationing that can only occur with the full cooperation of both state and federal governments. The current system costs about a trillion dollars in overhead that is directed to Wall Street profits and unnecessary meddling by middle managers. The only people who “sweep mental health under the rug” are large healthcare organizations and state bureaucrats who disproportionately ration it.  The "science of mental health" is not difficult at all.  Being forced to do it for free is difficult.

The 1980s were a critical time in establishing the managed care industry and taking all healthcare out of the purview of physicians.  While rationing psychiatric resources was being ramped up, services to treat alcoholism and addiction were essentially demolished. Suddenly you could not longer get detoxification services at most hospitals.  People were sent to social detox units run by counties where there was no medical coverage.  The thinking was that if a person developed medical complications like seizures or delirium tremens they could always be sent back to the hospital. The biggest risk was continued substance use and immediate relapse. Residential and outpatient treatment facilities never materialized.  Inadequate funding was a significant problem.  The managed care industry played a role in that case as well with absurd expectations and limits on treatment.  It is no accident that treatment for substance use disorders basically became non-existent.  None of the disproportionate rationing of mental health or substance abuse treatment is new.  It has been like this for 30 years because it is the government endorsed model of care.  

Overall, this editorial is a smokescreen over the proximate issues of guns and racism.  The author trivializes this as political rhetoric when in fact the rhetoric has all been pro-guns and pro-white supremacy.  It is the only rational explanation for turning the United States into an armed camp that has progressively increased the likelihood of gun violence. We are not talking about a pandemic precipitated phenomenon.  The gun violence has been multi-year and the pro-gun party has “doubled down” on it to make it more likely.  As far as politics go – now that we know how a partisan Supreme Court works – the Heller decision and the resulting liberalization of gun ownership should not come as a surprise.  On the issue of hate crimes, I can’t really think of anything more relevant in a case based on the public disclosures.  This was a specific crime directed at black Americans intentionally perpetrated in a neighborhood that was scouted ahead of time for that ethnicity. Brushing that aside to claim that this is a response to an embarrassing record on mental illness, when there is no evidence that is a factor is disingenuous.

American history including other recent mass shootings tells us that racism can be a causative factor.  What is never addressed is the omnipresent gun culture in the USA.  People with an apparent need for military weapons and handguns and politicians willing to give them unlimited access to carrying them in public, carrying them without permits, and stand your ground laws - encouraging violent confrontations with firearms.  All fueled by one party and their affiliated special interests.

Disingenuous discourse and misinformation is what we typically see these days. If you want the facts about what needs to be there in terms of a functional mental health system (and I know there are absolutely no business people and very few politicians that do) – ask a psychiatrist. If you want to know about what gun control needs to be in effect rather than claiming that psychiatrists are not preventing gun violence from people with no mental illness – you can also ask me.

I could put all of those details on a 4” x 6” card and it would work. 

But there is certainly nobody on the right or at the WSJ who wants to know that either.

 

George Dawson, MD, DFAPA

 

References:

1:  Daniel Henninger. The Next Pandemic: Mental Illness.  Wall Street Journal. May 18, 2022.

Graphics Credit:  Eduardo Colon, MD

The run on guns and ammunition - is this mass psychogenic illness?

I was watching my usual Sunday morning news programs two weeks ago when I heard that Wal-Mart had such a run on their ammunition supply customers that they were limiting sales to three boxes per customer per day.  That brings up the image of tens of thousands of people going to Wal-Mart every day to buy their three boxes of ammo.  What is it about the American psyche that drives this behavior and the recent stockpiling of guns?

It reminded me of the Y2K situation from over a decade ago.  Do you remember that scenario?  In the antithesis of the Terminator series, computers would be crippled by inadequate programming to account for the change to the 21st century.  The power grids would collapse.  The logistics of food and medical supplies would be paralyzed.  There would be chaos in the streets.  In Minnesota in the middle of winter that translated to a run on electrical power generators.  It got to the point that one of the big home stores cancelled their return policy for generators.  I never noticed it but I wonder if the generator aisle at the Home Depot ever looked like this gun shop display.

