Firearms and psychiatry

The experience and repercussions of mental illness cannot be fully understood as simple disease processes. A mind, healthy or afflicted, exists within various simultaneous contexts. The consequences of psychiatric illness are a function of the disorder itself, but are also importantly influenced by temperamental, teleological and extrinsic factors, including the sufferer’s physical environment. When an illness renders a patient a danger to themselves or others, the extent of that danger is in part determined by their surroundings and the available tools at hand. While any violent or suicidal impulse risks injury, in certain parts of the world where dangerous weapons are readily available these impulses are far more likely to result in death.

In Sri Lanka, where an agricultural economy meant widespread access to dangerous pesticides, suicide rates were driven almost entirely by poisoning. When the most lethal pesticides were made less accessible in the 1990s, suicide rates dropped by half (Gunnell et al., 2007). In the UK, when household ovens switched over from lethal carbon monoxide producing coal gas to safer natural gas, total English suicide rates decreased by 33% (Kreitman, 1976). When barriers prevent access to a lethal method, we find minimal or no replacement of this method by other means (Berman et al., 2021). In the US, the most common lethal method of suicide is the firearm. Areas of the country with higher levels of gun ownership demonstrate 50% higher suicide rates, after appropriate adjustment (Miller et al., 2015). Individuals with access to a firearm have a three-fold risk of suicide compared to those without firearm access (Anglemyer et al., 2014). Unsurprisingly, laws regulating access to firearms by requiring permits, safe storage, and emergency removals, individually and in combination, have been found to reduce suicide and homicide rates (Anestis & Anestis, 2015; Kaufman et al., 2018; Swanson et al., 2021).

One reason that firearms play such a large role in suicide rates is their lethality. Their presence in the environment does not make a person more likely to harbour suicidal thoughts or change their core psychiatric symptoms in any meaningful way. So, who are the suicide decedents who use a firearm rather than another accessible, but less lethal, method? In this volume, Bond et al. compare suicide decedents who used firearms to those who died by hanging and found that firearm ownership itself was the major differentiating risk factor. That is, it is simply access to a firearm which influences that choice of method, beyond any other tested factor. Later in this issue, Thomas et al. undertake a deeper dive into method selection, method switching, resultant fatality, and the predictors of re-attempt. Their findings highlight the importance of method lethality but provide hope for ongoing survival after non-fatal attempts. Both studies underscore a need for psychiatrists to counsel patients and their caregivers regarding lethal means access— a conversation that Salhi et al. then demonstrate to be feasible and welcome by clinicians in emergency departments.

Two population level trends are presently drawing increased attention to the interface between firearms and psychiatry. First, the COVID-19 pandemic has led to an unprecedented surge in new firearm purchases, while simultaneously resulting in dramatic increases in mental distress, financial instability, and barriers to mental health care, potentially contributing to increased suicides in vulnerable populations (Bray et al., 2021). This volume begins with Crifasi et al.’s survey of these pandemic era gun purchasers and finds that one third of them are new to gun ownership and therefore less likely to be trained in safe storage or familiar with the dangers inherent in firearm access. Later in this issue, the authors detail the development of an online safe storage map, providing a valuable tool for clinicians and gun owners who may be in crisis and in need of temporary storage. Such maps are an example of the collaborations between firearm businesses and public health leaders that will be vital to mitigating the risks of gun ownership.

A second trend requiring attention stems from our ageing population and corresponding increases in new dementia diagnoses. Older Americans are more likely to own firearms, and it has been estimated that as many as 60% of those living with dementia have access to a gun (Spangenberg et al., 1999). In this volume, Polzer et al. investigate the clinical considerations and caregiver concerns surrounding firearm access in patients with dementia, in order to identify barriers and facilitate an important dialogue with key stakeholders.

Although almost two-thirds of firearm deaths in the US are suicides, many of the laws and policies working at the interface of dangerousness and firearm access are driven by high profile mass shootings. While less common than suicide, such shootings are undeniably tragic and provoke political pressures that demand response. Unfortunately, a stigmatising narrative has developed which demonises mental illness and shifts public focus away from hazardous weapons and on to our patients. In reality, those suffering from mental illness are far more likely to be the victims of violence than the perpetrators (Appelbaum, 2013). The fear of being seen as dangerous may inhibit patient openness or even prevent care seeking and ultimately cost lives.

Psychiatrists are thrust directly into this nuanced intersection of mental illness, dangerousness, and stigma when we are asked to assess risks of violence. No perfect risk stratification tool exists, but the stakes demand that we do our best with the imperfect predictors and assessments we do have at our disposal. In this issue, Barnhorst and Rozel provide a guide to the prediction of mass shootings in the context of psychiatric evaluation. They lay out potential mitigation measures ranging from treatment to disarmament, as well as the legal considerations complicating the evaluator’s role. Lankford and Silva then remind us that no case can be looked at only in cross-section, as they detail the characteristic time course of events leading up to a mass shooting in terms of contact with mental healthcare if present, contributing life stressors, and windows of firearm acquisition.

As physicians, we strive to minimise the suffering that mental illnesses inflict on our patients. Much of this work is accomplished through direct therapies, but we also recognise the broader social and environmental needs that must be addressed if our patients are to survive and flourish. This may include hospitalisation in times of crisis, with the express purpose of minimising potential harm during vulnerable periods. By this same token, recognising sources of risk and injury in the patient’s home environment is an imperative of comprehensive psychiatry and a responsibility of care. For our patients, access to a firearm may represent the difference between a fatal conclusion and the opportunity to rebuild. We cannot afford to ignore the role of firearm access in psychiatric outcomes.

Disclosure statement

No potential conflict of interest was reported by the author(s).