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American Gun Violence & Mental Illness: Reducing Risk, Restoring Health, Respecting Rights & Reviving Communities

Jeffrey W. Swanson is Professor in Psychiatry and Behavioral Sciences at Duke University School of Medicine. He is a Faculty Affiliate of the Wilson Center for Science and Justice at Duke Law School, the Center for Firearms Law at Duke Law School, and the Center for Child and Family Policy at Duke Sanford School of Public Policy. He has published in journals such as JAMA, Health Affairs, American Journal of Psychiatry, American Journal of Public Health , and Law & Human Behavior .

Mark L. Rosenberg was the Founding Director of the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention, and the former President and CEO of Task Force for Global Health. He is the author of Patients: The Experience of Illness (1980), Howard Hiatt: How This Extraordinary Mentor Transformed Health with Science and Compassion (2018), and Real Collaboration: What Global Health Needs to Succeed (with Elisabeth S. Hayes, Margaret H. McIntyre, and Nancy Neill, 2010), and editor of Violence in America: A Public Health Approach (with Mary Ann Fenley, 1991).

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Jeffrey W. Swanson , Mark L. Rosenberg; American Gun Violence & Mental Illness: Reducing Risk, Restoring Health, Respecting Rights & Reviving Communities. Daedalus 2023; 152 (4): 45–74. doi: https://doi.org/10.1162/daed_a_02031

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Intentional injuries claimed nearly two hundred lives every day in the United States in 2020, about two-thirds of them suicides, each a story of irretrievable human loss. This essay addresses the complex intersection of injurious behavior with mental illness and access to firearms. It explores what more can be done to stop gun violence while respecting the rights of lawful gun owners, preserving the dignity of persons with mental illnesses, and promoting racial equity. Strategies to prevent firearm injury in the United States are uniquely conditioned by a constitutional right to bear arms, the cultural entrenchment and prevalence of private gun ownership, and strident political disagreement on regulatory solutions to stem gun violence. Broad implementation of a range of complementary policies is needed, including community-based programs to address the social and developmental determinants of violence, improved access to a continuum of mental health services, firearm restrictions based on behavioral indicators of risk (not mental illness, per se), licensing for firearm purchase or ownership, comprehensive background checks for firearm purchase, and supply-side approaches to interrupt illegal firearm markets.

In the summer of 2022, following a pair of highly publicized mass-casualty shootings in upstate New York and West Texas, a bitterly divided United States Congress responded to a groundswell of public outrage and forged a path to consensus on the first major piece of gun violence legislation in over twenty-five years. 1 After decades of federal dithering on gun violence, lawmakers enacted a statute that (among other things) promotes the temporary removal of firearms from people at high risk of suicide or violence against others, expands background checks with a waiting period for gun buyers under age twenty-one, and toughens penalties for illegal gun trafficking. But these provisions were wrapped in a bill that makes no mention of firearms in its title-the Bipartisan Safer Communities Act-and designates the large majority of its $13 billion in funding for expanding mental health services in the community and in schools. 2 Why did lawmakers think gun violence and mental illness had to be addressed together in a bill about community safety, as if they were the same problem? And how did we get to that point?

This essay examines the prevailing assumption that mental illness and violence are strongly interconnected, and that the key to reducing gun violence is therefore to reinvigorate our nation's failing public behavioral health care system with new capacities to identify, confine, and treat mentally ill people who are potentially violent. There is no question that more effective and accessible mental health services are sorely needed, especially in schools and many neglected communities. If appropriately channeled, the new federal funding could be a welcome resource for that purpose. But while improvements in mental health services may prevent some gun suicides, we argue that such improvements will do little, by themselves, to stem the tide of firearm homicides. Mental illness and gun homicides are two different public health problems that intersect on their edges. Recognizing them as such allows us to see that a broad set of interventions, policies, and legal tools is needed to address the upstream social determinants as well as proximal causes of gun violence-to mitigate its devastating consequences for individuals and communities-but also, and separately, to improve outcomes for people with serious mental illnesses. We advocate and know that it is possible to use science to identify effective, equitable, and feasible ways to reduce gun violence while respecting the rights of lawful gun owners, and to do so without adding to the burden of stigma that people with mental illnesses often bear when others regard them with misplaced fear and scorn.

What is the nature of the problem, and why has it been so intractable to policy solutions? Despite increasing public concern over the nation's long-running epidemic of gun violence, federal officials have largely been unable to act effectively to limit the death toll. The rate of firearm-related mortality increased 45 percent between 2010 and 2021. 3 Efforts to prevent gun violence have been stymied by an intensely politicized disagreement over the very nature of the problem to be solved: Is gun violence mainly about “dangerous people” or “dangerous weapons”? How that definitional question is framed and answered tends to bifurcate policy choices into those that restrict access to firearms and those that restrain the behavior of people perceived to threaten public safety-including, importantly, people with mental illnesses who are so often stereotyped as prone to violence and scapegoated for mass shootings. We argue that policy options that force such a dichotomous choice are unnecessary and counter-productive. Rather, both approaches are important, and even politically feasible in combination, as the Safer Communities Act illustrates. In what follows, we examine dimensions of both problems: gun violence and inadequately treated mental illness in the community. We discuss how these problems are related and not related, and highlight critical opportunities to implement a range of complementary, evidence-based solutions.

What are the dimensions of gun violence in the United States? More than 1.7 million people have been injured by firearms within the borders of the United States since the beginning of the twenty-first century, and more than 700,000 have died, a total surpassing the combined American military combat death toll of World War I and II combined. 4 Fifty-nine percent of those gun deaths were suicides, 37 percent were homicides, and the remaining 4 percent were attributable to law enforcement actions or injuries that were unintentional or of unknown intent. Mass shooting fatalities-incidents in which at least four people are murdered with a firearm-terrify the public and galvanize media attention, but they account for less than 1 percent of gun homicides. On the day of any mass shooting that claims four or more lives, an average of 124 others perish from firearm-related injuries in the United States. 5 Circumstances surrounding these deaths are diverse, ranging from suicides to gang shootings, domestic violence incidents, and arguments gone bad between impulsive, intoxicated, armed young men in the middle of the night. This is the drip, drip, drip of quotidian gun violence in America.

We do not mean, in any way, to trivialize mass shootings with this relative comparison of lives lost. Indeed, the impact of mass shootings goes far beyond their death toll. A 2019 national survey by the American Psychological Association found that 71 percent of U.S. adults reported experiencing fear of mass shootings as “a significant source of stress in their lives,” causing one out of three people to avoid certain public places. 6

Over the past two decades, while chronic disease mortality declined substantially, the gun suicide rate increased by 17 percent and the gun homicide rate by 57 percent. 7 What is different about firearm-related violence, and why does it seem so refractory to public health experts’ efforts to solve the problem? Why are we not prioritizing public resources to address gun violence in any way commensurate with the fiscal and social costs that the problem represents? The aforementioned new legislation appropriates $13 billion - not trivial - to a public health problem that costs our society an estimated $557 billion each year. 8 This total includes costs to the health care system, the criminal legal system, lost productivity and opportunities, and an attempt to place a dollar value on the lingering distress and void that victims of gun violence leave in the emotional and social lives of their loved ones and communities. There are additional costs to a great number of other people who may not have personally known victims of violence but suffer psychological trauma and high levels of anxiety simply from living in a community marked by daily violence.

What are the dimensions of serious mental illness as a public health problem? Approximately fourteen million adults in the United States suffer from a serious mental illness that causes a functional disability in one or more important areas of life activity. 9 These are severe health conditions such as schizophrenia, bipolar disorder, and recurring major depression that impair the brain's capacity to reason and regulate mood. They tend to strike young people in their late teens or twenties, often curtailing their opportunities for educational attainment and employment, and wrecking their social relationships. To have some chance at recovery and achieving their human potential, people afflicted with these disorders typically need specialized interventions, treatment, and support over an extended period. For some, their needs require services across a continuum of care, from case management, intensive outpatient treatment, and pharmacotherapy to periodic but timely hospitalizations and longer-term psychosocial rehabilitation.

That one out of three people with a serious mental illness got no treatment at all in the past year-an estimated five million total-is a tragedy and nothing short of a national scandal. 10 These are some of the most marginalized and disadvantaged members of our society, often friendless and estranged from their families, left to navigate alone a public system of care that is fragmented and overburdened, where barriers to access loom large and the professional work force is far too thinly spread. How did this happen?

In the middle of the twentieth century, one-half million adults with serious mental illnesses were housed in large state mental hospitals throughout the United States, under generally dismal conditions. They were often confined against their will and for lengthy periods of time, many of them subdued by high-dose chemical regimens of major tranquilizers and neuroleptics. All that has changed. Today, less than one-half of 1 percent of adults with serious mental illness (about forty thousand people) are treated in state psychiatric hospitals. 11 The need for inpatient psychiatric beds far exceeds the supply. 12 Many adults who experience a serious mental health crisis spend days boarding in an emergency room with little treatment while they wait for an inpatient psychiatric bed to become available. 13 Approximately one hundred thousand are living in homeless shelters or on the streets. 14

The majority of these unfortunate members of our human community are no more dangerous to others than anyone else. But they might as well be, because most adults in the United States believe that mentally ill individuals are violent, and people in general (along with the politicians they elect) tend to act on what they believe to be true. 15 This often means supporting policies that resort to coercive and punitive interventions to remove mentally ill individuals from society, without due regard for their dignity and basic humanity. An estimated 740,000 people with mental illnesses are incarcerated in state prisons and local jails. 16 On any given day, more people with disabling behavioral health conditions can be found in our biggest city jails than ever inhabited the largest asylums in the mid-twentieth century.

The causes of the dramatic historical shift in the way our society has treated (or abandoned, more accurately stated) people with mental illnesses are numerous and complex. 17 Scholars have proposed several reasons, including the discoveries in the 1950s of new pharmacotherapies that promised (prematurely, as it turned out) definitive relief from psychiatric symptoms with minimal outpatient medical management; the withering sociological and humanitarian critiques of so-called “total institutions” in the 1960s; 18 the civil libertarian reforms of involuntary commitment laws in the 1970s-disqualifying all but the “imminently dangerous” from the hospital care that many still needed and leaving them to “rot with their rights on;” 19 the divestment and devolution of centralized public mental health authorities with the advent of managed care and privatization of behavioral health services in the 1980s; 20 the continuing disappearance of subsidized and low-cost housing in many of our biggest cities; 21 and epidemic waves of illicit drug use and a misbegotten policy of mass incarceration in the 1990s, 2000s, and beyond. 22 All of these factors together contributed, in complex and intertwining ways, to a phenomenon that is often referred to elliptically as “deinstitutionalization,” but which amounted to a cruel betrayal of people with serious and disabling mental illnesses.

This is the sad state of affairs that many politicians and pundits presumably are referring to when they respond to mass shootings by saying, in essence, “Fix mental health.” Texas Governor Gregg Abbott exemplified this view in his statement following the massacre of school children in Uvalde in 2022:

We as a state, we as a society, need to do a better job with mental health. Anybody who shoots somebody else has a mental health challenge. Period. We as a government need to find a way to target that mental health challenge and to do something about it. 23

Abbott's statement, while resonating with public opinion and widespread fear of the mentally ill, collides with empirical data. The vast majority of people with serious mental illness are not violent toward others. Only an estimated 3 percent of gun homicides are perpetrated by people with serious mental illness, and as we discuss in more detail later, 4 percent of all violent behavior risk is attributable to serious mental illness in multivariable analysis. 24 It is not that mental illness poses no relative increased risk of gun violence at all, but it is not the place one would start to reduce gun violence.

Still, it is noteworthy that Abbott's blanket statement about people who shoot others refers to “mental health challenges,” not necessarily serious diagnosable mental disorders. It stands to reason that many, if not most people who shoot to kill another human being are experiencing, at the time, negative emotions antithetical to a state of mental well-being: feelings of anger, fear, anxiety, frustration, resentment, isolation, hopelessness, or despair. These fall on the extreme end of the spectrum of normal human emotions that most people might experience at some points in their lives. Psychotherapy or pharmacotherapy may help some people who experience distressing and destructive feelings. In 2020, one in five adults received some mental health treatment in the past twelve months, including 17 percent who had taken medication for their mental health and 10 percent who received counseling or therapy from a mental health professional. 25 But we do not have a behavioral health care system that is designed, organized, and financed to deliver interventions to even a fraction of all the people who experience undesirable emotional states. Even if we did, it is far from clear that currently available interventions would work well enough, and for enough of the people at highest risk, to expect to make a dent in gun violence. Meanwhile, the types of psychopathologies that our mental health system is mostly designed to treat contribute very little to the problem of gun homicides.

What causes gun violence: dangerous people or dangerous guns? How does the answer to that question constrain policy solutions, and is it the right question? At its simplest level, gun violence requires two components: injurious behavior and access to a firearm. The perception that gun violence is caused primarily by one of these ingredients or the other creates an explanatory conflict that has come to characterize our nation's highly politicized cultural divide over private rights and public safety. But finding our way to real solutions requires us to move away from this either/or perspective. In our view, both ingredients are important and even complementary concerns. Unfortunately, discussion of gun policy in the public square has become so polarized that many see only a dichotomous choice. To the right of our political center, gun rights advocates tend to view even limited gun regulations as a slippery slope that will lead to all civilians losing their guns. To the left, public health law scholars argue that government should play a major role in regulating the public's access to firearms. This view underlies safe storage requirements, the restriction of guns in sensitive places, disqualification of people at risk of harming themselves or others from possessing guns, giving law enforcement officers and judges the clear legal authority to remove guns from people who behave dangerously, and the legal prohibition of certain types of guns and ammunition.

The argument for gun regulation assumes that there will always be some people in the community at risk of harming others at certain times, but we cannot predict or control that risk with any degree of precision. Therefore, the argument goes, we should try to minimize the catastrophic damage that such behavior can do when potentiated by a firearm, by restricting access to the most lethal technologies, for certain people, at certain times and places. But comprehensive regulatory strategies to prevent firearm injury in the United States are uniquely constrained by a constitutional right to bear arms, the fact that four out of ten Americans live in a household with a gun, and the degree to which the American public is strongly divided between those committed to gun rights and those committed to gun control. 26 Thus, while many other advanced countries have successfully avoided a more serious gun violence problem by broadly restricting legal access to firearms in their populations, U.S. policymakers have had to focus selectively on prohibiting certain groups of putatively dangerous people-such as those convicted of a felony or involuntarily committed to a mental hospital-from purchasing or possessing guns. 27 Having relied on this approach for more than fifty years, the United States still suffers with a per-capita firearm fatality rate that is more than five times higher than Canada's, eight times higher than Denmark's, twelve times higher than Australia's, fifty-three times higher than the United Kingdom's, and 203 times higher than Japan's gun death rate. 28

Clearly, policies that rely on point-of-sale firearm prohibitions for people with a mental health adjudication or criminal record have not been enough to reduce gun violence in America. Moreover, the institutions responsible for determining whether someone has a gun-disqualifying record-mainly the criminal legal system and the public sector mental health care system-operate in the long shadow of America's legacy of racial discrimination. Unsurprisingly, gun restrictions fall disproportionately on communities of color, as does the burden of gun violence itself. 29 Thus, targeted categorical restrictions on who can purchase a gun from a licensed dealer have not only failed to solve America's gun violence problem, but arguably have perpetuated racial inequities. 30 Gun violence prevention policy in the United States faces the triple challenge of saving lives, respecting individuals’ constitutional rights, and promoting racial justice-and must accomplish these goals despite stiff political headwinds.

An evidence-based approach to gun violence prevention is specifically limited by the U.S. Supreme Court's interpretation of the Second Amendment, and by the state of our knowledge about which policies, legislation, and programs are most effective in both protecting the rights of law-abiding gun owners and reducing gun violence. In D.C. v. Heller (2007), the Court held that individuals, not just standing militias, have a constitutional right to possess firearms for personal protection in the home. 31 In Bruen v. New York Pistol and Rifle Association (2022), the Court substantially expanded gun rights by declaring that it was unconstitutional for a state to require an applicant for a concealed-carry license to show they had a good reason to walk around with a handgun; rather, they have a right to do so, if they are not otherwise prohibited. 32 Justice Clarence Thomas's opinion for the majority thus limits states’ ability to craft discretionary concealed-carry licensing schemes. It also requires lower appellate courts going forward to consider only constitutional “text, history, and tradition” as the criteria for deciding Second Amendment challenges to states’ existing gun restrictions. This could limit opportunities for public health science to weigh in to help courts decide whether gun-related laws today are narrowly tailored or they serve a compelling government interest (such as saving lives). 33

The Court's opinion aligns with libertarian values on the political right, marked by a general aversion to government infringement into private life and the belief that individual moral actors are solely responsible for the consequences of their bad choices. This view tends to bifurcate the population into “good people” (us) and “bad people” (them). The bad people cannot be expected to abide by gun laws, and the good people do not need such laws. According to this view, the main effect of gun control laws is to restrict good people's access to the protective weapons they need to defend themselves from the bad people. The corresponding policy solution is to have fewer laws restricting good people, and fewer bad people in the community.

The narrative that equates gun violence and mental illness is an important example of this approach. In his immediate response to a mass shooting in 2019, former President Donald Trump proposed to address gun violence by building more psychiatric hospitals in which to confine the “crazy people” that he assumed were always responsible for mass shootings: “I think we have to start building institutions again,” he said, “because you know, if you look at the ‘60s and the ‘70s, so many of these institutions were closed, and the people were just allowed to go onto the streets…. We can't let these people be on the streets.” 34

In his view that America's gun violence problem is about mental illness, not guns, the former president has prominent company. In 2018, after seventeen people were shot to death in a high school in Florida, Republican Senator from Iowa Joni Ernst stated: “The root cause is not that we have the Second Amendment. It is that we're not adequately addressing mental illness across the United States. We need to focus on that.” 35 The next year, after twenty-two people were shot to death at a Walmart in El Paso, Texas Governor Gregg Abbott again responded by saying, “Bottom line is mental health is a large contributor to any type of violence or shooting violence.” 36 And putting this view in the most succinct and provocative way, author Ann Coulter stated, “Guns don't kill people, the mentally ill do.” 37

Are they right? And how would we know? If mental illness were a driving cause of gun violence, we might expect the firearm fatality rate to be higher in states with less public funding for mental health services, fewer psychiatric beds per capita, and a higher estimated prevalence of untreated mental illness in the community. It is not. Instead, gun-related homicide and suicide rates tend to be higher in states with more guns per capita and weaker gun laws. 38 At the same time, it would be a mistake to conclude that mental health in the population is totally unrelated to gun violence; as we have suggested, most people who intentionally use a firearm to injure another person or themselves are not paragons of mental well-being. But they probably have never been involuntarily committed to a psychiatric hospital and would not be legally restricted from owning a firearm on the basis of a mental health-related adjudication record. We need better criteria. 39

The case of the shooter in Parkland, Florida, illustrates this problem. It is clear that the shooter had concerning problems and risk factors for violence in his past, but it is far from clear that he would have qualified for a gun-disqualifying mental health adjudication. 40 That is because the federal and state criteria for denying a gun purchase are not only overbroad, but too narrow. While many people who cannot legally buy guns would pose little risk of harm even if they could, many who actually do pose a risk-people with impulsive and destructive anger traits, for example-have no record that would deny them a firearm. 41

Analyses of mass shooters suggest that the perpetrators often suffer from social, emotional, and behavioral difficulties, but most have not been hospitalized against their will, nor have they been given a diagnosis of serious depression, bipolar disorder, or a thought disorder. Frequently, they have character disorders and a pattern of escalating risk marked by “changes in behavior, demeanor or appearance, uncharacteristic fights or arguments, and telling others of plans for violence, a phenomenon known as ‘leakage.’” 42 They typically do not have the sorts of mental health diagnoses that tend to characterize involuntarily committed psychiatric patients who thereby lose their gun rights. 43

Sometimes, legally mandated outpatient psychiatric treatment-either in the form of a civil court order or a condition of a criminal case diversion-can help to leverage access to intensive services for people whose mental illness has affected their ability to recognize their own need for treatment and to comply with recommended treatment, resulting in a deleterious pattern of repeated involuntary hospitalizations, arrests, or violent behavior. 44 Outpatient civil commitment and analogous legal dispositions also typically confer a firearm restriction under federal or state law. But in general, we do not have a system or procedures in place to identify high-risk individuals who have no record of a mental health adjudication or felony criminal conviction. We need criteria that are sensitive, specific, and comprehensive enough to help identify individuals at high risk of violence and ensure that they cannot purchase and possess firearms.

If we could develop the capacity to identify persons with escalating patterns of risk, and a fair and effective legal process to prevent such persons from acquiring guns, we would be better able to prevent gun homicides and suicides. Such a system requires public participation in gathering information about individuals at risk of harming themselves or others. While certain potential problems arise when enlisting the public in surveillance of their neighbors, there are also plenty of examples in which the public plays an important role in public health interventions. 45 This is the model underlying the implementation of extreme risk protection orders (also known as red flag laws), which have been shown to be effective in preventing firearm-related suicides in Connecticut and Indiana, where laws have been instituted at the state level. 46 The effectiveness of widespread public participation in the Air Force suicide prevention program is another example. This intervention consisted of instructing every single person in a targeted unit-from officers, enlisted personnel, and their families to service providers like beauticians, barbers, and commissary staff-to be on the lookout for anyone who seemed depressed, despairing, or hopeless. All individuals who appeared to have these symptoms were referred to mental health professionals for screening and interventions where appropriate. This intervention in which “the public” was mobilized resulted in previously unheard of reductions of suicide of 25-40 percent. 47

Negative and stigmatizing messages about the supposed dangerousness of mentally ill people are destructive and insidious, in part because they resonate with what a large proportion of the public already believes. Data from the 2006 General Social Survey suggest that Americans believe that people with schizophrenia are especially dangerous. After reading a vignette about an individual with common symptoms of schizophrenia, 60 percent of respondents reported that they viewed the described individual as likely or very likely to be dangerous toward others, even though the vignette description did not include any information about violent behavior or characteristics. 48

Fear and social opprobrium directed toward “the mentally ill” are rooted in Western cultural-historical beliefs going back to ancient times. People who behave in extremely strange ways-for example, those who appear to see invisible visions and hear inaudible voices, who hold bizarre beliefs or succumb to extreme emotions incongruent with the shared experience of others - have often been treated with fear, have been socially ostracized, and thought to be in need of redemptive or miraculous healing. Biblical narratives about demonic possession converge with modern descriptions of psychotic illness. It stands to reason, then, that mental illnesses would serve as a convenient scapegoat for gun violence, perhaps especially for those people with more traditional and conservative habits of thought.

