Irrational American Gun Landscape Gets Worse….

The Supreme Court voted 6-3 to lift the ban on bump stocks yesterday (on June 14, 2024). The bump stock is a device that allows a shooter to depress the trigger of a semiautomatic rifle once.  After the initial firing the recoil energy of the firearm is used to bring the trigger back against the trigger finger for repeated firing without a subsequent trigger pull.  The result is a very high rate of fire with various quotes of 800 rounds per minute.  The limiting factor is rounds in the magazine and a standard magazine is 30 rounds with some states having lower limits or no limits.  

The majority decision was done by the Republican appointed justices (Roberts, Alito, Gorsuch, Kavanaugh, and Barrett), who used a series of rationalizations to show that in their opinion the bump stock does not convert a semiautomatic weapon to a machine gun as defined by the National Firearms Act of 1934.  Note that the majority opinion uses graphics (Figures 1-6) from the Firearms Policy Foundation - an organization that fights gun control laws (see reference 2 and their web site).  The dissenting opinion by Justice Sotomayor in the final few pages points out the inconsistencies in the majority opinion.  

Both court opinions include the precipitant for the bump stock ban – a 2017 Las Vegas shooting where the perpetrator was able to fire over 1,058 rounds from a hotel room into a crowd at a music festival killing 60 people and wounding 413.  An additional 454 people were injured in the ensuing panic. The gunfire occurred from 10:05 to 10:15 PM.  It is the deadliest mass shooting in the country that holds the record for mass shootings.  From the perspective of bump stocks, the Las Vegas shooter used 14 AR-15 (.223 cal) semiautomatic rifles and 8 AR-10 (.308 cal) semiautomatic rifles.  All of the AR-15s were fitted with bump stocks and 100 round magazines.  None of the AR-10s were fitted with bump stocks and 5 of 8 had 25 round magazines.  The remaining three AR-10s had no magazines. The AR-15s had a potential capacity of  1400 rounds that could have been discharged with a bump stock. The relevant factors from this list is that magazine capacity rather than firing rate is the major limiting factor in the total number of rounds that can be discharged and the shooter overcame that limitation by using more firearms with bump stocks. Only 15 states ban or restrict large capacity magazines.

There are various opinions in the media about how a bump stock ban originated in the Trump administration. The politics is interesting because the precipitating event was so egregious that the National Rifle Association supported restrictions on bump stocks.  I can find no action by the Trump administration other than encouraging the Bureau of Alcohol, Tobacco, and Firearms (ATF) to consider rule changes and in fact this report suggests there was a memo circulated with the usual “guns don’t kill people” message.  The Supreme Court refers to the ATF rule changes but also makes one reference to Trump.  Unless I missed something it seems clear that he did very little on the issue.

At the end of the day – we have a typical party line vote supporting gun extremism.  I don’t care who you are – the only reason you need a bump stock is to kill large numbers of people.  A bump stock is not useful for hunting or target shooting.  It converts a weapon that is already a military weapon (semi-automatic rifle) to what is essentially a fully automatic rifle. Justice Sotomayor’s opinion also includes the original reason for the machine gun ban and that was to keep these weapons out of the hands of gangsters.  Two of the typical gun extremist arguments against even minimal forms of gun control are:  “We already have enough gun laws on the books and they are not enforced” and “If we have more gun control laws only the criminals will have guns.”  They make these arguments while continuing to deregulate guns, make gun regulations harder to enforce, and make guns even more widely accessible either by Republican legislators or judges.

A second development on firearms was a recently released report by the CDC on the accessibility of firearms by children.  This is a timely study because of the April 2024 Michigan court case against a couple whose son shot and killed 4 students at his high school.  In that case the couple was found guilty of involuntary manslaughter and sentenced to 10 years in prison because their son used an unsecure handgun and they did not attend to behavior suggesting he could become violent. At the time of the shooting Michigan did not have a statute about securing firearms at home and that law was passed during the first prosecution of the parents. It was widely hailed as a warning to parents about securing firearms at home.

The CDC report was based on a Behavioral Risk Factor Surveillance System module administered in 8 states (AK, CA, MN NV, NM, NC, OH, and OK)  in 2021–2022.  The survey was administered by land line telephone calls. The nonresponse rate ranged from 3.5% to 12.8% by state.  The prevalence of firearms kept “in or around the home” was 18.4% (CA) to 50.6% (AK).  The general figure from Gallup is in the high 40%.  In 19.5% (MN) to 43.8% (NC) the firearm was stored loaded. Half of those reporting storing a loaded firearm said it was unlocked.  25.2% (OH) to 41.4% (AK) of those reporting storing an unlocked loaded firearm also reported children less than the age of 17 in the home.  For adults 65 years of age or older 58.5% (NM) to 72.5% (OK) of those with firearms had them stored unlocked.  The authors list the usual limitations of telephone self-report surveys but do not comment on cultural or political factors like the belief of some gun owners that the government is coming for their guns.  

The authors conclude that unlocked firearms may place children and other vulnerable populations at risk.  There is a higher suicide risk in the elderly.  It also illustrates how common the scenario is that led to the conviction of the parents for their son being a mass shooter. A secondary consideration of those convictions was a warning to parents that firearms at home need to be secured to prevent them from similar risks. As I commented at the time, that is a very inefficient approach to a problem that could be addressed at the population wide level. It is in effect, one political party putting parents at risk to continue saturating the population with firearms. And now we know it may be  about four in ten parents who store unlocked, loaded firearms, with children in the home.

To me, mass shootings are a function of:

- mass availability of high-capacity and rapid-fire firearms - both rifles and handguns

- gun extremism translated into effects at every level

- cultural effects - the disgruntled employee/student/etc as mass shooter has been an American meme for 50 years...

The Republican Party and their judicial appointees essentially control two of those three variables.  They are a party with no good ideas but they know how to get votes by stimulating excessive emotion around issues like firearms and abortion.  Their current approach to firearms is to place large part of the population at chronic risk with an arbitrary interpretation of the Second Amendment that they think that they can use to get votes. The basis for their gun extremist view, including the current Supreme Court decision is based on false premises rather than rational thought or legal precedent.  Americans generally don’t expect much from political parties and now they can expect the same from a highly partisan Supreme Court.    

George Dawson, MD, DFAPA

 

Supplementary:

I frequently talk about gun extremism on this blog and decided to attach a checklist of what I consider gun extremism to be.  Basically it is a marked divergence with common sense gun laws from the 1970s and earlier (see Tombstone ordinance from 1881). From a political standpoint it is clearly a political maneuver to excite and agitate people and get them to vote for a particular political party.  Like all of the so-called hot button issues it is an exercise in rhetoric and conspiracy theories that has unfortunately led to historic levels of gun violence in the US when compared with high income and low and medium income countries around the world.    

 

Gun extremism checklist:

☐  Advance “stand your ground” and “castle doctrine” laws.

