Why Psychiatrists Must Confront Gun-related Violence - Psychiatric Times (blog)

During my recent stay in Scotland, I had a most peculiar experience while walking through the streets of Edinburgh, Glasgow, and Stirling, late at night: I felt safe. This is a sensation I almost never have while walking in American cities of comparable size. As my wife and I learned during our stay there, Scotland has a violent and bloody history, going back many centuries. And, to be sure, modern-day Scots—a remarkably friendly and civil people—must deal with crime, drugs, and violence, just as Americans do. But they do not worry much about gun-related violence. According to the London-based Gun Control Network, there were a grand total of four gun-related homicides in Scotland, between 2009 and 2011.¹ That's right: four. Leaving aside per capita comparisons for the moment, keep in mind that there were over 20,000 gun homicides in the US during 2009-2010 alone.²

And lest you suppose that the Scots are stabbing or bludgeoning each other in droves—(ie, committing thousands of non-gun-related homicides)—Scotland's average total homicide rate between 2006 and 2008 was less than half the average for the US homicide rate during this same period.^3,4

I don't want to draw any sweeping conclusions from this one comparison—I simply want to introduce an international perspective to the issue of firearms regulation. I also want to argue that this contentious issue is of urgent relevance to psychiatry, as several articles in Psychiatric Times have demonstrated.^5-7

Why should psychiatrists care about firearms regulation? The reason that might first come to mind—the putative role of mental illness in several recent mass shootings—is actually the least important. (As I write, reports of a new mass shooting in Wisconsin are trickling in). Aurora, Colorado-type mass shootings—horrific though they are—actually amount to a minuscule percentage of gun-related deaths in the US. There are more compelling reasons why psychiatrists should be involved in the gun control debate. 

First, psychiatrists are experts in assessing risk factors for suicide, and gun possession is a major risk factor for completed suicide. The US has a firearm- suicide rate almost 6 times higher than comparison countries.⁸ One study of handgun possession in California found that,  in the first week after the purchase of a handgun, the rate of firearms suicide among purchasers is about 57 times as high as the adjusted rate in the general population.⁹

Similarly, a recent review concluded that:
 

       "There are at least a dozen US case–control studies in the peer-reviewed literature, all of which have found that a gun in the home is associated with an increased risk of suicide. The increase in risk is large, typically 2 to 10 times that in homes without guns, depending on the sample population."¹⁰
 

Second, psychiatrists are frequently called upon to assess "dangerousness" to others. Such requests may originate in emergency settings; on inpatient units, or in the context of a forensic evaluation. While persons with psychiatric illness comprise only a small fraction of those involved in gun violence, gun possession per se is an important factor in any determination of dangerousness to others—particularly in this country. Compared with other high-income countries, firearm homicide rates in the US are nearly 20 times higher; and in the population aged 15 to 24, firearm homicide rates are almost 43 times higher here than in other high-income countries.⁸

These extraordinary rates of gun-related killing cannot be written off as artifacts of faulty study methods or misinterpretation of the data. For example, the claim that other high-income countries have higher overall homicide rates than the US, owing to non-gun-related homicides (via stabbings, blunt objects, etc) is not borne out by the best available data. Thus, the following Table⁴ shows overall intentional homicide rates and intentional gun-related homicide rates in the US and 3 other high-income countries for 2009* (The United Nations Office on Drugs and Crime defines "intentional homicide" as "...unlawful death purposely inflicted on a person by another person"). It also shows percentage of homicides from firearms.

Simply stated, the extraordinarily high rate of intentional homicides in the US compared with these other countries is driven by the high percentage of homicides due to guns. The weapon of choice makes a huge difference in lethality—after all, when was the last time you heard of a mass knifing? 

Gun violence in the US
What about the relationship of gun ownership, firearms laws, and violent crime in the US? Of course, proving causal connections (vs mere associations) between gun regulations and violent crime rates is exceedingly difficult, given the multitude of confounding variables. Yet one myth that continues to be proffered by those who oppose any regulation of firearms is that gun ownership decreases crime rates and "keeps people safe." In truth, there is little credible evidence to support these claims, and considerable evidence against them. Thus, a recent review in the New England Journal of Medicine concluded that:
 

 "Americans have purchased millions of guns, predominantly handguns, believing that having a gun at home makes them safer. In fact, handgun purchasers substantially increase their risk of a violent death. This increase begins the moment the gun is acquired— suicide is the leading cause of death among handgun owners in the first year after purchase—and lasts for years. . . Gun ownership and gun violence [rates] rise and fall together. . .  [Moreover] permissive policies regarding carrying guns have not reduced crime rates, and permissive states generally have higher rates of gun-related deaths than others do (see map)."¹¹
 

These conclusions are consistent with a study from the Violence Policy Center (VPC), based on 2008 data from the CDC. The VPC study found that: 
 

          "States with higher gun ownership rates and weak gun laws have the highest rates of gun death. . . The analysis reveals that the five states with the highest per capita gun death rates were Alaska, Mississippi, Louisiana, Alabama, and Wyoming. Each of these states had a per capita gun death rate far exceeding the national per capita gun death rate of 10.38 per 100,000 for 2008. Each state has lax gun laws and higher gun ownership rates. By contrast, states with strong gun laws and low rates of gun ownership had far lower rates of firearm-related death."¹² 
 

Voices opposed to firearms regulation often point to John R. Lott's book, More Guns, Less Crime: Understanding Crime and Gun Control Laws (3rd ed, 2010). This work purports to show an inverse relationship between gun ownership and violent crime; eg, it claims that states allowing citizens to carry concealed weapons ("right to carry") show decreased rates of violent crime. Lott's claims and methods, however, have been vigorously challenged by many scholars. A recent (2009) comprehensive review by Yale Law school professors Ian Ayres and John J. Donohue III found that "right to carry" (RTC) laws were clearly associated with an increase in aggravated assaults; and possibly with higher rates of murder and robbery, although the latter findings were not statistically significant.¹³

