Psychiatric care versus gun control - an expected outcome

Just in case you are keeping score the Senate voted down some modest gun control proposals last week.  The issue of coming together over mental health care to address one of the dimensions of mass shootings also did not happen.  In the political calculus, it makes sense that if legislators did not fear the gun control lobby they had a lot less to fear from a mental health lobby ambivalent about dovetailing improved mental health care with gun control.

The pro gun advocates especially the NRA have always underscored the idea that they support law abiding citizens having access to firearms.  Their mantra for years has been that if there are more obstacles to law abiding citizens getting guns then only criminals would have them.  Never mind the significant number of accidental deaths every year and the fact that firearm suicide is consistently greater that firearm homicide in this country.  That detail is not lost on psychiatrists interviewing patients who have told us that they were impulsively looking for a gun to kill themselves and the only thing that prevented it was a background check and a waiting period.  The main provision of the attempted legislation was an extension of background checks.  If the pro gun lobby believes that it is protecting the right of law abiding citizens to purchase firearms, there should be no problem at all with universal background checks.  That should cut across all venues where firearms are bought and traded.  I have not heard a single rational explanation for voting down extended or universal background checks.

Reaction to the failure of this legislation was as swift as the Sunday morning talk shows.  Bob Scheiffer interviewed family members of the victims of the Sandy Hook incident on Face the Nation.  They were clearly upset about the vote in the Senate as captured in this quote from Neil Heslin father of 6 year old Jesse Heslin one of the victims of this incident:

"....As simple as a background check, putting aside the assault weapon ban or limitation or control, it's just a stepping stone of the background check with the mental health and the school security. I think the most discouraging part of this week was to, after the vote, to see who voted and who didn't vote, support it, and realize it's a political game. It was nothing bipartisan about it, at all. And we aren't going to go away. I know I'm not. We're not going to stop until there are changes that are made."

In the vacuum of no discussion of the vote against the bill or partisan rhetoric, very little was said in the press about the money behind the vote.  OpenSecrets.org did an excellent job of showing that like most things in American politics it looks like a significant factor.  Their research clearly shows that the pro-gun lobby can outspend the gun control lobby by as much as 15:1 with most of the money going to Republicans.  There are a couple of things working against the pro-gun lobby and all of that money - public support for common sense gun measures like background checks is at an all time high.   The second factor is difficult to say out loud but in American culture you can depend on it.  There will be more incidents and the pro-gun solutions (armed guards in schools, keeping the guns out of the hands of criminals and the mentally ill) are not really solutions.  The pro-gun lobby has demonstrated that they do not take that task seriously.

George Dawson, MD, DFAPA

Senate Blocks Drive for Gun Control.  NYTimes April 17, 2013.

S. 649 Roll Call Vote

No applause from me

The APA came out with a press release today in response to President Obama's initiative to reduce gun violence and prevent future mass shootings.  Although the release "applauds" these proposals they seem to be short on the mental health side. From the APA release:

“ We are heartened that the Administration plans to finalize rules governing mental health parity under the 2008 Mental Health Parity and Addiction Equity Act, the Affordable Care Act, and Medicaid. We strongly urge the Administration to close loopholes involving so-called ‘non-quantitative treatment limits’ and to ensure that health plans deliver a full scope of mental health services in order to comply with the law. Such action will best ensure that Americans get the full range of mental health services we believe they are intended to receive under federal law.”

So I guess the APA is applauding the initiative but encouraging the closing of loopholes. Call me a skeptic but 20 years of rationing mental health services and cutting them to the bone through managed care intermediaries and aggregating those managed care intermediaries into accountable care organizations does not bode well for the "full range of mental health services". The APA seems to have the naïve position that you can support managed care tactics and provide increased access to quality mental health services.

The next point in the APA release supports school screening and enhanced mental health services in schools for both violence prevention and to identify children at risk or in need of current mental health services. Those are certainly laudable goals but there is minimal evidence that screening is effective. There is also the problem of a lack of infrastructure.  Twenty years of rationing and restricting access to psychiatric services has resulted in long waiting lists or completely unavailable services. If you talk with a child psychiatrist, they will tell you that the current system is set up to offer medications in place of a more comprehensive approach to psychiatric treatment. At the social services level, residential treatment for children with severe problems is practically nonexistent. As a recent example, I was informed last week of a school social worker who could not get a child assessed for admission to an adolescent psychiatric unit and when that was not possible could not get an appointment to see a psychiatrist in a major metropolitan area. Screening for problems does not make any sense unless there is an infrastructure available to address those problems when they are found.

The final point in the APA release addresses the issue of physicians being able to discuss firearms at home with their patients. This has been a standard intervention for physicians ever since I have been practicing and it is always part of an assessment for suicide and homicide risk. There was a state initiative last year making it illegal for physicians to discuss firearms in the home with their patients. Part of the rationale for that law was that it could result in firearm owners being identified and placed them at theoretical risk for their firearms to be confiscated by the state.  I can say from experience that my discussions with patients about firearm safety and the discussions of other physicians that I have been aware of have been highly productive and have probably saved countless lives. The best example I can think of is talking with a primary care physician who asked me to take a look at a closet full of firearms that he convinced patients to turn into him over the years before he turned them into the police. Those patients were all depressed and suicidal and at high risk for impulsive acts. He would not have been able to make that intervention with a gag law in place preventing those discussions.

What about the President's original release?  It had 84 instances of the word "mental" usually as "mental illness" or "mental health".  As noted above it has received some accolades from the APA and other members of the mental health community. It elicited a strong and poorly thought out response from the NRA  who produced a YouTube video accusing the President of being elitist and a “hypocrite” because his daughters had armed security but he expected that everyone else’s kids would be protected by gun free zones.  The White House responded quickly:

“Most Americans agree that a president’s children should not be used as pawns in a political fight,” said Jay Carney, the White House press secretary. “But to go so far as to make the safety of the president’s children the subject of an attack ad is repugnant and cowardly.”

The full text of the White House 22 page document is located at this link.  It is ambitious and covers a lot of ground in terms of the specific regulation of firearms, school safety, and increasing mental health services. The firearm regulation is most specific in that it closes background check loopholes, bans assault weapons, outlaws armor piercing bullets, and sets the maximum magazine size at 10 cartridges.  Part of this document is a "call to Congress" so it is not clear to me how much can be accomplished by the President's executive orders as opposed to Congressional action.  I am reminded of the NRA President last weekend stating that Congress would never pass a ban on assault weapons.  The Executive Order section of that part of the document lists the following activities:

1.  Addressing unnecessary legal barriers in health laws that prevent some states from making information available about those prohibited from having guns.