☐  Eliminate bans on handguns

☐  Eliminate bans on assault weapons

☐  Minimize the characterization of “assault weapons” or military style weapons because they are not fully automatic weapons

☐  Eliminate bans on large capacity magazines

☐  Eliminate waiting periods

☐  Eliminate bans on public carry of guns

☐  Eliminate the need for permits to purchase handguns and/or carry them openly or as concealed weapons

☐  Eliminate gun-free locations (ie. places of worship, public transportation, healthcare facilities, public buildings)

☐  Eliminate bans on self-manufacturing of firearms

☐  Eliminate laws on age limits to firearm purchase and possession

☐  Eliminate laws on age limits for handgun and ammunition purchase

☐  Eliminate bans on gun accessories like bump stocks and pistol grip extensions

☐  Eliminate laws on “cannot issue” firearms to certain purchasers

☐  Eliminate gun purchase bans for perpetrators of domestic violence

☐  Eliminate gun purchase bans for convicted felons

References:

1:  Friar NW, Merrill-Francis M, Parker EM, Siordia C, Simon TR. Firearm Storage Behaviors — Behavioral Risk Factor Surveillance System, Eight States, 2021–2022. MMWR Morb Mortal Wkly Rep 2024;73:523–528. DOI: http://dx.doi.org/10.15585/mmwr.mm7323a1

2:  Lithwick D, Stern MJ. The Group Helping the Supreme Court Rewrite America’s Gun Laws Is Worse Than the NRA.  Slate June 15, 2024.  https://slate.com/news-and-politics/2024/06/supreme-court-nra-gun-laws-bump-stocks.html

3:  McClellan C, Tekin E. Stand your ground laws, homicides, and injuries. Journal of human resources. 2017 Jul 1;52(3):621-53.

4:  Rosenthal L. The limits of Second Amendment originalism and the constitutional case for gun control. Wash. UL Rev.. 2014;92:1187.

5:  Rowh A, Zwald M, Fowler K, Jack S, Siordia C, Walters J. Emergency Medical Services Encounters for Firearm Injuries — 858 Counties, United States, January 2019–September 2023. MMWR Morb Mortal Wkly Rep 2024;73:551–557. DOI: http://dx.doi.org/10.15585/mmwr.mm7324a3

6:  Andrade EG, Hoofnagle MH, Kaufman E, Seamon MJ, Pah AR, Morrison CN. Firearm laws and illegal firearm flow between US states. J Trauma Acute Care Surg. 2020 Jun;88(6):752-759. doi: 10.1097/TA.0000000000002642. PMID: 32102044; PMCID: PMC7799862.

"States with stricter firearm legislation are negatively impacted by states with weaker regulations, as crime guns flow from out-of-state."

 

Graphics Credit:

From Wikimedia Commons per the posted Creative Commons licensing agreement. Click on the graphic for all details including author, color coding, and specific CC license.

Likely and Unlikely Causes of Mass Shootings

     

The pace of mass shootings and school shootings in the United States continues unabated at this time. I am writing this like I have written many posts in the past – a few days after a mass shooting in a school.  I just heard a news reports saying that this was the 167^th school shooting since Columbine on April 20, 1999.  NPR posted a story saying that there is a shooting or a potential for shooting in schools every day (1) – based either on a gun discharge of someone brandishing a firearm in school. They reference the K-12 School Shooting Database stating that this is the 39^th incident this year that involved gunfire on school grounds.

The media descriptions of the current incident follow much of the coverage in the past about unclear motive, shocking circumstances, unpredictability, questions of an “emotional disorder” and counseling, and the devastating impact on families and the community. I saw a forensic psychiatrist interviewed speculating on the aggressive dynamics based on the detail that the shooter recently disclosed a transsexual orientation.  A clergyman was interviewed and suggested the shooter was really looking for the school minister who was providing counseling.  One of the shooter’s fiends was interviewed.  She was contacted immediately prior to the incident and promptly notified authorities – but by then it was too late. The video of the SWAT team running through the hallways and eventually running toward gunfire and killing the shooter keeps playing.  In some cases that video is compared directly to the Uvalde, Texas video  and comments are made about this is a much better example of how law enforcement should respond. I saw some of these reports where they put up the response time on the screen.  

There are the usual expressions of “enough is enough” and “we don’t send our kids to school for this to happen.”  Republican Representative Tim Burchett came right out and said what most people were thinking: “ We’re not gonna fix it….” But then to make it more palatable he added: “criminals are gonna be criminals.”  He thought we needed a “revival” to “change peoples’ hearts in this country.” Later he disclosed he was home schooling his daughter (3).

I am already on record on this blog writing about the real cause of mass shootings and gun violence in general and it is the politics of gun extremism.  The Republican party has figured out that gun extremism works for them along with several other easily demagogued social issues like abortion, voter suppression, education, anti-science, anti-climate change, and more recently “wokeism”. That has led to a series of initiatives to drastically reduce gun regulations.  There has been an undeniable increase in deaths due to gun violence.  Mass shootings, suicide, homicide, and accidental deaths are all routinely ignored as calls for regulations that were effective for decades until Republican advocates rolled them back – even though gun regulations in the past were never a problem.

The typical rhetoric used is a gun extremist interpretation of the Second Amendment.  In the case of voters, it was the usual emotional appeal that “they” were coming to take their guns.  Anyone familiar with the distribution of guns in the United states realizes this is an impossibility, but it is a rallying point for emotional rather than rational appeals.  In recent years we have seen the rhetoric extended to mental illness as a cause of mass shootings.  There is some confluence with antipsychiatry factions who falsely equate psychiatry with the pharmaceutical industry and suggest that antidepressant drugs cause the mass shooting phenomena.  This post will provide clear evidence to the contrary.

On the issue of common psychiatric disorders in comparing the countries that utilize the most antidepressant prescriptions – the prevalence of those disorders is consistent among the United States and the other countries at the top of the list.  These disorders include depression, anxiety disorders, and substance use disorders – conditions that antidepressants are all commonly prescribed for. English speaking and European countries had similar prevalence (4) with possibly lower prevalence in Asia. There are similar variations in the estimated prevalence of schizophrenia and mood disorders in different areas of the world (5, 6).  

A good summary document on the research about mental illness and mass shooting incidents is available from the Treatment Advocacy Center (10).  They summarize the results of several studies as indicating that at least one third of the perpetrators had "serious untreated mental illness."  Their review is remarkable for a wide range of methodologies and selection biases that probably overestimates the number of cases of severe mental illness in mass shootings.  Smaller sample sizes generally showed a greater number of cases of severe mental illness.  In the case of a study by Stone (11) he found that 32% of 228 mass killers had severe mental illness but during the sampling period there were 1,000 incidents.  The variation is often considered due to methodological differences in the surveys but as previously illustrated– even significant differences in incidence and prevalence of these disorders is unlikely to account for the huge differences in gun deaths between the USA and other countries.  The main difference is that people with the same mental illnesses have much easier gun access in the US.

