Diversity in Healthcare, Psychopathology and Writing and Rhetoric (Due 24 hours)

PERSPECTIVES

Mental Illness, Mass Shootings, and the Future of Psychiatric Research into American Gun Violence

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Jonathan M. Metzl, MD, PhD, Jennifer Piemonte, MS, and Tara McKay, PhD

Abstract: This article outlines a four-part strategy for future research in mental health and complementary disciplines that will broaden understanding of mass shootings and multi-victim gun homicides. First, researchers must abandon the starting assumption that acts of mass violence are driven primarily by diagnosable psychopathology in isolated “lone wolf” individuals. The destructive motivations must be situated, instead, within larger social structures and cultural scripts. Second, mental health professionals and scholars must carefully scrutinize any apparent correlation of violence with mental illness for evidence of racial bias in the official systems that define, measure, and record psychiatric diagno- ses, as well as those that enforce laws and impose criminal justice sanctions. Third, to better understand the role of firearm access in the occurrence and lethality of mass shootings, research should be guided by an overarching framework that incorporates social, cultural, legal, and political, but also psychological, aspects of private gun ownership in the United States. Fourth, effective policies and interventions to reduce the incidence of mass shootings over time—and to prevent serious acts of violencemore generally—will require an expanded body of well-funded interdisciplinary research that is informed and implemented through the sustained engagement of researchers with affected communities and other stakeholders in gun violence prevention. Emerging evidence that the coronavirus pandemic has produced a sharp in- crease both in civilian gun sales and in the social and psychological determinants of injurious behavior adds special ur- gency to this agenda.

Keywords: gun violence, mass shootings, mental illness, psychiatric research, racial justice

Indiscriminate shooting rampages in public places accounted for approximately 0.5%of homicides in the United States in 2019,1,2 yet an estimated 71% of adults experienced fear of

mass shootings as “a significant source of stress in their lives,” causing 1 out of 3 people to avoid certain public places, accord- ing to a national survey by the American Psychological Associ- ation.3,4 In their responses to heightened community concerns over the threat of mass shootings, numerous public officials in recent years have pointed to “mental illness” as a simplified ex- planation for these terrifying acts of violence.5 The “deranged shooter” narrative resonates with a persistent (if largely false) belief amongmajorities of adults in the United States: the notion that people diagnosed with serious psychiatric disorders such as

he Department of Medicine, Health, and Society (Drs. Metzl and ), Vanderbilt University; Joint Program in Psychology and Women’s nder Studies, University of Michigan (Ms. Piemonte).

l manuscript received 18 February 2020; revised manuscripts re- 25 June and 6 October 2020, accepted for publication subject to revi- October 2020; revised manuscript received 2 November 2020.

pondence: Jonathan Metzl, MD, PhD, 300 Calhoun Hall, 2301 ilt Place,Nashville, TN37235-1665. Email: [email protected]

ght © 2021 The Author(s). Published byWolters Kluwer Health, Inc. on f the President and Fellows of Harvard College. This is an open access distributed under the terms of the Creative Commons Attribution-Non ercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissi- ownload and share the work provided it is properly cited. The work cannot ged in any way or used commercially without permission from the journal.

0.1097/HRP.0000000000000280

d Review of Psychiatry

schizophrenia are likely or very likely to be violent.6 This con- struction of the problem relies on an elastic and pejorative definition ofmental illness and places psychiatrists in an often unwelcome yet strategic spotlight.7

On the one hand, the public’s a priori definition of mass shooters as seriously mentally ill invites and reinforces unrealistic expectations that mental health experts should be able to predict andprevent acts ofmass violence. It tends to inspire public support for restrictive policies and interventions targeting psychiatric pa- tients.6 On the other hand, the “deranged shooter” story can give mental health professionals a powerful voice and audience— people look to them for answers and solutions—which trans- lates into opportunities to reframe the debate over what should actually be done about mass shootings in the United States.

What can psychiatrists and other mental health clinicians, researchers, and policy makers do to foster evidence-based solu- tions topreventmass shootings, and tomitigate thepopulation risk of firearm injuries in general, without adding to the burden of stigma and social rejection that people who are recovering from mental illnesses may feel when others assume they are dangerous?

Existing scientific evidence paints a complex—if incomplete —picture of the causes of mass shootings and other acts of se- rious violence. Until recently, a congressional ban on federal funding for most gun-related research has prevented scientists and scholars from conducting the full range of interdisciplinary studies that would provide a better understanding of the prob- lem and point the way to effective solutions.8

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In what follows, we outline a four-part strategy for future research in mental health and complementary disciplines that will broaden our understanding of these tragic events and how to effectively prevent them.

First, researchers must abandon the starting assumption that acts of mass violence are driven primarily by diagnosable psychopathology in isolated “lone wolf” individuals, and must rather situate such destructive motivations within larger social structures and cultural scripts. Second, mental health professionals and scholars must carefully scrutinize any ap- parent correlation of violence with mental illness for evidence of racial bias in the official systems that define, measure, and record psychiatric diagnoses, as well as those that enforce laws and impose criminal justice sanctions. Third, to better understand the role of firearm access in the occurrence and le- thality of mass shootings, research should be guided by an overarching framework that incorporates social, cultural, le- gal, and political, but also psychological, aspects of private gun ownership in the United States; what is needed is a sustained inquiry into how these dimensions might shape the contours of gun violence as a broader public health prob- lem. Fourth, effective policies and interventions to reduce the incidence of mass shootings over time—and to prevent seri- ous acts of violence more generally—will require an ex- panded body of well-funded interdisciplinary research that is informed and implemented through the sustained engage- ment of researchers with affected communities and other stakeholders in gun violence prevention. Emerging evidence that the coronavirus pandemic has produced a sharp increase both in civilian gun sales and in the social and psychological determinants of injurious behavior—especially inmarginalized communities—adds special urgency to our agenda.9