Alternatively, the perspective from the political left has maintained that gun violence prevention should focus mainly on guns, even while efforts to pass gun-related legislation at the federal level have been stymied by the political power of gun rights advocates, as led and mobilized by the National Rifle Association (NRA). As a single-issue lobbying group, the NRA has been most effective in mobilizing resistance by spreading the myth that any data collection, research, or policy discussions around gun control will lead to all civilians losing their guns. The NRA has also been effective in convincing gun owners that their identity as gun owners is closely linked to their identity as someone who cares about protecting their family and their country. The NRA conducted a campaign to stop all federal funding for gun violence prevention research for more than twenty years, with the result that there remain large gaps in our scientific knowledge about what causes and how to prevent gun violence. 49

What do we know about mental illness and gun suicides? Guns were used in over half the suicides in the United States in 2020-24,292 out of 45,979 suicide deaths-and suicides account for about six out of ten firearm-related fatalities. 50 Mental illness is a strong contributor to suicide, but suicide is caused by many other factors as well and often cannot be prevented by mental health treatment alone. Access to firearms is one of the most important modifiable determinants of suicide mortality in the United States. Evidence-based firearm restrictions and policies that limit gun access to people who pose a clear risk of intentional self-harm could prevent many suicides without infringing the rights of lawful gun owners. 51

Epidemiological research has demonstrated that the relative risk of suicide is eight times higher in persons with serious psychiatric illnesses and substance-use disorders. 52 Conversely, populations with greater access to mental health care have much lower suicide rates. 53 These findings suggest that the most effective suicide prevention approaches will consist of finding high-risk persons with mental health problems and helping them to get appropriate treatment. This strategy would include protocols for screening and risk assessment for suicide in schools and clinical settings, educating the public to recognize very early signs of depression, hopelessness, or suicidal intent in others, and how to refer them to professionals for help. This approach has proven effective to a certain degree in certain settings, but behavioral health treatment is not always effective and it fails to prevent many suicides. 54 The suicide rate among patients recently discharged from psychiatric hospitals is one hundred times higher than the rate in the general population. 55 Analysis of data from the National Violent Death Reporting System finds that 27 percent of those who died from suicide were currently receiving treatment for a mental health or substance abuse condition at the time of their suicide. 56

There are many risk factors for suicide that are not related to either mental illness or addiction problems and these are not within the purview of standard mental health treatment. Averaging many different studies, the proportion of suicide risk that is attributable to mental health disorders is about 57 percent for males and 77 percent for females; the remainder of the risk is attributable to social, economic, circumstantial, and other factors that are not directly connected to psychopathology. 57 Interventions that address access to lethal means have untapped potential to prevent a large number of suicide deaths. 58 Most people who try to end their own life get a second chance, but fatality rates vary dramatically by the method of intentional self-harm. People who use firearms rarely survive; almost nine out of ten die. 59 In the United States, even though men have lower rates of depression, they are nearly four times more likely than women to die of suicide, and greater access to firearms is one reason for this. 60 Gun-safety and safe-storage practices can thus have a beneficial impact on suicide prevention, especially in the male population. The challenge is to keep guns out of the hands of people at highest risk of suicide, without unduly infringing the Second Amendment rights of many gun owners who are unlikely to harm anyone.

What do we know about mental illness and interpersonal violence? Are mental illness and interpersonal violence causally related, and if so, how? This is a simple-sounding question with a slippery answer, one that varies widely with the elastic definitions of its primary terms. 61 If we define mental illness broadly to include every pathologized pattern psychiatrists have ever characterized as conditions for which people might need their professional help-distorted thoughts, dysregulated moods, dysfunctional behavior, destructive relationships, deviant personalities, or debilitating substance use-then serious violent behavior itself can easily stand as a defining indicator of some form of mental illness. The argument goes, anyone who would shoot to kill another person must not be thinking clearly and must be mentally ill.

The most salient example of this definitional tautology is the common construal of any public mass-casualty shooting as the act of a sick mind. If we believe this to be literally true (in a clinical sense), we must ignore or deny scientific studies showing that most mass shooters do not, in fact, have a major diagnosable psychiatric disorder. Instead, they tend to be angry, alienated, resentful young men in the thrall of a deviant cultural script, and with easy access to an instrument designed to kill multiple people in seconds. 62

A much different answer is obtained when our questions define mental illness and violence independently and more precisely. For example, by how much, if at all, do the symptoms of certain well-described psychiatric illnesses-schizophrenia, bipolar disorder, and major depression-statistically increase the likelihood that people with these illnesses will intentionally engage in violent behaviors toward others within a discrete period of time? Will they hit, push, shove, kick, choke, or throw something at another person, or use a weapon like a stick, knife, or gun to harm or threaten someone? And how much does risk of violence, defined in this way, statistically increase in the presence of excessive alcohol and illicit drug use, whether alone or in combination with serious psychiatric conditions?

The first empirical answers to these questions came more than three decades ago from the landmark National Institute of Mental Health (NIMH) Epidemiologic Catchment Area (ECA) study. 63 A careful understanding of the study's groundbreaking design and method is important to seeing why its powerful findings mattered then, and still matter now. Research teams conducted structured psychiatric diagnostic interviews with more than ten thousand randomly selected adults living in Baltimore, St. Louis, and Los Angeles and surrounding areas. The ECA researchers conducted a lengthy confidential household interview with each selected participant, first gathering systematic information about the presence or absence of symptoms of specific behavioral health disorders as codified by the American Psychiatric Association's diagnostic manual. 64 After the data were assembled, a computer algorithm was used to analyze each respondent's symptom pattern and mimic a trained psychiatrist's diagnostic assessment; a putative lifetime diagnosis of one or more psychiatric disorders was assigned to those who had ever met the corresponding clinical criteria, a past-year diagnosis to those who qualified with active symptoms in the previous twelve months.

The ECA study's interview also included questions about whether the participant had ever engaged in specific violent behaviors, and how recently. The behaviors included getting into a physical fight while drinking, hitting or throwing things at a domestic partner, hitting a child hard enough to cause a bruise or require medical attention or bedrest, engaging in physical fights that came to swapping blows with other people (not a domestic partner or child, irrespective of drinking), and using a weapon such as a stick, knife, or gun in a fight.

Importantly, the study's community-representative random sampling design avoided the selection bias inherent in two kinds of previous research: retrospective studies of violence in psychiatric patients found in hospitals, secure forensic facilities, and intensive community treatment programs; and studies of psychopathology in people arrested or incarcerated for violent crimes. 65 These earlier studies tended to vastly overestimate the connection between interpersonal violence and mental illness in the community, and it is not difficult to see why. They only looked at the very small proportion of mentally ill individuals who had already been identified as violent, or who needed treatment in a confined or supervised setting to mitigate the risk of harm.

The ECA study found a modest but statistically significant association between having a serious mental illness alone (schizophrenia, bipolar disorder, or depression without co-occurring alcohol or drug-use disorder) and committing one or more acts of interpersonal violence in the previous year. Approximately 7 percent of adults with these disorders reported that they had engaged in some minor or serious violent behavior in the previous year, compared with 2 percent of the general population of adults without these illnesses.

To test whether the increased relative risk might be explained by other correlates of violence that could be more common in people with mental illnesses, the researchers conducted a multivariable analysis that accounted for the independent and covarying effects of age, sex, race, marital status, and socioeconomic status (the latter being a composite of information on income, educational attainment, and occupational prestige). The results held up in a controlled model. Stated in terms of relative risk, then, people with serious mental illnesses were about three times more likely to be violent than those without those illnesses. When respondents with co-occurring substance use disorders were included among those with the aforementioned disorders, the prevalence of any violence went to 12 percent in the past year, and 25 percent ever in the person's lifetime. 66

But the findings could be viewed another way. The absolute risk in people with serious mental illnesses was very low. While it was true these individuals were three times more likely to be violent than other people, it was equally true that the vast majority-97 percent-did not engage in violent behavior. Moreover, the ECA data could be arrayed to answer yet another question, and perhaps even a policy-relevant question about violence and mental illness. If we were to succeed in curing all serious mental illnesses (or at least eliminating any excess violence-risk linked to them), how much less violence would we have in society? The ECA data's answer to that intriguing counterfactual question was that violence would go down by approximately 4 percent, and 96 percent of it would remain.

But if not mental illness, then what is the major driver of violence? The ECA project had an answer to that question, too-one that has been confirmed and elaborated in many other studies in the ensuing decades. 67 The analysis showed there is no one cause, no one explanation, and therefore no one solution to the problem. Rather, violence is caused by many factors that interact with each other in complex ways. Much of it is about demographics, resources, and position in social structure. Violence rates are by far the highest in young men with lower incomes, less education, and either no employment or poorly paid jobs with little prestige. 68 What role does hopelessness play in making violence a way to relieve anger and frustration, a way that does not seem to the shooters to come with a particularly high cost? Should our mental health “system” try to find and help people who are feeling angry and hopeless? What would it take to build the capacity for this?

Alcohol and illicit drug use disorders dramatically increase the risk of violent behavior, especially in combination with other risk factors. In the ECA study, approximately 34 percent of the population risk of violence was attributable to substance abuse; there are several reasons for this. Part of the correlation is due to the pharmacological effects of psychoactive substances. Alcohol, for example, is a central nervous system depressant that can alter mood, distort judgment, heighten perception of threat and malevolent intent from others, and disinhibit aggressive impulses. Intoxication may enable otherwise controlled negative affective states-such as feelings of anger, resentment, envy, or jealousy-to find expression in overtly injurious physical acts of violence directed at others. Psychoactive substances may also increase violence-risk in some individuals by exacerbating certain psychiatric symptoms, such as persecutory delusions, which can sometimes motivate instrumental acts of violence as retaliation for imagined victimization.

Problematic substance use can lead to violence by creating extreme conflict in social relationships, and by exposing affected individuals to social networks such as those involved with illegal drug markets where violence might be normalized. Finally, the nexus of alcohol and drugs and violence can be self-perpetuating, through observed and learned behavior in early development, reinforcement of substance use and violence as a maladaptive response to conflict or economic deprivation, and exposure to environments where these are linked in socially toxic surroundings. We as a country do not have the capacity to treat all those suffering from addiction to alcohol or other drugs. There are, however, compelling arguments-social, economic, medical, and moral-why we should develop that capacity.

A range of effective public policies to prevent gun violence must address both lethal means and the behavior of people at risk-tailoring restrictions on access to guns, expanding access to behavioral health services, and mitigating the cultural, social-economic, and political determinants of using guns in harmful ways. The potential for developing and expanding a complementary, evidence-based approach to both improving mental health and reducing gun violence in the population gives us reason to hope we will one day live in a society with greater community well-being and far less gun violence. A general strategy to reduce the burden of gun violence without infringing on the rights of law-abiding gun owners is to keep guns away from people who should not have them. This is difficult, but not impossible.

There are several parts to the task. First, we need to identify all the people who are already legally prohibited from possessing firearms and ensure that, in fact, they do not have access to firearms, which could be done through comprehensive record reporting, expanded background checks, and tamping down illegal transfers on the secondary gun market. Second, we need to identify people who are at high risk of using guns to harm themselves or others but do not yet (for various reasons) have a gun-disqualifying record and could pass a background check to buy a gun from a licensed firearm dealer. These individuals, too, should be separated from firearms. Reforms are needed in our existing legal criteria for prohibiting guns-especially in some states-so that the restrictions would apply to high-risk individuals such as those convicted of violent misdemeanors, persons subject to temporary domestic violence orders of protection, and those with multiple drunk-driving convictions. 69

The criteria of mental illness, when further specified and judiciously applied, may be one way to identify high-risk individuals, that is, to the extent that injurious behavior directed toward others or themselves is indeed related to some particular manifestations of mental illness. Examples include suicidal depression, paranoid delusions with homicidal command hallucinations, and posttraumatic stress rooted in violent victimization, especially when these states of compromised mental health are combined with alcohol or other drug intoxication. But we need ways to focus on the highest risk subjects rather than trying to prevent violence by “fixing the mental health system.” If violence-prevention is the primary goal, we should focus narrowly on ways to identify and deliver timely interventions to people at high risk of harming themselves or others, at limited times when they are at their highest risk. Interventions should both provide access to treatment services and remove access to lethal means. For people experiencing a dangerous mental health crisis, extreme risk protection orders (ERPOs) used in conjunction with short-term involuntary hospitalization illustrate how different legal tools can work together to address both the how and the why of a potential suicide.

There are certainly improvements to be made in our behavioral health care system that could reduce vectors of violence in the community, at least indirectly- for example, expanding drug-addiction treatment and certain criminal diversion programs, and fixing the psychiatric bed shortage (or misallocation, poor distribution of inpatient capacity). These efforts could help alleviate several aspects of the problem that are made worse by untreated psychiatric illness: homelessness, mass incarceration of people with serious mental illnesses, and emergency room boarding of acutely ill psychiatric patients. Each of these problems amounts to a domestic humanitarian crisis of its own, in a country that must do far better.

Involuntary commitment criteria may help to select a population at higher risk of gun violence; the existing criteria that include dangerousness to self or others are specific and make sense, as long as there are opportunities for restoration of rights after a suitable period of time has passed to allow risk to subside. 70 But involuntary commitment to a hospital has never been a very sensitive criterion for gun disqualification, and is even less so now, in a world after deinstitutionalization has run its course and we have very low rates of psychiatric hospitalization (whether involuntary or not). Thus, trying to disqualify only such people from purchasing guns will miss the largest group of persons with symptoms of mental illness who go on to commit violent acts. A longitudinal study of 23,292 previously hospitalized, public-sector patients with a diagnosis of serious mental illness in Connecticut reported that 96 percent of violent crimes in the study population were perpetrated by individuals who had never been involuntarily committed to a hospital, a group ostensibly receiving less inpatient treatment and who did not lose their gun rights through the mental health prohibitor. 71 A nationally representative psychiatric epidemiological study described a group of adults with impulsive anger problems and access to firearms, comprising an estimated 8.9 percent of the adult population of the United States. A substantial proportion of these individuals with destructive and uncontrolled anger combined with gun access met criteria for some type of psychopathology (including personality disorders and substance use disorders), but only one in ten had been admitted to a hospital for a mental health problem. The majority with this risky combination of impulsive anger and access to guns would not have lost their firearm rights through involuntary commitment. 72

A clinical or judicial finding of dangerousness in conjunction with brief emergency psychiatric hospitalization for evaluation should be leveraged to at least temporarily limit a mentally ill person's ability to legally purchase a firearm, irrespective of whether a formal involuntary commitment occurs. Studies suggest that violence-risk in psychiatric patients is not necessarily inherent or persistent but rather a function of fluctuating risk factors that select people into different clinical settings at different moments in the course of their illness. Violence-risk tends to be elevated during times of crisis and is most likely to become apparent in periods immediately surrounding contact with the mental health care system during these crises. Involuntary commitment proceedings tend to occur at such times and result in a legal restriction of firearms. Short-term holds for a psychiatric examination also coincide with crises but, in twenty-eight states, do not affect firearms rights. This is an opportunity for reform. 73

What reforms are most needed and would work best to prevent gun violence and improve outcomes for people with mental illnesses? The Safer Communities Act was an encouraging step, in that it incorporates interventions and policies that were scientifically investigated and found to be effective. Research can help to design and evaluate interventions that will simultaneously reduce gun violence and protect the rights of law-abiding citizens. Basically, this means keeping guns out of the hands of persons who cannot legally have them but allowing law-abiding citizens to have and use them. Examples of programs and policies that do this include gun licensing, safe storage regulations, enforcement of laws prohibiting gun ownership by persons convicted of domestic violence felonies or misdemeanors, ERPOs or red-flag laws, waiting periods, and uniform background checks without loopholes. Science can also help us find and evaluate more programs and interventions like these. 74

There should not be a forced choice between suicide-prevention policies that increase the public's access to mental health treatment interventions and those that decrease at-risk individuals’ access to firearms. Both approaches have their place and should be complementary. Both approaches should also be designed to target individuals at high risk for shooting themselves or another. Gun restrictions that apply to people with mental illnesses must be narrowly focused on behavioral indicators of suicide risk to avoid stigmatizing people in recovery and unduly restricting the rights of millions of people who pose no elevated risk of harming themselves or others. 75 But crisis-focused behavioral health care interventions are unlikely to substantially curtail the population-level prevalence of suicidal thoughts and self-injurious behaviors. In the interest of keeping more people alive who will inevitably experience the impulse to end their own life, policy-makers in the United States should put more emphasis on expanding the use of tailored legal tools to reduce such individuals’ access to firearms. The statutory reforms summarized below are targeted, achievable modifications to existing constitutionally tested policy templates that could save lives when enacted at the state or federal level.

First, state legislators should expand and sharpen gun-prohibiting legal criteria to better align with risk. 76 This would ensure that a greater proportion of individuals at risk of suicide would not have access to a gun during a season of hopelessness or a moment of intoxicated despair. States should prohibit purchase and possession of or access to firearms for a temporary period of time by persons with a record of a brief involuntary hold for a psychiatric examination. And they should prohibit purchase and possession of or access to firearms for persons with a record of repeated alcohol-impaired driving, because these individuals are very likely to suffer from alcohol-dependence disorder, which is an especially robust risk factor for lifetime suicide risk. 77 State legislators could institute a time-limited gun prohibition-five to ten years-applicable to anyone who acquires a second DUI conviction. 78 This would not prevent such a person from ever feeling suicidal, but it would reduce their access to the most lethal method of suicide and make any future suicide attempts much more survivable.

Second, state legislators should enact and widely implement ERPO laws that enable police officers or, in some states, concerned family members and health care providers to seek a civil restraining order to temporarily remove firearms from a person who is behaving dangerously. 79 The twenty-one states and the District of Columbia that have already enacted such laws could improve them, and those states that have not yet enacted such laws can design and implement them using funds made available from the Safer Communities Act. ERPOs should confer a purchase prohibition in the FBI‘s background-check database to prevent persons who are behaving dangerously from acquiring firearms. ERPOs should be applicable to persons under age eighteen who meet the risk-criteria specified in the statute. Clinicians should be authorized to petition for an ERPO for their patients who pose a significant risk of harming themselves or others. States should authorize ERPO petitioners to include physicians and other primary care and mental health care providers. States should adopt an innovative policy known as precommitment against suicide (PAS), or voluntary self-enrollment in the NICS. 80 The PAS amounts to a self-initiated, opt-in waiting period for buying a gun, and it could save many lives. 81

To meaningfully reduce gun violence, more community-based work is needed that is focused neither on guns nor persons with mental illness. When we talk about firearm-injury prevention, we typically consider prevention strategies that are directly tied to individuals who possess firearms, such as safe storage, background checks, ERPOs, licensing, and carrying. From the legal design of gun restrictions to the mechanical design of guns themselves, these are all clearly important, but we need more. The roots of our gun-violence problem run deeper, and so must our policies to contain and excise it. The roots that need to be examined include the social and economic determinants of gun violence like poverty, racism, discrimination, and lack of access to jobs, health care, and quality education. 82 Evidence-based policies for prevention of community violence include promoting family environments that support healthy development, providing quality education early in life, strengthening young people's skills, connecting youth to caring adults and activities, creating protective environments such as by changing the physical design of communities, intervening to lessen harms and prevent future risk, street outreach, and hospital-based programs for victims and survivors of gun violence. Many of these latter types of strategies have been emphasized by the White House and others as part of their efforts to address community violence. 83 Political strategies to develop bipartisan support for laws and policies such as the Safer Communities Act will, incrementally and over the long term, reduce the gun violence toll.

Ecologist Garrett Hardin first used the term “tragedy of the commons” to describe what happens when individuals have access to a community resource for which they do not have to pay. 84 They tend to take only their self-interest into account and deplete the public resource. For example, if there is a common pasture in a town where families can let their cows graze for free, there will soon be too many cows eating too little grass and the commons will be stripped bare. Alexandra Spiliakos, writing for Harvard Business School Online, aptly describes this phenomenon:

[Individuals tend to] … make decisions based on their personal needs, regardless of the negative impact it may have on others. In some cases, an individual's belief that others won't act in the best interest of the group can lead them to justify selfish behavior. Potential overuse of a common-pool resource-hybrid between a public and private good-can also influence individuals to act with their short-term interest in mind, resulting in the use of an unsustainable product and disregard for the harm it could cause to the environment or general public. 85

An individual's decision to purchase a firearm for personal protection is a self-interested act that carries little real cost-until the tragedy of the commons eventually follows. When many people in the community feel the same need to acquire their own guns, the purpose of the first individual's self-interested act is defeated. Everyone is less safe when all are armed. More guns will be stolen and resold illegally and used to commit crimes. In turn, more people will feel unsafe and perceive a need to acquire guns. Even more guns will be purchased, and more residents will feel threatened. The U.S. gun industry, the NRA, and a generation of politicians in their sway have capitalized on this phenomenon, to the ultimate detriment of our civil society and at the cost of many lives lost and families and communities damaged by fear and anxiety.

Consider another relevant example: imagine that a single unsheltered person with mental disability appears on a village green, asking for money to survive. Other citizens feel generous and open their wallets. But when many citizens in large urban centers encounter a growing mass of homeless people with untreated serious mental illnesses encamped on the streets and in city parks, everyone feels threatened; eventually, a whole community's sense of security erodes. In that social environment, imagine that a single act of violence occurs and is attributed to a “homeless mentally ill” subway denizen. Public fear escalates as public trust recedes. Media narratives amplify the story and accentuate its resemblance to a culturally entrenched urban myth about violent insanity. Is it any wonder, then, that a mass shooting prompts cries to “fix mental health”? Or that popular state laws authorizing mandatory outpatient mental health treatment-Kendra's Law in New York, Laura's Law in California, and Kevin's Law in Michigan-are named for victims of homicides committed by people with serious mental illness?

The tragedy of the commons helps us understand how the proliferation of guns can erode the social fabric. With this in mind, we must take the measure of gun violence not only on the dimension of public safety, but overall community well-being. For many individuals, guns provide pleasure, affinity with other gun owners, a sense of personal efficacy, and security. But at a certain point, as economist David Hemenway and his colleagues have shown, a large number of guns in a community is associated with increased levels of homicide, suicide, and unintentional injury. 86 These, in turn, bring increased anxiety, fear, and loss. A sense of danger from homeless persons with behavioral health disorders in the community also contributes to increased anxiety and diminished quality of life. The erosion of the social safety net imposes great burdens on many communities. In responding to all these actual and perceived threats, accurate and effectively delivered information can help individuals and communities reduce their risks and destigmatize mental illness.

In moving toward prevention, it will be important to address the social and economic determinants of health that so often result in infectious diseases and injuries taking a disproportionately large toll on the poor and marginalized communities. Lingering racial disparities and inequality in the functioning of our nation's health care organizations, human services and social welfare institutions, and (perhaps especially) in our criminal legal system all reflect our cultural habits of thought as well as political priorities. These are historically entrenched but can be dislodged to make way for serious reforms. To be sure, thoroughgoing change is needed both in social structures and attitudes that perpetuate racial inequality in communities most adversely affected by gun violence. But the very proposed solutions to the problem must also avoid reproducing and reinforcing the patterns of racial inequality already embedded in these systems, such as expanding draconian prison sentences for certain gun-related infractions that are likely to fall heavily on overpoliced and overincarcerated young Black men.