Several studies of people involved as shooters have shown that some of them have psychiatric diagnoses and in some cases they are being treated by psychiatrists.  Some are prescribed medications but the toxicology at the time of the incident is typically not available. In a related study of murder-suicide by the New York City Medical Examiner’s office that of 127 cases over a 9-year period only 3 (2.4%) were taking antidepressants (7).  Two were taking amitriptyline and 1 was taking sertraline. The authors made the point that antidepressant use in this case series was much lower than the expected population rate.  In a series of 27 elderly men who killed their spouse and then died by suicide – more disease conditions and depression were seen as possible predisposing factors – but none tested positive for antidepressants (8).  When considering the prescribing of antidepressants in general,  epidemiological studies suggest that most of these medications are prescribed by non-psychiatrists. With the proliferation of non-physician prescribers, managed care strategies designed to accelerate antidepressant prescribing based on limited assessments, and widely advertised televisit prescribing it is likely that gap between psychiatrist and other prescribers has increased substantially and will continue to grow.

The argument has been made that people become agitated, suicidal, and homicidal on antidepressants. This is a recurrent theme that is often related to medicolegal considerations, criticism of the pharmaceutical industry, and psychiatric criticism.  There is often a suggested scenario of the antidepressants (especially selective serotonin reuptake inhibitors or SSRIs) causing agitation or activation making suicidal or aggressive behavior more likely.  After reviewing the existing evidence the FDA has placed a black box warning for suicidality in "children, adolescents, and young adults".  There are also warning and counseling bullet points on clinical worsening as evidence by: "emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down".  Standard medical and psychiatric practice advises the patient of these potential risks and what the plan should be if they occur.  In 35 years of clinical practice my observations were that these symptoms were rare and most likely to occur if an antidepressant was discontinued and the patient experienced significant sleep disturbance. The patients I treated with severe aggressive behavior were generally untreated for psychiatric disorders and often had substance use disorders.  A recommendation I have not seen is that all of these incidents should be studied from a prospective comprehensive psychiatric standpoint as they occur with no selection bias.  That study should include toxicology, detailed collateral information, analysis of available medical records, and post mortem analysis if relevant.

In choosing a reference (9) for international comparison of mass shooting phenomenon it is important to consider how the database is constructed. In choosing reference 9, the author described a clear rationale and methodology.  The basic criteria include an incident where there are at least 4 shooting deaths and the shooter is acting alone and not due to criminal or terroristic motivations. Since mass shootings in the US have been motivated by neither – there would be no equivalent comparison with incidents in the US. The author also compares the US to the 35 United Nations definition economically developed countries (see Supplement 1). The time frame of 1998-2019 was chosen.  On that basis half of the countries did not have a single mass shooting incident, ten had more than one, five had more than 20 fatalities, and the US had 12 times as many incidents as the country with the second most mass shootings. Much greater detail is included in the original reference.

I prepared two reference tables based on this data (click on either table for a better view).  The graphic at the top of this page does not include suicide and homicide rates for each country.  The table below includes both of these rates.  Data sources are referenced in the tables.  

 

The countries are arranged by defined daily doses (DDD) of antidepressant medications.  DDD is a World Health Organization (WHO) defined metric for medication utilization. It looks at the total amount of a defined class of medication using the Anatomic Therapeutic Chemical (ATC) classification based on the usual prescribed dose of medication. In that system antidepressants are listed as a class.  US data are highlighted in the table because they represent the focus of this post.

What are some likely and unlikely observations from the Table.  First, it is unlikely that antidepressant prescriptions are a proximate cause of mass shootings.  The countries bracketing the US in antidepressant utilization (Iceland and Portugal) each had no mass shooting during the period of interest (1999-2018).  Second, gun availability stands out as an obvious factor in mass shootings, gun related suicides, and gun related homicides.  Third, gun availability in the US (120.5 firearms per 100 person) nearly equals gun availability in every other country in the table (128.4 firearms per 100 persons).  Fourth, no country had homicide rates similar to the US, but 3 of the countries had similar suicide rates but much lower rates of gun suicides. The reference study looks at locations, relationships, and firearms as relevant points but no comments on mental illness or toxicology at the time of the incident. The author also points out that in many countries mass shootings trigger government intervention focused on decreasing the likelihood of future shootings.  Except for a time limited assault rifle ban that does not happen in the United States.  The gun regulatory landscape is headed in the opposite direction with a movement to permitless access to handguns.

In summary, the gun violence landscape in the United States is bleak. Despite rationalizations that this is really a mental illness or mental illness treatment problem there is no real supporting evidence, since the distribution of mental illnesses in the US is the same as comparable countries with no to few mass shootings. There is low quality evidence that mental illness may be a factor in 15-30% of incidents - but the only way to explain why that is a factor is those people have much easier access to firearms.  The overwhelming evidence is that this is a problem of gun extremism, gun access, and sociocultural factors like subcultural acceptable violence, media notoriety, and politically reinforced messaging about gun use. The only way to address the problem based on international examples is to decrease gun access.  That is unlikely as long as one major party and their appointed judges need to activate their base with false messaging and flood the country with easy to access firearms.  They bear the ultimate responsibility.

George Dawson, MD, DFAPA

 

Supplementary 1:  UN Classified Developed Countries (total of 36) for reference 3 in Table and reference 9 below:  Australia, Austria, Belgium, Bulgaria, Canada, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, Latvia, Lithuania, Luxembourg, Malta, Netherlands, New Zealand, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, United Kingdom, and the United States.

 

 References:

1:   Florido A, Summers J. By one measure, the U.S. has had a shooting on school grounds almost every day.  https://www.npr.org/2023/03/28/1166630346/by-one-measure-the-u-s-has-had-a-shooting-on-school-grounds-almost-every-day

2:  K-12 School Shooting Database:  https://k12ssdb.org/all-shootings

3:  Winter J.  After the Nashville shooting a faithless remedy for gun violence. New Yorker.  Amrch 29, 2023:  https://www.newyorker.com/news/daily-comment/after-the-nashville-school-shooting-a-faithless-remedy-for-gun-violence

4:  Steel Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, Silove D. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980-2013. Int J Epidemiol. 2014 Apr;43(2):476-93. doi: 10.1093/ije/dyu038. Epub 2014 Mar 19. PMID: 24648481; PMCID: PMC3997379.

5:  Goldner EM, Hsu L, Waraich P, Somers JM. Prevalence and incidence studies of schizophrenic disorders: a systematic review of the literature. Can J Psychiatry. 2002 Nov;47(9):833-43. doi: 10.1177/070674370204700904. PMID: 12500753.

6:  Waraich P, Goldner EM, Somers JM, Hsu L. Prevalence and incidence studies of mood disorders: a systematic review of the literature. Can J Psychiatry. 2004 Feb;49(2):124-38. doi: 10.1177/070674370404900208. PMID: 15065747.

7:  Tardiff K, Marzuk PM, Leon AC. Role of antidepressants in murder and suicide. Am J Psychiatry. 2002 Jul;159(7):1248-9. doi: 10.1176/appi.ajp.159.7.1248. PMID: 12091219.