Acts of mass murder implicate the psychologies of perpe- trators. A better understanding of the reasons behind their behaviors—a kind of “rationality within irrationality”10—re- mains important to the hope of preventing such crimes in the future.11 Retrospective analyses suggest that a nontrivial minor- ity of high-profile mass shooters demonstrated clinical symp- toms, including paranoia, depression, and delusions, at some point in their lives.12–14 Still, the assumption thatmass shootings are driven solely or even primarily by diagnosable psychopa- thology stretches the limits ofmental health expertise. It also sets up a false expectation that advancing neuroscience and better therapies tomanage psychiatric symptomswill provide “the an- swer” to solving gun violence. There is no existing or forthcom- ing unified theory of impaired brain functioning or of cognitive, mood, or behavioral dysregulation that could adequately ex- plain mass shootings or multiple-victim gun homicides.

Symptoms of mental illness by themselves rarely cause vio- lent behavior and thus cannot reliably predict it. Certain psychi- atric symptoms, such as paranoid delusionswith hostile content, are highly nonspecific risk factors that may increase the relative probability of violence, especially in the presence of other cata- lyzing factors such as substance intoxication.15,16 Yet the abso- lute probability of serious violent acts in psychiatric patients

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with these “high risk” symptoms remains low. In general, fo- cusing on individual clinical factors alone leaves too much unexplained, as it tends to ignore the important social con- texts surrounding mass shootings and multiple-victim homi- cides.17 To assume that gun violence is primarily a problem confined to a perpetrator’s brain may impede inquiry into a ranges of factors that could be crucial to a full understanding of mass shootings—factors such as the perpetrator’s sex, race, socioeconomic status, relationships, attitudes, personal history, the place where a shooting occurs and the perpetra- tor’s (dis)connection to it, and the ways in which local gun cultures and unrestricted access to guns might create the con- ditions under which these events become more likely.

How canmental health research change the dominant nar- ratives surrounding mass shootings and multiple-victim ho- micides, and thus broaden debates about the community effects of gun violence? Our selective literature review and re- search agenda present a strategy for moving beyond the “diagnose-the-mass-shooter” framework to a perspective that emphasizes the multi-determined nature of gun trauma. In so doing, we advocate for broadening the scope of concern and the potential contribution of mental health experts and researchers to include the larger gun-violence epidemic, rec- ognizing its structural dimensions as within their purview, es- pecially at the intersection with social science, public health, and other complementary disciplines.

AN AGENDA FOR MENTAL HEALTH RESEARCH INTO MASS SHOOTINGS AND MULTIPLE-VICTIM GUN HOMICIDES

1. Move Beyond Simplistic Mass Shooter Profiling and Media-Driven “Diagnose-the-Shooter” Formulations to Situate Destructive Motivations Within Larger Social Structures and Cultural Scripts Politicians and media commentators often quickly label mass shooters as “mentally ill” without defining the term and before any valid psychiatric history is known, simply on the basis of the aberrant nature of the crime itself: “What sane person could do such a thing?” Media-stylized accounts of the motivation of mass shooters tend to rely onmisleading stereotypes of the inher- ent dangerousness of mental illness. When such accounts are widely adopted as master explanations for shooting rampages, the easily recognizable features of the narrative can obscure the role of many other potentially important contributing factors. These might include the perpetrator’s stressful economic circum- stances and level of social disadvantage,maladaptive personality development in response to early-life trauma, the psychological sequelae of domestic violence exposure, aggrieved resentment and smoldering anger against individuals or groups perceived to be hostile and threatening,18 and male gender and aberrant constructions of masculinity—all enhanced by the disinhibiting effects of substance intoxication and easy access to a semi- automatic firearm. These kinds of vectors and background con- ditions, often interacting with each other in complex ways, can

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be far more germane to comprehending a particular act of mass violence than a diagnosis of acute psychopathololgy.19

Recent studies suggest that approximately 25% of mass murderers had exhibited a mental illness, but most of them had not appeared on the radar of either the mental health or law enforcement systems.13 Similarly, a Federal Bureau of In- vestigation (FBI) study of 63 active-shooter incidents between 2000 and 2013 found that 25% of shooters were known to have been diagnosed with a mental illness of some kind, rang- ing fromminor tomore serious disorders. The study concluded that “formally diagnosed mental illness is not a very specific predictor of violence of any type, let alone targeted violence.”12

These relatively weak associations highlight how mental ill- nesses in themselves rarely cause violent behavior and are not reliable predictors of multiple-victim gun crimes.16,20

In some sense, each mass shooting incident is unique. Sub- stance use comorbidity and a range of putative risk factors ranging from the shooter’s level of economic distress and housing insecurity to politically extremist attitudes and ideol- ogy, to social isolation have been cited as stressors in analyses of mass shootings.21No single variable emerged as a common feature of mass shooters. Still, the “diagnose-the-shooter” narrative persists and furthers a number of stigmatizing ste- reotypes, such as the notion that persons with mental illness resemble “ticking time bombs.”11,22 Representations of peo- ple with mental illness as being irrationally and unpredictably violent can have real adverse consequences, ranging from community resistance to the placement of housing and treat- ment facilities for people with mental illness in particular neighborhoods, to the escalation of tense interactions be- tween people with mental illness and law enforcement offi- cers, often resulting in avoidable arrests and incarcerations and sometimes ending in fatal shootings by the police.23,24

Defining an appropriate role for mental health practi- tioners in preventing mass shootings is inherently difficult. While recent studies have found that the majority of mass shooters did not show signs of acute psychosis or serious mood disorder, the estimated prevalence of psychiatric disor- der is still higher among these perpetrators than in the general adult population. As we have already suggested, there is some evidence that certain combinations of clinical symptoms and affect patterns may temporarily increase risk of gun violence. Researchers have identified delusions, fixation, and perceived persecution as clinical symptoms that may precede violent be- havior.16,25 But does this implicate psychopathology in mass shooting, and therefore call for psychiatric surveillance and risk assessment to prevent at least some of these events?