The social and economic determinants of gun violence are complex and long-standing, and they are intertwined with the abandonment of disempowered and marginalized communities. These include people of color and those with serious mental illnesses, but also the legions of traumatized veterans, and the unemployed or underemployed workers now marooned in economically moribund small towns and rural and agricultural communities left behind by global economic development. Urban gun homicide and rural gun suicide are very different problems with distinct causes, yet they echo from common canyons of human despair. We need a different way of approaching these long-standing and complex problems. They are all too often ignored because they have many causes, require multisectoral collaboration, and cannot be solved without a substantial appropriation of public resources. They also take far longer to solve than the length of a politician's term in office: most politicians want to support programs that are likely to yield easily measured and impressive results before they are next up for reelection. In this light, the Bipartisan Safer Communities Act provides a heartening exception to what has been a dismal norm in the bitterly divided politics of our day: that our existing democratic governance structures seem to have lost the capacity to deliver substantial, equitable, and evidence-based solutions to difficult social problems.

Critical policy opportunities are emerging to reduce gun violence and create safer communities with healthier people. To seize these opportunities, we must communicate effectively. How we communicate information about gun violence to legislators and the public is vitally important. 87 We have learned from our country's experience with COVID-19. We now have a range of interventions that might be thought of as “vaccines against violence”: firearm licensing, universal background checks, ERPO laws, safe storage, and laws that prohibit persons with records as violent misdemeanants, habitual drunk drivers, or domestic abusers from purchasing firearms. Over time, research can help us identify and test more and more of these “immunizations” against firearm injuries. But we will still need to overcome our own version of vaccine hesitancy. We will have to overcome the myth that research and policy to prevent gun violence will lead to everyone losing all their guns. This is a myth that has polarized our citizens and politicians into two camps: gun rights and gun control. We must develop the evidence base for gun violence prevention, but that by itself will not be enough. With science, we can find those interventions that will both reduce the toll of gun violence and protect the rights of law-abiding gun owners. But vaccines don't prevent illness; vaccinations do. Laws like the Safer Communities Act provide an opportunity for effective prevention, but they must be implemented to have an impact. We must draw upon the important lessons from marketing and behavior change to design campaigns that will reach gun owners and gun violence prevention advocates alike, to reinforce the notion that they share a common goal in wanting to reduce the toll of gun violence. We can find ways to do this by working in our homes and our communities.

We need to put the public back into an active role in public health, whether the prevalent affliction to be solved is COVID-19, serious mental illness, or gun violence. Government institutions-even operating at all levels-cannot by themselves do everything necessary for effective prevention. As we saw in the Air Force experiment for suicide prevention, a bigger impact than ever before was achieved by mobilizing and involving the whole community. 88 Solving big problems like gun violence and mental illness require ambitious policies. They also require individual people who care deeply for their families, friends, neighbors, and communities-people who learn to care, perhaps especially, for those they may disagree with. The golden rule provides a good guide. There is a way out of the morass of gun violence in which we currently find ourselves. We remain optimistic that we can solve this problem if we have the courage to act, the moral compass to steer us toward equity, and the wisdom to use science to find those solutions that both reduce gun violence and protect the gun rights provided by our Constitution.

Sheryl Gay Stolberg, “For Gun Violence Researchers, Bipartisan Bill Is a ‘Glass Half Full,’” The New York Times , June 27, 2022, https://www.nytimes.com/2022/06/26/us/politics/gun-control-research-bipartisan-bill.html .

Bipartisan Safer Communities Act of 2022, Pub. L. No. 117-159, 136 Stat. 1313 (2022).

Centers for Disease Control and Prevention (CDC), “WISQARS: Web-based Injury Statistics Query and Reporting System,” last modified August 23, 2023, https://www.cdc.gov/injury/wisqars/index.html .

This is a daily average calculated from CDC data reporting a total of 45,222 firearm-related deaths in the United States in 2020, the latest year reported as of this writing.

Wendy Rubin, Stress in America: Stress and Current Events (Washington, D.C.: American Psychological Association, 2019), https://www.apa.org/news/press/releases/stress/2019/stress-america-2019.pdf . See also American Psychological Association, “One-Third of U.S. Adults Say Fear of Mass Shootings Prevents Them from Going to Certain Places or Events,” August 15, 2019, https://www.apa.org/news/press/releases/2019/08/fear-mass-shooting .

Melonie Heron, Deaths: Leading Causes for 2017 , National Vital Statistics Reports, vol. 68, no. 6 (Atlanta: Centers for Disease Control and Prevention: 2019), https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_06-508.pdf .

Everytown for Gun Safety, “The Economic Cost of Gun Violence,” July 19, 2022, https://everytownresearch.org/report/the-economic-cost-of-gun-violence .

Substance Abuse and Mental Health Services Administration (SAMHSA), “2020 NSDUH [National Survey of Drug Use and Health] Detailed Tables,” January 11, 2022, https://www.samhsa.gov/data/report/2020-nsduh-detailed-tables .

Ted Lutterman, Robert Shaw, William Fisher, and Ronald Manderscheid, Trends in Psychiatric Inpatient Capacity, United States and Each State, 1970 to 2014 (Alexandria, Va.: National Association of State Mental Health Program Directors, 2017), https://www.nasmhpd.org/sites/default/files/TACPaper.2.Psychiatric-Inpatient-Capacity_508C.pdf . See also Ted Lutterman and Ronald Manderschied, Trends in Total Psychiatric Inpatient and Other 24-Hour Mental Health Residential Treatment Capacity, 1970 to 2014 (Alexandria, Va.: National Association of County Behavioral Health and Developmental Disability Directors, 2017), https://www.nasmhpd.org/sites/default/files/2%20NRI-2017%20NRI%20Meeting–Distribution%20of%20Psychiatric%20Inpatient%20Capacity%2C%20United%20States_0.pdf .

Eric Slade and Marisa Elena Domino, “Are There Enough Inpatient Psychiatric Beds?” in The Palgrave Handbook of American Mental Health Policy , ed. Howard H. Goldman, Richard G. Frank, and Joseph P. Morrissey (London: Palgrave Macmillan, 2020), 129-169.

Kimberly Nordstrom, Jon S. Berlin, Sara Siris Nash, et al., “Boarding of Mentally Ill Patients in Emergency Departments,” Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health 20 (5) (2019): 690-695, https://doi.org/10.5811/westjem.2019.6.42422 .

U.S. Department of Housing and Urban Development, “HUD 2015 Continuum of Care Homeless Assistance Programs Homeless Populations and Subpopulations,” October 27, 2015, https://files.hudexchange.info/reports/published/CoC_PopSub_NatlTerrDC_2015.pdf .

John S. Rozel and Edward P. Mulvey, “The Link between Mental Illness and Firearm Violence: Implications for Social Policy and Clinical Practice,” Annual Review of Clinical Psychology 13 (2017): 445-469, https://doi.org/10.1146/annurev-clinpsy-021815-093459 .

Jennifer Bronson and Marcus Berzofsky, Indicators of Mental Health Problems Reported by Prisoners and Jail Inmates, 2011-12 (Washington, D.C.: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 2017), https://bjs.ojp.gov/content/pub/pdf/imhprpji1112.pdf .

Gerald N. Grob, “The Paradox of Deinstitutionalization,” Society 32 (5) (1995): 51-59, http://hdl.handle.net/10822/885508 . For a more recent review and commentary, see Andrew Scull, “‘Community Care’: Historical Perspective on Deinstitutionalization,” Perspectives in Biology and Medicine 64 (1) (2021): 70-81, https://doi.org/10.1353/pbm.2021.0006 .

Erving Goffman, Asylums: Essays on the Condition of the Social Situation of Mental Patients and Other Inmates (New York: Anchor Books, 1961). The book comprises four free-standing essays that are considered classics in twentieth-century sociology: “On the Characteristics of Total Institutions,” “The Moral Career of the Mental Patient,” “The Underlife of a Public Institution,” and “The Medical Model and Mental Hospitalization.”

Paul Appelbaum, Almost a Revolution: Mental Health Law and the Limits of Change (Oxford: Oxford University Press, 1994). See also W. Lawrence Fitch and Jeffrey W. Swanson, who write, “Allowing people to ‘rot with their rights on,’ as Paul Appelbaum and Thomas Gutheil once put it (echoing Darryl Treffert, in his 1973 letter), is inhumane-assuming, of course, that the treatments occasioned by commitment, even if provided over objection, are effective and can prevent or mitigate such suffering.” W. Lawrence Fitch and Jeffrey W. Swanson, Civil Commitment and the Mental Health Care Continuum: Historical Trends and Principles for Law and Practice (Rockville, Md.: Substance Abuse and Mental Health Services Administration, Office of the Chief Medical Officer, 2019), 26, https://www.samhsa.gov/sites/default/files/civil-commitment-continuum-of-care.pdf . See also Paul S. Appelbaum and Thomas G. Gutheil, “‘Rotting with Their Rights On’: Constitutional Theory and Clinical Reality in Drug Refusal by Psychiatric Patients,” Journal of the American Academy of Psychiatry and the Law 7 (3) (1979): 306-315, https://jaapl.org/content/jaapl/7/3/306.full.pdf ; and Darold A. Treffert “Dying with Their Rights On,” American Journal of Psychiatry 130 (9) (1974): 1041, https://doi.org/10.1176/ajp.130.9.1041 .

David Mechanic and David A. Rochefort, “Deinstitutionalization: An Appraisal of Reform,” Annual Review of Sociology 16 (1990): 301-327, https://doi.org/10.1146/annurev.so.16.080190.001505 .

Meghan P. Carter, “How Evictions from Subsidized Housing Routinely Violate the Rights of Persons with Mental Illness,” Northwestern Journal of Law & Social Policy 5 (1) (2010): 118-148, https://scholarlycommons.law.northwestern.edu/njlsp/vol5/iss1/5 .

See Risdon N. Slate, “Deinstitutionalization, Criminalization of Mental Illness, and the Principle of Therapeutic Jurisprudence,” Southern California Interdisciplinary Law Journal 26 (2) (2017): 341-356, https://gould.usc.edu/why/students/orgs/ilj/assets/docs/26-2-Slate.pdf .

Mary Kekatos, “As Gov. Abbott Places Shooting Blame on Mental Health, What Has Texas Done to Address It?” ABC News, May 27, 2022, https://abcnews.go.com/Health/gov-abbott-places-shooting-blame-mental-health-texas/story?id=84993527 .

Jeffrey W. Swanson, Elizabeth E. McGinty, Seena Fazel, and Vickie M. Mays, “Mental Illness and Reduction of Gun Violence and Suicide: Bringing Epidemiologic Research to Policy,” Annals of Epidemiology 25 (5) (2015): 366-376, https://doi.org/10.1016/j.annepidem.2014.03.004 .

Emily P. Terlizzi and Tina Norris, “Mental Health Treatment among Adults: United States 2020,” NCHS Data Brief 419 (Hyattsville, Md: National Center for Health Statistics, 2021), https://www.cdc.gov/nchs/data/databriefs/db419.pdf .

District of Columbia v. Heller , 128 S. Ct. 2783, 554 U.S. 570, 171 L. Ed. 2d 637, 2008. The Heller decision doctrine was extended to the states in McDonald v. City of Chicago , 561 U.S. 3025, 130 S. Ct. 3020, 177 L. Ed. 2nd 894, 2010. See also Kim Parker, Juliana Menasce Horowitz, Ruth Igielnik, et al., “America's Complex Relationship with Guns: An In-Depth Look at the Attitudes and Experiences of U.S. Adults,” Pew Research Center, June 22, 2017, http://www.pewsocialtrends.org/2017/06/22/americas-complex-relationship-with-guns .

Gun Control Act of 1968, Pub. L. No. 90-618, 82 Stat. 1213-2, 18 U.S. Code § 922 (g)(4).

World Population Review, “Gun Deaths by Country, 2021,” https://worldpopulationreview.com/country-rankings/gun-deaths-by-country (accessed September 15, 2021).

Jeffrey W. Swanson, “The Color of Risk Protection Orders: Gun Violence, Gun Laws, and Racial Justice,” Injury Epidemiology 7 (1) (2020): 1-6, https://doi.org/10.1186/s40621-020-00272-z .

Centers for Disease Control and Prevention, “WISQARS: Web-based Injury Statistics Query and Reporting System”; and Jeffrey W. Swanson, Colleen L. Barry, and Marvin S. Swartz, “Gun Violence Prevention and Mental Health Policy,” in The Palgrave Handbook of American Mental Health Policy , ed. Howard H. Goldman, Richard G. Frank, and Joseph P. Morrissey (London: Palgrave Macmillan, 2020), 510-542, https://doi.org/10.1007/978-3-030-11908-9_18 .

District of Columbia, et al. v. Dick Anthony Heller , 554 U.S. 570, 171 L. Ed. 2d 637, 2008.

New York State Rifle & Pistol Association, Inc., et al., v. Kevin P. Bruen, in his Official Capacity as Superintendent of New York State Police, et al. , 597 U.S.____, 213 L. Ed. 2d 387, 2022. See also Ali Rosenblatt, “Proper Cause for Concern: New York Rifle & Pistol Association v. Bruen,” Duke Journal of Constitutional Law and Public Policy 17 (1) (2022): 239, https://scholarship.law.duke.edu/cgi/viewcontent.cgi?article=1212&context=djclpp_sidebar .

New York State Rifle &Pistol Association, Inc., et al., Petitioners, v. Kevin P. Bruen, in his Official Capacity as Superintendent of New York State Police, et al .

Maegan Vazquez, “Trump Suggests Opening More Mental Institutions to Deal with Mass Shootings,” CNN, August 15, 2019. https://www.cnn.com/2019/08/15/politics/trump-guns-mental-institutions .

Jason Noble, “Mental Health Care, Not Gun Regulation, Is Key to Ending Mass Shootings, Joni Ernst Says,” Des Moines Register , February 15, 2018, https://www.desmoinesregister.com/story/news/2018/02/15/mental-health-care-not-gun-regulation-key-ending-mass-shootings-joni-ernst-says/342007002 .

Jolie McCullough and Alain Stephens, “Greg Abbott Invoked Mental Illness after the El Paso Shooting. There's Been No Indication that Was a Factor,” The Texas Tribune , August 8, 2019, https://www.texastribune.org/2019/08/08/el-paso-shooting-greg-abbott-mental-illness .

Ann Coulter, “Guns Don't Kill People, the Mentally Ill Do,” January 16, 2013, http://www.anncoulter.com/columns/2013-01-16.html .

Swanson, Barry, and Swartz, “Gun Violence Prevention and Mental Health Policy.”

Jeffrey W. Swanson, Nancy A. Sampson, Maria V. Petukhova, et al., “Guns, Impulsive Angry Behavior, and Mental Disorders: Results from the National Comorbidity Survey Replication (NCS-R),” Behavioral Sciences and the Law 33 (2-3) (2015): 199-212, https://doi.org/10.1002/bsl.2172 .

Jaclyn Schildkraut, Rebecca G. Cowan, and Tessa M. Mosher, “The Parkland Mass Shooting and the Path to Intended Violence: A Case Study of Missed Opportunities and Avenues for Future Prevention,” Homicide Studies (2022), https://doi.org/10.1177/10887679211062518 .

Alan R. Felthous and Jeffrey Swanson, “Prohibition of Persons with Mental Illness from Gun Ownership under Tyler,” The Journal of the American Academy of Psychiatry and the Law 45 (4) (2017): 478-484, https://jaapl.org/content/45/4/478 .

Sheila Dewan, “What are the Real Warning Signs of a Mass Shooting?” The New York Times , August 23, 2022, https://www.nytimes.com/2022/08/22/us/mass-shootings-mental-illness.html .

Ibid.; and Swanson, Sampson, Petukhova, et al., “Guns, Impulsive Angry Behavior, and Mental Disorders.”

Jeffrey W. Swanson, Richard A. Van Dorn, John Monahan, and Marvin S. Swartz, “Violence and Leveraged Community Treatment for Persons with Mental Disorder,” American Journal of Psychiatry 163 (8) (2006): 1404-1411, https://doi.org/10.1176/ajp.2006.163.8.1404 .

Ginny Brunton, James Thomas, Alison O'Mara-Eves, et al., “Narratives of Community Engagement: A Systematic Review-Derived Conceptual Framework for Public Health Interventions,” BMC Public Health 17 (2017): 944, https://doi.org/10.1186/s12889-017-4958-4 .

Jeffrey W. Swanson, Michael A. Norko, Hsiu-Ju Lin, et al., “Implementation and Effectiveness of Connecticut's Risk-Based Gun Removal Law: Does It Prevent Suicides?” Law and Contemporary Problems 80 (2) (2017): 101-128, https://scholarship.law.duke.edu/lcp/vol80/iss2/8 ; Jeffrey W. Swanson, Michele M. Easter, Kelly Alanis-Hirsch, et al., “Criminal Justice and Suicide Outcomes with Indiana's Risk-Based Gun Seizure Law,” Journal of the American Academy of Psychiatry and Law 47 (2) (2019): 188-197, https://hdl.handle.net/1805/22638 ; Jeffrey W. Swanson, “Understanding the Research on Extreme Risk Protection Orders: Varying Results, Same Message,” Psychiatric Services 70 (10) (2019): 953-954, https://doi.org/10.1176/appi.ps.201900291 ; and April M. Zeoli, Shannon Frattaroli, Leslie Barnard, et al., “Extreme Risk Protection Orders in Response to Threats of Multiple Victim/Mass Shooting in Six U.S. States: A Descriptive Study,” Preventive Medicine 165 (2022): 107304, https://doi.org/10.1016/j.ypmed.2022.107304 .

Kerry L. Knox, Steven Pflanz, Gerald W. Talcott, et al., “The U.S. Air Force Suicide Prevention Program: Implications for Public Health Policy,” American Journal of Public Health 100 (12) (2010): 2457-2463, https://doi.org/10.2105/AJPH.2009.159871 .

Bernice A. Pescosolido, Jack K. Martin, J. Scott Long, et al., “‘A Disease Like Any Other’? A Decade of Change in Public Reactions to Schizophrenia, Depression, and Alcohol Dependence,” American Journal of Psychiatry 167 (11) (2010): 1321e30, https://doi.org/10.1176/appi.ajp.2010.09121743 ; and Bernica A. Pescosolido, John Monahan, Bruce G. Link, et al., “The Public's View of the Competence, Dangerousness, and Need for Legal Coercion of Persons with Mental Health Problems,” American Journal of Public Health 89 (9) 1999: 1339-1345, https://doi.org/10.2105/AJPH.89.9.1339 .

Brian Dawson, “It Was Really a Love Story: How an NRA Ally Became a Gun Control Advocate,” The New York Times , June 22, 2022, https://www.nytimes.com/2022/06/22/opinion/gun-safety-research.html .

Centers for Disease Control and Prevention, “Fatal Injury Reports 1981-2018: Web-based Injury Statistics Query and Reporting System (WISQARS),” last modified: August 28, 2023, https://www.cdc.gov/injury/wisqars/fatal/index.html .

Jeffrey W. Swanson “Preventing Suicide through Better Firearm Safety Policy in the United States,” Psychiatric Services 72 (2) (2021): 174-179, https://doi.org/10.1176/appi.ps.202000317 .

Lay San Too, Matthew J. Spittal, Lyndal Bugeja, et al., “The Association between Mental Disorders and Suicide: A Systematic Review and Meta-Analysis of Record Linkage Studies,” Journal of Affective Disorders 259 (2019): 302-313, https://doi.org/10.1016/j.jad.2019.08.054 ; and Frances L. Lynch, Edward L. Peterson, Christine Y. Lu, et al., “Substance Use Disorders and Risk of Suicide in a General U.S. Population: A Case Control Study,” Addiction Science & Clinical Practice 15 (2020): 14, https://doi.org/10.1186/s13722-020-0181-1 .

Stephanie Brooks Holliday, The Relationship Between Mental Health Care Access and Suicide (Santa Monica, Calif.: RAND Corporation, 2018), https://www.rand.org/research/gun-policy/analysis/essays/mental-health-access-and-suicide.html .

Khalid Saad Al-Harbi, “Treatment-Resistant Depression: Therapeutic Trends, Challenges, and Future Directions,” Patient Preference and Adherence 6 (2012): 369-388, https://doi.org/10.2147/ppa.s29716 .

Daniel Thomas Chung, Christopher James Ryan, Dusan Hadzi-Pavlovic, et al., “Suicide Rates after Discharge from Psychiatric Facilities: A Systematic Review and Meta-Analysis,” JAMA Psychiatry 74 (7) (2017): 694-702, https://doi.org/10.1001/jamapsychiatry.2017.1044 .

Allison E. Bond, Shelby L. Bandel, Taylor R. Rodriguez, et al., “Mental Health Treatment Seeking and History of Suicidal Thoughts Among Suicide Decedents by Mechanism, 2003-2018,” JAMA Network Open 5 (3) (2022): e222101, https://doi.org/10.1001/jamanetworkopen.2022.2101 .

Zhuoyang Li, Andrew Page, Graham Martin, and Richard Taylor, “Attributable Risk of Psychiatric and Socio-Economic Factors for Suicide from Individual-Level, Population-Based Studies: A Systematic Review,” Social Science & Medicine 72 (4) (2011): 608-616, https://doi.org/10.1016/j.socscimed.2010.11.008 .

Jeffrey W. Swanson, Richard J. Bonnie, and Paul S. Appelbaum, “Getting Serious about Reducing Suicide: More ‘How’ and Less ‘Why,’” JAMA 314 (21) (2015): 2229-2230, https://doi.org10.1001/jama.2015.15566 .

Matthew Miller, Deborah Azrael, and Catherine Barber, “Suicide Mortality in the United States: The Importance of Attending to Method in Understanding Population-Level Disparities in the Burden of Suicide,” Annual Review of Public Health 33 (2012): 393-408, https://doi.org/10.1146/annurev-publhealth-031811-124636 .

Paul R. Albert, “Why Is Depression More Prevalent in Women?” Journal of Psychiatry and Neuroscience 40 (4) (2015): 219-221, https://doi.org/10.1503/jpn.150205 .

Jeffrey W. Swanson, “Introduction: Violence and Mental Illness,” Harvard Review of Psychiatry 29 (1) (2021): 1-5, https://doi.org/10.1097/hrp.0000000000000281 .

Jonathan M. Metzl, Jennifer Piemonte, and Tara McKay, “Mental Illness, Mass Shootings, and the Future of Psychiatric Research into American Gun Violence,” Harvard Review of Psychiatry 29 (1) (2021): 81-89, https://doi.org/10.1097/hrp.0000000000000280 . See also Mass Violence in America: Causes, Impacts and Solutions , ed. Joe Parks, Donald Bechtold, Frank Shelp, et al. (Washington, D.C.: National Council for Mental Well-Being, 2019) https://www.thenationalcouncil.org/resources/mass-violence-in-america-causes-impacts-and-solutions ; and Jennifer Skeem and Edward Mulvey, “What Role Does Serious Mental Illness Play in Mass Shootings, and How Should We Address It?” Criminology & Public Policy 19 (1) (2020): 85-108, https://doi.org/10.1111/1745-9133.12473 .