8:  Malphurs JE, Eisdorfer C, Cohen D. A comparison of antecedents of homicide-suicide and suicide in older married men. Am J Geriatr Psychiatry. 2001 Winter;9(1):49-57. PMID: 11156752.

9:  Silva JR. Global mass shootings: Comparing the United States against developed and developing countries. International Journal of Comparative and Applied Criminal Justice. 2022 Mar 21:1-24.

10: Treatment Advocacy Center.  Serious Mental Illness and Mass Homicide. June 2018,  https://www.treatmentadvocacycenter.org/key-issues/violence/3626-serious-mental-illness-and-mass-homicide

11:  Stone, M. F. (2015). Mass murder, mental illness, and men. Violence and Gender. 2015; 2, 51-86.

 

 

 

Mass Shootings Again and Again

There seems to be some optimism that Congress may be more motivated to do something about mass shootings in America given the recent events.  As I have said before - I will believe it when I see it.  Gun control is the prototypical deadlock in the USA, largely due to the effects of the gun lobby and their resistance to common sense gun legislation such as universal background checks, ban on high capacity magazine, and ban on assault weapons.  If anything, the rhetoric in these areas has intensified.  The assault weapons for example are described as not more than semi-automatic weapons just like hunting rifles.  Forget about the fact that the Sandy Hook Elementary shooter fired 154 rounds in 4 minutes from the 10-30 round magazines he  brought with him - killing 26 people 20 of whom were children.  Putting "mass shooting" in the search box in the upper right hand corner of this block will pull up about 14 essays dating back 7 years to 2012 including a proposal to consider violence prevention as a public health intervention.

Another important level of the deadlock is the Supreme Court. Interpretation of the Second Amendment can occur at several levels and in the current Court 5/9 justices are Republican appointees making restrictive gun legislation less likely.  Gun advocates controlled the narrative about the Second Amendment early on so that the preamble is typically ignored.  Gun advocate rhetoric is basically that gun ownership of practically any gun one might want to own is an unconditional right.

Over the years the pattern remains the same.  The issue of mass shooters disrupting American society and killing people is always minimized relative the "rights" of gun owners. The spokespeople on this issue don't even attempt to address the problem. They immediately produce pro-gun rhetoric and maintain that nothing needs to be done.  They are obviously wrong about that.  Mass shootings are the problem.  That is not a gun rights problem or a gang violence problem. It is a problem of keeping guns out of the hands of mass shooters. A secondary public health issue is keeping guns out of the hands of suicidal people. Limiting access is a known solution to both problems. Every reasonable solution should be available to solve that problem including universal background checks and outright bans on weapon types and permanent bans of some people purchasing firearms as well as confiscation and destruction of firearms.

The police response to terroristic threats is instructive. 30 years ago, I received a fax from the local police that a person had purchased a handgun and they were "letting me know" about it.  I called them back immediately and they told me: "We can't do anything because they haven’t done anything yet." Within a few weeks I was personally threatened at home with a handgun concealed under a newspaper and they were planning to use it. Flash forward 20 years and I had a similar threat on my voice mail. I called the police in; they listened to it and told me they were going out to talk to the caller. They called me and said they had talked with him, and that if he contacted me again, they were going to arrest him for terroristic threats. I never heard from him again.

The threshold for police intervention needs to be at least this low for every person identified as a potential threat with access to firearms. Terroristic threats or behavior should be the threshold for police intervention.  In the NICS system persons who have been convicted of misdemeanor domestic violence or subject to a restraining order for harassing, stalking or threatening are prohibited persons and they would fail this federal background check that rejects firearm purchases. In many cases, early signs were noted by members of the public and family members, but it was not clear which authorities should be contacted and how the problem should have been approached.  The protocol for identifying potential mass shooters and the response by the police needs to be standardized and widely applied.  The police response in almost every locality is also a political issue as evidenced by the very gradual adoption of consistent domestic violence laws.

There has been some blurring of boundaries between psychiatrists and the police - most notably by the Tarasoff laws that transfer what I consider to be a police action (warning potential victims) to clinicians.  In many states now, commitment laws are decided by the police since only they are allowed to put people on mental health holds. This is a completely illogical approach to psychiatric emergencies and holds.  There should be a clear division between clinicians and the police.  Clinicians do not take custody of people or discuss confidential information outside of what is legally required and that generally is to specific government authorities and not members of the public.

There have been no public health interventions focused on mass homicide prevention. I have been an advocate for this for a long time. There needs to be a campaign that focuses on anger control and what the resources might be to address it. On acute care psychiatric units, much of what is focused on has to do with the prevention of aggression and violence it has several causes. The message that anger - especially if it involved aggression even to the point of homicidal thinking and planning is a treatable problem and it can be treated before anyone is hurt or that person's life is ruined. Instead of treating it we have allowed mass homicide to persist as a way to express anger in a subculture of largely men. There are many forces in social media reinforcing this inappropriate expression of anger.

Although I have mentioned psychiatric problems here and see violent psychiatric patients as being part of the problem, they are not by any means the major part. I am sure that a personality disorder diagnosis exists in many of these remaining men, but the majority have not had any psychiatric contact. 

Psychiatry in itself will never be a solution to the problem without cultural changes at the level of this violent subculture and their way of expressing their anger and the law enforcement culture seriously resetting the threshold for intervention.  There also has to be a clear intervention to keep highly lethal firearms out of the hands of potential mass shooters. 

Pro-gun rhetoric never addresses that basic point.



George Dawson, MD, DFAPA

The NYTimes Editorial On Why Mental Health Can't Stop Mass Shooters -What's Wrong With It?

There was a New York Times editorial titled "The Mental Health System Can't Stop Mass Shooters" dated February 20, 2018.  It was written by Amy Barnhorst, MD, a psychiatrist and vice chairwoman of community psychiatry for University of California, Davis.  Since it popped up it is being posted to Twitter by more and more psychiatrists.  It does contain a lot of accuracy and realism about the issue of assessing people acutely and whether or not they can be legally held on the basis of their dangerous behavior.  Dr. Barnhorst gives examples of people who allegedly make threats and then deny them.  She discusses the legal standard for commitment and its subjective interpretation.  For example, even though a statute seems to have a clear standard they are many scenarios in the grey zone, where a decision could be made to err on the safe side.  That involves hospitalizing the patient against his or her will because the risk is there and their behavior cannot be predicted.  If hospitalized, she anticipates the outcome when the patient appears in front of a hearing officer and gets released.  That last scenario is very real and I would guess that the majority of decisions on the front end in these cases take into account what might happen in court.