Ironically in this context, disorders such as major depres- sion and schizophrenia are often marked by psychomotor slowing, negative affect, intellectual disorganization, social isolation, and other symptom clusters that would seem to ren- der a person less likely to plan and implement a complex gun crime.18,26 It is perhaps not surprising, then, that some studies have found that persons diagnosedwith these mental illnesses are less likely than non–mentally ill offenders to use firearms

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in violent crimes.27 Along these lines, Swanson and col- leagues28 found that adults with serious mental illnesses in public behavioral health systems in Florida were at least no more likely than other adults in the general population to be arrested for a gun-related violent crime.

A study of individuals who were clinically fixated on harming members of Congress found that having a psychiatric diagnosis alone was not associated with aggression or actual violent behavior. More relevant predictors included the indi- vidual’s motives and means.29,30 The MacArthur Violence Risk Assessment Study31 identified a group of 100 repeatedly violent individuals in a sample of 1136 discharged psychiatric inpatients but found that psychosis immediately preceded only 12%of violent incidents. The researchers concluded that “psy- chosis sometimes foreshadows violence for a fraction of high-risk individuals, but violence prevention efforts should also target factors like anger and social deviance.”32 In addi- tion, the MacArthur study found that only 2.4% of the study participants engaged in any act of firearm-involved violence, defined to include brandishing or threatening someone with a gun, over the 12-month follow-up period.31

A large U.S. study of schizophrenia patients in the commu- nity found that 5.4% of participants engaged in at least one act of injurious violence during an 18-month follow-up pe- riod, but baseline symptoms of psychosis or depression did not predict injurious violence. Rather, the significant predic- tors were severity of illicit drug use (hazard ratio = 2.93), re- cent violent victimization (hazard ratio = 3.52), childhood sexual abuse (hazard ratio = 1.85), andmedication nonadher- ence (hazard ratio = 1.39).33 These findings would suggest that the large majority of patients with schizophrenia do not engage in acts of serious violence, and even when they do, psychiatric symptoms alone do not provide a sufficient expla- nation for their violent behavior.

Still, “mental health” remains the focus of many existing regulations as well as proposed policies to prevent gun vio- lence in the community. Despite evidence that there is no strong connection between gun crime and mental illness,2 fed- eral law since 1968 has prohibited firearm purchase or posses- sion by anyone with a record of involuntary civil commitment to a psychiatric hospital or other mental health–related adjudi- cation.34 A few studies have suggested that this restriction pre- vents some violent crime—and gun crime, in particular—but its population-level impact is severely limited since very few patients are involuntarily committed.35,36 The vast majority of violent gun crimes are perpetrated by people who would never be committable to a psychiatric hospital, and the im- portant correlates of violent behavior tend to be the same in psychiatric and nonpsychiatric populations—for example, being young, male, or socially disadvantaged, exposure to trauma in early life, and using drugs and alcohol to excess. Future research into mass shootings and other acts of serious violence should move beyond the diagnostic template that looks for psychopathology to adequately explain the perpe- trator’s behavior.

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2. Scrutinize any Apparent Correlation of Violence with Mental Illness for Evidence of Racial Bias in the Official Systems That Define, Measure, and Record Psychiatric Diagnoses, as Well as Those That Enforce Laws and Impose Criminal Justice Sanctions U.S. popular and political discourse frequently applies the mental illness descriptor to white male shooters, but analysis of whiteness itself, or discussions of whiteness as a race or eth- nicity, are usually omitted from published studies about U.S. mass shootings.37–39 By contrast, race and ethnicity often play a key role in accounts of mass shootings when the perpe- trator is not white. For example, after the 2007mass shooting at Virginia Tech University perpetrated by a college student of Korean-American heritage, media outlets reported that Asian-Americans experienced fear of retaliation and felt forced to issue an apology on behalf of their “group.”40

A content analysis of news documents covering mass shootings from 2013 to 2015 found that white and Latinx male perpetratorsweremore likely to have their crimes attrib- uted to mental illness than were shootings by black men.41

White men were qualitatively described as more sympathetic characters than black and Latinx men, who were more often labeled as violent threats to public safety.41 Despite the popu- lar stereotype of mass shooters being white, statistically just over half (57%) of the perpetrators of FBI-defined mass shootings since the early 1980s have been white, and the ma- jority of victims of mass shootings in recent years have been nonwhite individuals.42,43 When a mass shooting occurs and the identified perpetrator is black, content analysis shows that politicians’ press briefings, media reports, and research articles rarely mention mental health and illness in descrip- tions of the perpetrator. Rather, such incidents are more likely to be described under rubrics such as “gang disputes,” “drive- by shootings,” or other forms of “urban” violence, often with little further elaboration on motives or effects.44,45

These white/black dichotomies in the definition of mass shootings carry implications for resource allocation for study- ing these incidents and for potentially interrupting their causal pathways and mitigating their harmful consequences to individuals and communities. Defining urban violence as essentially out-of-range for our concern with mass shootings makes it much more difficult for researchers to discover the ways in which these shootings, too—as commonplace as they have become in certain urban neighborhoods—can have pro- found and lasting psychological and community effects.46

Mass shootings in urban areas have received little attention from mental health researchers, and the relatively few studies on this topic mostly amount to superficial, group-based com- parisons between urban and suburban perpetrators. For exam- ple, Knoll47 describes aspects of social identity in summarizing how urban and suburban perpetrators seem to differ, citing an urban “honor culture” and strong, group-based “social hierar- chies” as the context for urbanmass violence, in contrast to the image an isolated loner who commits amass shooting in a sub- urban public setting.

