Short abstract
This article, part of RAND's Gun Policy in America project, synthesizes the available scientific data on whether mental illness is a risk factor for gun violence.
Keywords: Crime and Violence Prevention, Government Legislation, Gun Violence, Law Enforcement, Mental Health and Illness, Suicide, United States
Abstract
In this article, part of RAND's Gun Policy in America project, the authors describe the nuanced picture relating mental illness with gun violence. For example, suicide risk is elevated among people with certain mental illnesses, but suicide among those with such diagnoses is still rare. Homicide risk is also elevated among people with certain mental conditions (e.g., schizophrenia) and among people with co-occurring mental health conditions and substance use disorders, but these individuals still account for the minority of homicides and acts of mass violence in the United States. On the other hand, people with mental health conditions appear to be at increased risk for being victims of interpersonal violence.
In the aftermath of acts of gun violence, questions often arise about whether the assailant had a history of one or more mental health conditions. For example, after two mass shootings in a single weekend in Texas in August 2019, then-President Donald Trump stated, “Mental illness and hatred pulls the trigger” (Abutaleb and Wan, 2019). In 2018, more than 50 percent of Americans believed that people with schizophrenia and alcohol use disorders posed a danger to others, and 30 percent believed that people with depression posed such a threat (Pescosolido, Manago, and Monahan, 2019). In this essay, we summarize the scientific research about whether and how mental illness and gun violence, including self-directed and interpersonal violence, are related.
Mental health conditions are diverse in both symptoms and severity, and these factors affect the likelihood that someone with a given condition has received a formal diagnosis and received treatment. In 2018, 65 percent of adults with a major depressive episode in the past year received treatment for depression (Lipari and Park-Lee, 2019). Among adults with any mental illness, only 43 percent received mental health services. Among those with serious mental illness—defined as a “diagnosable mental, behavioral, or emotional disorder, other than a developmental or substance use disorder, that substantially interfered with or limited one or more major life activities”—only 64 percent received treatment (Lipari and Park-Lee, 2019, pp. 33–34). Thus, diagnoses and treatment for mental health conditions should be considered imperfect markers of mental illness. This is a major limitation of much of the research that has sought to examine the relationship between mental illness and suicide or firearm violence.
Mental Illness and Suicide
In 2018, 48,344 people died by suicide in the United States, 24,432 (51 percent) of whom used a firearm to end their life (Centers for Disease Control and Prevention, 2020). A meta-review (a review of systematic reviews) found evidence that people with schizophrenia, borderline personality disorder, bipolar disorder, or depression have higher rates of suicide than the general population does (standardized mortality ratios = 12.9, 45.1, 17.1., 19.7, respectively), and those with anxiety disorders (odds ratio = 3.3) and posttraumatic stress disorder (odds ratio = 2.5) specifically have elevated risk of dying by suicide relative to those without these conditions (Chesney, Goodwin, and Fazel, 2014).1 However, elevated mortality rates or risk associated with specific mental health conditions do not necessarily indicate that these conditions can usefully predict future suicide, because suicide still remains relatively rare among those with the mental health conditions. For example, meta-analyses suggest that 5 percent of those diagnosed with schizophrenia die by suicide (Palmer, Pankratz, and Bostwick, 2005), and Danish registry data indicate that, among those who have received psychiatric care after age 15, 2.1 percent of women and 4.3 percent of men died by suicide (Nordentoft, Mortensen, and Pedersen, 2011). A 2017 review confirmed that knowing that a person had a mental health problem did little to improve the prediction of suicide beyond random guessing (Franklin et al., 2017).
Retrospective analyses have found that between 45 and 90 percent of people who die by suicide have mental health or substance use disorders. Generally speaking, lower estimates derive from studies that rely on diagnostic markers of mental illness. For example, in a study of 5,894 suicides across 11 health care systems between 2000 and 2010, 45 percent of individuals received a mental health diagnosis in the year before death and 24 percent had a health care visit coded with a mental health diagnosis in the four weeks before death (Ahmedani et al., 2014). These numbers are elevated if one includes visits that were coded with alcohol and drug dependency diagnoses (to 57 and 26 percent, respectively). Postmortem studies of suicide decedents, however, result in larger estimates of mental illness. In a random sample of 600 suicides between 2003 and 2011 from 17 states in the National Violent Death Reporting System (NVDRS), 75 percent of those who died had mental health or substance use problems, and 35 percent had received treatment for mental health or substance abuse (Stone et al., 2016). In the NVDRS, data on mental health problems and treatment come from postmortem reports based on medical records or brief interviews with family and friends, when available (Blair et al., 2016). This method of postmortem inquiry is elaborated upon in psychological autopsy studies, in which researchers attempt to make mental health diagnoses postmortem via “a combination of interviews of those closest to the deceased and an examination of corroborating evidence from sources such as hospital and general practice case-notes, social work reports and criminal records” (Cavanagh et al., 2003, p. 395). In a review of 154 psychological autopsy studies, an average of 90 percent of those who died by suicide had a mental health disorder (Cavanagh et al., 2003). There are two limitations of this approach. First, there is attribution bias, in which coroners or medical examiners are more likely to indicate mental health disorders in suicide cases. Second, in an attempt to find an explanation for the event, family and friends who are interviewed after the suicide often recall symptoms or behaviors in the decedent that may not have actually been present (Cavanagh et al., 2003). For these reasons, studies that use the NVDRS and those based on psychological autopsies may overestimate the prevalence of mental health disorders among those who die by suicide.