If the hypothetical patient did get committed he would not be able to acquire a gun with a functional background check system. That system does not currently exist. If guns were involved in his case before hospitalization, the police may have confiscated them.  Unless his legal status changes they may give him the guns back.  In some cases the patient is told to ask their psychiatrist to write a letter to get their guns back.  I am not aware of any psychiatrist who has done that.  The FBI NICS system lists all of the conditions that would prohibit a point of purchase gun sale (assuming a check is done).  That list includes: "A person adjudicated mental defective or involuntarily committed to a mental institution or incompetent to handle own affairs, including dispositions to criminal charges of found not guilty by reason of insanity or found incompetent to stand trial."   Various crimes including domestic abuse can also trigger a failure of the NICS check and when that happens the gun sale is cancelled.  Unfortunately not all states participate in this check system and there are numerous exceptions if they do.

I have diagrammed the various levels of arguments that apply to a psychiatrist doing a crisis evaluation on a person brought to the emergency department for making threats with firearms.  At the political level there is no nuance.  At this level the degree of distortion is the greatest.  The usual arguments about guns not killing people is a good example, but it extends even this morning to President Trump suggesting that more mental health resources will solve the mass shooting problem, when it clearly will not.  The legal arguments are slightly more informed, but still fairly crude.  Like most legal arguments they threaten or reassure.  For example, most psychiatric crisis statutes hold harmless anyone who reports a suicidal or aggressive person to the authorities.  On the other hand, if a psychiatrist places a person on a legal hold because they are potentially dangerous - it is typically illegal for that same psychiatrist to extend the hold if the court system has not done anything by the time it expires.  The civil commitment system has a way of starting to make decisions based on available resources and in many cases the statutes seem reinterpreted that way.

At the medical level, psychiatrists are left living with the legal and political arguments no matter how biased they may be and trying to come up with a plan to contain and treat the aggression.  It is not an easy task given the resource allocation to psychiatry - but after doing ti for 20 years - it is fairly obvious that acute care psychiatrists know what they are doing.  They are successful at stopping violence acutely and on a long term basis.  Given the legal biases they cannot do it alone.  There needs to be cooperation from the courts and the legal system and some patients should be treated in the legal rather than the mental health system. 

Getting back to Dr. Barnhorst's article one sentence that I disagreed completely with was:

"The reason the mental health system fails to prevent mass shootings is that mental illness is rarely the cause of such violence." 

She cites "angry young men who harbor violent fantasies" as basically being incurable.  The problem with mental illness and gun violence is that it is dealt with at a political level rather than a medical and diagnostic one.  The facts are seldom considered.  There are political factions that see violence as stigmatizing the mentally ill and political factions who want to scapegoat the mentally ill and take the heat off the gun advocates.  The reality is that people with severe mental illness are overrepresented in acts of violence compared with the nonmentally ill population. It is a small but significant number. In studies of mass homicides the number increases but it depends on the methodology.  There are for example school shooter databases that record events as anytime a firearm is discharged in a school.  That results in a very large number of weapon discharges but most where nobody is injured.  There are databases that just list events but there is no analysis of whether mental illness was a factor or not.  In mass shootings in half the cases the shooter is killed or suicides.  Even when the shooter survives the data is affected by the subsequent hearings - so there is rarely a pure diagnostic interview available.  The data analysis depends on making sure that both the events and the mental health diagnoses are as accurate as possible.

The most parsimonious assessment of this data was published by Michael Stone, MD in 2015 (1).  The paper is fairly exhaustive and I am not going to discuss the obvious pluses and minuses.  I do see it as a break from the usual sensational headlines and the analysis of the trends in mass homicide over time, especially associated with semiautomatic firearms - leaves no doubt that this is a large problem.

He identifies 235 mass murderers, and estimates that 46 (22%) of them were mentally ill.  His definition of mentally ill as essentially being psychotic.  He goes on to say that in the remaining fraction and additional 48 had paranoid personality disorder, 11 were depressed, and 2 had autism spectrum disorders. In other words another 26% of the sample had significant mental disorders that were not considered in the analysis because he did not consider them to be psychotic.  Another 45 (19%) has either antisocial personality disorder or psychopathic personality disorder - both mental conditions associated with criminal activity and thought to have no known methods of treatment.  Using this conservative methodology - it is apparent that mental illness in this population is not rare at all.  What should not be lost is that although mass shootings are very noticeable events - they are rare and therefore any overrepresentation of mental illness in this group, is diluted by what happens across the entire population where the majority of violent activity is associated with people having no mental illness and the overall trends in violent crimes are at a 20 year low.

My proposed solutions to the problem of semiautomatic weapon access and mass shooters/murders is approached this way:

1.  Increase the purchase age to 21 years.  Eliminate access to military style weapons.

2.  All purchases must be cleared through the NICS system.  All states must participate. Currently only 12 states participate in full point of contact background checks on every gun sale.

3.  The NICS system should include terroristic threats, stalking, and any gun confiscation by the police because of mental health grounds as exclusion criteria.  In other words, you are eliminated from gun purchases if you have been reported for these problems.  That may sound a bit stringent but I think there is precedent.  You cannot make threats about air travel at an airport.  If you have been charged with domestic abuse (Misdemeanor Crimes of Domestic Violence (MCDV)
 the are special instructions on what it takes to keep firearms from you.  I consider the safety of children in schools to be on par with these two cases (air travel and domestic violence threats).

4.  At the level of law enforcement, any firearms confiscated during a threat investigation should not be returned and that person should be investigated and reported to NICS Database.

5.  Uniform protocols need to be in place for terroristic threat assessment.  It is no longer acceptable to wait for a person to commit an act of aggression before there is a law enforcement intervention.  The person making the threat should be removed from that environment and contained pending further investigation.

6.  On the mental health side - rebuilding the infrastructure to adequately deal with this problem is a start.  Hospitals with large enough mental health capacity should have a unit to deal with aggression and violence.  There should be specialty units that collect outcome data on the diagnoses represented and work on improving those outcomes.

7.  On the law enforcement/corrections side there needs to be recognition that not all mental health problems can be treated like mental health problems.  Violent people with antisocial personality disorder and psychopathy are best treated in law enforcement setting and not in psychiatric settings.  In psychiatric setting they have a tendency to exploit and intimidate the other patients in those settings as well as the staff.  They should be treated by psychiatrist with expertise in these conditions and been seen in correctional settings.  Probation and parole contingencies may be the best approach but I am open to any references that suggest otherwise.

8.  In the early years of this blog - I was an advocate for violence prevention and I still am.  Violence and aggression have the most stigmatizing effects of any mental health symptoms.  I think it is safe to day that most psychiatrists actively avoid practicing in setting where they may have contact with aggressive patients.  It needs to be seen as a public health problem and education and prevention are a first step.

Those are my ideas this morning.  I may add more to this page later.  If you have a real interest in this topic Dr. Stone's paper is a compelling read.  If I find others of similar quality I will post them here.  Don't hesitate to send me a reference if you have one.

The bottom line is that no psychiatrist can operate in the current vacuum of realistic options and hope to contain a potential mass shooter.  And yet there is a clear overepresentation of mental illness in this population.  Some level of cooperation as suggested above will result in a much tighter system for addressing this issue.  We do it in airports and in domestic violence situations.  We can also apply more uniform and stringent expectations to schools.