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Meanwhile, a large body of research has focused on the link between violence and mental illness in general, much of it relying on data from the criminal justice system, forensic fa- cilities, state psychiatric hospitals, or other publically funded systems in the community. Due to the historical nexus of ra- cial discrimination and economic disadvantage—which had led indirectly to entrenched disparities in arrest and incarcer- ation as well as to involvement with the public behavioral health system—individuals who are identified as violent (or at risk of violence) in official institutional settings tend to be disproportionately people of color.48–50

These systems curate and disseminate the records of felony conviction and involuntary civil commitment that are used to determine that a person is ineligible to possess firearms under federal or state law. Specifically, official agencies report gun-disqualifying records to the FBI’s gun-purchase back- ground check database, with the result that racial disparities in the reporting institutions’ practices and policies tend to be reproduced in the implementation of firearm restrictions that are applied to putatively risky categories of people.51 As one example, a large study of gun restrictions in a population of adults with serious mental illnesses in Florida found that black individuals made up 15% of the surrounding popula- tion but 21% of the study group in the public behavioral health system, 31% of those disqualified from guns due to a mental health adjudication, and 36% of those disqualified due to a criminal record.28,49

As a result of these entrenched selection effects, much of what we know regarding the intersection of violence and mental illness extends only as far as people with mental ill- nesses who are socially and economically marginalized or use public services. But this misleading picture is often used to justify further institutionalization or incarceration that dis- proportionately affects people of color, producing an insidi- ous feedback loop between biased data and discriminatory practice. Studies that are able to account for a range of social correlates of violence inmultivariablemodels tend to find that the statistical association between violence and race is much attenuated, as is the link between violence and mental illness as defined in the official records of state agencies.31,52

In summary, racial bias can creep into available data and distort our understanding ofmass shootings and other gun vi- olence, limiting the scope of what should be a broader and more productive inquiry into the complex causes and effects of gun-related injury and death. What, for instance, are the psychologies that underlie shootings in areas of concentrated urban poverty, and what particular traumas emerge in their wake?53,54 What are the traumatizing effects for young peo- ple who frequently hear gunshots or have seen shootings or dead bodies?55,56 How can mental health expertise be effec- tively deployed to address these more quotidian, but no less problematic, aspects of gun violence in the United States?

Reckoningwith the biases in its own framework can then aid mental health research to promote anti-racist work57—such as collaborating with community-based violence interrupters,58

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imagining and advocating for structural change, and addressing how gun victimization in black communities intersects with other unequal systems, including health care, education, and community safety.46

3. Promote Awareness of the Social and Political Determinants of Firearm Violence To better understand the role of firearm access in the occur- rence and lethality of mass shootings and other forms of gun violence, research should be guided by an overarching framework that incorporates not only social, cultural, and political, but also psychological, aspects of private gun own- ership in the United States. Mental health researchers should play a key role in a sustained collaborative inquiry into how these dimensions might shape gun violence as a broader pub- lic health problem. Following the lead set by public health scholarship, adopting such an approach would enable mental health researchers to contribute productively to building in- terdisciplinary evidence for gun laws and policies that are both effective and equitable, minimizing potentially adverse collateral consequences for at-risk individuals who are sub- ject to restrictions.59Mental health professionals and scholars could have much to offer, for example, in the development of better guidelines for restoring firearm rights to persons with gun-disqualifying records in their remote past.60

A study byReeping and colleagues61 found that stateswith more permissive gun laws and higher rates of gun ownership also tend to have higher rates of mass shootings. But do these patterns mean that gun laws are effective, or do they reflect the intersectionality of other social and economic differences among states? Research by Steadman,31 Tuason,62 and others suggests that serious acts of violence attributed to “mental ill- ness” often are more robustly associated with socioeconomic factors that may also be indirectly linked to mental illness, in- cluding unemployment, insecure housing, histories of trauma, or lack of access to care.63 Perhaps the broader determinants of population well-being, illness, injury, and death can indepen- dently affect all of the following: cultural attitudes toward gun ownership; responses to social conflict; policies and laws concerning gun access; the motivations of a mass shooter; and the probability of being able to carry out an act of mass vi- olence.64 Understanding such potential connections through interdisciplinary research that includes a trained mental health lens could help to both reduce gun violence and improve other dimensions of population well-being over time.

4. Use Community Engagement to Expand the Scope and Impact of Research to Prevent Mass Shootings and Other Gun Violence Effective policies and interventions to reduce the incidence of mass shootings and other acts of serious violence will require an expanded body of well-funded interdisciplinary research that is informed and implemented through the sustained en- gagement of researchers with affected communities and other stakeholders. Within the mental health community, persons

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with lived experience as well as some family members and ad- vocates have been loath to engage with gun violence preven- tion efforts in the past, due to the perception that these efforts play upon the public’s exaggerated fear of people with mental illnesses and thus exacerbate the stigma and scorn that mentally ill individuals feel from others.65

In reality, people in the communitywho are recovering from seriousmental illnesses often havemore to fear fromother peo- ple. Like other vulnerable populations,54,66,67 persons diag- nosed with mental illnesses are statistically more likely to be victims than perpetrators of violent crime.18,68,69 They repre- sent between 25% and 58% of those shot and killed by police officers each year,70,71 and there is an apparent interaction be- tween race andmental illness when citizens are shot by law en- forcement officers. A recent study found that when police shot and killed people in the line of duty, their explanatory reports applied the label of “mental illness” more than twice as often to white individuals as to black individuals (32% vs. 15%).72

These findings suggest the need for community-engaged research to explore how perceptions and potential biases sur- rounding mental illness and firearms intersect with those that involve race, gender, and class.73 Such research could help to dismantle the stigmatizing assumption that mental illness causes violence, clearing the way for larger debates about community safety and resource allocation. This step could be important because studies have found that people who as- sociate mental illness with danger are less likely to support al- locating funds to community services and programs designed for individuals with mental illness.74–77

Future research should determine what are the best practices for engaging communities in gun violence prevention, and should better promote existing efforts in that regard. For instance, fol- lowing the Sandy Hook shooting, the Interdisciplinary Group on Preventing School and Community Violence recommended developing channels of communication between schools and surrounding communities.78 Their report highlights “chan- nels of efficient, user-friendly communication” and empha- sizes the importance of ongoing dialogue between different community stakeholders such as students, parents, health care providers, security and safety officers, and school admin- istrators.78 Community-engaged mental health researchers who are focused on broadening the discussion and inquiry into why mass shootings occur may occupy a strategic position for informing and fostering such dialogue among stakeholders.

