For many of us in the mental health field, the January 8 shooting in Tucson, Arizona was like a darker version of the movie, “Groundhog Day.” Surely we had seen this all before: the “senseless, horrific attack” on innocent persons; the “mentally disturbed young man” charged with murder; the ever-recurring polemical arguments between supporters and opponents of gun control.
While the facts are still unfolding, and the accused shooter’s motivations — Jared Lee Loughner — still unclear, the murders in Arizona have once again raised a number of troubling questions: what if any link is there between violence and mental illness? Which problems in our health care system may contribute to untreated or inadequately treated mental illness? How should we balance civil liberties — including legitimate second amendment rights — against society’s very real safety concerns, when deciding whether guns should be sold to those with a history of severe mental illness? And would the answers to these questions have made any substantial difference in the case of the Arizona shootings?
In dealing with these complex questions, I don’t claim to “represent” psychiatrists, physicians, or any particular interest group. I am writing as a concerned citizen who happens to be a psychiatrist and bioethicist. I do not propose to offer any armchair “diagnoses” of the person now charged with murder in the Arizona shooting. Nor do I want to pre-empt a determination of the shooter’s degree of responsibility and culpability — those will be determined, one hopes, through due process of law and appropriate expert testimony. (Mental illness, so-called, is sometimes a partial explanation of someone’s behavior — is not an “excuse” for carrying out evil acts, nor does it rule out personal or political motives for a given action). Finally, by way of personal disclosure, I am a supporter of both single-payer, national health insurance; as well as more stringent controls over the sale and possession of lethal firearms.
Let’s start with the supposed link between mental illness and violence. Though the data are complicated, the overall conclusion from recent research is that violence is not closely linked to the major psychiatric disorders (major depression, bipolar disorder, and schizophrenia) per se. For example, the 1998 MacArthur Violence Risk Assessment Study, led by John Monahan and Henry Steadman, evaluated psychiatric patients recently discharged from the hospital. Unlike some studies that relied solely on self‐reports of violence, the MacArthur study used a combination of self‐reports, collateral informants, and police and hospital records.
The study found that the prevalence of violence among discharged psychiatric patients without a substance abuse disorder was similar to that among community‐dwellers who did not abuse substances. Furthermore, violence by these discharged patients rarely involved vicious attacks on strangers or clinicians. Usually, it resembled violence committed by other community‐dwellers, such as hitting a family member inside the home. The study revealed 6 homicides committed by 3 of the 951 discharged patients — thus, approximately 0.3% (3 in 951) of the released population were homicidal or committed acts of lethal violence. This rate is indeed higher than that in the general population, and is certainly not to be dismissed lightly. Still, in my view, the findings suggest that lethal violence among discharged psychiatric patients is quite rare.
To be sure, the MacArthur study has been criticized on various methodological grounds (see Torrey et al, 2008). Furthermore, mental disorders do increase susceptibility to substance abuse, and thus, indirectly increase risk of violence.
Nevertheless, a recent study by Eric Elbogen and colleagues at the University of North Carolina Chapel Hill School of Medicine tends to confirm the MacArthur findings. Based on face-to-face surveys conducted by the National Institute on Alcohol Abuse and Alcoholism, and involving nearly 35,000 subjects, Elbogen and his team found that when psychiatric diagnosis was examined, severe mental illness alone was not associated with increased risk of violence — but severe mental illness plus substance abuse/dependence was significantly associated. Indeed, severe mental illness per se did not independently predict future violent behavior; rather, other factors — such as a history of physical abuse, environmental stressors, or parental arrest record — predicted violent acts.
The image of the violent mentally ill person must also be tempered by research from Linda A. Teplin and colleagues, of Northwestern University. Teplin et al have found that those with mental illness are much more likely to be victims than perpetrators of a violent crime. They discovered in their work that among psychiatric outpatients, about 8 percent reported committing a violent act, whereas about 27 percent reported being the victim of a violent crime.