2.  Improving incentives for states to share information with the system.

3.  Ensuring federal agencies share relevant information with the system.

4.  Directing the Attorney General to work with other agencies to review our

laws to make sure they are effective at identifying the dangerous or untrustworthy individuals that should not have access to guns.

The school safety initiative seems more nebulous. There is funding for 1000 "school resource officers and school based mental health professionals" and the recommendation to train 5000 additional “social workers, counselors, and psychologists.”   Considering the fact that there are probably close to 100,000 schools, this seems like a drop in the bucket.   Ensuring that each school has an emergency plan for contingencies like mass shootings does not seem to be a novel idea.  Creating safer school climates and reducing bullying has already been initiated in many school districts. There seems to be a clear lack of public health measures in the school that would reduce the likelihood of violent events.

The mental health initiative is equally lacking. In addition to the deficiencies I pointed out initially in this document, there is discussion of providing mental health training to teachers and school staff. There is probably evidence that teachers and school staff may over identify mental illness rather than under identify it.  Is this really a problem and will this level of screening be effective?   The document describes the initiative here as "increasing access" to mental health services. Screening larger numbers of students and identifying them as having potential problems actually creates a bottleneck in the system rather than increasing access.  The suggested mental health interventions in this document fall short in terms of both primary and secondary prevention of mental illness and associated aggressive behavior. Depending on a managed care model that has an established track record of dismantling the mental health infrastructure and providing limited access to poor quality care will do nothing to accommodate increasing referrals other than assure that referred students will be rapidly medicated.

My final analysis of the President’s initiative today is that it may be a starting point.  He is certainly taking the issue seriously and deserves plenty of credit for that.  His support for reopening firearm safety research that was closed by the gun lobby is important. What will become of the firearm regulation is anyone's guess at this point. The school and mental health initiatives are largely symbolic and I would not expect them to have any impact. What is sorely needed is the American Psychiatric Association coming out with standards, quality guidelines, and medical education initiatives to improve the care of people with severe mental illnesses who also happen to be aggressive.  An important piece of those guidelines should include the public health measures that were previously mentioned on this blog and those measures should also play a much larger role in any Executive initiative.

George Dawson, MD, DFAPA

Assault rifles, high capacity magazines, background checks and reverting to form

That is what it is coming down to according to the talking heads on the Sunday morning TV circuit this week.  Both the NRA and several politicians agree that there are not enough votes for an assault weapons ban.  There may be enough votes for a high capacity magazine ban but both sides acknowledge that these clips are inexpensive and there are already a lot of them out there.  The background checks issue is also debatable.  The NRA and the pro-gun factions are talking a lot about mental illness and needing to have a mechanism to prevent people with mental illnesses from getting guns.  There is minimal discussion of improved mental health services.  On CNN Sunday  morning there was acknowledgement that during tough budgetary times the line items supporting mental health treatment are the first to go.

So basically despite all of the hype about how the Sandy Hook incident was going to energize politicians to actually solve a problem – they appear to be rapidly reverting to form and not solving anything.  The NRA President seemed confident that nothing would happen (the NRA opposes any assault weapons ban or high capacity magazine ban), but cautioned that the President has a lot of political capital and might be able to influence the high capacity magazines.

I wanted to file this post tonight before the final recommendations of the Vice President because I think that there have been two recent articles in the medical literature that are very relevant. At the legislative level Jerome Kassirer, MD has a recent article in Archives of Internal Medicine. Dr. Kassirer is a former editor of the New England Journal of Medicine and I corresponded with him on this issue nearly 30 years ago.  He clearly has not lost interest over the years and brings several concepts into focus in his editorial. The first concerns the fundamentals of screening and how any effort to identify potential shooters would result in the false positives greatly outnumbering the true positives and how that renders screening impractical.  His primary focus has to do with countering political initiatives.  As an example the National Center for Injury Prevention and Control at the CDC is currently prevented from studying gun related injuries.  He advocates for countering that.  He advocates for a comprehensive analysis of gun ownership.  He also advocates for resistance to any laws that restrict physicians being able to talk about firearms with their patients. He wants to see universal background checks from gun purchases, gun safety devices including coded weapons, and restrictions on large capacity magazines and sales of large amounts of ammunition. His article refers to firearms as "Weapons of Mass Destruction".  Small arms and light weapons are in fact a major global problem.  This Federation of American Scientists primer highlights the issue and the fact that there have been over 1 million deaths due to small arms in the past decade. Some advocacy organizations estimate that as many as 250,000 people per year are killed by small arms fire worldwide.

The second very important article comes from the Journal of the American Medical Association. The authors of this article emphasize the public health approach to curbing gun violence. This is a very important concept that people have a difficult time grasping. Whenever I bring up the issue of psychiatrists being involved at the level of primary and secondary prevention most people distill that down to whether or not psychiatrists can predict violence.  A public health approach to violence prevention is much more comprehensive and multidimensional.  The authors give several good examples in this paper including modifying sociocultural norms.  They use the example of tobacco being media symbol of “modernity, autonomy, power, and sexuality" and how that was changed.  They suggest an analogous campaign to equate gun violence with weakness, irrationality, and cowardice. The article has a table that has 18 evidence-based public health interventions that have been successful in other areas that could be applied to gun violence.  This is actually the preferred strategy that I have been advocating for the past decade and the authors of this article state it very eloquently.

At this point in time it will be interesting to see if the Vice President's recommendations include any of the interventions suggested by these two articles or the recommendations from the APA.

George Dawson, MD, DFAPA

1: Kassirer JP. Weapons of Mass Destruction. Arch Intern Med. 2012 Dec 21:1-2.  doi: 10.1001/jamainternmed.2013.4026. [Epub ahead of print] PubMed PMID: 23262523.

2.  APA Recommendations to the Biden Task Force

3.  Mozaffarian D, Hemenway D, Ludwig DS. Curbing Gun Violence: Lessons From Public Health Successes. JAMA. 2013 Jan 7:1-2. doi: 10.1001/jama.2013.38. [Epub ahead of print] PubMed PMID: 23295618.

What is wrong with the APA's press release about the NRA statement?