Jeffrey W. Swanson, “Mental Disorder, Substance Abuse, and Community Violence: An Epidemiological Approach,” in Violence and Mental Disorder: Developments in Risk Assessment , ed. John Monahan and Henry J. Steadman (Chicago: University of Chicago Press, 1994), 101-136. See also Jeffrey W. Swanson, Charles E. Holzer III, Vijay K. Ganju, et al., “Violence and Psychiatric Disorder in the Community: Evidence from the Epidemiologic Catchment Area Surveys,” Hospital and Community Psychiatry 41 (7) (1990): 761-770, https://doi.org/10.1176/ps.417.761 .

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Third Edition (Washington, D.C.: American Psychiatric Association, 1980).

Simon Davis, “Violence by Psychiatric Inpatients: A Review,” Psychiatric Services 42 (6) (1991): 585-590, https://doi.org/10.1176/ps.42.6.585 ; and Bronson and Berzofsky, Indicators of Mental Health Problems Reported by Prisoners and Jail Inmates, 2011-12 .

Swanson, “Mental Disorder, Substance Abuse, and Community Violence.”

Eric B. Elbogen and Sally C. Johnson, “The Intricate Link between Violence and Mental Disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions,” Archives of General Psychiatry 66 (2) (2009): 152-161, https://doi.org/10.1001/archgenpsychiatry.2008.537 .

Jeffrey W. Swanson, Guangyu Tong, Michelle M. Easter, et al., “Gun Violence among Young Adults with a Juvenile Crime Record in North Carolina: Implications for Firearm Restrictions Based on Age and Risk,” Preventive Medicine 165 (2022), https://doi.org/10.1016/j.ypmed.2022.107279 .

Emily E. McGinty, Shannon Frattaroli, Paul S. Appelbaum, et al., “Using Research Evidence to Reframe the Policy Debate around Mental Illness and Guns: Process and Recommendations,” American Journal of Public Health 104 (11) (2014): e22-e26, https://doi.org/10.2105/AJPH.2014.302171 .

Felthous and Swanson, “Prohibition of Persons with Mental Illness from Gun Ownership under Tyler.”

Jeffrey W. Swanson, Allison Gilbert Robertson, Linda K. Frisman, et al., “Preventing Gun Violence Involving People with Serious Mental Illness,” in Reducing Gun Violence in America: Informing Policy with Evidence and Analysis , ed. Daniel W. Webster and Jon S. Vernick (Baltimore: Johns Hopkins University Press, 2013), 33-51.

Swanson, Sampson, Petukhova, et al., “Guns, Impulsive Angry Behavior, and Mental Disorders.”

Leslie C. Hedman, John Petrila, William H. Fisher, et al., “State Laws on Emergency Holds for Mental Health Stabilization,” Psychiatric Services 67 (5) (2016): 529-535, https://doi.org/10.1176/appi.ps.201500205 ; and Paul S. Appelbaum and Jeffrey W. Swanson, “Law & Psychiatry: Gun Laws and Mental Illness: How Sensible Are the Current Restrictions?” Psychiatric Services 61 (7) (2010): 652-654, https://doi.org/10.1176/ps.2010.61.7.652 .

Mark Rosenberg, “Considerations for Developing an Agenda for Gun Violence Prevention Research,” Annual Review of Public Health 42 (2021): 23-41, https://doi.org/10.1146/annurev-publhealth-012420-105117 ; and Jeffrey Swanson and John Rozel, “Doctors and Hospitals Can Help Prevent Gun Deaths. Here's How,” American Association of Medical Colleges, March 29, 2023, https://www.aamc.org/news-insights/doctors-and-hospitals-can-help-prevent-gun-deaths-here-s-how .

Katherine M. Keyes, Ava Hamilton, Jeffrey Swanson, et al., “Simulating the Suicide Prevention Effects of Firearms Restrictions Based on Psychiatric Hospitalization and Treatment Records: Social Benefits and Unintended Adverse Consequences,” American Journal of Public Health 109 (S3) (2019): S236-S243, https://doi.org/10.2105/AJPH.2019.305041 .

See Paul Appelbaum, Lanny Berman, Renee Binder, et al., Guns, Public Health, and Mental Illness: An Evidence-Based Approach for State Policy (Washington, D.C.: Educational Fund to Stop Gun Violence, 2013).

Howard J. Shaffer, Sarah E. Nelson, Debi A. LaPlante, et al., “The Epidemiology of Psychiatric Disorders among Repeat DUI Offenders Accepting a Treatment-Sentencing Option,” Journal of Consulting and Clinical Psychology 75 (5) (2007): 795-804, https://psycnet.apa.org/doi/10.1037/0022-006X.75.5.795 .

Appelbaum, Berman, Binder, et al., Guns, Public Health, and Mental Illness .

Giffords Law Center to Prevent Gun Violence, “Extreme Risk Protection Orders,” https://giffords.org/lawcenter/gun-laws/policy-areas/who-can-have-a-gun/extreme-risk-protection-orders (accessed September 20, 2023).

Frederick E. Vars, “Self-Defense against Gun Suicide,” Boston College Law Review 56 (4) (2015): 1465-1499.

Ian Ayres and Frederick E. Vars, “Libertarian Gun Control,” University of Pennsylvania Law Review 167 (2019): 921-974.

Jeffrey W. Swanson, Marvin S. Swartz, Susan M. Essock, et al., “The Social-Environmental Context of Violent Behavior in Persons Treated for Severe Mental Illness,” American Journal of Public Health 92 (9) (2001): 1523-1531, https://doi.org/10.2105/ajph.92.9.1523 .

Centers for Disease Control and Prevention, “Prevention Strategies,” last modified June 8, 2022, https://www.cdc.gov/violenceprevention/communityviolence/prevention.html .

Garret Hardin, “The Tragedy of the Commons,” Science 162 (3859) (1968): 1243-1248, https://doi.org/10.1126/science.162.3859.1243 .

Alexandra Spiliakos, “Tragedy of the Commons: What It Is and 5 Examples,” Harvard Business School Online's Business Insights Blog, February 6, 2019, https://online.hbs.edu/blog/post/tragedy-of-the-commons-impact-on-sustainability-issues .

Daniel Semenza, “More Guns, More Death: The Fundamental Fact that Supports a Comprehensive Approach to Reducing Gun Violence in America,” State University of New York Rockefeller Institute of Government, June 21, 2022, https://rockinst.org/blog/more-guns-more-death-the-fundamental-fact-that-supports-a-comprehensive-approach-to-reducing-gun-violence-in-america .

Emma E. McGinty, Howard H. Goldman, Bernice A. Pescosolido, and Colleen L. Barry, “Communicating about Mental Illness and Violence: Balancing Stigma and Increased Support for Services,” Journal of Health Politics, Policy and Law 43 (2) (2018): 185-228, https://doi.org/10.1215/03616878-4303507 .

Knox, Pflanz, Talcott, et al., “The U.S. Air Force Suicide Prevention Program.”

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Mental Health, Gun Violence, And Why America Connects Them

mental health and gun violence essay

General view during March for Our Lives 2022 on in Washington, DC. Paul Morigi/Getty Images for March For Our L hide caption

General view during March for Our Lives 2022 on in Washington, DC.

Congress is looking to pass a bipartisan gun safety proposal. And if it succeeds, the bill could come with a hefty investment in mental health treatment.

Lawmakers have yet to solidify their plans, but they've said a Senate bill would include bolstering school-based mental health services, crisis intervention, substance use disorder services, and suicide prevention.

Mental health providers say they'll take all the federal resources they can get, but they aren't convinced it will do much to prevent mass shootings.

Dr. Jeff Temple, a psychologist and founding director of the Center for Violence Prevention at the University of Texas Medical Branch, wrote an op-ed originally published in the Austin American-Statesman:

Making psychiatric disease the bogeyman is politically expedient – it allows policymakers to shy away from the true culprit. It also fits into how the public often views mental illness – as something to fear. Afterall, what else would cause someone to do something so heinous? The problem with this thinking is that it's wrong.

There's little evidence that people with mental health issues are more likely to assault or kill someone with a gun. In fact, people with mental illnesses are more likely to be the victims of this violence.

One area where mental health and guns do collide is suicide, which accounts for thousands more firearm deaths every year than homicides , according to data from the Centers for Disease Control and Prevention.

What's the nature of the connection between mental health and gun violence? And if it's tenuous, why is it brought up in the wake of tragedy?

Jeff Temple , Julie Rovner , and Dr. Steven Pliszka join us for the conversation.

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Is There a Link Between Mental Health and Gun Violence?

mental health and gun violence essay

By Maria Konnikova

A childhood picture of Jaylen Fryberg the deceased gunman in the MarysvillePilchuck High School shooting with a goodbye...

On Friday, October 24th, during the busy lunch hour in the school cafeteria of Marysville-Pilchuck High School, in Marysville, Washington, Jaylen Fryberg opened fire on his classmates, killing one student and wounding four others, three of whom later died from their injuries. Then he killed himself.

Just a week earlier, Fryberg had been crowned prince of the school's homecoming court—he was a community volunteer, student athlete, and all-around “ good kid .” But within hours of the shooting, that picture had changed. Quickly, media outlets  analyzed   his   tweets , Facebook page, Instagram account, and his text and Facebook messages. He was “ full of angst ” and “ anguished .” One media report  concluded that  “he just wasn’t in the right state of mind.” Another went further: he was a “depressed sociopath.” Many writers pointed out that the Maysville school district had recently received a large federal grant to improve mental-health services for students. “We used to have a much greater social safety net,” the district supervisor Jerry Jenkins  told  the Seattle  Times.  “Yes, he was popular, but there came a time when something changed. If people are educated to look for those, these are things they can do intervene,” Carolyn Reinach Wolf, a mental-health lawyer with a specialty in school shootings,  said . The suggestion underlying much of the coverage was that improvements in the mental-health system could have prevented the violence.

When mass shooters strike, speculations about their mental health—sometimes borne out, sometimes not—are never far behind. It seems intuitive that someone who could do something terrible must be, in some sense, insane. But is that actually true? Are gun violence and mental illness really so tightly intertwined?

Jeffrey Swanson, a medical sociologist and professor of psychiatry at Duke University, first became interested in the perceived intersection of violence and mental illness while working at the University of Texas Medical Branch at Galveston in the mid-eighties. It was his first job out of graduate school, and he had been asked to estimate how many people in Texas met the criteria for needing mental-health services. As he pored over different data sets, he sensed that there could be some connection between mental health and violence. But he also realized that there was no good statewide data on the connection. “Nobody knew anything about the real connection between violent behavior and psychiatric disorders,” he told me. And so he decided to spend his career in pursuit of that link.

In general, we seem to believe that violent behavior is connected to mental illness. And if the behavior is sensationally violent—as in mass shootings—the perpetrator must certainly have been sick. As recently as 2013, almost forty-six per cent of respondents to a national survey  said  that people with mental illness were more dangerous than other people. According to two recent  Gallup polls , from 2011 and 2013, more people believe that mass shootings result from a failure of the mental-health system than from easy access to guns. Eighty per cent of the population believes that mental illness is at least partially to blame for such incidents.

That belief has shaped our politics. The 1968 Gun Control Act prohibited anyone who had ever been committed to a mental hospital or had been “adjudicated as a mental defective” from purchasing firearms. That prohibition was reaffirmed, in 1993, by the Brady Handgun Violence Prevention Act. It has only become more strictly enforced in the intervening years, with the passing of the National Instant Criminal Background Check System Improvement Act, in 2008, as well as by statewide initiatives. In 2013, New York passed the Safe Act, which mandated that mental-health professionals file reports on patients “likely to engage in conduct that would result in harm to self or others”; those patients, who now number more than  thirty-four thousand , have had their guns seized and have been prevented from buying new ones.

Are those policies based on sound science? To understand that question, one has to start with the complexities of the term “mental illness.” The technical definition includes any condition that appears in the Diagnostic and Statistical Manual of Mental Disorders , but the D.S.M. has changed with the culture ; until the nineteen-eighties, homosexuality was listed in some form in the manual. Diagnostic criteria, too, may vary from state to state, hospital to hospital, and doctor to doctor. A diagnosis may change over time, too. Someone can be ill and then, later, be given a clean bill of health: mental illness is, in many cases, not a lifelong diagnosis, especially if it is being medicated. Conversely, someone may be ill but never diagnosed. What happens if the act of violence is the first diagnosable act? Any policy based on mental illness would have failed to prevent it.

When Swanson  first analyzed  the ostensible connection between violence and mental illness, looking at more than ten thousand individuals (both mentally ill and healthy) during the course of one year, he found that serious mental illness alone was a risk factor for violence—from minor incidents, like shoving, to armed assault—in only four per cent of cases. That is, if you took all of the incidents of violence reported among the people in the survey, mental illness alone could explain only four per cent of the incidents. When Swanson broke the samples down by demographics, he found that the occurrence of violence was more closely associated with whether someone was male, poor, and abusing either alcohol or drugs—and that those three factors alone could predict violent behavior with or without any sign of mental illness. If someone fit all three of those categories, the likelihood of them committing a violent act was high, even if they weren’t also mentally ill. If someone fit none, then mental illness was highly unlikely to be predictive of violence. “That study debunked two myths,” Swanson said. “One: people with mental illness are all dangerous. Well, the vast majority are not. And the other myth: that there’s no connection at all. There is one. It’s quite small, but it’s not completely nonexistent.”

In  2002 , Swanson repeated his study over the course of the year, tracking eight hundred people in four states who were being treated for either psychosis or a major mood disorder (the most severe forms of mental illness). The number who committed a violent act that year, he found, was thirteen per cent. But the likelihood was dependent on whether they were unemployed, poor, living in disadvantaged communities, using drugs or alcohol, and had suffered from “violent victimization” during a part of their lives. The association was a cumulative one: take away all of these factors and the risk fell to two per cent, which is the same risk as found in the general population. Add one, and the risk remained low. Add two, and the risk doubled, at the least. Add three, and the risk of violence rose to thirty per cent.

Other people have since taken up Swanson’s work. A  subsequent study  of over a thousand discharged psychiatric inpatients, known as the MacArthur Violence Risk Assessment Study, found that, a year after their release, patients were only more likely than the average person to be violent if they were also abusing alcohol or drugs. Absent substance abuse, they were no more likely to act violently than were a set of randomly selected neighbors. Two years ago,  an analysis  of the National Epidemiologic Survey on Alcohol and Related Conditions (which contained data on more than thirty-two thousand individuals) found that just under three per cent of people suffering from severe mental illness had acted violently in the last year, as compared to just under one per cent of the general population. Those who also abused alcohol or drugs were at an elevated, ten-per-cent risk.

Internationally ,  too , these results have  held , revealing a steady but low link between mental illness and violence, which often coincides with other factors. The same general pattern also emerges if you work backward from incidents of gun violence. Taking a  non-random sample  of twenty-seven mass murders that took place between 1958 and 1999, J. Reid Meloy, a psychiatrist at the University of California, San Diego, found that the perpetrators, all of whom were adolescent men, were likely to be loners as well as to abuse drugs or alcohol. Close to half had been bullied in the past, and close to half had a history of violence. Twenty-three per cent also had a history of mental illness, but only two of them were exhibiting psychotic symptoms at the time of the violence. When you accounted for the other factors, mental illness added little predictive value. Swanson’s own  meta-analysis of the existing data , on the links between violence and mental health, which is due out later this year, shows the same basic formula playing out in study after study: mental-health problems do increase the likelihood of violence, but only by a very small amount.

Psychiatrists also have a very hard time predicting which of their patients will go on to commit a violent act. In  one study , the University of Pittsburgh psychiatrist Charles Lidz and his colleagues had doctors at a psychiatric emergency department evaluate admitted patients and predict whether or not they would commit violence against others. They found that, over the next six months, fifty-three per cent of those patients who doctors predicted would commit a violent act actually did. Thirty-six per cent of the patients thought not to be violent in fact went on to commit a violent act. For female patients, the prediction rates were no better than chance. A  2012 meta-analysis  of data from close to twenty-five thousand participants, from thirteen countries, led by the Oxford University psychiatrist Seena Fazel, found that the nine assessment tools most commonly used to predict violence—from actuarial ones like the Psychopathy Checklist to clinical judgment tools like the Structured Assessment of Violence Risk in Youth—had only “low to moderate” predictive value.

There is one exception, however, that runs through all of the data: violence against oneself. Mental illness, Swanson has found, increases the risk of gun violence when that violence takes the form of suicide.  According  to the C.D.C., between twenty-one and forty-four per cent of those who commit suicide had previously exhibited mental-health problems—as indicated by a combination of family interviews and evidence of mental-health treatment found at the scene, such as psychiatric medications—while between sixteen and thirty-three per cent had a history of psychiatric treatment. As Swanson points out, many studies have shown an even higher risk of suicide among the mentally ill, up to ten to twenty times higher than the general population for bipolar disorder and depression, and thirteen times higher for schizophrenia-spectrum disorders.

When it comes to the other types of firearms fatalities, though, it seems fairly clear that the link is quite small and far from predictive. After an incident like  Sandy Hook  or Virginia Tech, policymakers often strive to improve gun control for the future—and those efforts often focus on mental health and the reporting of prior records, as in the case of Connecticut. But if you look at people like Jaylen Fryberg, Mason Campbell , or Karl Pierson , you see no formal diagnosis of mental illness, and often, no actual signs of instability, either. Even when there are signs, as in Pierson’s case, they often remain undiagnosed: Pierson was sent home from a mental-health evaluation with a clean bill of health. We’ll never know whether counselling could have helped Fryberg. Perhaps it could have. But policymakers should also be focussing on other metrics that may have far more to do with such events than mental illness ever has.

In all of his work, Swanson has found one recurring factor: past violence remains the single biggest predictor of future violence. “Any history of violent behavior is a much stronger predictor of future violence than mental-health diagnosis,” he told me. If Swanson had his way, gun prohibitions wouldn’t be based on mental health, but on records of violent behavior—not just felonies, but also including minor disputes. “There are lots of people out there carrying guns around who have high levels of trait anger—the type who smash and break things,” he said. “I believe they shouldn’t have guns. That’s what’s behind the idea of restricting firearms with people with misdemeanor violent-crime convictions or temporary domestic-violence restraining orders, or even multiple D.U.I.s.”

“We need to get upstream and try to prevent the unpredicted: how to have healthier, less violent communities in the first place,” Swanson said. Mental illness is easy to blame, easy to pinpoint, and easy to legislate against in regards to gun ownership. But that doesn’t mean that it is the right place to start in an attempt to curtail violence. The factors responsible for mass violence are messy, complex, and dynamic—and that is a far harder sell to legislators and voters alike. As Swanson put it, “People with mental illness are still people, and people aren’t all one thing or another.”

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The Reckoning

By Andrew Solomon

The Argument Over a Long-Standing Autism Intervention

By Jessica Winter

One of the Last Abortion Doctors in Indiana

By Peter Slevin

The Humanitarian Catastrophe in Gaza Can Only Get Worse

By Isaac Chotiner

Change how we talk about gun violence and mental health

A popular misconception holds that individuals living with mental illness are...

A popular misconception holds that individuals living with mental illness are largely responsible for incidents of mass gun violence. Credit: Getty Images/iStockphoto/kmatija

We must change how we talk about gun violence and mental health.

After a mass shooting, news reports commonly describe the shooter as “psychotic” or “mentally disturbed.” A popular misconception holds that individuals living with mental illness are largely responsible for incidents of mass gun violence and for a large share of community violence. These claims are mostly made without evidence and before any psychiatric history is known, leading to solutions that stigmatize millions of Americans and do little to increase safety. Dialogue and solutions need to be fact-based.

When someone with a mental health disorder engages in violent behavior, there is a tendency to extrapolate that to other people with the same or similar disorders, disregarding the millions of people with a mental health condition who have never been violent. In fact, people with mental illness are more likely to be victims than perpetrators of violence. 

Violence has many contributing risk factors. Mental illness alone is very rarely the cause. Only about 4% of interpersonal violence in the United States is attributable to mental illness alone. If we were to somehow “cure” mental illness nationwide, we would still be left with 96% of all interpersonal violence.

Gun violence prevention policies that focus disproportionately on a mental health diagnosis fuel prejudice toward and fear of people living with mental illness, who might then avoid mental health services. Policies and programs should instead focus on evidence-based, behavioral risk factors for future violence, such as past violent behavior, the perpetration of domestic violence, and toxic stress.

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Risk factors associated with mass shootings include a perpetrator’s stressful economic circumstances and high level of social disadvantage, lack of support to cope with early-life trauma, ongoing resentment or smoldering anger against individuals or groups perceived to be hostile or threatening, aberrant constructions of masculinity, and being young, male and impulsive, all of which are exacerbated by the disinhibiting effects of substance intoxication and easy access to a semiautomatic firearm. Mass killers do not fit a single profile and certainly no pattern of insanity; most have never been diagnosed with a serious psychiatric disorder.

Mass shootings account for less than 1% of firearm homicides and tend to be committed by those with issues besides diagnosable mental illnesses. In New York State, red flag laws allow family members and police officers to seek civil restraining orders to temporarily remove guns from people who pose an imminent risk of harming themselves or others. These orders can significantly reduce the risk factor for firearm suicide, which account for more than half of all suicide deaths.

As a society, we need human service programs that include wraparound support for struggling individuals and families. We must better engage with young people; schools have a captive audience. Parents and other adults must be part of the solutions, and teach children to be more supportive of each other. This can be as simple as asking someone if they are OK. What fuels gun violence is anger, a lack of opportunity, and feeling alienated and isolated. Let’s help people feel connected.

Misinformation contributes to discrimination that has a real and negative effect on people’s lives. When lawmakers base policy on fear and prejudice — when they focus narrowly on removing guns from people with mental illness and ignore issues like firearms access and safe storage — the results endanger civil rights and fail to make our communities safer. Let’s step up, challenge myths and misinformation, and demand real solutions.

This guest essay reflects the views of Colleen Merlo, chief executive of the Association for Mental Health and Wellness in Ronkonkoma.

My OCD Can’t Keep Me Safe From America’s Gun Violence—But It Tries

Obsessive compulsive, anxiety disorder concept

I t was the 1980s. Washington D.C. was being called the “murder capital” of America, and the nightly news in Northern Virginia where I grew up showed an onslaught of politics, gangs, drugs, and guns. The little television stacked on the microwave was always on. At the dinner table, Dad snapped the newspaper open. Mom hurried with a warm batch of rolls. The reporter said “drive-by” and “shooting” over artistic close-up camera footage of blood puddled in the street. The puddle strobed red and blue as if lights were shining up through a portal that the blood had opened in the street, where the dead go and don’t return. It was a portal I was afraid I’d slip through—one I thought about constantly and where I feared my own blood would spill.