Do We Really Have “The Best Health Care System in the World”?
What about the quality of health care in the U.S.? First, I commend the Obama administration for its efforts to increase the availability of affordable health care. Unfortunately, the recent Patient Protection and Affordable Care Act (PPACA) does little to address the fundamental problem in the U.S.: the lack of universal access to health care, as would be provided under a publicly-funded, single-payer insurance plan. By the end of the decade, PPACA will still leave more than 20 million Americans without health insurance.
And yet, we continue to hear that the U.S. has “the best health-care system in the world.” (For example, the newly-appointed Speaker of the House, Rep. John Boehner, stated in an interview with Fox News that PPACA “…will ruin the best health care system in the world”).
Now, as a physician for over 30 years, I yield to no one in my respect for the consummate technical skills, innovative research, and just plain hard work on the part of my U.S. medical colleagues—not to mention the tremendous efforts of our nurses, physician assistants, and other health care professionals. But these assets do not demonstrate that we have the best health care system, if by that we mean, “the ways by which sick individuals gain access to timely, appropriate medical care.”
As Victor Fuchs PhD, of Stanford University recently wrote in the New England Journal of Medicine (Dec. 2, 2010), the U.S. government:
“…currently spends more per capita for health care than eight European countries spend from all sources on health care. Though life expectancy is far from a perfect measure of the quality of care…life expectancy at birth in every one of these eight countries is higher than that in the U.S.”
And, in a recent report on “amenable mortality” (preventable deaths) in 19 countries, by Nolte & McKee (2008), researchers found that the United States placed last. While the other nations improved dramatically between the two study periods—1997–98 and 2002–03—the U.S. improved only slightly on the measure.
Another study, by Schoen et al, found that a third of Americans say they have gone without medical care or skipped filling a prescription because of cost, compared to 5 percent in the Netherlands. The study is the latest in a series by the non-profit Commonwealth Fund showing that while Americans pay far more per capita for healthcare, they are less satisfied with the results and less healthy than people in other industrialized countries. Other key findings of this study:
- One-fifth (20%) of U.S. adults had major problems paying medical bills, compared with 9 percent or less in all other countries.
- Thirty-one percent of U.S. adults reported spending a great deal of time dealing with insurance paperwork, disputes, having a claim denied, or receiving less payment than expected. This compared with 13 percent of adults in Switzerland, 20 percent in the Netherlands, and 23 percent in Germany reporting these problems.
- The U.S. lags behind many countries in access to primary care when sick. Only 57 percent of adults in the U.S. saw their doctor the same or next day when they were sick, compared with 70 percent in the UK, 72 percent in the Netherlands, and 78 percent in New Zealand.
How Accessible is our System of Mental Health Care?
Given our problems with health care in general, it shouldn’t be surprising that access to mental health care is also far from optimal in the U.S. The result may be that psychiatrically ill persons who would not be prone to violence if adequately treated are subject to periods of aggression or violence—particularly if they are abusing alcohol or street drugs. Indeed, in my experience with so-called “dual diagnosis” patients, I have been struck by the often inadequate, fragmented care provided to those with major mental illness (major depression, bipolar disorder, schizophrenia) who also abuse drugs or alcohol.
How do we do in the U.S. compared with other countries? One study by Bijl and colleagues found that the treatment frequency of persons with serious mental illness varied considerably in five countries. The authors found that “The low treatment rate among serious cases is most striking in the United States, where only about one-third of serious cases received treatment.” The percent who received treatment for “serious” mental illness in the US was about 37%, versus 52% in Canada, 67% in Germany, 48% in Chile, and 66% in the Netherlands.
