Saturday, January 12, 2013

Mental Illness and Guns: A public health perspective

I have been somewhat reluctant to write about the issues surrounding the mass shootings that have become epidemic in our country. Since the Newtown elementary school massacre it appears as if everyone else has done so, and I didn’t know what, if anything, I could add that would be of value. I still don’t, but I would like to try to emphasize the public health and medical issues here. Everyone talks about getting beyond rhetoric, but mostly we hear rhetoric and have yet to see results.

In his column in the New York Times on December 28, 2012, “Guns and Mental Illness”, Joe Nocera addresses those two aspects of the controversy, which I agree are the key ones. However, while I generally think his points are valid, I disagree with his characterization that gun control is a “liberal” issue while mental health has been the focus of conservatives. For good, or bad, and too often bad, both issues have been neglected by too many for too long. When it comes to death, dramatically in the case of mass killings such as Newtown or Aurora or Columbine, much more commonly in “simple” individual killings, and most commonly in the case of suicide, they are tied together. Nocera starts with mental health, so I’ll start with guns.

I have written about guns several times before (“Mexican Murders and US Guns”, March 24, 2009,
 “The Arizona shootings: When will we ever learn?“, January 9, 2011, “Why we don’t spend enough on public health”, September 22, 2011, and even discussed a New England Journal of Medicine article (Why we don’t spend enough on public health”)[1]  by Dr. David Hemenway of the Harvard School of Public Health and Director of their Injury Control Research Center and Youth Violence Prevention Center (“Public Health and Changing People's Minds, May 15, 2010). Guns are efficient and effective killing machines. This is, after all, the reason that hunters and warriors like them. They can be made more efficient, by being automatic or semi-automatic, and by having magazines that hold many bullets. These are generally considered positives on the war side (and by gangsters), but are often seen as “un-sporting”, so that most states have laws governing their use in hunting. The statistics on gun violence in the US are staggering, and seen from a public health perspective represent a severe and continuing epidemic. Likely the best book on this topic is “Private Guns, Public Health”[2], by Dr. Hemenway. He presents extensive statistics on injury and death resulting from guns, and emphasizes a addressing this problem through efforts to both increase the safety of guns themselves (as we have for cars) and limiting their availability (as we have for cigarettes). This is a harm-reduction approach.

Much of the data cited by Hemenway is sobering, and some is so downright shocking that one might think it difficult to ignore. There are over 30,000 suicides in the US per year, and a high proportion are from guns, because guns are much more effective, and are less likely to allow a second chance; the “success” rate for suicide by gun exceeds 95% while for intentional overdoses it is less than 5%. One of the populations most at risk for suicide is young men; Hemenway notes that the successful suicide rate in this group is several times higher in “low gun control” states (mostly Southern and Mountain) than in “high gun control” states (mostly Northeast and Hawaii). This is not because of less suicidal intent in, say, Massachusetts than Montana, but the easy availability of guns.[3]

But we know about the effectiveness of guns. You can kill someone with a baseball bat, or a knife, or a lead pipe or wrench or candlestick in the Library, but not as efficiently, reliably, effectively, and potentially randomly as you can with a gun. The recent episode of a knife-wielder in China is one example. Adam Lanza wouldn’t have been able to kill many with a candlestick. Innocent children are rarely victims in drive-by knifings. The NRA used to say “guns don’t kill people, people kill people”. Yes, but they do it much better with guns. Now they say that the solution to “bad guys with guns” is “good guys with guns”. This is so ridiculous (can you imagine a bunch of “good guys” blazing away at whoever they thought might be the shooter in the dark in the Aurora, CO, theater?) that NRA bumper stickers are now being amended by new ones saying “Not MY NRA!” in response.

What about mental health? Nocera does an excellent job of summarizing the problem confronting the chronically mentally ill; with a progressive philosophy of “de-institutionalization” mental hospitals were closed with the promise of comprehensive, community-based mental health services being available in the community. But, of course, funding was not forthcoming for those services, nor does it appear that it will ever be adequate. Nocera is correct in saying conservatives have pointed to mental illness (rather than guns) as the cause of such violence, but in addition to not supporting any gun regulation, these same “conservatives” have led the charge in de-funding and under-funding mental health services. The constituency supporting such services, especially for those who cannot afford private care, is not big or effective enough. Apparently these politicians are in favor of supporting (retroactively) mental health care for those who commit mass murder, but not prospectively for the millions in need. One word that is commonly used for such an approach is “hypocrisy”, but this does not shame politicians.

I have written about the “sensitivity” and “specificity” of tests, particularly with regard to screening.  However, the same concept can be used for assessing risk of any condition, such as mental illness and the probability of committing gun violence on a large scale. If “committing mass murder” (as opposed to individual homicide or suicide) is considered the disease, then assessing for mental illness would be pretty sensitive – that is most mass murderers are mentally ill and there are relatively few “false negatives” – people who are mass murderers but not mentally ill. But it is pathetically not specific, for the overwhelming number of mentally ill persons will never be mass murders. They would be “false positives”. But this in no way means that they should not receiving comprehensive and effective mental health services.

So, which is the greater problem? Which should be addressed first? The answer is both, and, more to the point, either would be an improvement. On guns, there need to be bans on assault and automatic weapons and on high-capacity clips and “cop-killer” bullets, and background checks on gun purchasers and closure of the “gun show loophole”. On mental health, there need to be ubiquitous and well-funded mental health treatment programs in all of our communities, with outreach workers and close collaboration with primary care medical providers. Both strategies are critical, both are quite (although, obviously, not completely) effective in other countries.

But I would be happy if we would do one of them. I mostly, however, hear a lot of talk and am fearful that we will, ultimately not do either.

[1] Hemenway D, “Why we don’t spend enough on public health”, NEJM 6May2010;362(10);1657-8.
[2] Hemenway D. “Private Guns, Public Health”. University of Michigan Press. Ann Arbor. 2004.
[3] Full disclosure: Ten years ago, my 24-year old son committed suicide with a gun. As far as I know, he’d never used one before. He left his home in a “high gun control” state and went to a “low gun control state” where he knew no one, acquired the gun, and completed his suicide. A testimony to the impossibility of preventing suicide? A condemnation of the ease with which he obtained the gun? Make of this what you will.

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