DISCUSSION It is important to move beyond a preoccupation with deter- mining the mental health status of mass shooters and, more generally, with the question whether “the mentally ill” are prone to gun violence. This preoccupation has served to limit the important role that mental health expertise could actually play in addressing broader questions involving the balance between the perceived benefits of gun ownership and the risk that guns may pose in the hands of some persons at certain times—all in the interest of promoting the well-being of

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individuals and society. The ability to acquire reliable data on the causes and consequences of gun violence was seriously ham- pered by a decades-long federal ban on funding for gun-related research at the Centers for Disease Control and Prevention. That ban, which prohibited any studies that could have been perceived as promoting gun control, had a chilling effect on all federal research funding aimed at preventing gun violence. But now that the ban has been at least nominally lifted and some new federal funds have been appropriated for such research at the CDC and National Institutes of Health, the time has come for mental health experts and researchers to join other scholars in complementary disciplines and seize the opportunity to build the next generation of research to prevent violence. They must develop broad conceptual frameworks and creative methodologies to study gun violence as the persistent and multifaceted public health crisis that it is, and to insist on a level of public investment commensurate with the human and societal cost that gun violence exacts.

The reviewed literature makes clear that a diagnosis of a mental illness alone is an negligible factor in any effort to ex- plain, predict, and prevent mass shootings or other acts of se- rious gun violence. These tragic events have many individual and social determinants—from trauma history to substance dependence, from unemployment and insecure housing to the proliferation of guns in the community—that may inter- act with each other in complex ways. Public mass shootings are still rare events when considered at the population level, notwithstanding a fearful public’s perception of their fre- quency and salience; these will always be exceedingly difficult events to study, predict, and prevent. Filling in the gaps in knowledge about these events requires a better understanding of the cultures and contexts that surround guns in America, in addition to a focus on specific shootings. More broadly, preventing gun-related injuries and deaths is a collective, so- cial responsibility. Psychiatry stands to be an agent of change in promoting interventions and solutions for improving the health of a community, rather than narrowly addressing the most sensationalized manifestations of gun violence.

This body of research becomes more salient as gun owner- ship emerges as an important theme in narratives surrounding America’s responses to the COVID-19 pandemic and the reckoning with racism in the aftermath of the killing of George Floyd.79 Unprecedented surges in gun ownership,80

weapons brandished in the lobbies of statehouses,81 and armed presence at protests and counter-protests across the country82 have marked the American pandemic moment. Mental health experts have also warned of a “perfect storm” for suicide risk that is especially concentrated in COVID-distressed communities, with a sharp increase in the socioeconomic and psychological determinants of self-injurious behavior co- inciding with an influx of guns, the most lethal of suicide methods. And while these trends may heighten the risk of gun-related morbidity and mortality linked to mental illness, they also illuminate gaps, blind spots, and omissions in men- tal health expertise: we need to know more.

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Just like mortality rates from the novel coronavirus, social vulnerabilities and inequities that contribute to gun trauma have been exposed and exacerbated by the shift in resources away from communities that were already at risk. Recent multiple-victim shootings in cities like Baltimore and Philadelphia were all the more lethal because first responders and emergency roomswere already deployed to capacity with COVID-19 treatment instead.83–85

Future research will need to address ways in which U.S. gun trauma has morphed in relation to the changing struc- tures surrounding human interactions.86 For instance, the possibilities that previously public gun violence is shifting during the pandemic to private spaces or that it involves new or different victims are developments that heighten the urgency of recalibrating risk assessment and mounting inter- ventions that can reach people where they reside.

Again, people who are already within the mental health system do not represent the highest-risk groups for many types of gun violence, such as intimate partner shootings and other stress-induced and alcohol-fueled tragedies that in- creasingly occur in private residences during the pandemic.87

Calling the police is not always the most realistic or desired first step in these delicate situations; mental health experts might, instead, need to develop new networks through part- nerships with organizations, technology platforms, and ser- vices that reach individuals in threatening circumstances. Here, for instance, mental health knowledge tailored to these situations could be adapted and disseminated by social media companies, first responders, employment boards, or other de- livery services.18

By reframing and broadening their approach tomass-casualty shootings, mental health professionals and researchers could move mental health expertise to the fore in promoting firearm safety in schools, workplaces, and public gatherings, and among and between differing communities in post-pandemic America.88

Moving beyond diagnostic frameworks and the futile quest to “foresee” mass shootings will allow mental health research to more fully address how mass shootings and multiple-victim homicides occur within broader systems and frameworks. Do- ing so could broaden our understanding of gun violence and point the way to fair and effective policy solutions that could savemany lives, while respecting both the rights of gun owners and the dignity of persons affected by mental illness.89

Declaration of interest: The authors report no conflicts of in- terest. The authors alone are responsible for the content and writing of the article.

This article and the research behind it would not have been possible without the exceptional support of Jeffrey Swanson, PhD. His enthusiasm and exacting attention to detail have been an inspiration, and our findings reflect his ongoing en- couragement, generosity, and breadth of knowledge.

