Sense from nonsense: Mental health policy after Newtown

A logical question: If people with mental illness are no more likely than the rest of the population to be violent, then why is the mental health field using the Newtown tragedy as the premise for asking for more funding for mental health treatment and more screening of children?

Bottom line: Is there a really connection between mental illness and violence, or not?

We asked three top mental health experts this question. Their answer: The field of mental illness gets so little attention that if this is what it takes to get help, so be it. But, no one is particularly happy about it.  

“There is no question that mental illness receives a disproportionate share of attention when issues related to gun violence are discussed,” said Paul S. Appelbaum, M.D., chair of the American Psychiatric Association’s Committee on Judicial Action. “I think it's fair to say that the mental health community is ambivalent about that attention,” he told Behavioral Healthcare. “On one hand, it cements in the public's mind the link between violence and mental illness, and distracts attention from policies that might truly be effective in reducing gun violence, such as restricting availability of weapons designed to kill large numbers of people. Those are unfortunate consequences.”

What is also unfortunate is that the only time policy makers appear to be interested in improving the mental health system is in the wake of a horrific act of violence, said Appelbaum, who is Dollard Professor of Psychiatry, Medicine, & Law, and director of the Division of Law, Ethics, and Psychiatry at Columbia University College of Physicians & Surgeons.

“Mental health and substance use prevention, early intervention and treatment, community mental health (and substance use) first aid are important in reducing risk for gun violence and reducing the community-wide impacts of these traumas,” said Eric Goplerud, Ph.D. who with Ron Manderscheid, Ph.D. has been spearheading an effort to raise the importance of mental health system improvements on the federal level. Goplerud also suggested that “screening should not single out people with mental illnesses” nor should talk of a provider’s ‘duty to inform’ about possible risk for violence single out those who treat people with mental illnesses. 

The facts

It is very important to get the science right in such a charged debate, said Goplerud, who is senior vice president of Substance Abuse, Mental Health, and Criminal Justice Studies at NORC at the University of Chicago. “The potential for possible misrepresentation by well-meaning advocates of improved mental health and substance use prevention and treatment services who experience the negative effects of discrimination against people with mental illness and addiction must be leavened by the research.” This, he maintains, “does indicate a slightly increased risk of violence.”

There is some increased risk of violence associated with mental illness, agreed Appelbaum. “However, the increase is modest, much of it is accounted for by extrinsic variables such as substance abuse. Only a very small proportion of violence in our country is attributable to mental illness,” he said, clarifying that “The best available data suggest that about 4 percent of violent crimes in the U.S. are attributable to mental illness.”

Jeffrey Swanson, Ph.D., professor in the Department of Psychiatry & Behavioral Sciences at Duke University School of Medicine, noted that suicide accounts for about 60 percent of gun deaths in the United States. Here, there’s a clear link: untreated mental illness is a major risk factor for suicide.

But when asked to consider the assertion, “people with mental illness are no more likely than the rest of the population to commit gun violence,” Swanson paused, suggesting that the assertion needed to be rephrased. Instead, he suggested this statement: “The best evidence, when correctly analyzed, shows that mental illness alone (even without substance abuse), despite a very low absolute risk of violence, does confer a modest increase in relative risk of violence,” he said. But this means comparing serious mental illness alone – not all mental illness – to people with no disorder, he said.

“In a nutshell: most people with mental illness alone are not violent, and most violence is not committed by people with mental illness alone, but people with mental illness alone are somewhat more likely – in relative terms – to commit violent acts than people with no disorder,” said Swanson.

What link?

But this still doesn’t do much to explain the odd connection (or disconnection) between mental illness and gun violence. It’s complicated, Swanson explains.

“While it is important to uncouple mental illness from the broader problem of violence in society, some might argue that public attention focused on mass shootings by disturbed individuals is not necessarily all bad for those with a stake in mental health. Stigma and negative attitudes may increase in the short run, but public support for mental health services could increase, and that support could bring long-term benefits.”

Swanson added that a new post-Newtown public opinion poll from Johns Hopkins shows that a majority of Americans now support increased government spending on mental health screening and treatment as one strategy to reduce gun violence. And, of course, when the American public supports increased spending on mental health screening and treatment, it’s an opening for mental health advocacy that none in the field can ignore.   

So, however tenuous the link between mental illness and violence, mental health professionals agree on two things, said Applebaum: “that the mental health safety net in this country is in tatters” and that “it is difficult to walk away from any opportunity to make it better.”

Swanson agreed that the situation – using gun violence to get more funding for mental health treatment – is a two-edged sword. “I think mental health stakeholders are somewhat divided and ambivalent on whether to try to completely uncouple mental health advocacy from concerns about violence, or to go ahead and capitalize on public attention after a mass shooting and use that opportunity to garner support for increased government investment, improved mental health screening and treatment access, and mental health system reforms.”

“In the best of all worlds, we could have a discussion about improving the mental health system without linking it to acts of violence,” said Appelbaum. “Unfortunately, we that doesn't seem to be the world we live in.”