Untreated mental disorders, unchecked guns

The stories of mass violence by three young men – in Newtown, in Aurora, in Tucson – demonstrate a rare, but tragic convergence of two inadequate systems. The first, our mental health system, is chronically underfunded and, in many areas, inadequate due in part to public ignorance and apathy. The second, our system for firearms regulation, is also inconsistent and limited, not due to apathy but to the passionate involvement of gun enthusiasts. 

In many localities, the result is a nation that makes it far more difficult for troubled young men like Adam Lanza, James Holmes, or Jared Loughner (or their families) to locate and obtain routine or crisis mental health services than it does for them to locate and obtain firearms.

Behavioral Healthcare interviewed mental health experts a year after the Newtown tragedy for their insights, albeit speculative, into the mind of Adam Lanza and their thoughts about whether possible changes to the mental health treatment system could avert future tragedies, yet enable Americans to enjoy their current and broad “right to keep and bear arms.”

Aging out

At age 20, Adam Lanza was aging out of youth services and transitioning to the adult world, noted Marvin S. Swartz, M.D., a professor in psychiatry and behavioral sciences at Duke University. “You can imagine that the mother was desperate, probably doing anything she could trying to engage her kid in a system.” As special needs youth age into adulthood, they enter a world where already scarce mental health resources become even more scarce, he said. “You can empathize with her desperation.”

The father of Jared Loughner, the shooter in the Tucson incident, was also at a loss about what to do with his 25-year old son, said Swartz. “There’s some evidence that he was trying to figure out how to get him help.” And James Holmes, the 26-year old Colorado shooter, already had a parent, a psychiatrist and a university threat assessment team concerned about him.

“There are all kinds of points of leverage,” Swartz continued. “But when they all fail, we have these cases." The tragic constant in all three cases is that the young men found and used guns before they found help.

‘You would have to detain the haystack’

Swartz, together with two other experts in mental illness and the law concur: Mass gun homicides by people with a mental illness are so rare that looking for people who are "likely" to commit them – people like Lanza – is like looking for a needle in a haystack. To be successful, “you would have to detain the haystack,” said Jeffrey W. Swanson, Ph.D., a colleague of Swartz who is also a professor in psychiatry and behavioral sciences at Duke University.

Why? Because, he explained, while crimes like Lanza’s are very rare, young men whose profiles are similar to that of Lanza are not: “The average 17-year-old has a good chance of living in a home with multiple firearms,” Swanson said. “Add to that the characteristics of young men who have had some psychopathology, are isolated, probably angry, and perhaps delusional, perhaps something else – it’s not a very small set.”

But let’s say the mental health system was not overburdened, Swanson continued, and had the resources to effectively detain and treat potentially violent, mentally ill individuals. According to Paul Appelbaum, M.D., past president of the American Psychiatric Association, the improvements would be helpful, but they wouldn’t reduce the incidence of mass gun-related homicides. “We’ve identified an area that needs attention – mental health treatment – but we’ve made a mistake as to why,” he said.

Saving 100,000 lives

The mistake bears explaining: Swanson, Swartz, and Appelbaum explain that more than 85 gun-related deaths occur daily in the United States, or more than 31,000 annually. Of these, however, more than 61% are suicides with the “majority” attributed to individuals who have a mental illness. Just 4% of gun-related homicides are attributable to individuals with a mental illness.

The 4 percent figure comes from Swanson’s analysis of the “attributable risk” of any minor or serious violence, using community-representative data from the National Institutes of Mental Health (NIMH) Epidemiologic Catchment; the data has been corroborated in other studies. “To be precise, the figure also excludes the contribution of substance abuse, which may co-occur with mental illness and elevates violence risk,” said Swanson.

“The total number of people who have died in the US as the result of gunshot in the past 10 years exceeds 300,000,” said Swanson. He has estimated that the number could have been reduced by one third – to about 200,000 – if mental illness were eliminated as a risk factor. “But 90 percent of that reduction would be from suicide prevention,” he said. “About 10 percent would be from preventing homicides in people with mental disorders, including those with co-occurring alcohol and drug disorders.” 

Thus, the trio states emphatically that it is not armed and mentally ill people that drive the statistics on gun-related homicides, but the proliferation of guns, the laxity of regulations that enable nearly anyone to get a gun, and the absence of needed mental health or crisis services.