The APA released a statement about the NRA's comments, probably Mr. LaPierre's statements on Meet the Press on Sunday and a separate NRA release. There are several problems with the APA statement:

1.   The American Psychiatric Association expressed disappointment today in the comments from Wayne LaPierre…

Why would the APA be "disappointed" in a predictable statement from a gun lobbyist?  I really found nothing surprising in Mr. LaPierre's presentation or the specific content. As I previously posted, the NRA predictably sees guns as the solution to gun violence.  The concept "more guns less crime" has been a driving force behind their nationwide campaign for concealed carry laws. The concealed weapons that are being carried are handguns and handguns are responsible for the largest percentage of gun homicides in the United States. It is probably a good idea to come up with a solution rather than reacting to a predictable statement.

2.  The person involved in the shooting is named…

Although it is controversial, there is some evidence that media coverage is one factor that can lead predispose individuals to copy a particular crime.  Although this press release is a minimal amount of information relative to other news coverage, it does represent an opportunity for modeling techniques for more appropriate media coverage and that might include anonymity of the perpetrator.  The NRA release makes the same mistake.

3.   In addition, he conflated mental illness with evil at several points in his talk and suggested that those who commit heinous gun crimes are “so possessed by voices and driven by demons that no sane person can ever possibly comprehend them,” a description that leads to the further stigmatization of people with mental illnesses.

It is always difficult to tell how rhetorical a person is being when they use terms like "evil" and "demons". If they are considered to be descriptive terms for a supernatural force that suggests an etiology of mental illness that was popular in the Dark Ages.  Evil on the other hand does have a more generic definition of "morally wrong or bad;  immoral; wicked”.  In this case it is important to know if the speaker is referring to a definition that is based on evil as a supernatural force or a more common description. This is another educational point. People who experience voices and irrational thoughts involving homicide can be understood. Psychiatrists can understand them and can help them to come up with a plan to avoid acting on those thoughts and impulses and getting rid of them.  The NRA release is basically an indication of a high degree of naïveté in thinking about the unique conscious state of individuals.  The APA release should correct that.

4.  The APA notes that people with mental illnesses are rarely violent and that they are far more likely to be the victims of crimes than the perpetrators

The actual numbers here are irrelevant.  Psychiatric epidemiology cannot be casually understood and the media generally has the population whipped up about the notion of psychiatric overdiagnosis of everything anyway. The idea that some mentally ill persons are dangerous is common sense and forms the basis of civil commitment and emergency detention laws in every state of the union. Advocates need to step away from the notion that recognizing this fact is "stigmatizing". The APA needs to recognize that their members in acute care settings are dealing with this problem every day and need support. It is an undeniable fact that some persons with mental illness are dangerous and it is an undeniable fact that most of the dangerous people do not have mental illness. Trying to parse that sentence usually results in inertia that prevents any progress toward solutions.

The APA seems to have missed a golden opportunity to suggest a plan to address the current problem. The problem will not be addressed by responding to predictable NRA rhetoric.  There several other nonstarters in terms of a productive dialogue on this issue including - the specifics of the Second Amendment and specific gun control regulations. The moderator of Meet The Press made an excellent point in the interview on Sunday when he asked about closing the loophole that 40% of gun purchases occur at gun shows where there are no background checks. It was clear that the NRA was not interested in closing that loophole. The main problem is that the APA has no standing in that argument. Second nonstarter is the whole issue of predictability. Any news outlet can find a psychiatrist somewhere who will comment that psychiatrists cannot predict anything. That usually ends the story. If your cardiologist cannot predict when you will have a heart attack, why would anyone think that a psychiatrist could predict a rare event happening in a much more complicated organ? Psychiatrists need to be focused on public health interventions to reduce the incidence of violence and aggression in the general population and where it is associated with psychiatric disorders. 

What about Mr. LaPierre’s criticism of the mental health system?

“They didn't want mentally ill in institutions. So they put them all back on the streets. And then nobody thought what happens when you put all these mentally ill people back on the streets, and what happens when they start taking their medicine.  We have a completely cracked mentally ill system that's got these monsters walking the streets. And we've got to deal with the underlying causes and connections if we're ever going to get to the truth in this country and stop this…”

Is it an accurate global description of what has happened to the mental health system in this country? He certainly is not using the language of a mental health professional or a person with any sensitivity toward people with mental illness.  There are numerous pages on this blog documenting how the mental health system has been decimated over the past 25 years and some of the factors responsible for that. Just yesterday I was advised of a school social worker who not only was unable to get a child hospitalized but could not get them an outpatient appointment to see a psychiatrist. The government and the managed care industry have spent 25 years denying people access to mental health care and psychiatrists. They have also spent 25 years denying people access to quality mental health care that psychiatrists are trained to provide. We have minimal infrastructure to help people with the most severe forms of illness and many hospital inpatient units do discharge people to the street even though they are unchanged since they were admitted.   Any serious dialogue about the mental health aspects of aggression and violence needs to address that problem.

That is where the APA’s voice should be the loudest.

George Dawson, MD, DFAPA

Supplementary Material:  Quotes from and locations of transcripts – feel free to double check my work.

MTP transcript  12/23:  http://www.msnbc.msn.com/id/50283245/ns/meet_the_press-transcripts/t/december-wayne-lapierre-chuck-schumer-lindsey-graham-jason-chaffetz-harold-ford-jr-andrea-mitchell-chuck-todd/#.UNlaJ-RqYrV

"I'm telling you what I think will make people safe. And what every mom and dad will make them feel better when they drop their kid off at school in January, is if we have a police officer in that school, a good guy, that if some horrible monster tries to do something, they'll be there to protect them." (p2)

"Look at the facts at Columbine. They've changed every police procedure since Columbine. I mean I don't understand why you can't, just for a minute, imagine that when that horrible monster tried to shoot his way into Sandy Hook School, that if a good guy with a gun had been there, he might have been able to stop..."—(p3)

"There are so many different ways he could have done it. And there's an endless amount of ways a monster.."—(p6)

"I don't think it will. I keep saying it, and you just won't accept it. It's not going to work. It hasn't worked. Dianne Feinstein had her ban, and Columbine occurred. It's not going to work. I'll tell you what would work. We have a mental health system in this country that has completely and totally collapsed. We have no national database of these lunatics." (p6)

"23 states, my (UNINTEL) however long ago was Virginia Tech? 23 states are still putting only a small number of records into the system. And a lot of states are putting none. So, when they go through the national instant check system, and they go to try to screen out one of those lunatics, the (p6)

