Identification of Policy Issue
Violence in America is a major public health issue requiring urgent evidence-based policy solutions. National data indicates a recent rise in gun violence, which encompasses suicide, homicide, mass shooting, criminal violence, and fatal or nonfatal injury (American Academy of Family Physicians [AAFP], 2021). According to Centers for Disease Control and Prevention [CDC] (2020a), over 39,000 firearm deaths were reported in the U.S. in 2019, representing an age-adjusted rate of 11.8%. In addition, several nonfatal injuries were reported from gun violence. Consequences to families society, and the economy are grave to lost incomes, care for survivors, treatment costs, and high criminal justice spending.
Suicide and homicide rates due to gun violence are 8 and 25 times higher in the United States than other developed nations, respectively (Rozel & Mulvey, 2017). These alarming statistics, coupled with its adverse effect on the security and health of the people, calls for a public health approach to address risk factors. Programs to curb firearm violence need to be based on evidence and research. Although poor mental health is not a primary cause of criminal firearm use, the risk of gun-related injury or death can be reduced through psychiatric care for mentally disturbed, depressed, or suicidal individuals (Rozel & Mulvey, 2017). Therefore, policies promoting treatment for people with mental illnesses are needed to address this issue. Increasing the present level of access to standard care is a priority for the country. According to the American Psychological Association [APA] (2021), proactive gun violence prevention should include behavioral threat assessment of at-risk individuals in academic institutions, workplaces, and homes to inform intervention where the threat of violence is determined. This position paper evaluates a House of Representatives health bill known as the Mental Health Access and Gun Prevention Act of 2021 that seeks to expand access to mental health treatment as a way to curb gun violence (Congress.Gov, 2021).
Position Statements
According to the APA (2021) most mentally ill individuals are not the main perpetrators of gun violence, as they account for less than 1% of all-year firearm-related homicides. However, a small subset of patients with severe psychiatric conditions has been implicated in 3% of mass shooting incidents in the past decade (APA, 2021). The Mental Health Access and Gun Prevention Act of 2021 of 2021 seeks to enhance access to mental health services to curb firearm violence (Congress.Gov, 2021). On this policy issue, my position is that mental health promotion via high-quality preventive interventions, diagnosis, and treatment is critical for preventing gun violence at the individual level. Readily accessible, integrated, and community-level services can reduce the risk of violent firearm use among mentally ill patients and those with a substance use diagnosis.
Support for the position taken above comes from research evidence on antecendents to gun violence and links to mental health. First, health is not limited to the physical wellbeing but also includes mental and emotional components (McCauley et al., 2020). Second, access to quality, adequate, evidence-based, and culturally sensitive care for at-risk groups, such as substance abusers, has the potential to curb gun violence among people struggling with mental illness. Third, a proactive health care system that is responsive to risk factors of poor mental health is crucial to preventing gun violence compared to reactive responses (Swanson, 2020). Fourth, policy proposals must address unfair victimization of individuals with mental or drug abuse disorders, especially the destitute and ex-convicts, as such diagnoses do not always predict violent gun use (APA, 2021). Fifth, availing behavioral threat assessment at learning institutions and offices as a part of broader mental health care is a necessity. This service will help identify people at risk of self-harm or homicide early for a timely intervention (APA, 2021). Lastly, community-level therapeutic services for substance abuse disorders are a protective measure to reduce the threat of firearm violence (CDCb, 2020).
Background Information
Gun violence is a pervasive issue that will only grow in severity if preventive measures are not adopted urgently. However, first, the link between psychiatric illness and gun violence must be demystified; research evidence suggests that this correlation is weak (Rozel & Mulvey, 2017). It is estimated that one in five people or 43 million individuals in the U.S. struggle with poor mental health each year, with 9.8 million severe diagnoses being reported (CDC, 2018). The most prevalent diagnosable psychiatric conditions identified in the American population are schizophrenia and bipolar disorder (National Institute of Mental Health, 2018). While poor mental health may be a risk factor in gun violence, it is not necessarily a cause, as a stronger correlation exists between being a gun violence victim and psychiatric symptoms (Rozel & Mulvey, 2017). Other individual, family, racial, and sociocultural issues, such as peer pressure and exposure to guns during adolescence, predict violent firearm use (Rozel & Mulvey, 2017).
The incidents of gun-related injury and deaths are relatively high in the U.S. According to the American Psychological Association (2021), gun homicide rate and deaths are about 24 and 11 times higher than levels in other developed countries, respectively. Mass shootings in schools and public places have become a pervasive problem in recent years. While these trends can be attributed to high gun ownership in the U.S. compared to other countries, severe mental illness contributes to the risk of violent actions (APA, 2021). Overall, about 4% of gun-related violence and 22% of mass homicide are linked to mental illness, mainly schizophrenia (APA, 2021). These statistics suggest that violent firearm use by mentally ill persons represents only a small proportion of interpersonal violence. However, their involvement in mass shootings calls for policy interventions to curb the rare incidents where mental illness leads to death or the more frequent cases where depressive symptoms cause suicide.