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REFERENCES 1. FollmanM, Aronsen G, Pan D. USmass shootings, 1982–2020:

data fromMother Jones’ investigation.Mother Jones 2020;26 Feb. https://www.motherjones.com/politics/2012/12/mass-shootings- mother-jones-full-data/

2. Centers for Disease Control and Prevention.Web-based injury sta- tistics query and reporting system: fatal injury reports 1981–2018. 2020. Available at https://www.cdc.gov/injury/wisqars/fatal.html

3. American Psychological Association. Stress in America: stress and current events. 2019. https://www.apa.org/news/press/ releases/stress/2019/stress-america-2019.pdf

4. American Psychological Association. One-third of US adults say fear of mass shootings prevents them from going to certain places or events. 2019;15 Aug. https://www.apa.org/news/ press/releases/2019/08/fear-mass-shooting

5. Swanson JW, Barry CL, Swartz MS. Gun violence prevention and mental health policy. In: Goldman HH, Frank RG, Morrissey JP, eds. The Palgrave handbookofAmericanmental health policy. Cham, Switzerland: Springer International, 2019:510–42.

6. Pescosolido BA, Martin JK, Long JS, Medina TR, Phelan JC, Link BG. “A disease like any other”? A decade of change in pub- lic reactions to schizophrenia, depression, and alcohol depen- dence. Am J Psychiatry 2010;167:1321–30.

7. Bhuyan N. Don’t blame mental illness for mass shootings. American Academy of Family Physicians 2019. https://www. aafp.org/news/blogs/freshperspectives/entry/20190918fp- massshootings.html

8. Stark DE, Shah NH. Funding and publication of research on gun violence and other leading causes of death. JAMA2017;317:84–5.

9. Mannix R, Lee LK, Fleegler EW. Coronavirus disease 2019 (COVID-19) and firearms in the United States: will an epidemic of suicide follow? Ann Intern Med 2020;173:228–9.

10. LinkB,Monahan J, StueveA,Cullen F.Real in their consequences: a sociological approach to understanding the association between psychotic symptoms and violence. Am Sociol Rev 1999;64:316–32.

11. Piemonte JL, Metzl JM. Gun violence and mental health: myths and strategies for sociolegal research. In: JacobM-A, Kirkland A, eds. Research handbook for socio-legal studies of medicine and health. Cheltenham, UK: Edward Elgar, 2020.

12. Silver J, Simons A, Craun S. A study of the pre-attack behaviors of active shooters in the United States between 2000–2013. Washington, DC: Federal Bureau of Investigation, US Depart- ment of Justice, 2018.

13. Stone MH. Mass murder, mental illness, and men. Violence Gend 2015;2:51–86.

14. Rubin R.Mental health reformwill not reduce US gun violence, experts say. JAMA 2016;315:119–21.

15. Swanson JW, Swartz MS, van Dorn RA, et al. A national study of violent behavior in persons with schizophrenia. Arch Gen Psychiatry 2006;63:490–9.

16. Corner E, Gill P, Schouten R, Farnham F.Mental disorders, per- sonality traits, and grievance-fueled targeted violence: the evi- dence base and implications for research and practice. J Pers Assess 2018;100:459–70.

17. Hirschtrit ME, Binder RL. A reassessment of blaming mass shootings on mental illness. JAMA Psychiatry 2018;75:311–2.

18. Rozel JS, Mulvey EP. The link between mental illness and fire- arm violence: implications for social policy and clinical practice. Annu Rev Clin Psychol 2017;13:445–69. https://www.ncbi. nlm.nih.gov/pmc/articles/PMC5784421/

19. Gramlich J. What the data says about gun deaths in the US. 2019. https://www.pewresearch.org/fact-tank/2019/08/16/ what-the-data-says-about-gun-deaths-in-the-u-s/

20. Haelle T. Most profiles of mass shooters do not include mental illness. Clin Psychiatry News 2018;26 Oct. https://www.

Harvard Review of Psychiatry

mdedge.com/psychiatry/article/178214/addiction-medicine/ most-profiles-mass-shooters-do-not-include-mental

21. Anisin A. A configurational analysis of 44 US mass shootings: 1975–2015. Int J Comp Appl Crim Justice 2018;42:55–73.

22. McCausland P. Connecting mental illness and mass shooting misses the point, experts say. NBC News 2017;19 Nov. https:// www.nbcnews.com/news/us-news/connecting-mental-illness- gun-violence-misses-point-experts-say-n821696

23. Stone D. Dangerous minds: myths and realities behind the vio- lent behavior of the mentally ill, public perceptions, and the ju- dicial response through involuntary civil commitment. Law Psychol Rev 2018;42:59+.

24. Treatment Advocacy Center. People with untreated mental illness 16 times more likely to be killed by law enforcement. 2018. https:// www.treatmentadvocacycenter.org/key-issues/criminalization-of- mental-illness/2976-people-with-untreated-mental-illness-16-times- more-likely-to-be-killed-by-law-enforcement

25. Swanson JW, McGinty EE, Fazel S, Mays VM. Mental illness and reduction of gun violence and suicide: bringing epidemio- logic research to policy. Ann Epidemiol 2015;25:366–76.

26. Metzl JM. The protest psychosis: how schizophrenia became a black disease. Boston: Beacon, 2010.

27. Knoll JL, George D, Annas MPH. Mass shootings and mental illness. In Gold LH, Simon RI, eds. Gun violence and mental ill- ness: common misperceptions. Washington, DC: American Psy- chiatric Publishing, 2015.

28. Swanson JW, Easter MM, Robertson AG, et al. Gun violence, mental illness, and laws that prohibit gun possession: evidence from two Florida counties. Health Aff 2016;35:1067–75.