"I talked to a police officer the other day. He said, "Wayne," he said, "let me tell you this. Every police officer walking the street knows s lunatic that's out there, some mentally disturbed person that ought to be in an institution, is out walking the street because they dealt with the institutional side. They didn't want mentally ill in institutions. So they put them all back on the streets. And then nobody thought what happens when you put all these mentally ill people back on the streets, and what happens when they start taking their medicine."We have a completely cracked mentally ill system that's got these monsters walking the streets. And we've got to deal with the underlying causes and connections if we're ever going to get to the truth in this country and stop this"—(p7)

NRA transcript 12/21: http://home.nra.org/pdf/Transcript_PDF.pdf

"The truth is that our society is populated by an unknown number of genuine monsters — people so deranged, so evil, so possessed by voices and driven by demons that no sane person can possibly ever

comprehend them." (p2)

"Yet when it comes to the most beloved, innocent and vulnerable members of the American family — our children — we as a society leave them utterly defenseless, and the monsters and predators of this world know it and exploit it. That must change now!" (p2)

"As parents, we do everything we can to keep our children safe. It is now time for us to assume responsibility for their safety at school.  The only way to stop a monster from killing our kids is to be personally involved and invested in a plan of absolute protection. The only thing that stops a bad guy with a gun is a good guy with a gun. Would you rather have your 911 call bring a good guy with a gun from a mile away ... or a minute away?" (p5)

"Now, I can imagine the shocking headlines you'll print tomorrow morning: "More guns," you'll claim, "are the NRA's answer to everything!" Your implication will be that guns are evil and have no  place in society, much less in our schools. But since when did the word "gun" automatically become a bad word?" (p5)

"Is the press and political class here in Washington so consumed by fear and hatred of the NRA and America’s gun owners that you're willing to accept a world where real resistance to evil monsters is a lone, unarmed school principal left to surrender her life to shield the children in her care?" (p6)

Additional Reference:

Copycat Phenomenon in medical literature (references 5, 13, 20, 26 are most relevant).

"The only thing that stops a bad guy with a gun is a good guy with a gun"

That is a direct quote from the NRA's chief lobbyist Wayne Lapierre.  In the same NYTimes piece he goes on to say that declaring our schools gun free zones serves only: "“tell every insane killer in America that schools are the safest place to effect maximum mayhem with minimum risk.”  There has been some mild outrage in response to this comments but I don't know what people would expect from the NRA.  They see guns as a solution to everything.  They literally believe that with guns there is less crime despite the hard data that points to the fact that the USA has the highest (by far) homicide rate by firearms, the highest rate of gun ownership, and the highest rate of assault deaths of any of the top 30 countries of the Organization for Economic Cooperation and Development.  In fact, this NY Times graphic of the data shows that over half of the homicide rate is firearm related.  The total homicides in the US at 9,960 is nearly seven times greater than the total of all the other countries on the list.  The total number of suicides by firearms greatly exceeds this number (18,735 in 2009).  It seems to me that the gun data suggests that we currently have maximum mayhem with maximum risk.

Getting back to the proposed NRA solution.  Let's look at the arithmetic first.  Just considering the number of public schools in the US, current data from the National Center for Education Statistics puts that number at 98,817.  Assuming a cost of one armed guard per school with vacation coverage and benefits I would conservatively estimate a cost of about $100,000 per year or a total of about $9.8 billion dollars per year.  That is a substantial outlay of capital for what is an unproven strategy.  According to the Wikipedia list there have been 40 school shootings since 1989.  Using a a mean number of schools during the period (or about 91,638) would mean that the odds of one of these armed guards encountering a shooter would be about 2/91,638 on an annual basis.  The Transportation Security Administration responsible for airport security has a total budget of  $7.7 billion and they cover 450 airports but confiscate 1,300 firearms and 125,000 prohibited items per year.  $929 million of the TSA budget is for the Federal Air Marshal Service that assigns agents to commercial flights.  To put an armed guard in the schools would roughly cost what it costs to secure air travel in the US.  The main difference would be that school guards might have a much lower level of vigilance than air travel security and they would need to be very vigilant to head off a sudden and potentially very lethal attack.

Arithmetic aside, there is also the question of associated costs.  In medicine we are familiar with the screening arguments for breast and prostate cancer.  There is always a false positive and false negative cost.  With false positive PSAs and mammograms there is the ordeal of unnecessary biopsies and exposure to other unnecessary tests.  There is no way to estimate the impact of armed guards at schools.  Currently there are about 500,000 violent crime and over a million thefts committed against teachers in America's middle and high schools.  In a previous Institute of Medicine report,  the authors found that a  "substantial number of boys" carry firearms in schools.  That same study reported:

"Despite all this effort to keep guns from children  the committee was somewhat astounded at the ease with which the young people in these cases acquired the weapons they used.  Only in the Jonesboro case were the powerful weapons in the home of one of the too well secured for them to access.  But it was easy to defeat the security measures of another relative and get hold of a powerful semiautomatic rifle with a scope.  In general, it is easy for young teens to circumvent both the law and informal controls designed to deny them weapons they use in their crimes." (ref 1)

There is also the risk of unintentional discharge of weapons.  The New York City Police Department keeps a public record of all weapons discharges from its 33,497 police officers.  According to this report there have been 15-27 "unintentional discharges" per year over the past ten years.  With a school workforce nearly three times as large and possibly less vigilant than an NYPD officer that is potentially a lot of accidental discharges.   How many are acceptable in and around our schools?  The false negative/false positive cost of putting  armed guards into schools based on these factors is really unknown.  

Considering this problem has also led me to think about some epidemiological concepts that we were all taught in medical school.  Primary prevention measures are designed to reduce the incidence of new cases of disease.  Secondary prevention is focused more on people who are identified as being at risk but who are unaware of the fact that they may have the problem.  Tertiary prevention occurs after the problem is declared.  In the case of suicidal or homicidal behavior that means after the critical incident occurs.  This paper looks at these concepts in the case of suicidal behavior.  As far as I can tell there has been no exhaustive look at a timeline of all of the preventive factors that occur prior to mass shooting events or school violence events.  The usual method of analysis is looking at cases for a common profile and as the IOM report showed - there was none.

This analysis cannot predict whether the NRA stand on guns in schools will be protective or not.  It is much more complex than a statement that guns are a solution to gun crimes.  Based on what we know about these situations a key strategy is preventing the shooter from picking up the weapon in the first place.

George Dawson, MD, DFAPA

1.  National Research Council and Institute of Medicine. (2003) Deadly Lessons - Understanding Lethal School Violence.  Case Studies of School Violence Committee.  Mark H. Moore, Carol V. Petrie, Anthony A. Braga, and Brenda L. McLaughlin, Editors.  Division of Behavioral and Social Sciences and Education.  Washington, DC: The National Academies Press.