George Dawson, MD, DFAPA


References:

1:  Amy Barnhorst.  The Mental Health System Can't Stop Mass Shooters.  New York Times February 20, 2018.  Full Text Link

2:  Stone MH.  Mass Murder, Mental Illness, and Men.   Violence and Gender. Mar 2015: 51-86. Free Full Text Link



Graphics Credit:

Photo of the M4 Assault Rifle is per Shutterstock and licensed through their agreement.

Layered arguments graphic was done by me in Visio.

 

Mass Shootings in America - Why They Are not Terrorism

You will find more statistics at Statista

American media is so used to mass shootings that many are set up to reflexively release provocative and often poorly thought out theories after the incident.  The fact that there is rarely much more information about the shooter's motive reinforces this process.  The tragic event in Las Vegas is no exception.  It is currently the worst mass shooting incident in the USA and here is a link to the previous two.  There is the usual gun debate and public relations maneuvers by wide gun access advocates.  There are the rational responses by citizens calling for some measure of gun control.  I say rational because there is excellent evidence (1) that stricter gun laws enacted after a mass shooting incident, prevent further mass shooting incidents.  In the media coverage after this incident and on various social media cites there appears to be some confusion over whether American mass shooters are terrorists or not.

Before I go on, I have noticed that in social media many people are posting state statutes that equate terrorism with acts of violence.  The US Code defines both international and domestic terrorism as intimidation or coercion on a domestic population in order to influence the conduct or policy of the government.  I would take it a step further in that there needs to be an ideological message.  All of the news about who takes "credit" for these incidents implies this is a critical dynamic along with all of the publicity generated by many of these groups with very explicit messages.

For all of these reasons, typical mass shooters in the United States are not terrorists.  There is no ideology, no message, and no attempt to influence the government.  There certainly may be mental illness, but that alone is insufficient to produce a typical mass shooter.  There are many more mass shooters that are not technically mentally ill than those who are, but I will admit that the methodology for studying the problem is inadequate since many of these perpetrators are dead or unwilling/unable to produce a coherent story.  I will also be the first to admit that this is my impression, because the data on mass shooters is large and I have no access to all of that data.  For example, the NY Times came out with a graphic showing that in the past 477  days in the US there were 521 mass shootings (2).  They use the criteria of 4 or more people killed or injured qualifying as a mass shooting.  I have no access to that data.  There have been attempts to look at the data according to specific types of mass shooters like rampage killings.  The most recent FBI study looked at where the events occurred, if there was any connection between the shooter and the location.  It did not focus on the potential motivations of the shooters despite having access to all of the data:

Though this study did not focus on the motivation of the shooters, the study did identify some shooter characteristics. In all but 2 of the incidents, the shooter chose to act alone. Only 6 female shooters were identified. Shooter ages as a whole showed no pattern. However, some patterns were seen in incident sub-groups. For example, 12 of 14 shooters in high school shootings were students at the schools, and 5 of the 6 shooters at middle schools were students at the schools. (p. 20).
  
It did look at some specific locations and the relationship of the shooter (employee, family member)  to that location.  The critical analysis of this report was that it appeared that although mass shootings have occurred a long time in the United States - they appeared to be increasing in rate and lethality as indicated by the following graphic from that report:

The graphic points out that not only is the general problem of mass shooting being ignored from  policy perspective, the increasing rate and lethality of these incidents is being ignored.  From the FBI report some of the motivations clearly involve enraged employees or former employees.  Mental illness was omitted as a possible motivation.  All of the vignettes of each incident are attached to the end of the report.

My views on mass shootings, violence prevention, and even homicide prevention have not changed from my previous posts in this area.  I will add one more dimension to the issue and that is the cultural meme of the mass shooter in America.  Granted there are various etiologies that can produce a mass shooter, but after terrorism has been  eliminated there is a prominent cultural meme present in the USA and that is - if I feel like I have been wronged - I can pick up a gun and and make things right (at least in my own mind).  Americans are oblivious  to the presence of this thought pattern in our culture and what it implies.  The most significant implication is that reality is suspended if I merely feel like I have been wronged.  The reality of why I was fired, divorced, arrested is secondary to my thoughts on the matter.  Most adults in this country have had experience dealing with somebody who had this pattern of thinking.  To some extent most people with some level of self awareness can catch themselves in the process of making the same errors - most frequently when angry or emotionally upset.  Varying degrees of road rage is a classic example.  There is an anthropological argument that violence, aggression, and homicide are age old solutions to often minor disagreements.  In many cases the aggression spreads to a  larger number of targets than were involved in the original conflict.

There is the issue of violent and homicidal fantasy being common in both normative and violent criminal populations (4).  Various theories about the function of these homicidal fantasies exist.  Some homicidal fantasies seem higher risk than others but the study of fantasy per se, is limited by inadequate methodology including degree of self disclosure and lack of long term follow up.  Much of the work is anecdotal.
   
At the cultural level is there a larger problem in America?  American culture unquestionably has viewed firearms as tools for settling disputes.  That plays out time and time again in various movies and to varying degrees in American subcultures where being capable of violence and aggression is synonymous with being respected. To be very clear most people can tell the difference, but cultural influences can have a powerful effect.

No matter what the intrapsychic or cultural ground for gun violence, one thing is obvious if a firearm is available it is more likely to be used in both incidents of suicide and homicide.  We currently have a Congress and various political factions that are in denial of that basic fact.  Unless there is a radical change in that political approach and/or a concerted effort toward violence and homicide prevention reversing the trend in the FBI graph is unlikely.


George Dawson, MD, DFAPA




References: 

1:  Chapman S, Alpers P, Agho K, Jones M. Australia's 1996 gun law reforms: faster falls in firearm deaths, firearm suicides, and a decade without mass shootings. Inj Prev. 2015 Oct;21(5):355-62. doi: 10.1136/ip.2006.013714rep. PubMed PMID: 26396147.

2:  The Editorial Board.  477 Days. 521 Mass Shootings. Zero Action From Congress. New York Times; October 2, 2017.

3:   Blair, J. Pete, and Schweit, Katherine W. (2014). A Study of Active Shooter Incidents, 2000 - 2013. Texas State University and Federal Bureau of Investigation, U.S. Department of Justice, Washington D.C. 2014.

4: Gellerman DM, Suddath R. Violent fantasy, dangerousness, and the duty to warn and protect. J Am Acad Psychiatry Law. 2005;33(4):484-95. PubMed PMID: 16394225

Worst Mass Shooting in US History

I got up Sunday morning and the CNN headlines stated: "50 dead, 53 injured.....".  What appears to have been a single shooter entered an Orlando nightclub last night  at about 2AM and shot 92 people with an assault rifle.  I saw Dr. Michael Cheatham  of Orlando Regional Medical Center say that a mass casualty incident was declared and an additional 6 trauma surgeons and a pediatric trauma surgeon were brought in.  The FBI is investigating it as an act of terror or a hate crime.  The shooter was a 29 year old man who had been investigated by the FBI for possible ties to Islamic extremism.  He had been working as a security guard for a company who provides services to the federal government.  He was licensed to purchase firearms.  He purchased two firearms shortly before the shooting - a Sig Sauer MCX Carbine 0.223 cal on June 4 and a Glock 19  9mm pistol on June 9 from the same gun shop.  Some reports suggest he was also carrying a Walther P22 .22LR pistol, purchase date unknown.  Prior to this incident the worst mass shooting incident was the Virginia Tech incident in 2007 that killed 32 people.  