“The elephant in the room”

The “elephant in the room” when it comes to mental illness and gun deaths is suicide, said Swanson, who cited a passage from “Preventing gun violence involving people with serious mental illness,” a piece a he authored with Swartz and Appelbaum and recently published:

When we bring suicide into the picture of gun violence, mental illness legitimately becomes a strong vector of concern; it should become an important component of effective policy to prevent firearm violence. Suicides account for 61% of all firearm fatalities in the United States - 19,393 of the 31,672 gun deaths recorded in 2010 (Centers for Disease Control and Prevention 2013). Suicide is the third leading cause of death in Americans aged 15 to 24, perhaps not coincidentally the age group when young people go off to college, join the military, and experience a first episode of major mental illness. The majority of suicide victims had identified mental health problems and a history of some treatment. “How did they get a gun?” is an important question to answer. “Where was the treatment, and why did it fail?” may be even more important.

CDC statistics show there were 28,663 firearms deaths in 2000, and that the number increased over the decade to 31,672 in 2010, said Swanson. The increase in gun deaths closely tracked the general increase in the base population, with the rate per 100,000 thus remaining quite stable—from 10.19 per 100,000 in 2000 to 10.26 per 100,000 in 2010.

It’s important to distinguish between gun deaths and gun homicides, said Swanson. In 2000, the CDC recorded 10,828 homicides by firearms. That number increased slowly over the next decade to 11,078 in the year 2010. The gun homicide rate per 100,000 in the base population increased from 3.82 in 2000 to 4.27 in 2007, decreasing to 3.99 in 2010.

Figure 2: Gun deaths, comparing suicide and homicide statistics

Some gun-control opponents object to the inclusion of gun-related suicides in the total deaths attributed to guns. They use this contention to dispute the 4 percent figure cited by Swanson and his colleagues. But Swanson disagrees. “From a public health and safety point of view – not to mention basic humanitarian concern – there is no legitimate reason to exclude gun suicides from the total of firearms-related mortality in the United States,” he said. “My uncle and aunt who lost their 19-year-old daughter to a gun suicide during her freshman year of college would surely not consider the accounting of their loss as an ‘inflation’ of the nation’s gun death statistics – as some sort of statistical chicanery to make guns appear more dangerous than they are – nor should they.”

Treatment plus limitations = improved safety

Kristin, the 19-year-old, might have been saved by timely treatment, said Swanson. But she also might have been saved by a legal requirement of a waiting period for buying the shotgun she used, he said, adding that she had told the licensed dealer that the gun was to be a Christmas gift for her father. “Both measures – improved recognition and treatment of suicidal depression, and limiting legal access to lethal means during periods of heightened risk – should be complimentary priorities on the gun violence prevention agenda,” said Swanson.

It is true that it is gun homicides that put mental illness on the map in this country. “But to include gun suicides in our nation’s gun death toll is to accurately characterize the scope of the problem,” said Swanson, noting that suicide is the third leading cause of death for young people between the ages of 10 and 24 in the US, and firearms are used in nearly half of completed suicides. About 1 in 5 suicides is a military veteran, and 72 percent of these used a gun, he said. Suicide attempts using a firearm almost always succeed, with a case fatality rate of nearly 90 percent. People who survive a suicide attempt are unlikely to die subsequently from it. However, if people use a gun the first time they try suicide, they won’t get a second chance; it’s a “permanent solution to a temporary problem.”

Joel Dvoskin, the former head of New York State’s forensic and correctional mental health services who now works as a Tuscon-based consultant, said that when it comes to violence, those who have a mental illness are far more likely to use a gun on themselves than on someone else. While the US homicide rate has remained relatively steady for years despite a recent period of mental health cuts, the suicide rate has risen. “This is where you see the impact of cuts,” he said.

Resorting to violence is an impulsive act, often driven by fear or anger, he continues. “Many suicides are impulsive. When better and more responsive and crisis services are available, people have a better option than suicide.” Crisis services, he believes, can also have an impact on preventing homicides and other violence toward others, whether a crisis is related to a mental illness or not. The problem isn’t that mentally ill people are more likely to be violent, he explains. It is that when people, including the mentally ill, have a crisis and are unable to cope with a surge of fear, anger, or other negative emotions, there are no crisis services available. In the absence of help, some people will spiral toward violence, whose deathly potential increases with the access to guns.