2.  Ganz D, Braquehais MD, Sher L (2010) Secondary Prevention of Suicide. PLoS Med 7(6): e1000271. doi:10.1371/journal.pmed.1000271

3.  New York City Police Department.  Annual Firearms Discharge Report 2011.

4.  Meet  the Press Transcript. Sunday December 23, 2013.  Wayne LaPierre discusses current NRA positions on school safety and gun control.

Homicide Debate Goes Further Off the Rails

Apparently broadcast news is about as reliable as the Internet these days.  I was watching an "expert" on the weekend discuss the connection between homicide and antidepressant medications.  He apparently believed that there was one.  I understand that Sanjay Gupta made a similar comment today on CNN.  The misinformation is flying out there.  There are several political interests that would like that statement to be true and they appear to be out in full force. What is the short answer to the association between antidepressants and homicide?  Who can you believe?

Well there is always the scientific approach and a review of the medical literature.  Admittedly the literature is a lot drier and less entertaining than Dr. Gupta.

There is also simple arithmetic   The American media like to give the impression that violent crime and homicide are at epidemic levels.  It is always a shock when people discover that in fact we are at a 30 year low:

The homicide rate has actually declined from 10.2 per 100,000 in 1980 to 5.0 per 100,000 in 2009.  What are the odds of that happening if a major new cause of homicide is being added at the same time (namely antidepressants).  How does that compare with antidepressant use?  A recent study estimated that from 1996 to 2005, the number of Americans older than 6 years of age in surveyed households who received at least one antidepressant in the year studies increased from 5.84% in 1996 to 10.12% in 2005.  From the table there was a 24% reduction in the homicide rate during a time that antidepressant use nearly doubled.  One in ten Americans received an antidepressant prescription   The authors of this study noted this trend was broad based and correlated with a lower percentage of people receiving psychotherapy.

But what does that tell us about the observation that antidepressants cause homicide?  Technically there is no current way to demonstrate causality from a negative correlation between homicide rates and the rate of people taking antidepressants.  A large scale significant negative correlation between antidepressant use and lethal violence over a 15 year period has already been reported in the Netherlands.

What about the commentator suggesting that the toxicology of homicide perpetrators shows that they can have psychiatric drugs present that explain their homicidal behavior.  In fact, a study looking at that issue showed that 2.4% of 127 murder-suicide perpetrators had toxicology that was positive for antidepressants.  That is a lower than expected rate of antidepressant use than in the general population.   In a study of elderly spousal homicide-suicide perpetrators, depression was seen as an antecedent to this act but none of the perpetrators tested positive for antidepressants.

Given these observations any claim that antidepressant or any psychiatric drug causes homicidal behavior needs to be backed up with some hard data.  I don't mean a series of cases reported by somebody to make a point and I don't mean a legal decision where lawyers and judges can pretend that scientific data do not exist and make a decision about what they hear in a court room.  I also do not mean listening to somebody claim that we will never know the real relationship until we conduct "prospective double blind placebo controlled studies" of homicidality as a medication side effect.  If it isn't obvious, that study would by definition be unethical and would not pass the scrutiny of any human subjects committee.

Anyone with potential homicidal thinking needs close supervision and treatment.  They may need inpatient treatment in a unit that specialized in treating homicidal thinking and behavior.  Any clinician working in these settings will tell you that the people being treated generally come in with aggressive and violent thoughts and behavior before they take any medication.  If they have positive toxicology associated with homicidal thinking it is generally alcohol or an illicit drug like cocaine or methamphetamine.  Anyone with this problem also needs close monitoring and management of medication side effects.  Antidepressants can cause agitation and restlessness.  There are some people who do not benefit from antidepressants.  In the case of persons with the potential for aggression and suicide the medication response may need to be determined in a controlled environment before they can be safely treated.  Like all medications antidepressants are not perfect medications and they need to be administered by an expert who can provide effective treatment while managing and eliminating any potential drug side effects.

George Dawson, MD, DFAPA

Guns Are Not Cooling Off Between Mass Shootings

I have previously posted my concerns about mass shootings and the general paralysis on dealing with this problem.  The gun lobby has unquestionable political power on this issue, but that is also due to judicial interpretation of the Second Amendment as it is written.  Today's New York Times describes a mass shooting at an elementary school in Connecticut.  At the time I am typing this, the death toll is 20 children, 6 adults, and the gunman.  This incident occurs three days after a shopping mall shooting in Oregon.

Most people would think that nothing would be more motivating for major societal changes than children being attacked in this manner.  Unfortunately this is not the first time that children have been victimized by mass shooters.  On October 2, 2006 a gunman shot 10 girls and killed 5 before committing suicide.  According to the Wikipedia article that was the third school shooting that week.  Altogether there have been 31 school shootings since the Columbine incident on April 20, 1999.

My question and the question I have been asking for the past decade is what positive steps are going to be taken to resolve this problem?  How many more lives need to be lost?  How many more children need to be shot while they are attending school?  Some may consider these questions to be provocative, but given the dearth of action and the excuses we hear from public health officials and politicians, I am left in the position of continuing to sound an alarm that should have been heard a couple of decades ago.  After all, the elections are over.  The major parties don't have to worry about alienating the pro-gun or the pro-gun control lobbyists and activists.  This will not be solved as a Second Amendment or political issue.  I have said it before and I will say it again - the basic approach to the problem is a scientific one and a proactive public health one that involves the following sequence of action:

1.  Get the message out that homicidal thoughts - especially thoughts that involve random violence toward strangers are abnormal and treatable.  The public health message should include what to do when the thoughts have been identified.

2.  Provide explanations for changes in thought patterns that lead to homicidal thinking.

3.  Provide a discussion of the emotional, personal and economic costs of this kind of violence.

4.  Emphasize that the precursors to homicidal thinking are generally treatable and provide accessible treatment options and interventions.

5.  The cultural symbol of the lone gunman in our society is a mythical figure that needs to go.  There needs to be a lot of work done on dispelling that myth.  I don't think that this repetitive behavior by individuals with a probable psychosis is an accident.  Delusions do not occur in a vacuum and if there is a mythical explanation out there for righting the wrongs of a delusional person - someone will incorporate it into their belief system.  The lone gunman is a grandiose and delusional solution for too many people.  If I am right it will affect even more.