29. ScaloraMJ, Baumgartner J v, ZimmermanW, et al. An epidemi- ological assessment of problematic contacts to members of Con- gress. J Forensic Sci 2002;47:1360–4.

30. Fox JA, Levin J. Extreme Killing. Understanding serial andmass murder. Thousand Oaks, CA: Sage, 2005.

31. SteadmanHJ,Monahan J, Pinals DA, Vesselinov R, Robbins PC. Gun violence and victimization of strangers by persons with a mental illness: data from the MacArthur Violence Risk Assess- ment Study. Psychiatr Serv 2015;66:1238–41.

32. Skeem J, Kennealy P,Monahan J, Peterson J, Appelbaum P. Psy- chosis uncommonly and inconsistently precedes violence among high-risk individuals. Clin Psychol Sci 2016;4:40–9.

33. Buchanan A, Sint K, Swanson JW, Rosenheck R. Correlates of future violence in people being treated for schizophrenia. Am J Psychiatry 2019;176:694–701.

34. Gun Control Act of 1968. Public Law 90-618, 82 Stat. 1213. 35. Swanson JW, Tong G, Robertson AG, SwartzMS. Gun-related and

other violent crime after involuntary commitment and short-term emergency holds. J Am Acad Psychiatry Law 2020 (forthcoming).

36. Swanson JW, Robertson AG, Frisman LK, et al. Preventing gun violence involving people with serious mental illness. In: Webster DW, Vernick JS. Reducing gun violence in America: informing policy with evidence and analysis. Baltimore, MD, Johns Hopkins University Press, 2013:33–51.

37. Metzl JM. Dying of whiteness: how the politics of racial resent- ment is killing America’s heartland. New York: Basic, 2019.

38. Schildkraut J, Elsass HJ. Mass shootings: media, myths, and re- alities. Santa Barbara, CA: Praeger, 2016.

39. Verlinden S, Hersen M, Thomas J. Risk factors in school shoot- ings. Clin Psychol Rev 2000;20:3–56.

40. Mingus W, Zopf B. White means never having to say you’re sorry: the racial project in explaining mass shootings. Soc Thought Res 2000;20:3–56.

41. Duxbury SW, Frizzell LC, Lindsay SL.Mental illness, themedia, and the moral politics of mass violence: the role of race in mass shootings coverage. J Res Crime Delinq 2018;55:788–97.

www.harvardreviewofpsychiatry.org 87

J. Metzl et al.

42. Gun Violence Archive. General methodology. 2020. https:// www.gunviolencearchive.org/methodology

43. Beckett L. Most victims of US mass shootings are black, data analysis finds. Guardian 2016;24 May. https://www. theguardian.com/us-news/2016/may/23/mass-shootings- tracker-analysis-us-gun-control-reddit

44. Butts R. Police: man killed was among shooters in Madisonville. Cincinnati Enquirer 2015;22 Aug. https://www.cincinnati.com/ story/news/2015/08/22/police-5-injured-2-dead-madisonville- shooting/32189603

45. Schildkraut J, Elsass HJ, Meredith K. Mass shootings and the media: why all events are not created equal. J Crime Justice 2017;41:223–43.

46. Lee J. The pill hustle: risky pain management for a gunshot vic- tim. Soc Sci Med 2013;99:162–8.

47. Knoll JL. Mass shootings: research and lessons. Psychiatr Times 2013;13 Feb. https://www.psychiatrictimes.com/view/mass- shootings-research-and-lessons

48. Federal Bureau of Investigation, US Department of Justice. Fed- eral denials: reasons why the NICS section denies: November 30, 1998–January 31, 2020. [2020]. https://www.fbi.gov/file-re- pository/federal_denials.pdf

49. Price M, Norris DM. Firearm laws: a primer for psychiatrists. Harv Rev Psychiatry 2010;18:326–36.

50. Swanson JW, Swartz MS, van Dorn RA, et al. Racial disparities in involuntary outpatient commitment: are they real? Health Aff 2009;28:816–26.

51. Swanson JW. The color of risk protection orders: gun violence, gun laws, and racial justice. Inj Epidemiol 2020;7:46.

52. Prins SJ, Skeem JL, Mauro C, Link BG. Criminogenic factors, psychotic symptoms, and incident arrests among people with se- rious mental illnesses under intensive outpatient treatment. Law Hum Behav 2015;39:177–88.

53. Rhee N. For Chicago kids shaken by gun violence, a shortage of trauma. Trace 2019;11 Nov. https://www.thetrace.org/2019/11/ for-chicago-kids-shaken-by-gun-violence-a-shortage-of- trauma-support-compounds-the-harm/

54. Santilli A, O’Connor Duffany K, Carroll-Scott A. Bridging the response tomass shootings and urban violence: exposure to violence in New Haven, Connecticut. Am J Public Health 2017;107:374–9.

55. Lee J. Wounded: life after the shooting. Ann Am Acad Pol Soc Sci 2012;642:244–57.

56. ZinzowHM, Ruggiero KJ, Hanson RF, Smith DW, Saunders BE, KilpatrickDG.Witnessed community and parental violence in re- lationship substance use and delinquency in a national sample of adolescents. J Trauma Stress 2009;22:525–33.

57. Kendi IX. How to be an antiracist. New York: OneWorld, 2019. 58. Bliss J. Gideon’s army violence interrupters canvass the commu-

nity to defuse conflicts and bring peace. Tennessean 2020;21 Jun. 59. Barry CL, Webster DW, Stone E, Crifasi CK, Vernick JS,

McGinty EE. Public support for gun violence prevention policies among gun owners and non-gun owners in 2017. Am J Public Health 2018;108:878–81.

60. Bonnie RJ, Appelbaum PS, Pinals DA. The evolving position of the American Psychiatric Association on firearm policy (1993–2014). Behav Sci Law 2015;33:178–85.