Efforts to prevent the occasions where psychiatric conditions cause gun-related injury or death must entail increasing resources to mental health treatment. The present level of access to these services in the U.S. is inadequate. Rozel and Mulvey (2017) estimate that over one-third of Americans with severe mental conditions do not receive the needed treatment, while others could benefit from more therapy. Many effective treatments for psychiatric or substance use disorders are available but not all individuals receive minimally adequate care in quality or quantity. The severity of impairment related to mental disorder predicts violent gun use. Since few people with severely or mildly impaired functioning receive treatment, the risk of firearm violence in this group remains high.
The standard care for mental illness, irrespective of impairment level, involves psychiatric drugs (antidepressants or anxiolytics) that help treat symptoms in inpatient and outpatient settings. Psychotherapy and behavior therapy techniques are used together with prescription medication to improve outcomes for these people (American Psychological Association, 2021). However, most individuals with unmet mental health needs are not under treatment for various reasons. Some have no perceived need for such services, whereas others do not seek psychiatric care because the associated stigma or a belief that the treatment will not help. A significant number report access barriers, including financial limitations, time constraints, or transportation. Therefore, cost is the main reason for not receiving treatment, contributing to gun violence.
The quantity and adequacy of treatment are important considerations in measuring access to mental health in the community. According to Holland et al. (2021), adults receiving psychiatric care make four visits annually, with in a specialty setting (a psychotherapist) making more calls than those in primary care settings. These data indicate that that mental health treatment is insufficient. Therefore, Americans diagnosed with mood, anxiety, or substance abuse disorders do not receive minimally adequate medication or therapy. Increased access to appropriate levels of behavioral health services would lead to optimal outcomes to curb violent firearm use.
The House of Representatives bill number H.R. 137 – Mental Health Access and Gun Violence Prevention Act of 2021 – will ensure mental health adequacy by authorizing more funding to psychiatric care and treatment (Congress.Gov, 2021). The bill is based on the findings that suicide is a major cause of firearm-related death in the U.S., mentally ill individuals are often the victims, and a quarter of all Americans struggle with mental illness, with less than half of them receiving the needed care (American Psychological Association, 2021). If enacted, this law will enhance access to treatment and services and promote background checks for gun ownership because it authorizes the release of $500 million in the 2022 fiscal year to finance programs providing mental health care treatment and incentivize the reporting of relevant disqualifying information to the National Instant Criminal Background Check System (Congress.Gov, 2021).
Supportive Evidence for Both Sides
The issue of gun violence prevention through increased access to mental health treatment involves two perspectives. On one side are those who argue that psychiatric disorders are not the cause of gun-related injury, homicide, or suicide. Research evidence supporting this perspective attributes gun violence to factors such as racial hatred or discrimination and easy access to firearms (Rozel & Mulvey, 2017; Teasley, 2018). Another risk factor for gun violence is pandemic-related financial hardships and unemployment. A recent survey of Californian respondents reported that growing concerns over being targets possible gun violence perpetrated by people aggrieved by pandemic-related losses (Kravitz-Wirtz et al., 2021). In response, most people have acquired guns to protect themselves from armed robbers and burglars.
The central argument is that programs focusing only on mental health create fear and prejudice against mentally ill persons. Other ignored social, economic, and cultural issues are powerful predictors of gun violence. The net effect of associating mental illness with the risk of violent firearm use is that fewer people with unmet psychiatric needs are less likely to seek mental health services due to stigma (APA, 2021). Further, suicide, a leading mortality risk that accounts for three fifths of gun related deaths, is multifactorial (Teasley, 2018). Not everyone exhibiting suicidal behavior is mentally ill or has a known psychiatric diagnosis before death, as perpetrators with these conditions account for less than 1% of all-year firearm-related homicides (AAFP, 2021).
On the contrary, modifiable life stressors, such as grief, criminal involvement, financial problems, and substance abuse have been linked to an increase in impulsive actions and suicidal ideation (Rozel & Mulvey, 2017). For example, firearm owners charged with DIU offense or being drunk and disorderly have a fivefold higher risk of committing firearm-related crime than those who do not drink (Wintemute et al., 2018). Thus, alcohol-related conviction is a strong predictor of violent firearm use.