Getting shot is not my story. In reality, certain historical, governmental, and racial forces were at work in the nation’s capital that, if they’d been explained to me at the time, might have offered some clarity that I—a 10-year-old middle-class white girl—had a low chance of being targeted. But my then-undiagnosed obsessive-compulsive disorder (OCD) didn’t care about that.

When OCD attaches itself to your darkest fears, it doesn’t consider the likelihood that the thing you’re afraid of will happen. OCD says the danger is here. Now. And in many ways today, 40 years later, the continued proliferation of gun violence in this country says the same thing. At least, that’s how I hear it.

A common behavior in people with OCD is reassurance-seeking. “Are you sure that’s not a man with a gun on the porch? Will you check again?” But when I was a kid, I did the opposite. In the mornings, the news programs were the same as the night before. A torn “CAUTION” tape flapped in the breeze. The camera zoomed in on blood that had dried dripping down a curb. I spooned sugar into my bowl of cereal while eyeing the window for a gunman to appear—here, now. In my head, I heard gunshots and shattering glass, envisioned hiding behind the island cabinet or escaping to the living room.

Read More: What Does It Mean to Have OCD? These Are 5 Common Symptoms

It’s not that I didn’t want a gentle hand of assurance on my shoulder, to hear the words “you’re safe.” But asking for it would have meant saying out loud the violent things I was seeing in my head—violent things that seemed to exist in no one else’s head but mine. Here was my sister at the breakfast table, tracing a route through the maze on the back of the cereal box. There was my mother reaching deep into the fridge. I was the only one checking the window for guns. There was something deeply wrong with me, I figured, so I kept my thoughts to myself.

At my family’s church, the pastor told the congregation God wouldn’t give us more than we could handle, and we could handle more than we thought. I don’t know if he meant that to feel comforting. I sat in the pew trying to be perfect, turning to the right page in the hymnbook and not wriggling in my ruffled dress. Secretly, I’d tap my toes inside my shoes, left-right, left-right to the beat of the counting that was beginning to take over my mind. “One, two, three, four, one, two, three, four.”

God already knew what I was afraid of, so there was no sense begging for it not to happen. He was going to teach me a lesson about how much I could handle, and guns were the one thing I couldn’t bear. And that anxious feeling I got when I thought about it could be eased by the ritual of counting.

Anything four was good, and four was everywhere, especially my bedroom. The bulletin board where I pinned my gymnastics ribbons had four sides. Windows had four sides. The ceiling, where I’d always wanted to stick glow-in-the-dark stars but wasn’t allowed because they might peel off the paint, had four sides. “One, two, three, four, one, two, three, four,” I would count and count, pointing my toes left-right, left-right under the sheets. The ritual was a kind of self-soothing. The numbers running through my head were as close as I could get to manifesting that warm hand on my shoulder I was too ashamed to ask for. OCD promised I could keep myself and my family safe. If I counted the sides of the window, no bullets would be able to pierce through the glass. If I pointed my toes, I wouldn’t die. So that’s what I did at night instead of praying.

In my 20s, I sought help for depression and anxiety, mental disorders that come along with OCD, but not the OCD itself. I did talk therapy and cognitive behavioral therapy. One therapist told me to wear a rubber band around my wrist and snap it every time I had a negative thought. Bad dog . No . Another asked me to hold a lightboard in my lap and watch two orange bulbs flash alternately left and right. It triggered the counting. The therapist asked me to call a disturbing thought to mind, but I could hardly think about guns when the lights were triggering the very thoughts that drowned out the thought of guns: one, two, three, four, left-right, left-right. The therapy wasn’t working, and I didn’t know how—or wasn’t ready—to tell the therapists why. And some of it was confusing in relation to my OCD rules. For example, does visualizing violence count as a negative thought if it’s keeping me safe? And even if it wasn’t keeping me safe, I wasn’t ready to risk breaking the spell.

I was in my 30s, sitting on a slippery leather chair in the office of a therapist who specialized in OCD, when I finally shared enough of my secret thoughts to be called out for their flawed logic. I wasn’t ready to talk about guns, but I told him other OCD things, like how I’d kept my plane from falling out of the sky by counting the four sides of the rounded rectangular window the entire two-hour flight. And that’s when the therapist said something like, “So, you believe you’re holding up the airplane with the power of your mind ?” The insinuation was that this was a preposterous thing to believe, and if I could only recognize how preposterous it was, my problems would go away. The counting and tapping and flashes of violence that made me flinch would all go away.

If that was the key, if I just had to “get it,” then by that logic, I should have been cured already. I wasn’t stupid. But OCD doesn’t obey the rules of logic—and it didn’t go away.

Read More: What It Really Means to Have Intrusive Thoughts

Exposure and response prevention (ERP) therapy is an effective treatment targeted for obsessive-compulsive disorder. But even when I’d found that OCD specialist, I didn’t talk about guns. When I’d told him about the intrusive visualizations of driving the car off the road into the water, he’d wanted me to drive on the highway more often, the one with the bridge over the lake. So, if I’d told him about the intrusive visualizations of gun violence, would I have had to look at pictures of guns? Would I have had to hold a gun? Shoot a gun? Watch more videos of gun violence?

Part of my mind says it is logical and correct to be afraid. In 2019, Amnesty International issued a Travel Advisory for anyone planning a trip to the United States “in light of ongoing high levels of gun violence in the country.” It says to avoid “places where large numbers of people gather, especially cultural events, places of worship, schools, and shopping malls.” That seems reasonable enough for the length of a vacation, but what about those of us who live here?

The violence, the gunshots—it doesn’t stop. In 2023, according to the Gun Violence Archive , there were 656 mass shootings and 40 mass murders in America. There were over 43,000 total gun-related deaths including suicide. And since 2020, firearms have surpassed any other cause of mortality for teens and children. The U.S. has failed to protect its people from the threat of gun violence—a failure, according to Amnesty International , of its obligation to do so under international human rights law. Instead, condolences of “thoughts and prayers” offered by politicians in the wake of the latest mass shooting have become a meme-ified, disingenuous catchphrase, a stand-in for inaction .

This is where the tricky promises of OCD sneak in. Because OCD isn’t logical; it’s emotional. When I’m feeling the most helpless and afraid, OCD says, “Here’s an action you can take right now: Count! Tap!” OCD says that just thinking about gun violence, as long as you do it until it feels “right,” can prevent gun violence from happening. These days, the longer I lie in bed and think, the more deeply I conjure the same horrific scene unfolding again and again—the man muscling through the door to murder my family, revising the struggle for the gun like a choreographer who approaches her dancers to lift his arm higher, turn her hip, deciding who trips on the fringe of the rug and when—the slower the world of objective reality turns around me until all that exists is this meditative, circular rumination. In those minutes, my thoughts feel powerful. So far, my family hasn’t gotten shot. I haven’t gotten shot. It’s working.

But it only works to prevent the exact scenarios I know about. The problem with this kind of thinking is that it breeds more of this kind of thinking. And before long it becomes clear—there are countless ways to die.

OCD is prayer, incantation, rumination, and superstition, all rolled into one. If a bullet is coming, then “one, two, three, four.” I count until the counting replaces the imaginary thump of the bullet hurting me or someone I love. I count until I can’t stop counting and then the problem is not the bullet but the counting, and no one around me knows I’m doing it, and I’ve been doing it for days and months and years and decades. And through it all, I feel exhausted and alone.

Read More: Guns Are Not Just a Public Health Problem

Some nights I quietly tap the navigation buttons on the remote control compulsively in a pattern, right left top bottom, and if I try to stop, I get this restless feeling in my hand and think maybe the living room will be hit by a drive-by shooting. Sometimes I tap so fast I press a button by mistake and pause the show or skip it back 10 seconds, and my husband looks over and says, “What are you doing?” I’m mad when he goes up to bed first and leaves me sitting downstairs with the impossible task of passing through the foyer alone in the dark by the window where the man on the porch points his gun at my head. How can he abandon me like this? How come he gets to amble up the stairs unafraid. Like he’s not even thinking about guns. Like he’s safe in his own home.

I want to get better. Sometimes I practice on my own, pausing ever so slightly with my back to the window. My neck comes alive with creepy crawlies. The important thing is not that I do it until I don’t feel afraid, but that I do it until I can do it without counting. Even delaying the rituals by seconds or minutes is progress. I try to resist the intensifying sizzle of walls and frames and books and shelves taunting me with whispers of four . I still my toes inside my shoes. I dare to walk calmly upstairs and not race on all fours gripping the carpet, outrunning an imaginary bullet. Some nights I glide past the window on my way to bed and don’t think about the gun at all.

And then, our phones light up with a neighborhood alert. A young man has shot and killed a young woman at the grocery store two blocks from our house. All night, he’s on the run. Police patrol the streets shouting at people to get back inside their homes. Our neighbor’s garage is open, overflowing with furniture and boxes. We call the non-emergency line to say it’s a good hiding spot and maybe they should check. This time, it is logical and correct to check. Our kindergartner is asleep upstairs.

In America, it’s possible to get shot anywhere, and it’s probably going to be captured on video. If gun violence isn’t happening to us in our own neighborhoods, it’s happening on the screens inside our homes and in the palms of our hands. As a nation, we are exposed to guns. But that exposure is not a form of therapy. If exposure to guns alone could cure me, I should have been cured already.

And all that time and effort I’ve spent distracted by rituals? It’s been a waste. It’s been no more effective than thoughts and prayers.

On lunch breaks, I walk to the lake one block from my office. Someone has zip-tied stuffed animals and plastic flowers to a sign in the parking lot, along with the laminated photo of another victim of gun violence. Over the weeks, a mylar balloon sinks lower to the ground like a weary ghost.

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Essay on Gun Control & Gun Violence

Gun control and gun violence are among the most contentious and divisive issues in modern society, especially in countries like the United States. The debate encompasses a range of complex and intertwined topics, including public safety, individual rights, and the role of government. This essay aims to explore various aspects of gun control and gun violence, examining the impacts, the arguments for and against stricter gun laws, and the potential solutions to reduce gun-related incidents.

The Current State of Gun Violence

Gun violence is a significant issue that affects thousands of lives every year. It manifests in various forms, including mass shootings, homicides, suicides, and accidental discharges. The prevalence of gun violence is often attributed to the easy accessibility of firearms, cultural attitudes towards guns, and gaps in the legal and mental health systems. The impact of such violence is far-reaching, affecting not only the victims and their families but also the broader community in terms of trauma, fear, and economic costs.

The Debate on Gun Control

The gun control debate is highly polarized. Proponents of stricter gun control argue that it is essential for public safety. They cite statistics showing that countries with stringent gun laws have lower rates of gun violence. Their argument is based on the premise that reducing the availability of firearms will lead to fewer gun-related incidents.

On the other hand, opponents of gun control assert that it infringes on individual rights, particularly the Second Amendment in the United States, which guarantees the right to bear arms. They argue that responsible gun ownership can deter crime and that restrictions punish law-abiding citizens rather than criminals who are unlikely to obey the laws.

Legislative Measures and Their Effectiveness

Legislative measures aimed at controlling gun violence involve laws and regulations that govern the sale, possession, and use of firearms. Key legislative measures include:

  • Background Checks: These are designed to prevent individuals with criminal records or mental health issues from purchasing guns. While widely supported, their effectiveness depends on the comprehensiveness of the databases used and the thoroughness of the checks.
  • Waiting Periods: Imposed between the purchase and possession of a firearm, waiting periods aim to reduce impulsive acts of violence, including suicides. Studies have shown that waiting periods can lead to a reduction in gun-related suicides.
  • Assault Weapons Ban: Bans on certain types of firearms, particularly those designed for military use, aim to reduce the firepower available to the general public. The effectiveness of such bans is debated, with some studies suggesting a reduction in mass shooting incidents, while others see little impact on overall crime rates.
  • Restrictions for High-Risk Individuals: Laws that prevent individuals with a history of domestic violence or mental illness from accessing guns are crucial. These laws aim to reduce the likelihood of firearms falling into the hands of those most likely to use them harmfully.

The effectiveness of these legislative measures is a subject of ongoing debate. Critics argue that criminals do not obey laws and that such measures only restrict law-abiding citizens. Proponents, however, point to statistical evidence from regions with strict gun laws, showing reduced rates of gun violence. The ultimate effectiveness often depends on the specific context and enforcement of these laws.

The Role of Mental Health in Gun Violence

Mental health is often a focal point in the discussion of gun violence. While a small percentage of gun violence incidents are committed by individuals with mental health issues, the stereotype that mental illness is a primary cause of gun violence is misleading. Nonetheless, improving mental health care and ensuring that individuals with severe mental illnesses do not have access to firearms are essential components of any comprehensive approach to reducing gun violence.

Community and Societal Interventions

Community and societal interventions are crucial in the fight against gun violence. These interventions often focus on addressing the root causes of violence and involve:

  • Education and Awareness Programs: These programs aim to educate the public about gun safety and the risks associated with firearms. They can include training on safe storage and handling of guns.
  • Community Policing Strategies: Building relationships between law enforcement and communities can help in the early identification and prevention of potential gun violence incidents. Community policing emphasizes trust-building and cooperation with community members.
  • Youth Engagement Programs: Programs that engage youth in positive activities can provide alternatives to gang involvement and reduce urban crime. Mentorship and after-school programs are examples of effective strategies to engage young people.
  • Mental Health Support: Providing accessible mental health care and support can play a significant role in preventing gun violence. This includes not only treatment but also early identification of individuals at risk.

The Impact of Gun Control on Crime Rates

The impact of gun control on crime rates is a complex and often controversial topic. Several factors influence the effectiveness of gun control measures in reducing crime:

  • Reduction in Suicides: Evidence suggests that stricter gun control laws can lead to a decrease in suicides, as firearms are a common method of suicide.
  • Mass Shootings: Some studies have found that regions with stricter gun control laws have fewer mass shooting incidents. However, the overall impact on crime rates is less clear.
  • Overall Crime Rates: The relationship between gun control and overall crime rates is nuanced. While stricter gun laws may reduce gun-related crimes, they do not necessarily lead to a decrease in other forms of violent crime.
  • Illegal Gun Markets: The availability of illegal firearms can undermine the effectiveness of gun control measures. The impact on crime rates is diminished if criminals can easily access guns through illegal means.

International Perspectives on Gun Control

Comparing gun control laws and gun violence rates in different countries offers valuable insights. Countries like Japan and the United Kingdom, with strict gun control laws, have significantly lower rates of gun violence compared to the United States. These international examples are often used in the gun control debate to argue for stricter regulations in countries with higher rates of gun violence.

The Future of Gun Control

The future of gun control is uncertain and heavily dependent on political, cultural, and societal dynamics. Any progress in this area requires a balanced approach that considers the rights of individuals, public safety, and the effectiveness of proposed measures. It also demands a comprehensive strategy that includes not only legal changes but also educational initiatives, community engagement, and mental health support.

Gun control and gun violence are complex issues with no easy solutions. While legislative measures are crucial, they must be part of a broader strategy that includes community involvement, mental health support, and addressing socio-economic factors contributing to violence. The debate over gun control requires thoughtful discussion, respect for differing viewpoints, and a commitment to finding balanced and effective solutions. Ultimately, the goal is to create a society where the rights of individuals are protected while ensuring public safety and reducing the incidence of gun violence.

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Low SVI indicates lower than 25th percentile; moderate SVI, 25th to 50th percentile; high SVI, 51st to 75th percentile; and very high SVI, higher than 75th percentile.

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Kwon EG , Rice-Townsend SE , Agoubi LL , Rowhani-Rahbar A , Nehra D. Association of Community Vulnerability and State Gun Laws With Firearm Deaths in Children and Adolescents Aged 10 to 19 Years. JAMA Netw Open. 2023;6(5):e2314863. doi:10.1001/jamanetworkopen.2023.14863

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Association of Community Vulnerability and State Gun Laws With Firearm Deaths in Children and Adolescents Aged 10 to 19 Years

  • 1 Division of General and Thoracic Surgery, Seattle Children’s Hospital, University of Washington, Seattle
  • 2 Division of Trauma, Burn, and Critical Care Surgery, Harborview Medical Center, University of Washington, Seattle
  • 3 Department of Epidemiology, University of Washington, Seattle

Question   Are community-level factors and state-level gun laws associated with rates of firearm-related deaths in children and adolescents?

Findings   In this cross-sectional study including 5813 youths aged 10 to 19 years who died of an assault-related firearm injury, death rates increased in a stepwise fashion with increasing community-level social vulnerability; this trend persisted among all types of state gun laws. States with restrictive gun laws had lower rates of assault-related firearm deaths among youths; however, youths from socially vulnerable communities were disproportionately impacted across the spectrum of state gun laws.

Meaning   These findings suggest that legislation may not be sufficient to solve the problem of assault-related firearm deaths among children and adolescents.

Importance   Firearm-related injuries are the leading cause of death among children and adolescents in the US. For youths aged 10 to 19 years, 64% of firearm-related deaths are due to assault. Understanding the association between the rate of death due to assault-related firearm injury and both community-level vulnerability and state-level gun laws may inform prevention efforts and public health policy.

Objective   To assess the rate of death due to assault-related firearm injury stratified by community-level social vulnerability and state-level gun laws in a national cohort of youths aged 10 to 19 years.

Design, Setting, and Participants   This national cross-sectional study used the Gun Violence Archive to identify all assault-related firearm deaths among youths aged 10 to 19 years occurring in the US between January 1, 2020, and June 30, 2022.

Exposure   Census tract–level social vulnerability (measured by the Centers for Disease Control and Prevention social vulnerability index [SVI]; categorized in quartiles as low [<25th percentile], moderate [25th-50th percentile], high [51st-75th percentile], or very high [>75th percentile]) and state-level gun laws (measured by the Giffords Law Center gun law scorecard rating; categorized as restrictive, moderate, or permissive).

Main Outcomes and Measures   Youth death rate (per 100 000 person-years) due to assault-related firearm injury.

Results   Among 5813 youths aged 10 to 19 years who died of an assault-related firearm injury over the 2.5-year study period, the mean (SD) age was 17.1 (1.9) years, and 4979 (85.7%) were male. The death rate per 100 000 person-years in the low SVI cohort was 1.2 compared with 2.5 in the moderate SVI cohort, 5.2 in the high SVI cohort, and 13.3 in the very high SVI cohort. The mortality rate ratio of the very high SVI cohort compared with the low SVI cohort was 11.43 (95% CI, 10.17-12.88). When further stratifying deaths by the Giffords Law Center state-level gun law scorecard rating, the stepwise increase in death rate (per 100 000 person-years) with increasing SVI persisted, regardless of whether the Census tract was in a state with restrictive gun laws (0.83 in the low SVI cohort vs 10.11 in the very high SVI cohort), moderate gun laws (0.81 in the low SVI cohort vs 13.18 in the very high SVI cohort), or permissive gun laws (1.68 in the low SVI cohort vs 16.03 in the very high SVI cohort). The death rate per 100 000 person-years was higher for each SVI category in states with permissive compared with restrictive gun laws (eg, moderate SVI: 3.37 vs 1.71; high SVI: 6.33 vs 3.78).

Conclusions and Relevance   In this study, socially vulnerable communities in the US experienced a disproportionate number of assault-related firearm deaths among youths. Although stricter gun laws were associated with lower death rates in all communities, these gun laws did not equalize the consequences on a relative scale, and disadvantaged communities remained disproportionately impacted. While legislation is necessary, it may not be sufficient to solve the problem of assault-related firearm deaths among children and adolescents.

In the US, firearm-related injuries are now the leading cause of death among children and adolescents aged 1 to 19 years. 1 Assault-related violence accounts for 64% of firearm-related deaths in youths aged 10 to 19 years. 2

Social vulnerability indices (SVIs), which measure socioeconomic and population characteristics of discrete geographic regions, are emerging as a useful collective measure of social and societal determinants of health. Previous studies 3 , 4 have found that children living in socially vulnerable and disadvantaged communities are at increased risk of violent firearm-related injury. Higher social vulnerability has also been correlated with higher overall injury-related fatality rates. 5 To our knowledge, the association between community-level social vulnerability and assault-related firearm deaths among youths on a national level has not been previously reported. This lack of research is at least partly because access to detailed data on locations of firearm-related deaths at a national level is limited. The Gun Violence Archive (GVA) maintains an online archive of firearm-related violence incidents detailing the precise locations of firearm-related injuries and deaths, presenting an opportunity to evaluate this association. 6

In the US, states with more restrictive gun laws have been reported to have lower rates of firearm-related violence 7 ; similarly, findings from a systematic review 8 suggest that in certain nations, the simultaneous implementation of laws targeting multiple firearm restrictions is associated with a reduction in firearm-related deaths. However, it is not understood whether the strength of state-level gun laws has differential consequences for the rate of firearm-related violence in communities with different levels of social vulnerability and disadvantage. We sought to assess the rate of death due to assault-related firearm injury stratified by community-level social vulnerability and state-level gun laws in a national cohort of youths aged 10 to 19 years.

This study used publicly available deidentified data and did not require institutional review board approval per guidelines on human participant research from the University of Washington. 9 The study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline for cross-sectional studies.

The GVA was used to identify all assault-related firearm deaths among youths aged 10 to 19 years occurring between January 1, 2020, and June 30, 2022. The GVA is a nonpartisan nonprofit organization dedicated to maintaining an online archive of gun violence incidents collected from more than 7500 commercial, governmental, law enforcement, and media sources. It provides near real-time data that capture details surrounding each incident, including date, street location, age, sex, and intention (eg, murder, suicide, domestic violence, or police action). 6 The GVA records of gun violence deaths have been correlated ( r  = 0.95) with firearm-related deaths reported by the Centers for Disease Control and Prevention, 10 confirming GVA records to be a reliable source of assault-related firearm deaths. Incidents with no identifiable address and deaths related to suicide were excluded.

Social vulnerability was determined using the SVI developed by the Centers for Disease Control and Prevention 11 ; this SVI provides a comprehensive ranking of the relative vulnerability of every US Census tract, with higher values indicating greater vulnerability. The SVI captures the potential negative consequences for the community due to the aggregate of demographic and social factors in 4 domains: (1) socioeconomic status, (2) household composition and disability, (3) racial and ethnic minority status and language, and (4) housing type and transportation. The Census tract of each incident was determined by converting the incident addresses provided in the GVA to geographic coordinates, which were then matched to Census tract–level geographic identifiers using the Census geocoder. 12 The geographic identifiers were then linked to the Census tract–level SVI using the 2018 Census tract rankings. Youths were categorized into the following quartiles based on composite SVI: low SVI (<25th percentile), moderate SVI (25th-50th percentile), high SVI (51st-75th percentile), and very high SVI (>75th percentile). Data on youth race and ethnicity categories were not collected because this information is not available through the GVA.