“There are two converging sets of truths here,” said Swartz. “One is that the mental health system is fragmented and under-resourced, and the other is that we have a terrible problem with gun safety.” Neither system is “up to the task."

Newtown: Findings and follow-up steps

The Connecticut state police released their final report on the Newtown massacre in late December. The report is based on interviews with many of the people who knew the troubled young man, starting in his early years. It forms the basis of the state’s division of criminal justice report which concluded that the investigation found no motive for Lanza’s shooting of 20 schoolchildren, six school staffers, his mother, and himself.

The report concluded that there was no connection between Lanza’s mental health problems and the crime. But the question received special attention, since Lanza’s history included a diagnosis of Asperger’s disorder (a diagnosis which was folded into the autism spectrum in DSM-5), compulsive behaviors, and odd behaviors, including a preoccupation with violence. The reports note that the crime was not impulsive in nature; it was clearly well planned.

In Congress, efforts by a broad coalition of groups to place greater restrictions on access to certain guns and accessories (assault style weapons and high capacity magazines) failed. Gun advocates argued successfully against additional gun regulations, playing to public fears that deranged, mentally ill people were a key hazard and suggesting gun purchase restrictions based on an individual’s mental health history. However, five states have enacted stricter gun rules, including universal background checks and assault weapons bans.

The Mental Health Awareness and Improvement Act, proposed following the Newtown shootings, would train 5,000 mental health providers to provide early recognition and intervention in schools and beef up service resources “transition age” youth like Lanza in the years between school and adulthood. However, the legislation is in limbo, attached to a larger, but stalled, gun-regulation measure.

A December 2013 report from the Consortium for Risk-Based Firearm Policy, to which Appelbaum, Swanson, and Swartz contributed, concluded that mental illness is not unimportant, but it is connected to a very small proportion of gun violence. “If we are going to talk about mental illness, let’s talk about when they come in for help,” said Swanson. “That’s a time we should put up a wall between the person and the guns.” To that end, the Consortium’s report suggests a number of approaches that could be used to disqualify and restore individual access to firearms based on mental health findings.

Torrey: A case for outpatient commitment

E. Fuller Torrey, M.D., perhaps the nation’s foremost advocate of outpatient commitment, was “very disappointed” by the reports from Connecticut on the December 2012 Newtown shootings. “It was consistent with the way Connecticut handled the whole situation, by saying nobody can talk about it, and then putting out a report that says almost nothing about psychiatric issues,” he told Behavioral Healthcare.

Torrey noted that the evidence is overwhelming that people with severe mental illness who are being treated are not more dangerous or more likely to be violent than other people.  However, he added, “that’s not true when they’re being actively psychotic.”

He believes Lanza had an autism spectrum disorder in childhood and then developed psychotic features on top of it. “The question is, at what point did he start to develop psychotic features?” asked Torrey.

“There are probably people who know the answers,” he continued. But those answers are not in the Connecticut reports, which he says were “sanitized” to protect people. “There are a lot of families who are very unhappy at losing their children, and if there’s any allegation publicly that someone was aware that this kid was disturbed, lawsuits could follow.”

While Torrey agrees that assault weapons should not be available, he contends that involuntary commitment, not gun control, is the best way to prevent a tragedy like Newtown. “This [Lanza] was a kid who was clearly disturbed, going downhill, and the question is at what point can you take that kid for an involuntary hospitalization?” he said. In most states, commitment is only allowed if a person has proven himself dangerous. “But we need laws that allow you to evaluate people based on the need for treatment,” he said. “If a person is not aware of their own illness, you need to treat them.”

“There is good treatment out there, and the vast majority of people respond to it,” said Torrey. “You would expect the kind of psychotic features that Adam Lanza developed to respond to medication,” he said. “But it’s never effective unless you take it.” 

Of course, more than medication would be required. “In a disturbed kid like this who had preexisting autism spectrum, you would need a good rehab program,” said Torrey. But he added that if Lanza were as bright as he seemed, he could have held a job if he were on medication.

Many consumer advocates and psychiatrists oppose involuntary medication, particularly the ideology of Torrey’s Treatment Advocacy Center which holds that many people with mental illness should be treated forcibly because they don’t think they’re sick.

Alison Knopf is a freelance writer.