6.  Study that sequence of events and outcomes locally to figure out what modifications are best in specific areas.

One of the main problems here may be the deterioration in psychiatric services over the past three decades largely as a result of government and managed care manipulations.  Ironically being a danger to yourself or others is considered the main reason for being in an inpatient psychiatric unit these days.  I wonder how much of the inertia in dealing with the problem of mass homicide comes from the same forces that want to restrict access to psychiatric care?  Setting up the remaining inpatient units to deal with a part of this problem would require more resources for infrastructure, staff training, and to recruit the expertise needed to make a difference.

The bottom line here is that the mass homicide epidemic will only be solved by public health measures.  This is not a question of good versus evil.  This is not a question of accepting this as a problem that cannot be solved, grieving, and moving on.  This is a question of identifiable thought patterns changing and leading to homicidal behavior and intervening at that level.

George Dawson, MD, DFAPA

More On Homicide Prevention

As the number of mass homicides becomes even more noticeable it is getting some attention in the psychiatric press. This months Psychiatric News has a story that looks at the issue of "explanations" for mass killings. There were a couple of new terms that I was not familiar with such as "rampage violence" or "rampage", "autogenic", or "pseudo-commando" killings.  The perspective in the article was generally public health research or the perspective of forensic psychiatrists. Inconsistencies were apparent such as:

"... Much research has shown that mental illness in the absence of substance abuse does not lead to violence and that most crimes are committed by people who have not been diagnosed with mental illness."

Followed by:

"Even when behavior reaches a level troubling to family or neighbors, getting an affected individual into treatment is difficult, especially in a society that highly values individual liberty..."

Are they referring only to those people who are abusing substances or only those people who become violent as a result of mental illness? My experience is that both categories are important and that is illustrated within the same article that refers to a study of five "pseudo-commando" murders where common traits were noted including the fact that all of the subjects were "suspicious, resentful, narcissistic, and often paranoid".

The overall tone of the article is that we may be too focused on mass homicide because only a small number of people were killed in these incidents compared to the 30 to 40 people per day who die from homicide and that violence prediction may be a futile approach. There is also commentary on why neither the Democrats or Republicans want to comment on this issue. An uncritical statement about the "support for gun ownership" being at an all-time high is included in the same paragraph.  Like most things political in the US, all you have to do is follow the money.

The same issue was covered in the September issue of Psychiatric Times.  Lloyd Sederer, MD takes the position that apathy fueled the lack of a sea change in gun control following the incident when Congresswomen Gifford was shot and several people at that same event were killed.  He includes an apathetic quote from Jack Kerouac and a nonviolent activist quote from Gandhi.  Allen Frances, MD makes the reasonable observation that understanding the psychology of a mass killer will not prevent mass homicide, but proceeds to stretch that into the fact that this is a gun issue:

"We must accept the fact that a small cohort of deranged and disaffected potential mass murderers will always exist undetected in our midst."

and

"The largely unnoticed elephant in the room is how astoundingly easy it is for the killers to buy supercharged firearms and unlimited rounds of ammo.  The ubiquity of powerful weaponry is what takes the US such a dangerous place to live."

He goes on to suggest that there are only two choices in this matter: accept mass murder as a way of life or adopt sane gun policies with the rest of the civilized world.

I don't think that gun laws are the best or only approach.  The idea that "supercharged" firearms are the culprit here or the extension to banning assault weapons as the solution misses the obvious fact that even common widely available firearms - shotguns and handguns are highly lethal.  Anyone armed with those weapons alone would be unstoppable in a mass shooting situation.  Secondly, the effects of stringent firearms laws have mixed results.  The mass shooting in Norway is an example of how tight firearm regulation can be circumvented.  It is well known that there are a massive amount of firearms under private possession in the US, making the effect of firearm legislation even less likely.  There are also the cases of heavily armed citizenry with only a fraction of the gun homicides that we have in the US.  Michael Moore's comparison of the US with Canada in "Bowling for Columbine" comes to mind.

The previous posts on this blog suggest clear reasons why gun ownership is at an all-time high. The problem is that much can be done apart from the gun ownership issue and the solutions are available from psychiatrists who are used to assessing and treating people with mental illness, severe personality disorders, threatening behavior, or history of violent or aggressive behavior. The critical dimension that is not covered is the issue of prevention and the necessity of an open discussion about homicide and how to prevent it. Education about markers that are associated with mass homicide is useful, but the focus needs to be on how to help the person who starts to experience homicidal ideation before they lose control.  That is also consistent with a humanistic approach to the problem.  I have treated many "deranged and disaffected potential mass murderers" who went back to their families and back to work.  We need a culture that is much more savvy about the origins of violence and aggression.  It is too easy to say that this behavior is due to "evil" and maintain attitudes consistent with that approach.  Time to develop research on the prevention of mass homicide, identify the individuals at risk, and offer effective treatment.

George Dawson, MD, DFAPA

Aaron Levin.  Experts again seek explanations for mass killings.  Psychiatric News 2012 (47)17: 1,20.

Lloyd I. Sederer.  The enemy is apathy.  Psychiatric Times 2012 (29)9: 1-2.

Allen Frances.  Mass murderers, madness, and gun control.  Psychiatric Times 2012 (29)9:1-2.

Violence Prevention - Is The Scientific Community Finally Getting It?

I have been an advocate for violence prevention including mass homicides and mass shootings for many years now.  It has involved swimming upstream against politicians and the public in general who seem to believe that violence prevention is not possible.  A large part of that attitude is secondary to politics involved with the Second Amendment and a strong lobby from firearm advocates.  My position has been that you can study the problem scientifically and come up with solutions independent of the firearms issue based on the experience of psychiatrists who routinely treat people who are potentially violent and aggressive.

I was very interested to see the editorial in this week's Nature advocating the scientific study of mass homicides and firearm violence. They make the interesting observation that one media story referred to one of the recent perpetrators as being supported by the United States National Institutes of Health and somehow implicating that agency in the shooting spree and that:

"In this climate, discussions of the multiple murders sounded all too often like descriptions of the random and inevitable carnage caused by a tornado or earthquake".

Even more interesting is the fact that the National Rifle Association began a successful campaign to squash any scientific efforts to study the problem in 1996 when it shut down a gun violence research effort by the Centers for Disease Control and Prevention. The authors go on to list two New England Journal of Medicine studies from that group that showed a 2.7 fold greater risk of homicide in people living in homes where there was a firearm and a 4.8 fold greater risk of suicide.  Even worse:

 "Congress has included in annual spending laws the stipulation that none of the CDC's injury prevention funds "may be used to advocate or promote gun control"."