All of the signs point to this being a record year for gun and ammunition sales.  The National Instant Criminal Background Check System (NICS) has a record number of checks.  Nine of ten of the top highest days and 10/10 of the top ten highest weeks for gun checks since the system was started in November 1998 have occurred within the past two months (see below).   The charts below give the NICS checks month by month since then and the actual listing of top days and weeks for checks.  Although there is usually a disclaimer about how checks do not necessarily equate to gun purchases, the issue has been studied and for each check there is about a 70% chance that a firearm will be acquired taking into account all of the possible outcomes. (click to enlarge)

Another perspective comes from the Bureau of Alcohol, Tobacco, Firearms, and Explosives.  They keep a record of firearm manufacturing in the US by the type of firearm and also whether or not a firearm is exported.  The data going back to 1998 is available on their web site.  I plotted that data for rifles, pistols, revolvers, and shotguns on the following graph.  Some interesting trends noted include the fairly recent increase in rifle production. There were relatively flat revolver and shotgun sales, and a sharp increase in pistol production over the past decade.   The year 2004 is also an interesting inflection point for rifle sales since that was the year that the ten year ban on assault rifles expired.   Without knowing the exact breakdown of rifle sales, the rise at that point combined with flat rate of shotgun sales suggests that the rising rate represents sales of assault rifles or military style weapons that are not necessary for hunting.

All of the signs point to a greater prevalence of guns in homes and communities especially hand guns.  Not only that but it appears that Americans are arming themselves at a much higher rate than at any time since we started to keep these statistics.  They also appear to be arming themselves using handguns and possible military style weapons that are not typically used for hunting.  Hunters are frequently mentioned in NRA and pro-gun rhetoric but they certainly are not responsible for the huge increase in hand gun sales.  If we are ruling out hunters who is buying the guns?

My guess is that it comes down to people arming themselves because they believe that they need protection.  Although a previous post here clearly shows that the violent crime rate is at an all-time low there are numerous self protection ideologies.  At one time or another I have heard the following arguments:

1.  Protect yourself against violent criminals (even though there are fewer of them and they seem to be committing fewer violent crimes than at any point in the past 30 years).

2.  Protect yourself against terrorists.  My guess is that terrorists would not be foolhardy enough to walk into any well armed American neighborhood and start a gun fight

3.  Protect yourself against the government.  This is an interesting argument because it basically is the same thing as treason.  When I argued that point with a famous gun advocate he pointed out that it would depend on "who won".  Some conservative and liberal politicians of both parties have made this argument, including Minnesota's well known liberal Senator Hubert H. Humphrey.  The basic argument is that if the government becomes completely unresponsive to the people for one reason or the other - we should have enough firepower to overcome it.  I guess if we can't vote the bums out - there is always another way.

4.  Protect yourself against your neighbors.  This is the survivalist argument.  The survivalists believe that we are always "9 meals away from chaos".  It is therefore logical to stockpile food.  When the apocalyptic event happens, you need enough guns and ammo to shoot anyone who threatens you or your food stockpile.

5.  Protect yourself against the zombies.  That's right - you thought the zombie apocalypse was just fiction.  I happened to catch an episode of Doomsday Preppers that was full of information ranging from how zombies might scientifically happen to staircase design that would slow them down long enough so that you could administer the old "double tap". 

An inspection of the above list suggests that there are many more imagined than real threats.  Possibly several orders of magnitude greater if you are considering that all of your neighbors who ignored your warnings about the apocalypse are either coming for your food or have contracted the virus that turns them into zombies and want to eat you for food.  In that scenario - how much ammo is enough?  All of this would be more fodder for the film industry if it was not true at some level.  Very few real threats and many imagined would seem to be driving the current gun buying frenzy.  After all - what would happen if any of the mass scenarios unfolded and we did not have enough guns and ammo?

I don't want to go too far out onto a limb here.  For all of you DSM5 detractors - don't worry there is no diagnostic category to critique.  I think that there is room for studying the problem, but it would involve collecting data from the gun purchasers and we all know that would not fly.  Anyone knows that if you can be identified - the government can kick your door down and take your guns.  

George Dawson, MD, DFAPA

FBI NICS Web Site

FBI Instant Background Checks November 30, 1998- January 31, 2013.

ATF Annual Firearms Manufacturing Report and Export Report 2011.

ATF Statistical Web Site