We often hear of supposed “over-treatment” of depression in this country. While that may occur in some care settings, a recent study by González and colleagues found that many U.S. patients with depression are not getting any kind of care at all. As the lead author, Hector Gonzalez MD, put it in an interview with the Wall Street Journal, “Few Americans with depression actually get any kind of care, and even fewer get care consistent with the [best practice] standards of care.” Gonzalez et al found, in particular, that Mexican American and African American individuals meeting 12-month major depression criteria “…consistently and significantly had lower odds for any depression therapy and guideline-concordant therapies.”
Firearms and Persons with Serious Mental Illness
The issue of gun control and “second amendment rights” remains hotly contested in this country, with passionate views on both sides of the controversy. I do not propose to address—much less resolve!—the complex constitutional questions that underlie this debate. However, it is worth noting that, according to data from the National Comorbidity Survey, persons with lifetime mental disorders were just as likely as those without a mental disorder to have access to a gun, carry a gun, or store a gun in an unsafe manner (Ilgen et al, 2008). This has very clear implications for the assessment of suicide risk, since over half of all suicides in this country employ firearms (based on 2005 data from Miller & Hemenway, 2008). However, the possession of firearms by mentally ill persons who are not receiving adequate treatment—or are abusing substances—also has obvious implications for the risk of homicide.
After the Virginia Tech shooting in April, 2007, The NICS (National Instant Check System) Improvement Amendments Act was signed into law in January, 2008. According to the Bureau of Justice Statistics, the Virginia Tech shooter, Seung-Hui Cho, was able to purchase firearms from a licensed dealer because information about his mental health history that would have rendered him ineligible was not available to the NICS. As a result, the system was unable to deny the sale of firearms to Cho. The NICS Improvement Act seeks to address the gap in such mental health treatment information available to NICS.
According to the New York Times, Jared Lee Loughner—accused shooter in the Arizona attacks—had exhibited such disturbed behavior at Pima Community College that school administrators informed Mr. Loughner’s parents that their son had been suspended, and would have to get a mental health evaluation to return to college. Instead, Loughner dropped out of college in October, 2010. In November, he was (quite legally) able to purchase the semi-automatic pistol used in the killings. However, as of this writing, it is unclear whether Loughner received any mental health treatment, or whether he had any mental health history that would have disqualified him from obtaining firearms under Arizona law.
One question arising from this chain of events is whether suspension from a school or university for “mental health reasons” ought to prompt notification of the NICS system. In my view, it should—if the student’s behavior was judged to be threatening or violent. (This would not include students who take a voluntary leave of absence for mental health reasons). However, given the recent trend toward diminished restrictions on gun sales and ownership, this additional safeguard seems very unlikely to find its way into law. For example, in February, 2010, the state of Virginia General Assembly approved a bill that allows people to carry concealed weapons in bars and restaurants that serve alcohol, and the Virginia House of Delegates voted to repeal a 17-year-old ban on buying more than one handgun a month (N.Y. Times, Feb. 23, 2010). And, in July, 2010, Arizona joined Alaska and Vermont as the only states to allow concealed weapons without a permit.
The philosopher George Santayana observed that, “Those who cannot remember the past are condemned to repeat it.” I often wonder how many more Columbines and Virginia Techs and Tucson-type massacres this country will endure before we begin a serious examination of our health care system and our laws pertaining to gun possession. Of course, a certain amount of violence is inevitable in any culture, and even the best laws, policies, and health care programs cannot prevent all acts of violence. Still, we can do far better in this country than we have managed thus far. For one thing, as I have argued elsewhere, we need to restore civility and responsibility to our discourse, both “online” and in other contexts.* The atmosphere of vitriol and invective that now pervades this country cannot but exacerbate the violent tendencies of some unbalanced individuals.
It is wrong to equate mental illness with a high risk of violence, or to perpetuate the myth of the “psychotic killer.” The vast majority of those with major mental illnesses — such as schizophrenia and bipolar disorder — are not violent, but are themselves often victims of violence. Nevertheless, in the absence of proper care and treatment — and with the additional precipitant of substance abuse — a subset of those with severe psychiatric disorders are at increased risk of violence. The easy availability of lethal firearms puts such individuals at further risk. We need to address these problems through comprehensive reform of both our health care system and our gun control laws. As a nation that claims to embrace civilized values, we cannot afford to do less.