Population estimates of youths aged 10 to 19 years by Census tract in 2020 were obtained from the Surveillance, Epidemiology, and End Results Program (SEER) database 13 and used for population adjustment. The Giffords Law Center (hereafter, Giffords) 2020 and 2021 gun law scorecard (which categorizes ratings as A, B, C, D, and F) was used to classify Census tracts by state as having restrictive (A and B ratings), moderate (C rating), or permissive (D and F ratings) firearm laws. 14

Estimated death rates by SVI category were calculated using the total number of deaths in each SVI category (extracted from the GVA) and per 100 000 person-years from the 2020 SEER population estimates within each SVI category across the 2.5-year study period. Crude mortality rate ratios were calculated, with the low SVI category as the reference group. A similar model was used to estimate the death rates and mortality rate ratios across the SVI categories and Gifford scorecard ratings. All Census tracts were included to estimate person-years regardless of whether the tract had any deaths reported. A Poisson regression model was used to test the interaction between SVI category and Giffords state-level gun law scorecard rating. The linear plots and their slopes were estimated from linear regression analysis of death rates per 100 000 person-years over incident month and year. Changes in death rates over time were assessed using the Mann-Kendall trend test and the Theil-Sen median slope estimator. All analyses were performed using Stata software, version 15/IC (StataCorp LLC). The threshold for statistical significance was 2-tailed P  = .05.

We used the GVA to identify 6154 youths aged 10 to 19 years who died due to an assault-related firearm injury between January 2020 and June 2022. After excluding youths who died of suicide (n = 248), incidents without an address (n = 85), and incidents in Census tracts without SVI data (n = 8), 5813 individuals were included in the SVI analysis. For analyses related to Giffords gun law scorecard ratings, an additional 61 deaths due to incidents occurring in an area without a Giffords scorecard rating (ie, Washington, District of Columbia) were excluded, leaving 5752 youths included.

Among 5813 youths, the mean (SD) age was 17.1 (1.9) years; 4979 (85.7%) were male and 834 (14.3%) were female. Using SEER population estimates, the total population of youths aged 10 to 19 years in each SVI quartile was similar ( Table 1 ). The total number of assault-related firearm deaths among youths in the low SVI cohort was 309 compared with 633 in the moderate SVI cohort, 1306 in the high SVI cohort, and 3565 in the very high SVI cohort. The death rate per 100 000 person-years for the low SVI cohort was 1.2 compared with 2.5 for the moderate SVI cohort, 5.2 for the high SVI cohort, and 13.3 for the very high SVI cohort, representing an 11-fold higher death rate in communities with very high social vulnerability compared with communities with low social vulnerability. Compared with the low SVI cohort, the mortality rate ratio was higher in each SVI cohort, with a mortality rate ratio of 2.16 (95% CI, 1.88-2.48) for the moderate SVI cohort, 4.46 (95% CI, 3.94-5.07) for the high SVI cohort, and 11.43 (95% CI, 10.17-12.88) for the very high SVI cohort. Incidents among youths in communities with very high SVI accounted for 25.9% of the total youth population and 61.3% of assault-related firearm deaths ( Table 1 ). Although there was seasonal variation in the monthly death rate per 100 000 person-years during the study period, death rates per 100 000 person-years increased over time in the high SVI communities, with a median slope of 0.060 (95% CI, 0.173-0.581; P  < .001). Trends in other SVI communities were not statistically significant due to seasonal variation in the number of deaths over the 2.5-year study period; however, a steady increase in the number of deaths over time was seen in all SVI communities with positive slopes in the linear regression model for each SVI category ( Figure ).

Stratifying the overall cohort by Giffords gun law scorecard rating, the death rate per 100 000 person-years for Census tracts in states with restrictive gun laws (Giffords A and B ratings) was 4.21 compared with 4.95 for Census tracts in states with moderate gun laws (Giffords C rating) and 7.04 for Census tracts in states with permissive gun laws (Giffords D and F ratings). The mortality rate ratios were 1.17 (95% CI, 1.08-1.27) for Census tracts in states with moderate gun laws and 1.67 (95% CI, 1.57-1.77) for Census tracts in states with permissive gun laws compared with Census tracts in states with restrictive gun laws. Population-adjusted death rates and mortality rate ratios stratified by Giffords state-level gun law scorecard rating and composite SVI quartile are shown in Table 2 . There was an increase in death rate (per 100 000 person-years) with increasing SVI regardless of whether the Census tract was in a state with restrictive gun laws (0.83 in the low SVI cohort vs 10.11 in the very high SVI cohort), moderate gun laws (0.81 in the low SVI cohort vs 13.18 in the very high SVI cohort), or permissive gun laws (1.68 in the low SVI cohort vs 16.03 in the very high SVI cohort). The death rate per 100 000 person-years was higher for each SVI category in states with permissive gun laws compared with states with restrictive gun laws (eg, moderate SVI: 3.37 vs 1.71; high SVI: 6.33 vs 3.78) ( Table 2 ). The SVI category and Giffords gun law scorecard rating were found to interact in their association with assault-related firearm deaths among youths (Poisson regression model: P  = .009).

This national cross-sectional study found that Census tracts with higher levels of social vulnerability experienced a disproportionate number of assault-related firearm deaths among youths. Communities with very high social vulnerability had an 11-fold higher death rate than communities with low social vulnerability. Although the assault-related firearm death rate among youths was higher overall in states with permissive compared with restrictive gun laws, the increase in death rate with increasing social vulnerability persisted, regardless of restrictive, moderate, or permissive gun laws.

Our findings on the association between community-level social vulnerability and assault-related firearm deaths among youths add to the growing body of literature focusing on the troubling associations between neighborhood disadvantage, lack of opportunity, and violence. 3 , 4 , 10 , 15 , 16 Previous studies have described higher numbers of firearm injury-related emergency department visits, 3 , 4 increased urban firearm violence, 16 and increased fatal police shootings 17 with increased community-level social vulnerability. There is likely a complex array of social phenomena that contribute to these associations. Children and adolescents living in disadvantaged communities are often exposed to lack of economic resources and opportunity, reduced social investment, lack of safe and green spaces, and high levels of community disorganization. 18 - 21 These community-level factors combined with individual- and family-level instability can disrupt normal parent-child relationships and contribute to high-risk behaviors in youths. 22 The combination of a lack of opportunity and hopelessness may be a common pathway to high-risk behaviors and violence. Our study revealed that these same disadvantaged communities experienced a disproportionate number of assault-related firearm deaths among youths.

To our knowledge, this study is one of the first to describe assault-related firearm deaths among youths by both community-level vulnerability and state-level gun laws. We found the strength of a state’s gun laws to be associated with the rate of assault-related firearm deaths among youths; specifically, stricter gun laws were associated with a lower rate of assault-related firearm deaths. However, these gun laws did not seem to equalize the consequences on a relative scale, as community-level disadvantage was associated with a disproportionate number of assault-related firearm deaths among youths across the spectrum of state gun laws. Our findings suggest that more restrictive firearm laws are unlikely by themselves to reduce the disparities observed in firearm death rates among youths across communities. A previous systematic review 8 suggested that very few of the existing state-specific firearm laws are associated with reductions in firearm-related mortality; however, this finding must be interpreted with caution because there are limited high-quality studies on the association between firearm legislation and injury, limiting our understanding of the true impact of specific firearm legislation. 23 Notably, some firearm laws, specifically those focused on the purchase, access, and use of firearms, have been associated with reductions in firearm-related mortality. 8 Our results suggest that legislation alone, although important, will not address the problem of gun violence in the US and needs to be accompanied by genuine, deep, and long-term investment in historically marginalized communities to reduce inequities.

This study has limitations. First, this is an ecological study, and measures of exposure are based on the mean in the population; thus, our results do not necessarily apply at the individual level. Second, we used the GVA to identify all assault-related firearm deaths among youths. Although the GVA is a rigorously maintained online archive of gun violence–related incidents, there is the potential for both missed events and misclassification, 6 and detailed demographic data are not available. Third, the GVA records the incident address, and our results describe only the association between the community-level vulnerability of the incident location and youth death related to firearm violence, which may be different from the vulnerability of the community of residence. Fourth, the death rates were calculated using the most up-to-date population estimates available from the SEER database. These SEER database population estimates were for 2020 and were used for the study period extending from January 2020 to June 2022. Changes in the total population of youths aged 10 to 19 years that may have occurred during the study period could not be accounted for. Fifth, this is a national cross-sectional study based on US data; thus, the results are not generalizable to other countries.

This cross-sectional study of youths who died of assault-related firearm injury found that socially vulnerable communities in the US experience a disproportionate number of assault-related firearm deaths among youths. Although stricter state-level gun laws were associated with decreases in death rates in all communities, the rates in disadvantaged communities remained disproportionately higher, regardless of the strength of the gun laws. Thoughtful and sincere investment in the most disadvantaged communities with the aim of creating opportunity and building community health and safety should be considered an important public health strategy to successfully reduce youth gun violence.

Accepted for Publication: April 7, 2023.

Published: May 24, 2023. doi:10.1001/jamanetworkopen.2023.14863

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Kwon EG et al. JAMA Network Open .

Corresponding Author: Deepika Nehra, MD, Division of Trauma, Burn, and Critical Care Surgery, Harborview Medical Center, University of Washington, 325 9th Ave, Box 359796, Seattle, WA 98104-2499 ( [email protected] ).

Author Contributions: Dr Nehra had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kwon, Rice-Townsend, Agoubi, Nehra.

Acquisition, analysis, or interpretation of data: Kwon, Rice-Townsend, Rowhani-Rahbar, Nehra.

Drafting of the manuscript: Kwon, Nehra.

Critical revision of the manuscript for important intellectual content: Rice-Townsend, Agoubi, Rowhani-Rahbar, Nehra.

Statistical analysis: Kwon.

Administrative, technical, or material support: Rice-Townsend, Agoubi, Rowhani-Rahbar, Nehra.

Supervision: Rowhani-Rahbar, Nehra.

Conflict of Interest Disclosures: Dr Agoubi reported receiving grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.

Data Sharing Statement: See the Supplement .

Additional Contributions: The authors would like to acknowledge Keegan A. Stromberg, BS, and Laura V. Hennessey, RN, of the Division of Trauma, Burn, and Critical Care Surgery at Harborview Medical Center, University of Washington, Seattle, for their valuable contributions (without compensation) to the data collection for this study.

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The Mental Illness and Gun Violence Analysis Essay

Introduction, the issue and suggested connections, media coverage, findings on the prevalence of violent actions, mass shootings and terrorism, the influence of stigma on mental health care, gun control laws, crime patterns, and social implications.

The analysis of criminality and people’s mental health contains not only the effect of inflicted harm on one’s mental stability but also the potential predisposition of people with mental illnesses towards violent behaviour. The recent portrayals of violent crimes against small or large groups of people have often mentioned mental illness as a characteristic that is prevalent among offenders (McGinty, Kennedy-Hendricks, Choksy, & Barry, 2016). This framing of criminals is used by the advocates of specific gun regulations in some countries.

They argue that the creation of a particular mental background check will lead to the reduced rate of violent crimes as people who may supposedly endanger others will be restricted from accessing firearms (Corner & Gill, 2015).

In states where gun control laws are strict, the connection between mental illness and violence is debated as well – this discussion can be focused on acts of violence and terrorism by individuals and groups (Corner & Gill, 2015). In this case, similar aspects of the stigma surrounding mental illness persist, including such characteristics as the lack of control and one’s aggressive tendencies. However, the question of whether mental illness has a direct link to violent behaviours remains underexplored by the public.

Scholarly research suggests that the stigma surrounding mental health and its correlation with gun violence and other crimes cannot be supported by evidence (McGinty et al., 2014a). While mental illness affects a person’s perception of the world, it does not determine one’s probability of engaging in crimes and does not always indicate the increased prevalence of violent behaviours.

The main problem in the current representation of the correlation between mental illness and crime is the opinion that people with mental health problems are more likely than others to engage in illegal activities. This idea may be expressed by the public and exacerbated by media, advocates, and other influential speakers (Varshney, Mahapatra, Krishnan, Gupta, & Deb, 2016). The debate surrounding this concept often leads to people recollecting the incidents of gun violence, mass shootings, and lone-actor terrorist activity as situations that were initiated by people with mental illnesses.

The idea that one’s criminal behaviour can be reassessed based on their mental health also lies at the core of the crime-related legislation. Thus, when discussing the gun selling industry, some people suggest that a background check of a buyer’s mental health history can be used to allow or restrict gun usage (Swanson et al., 2016). In order to evaluate the arguments supporting and opposing this viewpoint, it is necessary to address the media representation of this problem, the public opinion and stigma related to mental health, as well as statistics and scholarly findings that consider the discussed links. The relationship between violent behaviours and mental illness traits can also be considered to provide a possible way of reforming the coverage of this problem.

The basis of the discussed connection between crimes and mental illnesses is apparent in media coverage of illegal activities and some specific types of incidents. The primary example in which mental illness is used as the leading characteristic of an offender is the use of guns for lone-actor shootings and terrorist acts. It should be noted that the majority of the discussed situations occurred in the United States, although some recent accidents also happened in Europe and other countries.

According to McGinty, Webster, Jarlenski, and Barry (2014c), the prevalence of the offender being described as having a serious mental issue was substantial in stories covering gun violence. Similarly, McGinty et al. (2016) find that the use of this characteristic has greatly increased in the last fifteen to ten years. Thus, the framing of shooters as people with mental health problems became more popular than before in the media.

The effect of this coverage significantly alters the way the public views persons with mental illnesses. The stigma that surrounds people with depression, bipolar disorder, schizophrenia, and other conditions is now strongly associated with violence and lack of personal control, as well as sociopathic tendencies and failure to understand intimate boundaries (Swanson, McGinty, Fazel, & Mays, 2015a). As a contrast, according to research findings, individuals with mental illnesses are more likely to become targets of violent behaviour than its initiators (Monahan, Vesselinov, Robbins, & Appelbaum, 2017). Nonetheless, the developed viewpoint of mental health affects people’s perceptions about crime.

Many researchers have considered the correlation between violent behaviour (with the focus on shootings) and people with mental illnesses. Metzl and MacLeish (2015) point out that the public shares four main assumptions about this issue – a diagnosis of a mental illness can predict crimes, mental problems cause crimes, only mentally ill persons commit mass shootings, and these incidents cannot be prevented by gun control laws. These statements are included in the basis of many scholars’ hypotheses for researching the topic.

The findings of the mentioned above studies, however, do not agree with the public’s opinion. For instance, Swanson et al. (2016) discover that people with mental illnesses with access to firearms do not endanger other people as much as healthy individuals. On the other hand, they are more likely to endanger themselves due to mental health issues often being accompanied by suicidal ideations (Swanson et al., 2016).

Wintemute (2015) also states that mental illness does not contribute to violence towards others but is a serious factor in people’s rates of self-harm. The author argues that firearm ownership is one of the most prevalent factors in homicide cases (Wintemute, 2015). Therefore, the portrayal of the so-called “dangerous people” expressed in the media is in direct opposition to the statistics and scholarly findings.

The incidents that involve multiple victims or end in the attacker committing suicide are also often perceived through the lens of mental illness. Corner and Gill (2015) analyse the possibility of lone and group terrorists to have a mental disorder. They find that while individuals committing a terrorist crime alone are more likely to have mental health disturbances than terrorist group members, they also reveal that lone terrorists often act because of outside influence, stress, and prejudice (Corner & Gill, 2015). Therefore, the connection between criminality and mental illness is not direct – people’s behaviour is heavily influenced by other factors which may be linked to stigma or unrelated problems.

Studies about mass shooters also disparage the idea that these persons commit violent crimes due to having a mental health issue. Baumann and Teasdale (2018) conclude that the focus on mental illness is incorrect because people with mental problems and access to firearms constitute a more significant danger to themselves rather than society. The scholars urge the need to reframe the debate around mental illness and centre the discussion on the protection of persons with severe mental illness from harming themselves (Baumann & Teasdale, 2018). Whether these individuals possess a firearm or not, they can endanger themselves by not receiving proper treatment.

The problem of social barriers to accessing mental health care can also be noted in this discussion. The stigma supported by the media and the public can contribute to the individuals being reluctant to interact with health providers. According to Corrigan, Druss, and Perlick (2014), the problematic depiction of people with mental health issues as violent offenders puts people at risk of leaving their conditions untreated. This lack of care can result in individuals losing control of their cognitive abilities, experiencing chronic stress, and being unable to function in society. Therefore, one can suggest that such negative portrayal not only fails to encourage positive change but also exacerbates the problem and exposes more people to dangerous behaviours and self-harm.

These assumptions also impact the treatment of offenders with mental health issues. Skeem, Winter, Kennealy, Louden, and Tatar (2014) find that individuals with mental illnesses are more likely than others to be “brought back to prison custody” after parole (p. 212).

Moreover, the lack of treatment for these individuals is strongly correlated with the probability of recidivism. The scholars note that general factors such as antisocial behaviours and the lack of impulse control should be the main focus of recidivism prevention initiatives (Skeem et al., 2014). This argument notes that psychiatric therapy is not that crucial for everybody because offenders without mental illnesses possess social problems as well.

As a result, the discussed stigma also removes any distinctions between mental illness and aggression, conflating the two concepts and uniting them under one idea of uncontrolled behaviour. Swanson et al. (2015b) state that people who can become angry easily own firearms more often than others. This connection is found by the authors to be more significant than that including people with mental illnesses.

Moreover, they establish that only a small proportion of people with severe mental illnesses (such as serious forms of bipolar disorder and schizophrenia) tend to be violent towards others, while more than 95% of these individuals do not engage in any harmful behaviour (Swanson et al., 2015b). Other factors, including social isolation and substance abuse, contribute to the problem heavily, having a tangible impact on people both with and without mental health issues (Swanson et al., 2015b). The correlation between anger and mental illness that strongly affects the public perspective is, therefore, not supported by evidence.

People with mental health problems become victims of abuse or self-harm more often than perpetrators of crime. Monahan et al. (2017) find that violent victimisation of such persons by other individuals occurs in 43% of investigated cases, while violent behaviour is expressed in 28% and self-victimisation in 23% (p. 517). Furthermore, approximately half of the study’s participants were involved at least in one type of violence. The scholars discover a strong correlation between violent behaviours and the history of abuse, stating that respondents were victimised as children by family members and other individuals (Monahan et al., 2017). Thus, it is possible to assume that the presence of mental illness is not the only contributing factor to violent behaviours.

The mentioned above idea that people with mental illnesses are the main perpetrators of crime in such incidents as mass shootings and violent attacks affects the ways in which some countries change their legislature. In the US, this is one of the common arguments for gun ownership proponents – this viewpoint distinguishes responsible firearms owners and supports limited possession of arms for certain groups of people, while not inflicting any changes on others.

McGinty, Webster, & Barry (2014b) disagree with this argument, basing their opposition on statistical findings and stating that gun ownership is a more impactful contributor to gun-related violence than mental illness. The idea that a background checking procedure is effective in reducing crimes directly challenges the research about mental health and abuse.

Other factors can affect the rate of crimes more effectively than people’s mental health. One of them is the concept of “contagion” – the spread of information about previous mass killings (Towers, Gomez-Lievano, Khan, MMubayi, & Castillo-Chavez, 2015). Social pressure and the combination of contagion and frequent exposure to violent events may contribute to a person’s urge to commit crimes. Other causes include the mentioned above possession of firearms, substance abuse, and prior history of violence.

Gun ownership is highlighted by Wintemute (2015) as the prevalent contributor to gun-related violence. It is also a factor that elevates the rates of suicide with the use of firearms (Towers et al., 2015). This link suggests that gun ownership endangers people with and without mental illnesses and poses a more significant threat than mental health problems.

The media portrayal of people with mental illnesses has a prevalence of negative characteristics, linking mental health disturbances with criminal activity. The main ideas that the public possesses correlate mental illnesses and crime, posing the concept of a “dangerous person” as the main reason for mass shootings and terrorist attacks. Scholarly research opposes this ideology and shows the lack of connection between violent crimes and mental health. In fact, some studies reveal that people with mental illnesses often become the target of abuse rather than its perpetrators. The existence of statistical findings refutes the argument that aims to approve mental health background checks as the sole barrier to purchasing firearms.

Moreover, this point of view fails to acknowledge other contributors to crime, some of which have a significant impact on criminal events. Gun ownership, whether legal or illegal, is a factor that affects the rate of shootings substantially. Other reasons include substance abuse and personality traits such as anger and aggressiveness. It should be noted that one’s personality should not be conflated with the existence of mental illness. The lack of social interaction and the inability to relate to other people’s emotions also should not viewed only as mental health problems.

The discrepancy in proposed viewpoints and scholarly findings suggests that mental illness remains to be stigmatised since it is linked to violence and lack of self-control. The debate about firearms in such countries as the US and the focus on mental illness as the main contributor to violent offences hinders the effectiveness of health care services and stops people from seeking professional assistance. More than that, it contributes to offenders with mental health issues having problems with receiving parole or asking for support after being freed. The connection between crime and mental health is indirect in cases where people with mental illnesses act as perpetrators.

Baumann, M. L., & Teasdale, B. (2018). Severe mental illness and firearm access: Is violence really the danger? International Journal of Law and Psychiatry , 56 , 44-49.

Corner, E., & Gill, P. (2015). A false dichotomy? Mental illness and lone-actor terrorism. Law and Human Behavior , 39 (1), 23-34.

Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The impact of mental illness stigma on seeking and participating in mental health care. Psychological Science in the Public Interest , 15 (2), 37-70.

McGinty, E. E., Frattaroli, S., Appelbaum, P. S., Bonnie, R. J., Grilley, A., Horwitz, J.,… Webster, D. W. (2014a). Using research evidence to reframe the policy debate around mental illness and guns: Process and recommendations. American Journal of Public Health , 104 (11), e22-e26.

McGinty, E. E., Kennedy-Hendricks, A., Choksy, S., & Barry, C. L. (2016). Trends in news media coverage of mental illness in the United States: 1995–2014. Health Affairs , 35 (6), 1121-1129.

McGinty, E. E., Webster, D. W., & Barry, C. L. (2014b). Gun policy and serious mental illness: Priorities for future research and policy. Psychiatric Services , 65 (1), 50-58.

McGinty, E. E., Webster, D. W., Jarlenski, M., & Barry, C. L. (2014c). News media framing of serious mental illness and gun violence in the United States, 1997-2012. American Journal of Public Health , 104 (3), 406-413.

Metzl, J. M., & MacLeish, K. T. (2015). Mental illness, mass shootings, and the politics of American firearms. American Journal of Public Health , 105 (2), 240-249.

Monahan, J., Vesselinov, R., Robbins, P. C., & Appelbaum, P. S. (2017). Violence to others, violent self-victimization, and violent victimization by others among persons with a mental illness. Psychiatric Services , 68 (5), 516-519.

Skeem, J. L., Winter, E., Kennealy, P. J., Louden, J. E., & Tatar, G. R., 2nd. (2014). Offenders with mental illness have criminogenic needs, too: Toward recidivism reduction. Law and Human Behavior , 38 (3), 212-224.

Swanson, J. W., Easter, M. M., Robertson, A. G., Swartz, M. S., Alanis-Hirsch, K., Moseley, D.,… Petrila, J. (2016). Gun violence, mental illness, and laws that prohibit gun possession: Evidence from two Florida counties. Health Affairs , 35 (6), 1067-1075.