There is some evidence to suggest that the prevalence of mental health disorders differs between firearm suicide decedents and nonfirearm suicide decedents. Data from the NVDRS indicate that men who used a firearm to take their own life were less likely to have had a past mental health diagnosis or to have received mental health treatment than were men who did not use a firearm (Kaplan, McFarland, and Huguet, 2009; Kaplan et al., 2012). However, investigations into the deaths of those who use a firearm during suicide may be less likely to uncover underlying mental health symptoms than are the investigations into the deaths of those who die by other means (because less time and resources are typically spent during an investigation when the cause of death is clear). Among men aged 65 or older who took their own lives by some means other than a firearm, 46 percent had a mental health diagnosis relative to 28 percent of those aged 65 or older who did use a firearm (Kaplan et al., 2012). On the other hand, a study of suicides and suicide attempts in Chicago between 1990 and 1997 found that those who used a gun were more likely to have a diagnosis of depression or psychosis (Shenassa, Catlin, and Buka, 2000).
If people with mental health disorders are less likely to use a firearm to attempt suicide, it may be because the families of those with mental health diagnoses, or the individuals with these diagnoses themselves, have been advised not to have a firearm in the home as a safety precaution. However, the evidence does not bear this out: People with a history of a mental health disorder were just as likely to live in a home with guns available as were those without a history of mental illness, with exceptions (adults with a history of bipolar disorder and adults with a past suicide attempt may have more-limited access to firearms) (Ilgen et al., 2008; Simonetti et al., 2015). Thus, the relationship between mental illness and the method used to end one's life remains unclear.
In conclusion, at least half of those who die by suicide have a mental health or substance use disorder, but these disorders are often unrecognized or undiagnosed. Among those with a mental health diagnosis, fewer than 5 percent are likely to die by suicide, but this percentage depends on the specific mental health condition. Prevalence of mental illness may be lower among those who use a firearm to end their lives.
Mental Illness and Firearm Interpersonal Violence
In 2018, 18,830 people died by homicide in the United States, 13,958 (74 percent) of whom died by firearm (Centers for Disease Control and Prevention, 2020). A review by Skeem and Mulvey, 2020, examined the evidence base on mental illness and interpersonal violence, including gun violence and mass shootings. The authors highlighted data from the MacArthur Violence Risk Assessment Study, which followed patients discharged from one of three acute, civil inpatient psychiatric facilities in the United States (see Steadman et al., 1998). That study was particularly significant because it measured acts of violence perpetration from official records and respondents' own self-reports, whereas many other studies relied exclusively on official records. Steadman et al., 2015, found that, among 951 patients in the study sample who completed at least one follow-up interview within one year of discharge from a psychiatric facility, there were 67 acts of interpersonal gun violence perpetrated by 23 people. Among those same 951 people, 19 acts of gun violence committed by nine people involved a stranger as a victim. Thus, within one year, 2 percent of those who were discharged committed an act of violence with a gun, and 1 percent committed an act of violence with a gun in which a stranger was the victim (Steadman et al., 2015). This is arguably the strongest evidence in the United States to date suggesting that few people with mental illness are violent with firearms against strangers.
There is also evidence that people with mental illnesses commit certain types of violent offenses at higher rates than those without mental health conditions do, at least for specific diagnoses. For example, Fazel et al., 2009, performed a meta-analysis and found that the risk of homicide among those with schizophrenia was 0.3 percent relative to 0.02 percent among those without a diagnosed mental illness. However, the risk of homicide among those with substance abuse was also 0.3 percent, implying that individuals with either diagnosis (schizophrenia or substance abuse) had a higher risk of committing homicide than did those without a mental illness diagnosis. Although the risk of committing homicide is elevated among those with schizophrenia, studies that have examined the percentage of violent crimes committed by people with evidence of schizophrenia or related psychoses found that these individuals account for less than 10 percent of violent crimes (Fazel et al., 2009), a finding largely explained by the relatively low prevalence (less than 1 percent) of these conditions among the general population (Kessler et al., 2005; Wu et al., 2006).