At the time of the attack the shooter called 911 and pledged allegiance to ISIS and mentioned the Boston bombers.  President Obama came on the networks at 2PM and referred to the incident:  "This was an act of terror or hate."  He pointed out that this was an attack on all Americans and he encouraged solidarity.  In an earlier commentary (posted above) he discussed solutions.  He used the example of highway traffic fatalities and how they were approached from a scientific and public health standpoint.  Vehicle safety improved.  Driver behaviors especially driving while intoxicated was confronted.  Although he did not mention it, the drinking age in the United States was increased to age 21 largely by political leverage using federal highway money granted to individual states.  He pointed out that these same public health measures cannot be used in the case of firearm violence because Congress has blocked research on firearm deaths and violence. He discussed a situation that he had just encountered, where people being tracked by the FBI for frequenting ISIL web sites could be put on the no-fly list but they could not be prohibited from purchasing firearms. That legislation is blocked by a gun lobby with a primary thesis that some members of the government want to take away Second Amendment rights and firearms from law-abiding citizens.   The President points out that nothing could be further from the truth and cited the fact that more firearms have been sold during his administration that practically any other time of the Republic.  I think the manufacturing statistics might back up that claim at least based on a chart I created during the first half of his administration.  Further information corroborating this statement is available at the document Firearms Commerce in the United States 2015 on the ATF website.  There is plenty of data there to corroborate both the President's remarks and the potential financial conflict of interest of the firearms lobby.  I am sure that the gun advocates will be the first to say they deserve credit for gun commerce rather than the President.  My speculation is that they would deflect the conflict of issue by either wrapping themselves in the Second Amendment or as advocates for all of the law-abiding gun owners.

I think that most physicians agree with a public health approach to gun violence and would like to see more data and strategies.  The existing data shows that gun availability is the single largest determinant when it comes to firearm deaths either due to suicide or homicide.  It accounts for the greatest correlation with adverse outcomes from gun violence.  By comparison psychiatric diagnosis does not.

The President's comments on the further political aspects of gun control legislation in the US especially people being investigated by the FBI, like the perpetrator was on two occasions cannot be prohibited from obtaining firearms.  That speaks directly to the pro-gun argument that all we have to do is focus on existing laws and get the guns out of the hands of the bad guys.  This law potentially puts guns directly into the hands of the bad guys and nothing is being done about it.  The Obama video was posted 10 days prior to the Orlando attack.

I won't belabor the points I have already made in a series of posts on this blog.  We are still seeing the same microanalysis and political opportunism that has become a routine part of mass shootings.  We are still seeing the lack of solutions like we have seen in the past.  The way it looks I can continue to post on the issue on out into the future it will probably be a problem long after I am gone.  I heard a gun advocate on public radio this morning and what he said after this incident was not only depressing and disingenuous, but it typifies a rigid illogical stance that no place in science, medicine, or the 21st century.  It illustrates why the gun lobby has Congress enact laws to stifle funding for epidemiological work on gun mortality and morbidity.   I suppose at this point it is just a question of when we hit the tipping point.  When will the majority of Americans start to reject this illogical philosophy?

If the gun advocates hit the street with this hard line attitude after the scope of a mass shooting like we witnessed in Orlando - I shudder to think of what the eventual human cost is going to be.




George Dawson, MD, DFAPA




Attribution:

Embedded video per PBS and the instruction on their site.  Original video was from June 2, 2016

Does Publicizing Mass Shooters Benefit Anyone?

I ran across this perspective posted on the Kottke blog.  It is basically a journalist writing an opinion piece about why the names of mass shooters should be used in the media.  I think it is a reaction to the banning of the use of the names and details of mass shooters by some law enforcement and the media.  The Sheriff in the most recent mass shooting incident refused to release the name of the shooter.  The argument against releasing the name of the shooter goes something like this.  At least part of the motivation of some of these shooters involves the fame and publicity that they will achieve based on the incident.  The mass shooting incidents have been in my estimation fairly compared to terrorist incidents where the victims are killed in some of the most horrible and sadistic ways possible as part of the media campaign by these organizations.  It enhances any kidnaping and extortion threats that they may have and also enhances their image as a ruthless and single-minded entity.  Until recently that behavior was also a ticket to widespread international media exposure.  When the media cycle becomes knee jerk in response to mass shootings or terrorist events it is predictable no-cost publicity to both types of perpetrators.

There is additional evidence in the personal effects of many of these shooters and well as evidence from the staging of the events that publicity is a strong motivating factor.  The shooters often have computers and written statements about the motivation for their acts, and some of that material describes the event as something for the world to see.

The counterargument from the journalist seems to be that it is important for the public to hear all this information.  He makes the expected argument of the press that all of the news needs to be reported.  He also spins the political angle and suggests that conservative gun advocates including the sheriff involved in the most recent incident and then Fox News have elected not to name the perpetrator and connects this with the right wing tendency to talk about mental illness being the problem and not uncontrolled access to firearms.

I am at the point where I cringe when reading these highly politicized arguments probably because that is all that I hear when it comes to psychiatry.  The general form of the argument is that people taking a certain position have a certain ideology and therefore the conflict of interest issue reigns supreme.  Because a news service or a sheriff have been identified as being right wing and supporters of continued open access to firearms, anything they say about maintaining the anonymity of the perpetrator can be discounted based on conflict of interest.  In other words, by maintaining the anonymity of the shooter and focusing on the mental state of the shooter, the focus is shifted inappropriately away from more functional legislation to reduce firearm access.  The writer acknowledges that part of the motivation of some of these shooters is publicity or infamy whether they survive or not.  It is hard to deny because a review of the personal effects of some of these shooters makes it explicit.  The author takes the view that denying this publicity essentially gives the appearance that something is being done and this is bullshit.

First off, that does not meet my definition of bullshit from the definitive essay by Frankfurt.  According to Frankfurt, the main differentiating point between bullshitters and liars is that bullshitters have a blatant disregard for the truth.  The truth in this case is that irrespective of political motivations it is highly likely that denying these men the publicity that they seek will result in fewer of these crimes.  It might even provide a public health path to treatment for many of these individual instead of acting out.  I would suggest statutes that address the issue of how mass shooters should be handled in the event of any incident and would not only see anonymity as being important, but also confiscating property and all of the written material and images from the perpetrator and making them available for academic study, but not for the evening news.