Acknowledgments: I wish to thank James L. Knoll IV, MD, and Dr. Eric Elbogen, for their comments on an earlier draft of this commentary.
A disclosure statement for Dr. Pies may be found at the Psychiatric Times website. He reports no financial conflicts of interest related to the content of this article. Dr. Pies is a member of PNHP, Physicians for a National Health Program. He has also provided occasional contributions to the Brady Campaign to Prevent Gun Violence.
References and Readings
(Anonymous) Jared Lee Loughner: New York Times, January 9, 2011. Accessed at: http://topics.nytimes.com/top/reference/timestopics/people/l/jared_lee_loughner/index.html
Baier B: John Boehner Talks Taxes, Health Care and GOP Agenda. Accessed at:http://www.foxnews.com/on-air/special-report/transcript/john-boehner-talks-taxes-health-care-and-gop-agenda?page=2#ixzz1AajvrJhA
Bell V: We’re too quick to use “mental illness” as an explanation for violence. Slate. Posted Sunday, Jan. 9, 2011. Accessed at: http://www.slate.com/id/2280619/
Elbogen EB, Johnson SC. The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2009 Feb;66(2):152-61.
Fuchs VR. Government payment for health care–causes and consequences. N Engl J Med. 2010 Dec 2;363(23):2181-3.
González HM, Vega WA, Williams DR, et al: Depression care in the United States: too little for too few. Arch Gen Psychiatry. 2010 Jan;67(1), 37-46.
Ilgen MA, Zivin K, McCammon RJ, Valenstein M. Mental illness, previous suicidality, and access to guns in the United States. Psychiatr Serv. 2008;59:198-200.
Kiley K: Arizona’s concealed-weapon law takes effect. Accessed at: http://www.azcentral.com/arizonarepublic/local/articles/2010/07/29/20100729arizona-concealed-weapons-law.html#ixzz1AbD81tsj.
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Norris DM, Price M: Firearms and Mental Illness. Psychiatric Times, October 30, 2009.
*Pies R: The Eight-Fold Path of Internet Ethics: A Primer for Health Care Professionals. Psychiatrc Times, January 5, 2011.
Schoen C, Osborn R, Squires, D et al: “How Health Insurance Design Affects Access to Care and Costs, by Income, in Eleven Countries,” Health Affairs Web First, Nov. 18, 2010. Accessed at: http://www.commonwealthfund.org/Content/Publications/In-the-Literature/2010/Nov/How-Health-Insurance-Design-Access-Care-Costs.aspx.
The NICS Improvement Amendments Act of 2007. Bureau of Justice Statistics. Accessed at: http://bjs.ojp.usdoj.gov/index.cfm?ty=tp&tid=49
Torrey EF, Stanley J, Monahan J, Steadman HJ; MacArthur Study GroupThe MacArthur Violence Risk Assessment Study revisited: two views ten years after its initial publication. Psychiatr Serv. 2008 Feb;59(2):147-52.
Urbina I: Fearing Obama Agenda, States Push to Loosen Gun Laws. N.Y. Times, Feb. 23, 2010. Accessed at: http://www.nytimes.com/2010/02/24/us/24guns.html.
Wang SS: Studies: Mental Ills Are Often Overtreated, Undertreated. Wall Street Journal Jan. 5, 2010. Accessed at: http://online.wsj.com/article/SB10001424052748703580904574638750777038042.html.
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Pies, R. (2011). The Arizona Shootings: A Recurrent American Tragedy. Psych Central. Retrieved on November 27, 2014, from http://psychcentral.com/blog/archives/2011/01/11/the-arizona-shootings-a-recurrent-american-tragedy/