Approximately 20 percent of all people with mood or anxiety disorders have co-occurring substance use disorders (Grant et al., 2004), and the prevalence of substance use disorders may be higher among people with psychoses, such as schizophrenia (Dixon, 1999). Among people with co-occurring mental health and substance use disorders, many abuse alcohol or drugs as a maladaptive coping mechanism to distract from mental distress or psychosis (Khantzian, 1997). The link between mental illness and interpersonal violence is often attributed to co-occurring substance abuse or dependence. For example, the meta-analysis of schizophrenia and interpersonal violence by Fazel et al., 2009, found a significantly elevated effect of interpersonal violence among those with co-occurring substance abuse (random effects odds ratio = 8.9) relative to those with schizophrenia alone (random effects odds ratio = 2.1). Researchers who used data from population-based epidemiologic studies also found greater rates of interpersonal violence among people with substance use disorders (relative to those with mental health conditions) or co-occurring mental health and substance use disorders (relative to those without mental health conditions or without co-occurring disorders) (see, for example, Swanson et al., 1990; Elbogen and Johnson, 2009). This has led some (e.g., Fazel et al., 2009) to call for interpersonal violence prevention strategies that focus specifically on addressing substance use disorders rather than mental illness per se.
With respect to mass violence, Skeem and Mulvey, 2020, concluded in their review that approximately 20 percent of mass violence is committed by a person with a mental health disorder. As with their examination of suicides, the authors also cautioned about biases inherent in making diagnoses after the event and the tautological quality of such diagnoses. In Skeem and Mulvey's words, such diagnoses have a circular quality: “‘Why did this man do this terrible thing?’ Because he is mentally ill. ‘And how do you know he is mentally ill?’ Because he did this terrible thing” (Skeem and Mulvey, 2020, p. 86). Also similar to suicide, mass violence is a relatively rare event, so it is challenging to conduct rigorous, fully powered studies to identify risk factors (see Chapter One of this report and Smart et al., 2020). Skeem and Mulvey, 2020, p. 92, describe that, “In studies that define mental illness expansively and include untrained ‘diagnoses' made in the wake of the rampage …, estimates of the proportion of mass shooters with confirmed or suspected mental health problems” ranged from 30 to 60 percent; in contrast, in studies that focused on formal diagnoses (e.g., from a health care provider), post-event diagnoses of a mental illness ranged from 13 to 15 percent.
In addition to the research examining the connection between having a mental illness and perpetrating interpersonal violence, there is research suggesting that people with mental health conditions are at increased risk for being victims of interpersonal violence. For instance, in a survey of people with severe mental illness who were receiving mental health services in Chicago, 25 percent had been the victim of a violent crime; comparatively, 3 percent of the general population had been the victim of a violent crime (Teplin et al., 2005). A 2014 study of homicide victims from England and Wales painted a more nuanced and complicated picture: Rodway et al., 2014, found that, between 2003 and 2005, there were nearly 1,500 homicide victims, of whom 90 (6 percent) had received mental health services in the 12 months prior to their death. This resulted in an increased risk estimate of victimization relative to the general population (the estimated homicide victimization rate was 2.34 per 100,000 mental health service users versus 0.91 per 100,000 in the general population). On the other hand, 213 individuals with mental illness were convicted of homicide in the same three-year study period. Among the 90 homicide victims with mental health diagnoses, 29 were killed by a perpetrator who also had a mental health diagnosis; in 23 cases, the two knew each other, and in 21 cases, both individuals were receiving treatment at the same facility.
In conclusion, people with certain mental illnesses, notably schizophrenia and related psychoses, have a higher risk of committing violent crime than people without such illnesses do, but less than 1 percent are likely to commit a firearm-related offense. In addition, data show that, because these mental health conditions are uncommon, individuals with these conditions commit less than 10 percent of violent crimes. For people with mental illness, having a co-occurring substance use disorder appears to increase risk for perpetrating violent acts, comparable to those with substance use disorders independent of a co-occurring mental illness. Although the evidence base is weak, people with mental illness may be overrepresented among those who commit acts of mass violence, but they still account for less than one-fourth of these events. On the other hand, victimization among people with mental illness appears elevated relative to the general population.
Summary and Conclusions
Studying the relationship between mental illness and suicide or firearm violence (both self-directed and interpersonal) is challenging because mental illness is often undiagnosed and undetected by the health care system. Furthermore, postmortem (for suicide) or post-event (for violent crime) diagnoses may be biased. It is likely that there is evidence of a mental illness among one-half or more of those who die by suicide. On the other hand, although violence is elevated among people with schizophrenia or related psychoses, these individuals still account for a relatively small share of violent acts overall. And the relationship between schizophrenia and violence may be more pronounced among those with co-occurring substance use disorders. However, having a mental illness or a co-occurring substance use disorder (or both) is a poor predictor of dying by suicide or committing an act of interpersonal violence; the majority of people with these conditions do not exhibit these outcomes. In fact, people with mental illness are much more likely than those in the general population to be victims of interpersonal violence.
Notes
The research described in this article was sponsored by Arnold Ventures and conducted by the Justice Policy Program within RAND Social and Economic Well-Being.
Standardized mortality ratios compare the mortality rate of those with a mental health condition and the mortality rate of the general population, which includes those with mental illness. In contrast, meta-analyses that present odds ratios compare suicide rates among those with the mental health condition and suicide rates among those without the mental health condition.
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