Besides substance abuse, there is evidence that increased access to guns contributes to high suicide rates in the American population (Siegel et al., 2013; Swanson, 2020). A one percent increase in gun ownership was associated with 0.9% surge in firearm homicide (Siegel et al., 2013). Thus, from this perspective, limiting the availability of firearms during stressful situations or times of elevated risk can avert potential homicide or suicide. Addressing homicide- or suicide-related stressors is a critical step in preventing gun violence. However, emphasizing on mental health system alone may be an effective measure for preventing injury or death due to violent firearm use. One study showed that increased access to preventive or therapeutic mental health services has a limited protective effect on gun-related deaths (Goldstein et al., 2019). Therefore, psychiatric disorders are not a significant risk factor for gun violence.
Further, mass shootings that have sparked public safety concerns are motivated by hate rather than functional impairment due to a mental illness (APA, 2021). Fazel and Grann (2006) found that only one in 20 gun-related violence could be attributed to severe mental illness. This suggests that psychiatric disorders account for only a miniscule percentage of annual gun homicides. On the contrary, evidence indicates that the perpetrator’s race is a stronger predictor of violent firearm use than mental health status (Goldstein et al., 2019). According to Teasley (2018), based on the analysis of 219 reported mass shootings, the media was likely to portray White or Latino shooters as mentally disturbed and African American perpetrators as extremists. However, in most cases, the culprits are not mentally ill but rather driven by hatred for another racial group over perceived injustices (APA, 2021). Bigotry and racial hatred in America has been shown to have a stronger link with mass shootings than poor mental health (Colagrossi, 2019). Hatred could also result from entitlement, insecurity, or anger over expanded rights to minority groups (Leander et al., 2020). In most of these cases, the perpetrators have no underlying psychiatric diagnosis, and have access to adequate mental health care (APA, 2021).
Some studies link enhanced accessibility of mental health services to lower suicide and homicide rates due to the perception that such services will not help (70% of family respondents of suicide victims) and stigma (52% of interviews) (Moskos et al., 2017). Federal policies that add more funding to community health programs providing psychiatric care can treat mental health issues that increase the risk of gun violence. Having more mental health care professionals is linked to lower levels of suicide incidence, suggesting that access to care can be an effective protective factor (Goldstein et al., 2019). Thus, a higher proportion of these providers, which is a measure of access to mental health, can protect against gun violence. Additionally, health coverage has been associated with lower gun-related suicide rates based (Goldstein et al., 2019). Health care availability improves mental health outcomes and risk factors for suicide or homicide, potentially reducing the risk of violent firearm uses (Goldstein et al., 2019). Proactive policies that appropriate funds to agencies, such as the proposed legislation, can increase the reach of programs and activities that address unmet population needs.
Potential Solutions
Firearm violence is a complex issue that needs evidence-based solutions. Research-based psychological recommendations can be useful in reducing the levels of violent gun use, including homicide and suicide, in America through policies. The potential solutions for this issue must address the risk or protective factors that increase or reduce the propensity to utilize guns in violent acts against oneself or other people. The policy measures or interventions for improving access to mental health care are discussed below.
Redirecting Developmental Risks and Social Issues that Increase Aggression
Various individual and sociocultural factors contribute to aggressive or anti-social behavior. School-based prevention efforts (school counselors) targeting adolescents or youth can help address aggression or depression that increase the risk of future violence (Teasley, 2018). Strengthening peer and community social support systems can reduce family conflicts and firearm levels in society, and redirect sociocultural processes that promote violent firearm use.
Accessible Mental Health Treatment
Although most mentally ill persons are not violent, for the at-risk group or depressed individuals, psychiatric treatment and care can potentially curb violent gun use. Identifying and treating people with mental illness in the community are critical. Increasing access to psychiatric treatment or psychotherapy, which is currently limited in the U.S., should be a priority (American Psychological Association, 2021). Programs and policies that enhance the availability of mental health can help prevent gun violence related to psychiatric conditions.
Behavioral Threat Assessment in Institutions
Behavioral risk assessment is a standard care for gun violence prevention in institutional settings. Schools, colleges, and companies should evaluate the threat a student or employee poses to himself or others based on behavior. The assessment entails collecting and analyzing relevant data to determine the risk for gun-related suicide or homicide and intervene (American Psychological Association, 2021). This proactive measure could potentially prevent mass shootings involving mentally disturbed or troubled individuals.
Firearm Prohibitions for At-risk Individuals
Gun violence usually results in death or life-threatening injury; hence, urgent measures are needed to address this problem. Prohibiting gun ownership by high-risk individuals, including those convicted of violent offences and mentally ill persons assessed as being suicidal or homicidal can prevent violence (Rozel & Mulvey, 2017). Strict licensing procedures for firearms and background checks for buyers are other interventions that can potentially reduce the risk of violent gun use.