Of course, laws have other purposes besides the reduction of crime. Laws represent society's values, and its wish to set limits on certain types of anti-social behavior. Thus, even if we learned, say, that laws against child abuse did not, by themselves, reduce rates of child abuse, we would still have a strong ethical justification for keeping such laws on the books. Similarly, even if we could not show, for example, that laws banning private ownership of semi-automatic weapons actually reduced mass killings, a civilized society might still have sound ethical reasons for retaining these laws, as statements of its moral values. But as it turns out, there is credible evidence that nationally-promulgated laws may have a salutary effect on mass shootings. Thus, as my colleague, forensic psychiatrist Dr. James Knoll has observed,
 

"Countries with less stringent gun control laws have been observed to have a higher risk of mass
murder than countries with stricter laws. One Australian observational study compared mass murders before and after 1996, the year of a widely publicized mass murder in Tasmania. Australia quickly enacted gun law reforms that included removing semiautomatic, pump-action shotguns and rifles from civilian possession. In the 18 years before the gun laws, the Australian authors reported 13 mass shootings. In the 10.5 years after the gun law reforms, there were none."¹⁴
 

Indeed, the authors of the Australian study concluded that "Removing large numbers of rapid-firing firearms from civilians may be an effective way of reducing mass shootings, firearm homicides and firearm suicides." Contrary to a popular notion that says, "If you remove dangerous firearms, people will just find other ways of killing themselves or others"—the so-called "substitution" hypothesis—these authors found "...no evidence of substitution effect for suicides or homicides."¹⁵ 

It is crucial to note that the Australian firearms regulations were nationally applied and enforced. A piecemeal approach to firearms regulation that affects only some cities or states cannot be expected to produce a robust effect on gun-homicides or mass shootings. For example, the recent spike in gun homicides in Chicago, IL—which mandates strict regulation of firearms—does not prove that firearms regulations are bound to fail. Chicago's tough firearms statutes are seriously undermined by guns brought in from suburban areas; guns from neighboring states with less stringent regulations; and by ". . . a well-funded gun lobby and an underfunded federal enforcement effort"¹⁶ that impedes crackdowns on Cook County gun dealers who sell to "straw buyers"—people without criminal records who buy guns for felons.

Finally, there is another reason psychiatrists are well-equipped to address the issue of gun control: we are experts in recognizing irrational fears. Many people in this country are, quite understandably, very concerned about their safety. But the notion that even reasonable regulation of firearms and ammunition represents the first step in "disarming" the populace is an unwarranted fear, based on flawed historical analogies.⁷ We can agree, as a society, that an individual "right to bear arms" should be respected, under recent interpretations of the second amendment. Yet we may still insist that stockpiling semi-automatic weapons against a hypothetical totalitarian state is no answer to the here-and-now reality of the carnage on our streets. Placing sensible restrictions on firearms—such as eliminating the sale of semi-automatic weapons—has been advocated by groups as politically diverse as the American Psychiatric Association and the International Association of Chiefs of Police.¹⁷  

If we, as a people, continue to sacrifice genuine security for a false sense of freedom, we shall find ourselves in a nation neither secure nor free.

References
1. Firearms offenses. Scotland.

2. Homicides by firearms - United Nations Office on Drugs and Crime. [Spreadsheet is accessible here]
3.Statistical Bulletin Crime and Justice Series: Homicide in Scotland, 2009-10

4. UNODC Homicide Statistics.

5. Robertson R. Point: The Case for Gun Control. Psychiatric Times. October 5, 2012.

6.Frances A. Mass Murders, Madness, and Gun Control. Psychiatric Times. July 30, 2012.

7. Horwitz J: COUNTERPOINT: Gun Control and the Second Amendment. Psychiatric Times. October 5, 2012.

8. Richardson EG, Hemenway D. Homicide, suicide, and unintentional firearm fatality: comparing the United States with other high-income countries, 2003. J Trauma. 2011;70:238-243.
9. Wintemute GJ, Parham CA, Beaumont JJ, et al. Mortality among recent purchasers of handguns. N Engl J Med. 1999; 341(21):1583-1589.
10. Miller M, Hemenway D. Guns and suicide in the United States. N Engl J Med. 2008;359:989-991.
11. Wintemute GJ. Guns, fear, the Constitution, and the public's health. N Engl J Med. 2008;358:1421-1424.
12. Violence Policy Center. States with higher gun ownership and weak gun laws lead nation in gun death. 13. Ayres I, Donohue JJ. More guns, less crime fails again: the latest evidence from1977 – 2006. Econ Journal Watch. 2009;6:218-238.

14. Knoll JL. The "Pseudocommando" mass murderer: Part II, the language of revenge. J Am Acad Psychiatry Law. 2010; 38:263–272.

15. Chapman S, Alpers P, Agho K, et al: Australia's 1996 gun law reforms: faster falls in firearm deaths, firearm suicides, and a decade without mass shootings. Injury Prev. 2006;12:365–372.
16. Main F. Chicago gangs don't have to go far to buy guns. Chicago Sun-Times. Aug 26, 2012. 17. International Association of Chiefs of Police. Violent crime in America: summit recommendations, Friday, December 28, 2001. For further reading:

• Harvard Injury Control Research Center: An extremely useful source of reliable data on gun-related violence.
• Miller M, Azrael D, Barber C. Suicide mortality in the United States: the importance of attending to method in understanding population-level disparities in the burden of suicide. Ann Rev Public Health. 2012;33:393-408.