The author also seems blind to the role of journalists in this process.  Every massacre triggers the standard response from journalists that I have written about on this blog many times.  All of the shocking details, the interviews with the aggrieved, the response from politicians, and the "profiling" of the perpetrator.  Then after a few days, the President comes on and we are all told to move on.  It seems that the President in his latest address has questioned the value of this process before members of the press have including this author.

My conclusion is that there has to be obvious progress in the area of gun control (yes - I said control).  But I have also accepted the fact that the power structure in this country does not have to yield to public opinion.  My decades of treating violent and aggressive people have also led me to understand that this is also a public health problem and as a public health problem - multiple measures need to be in place.   Restricting wide spread publicity for the perpetrators is one of many logical options.

There is also the issue of contagion.  Does a large incident with a lot of news coverage trigger copycat crimes?  There have been some anecdotal reports that copycat crimes occur in the specific area of school shooting.  The authors of a recent PLOS article (2), analyze the USA Today Mass Killing database and the the Brady Campaign School Shooting database.   The original databases and any modifications to them are available at this link.  The authors comment that a contagion model has been applied to several natural events like the financial markets, burglaries and terrorist attacks.  The authors specify the model they are using and go on to show that according to the USA Today database there was a mass killing (involving 4 or more people killed) every 12.5 in the US.  For the Brady database school sooting occurred every 31.6 days.  The authors illustrate there is a contagion effect for mass killings involving firearms but not mass killings that do not involve firearms.  They also show correlations between state prevalence of firearm ownership and mass shootings, but the authors note that mass shooters commit suicide 48% of the time and that is much higher than the expected suicide rate by perpetrators committing a single act of homicide (5-10%).  Mass shooters who commit suicide also kill 22% more people than mass shooters who do not.  The graphics and statistics in this article are great and I highly recommend a look at the graphs showing what part of the data is due to the contagion effect.  I also applaud the authors efforts to publish essentially public health research in an area that has been actively suppressed by Congress.  Scientific research on firearms policy is apparently incompatible with the Second Amendment.

So it turns out that there are probably legitimate reasons for withholding the identity of mass shooters and decreasing the disclosures about the incident and in some cases the audiovisual material that they have produced to promote their activity.  There is a well known journalistic tendency to wrap themselves in the flag when it comes to their not having complete access and the ability to disclose information, but the process is far from perfect and in many cases they defer to national security.   In the case of the databases involved there is clear asymmetry in terms of which incidents get publicity and which do not.  This is an opportunity for them to provide some news about public health interventions to prevent violence and mass shootings.

I don't think the importance of the notoriety or contagion factors in motivating mass shooters can be cancelled out by a conflict of interest argument.  But the conflict of interest card seems to be played like it is the trump card these days.

I also don't accept the "we as a society have made our choice" argument.  It's not really them it is us.  That argument is a stark contrast to how our government runs.  "We" are no more responsible for a society flush with guns that "we" were for three unnecessary wars based largely on fictional threats.  That oligarchy can function primarily with the full cooperation and lack of critical analysis by the American press.  The fact that late night comedians can produce more analysis of these issues than mainstream journalists is an indication of how much serious reporting is lacking.

There is probably no better example of reporting deficiency than how mass shooting incidents have been handled for decades.


George Dawson, MD, DFAPA


1:  Josh Marshall.  The Great Evasion.  TalkingPointsMemo.com  October 2, 2015.

2:  Towers S, Gomez-Lievano A, Khan M, Mubayi A, Castillo-Chavez C. Contagion in Mass Killings and School Shootings. PLoS One. 2015 Jul 2;10(7):e0117259. doi: 10.1371/journal.pone.0117259. eCollection 2015. PubMed PMID: 26135941.

Is President Obama Reading This Blog?

Not really, but you can find the mass shooting links on this blog at this link.  They extend back three years and they overlap with a number of posts on homicide prevention.  They also overlap in many areas with the President's speech.  This was President Obama's 15th address to the nation following a mass shooting incident.  A couple of other landmarks - this was the 40th time this year that a gunman opened fire in a school and the 294th mass shooting incident this year.  Both of these markers illustrate how tragic but absurd this problem is in America.  How can responsible people allow this to happen?

The President is coming to the only logical conclusion that a person can come to about mass shootings and the relationship to firearms.  That point in this speech was when he said that our thoughts and prayers for the families and survivors are not enough.  We cannot keep making these pat statements in response to continuous mass shootings as though nothing can be done to prevent them.  We cannot treat mass shootings like they are routine:

"Earlier this year, I answered a question in an interview by saying, “The United States of America is the one advanced nation on Earth in which we do not have sufficient common-sense gun-safety laws -- even in the face of repeated mass killings.”  And later that day, there was a mass shooting at a movie theater in Lafayette, Louisiana.  That day!  Somehow this has become routine.  The reporting is routine.  My response here at this podium ends up being routine.  The conversation in the aftermath of it.  We've become numb to this."

 The familiar refrain about condolences to everyone and now it is time to move on needs to stop.  With governments that regulate what a lot of us do at work every day - right down to how we cross the Ts and dot the Is - it is difficult to believe that more functional gun control laws cannot be passed.  In his speech he points out that this is possible and there are laws that have been shown to work in other countries and in specific counties and municipalities in the United States.

At one point he speaks to the mind of the perpetrator:

"We don't yet know why this individual did what he did. And it's fair to say that anybody who does this has a sickness in their minds, regardless of what they think their motivations may be. But we are not the only country on Earth that has people with mental illnesses or want to do harm to other people. We are the only advanced country on Earth that sees these kinds of mass shootings every few months."

People tend to get hung up on whether specific perpetrators have a diagnosable mental illness and whether it is treatable.  They tend to get hung up on whether the behavior of violent individuals can be predicted over time.  They tend to be very pessimistic about the nature of the problem and whether insightless people will ever be able to get the kind of help that they need to prevent mass shootings.  It might be easier if there was some education about the types of situations that lead to these problems and the fact that in most of those cases, help is available.  That specific help will prevent homicides and prevent the unnecessary loss of lives of both the perpetrators and the victims.  

The President ended with a comment on the political process and an appeal to gun owners on the issue of whether they are being supported on this issue by an unnamed organization or not.  It was a compelling speech and the arguments are powerful.  As a politician, he is focused on political action and on common sense gun safety laws.  I have stated that it might be best to proceed from a public health standpoint and a focus on violence prevention and forget about legal approaches largely because there has been no political will on this issue.  President Obama has given one of the most compelling speeches on this issue that I have ever witnessed and it will be interesting to see the result.

From the medical and psychiatric side, our advocacy still needs to be on the public health side of the equation.  For me that comes down to seeing the problem to a significant extent as violence and homicide prevention.  We need more public education on the predisposing mental states and how to get assistance when these states are recognized.




George Dawson, MD, DFAPA


References:

Statement by the President on the Shootings at Umpqua Community College, Roseburg, Oregon.  October 1, 2015.  Transcript