Defense of Position
This paper’s position is that enhanced availability of mental health services can reduce gun-related injury, suicide, and homicide in America. The Mental Health Access and Gun Prevention Act of 2021 seeks to increase resources by $500 million to programs and activities that provide treatment for mental illness and report information about mental health diagnoses useful during background checks for 2022 (Congress.Gov, 2021). Improved access to mental health services through policy may decrease gun violence rates in the country. First, more provider linkages to psychiatric or substance use screenings will enable general practitioners or social workers to identify, intervene, and refer people with mental illness to specialized treatment. Evidence suggests that a high density of psychiatrists and psychotherapists decreases suicide rates (Goldstein et al., 2019). Therefore, health care access is a strong predictor of lower gun violence involving high-risk groups or mentally disturbed persons.
In a population with a high proportion of individuals without insurance coverage, access to mental health services is limited. As a result, the incidence of suicide, homicide, and mass shootings is likely to be high due to unmet mental health needs in at-risk groups, such as adolescents and minority groups (Rozel & Mulvey, 2017). Goldstein et al. (2019) found that greater behavioral health services reduces gun-related suicide rate significantly across the United States. In this study, a 10.0% increase in number of psychotherapists was associated with a 1.2% decrease in gun-related suicide rates. Thus, unmet mental health needs due to a lack of mental health services may be associated with a higher risk of gun violence.
Federal and state laws (such as the pending Mental Health Access and Gun Prevention Act of 2021) that promote universal access to affordable care for psychiatric and substance use conditions can curb gun violence. Providing quality mental health treatment when needed is critical in preventing violent acts due to mental health diagnosis. Expansion of coverage will ensure minimally adequate care for the unemployed and low-income groups that may be predisposed to psychiatric disorders due to sociocultural risk factors (Rozel & Mulvey, 2017). Nonmedical or social determinants of health, such as unemployment among immigrants, has been linked to elevated psychological distress, even in nations with universal access to healthcare services (Brydsten et al., 2018).
Preventive efforts are bolstered when behavioral threat assessments are available in the community. Timely treatment will reduce the cost burden associated with treating severe mental illness. In one study, entering treatment early was associated with a lower rate of readmission for people with schizophrenia (Horvitz-Lennon et al., 2020). Thus, identifying individuals at risk of poor mental health, self-harm, or violence in schools for intervention requires increased access to counselors. The approach will ensure aggressive or antisocial behavior in adolescents are managed early to curb future violent acts (APA, 2021). Further, those with mental illness can enter treatment voluntarily at the first point of contact. The mental health system is underfunded in many states, resulting in fewer inpatient psychiatric beds to accommodate people requiring treatment: schizophrenia (Goldstein et al., 2019). Therefore, increased per capita beds through more funding could reduce the number of persons with untreated or undertreated mental disorder to ameliorate gun violence.
Summary/Conclusion
Gun violence is a pervasive issue in the American society that requires urgent evidence-based solutions. The involvement of mentally ill persons in homicide or mass shootings calls for interventions focusing on mental health and substance abuse. Although most people with acute psychiatric disorders such as schizophrenia, psychotic episodes, or bipolar are not violent, protective measures are needed to reduce their likelihood to commit gun violence (APA, 2021). This risk is more elevated in persons with comorbid psychiatric disorders or substance dependence than in those not experiencing a mental crisis (Goldstein et al., 2019). Severe mental illness accounts for about 1% of all-year firearm-related homicides (AAFP, 2021). Further, delayed treatment increases the need for inpatient treatment due to severe disease – a risk factor for gun violence (Horvitz-Lennon et al., 2020).
Thus, inadequate care for mental health needs is an underlying cause of violent gun use.
The position emphasized in this paper is that readily accessible, community-based, and culturally sensitive preventive care and treatments can potentially alleviate violent dispositions in this population. The premise that increased availability of these services in the community can prevent violent acts is supported by evidence (Rozel & Mulvey, 2017). In this view, the Mental Health Access and Gun Violence Prevention Act of 2021 aims to allocate more public resources to promote access to mental health care to curb violent firearm use. The current levels of access are inadequate, as psychiatric beds and providers are too few to meet population needs (Goldstein et al., 2019). For this reason, a significant proportion of Americans have unmet mental health needs, and therefore, are predisposed to commit violence. Socioeconomic risks related to the pandemic, including unemployment, and lost livelihoods have also been linked to elevated psychological distress, a risk factor in gun violence (Brydsten et al., 2018; Kravitz-Wirtz et al., 2021). Therefore, federal, population-level measures to expand mental health programs to communities can help reduce psychological problems that drive people into committing gun violence.
In addition, expanded coverage and supply of mental health practitioners may be effective protective factors in reducing gun violence. By allocating more resources to programs and activities that foster access to affordable preventive behavioral assessment and psychiatric care, the incidence of severe illness, a risk factor for suicide, is likely to decline. Age-appropriate mental health services that address developmental issues, such as aggression and antisocial behavior, during adolescence can deter future violence (Rozel & Mulvey, 2017). Effective treatment can improve outcomes and reduce aggressive acts that lead to injury or death.
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