This year the ban was extended to all agencies of the Department of Health and Human Services including the NIH.   There is nothing like a gag order on science based on political ideology. 

The authors conclude by saying that rational decisions on firearms cannot occur in a "scientific vacuum".   That is certainly accurate from both a psychiatric perspective and the firearms licensing and registration perspective. Based on their responses to the most recent incidents it should be clear that politicians are not thoughtful about this problem and they certainly have no solutions. We are well past time to study this problem scientifically and start to design approaches to make mass shootings a problem of the past rather than a frequently recurring problem.

George Dawson, MD, DFAPA

Who calls the shots? Nature. 2012 Aug 9;488(7410):129. doi: 10.1038/488129a. PubMed PMID: 22874927.

"Preventing Violence: Any Thoughts?"

The title of this post may look familiar because it was the title of a recent topic on the ShrinkRap blog.  That is why I put it in quotes.  I put in a post consistent with some the posts and articles I have written over the past couple of years on this topic.  I know that violence, especially violence associated with mental illness can be prevented.  It is one of the obvious jobs of psychiatrists and one of the dimensions that psychiatrists are supposed to assess on every one of their evaluations.  It was my job in acute care setting for over 25 years and during that time I have assessed and treated all forms of violence and suicidal behavior.  I have also talked with people after it was too late - after a homicide or suicide attempt had already occurred.

The responses to my post are instructive and I thought required a longer response than the brief back and forth on another blog.  The arguments against me are basically:

1.  You not only can't prevent violence but you are arrogant for suggesting it.
2.  You really aren't interested in violence prevention but you are a cog machine of the police state and inpatient care is basically an extension of that.
3.  You can treat aggressive people in an inpatient setting basically by oversedating them.
4.   People who are mentally ill who have problems with violence and aggression aren't stigmatized any more than people with mental illness who are not aggressive.

These are all common arguments that I will discuss in some detail, but there is also an overarching dynamic and that is basically that psychiatrists are arrogant, inept, unskilled, add very little to the solution of this problem and should just keep quiet.  All part of the zeitgeist that people get well in spite of psychiatrists not because of psychiatrists.  Nobody would suggest that a Cardiologist with 25 years experience in treating acute cardiac conditions should not be involved in discussing public health measures to prevent acute cardiac disorders.  Don't tell anyone that you are having chest pain?  Don't call 911?  Those are equivalent arguments.  We are left with the curious situation where the psychiatrist is held to same medical level of accountability as other physicians but his/her opinion is not wanted.  Instead we can listen to Presidential candidates and the talking heads all day long  who have no training, no experience, no ideas, and they all say the same thing: "Nothing can be done."

It is also very interesting that nobody wants to address the H-bomb - my suggestion that there should be direct discussion of homicidal ideation.  Homicidal ideation and behavior can be a symptom.  There should be public education about this.  Why no discussion?  Fear of contagion?  Where does my suggestion come from?  Is anyone interested?  I guess not.  It is far easier to continue saying that nothing can be done.  The media can talk about sexual behavior all day long.  They can in some circumstances talk about suicide.  But there is no discussion of violence and aggression other than to talk about what happened and who is to blame.  That is exactly the wrong discussion when aggression is a symptom related to mental illness.

So what about the level of aggression that psychiatrists typically contain and what is the evidence that they may be successful.  Any acute care psychiatric unit that sees patients who are taken involuntarily to an emergency department sees very high levels of aggression.  That includes, threats, assaults, violent confrontations with the police, and actual homicide.  The causes of this behavior are generally reversible because they are typically treatable mental illnesses or drug addiction or intoxication states. The news media likes to use the word "antisocial personality" as a cause and it can be, but people with that problem are typically not taken to a hospital.  The police recognize their behavior as more goal oriented and they do not have signs and symptoms of mental illness.  Once the psychiatric cause of the aggression is treated the threat of aggression is significantly diminished if not resolved.

In many cases people with severe psychiatric illnesses are treated on an involuntary basis.  They are acutely symptomatic and do not recognize that their judgment is impaired.  That places them at risk for ongoing aggression or self injury.  Every state has a legal procedure for involuntary treatment based on that principle.  The idea that involuntary treatment is necessary to preserve life has been established for a long time.  Civil commitment and guardianship proceedings are recognition that treatment and in some cases emergency placement can be life saving solutions.

The environment required to contain and treat these problems is critical.  It takes a cohesive treatment team that understands that the aggressive behavior that they are seeing is a symptom of mental illness.  The meaning is much different than dealing with directed aggression by people with antisocial personalities who are intending to harm or intimidate for their own personal gain.  That understanding is critical for every verbal and nonverbal interaction with aggressive patients.  Aggression cannot be contained if the hospital is run by administrators who are not aware of the cohesion necessary to run these units and who do not depend on staff who have special knowledge in treating aggression.  All of the staff working on these units have to be confident in their approach to aggression and comfortable being in these settings all day long.

Medication is frequently misunderstood in inpatient settings.  In 25 years of practice it is still very common to hear that medication turns people into "zombies".  Comments like: "I don't want to be turned into a zombie" or "You have turned everyone into zombies" are common.  I remember the last comment very well because it was made by an observer who was looking at people who were not taking any medication.  In fact, medication is used to treat acute symptoms and in this particular case symptoms that increase the risk of aggression.  The medications typically used are not sedating.  They cannot be because frequent discussions need to occur with the patient and a plan needs to be developed to reduce the risk of aggression in the future.  An approach developed by Kroll and MacKenzie many years ago is still a good blueprint for the problem.

There is no group of people stigmatized more than those with mental illness and aggression.  It is a Hollywood stereotype but I am not going to mention the movies.  This group is also disenfranchised by advocates who are concerned that any focus on this problem will add stigma to the majority of people with mental illness who are not aggressive or violent.  There are some organizations with an interest in preventing violence and aggression, but they are rare.

At some point in future generations there may be a more enlightened approach to the primitive thoughts about human consciousness, mental illness and aggression.  For now the collective consciousness seems to be operating from a perspective that is not useful for science or public health purposes.  There is no better example than aggression as a symptom needing treatment rather than incarceration and the need to identify that symptom as early as possible.

George Dawson, MD, DFAPA

Colorado Mass Shooting Day 2

I have been watching the media coverage of the mass shooting incident today - Interviews of family members, medical personnel and officials.  I saw a trauma surgeon at one of the receiving hospitals describe the current status of patients taken to his hospital.  He described this as a "mass casualty incident".  One reporter said that people don’t want insanity to replace evil as a focus of the prosecution.