61. Reeping PM, Cerda M, Kalesan B, Wiebe DJ, Galea S, Branas CC. State gun laws, gun ownership, and mass shootings in the US: cross section time series. BMJ 2019;364:1542.

62. TuasonMT,Güss CD.Gun violence in theUnited States in 2017 and the role of mental illness. Behav Sci Terror Polit Aggress 2020;12:231–42.

63. KwonR, Cabrera JF. Socioeconomic factors andmass shootings in the United States. Crit Public Health 2019;29:138–45.

64. Dawes DE. The political determinants of health. Baltimore, MD: Johns Hopkins University Press, 2020.

88 www.harvardreviewofpsychiatry.org

65. Swanson JW. Redirecting the mental health and gun violence conversation from mass shootings to suicide. Psychiatr Serv 2018;69:1198–9.

66. Hiday VA, Swartz MS, Swanson JW, Borum R, Wagner HR. Criminal victimization of persons with severe mental illness. Psychiatr Serv 1999;50:62–8.

67. Office of Research and Public Affairs, Treatment Advocacy Center. Victimization and serious mental illness. 2016. https:// www.treatmentadvocacycenter.org/storage/documents/ backgrounders/victimization-and-smi.pdf

68. Marvasti JA, Friel SL. Psychiatric diagnoses andmedications: do they cause gun violence? Conn Med 2019;83:113–22.

69. Teplin LA, McClelland GM, Abram KM, Weiner DA. Crime victimization in adults with severe mental illness: comparison with theNational Crime Victimization Survey. ArchGen Psychi- atry 2005;62:911–21.

70. Metzl JM. Living and dying inmental health: guns, race, and the history of schizophrenic violence. In: Das V, Han C, eds. Living and dying in the contemporaryworld: a compendium.Oakland: University of California Press, 2016.

71. Lane-McKinley K, Tsungmey T, Roberts LW. The Deborah Danner story: officer-involved deaths of people living with men- tal illness. Acad Psychiatry 2018;42:443–50.

72. Swanson JW. Alternative perspectives on police encounters and psychotic episodes. Schizophr Bull 2017;43:946–8.

73. Oexle N, Corrigan PW. Understanding mental illness stigma to- ward persons with multiple stigmatized conditions: implications of intersectionality theory. Psychiatr Serv 2018;69:587–9.

74. Corrigan P, Markowitz F, Watson A, Rowan D, Kubiak M. An attributionmodel of public discrimination towards persons with mental illness. J Health Soc Behav 2003;40:297–307.

75. Corrigan PW, Watson AC, Warpinski AC, Garcia G. Stigmatiz- ing attitudes about mental illness and allocation of resources to mental health services. Community Ment Health J 2004;40: 297–307.

76. McGinty EE, Goldman HH, Pescosolido BA, Barry CL. Com- municating about mental illness and violence: Balancing stigma and increased support for services. J Health Polit Policy Law 2018;43:185–228.

77. Wilson LC, Ballman AD, Buczek TJ. News content about mass shootings and attitudes towards mental illness. JMass Commun Q 2015;93:644–58.

78. Interdisciplinary Group on Preventing School and Community Violence. A call for more effective prevention of violence [Posi- tion statement]. 2012. https://curry.virginia.edu/articles/ sandyhookshooting

79. Miller C. Recent shootings in Seattle renew push for change. KOMO News 2020;4 Oct. https://komonews.com/news/local/ recent-shootings-in-seattle-renew-push-for-change

80. Alcorn C. Gun sales surge as coronavirus pandemic spreads. CNN Business 2020;19 Mar. https://www.cnn.com/2020/03/ 19/business/coronavirus-gun-sales/index.html

81. Hutchinson B. ‘Operation Gridlock’: convoy in Michigan’s capi- tal protests stay-at-home orders. ABCNews 2020;16Apr. https:// abcnews.go.com/US/convoy-protesting-stay-home-orders- targets-michigans-capital/story?id=70138816

82. Kunzia R, Griffin D, Devine C. Gun-toting members of the Boogaloo movement are showing up at protests. CNN Investi- gates 2020;4 Jun. https://www.cnn.com/2020/06/03/us/ boogaloo-extremist-protests-invs/index.html

83. Kaufman E. Please, stop shooting.We need the beds. N Y Times 2020;1 Apr. https://www.nytimes.com/2020/04/01/opinion/ covid-gun-violence-hospitals.html

84. Fenton J. Seven shot and officer discharges weapon in Baltimore’s Madison Park neighborhood early Tuesday night. Baltimore Sun 2020;17 Mar.

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85. McKay T, Metzl J, Piemonte JL. Effects of statewide coro- navirus public health measures and state gun laws on American gun violence. 2020. https://www.ssrn.com/abstract= 3680050

86. O’Neal G, Connors E. New poll: COVID-19 impacting mental well-being: Americans feeling anxious, especially for loved ones; older adults are less anxious. American Psychiatric Association 2020;25 Mar. https://www.psychiatry.org/newsroom/news- releases/new-poll-covid-19-impacting-mental-well-being- americans-feeling-anxious-especially-for-loved-ones-older- adults-are-less-anxious

Harvard Review of Psychiatry

87. Lennard N. Domestic violence is on the rise with coronavirus lockdown. The responses are missing the point. Intercept 2020; 13 Apr. https://theintercept.com/2020/04/13/coronavirus- lockdown-domestic-violence

88. Rosenberg J. Trump says Virginia’s democratic governor “should be under siege.” Mother Jones 2020;17 Apr. https:// www.motherjones.com/coronavirus-updates/2020/04/trump- says-virginias-democratic-governor-should-be-under-siege/

89. Medical Director Institute. Mass violence in America: causes, impacts and solutions. 2019. https://ncvc.dspacedirect.org/ handle/20.500.11990/1528

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