Variations in State Laws on Mental Health–Related Firearm Prohibition

Abstract

This quality improvement study assesses heterogeneity in state rules regarding reporting of mental health conditions to the National Instant Criminal Background Check System when individuals seek to acquire firearms.

Firearm access by individuals with mental illness is associated with increased risk of suicide or homicide.¹ The Federal Bureau of Investigation’s National Instant Criminal Background Check System (NICS) was created to prevent individuals with certain mental health incidents from acquiring firearms.² It relies on states to report mental health data so they can access national data on applicants’ mental health events and prevent gun possession when appropriate. However, federal law does not compel states to report to NICS. States develop their own rules regarding mental health reporting, including incident type; how, when, and who must report; and whether to report. We analyzed each state’s mental health firearm reporting laws to assess heterogeneity nationwide.

Methods

This quality improvement study used the Thomson Reuters Westlaw database to identify and collect data on each state’s laws regarding mental health reporting requirements (February to April 2022). We cross-checked findings with each state’s legislative page. After identifying the criteria and process for each state, we coded each requirement and developed via context analysis 10 mental health event reporting categories. Every required reporting mental health or substance use disorder event drafted in a state’s law was included. We abstracted processes variables about reported events and created categories within each variable: “who” refers to identified mandatory reporters; “when,” to the reporting timeline; “what,” to the type of information reported; and “to whom,” to state actors and agencies collecting the information and whether the state is obligated to report to NICS. We created indices of which and how many states fell into each category. Data were analyzed manually. The eMethods in Supplement 1 provide details. The study was approved by the University of Washington institutional review board; informed consent was waived per 45 CFR §46. We followed the SQUIRE reporting guideline.

Results

Significant heterogeneity on mental health reporting laws existed in every category. State laws were inconsistent as to whether data were provided to NICS: 39 states required reporting, 5 permitted reporting, 3 required reporting to a state agency while silent on NICS, and 3 had no reporting laws (Figure 1). The number of requirements varied across states (median, 3 [range, 0-8]; mean [SD], 2.9 [1.7]). Event types with mandated reporting to NICS varied substantially across states, including being adjudicated incompetent to manage affairs or having a guardian appointment (16 states), incompetent to stand trial (24), emergency hold for 72 hours (3), involuntary outpatient treatment (18), involuntary commitment (40), not guilty by reason of insanity (23), stakeholder observation (5), substance use disorder treatment (13), voluntary hospitalization (5), and voluntary outpatient treatment (1) (Figure 2).

Figure 1. State Comparison of Number of Required Mental Health Reporting Events.

Figure 2. Mental Health Events That Must Be Reported to the National Instant Criminal Background Check System per State Guidelines.

Discussion

The NICS may help reduce firearm-related injuries and deaths by providing data on firearm ownership prohibition because of a mental health determination in any state. Although NICS is intended to be a nationwide database, the substantial variability in reporting requirements across states suggests that the intended purpose of the NICS is hampered. Our research builds on National Consortium for Justice Information and Statistics findings of variations in reporting requirements based on a 2012 survey of 35 member states.³

A more robust approach is needed to ensure that critical information about individuals with mental health risks is accurately shared with the NICS. Prior work suggests that NICS’ reliability and utility would improve with national standards.^4,5 Prevention of firearm purchasing increased exponentially in states with increased requirements to report mental health to NICS.⁴ It is important to avoid unintended consequences, such as the risk of individuals avoiding mental health care because of reporting concerns. However, firearm access during a mental health crisis is associated with increased risk of suicide or harm to others⁶; it is imperative to identify consistent reporting strategies to prevent those in crisis from accessing firearms. A study limitation is that we captured statutes at a particular moment in time, although some state legislatures meet annually and revise their laws.

Supplement 1.

eMethods

Supplement 2.

Data Sharing Statement