In an interview that I think surprised the interviewer, a family member talked about the significant impact on her family.  When asked about how she would "get her head around this" she calmly explained that there are obvious problems when a person can acquire this amount of firearms, ammunition, and explosives in a short period of time.  She went on to add that she works in a school and is also aware of the fact that there are many children with psychological problems who never get adequate help.  She thought a lot of that problem was a lack of adequate financing. 

   

I have not listened to any right wing talk radio today, but from the other side of the aisle the New York Times headline this morning was "Gunman Kills 12 in Colorado, Reviving Gun Debate."  Mayor Bloomberg is quoted: “Maybe it’s time that the two people who want to be president of the United States stand up and tell us what they are going to do about it,” Mr. Bloomberg said during his weekly radio program, “because this is obviously a problem across the country.”

How did the Presidential candidates respond?  They both pulled down the campaign ads and apparently put the attack ads on hold.   From the President today: " And if there’s anything to take away from this tragedy, it’s a reminder that life is fragile.  Our time here is limited and it is precious.  And what matters in the end are not the small and trivial things which often consume our lives.  It’s how we choose to treat one another, and love one another.  It’s what we do on a daily basis to give our lives meaning and to give our lives purpose.  That’s what matters.  That’s why we’re here."   A similar excerpt from Mitt Romney: "There will be justice for those responsible, but that’s another matter for another day. Today is a moment to grieve and to remember, to reach out and to help, to appreciate our blessings in life. Each one of us will hold our kids a little closer, linger a bit longer with a colleague or a neighbor, reach out to a family member or friend. We’ll all spend a little less time thinking about the worries of our day and more time wondering about how to help those who are in need of compassion most."

These are the messages that we usually hear from politicians in response to mass shooting incidents.  At this point these messages are necessary, but the transition from this incident is as important.  After the messages of condolences, shared grief, and imminent justice that is usually all that happens.  Will either candidate respond to Mayor Bloomberg's challenge?  Based on the accumulated history to date it is doubtful.
  
A larger question is whether anything can be done apart from the reduced access to firearms argument.  In other words, is there an approach to directly intervene with people who develop homicidal ideation?  Popular consensus says no, but I think that it is much more likely than the repeal of the Second Amendment.

George Dawson, MD, DFAPA

Barack Obama. Remarks  by the President on the Shootings in Aurora Colorado.  July 20, 2012

Barack Obama.  Weekly Address: Remembering the Victims of the Aurora Colorado Shooting.  July 21, 2012.

Mitt Romney.  Remarks by Mitt Romney on the Shooting in Aurora, Colorado.  NYTimes July 20, 2012. 

Mass shootings - How Many Will Be Tolerated?

I have been asking myself that question repeatedly for the past several decades.  I summarized the problem a couple of months ago in this blog.  In the 12 hour aftermath of the incident in Aurora, Colorado I have already seen the predictable patterns.  Condolences from the President and the First Lady.  Right wing talk radio focused on gun rights and how the liberals will predictably want to restrict access to high capacity firearms.  Those same radio personalities talking about how you can never predict when these events will happen.  They just do and they cannot be prevented. One major network encouraging viewers to tune in for more details on the "Batman Massacre." 

We can expect more of the same over the next days to weeks and I will not expect any new solutions.  Mass shootings are devastating for the families involved.  They are also significant public health problems.  There is a body of knowledge out there that has not been applied to prevent these incidents and these incidents have not been systematically studied.  The principles in the commentary statement listed below still apply.  

It is time to stop acting like this is a problem that cannot be solved.

George Dawson, MD, DFAPA

A Commentary Statement submitted to the StarTribune January 18, 2011 from the Minnesota Psychiatric Society, The Barbara Schneider Foundation, and SAVE - Suicide Awareness Voices of Education

Violence and Gunplay - Why Nobody is Informed by the Media Anymore

Mass shootings have been a phenomenon of my lifetime.  I can still clearly remember the University at Texas-Austin shootings that occurred  on August 6, 1966. A single gunman killed 16 people and wounded 32 while holed up on the observation deck of an administrative building until he was shot and killed by the police. I first read about it in Life magazine. All the pictures in those days were black and white. Some of those pictures are available online on sites such as "Top 10 School Massacres.”  I generated this timeline of mass shootings when Google still had that feature in their search engine. 

The problem of course is that the mass shootings never really  stop.  In the USA, the press is so used to them that they seem to have a protocol.  Discuss the tragedy and whether or not the perpetrator was mentally ill, had undiagnosed problems or perhaps risk factors for aggression and violence.  Discuss any heroic deeds. Make the unbelievable statement that the victims were "in the wrong place at the wrong time."  And then move on as soon as possible.  There is never a solution or even a call for finding one.  It is like everyone has resigned themselves to to repetitive cycles of gunfire and death.  It is clear that the press does not want to see it any other way.

When you are practicing psychiatry especially in emergency situations and hospitals, you need to be more practical.  When I took the oral boards exams back in 1988 and subsequently when I was an examiner, one of the key dimensions that the examiners focused on was the assessment of dangerousness.  Failing to explore that could be an exam failing mistake.  Any psychiatric inpatient unit has aggression toward self or others as one of the main reasons for admission to acute care and forensic settings.  With the recent fragmentation and rationing of psychiatric services, many people who would have been treated in hosptials are diverted to jails instead.  That led one author to describe LA County jail as the country's largest psychiatric facility.  

I have introduced the idea of looking for solutions into professional and political forums for over a decade now and it is always met with intense resistance.  Some mental health advocates are threatened by the idea that it will further stigmatize the mentally ill as violent.  Many people consider the problem to be hopeless.  Others see it as the natural product of a heavily armed society and no matter what side you are on that argument - that is where the conversation ends.

In an attempt to reframe the issue so that this impasse could possibly be breached the Minnesota Psychiatric Society partnered with the the Barbara Schneider Foundation and SAVE Minnesota in the wake of a national shooting incident to suggest alternatives.  Rather than speculate about psychiatric disorders or gun control we were focused on solutions that you can read through the link below.

The actual commentary was never published by the editor who apparently stated that there was a conflict of interest because we seemed to be fishing for research dollars.   It appears that the press can only hear the cycle of tragedy, speculation about mental health problems, and the need to move on.  The problem with that is that we continue to move on to another shooting.

George Dawson, MD


A Commentary Statement submitted to the StarTribune January 18, 2011 from the Minnesota Psychiatric Society, The Barbara Schneider Foundation, and SAVE - Suicide Awareness Voices of Education