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Untreated mental disorders, unchecked guns

April 9, 2014
by Alison Knopf
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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:

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First, you can't just assume that all suicides were mentally ill to pad your numbers. You also can't assume those on illicit narcotics are mentally ill either. Additionally, people with mental illness are more likely to be victims of violent crime. This seems to insinuate that their victimization is a result of their acceptance of treatment. It's also professionally irresponsible to make statements assuming the mental state of Lanza at the time of the shooting. The crime was pre planned and deliberate. It is entirely plausible that Lanza acted with the same motivation as earlier mass killings such as the 1997 shooting at Dunblane. John Douglas noted that these are acts that cannot be ignored and are perpetrated by people who feel unheard and invalidated. This builds until their message becomes all consuming. They have no concern even for trying to get away with it. The claim that the "vast majority of people" respond to the "treatment" available is also ludicrous and unsupported by the research available. As to your appeals for involuntary treatment, we have that. There's a legal process, and since we have already established there's no way to just tell who will commit a mass killing, there's no reason to make it any easier to deny a person what few civil rights they have been allowed. To state it bluntly, If psychiatry is unable to establish a cause for mental illness or the motivation of someone they claim was actively psychotic, I wouldn't put much faith in their skills at telepathy either.

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