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Mental Illness, Violence and the Gun Control Debate: Evidence, Policy, Privacy and Stigma

Violence is a natural, human behavior, key to both our evolution as a species and to the reproductive success for many an individual vying for scarce food or mating opportunities.  And yet in our modern society, violence is often an unnatural, senseless act, borne out of impulsive aggression — without consideration for the future consequences — or at times, due to gross distortions of reality as can occur for individuals with severe mental illness.

While mental illness is a rare cause of violence, accounting for 3-5% of the violence that reaches our courts, it nonetheless figures prominently in the cultural understanding of violence, particularly since several recent high-profile mass killings involved individuals with clear suggestions of brewing or established psychotic illness.

How can society translate the science of violence and mental illness into practical public health policies that would better protect everyone?

A year after the Sandy Hook massacre, the world seems no closer to understanding why such a horrific act occurred in the case of Adam Lanza, who committed suicide and left few traces of his motives.  It’s no surprise that parents of victims are so desperate for answers and solution that they would entertain imposing routine brain check-ups through a functional MRI scan for those at risk for violence.  Their motives are clear and noble: they want to understand the root causes of violence and find ways that society can protect other children and families from having to undergo the same unimaginable pain and loss they continue to experience every day.  And yet, such a measure would almost certainly represent a violation of several constitutional rights, not to mention being impractical, well beyond the capabilities of the science, and probably by most peoples’ standards, a swing of the pendulum well beyond our comfort zone in the ongoing balance of individual autonomy and public safety.

Their proposals come from a profound and understable frustration with a government and scientific establishment that has yet to provide clear answers: Why and how can such acts can occur?  And more, critically, how can society translate the science of violence and mental illness into practical public health policies that would better protect everyone?

This translational question was the topic of a recent interdisciplinary panel, entitled “Mental Illness, Violence and the Gun Control Debate: Evidence, Policy, Privacy and Stigma” that took place on December 9th, 2013, as part of the Annual Meeting of the American College of Neuropsychopharmacology, in Hollywood, Florida.  The panel was led and introduced by Jerrold Rosenbaum, MD, Chief of Psychiatry at MGH, head of the ACNP Ethics Committee, and CLBB faculty member.

Other panelists included David Pickar, M.D., President of Gabriel Sciences, Johns Hopkins, who moderated the discussion.  J. Dee Higley, Ph.D., Professor at Brigham Young University, reviewed the biology of aggression and its conservation within the serotonin system, suggesting that neonatal levels of a serotonin metabolite (5-HIAA) is a reasonably good predictor of who will manifest violent behavior as an adult.  Emil Coccaro, M.D., Chair of Psychiatry and Behavioral Neuroscience at the University of Chicago provided his views as an expert on the biology of anger and aggression.  Kenneth Davis, M.D., President and CEO of the Mt. Sinai Medical Center, who discussed the recently enacted NY Secure Ammunition and Fireams Enforcement (SAFE) Act, which requires that “any mental health professional must report to a county official any patient who is likely to engage in conduct that would result in serious harm to self or others”.   Brian Frosh, State Senator from Maryland, discussed his state’s recent efforts to curb gun violence by limiting high-capacity weapons and banning ownership for anyone who has been involuntarily committed to a mental health institution.  Paul Appelbaum, M.D., Dollard Professor of Psychiatry, Medicine, and the Law at Columbia University, reminded the audience of the tenuous link between mental illness and gun violence and how policies intended to secure the public can often lead to increased stigma for those with mental illness.

J. Dee Higley reviews the link between serotonin metabolites in neonatal and adult cerebrospinal fluid, and how it may help predict individuals with violent tendencies.

Ultimately, while several members of the panel accepted the notion that guns should probably be removed from those with severe mental illness, only a few general recommendations seemed to reach consensus.  First, organizations like the ACNP should continue to advocate for broader access to mental health services.  Second, additional research on violence and the epidemiology of gun violence is critical to better understand the many factors that contribute to gun violence.  Any policies that are put into place purportedly to curb gun violence should carefully consider the potential ramifications and unintended consequences, including disincentivizing seeking clinical care.  Also critical is providing necessary support services for any individuals at risk for committing violence, through existing behavioral programs and longitudinal clinical follow up.

For more information on the Annual Meeting of the American College of Psychopharmacology, visit http://www.acnp.org/ or read more about the event here.

Abstract of the event is included below:

The tragic killings carried out by individuals with apparent serious mental illness has led to a national dialogue regarding the links between mental illness, violence and gun control.   The ACNP Ethics Committee determined it would be timely to explore the clinical knowledge and scientific evidence base regarding violence and mental illness.   This study panel will address the following questions:  1) Are patients being unfairly exploited as straw men in a debate to preserve 2nd amendment freedoms or do safety concerns justify singling out those who have suffered mental illness (who represent 6% of the population with severe disorders at any time and up to 45% with any disorder lifetime)?  2) Do concerns including stigmatization and privacy violation outweigh attempts to identify individuals at risk for gun violence?  3) Is there unwarranted generalizing beyond current scientific data and understanding?  In this study group data associating mental illness to risk for violence will be briefly summarized, including neuroscientific perspectives (David Pickar, Emil Coccaro, Dee Higley).  Maryland State Senator Brian Frosh, Chair Judicial Proceedings Committee, will summarize his legislative efforts and experience relating to gun control and the mentally ill.  Paul Appelbaum, Ken Davis and Jerrold Rosenbaum will provide practical and ethical perspective from academic, hospital and institutional medicine.  The ethical considerations drawn from privacy violation, civil liberty restriction and profiling will be central in the discussion.  The study group is designed for discussion/debate among the College membership in attendance with speakers briefly highlighting key elements to their topic.  The core features of the discussion will then be passed back to the Ethics Committee for their consideration.  Panel hopes to hear views of ACNP members on this issue of critical importance to psychiatry, psychology and the behavioral sciences.

UPDATE, March 19, 2014: For more on Adam Lanza, Sandy Hook, mental illness and violence, see the piece The Reckoning published on March 17, 2014 in The New Yorker, and reposted here.