Swanson, J. W., McGinty, E. E., Fazel, S., & Mays, V. M. (2015a). Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Annals of Epidemiology , 25 (5), 366-376.

Swanson, J. W., Sampson, N. A., Petukhova, M. V., Zaslavsky, A. M., Appelbaum, P. S., Swartz, M. S., & Kessler, R. C. (2015b). Guns, impulsive angry behavior, and mental disorders: Results from the National Comorbidity Survey Replication (NCS-R). Behavioral Sciences & the Law , 33 (2-3), 199-212.

Towers, S., Gomez-Lievano, A., Khan, M., Mubayi, A., & Castillo-Chavez, C. (2015). Contagion in mass killings and school shootings. PLoS One , 10 (7), e0117259.

Varshney, M., Mahapatra, A., Krishnan, V., Gupta, R., & Deb, K. S. (2016). Violence and mental illness: what is the true story? Journal of Epidemiology and Community Health , 70 (3), 223-225.

Wintemute, G. J. (2015). The epidemiology of firearm violence in the twenty-first century United States. Annual Review of Public Health , 36 , 5-19.

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Will We Ever Get Beyond ‘The Fire Next Time’?

mental health and gun violence essay

Supported by

By Elizabeth Hinton

Dr. Hinton is the author of “America on Fire.”

The fires that engulfed dozens of cities over the past year seem tame by comparison to the extreme protests that defined American life roughly a half-century ago, when the nation endured domestic violence on a scale not seen since the Civil War.

From 1964 to 1972, in the North and the South, the East and the West, in the Rust Belt and the Sunbelt — in nearly every city, small or large, where Black people lived in segregated, unequal conditions — residents threw rocks and bottles at police, shot at them with rifles, smashed the windows of businesses and institutions, hurled firebombs and plundered stores. These events caused hundreds of millions of dollars of property damage. Most immediately, they shaped the lives of the store owners whose businesses were destroyed. They haunted the parents who lost their teenage sons to police violence. And they resulted in deaths and serious injuries to scores of firefighters and cops.

To many observers, last summer’s nonviolent and violent protests strongly resembled the America of the civil rights era. What we witnessed in 2020 was the latest manifestation of an ongoing crisis that could have been solved if elected officials had properly understood the root causes the first time around. Americans have instead been living in a nation created in part by the extreme violence of the 1960s.

The enduring aftershocks have been felt more regularly, and more acutely, by Black people in American cities. Alongside the rollout of civil rights legislation and the programs of the war on poverty, Black Americans faced new policing practices that emerged under the banner of the so-called war on crime: the routine stop and frisks that attacked people’s dignity, the breaking up of community gatherings, the presence of armed, uniformed officers in the hallways of otherwise underresourced public schools, to give just a few examples.

These policing strategies remain in place, illuminated by the tens of millions of people around the world who took to the streets demanding justice for George Floyd, Breonna Taylor and Ahmaud Arbery.

Protests and rebellions will continue until the nation reverses its original, misguided response to the civil rights era, and no longer empowers police officers to patrol communities of color with force. The logic of American policing — searching for potential criminals in low-income communities and protecting property in middle-class and wealthy white areas — increases the likelihood of contact in targeted areas and, with it, police violence.

Even as officials today face the enormous challenge of battling a violent crime wave in many American cities alongside growing calls to defund or abolish the police, the history of Black rebellion demonstrates a fundamental reality: Police violence precipitates community violence in a vicious cycle.

Patrolling low-income neighborhoods with outside forces does not effectively promote public safety in our most vulnerable communities. On the contrary, it establishes a dynamic in which residents and officers view each other as the enemy, rendering both sides less safe. This dynamic escaped policymakers and many of the scholars they consulted back in the 1960s and continues to be ignored by them.

  • William Barber II and Jonathan Wilson-Hartgrove believe that “ the Trayvon Martin generation has come of age and is pushing the nation toward a Third Reconstruction.”
  • Hakeem Jefferson and Jennifer Chudy, two political scientists, look at the charts that answer the questions: “Did George Floyd’s death catalyze support for Black Lives Matter ? If so, for how long and for whom?”
  • Elizabeth Hinton, a historian, writes that “the history of Black rebellion demonstrates a fundamental reality: Police violence precipitates community violence .”
  • Levar Stoney, the mayor of Richmond, Va., reflects on taking down the Confederate monuments that “cast a long, dark shadow over our city.”
  • Talmon Smith, a Times Opinion editor, writes that the past year’s racial reckoning was “disproportionately experienced by privileged Americans.”
  • David W. McIvor, a political theorist, recalls the “wild swings between hope and anguish, possibility and anxiety” of last summer’s protests .
  • Six young Americans reflect on how the past year has changed them: “I’ve been a lot louder these days.”
  • 14 conservative voters discuss their feelings on race, politics and why “we are so divided right now.”

Authorities have funneled billions of dollars into the War on Crime, the War on Drugs and the prison system. Rather than contend with the underlying causes of these problems, this nation’s leaders further criminalized entire communities, guaranteeing that rebellions would only continue. By dismissing the idea that those underlying causes had anything to do with the violence as it unfolded, the punitive programs embraced by elected officials at all levels of government also failed to stem the homicides and crime that pervade the very same neighborhoods that are energetically policed.

The 1960s produced an image of “riots” as essentially Black. Yet historically speaking, most instances of collective violence have been perpetrated by white vigilantes hostile to integration who joined together in roving mobs taking “justice” into their own hands, often with the support of local police. The Jim Crow era was defined by bloody riots: the lynch mobs in East St. Louis in 1917 who forced Black wartime factory workers and their families to choose between being burned alive or shot to death; the massacres of Black people that characterized the Red Summer of 1919; the two thousand white men who committed various atrocities against the thriving Black community in Tulsa in 1921; and the “race riots” that resulted in violent confrontations on the streets of Detroit, Chicago and other major cities during the Second World War.

mental health and gun violence essay

It was only when white people no longer appeared to be the driving force behind rioting in the nation’s cities, and when Black collective violence against exploitative and repressive institutions surfaced every summer of Lyndon Johnson’s presidency (and on into Richard Nixon’s), that riots came to be largely seen as criminal and senseless.

A call for “law and order” became the main response from the white establishment. Convinced that Black rebellion was an attack on existing American institutions rather than an appeal for inclusion within them, officials dismissed the possibility that the “hoodlums” who “rioted,” as Johnson called them, shared most if not all of the same grievances as mainstream civil rights organizations.

Like the students who participated in the sit-in movement and the roughly 250,000 people who attended the March on Washington for Jobs and Freedom in 1963, the people who resorted to violent protest tactics sought full political and economic inclusion in American society. But in the view of Johnson and others, rioting and crime were two strains of the same pathology in Black communities that could be cured only by more cops on the streets. As local police began to assume many of the previous functions of the white mob, the terms of urban violence were set.

With its unprecedented investment in local law enforcement, Johnson’s Omnibus Crime Control and Safe Streets Act of 1968 offered a short-term solution that became a long-term reality. As the United States waged the Vietnam War abroad, federal policymakers built a pipeline to deliver riot control training, surplus army weapons and technological innovations to police in order to put down domestic political radicalism and Black rebellion. With its initial $400 million outlay (about $3 billion today) for crime control, the legislation enabled cities to flood police into areas that seemed prone to violence.

Black, Puerto Rican and Mexican-American communities had long been subject to targeted surveillance, frequent encounters with police, mass arrests, illegal searches and outright brutality. But after the Safe Streets Act, residents in big cities like New York, midsize cities like Phoenix, and smaller cities like Waterloo, Iowa, would be patrolled by police departments with arsenals at their disposal: new AR15s and M4 carbines, steel helmets, three-foot batons, masks, armored vehicles, two-way radios, tear gas — these and other techniques, weapons and tools flowed into thousands of cities across the United States.

The collective violence that this federal law inadvertently fueled was a consequence of the all too predictable presence of the police. The rebellions usually started when law enforcement meddled, often violently, in everyday activity. They happened when police seemed to be there for no reason or when the police intervened in matters that could be resolved internally (in disputes among friends and family, for example). Rebellions often began when the police enforced laws that would almost never be applied in white neighborhoods (laws against gathering in groups of a certain size or acting like a “suspicious person”). Likewise, they erupted when police failed to extend to residents the common courtesies afforded to whites (allowing white teenagers to drink in a park but arresting Mexican-American teens for the same behavior).

“If they would just leave us alone, there would be no trouble,” said a Black teenage boy who threw rocks in Decatur, Ill., during an uprising in August 1969. His common sense solution was a straightforward reaction to an obvious problem. Rebellion was always possible when ordinary life was policed, and often the mere sight of police was enough to prompt a violent response. During a five-day battle between police and Black residents in York, Pa., in July 1968, a reporter asked a male participant, “Why are young black Yorkers throwing rocks and bottles at policemen?” To which the young man replied, “Why do police hit people on the heads with their clubs?”

This was “the cycle” that entrenched racial inequality and put this nation on a path to mass incarceration: the recurring pattern of overpolicing and rebellion, of police violence and community violence, that helped define urban life in segregated low-income communities of color back then and through today. The cycle began with police officers, who moved through the ghettos of America “like an occupying soldier in a bitterly hostile country,” as James Baldwin famously observed in 1960, so that their very presence — their perceived callousness to the inequality around them — felt violent in itself.

As the cycle played out in cities large and small across the United States in the late 1960s and early 1970s, it set in motion dynamics between residents and police for decades to come, laying the foundation for “zero tolerance” and “broken windows” policing characterized by the aggressive enforcement of misdemeanors in order to prevent disorder. As rebellions persisted through the 1970s and beyond (although not with the frequency of those in the immediate post-civil-rights era), the cycle remained unbroken, further demonstrating that aggressive policing tends to incite violence, especially when residents are protesting the very thing that they are then subjected to.

The cycle’s consequences have, at times, taken the form of mass violence to which all Americans have been witness: in Miami in 1980, in Los Angeles in 1992, in Cincinnati in 2001, and in more recent years in Ferguson, Mo., Baltimore, and in Minneapolis last summer. Each was set off by an instance of police violence. Each drew calls for more “law and order.” Each involved heavily militarized police confronting residents who were fighting against a larger system of oppression.

These are examples of historical trends that began in the late 1960s. There are no longer rebellions against everyday policing practices, but instead against exceptional incidents of brutality and miscarriages of justice. Perhaps the status quo of omnipresent patrol and surveillance has become accepted, however bitterly. In this sense, at least, national and local authorities won the War on Crime.

Yet, if anything, embracing policing and incarceration as a policy response to racial and economic inequality appears to function as a crime-promotion program. Young Black people continue to live at greater risk of harm or death with police lingering in their community — either from each other or from an officer whose job is ostensibly to protect them. George Floyd’s murder is a legacy of this policy path, sustained over five decades. So too is the death of 9-year-old Janari Ricks, who was killed in late July 2020 when a person began firing gunshots in a parking lot in Chicago’s Cabrini-Green neighborhood.

Instead of building policies around the needs of the community, this nation has built them around controlling communities and, at the same time, has erected the largest prison system on the planet. Public safety mechanisms are essential to promote community vitality, but these mechanisms cannot and should not take the form of a uniformed officer, an outsider to the community armed with a gun. This is the lesson all of us can draw from the rebellions of the post-civil rights period, and it remains just as salient today.

As the tens of millions of people knew when they took to the streets last summer, justice is often not forthcoming for Black Americans — and reforming the police, though a rare and difficult accomplishment, is never enough. From the police-community relations programs championed by liberal commissions in the late 1960s and early 1970s, to the federal interventions that introduced sensitivity training and accountability for officers in more recent decades, to the use of body cameras that are meant to keep misconduct in check today, reforms have not stopped the policing strategies that have led to discriminatory enforcement and the killings of people of color in the past, and they won’t stop more killings from happening in the future.

Until this nation imagines a different approach to public safety, beyond police reforms, it is not a question of whether the cycle will be unleashed, whether another person of color will die at the hands of sworn, even well-trained officers, or whether another city will catch fire, but when.

Elizabeth Hinton ( @elizabhinton ) is a professor of history, law and African-American studies at Yale and the author of “ America on Fire : The Untold History of Police Violence and Black Rebellion Since the 1960s,” from which this essay is adapted.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

Follow The New York Times Opinion section on Facebook , Twitter (@NYTopinion) and Instagram .

mental health and gun violence essay

A Cry of ‘I Can’t Breathe’ United a Generation in a Gasp for Justice

May 25 should be a day of mourning for george floyd, 14 trump voters on the legacy of george floyd, ‘we still aren’t safe’: 6 young americans on george floyd’s death, support for black lives matter surged last year. did it last, how privilege and capital warped a movement, george floyd and the seeds of a new kind of activism, we took down the monuments to the lost cause. now we build., end the court doctrine that enables police brutality.

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Community Violence

Gary, Indiana, Begins to See Fewer Homicides as Community Leaders Band Together

Residents are challenging the city's decades-long reputation for violence as new programs show encouraging results.

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Michelle Pratchet can’t remember the last time she heard gunshots. The newfound quiet is a welcome change for the 54-year-old, who was born and raised in Gary, Indiana, a city often stigmatized for its history of violence.

“I just look at it like this,” she said. “Wherever you live, you have to make the best of it.”

Pratchet’s experience reflects an encouraging trend in Gary. In 2023, the city recorded 52 homicides, a 13 percent decrease from the previous year, according to the Gary Police Department. 

Community organizers, law enforcement, and local activists have united to disrupt cycles of violence once ubiquitous here, reclaiming their city as they do the work. They point to the positive impact of violence prevention programs established to target gun violence in particular over a decade ago — some of which went dormant during the pandemic — and newer anti-violence initiatives that are gaining momentum. These stakeholders have held community forums, organized fundraisers and anti-violence basketball games, and formed coalitions to encourage interaction between police and residents. 

“The police alone aren’t going to solve the problem,” said Chuck Hughes, a lifelong resident and former city council member who heads the Gary Chamber of Commerce. “The mayor isn’t going to solve the problem. It does take everybody, and it takes everybody supporting the people whose primary responsibility is to make a city safe. 

“It’s going to take a groundswell. All hands on deck.”

mental health and gun violence essay

Few people are as dedicated to curbing violence in the city as 23-year-old Aaliyah Stewart, who understands the repercussions of gun violence firsthand. When she was 7, she lost her older brother in a shooting outside a Gary gas station — he was 16. Six years later, her other brother was also fatally shot at age 20, leaving her an only child. 

Nearly a decade earlier, in the mid-1990s, drivers along Gary’s Broadway Avenue were greeted by a grave warning: a billboard declaring, in bold red letters, “CAUTION!!! You are currently in Gary, In. 1993 MURDER Capital of the Nation … Proceed with EXTREME CAUTION.” At the time, Gary was home to roughly 119,000 people, and endured 110 killings; its murder rate was 91 per 100,000 people, almost 10 times the national average. The city’s violence underscored deeper issues rooted in Gary’s dramatic shift from industrial prosperity to economic hardship.

mental health and gun violence essay

A former boomtown of the early 20th century, Gary reached its industrial peak in the 1970s, when the Gary Steel Mill employed 30,000 people. For the city’s Black residents, who made up 70% of the population, those jobs were ladders to the middle class. Within two decades, however, the workforce dwindled to 6,000 amid the erosion of the American steel industry, and the city’s resulting economic downturn led to white flight and increases in poverty and crime. “Certainly, the white flight and business disinvestment that occurred in the 1960s changed the city,” said James B. Lane, an emeritus history professor at Indiana University Northwest. “At this time, the civil rights movement was gaining steam, and white fear caused people to leave, which played a major role in the declining population of Gary and the collapse of the commercial district.”

The combination of systemic racism, decline in industry, and economic challenges can engender conditions ripe for violence, said Storm Ervin, a researcher at the Urban Institute’s Justice Policy Center, “especially in the Midwest.”

The decline in financial fortunes brought unique challenges to Gary, including a grim moniker that would be difficult to shake for years to come: “murder capital.” The label was printed in headlines nationwide, making Gary infamous across the country but also leaving an indelible mark on those who lived in it, shaping the city’s identity and often overshadowing its rich history. 

“I think that a lot of the stigma that we received is because we were a Black city,” said Hughes, the former council member and current chamber of commerce president. “There are plenty of other cities that have been labeled the murder capital annually, but because they have garden spots and vacation areas, they don’t get branded like that.” 

mental health and gun violence essay

Stewart, who lost both her brothers to gun violence, transformed her grief into action. She emerged as one of the dozens of key leaders in the city working to forge a brighter future for the city by starting the nonprofit I Am Them Foundation, to advocate against gun violence, when she was a high school freshman. One of the foundation’s early initiatives awarded $500 scholarships to students who wrote essays about what they would do to stop violence in their community. I Am Them has since extended its impact through an annual toy drive that gives hundreds of toys to children and teens every year.

“I think that gun violence as a whole will decrease once we find positive ways for young people to express themselves and to get out,” Stewart said. “I believe it will become better and easier for young kids to find new ways.” 

Last December, former Police Chief Anthony Titus proudly showcased one of the Gary Police Department’s latest advancements: a high-technology crime center, opened two months before to bolster the city’s crime-fighting efforts.

Over 1,400 residents and 500 businesses share camera feeds with the department through its Operation Safe Zone initiative, launched in 2022. The collaboration allows the department to monitor police body cameras, license plate readers, shot detectors, and security cameras all in real time, giving officers better monitoring capabilities and incident response times.  

It’s “another set of eyes” for the department, Titus said of the initiative.

While the center’s innovation has supported the GPD’s crime-fighting efforts, Titus emphasized that it’s the department’s community-oriented approach that has been a critical factor in the decline of homicides. As leader of the Gary Police Department from July to December 2023, he said he prioritized interacting with community members and increasing officers’ visibility by routinely patrolling areas most susceptible to crime, like parks, large businesses, and abandoned buildings. But he also made a point to engage with “every community organization that’s doing good in the city.” 

By embracing events like Coffee with a Cop and National Night Out, which introduced residents to law enforcement officials, Titus said the police have been able to combat crime and simultaneously help to change the narrative about his hometown and policing. “We’re trying to make sure that citizens’ concerns aren’t falling on deaf ears.”

Other residents emphasized that their memories of living in Gary contradicted the city’s reputation for violence.

“When you grow up in a community — even if there is danger — if you know the people you live around and you’re part of the community, it may not feel as dangerous as it may appear to an outsider,” said Maya Etienne, a 43-year-old resident.

mental health and gun violence essay

Local officials have created several programs focused on gun violence prevention and intervention over the years, each adopting a different approach to tackling violent crime.  

“I’ve never felt unsafe in Gary,” said state Representative Ragen Hatcher, a Democrat from Gary, who recently visited the White House to discuss gun violence prevention strategy, and whose father was the first Black mayor elected in Gary. “If you ask most residents of Gary, I don’t think most people feel unsafe here.”

Gary for Life, launched in 2015 under then-Mayor Karen Freeman-Wilson, was one of the longest-running initiatives. The program assisted victims of violent crimes and suspected gang members with resources like therapy, job training, and education, steering them away from crime and toward more positive life paths. 

“Even though there are some initiatives that may not be active at this point, I definitely see it moving forward in a positive direction,” said Joy Holliday, Gary for Life’s former program manager, noting the impact of outreach on community members and young people, and on declining homicide rates. “I think we’ve built a great foundation, and I think we’re actually seeing the fruit of our labor.”

mental health and gun violence essay

With the election of Mayor Jerome Prince in 2020, Gary increased its focus to youth violence prevention. In 2021, Prince launched THRIVE Gary, a program centered on helping the city’s youth develop lifetime goals and nonviolent conflict resolution techniques. It included roundtable discussions between residents, politicians, and law enforcement known as “peace circles,” access to mental health support through the MindRight app, and more summer job opportunities.

“I never really bought into the ‘murder capital of the world’ moniker,” said Prince, who was born and raised in Gary and pledged to address the “chilling spectacle of wanton killings” when he was elected. “There was a period where Gary was extremely violent, but that existed in many urban cities across America.”

On a crisp February afternoon, Etienne walked down 21st Avenue in her Midtown neighborhood. She drifted past one of three churches on the strip, then a boarded-up structure with a picture of a hot dog painted on its facade. 

Across the street, teenagers occupied a gas station. But the two corners flanking the business captured her attention: residential streets dotted with abandoned homes, Gary’s struggles evident in the peeling paint and crumbled roofs, punctuated by the remains of a half-burned house that resembled the set of a horror film. Amid the decay, Etienne still voiced her love for Gary and hope for its future.

Yet, her warm smile faded as she gestured to a lounge that closed after a fatal shooting occurred there last summer. 

“Where is the valuing of life?” she asked, her voice a mix of wonder and sorrow. “Why the lack of value in Black and brown lives? Not just in our city but around the entire world?”

Residents and local leaders are not naive about Gary’s dip in homicides. They acknowledge the work that still needs to be done. 

Etienne said she is glad that the city’s homicide numbers have declined, but she is unsure how to sustain positive momentum. “I don’t know what the formula is,” she said. Yet one part of the solution is clear for her: a stronger community, mutual respect, and self-worth.

“I do know that we have to know our neighbors. We have to know who we are around,” Etienne said. “And we have to value people, and we have to value ourselves.”

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The Unmasking of Wayne LaPierre

The NRA corruption trial forced its former CEO to tell the truth about himself, as the curtain dropped on a three-decade act.

mental health and gun violence essay

Breaking News

Maine’s deadliest shooting spurs additional gun control proposals

FILE - Crime scene tape still surrounds Schemengees Bar & Grille, Oct. 29, 2023, in Lewiston, Maine. Democrats in the Maine Legislature unveiled sweeping gun violence measures on Wednesday, Feb. 28, 2024, including a 72-hour waiting period for most gun purchases, adding to firearm bills and mental health spending already proposed by the governor after last year's shooting in Lewiston, the deadliest shooting in the state history. (AP Photo/Matt York, File)

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Democrats in the Maine Legislature unveiled sweeping gun violence measures on Wednesday including a 72-hour waiting period for most gun purchases, adding to firearm bills and mental health spending already proposed by the governor after the deadliest shooting in the state history .

Senate President Troy Jackson said lawmakers are not interested in taking away guns but they do want to seek consensus on ways to prevent gun violence following the shooting that claimed 18 lives.

“There has to be a way for level-headed people to come together and figure out a way that could possibly stop, or make it harder, for anything like this to happen again,” he said.

The suite of bills would expand spending on mental health, create mobile crisis centers and give 911 callers the option of connecting with mental health crisis workers as well as law enforcement. They would also ban bump stocks or other physical modifications that can transform a semiautomatic rifle into a machine gun.

Some of the proposals received a frosty reception from Republicans — especially the mandatory waiting period for gun purchases. Republicans tried unsuccessfully Wednesday to block it, noting that a similar bill was rejected last year.

Sen. Matt Harrington, R-York, accused Democrats of trying to ram through proposals that previously failed.

“These bills are here year after year after year. They get defeated. Now here we are dealing with them again because they don’t want to let the crisis in Lewiston go to waste,” he said.

Gun control has proven tricky in the past in a state that has a strong hunting tradition. But there seemed to be broad support for expanding mental health treatment with a goal of preventing gun violence and suicides. That’s something Harrington and many other Republicans agree with.

A bill sponsored by House Speaker Rachel Talbot Ross would spend $17.5 million to create six crisis receiving centers, form an office of violence prevention in the Department of Health and Human Services, expand mobile crisis response teams and mandate that gun dealers distribute suicide prevention materials.

Her bill would also create a statewide notification procedure for mass shootings, addressing concerns from the deaf community that some people had trouble getting information as the tragedy unfolded in Lewiston.

Democratic Gov. Janet Mills already proposed background checks for advertised private sales, construction of a network of mental health crisis centers and bigger penalties for reckless private sales to prohibited people. She also wants to allow police officers to go directly to a judge to start the process of removing guns from someone in a psychiatric crisis.

The proposals follow the tragedy that unfolded when an Army reservist opened fire in October at a bowling alley and at bar in Lewiston. Thirteen people were injured, in addition to the 18 deaths. The gunman, 40-year-old Robert Card, died by suicide.

Addressing lawmakers last month , Mills urged lawmakers not to give in to the cynical view that it’s pointless to try to change gun laws because the laws will simply be broken. “For the sake of the communities, individuals and families now suffering immeasurable pain, for the sake of our state, doing nothing is not an option,” the governor said, bringing lawmakers to their feet.

An independent investigative commission appointed by the governor and attorney general may release preliminary findings as early as next month to help inform lawmakers’ decisions. The Legislature is due to wrap up its work in April.

Follow David Sharp on X, the platform formerly known as Twitter, @David_Sharp_AP

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Nation-World

New York governor approves new congressional district maps that could give Democrats modest boost in fight for House

Abbas Alawich speaks during an election night gathering, Tuesday, Feb. 27, 2024, in Dearborn, Mich. Some Democratic voters pledged to vote "uncommitted" in Tuesday's primary to let President Joe Biden know they aren't happy with his support for Israel in its response to the Oct. 7 attacks by Hamas. (AP Photo/Carlos Osorio)

Michigan’s largest Arab American cities reject Biden over his handling of Israel-Hamas war

Dearborn and two other Michigan cities with large Arab and Muslim populations turned against President Joe Biden in the state’s primary after Democratic leaders there warned for months that voters were angry about his handling of the Israel-Hamas war

FILE - Insurrections loyal to President Donald Trump at the U.S. Capitol in Washington on Jan. 6, 2021. All eyes are on the Supreme Court in Donald Trump's federal 2020 election interference case. The conservative-majority Supreme Court's next moves could determine whether the former president stands trial in Washington ahead of the November election.(AP Photo/Jose Luis Magana, File)

Supreme Court, moving quickly, will decide if Trump can be prosecuted in election interference case

The Supreme Court has agreed to decide whether former President Donald Trump can be prosecuted on charges he interfered with the 2020 election and has set a course for a quick resolution

Supreme Court will decide if Trump can be prosecuted on election interference charges, indicating it will move quickly

FILE - The afternoon sun illuminates the Legislative Building, left, at the Capitol in Olympia, Wash, Oct. 9, 2018. The Washington state House has overwhelmingly approved legislation that would ban police from hog-tying suspects, a restraint technique that has long drawn concern due to the risk of suffocation. The vote on Wednesday, Feb. 28, 2024 came nearly four years after Manuel Ellis, a 33-year-old Black man, died in Tacoma, Washington, facedown with his hands and feet cuffed together behind him. (AP Photo/Ted S. Warren, File)

Washington state House overwhelmingly passes ban on hog-tying by police

The Washington state House has overwhelmingly approved legislation that would ban police from hog-tying suspects, a restraint technique that has long drawn concern because of the risk of suffocation

FILE - A sign for flu vaccination is displayed on a screen at a pharmacy store in Buffalo Grove, Ill., Tuesday, Feb. 13, 2024. Early estimates suggest flu shots are performing OK in the current U.S. winter flu season. The vaccines were around 40% effective in preventing adults from getting sick enough from the flu that they had to go to a doctor’s office, clinic or hospital, health officials said during a Centers for Disease Control and Prevention vaccines meeting Wednesday, Feb. 28, 2024. (AP Photo/Nam Y. Huh, File)

Flu shots are doing OK vs. virus, US numbers indicate

Early estimates suggest flu shots are performing OK in the current U.S. winter flu season

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Existential Well-being, Mental Health, and COVID-19: Reconsidering the Impact of Lockdown Stressors in Moscow

Affiliations.

  • 1 HSE University, Moscow, Russia.
  • 2 Moscow City University, Moscow, Russia.
  • PMID: 36699708
  • PMCID: PMC9833610
  • DOI: 10.11621/pir.2022.0202

Background: Initial psychological papers on COVID-19, mental health and wellbeing mostly focus on the aftermath lockdown-related stress and stress related to the disease itself. Still, we presume that personal well-being can be resistant to stressors depending on the way the person is settled in their life.

Objective: We seek to reconsider the contribution of lockdown-related stressors to existential well-being, to assess existential well-being during the outbreak and to compare the contribution of living conditions and COVID-19-related factors on well-being.

Design: An online survey was conducted during the peak of the outbreak in Moscow (April-May 2020) (N=880). The data was obtained using the "Test of Existential Motivations" questionnaire and a series of questions addressing (1) living conditions - mental and physical health, employment, and social distancing; (2) COVID-19-related stressors - non-chronic illness, financial losses, and unavailability of goods or services; (3) sociodemographic indicators - age, gender, and income. Data analysis included hierarchical multiple regression, one-sample t-test, and analysis of variance.

Results: Surprisingly, the existential well-being of Moscow citizens during the research period was moderate. Each of the three groups of factors predicted a similar proportion of the variance of well-being (3-3,9%). The strongest predictors of well-being were long-term mental health status and financial stability. The effect of COVID-19-related stressors was most pronounced when they co-occur.

Conclusion: The negative association between lockdown-related stressors and poor well-being is not universal. It is necessary to study the effect of COVID-19-related stressors in combination with individual living conditions and region-specific factors and to focus on the prevention of the occurrence of stressors.

Keywords: COVID-19 pandemic in Russia; COVID-19-related stressors; Well-being; existential fulfillment; existential psychology; mental health.

Copyright © Lomonosov Moscow State University, 2022Copyright © Russian Psychological Society, 2022.

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  • v.14(3); 2022 Mar

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Suicidality Among Men in Russia: A Review of Recent Epidemiological Data

Val bellman.

1 Psychiatry, University of Missouri, Kansas City School of Medicine, Kansas City, USA

Vaishalee Namdev

2 Medicine and Surgery, Mahatma Gandhi Medical College and Research Institute, Indore, IND

Suicide is a phenomenon that is not related to a specific class of countries but is a problem worldwide. Many studies have attempted to explain gender differences in suicidal behaviors. Unfortunately, Russia holds the world’s top place for the number of suicides committed by its male citizens. Russia is still demonstrating unusually high death rates due to non-natural causes, and these demographic trends are concerning. We analyzed suicidality among men in Russia over the past 20 years using official data published by the Federal State Statistics Service (Rosstat) and secondary sources. We also discussed male suicide as a social problem, analyzed, and evaluated male suicidality in Russia from 2000 to 2020, and reviewed the factors influencing the prevalence of male suicides over female suicides in Russia.

Russia is still going through one of the most significant historical changes in the last 100 years. Our analysis showed discrepancies between official numbers and data published by non-government organizations in Russia. Unemployment, low socioeconomic status, underdiagnosed and/or untreated mental illness, and substance abuse are major risk factors for suicide in Russian men. Cultural influences also make suicidal behavior socially scripted in Russia.

By providing examples and analyzing data, we aspire to encourage improvements in the practice of mental wellbeing in Russia and other post-Soviet countries. The recommendations within this report are intended as a starting point for dialogue to guide effective suicide prevention in this country.

Introduction

Suicides and self-harming behaviors are significant public health and social problems in post-Soviet Russia. Suicide is one of the leading causes of death worldwide [ 1 ], accounting for over 58,000 deaths annually in Europe [ 2 ] and 16,546 deaths in Russia in 2020 [ 3 ]. According to experts, there are 11.4 suicides per 100,000 people in the world, which equates to 804,000 suicides annually [ 4 ]. Although the suicide rates in Russia are gradually decreasing (39.1/100,000 in 2000 to 23.4/100,000 in 2010 and 11.3/100,000 in 2020 [ 3 ]), the number of suicides among men is significantly higher than among Russian females [ 5 , 6 ].

The suicide rates vary greatly between Russian cities and within the country, and the difference between regions varies tenfold. The suicide rates are higher in rural communities when compared with their urban counterparts. Social deprivation, economic depression, unemployment, heavy alcohol consumption, etc. are also more prevalent in rural areas of Russia. Indigenous peoples around the country are burdened with a markedly increased suicide rate, which may be associated with a challenging social situation, inadequate family support, lower socioeconomic status, and an increased prevalence of alcohol and psychoactive substances, which also act as suicide risk factors in general [ 7 , 8 ]. The suicide rates among men in Russia (26.1 per 100,000) were over three times higher than among women (6.9 per 100,000) in 2016. Committing suicide appears to be a male phenomenon over the past 20 years in post-Soviet Russia [ 9 ]. For suicide attempts, the level estimated by the World Health Organization (WHO) is 20 times higher than the suicide rate [ 10 ]; the gender gap is less pronounced.

This phenomenon, when men commit suicide more frequently than women while women are much likelier to commit suicide attempts, is known as the gender paradox of suicidal behavior [ 2 , 6 ]. All Russian citizens are expected to receive medical care that meets the highest standards, regardless of their race, religion, national origin, sexual orientation, gender identity, or expression. Although the Russian healthcare system remains gender-neutral, Russian men are not considered a “risk” group and are not involved in targeted state-sponsored suicide prevention programs [ 11 ].

Materials and methods

Data on the population and male suicide rates were taken from the official reports of Rosstat and the Ministry of Health of the Russian Federation for 2001-2020. Secondary data were obtained from international databases and published studies in Russian and English. We used descriptive statistics to summarize the information about the population being studied. This methodology helped us summarize data in the form of simple quantitative measures, such as percentages and means, or visual summaries, such as diagrams and bar charts. The literature review attempted to bring together all available evidence on a specific, clearly defined topic.

Published studies were identified through ‘pearl growing’, citation chasing, a search of databases, using the filters, and the authors’ topic knowledge. The articles were searched in MEDLINE, PubMed, EMBASE, COCHRANE, eLibrary, and CyberLeninka. A search of databases was undertaken in December 2021 using predefined keywords. Citation chasing was conducted by analyzing the references for each included study. A total of 122 potential papers were identified. We also included at least 20 Russian biomedical journals listed in databases, which were translated into English. The summary document contained the list of included and excluded articles; the inclusion status for each article was based on a review of the full-text manuscript. The inclusion criteria were articles with the target population, specific location, investigated epidemiological trends, or the comparison between two-to-three studied regions (cities, states, or districts). Exclusion criteria were unrelated, duplicated, unavailable full texts published before 2001. Data were abstracted from 60 eligible papers. Some of these sources had English-language abstracts, but other articles’ texts had to be translated. The evidence was graded for each source based on the quantity and quality of studies and potential data flaws. The quality, validity, and type of published data were considered. 

The citation management system EndNote allowed us to organize our literature databases with internet searches and have add-ons for Office programs, which made the process of literature citation convenient. However, the majority of articles in Russian could not be captured by the citation management system. Additionally, the search for article content was sometimes unavailable for search engines. The authors had to enter this information manually to ensure consistency in the referencing of studies. Some Russian sources were originally published as extensive PDF files of the entire journal issue without dividing it into separate articles and providing no descriptors, making manual, time-consuming input of information the only possibility.

Not only are men likelier to die of suicide than women between the ages of 10 and 60 years, but the suicide rate among men also grows with every decade of life, reaching a peak at 50 [ 12 , 13 ]. Russian men become increasingly inclined to commit suicide before their 60th birthday, usually via firearms or strangulation. Although men aged 60, 70, and 80 die from suicide less often than men aged 40 to 59, gender differences prevail. The suicide rate among men over 60 is about 30 cases, compared to about 10 (per 100,000 people) among women of the same age [ 11 , 12 ]. 

Official data illustrate that suicide rates among men have gradually decreased over the past 20 years. While in 2000 it was 68.4 cases per 100,000 people, in 2010, it was 41 cases per 100,000 people, gradually decreasing to 29.3, 27.6, 21.7, 20.5, and 19.8 cases in 2015, 2016, 2018, 2019, and 2020, respectively, per 100,000 people. Suicide mortality among women is significantly lower than among men. In 2015-2016, it was nearly four times lower than among men and amounted to 7.5 and 7.1 cases per 100,000 people, respectively, in 2015 and 2016. The suicide rate among men in 2000-2020 per 100,000 people is shown in Figure ​ Figure1 1 [ 3 ].

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According to official data, the suicide rate among all age groups decreased. In recent years, the suicide rate among adult men has varied. Data demonstrate that the suicide rate among men increases with every decade of life, reaching a peak of 50 years. Thus, at the age of 15-19 years, the mortality rate from suicide among men was 10-12 cases in 2015-2016 per 100,000 people, at the age of 20-24 years: 18-20 cases, 25-29 years: 24-26 cases, 30-34 years: 31-35 cases, 35-39 years: 37-40 cases, and reaching a maximum in the age group of 50-54 years at 38-41 cases, then decreases gradually. Figure ​ Figure2 2 summarizes data on male suicide mortality in 2015-2016, depending on the age per 100,000 people [ 12 ].

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The data show that the suicide mortality rate among the male population in various age groups has been steadily decreasing since 2002. Between 2000-2003, all age groups of the male population demonstrated a growth in the number of suicide cases. It peaked in this period (2000-2020), except for the 15-29 age group. Between 2004 and 2010, there was the fastest decline in the suicide mortality rate among the male population in different age groups, after which the rate of decline in the mortality rate slowed, which may have been due to the financial and economic crisis in Russia (2008-2010). Figures ​ Figures3 3 - ​ -5 5 summarize the changes in the suicide mortality rate among men in different age groups in 2000-2020 [ 3 ].

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Between 2000-2020, the male suicide rate was variable across all levels of urbanization with higher rates in nonmetropolitan/rural areas than in medium or large metropolitan clusters. Geographic disparities (specific federal districts versus Russia overall) in suicide rates might reflect suicide risk factors known to be prevalent in less urban areas, such as limited access to mental health care, social isolation, and substance abuse.

Official data show that in 2015-2017, the suicide mortality rates among the male population in the Central Federal District, the city of Moscow, and the North Caucasian Federal District were lower than the average for the Russian Federation. The lowest rates were seen in the city of Moscow and the North Caucasian Federal District. In the Northwestern Federal District, suicide mortality rates among the male population were about the same as those in the Russian Federation overall. In the Volga Federal District, Ural Federal District, Siberian Federal District, and Far Eastern Federal District, suicide mortality rates among the male population were higher than the average in Russia. Figure ​ Figure6 6 summarizes the male suicide mortality rates in various federal districts and the Russian Federation in 2015-2017 [ 11 , 12 ]. 

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Interestingly, Mal et al. (2020) stated that the highest suicide mortality rates were in five Russian federal districts: Northwestern, Volga, Ural, Siberian, and Far Eastern; however, their analysis focused on suicide mortality rates in general. Additionally, the authors indicated that suicide mortality rates were significantly lower in Central, Southern, and North Caucasian Federal Districts [ 14 ].

The impact of urbanization on suicidality in Russian men and on the mental health of the general population remains underestimated [ 15 ]. The highest degree of urbanization was recorded in the Northwestern Federal District of Russia, where almost 85 percent of the inhabitants lived in city areas. The extent to which the suicide rate in urban areas is influenced by exposure to risk factors other than urbanization remains unknown due to a lack of data. The lowest male suicide mortality rates in the Northwestern Federal District are seen in the city of St. Petersburg, where these numbers are lower than the indicators for the Northwestern Federal District. Suicide mortality rates among the male population in the Northwestern Federal District decreased in 2015-2017. The most significant decrease occurred in the Novgorod region. Figure ​ Figure7 7 shows the suicide mortality rates among the male population in various regions of the Northwestern Federal District in 2015-2017 [ 11 , 12 ].

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Interestingly, the regions located in the Northern Caucasus demonstrate significantly lower male suicide rates compared to the rest of the nation [ 16 ]. These numbers and demographic trends were noted almost 20 years ago and remain consistent with our data. The published data suggest that the highest suicide mortality rates among the male population in the North Caucasian Federal District were in the Republic of Alania, being higher than the indicators for the North Caucasian Federal District by about 15%. The lowest male suicide mortality rates were in the Republic of Ingushetia. The numbers are lower than these indicators for the whole North Caucasian Federal District by over two times. These male suicide mortality rates are the lowest of those discussed in this report. However, higher suicide rates were found among male soldiers who served in the Chechen wars and/or were actively serving in other areas of the Caucasus [ 17 ]. Figure ​ Figure8 8 shows suicide mortality rates among the male population in various regions of the North Caucasian Federal District in 2015-2017 [ 11 , 12 ].

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Interestingly, the Russian Southern Federal District borders the republics of the North Caucasus. While some parts of that district are ethnically like the North Caucasus, the male suicide mortality rates are like other regions of Russia with a predominantly Slavic population. Data on male suicide mortality rates in various regions of the Southern Federal District from 2015-2017 showed a gradual tendency to decrease, but those numbers are still significantly higher than in the North Caucasus region. In the Republic of Kalmykia, suicide mortality rates among the male population in 2015-2017 were higher than in the Southern Federal District by about 20%. In the Rostov region, suicide mortality rates among the male population in 2015-2017 were about 15% lower than those in the Southern Federal District. Figure ​ Figure9 9 illustrates suicide mortality rates among the male population in various regions of the Southern Federal District in 2015-2017. 

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The Central Federal District is located in the center of the European part of Russia. It is the district with the highest density of population in Russia-60.30 people per square kilometer: a high level of urbanization, as about 50% of the population lives in the Moscow region. This region has a high level of economic and social activity and a presumably better socioeconomic situation. However, male suicide mortality rates vary between cities. Suicide mortality rates among the male population in the Belgorod Region and the city of Moscow were lower than in the whole Central Federal District. In the Kursk and Moscow regions, mortality rates were about the same as in the Central Federal District, especially in 2017. In the regions of Bryansk, Vladimir, Voronezh, Ivanovo, Kaluga, Smolensk, Tver, and Yaroslavl, suicide mortality rates among the male population were higher than in the Central Federal District. In 2015-2017, nearly all regions of the Central Federal District demonstrated decreased male suicide mortality rates. The fastest rates of decline were observed in the regions of Belgorod, Kursk, Smolensk, and Tver. In the Voronezh region, there was an increase in the death rate from suicide among the male population. In Moscow in 2016, the suicide mortality rate increased among the male population compared to 2015. In 2017, this index dropped again. Males aged 55 years and older were more likely to die from suicide than any other age group for both males and females. Figure ​ Figure10 10 shows male suicide mortality rates in various regions of the Central Federal District and the Russian Federation in 2015-2017 [ 11 , 12 ].

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The red column (4.3) is the suicide mortality rate among the female population in Moscow in 2016 [ 11 , 12 ]

Male suicides in the Volga Federal District showed a linear trend of decline in 2015-2017, despite the risk factors for suicide generally increasing. The most significant decrease in male suicide mortality rates among the male population was observed in the Saratov region, which initially showed an unexpected increase in male suicide rates (higher than in the Volga Federal District by about 23%) [ 11 , 12 ]. Suicide mortality rates among the male population in the Ural Federal District in 2015-2017 also showed a tendency to decrease [ 11 , 12 ]. 

Social marginalization and depopulation are particularly widespread in regions of the Asian part of the country. Despite the implementation of additional state-run social and demographic incentives, the impoverishment of human capital is still evident in this region. This region is far removed from Russia’s European core and financial centers but remains uncomfortably close to dynamic and powerful China. Despite the oil and gas resources of East Siberia and the Far East Federal District, its regional product amounts to just 5-6 percent of Russia’s total gross domestic product (GDP). 

These two regions have long been known as underdeveloped and socially challenging. Despite these circumstances, the suicide mortality rates among the male population in the Siberian Federal District (SFD) in 2015-2017 also showed a tendency to decrease. The most significant decrease in suicide mortality rates among the male population occurred in the Altai Republic. In the Krasnoyarsk Region, the Irkutsk region, the indicators were fairly even, like the rates for the Siberian Federal District. Interestingly, in Omsk, suicide mortality rates among the male population in 2015-2017 were about 10% lower than those in the entire Siberian Federal District. The official data show that the highest male suicide mortality rates in the Far Eastern Federal District were in the Amur and Sakhalin Regions, being higher than these rates for the Far Eastern Federal District by 28% and 23%, respectively. Interestingly, the lowest male suicide mortality rates were in the Kamchatsky Territory, where these numbers were lower than the indicators for the Far Eastern Federal District by about 10-15%. Figures ​ Figures11 11 and 12 summarize data regarding male suicide mortality rates in various regions of the SFD and the Far Eastern Federal District in 2015-2017 [ 11 , 12 ]. 

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Data accuracy issues 

According to the World Bank, Russia ranks third in the world in the suicide mortality rate, and this rate in 2019 was 25.10/100,000 per year. However, this rate is disproportionally higher for men. It is important to mention that these rates have been declining over the past 20 years. The available data highlight that the suicide mortality rate among Russian men was as high as 96.7/100,000 in 2000 and decreased to 43.60 in 2019 [ 18 ]. Interestingly, these numbers do not correlate with the data provided by Rosstat [ 3 ]. Table ​ Table1 1 provides additional information on this matter.

Adopted from  macrotrends.com  [ 18 ]. 

The research data published in Russia are not always transparent. For example, the “event of undetermined intent” has shown exponential growth since 2014 and has exceeded suicide mortality rates [ 19 ]. The researchers believe that this subcategory includes “latent homicides and suicides,” while actual suicide mortality rates remain unclear. Local coding and data recording standards vary significantly and can negatively affect the transparency of the data. Specifically, many suicides are frequently listed within the “external causes of morbidity and mortality” subcategory [ 19 ]. The ICD-10 classification category includes multiple “environmental events and circumstances as the cause of injury, and other adverse effects,” where potential suicides can be included without any further systematization. “Latent suicides” include falls from heights, poisoning, and hanging with unspecified intent. They account for a significant proportion of suicide mortality. Since they are counted as events of undetermined intent, statistics show a sharp drop in suicide mortality rates, which has a linear trend [ 20 ]. This approach serves as a perfect example of data distortion practices. Moreover, there is no distinct updated information regarding suicides committed in Chechnya and in other North Caucasus republics. Yumaguzin (2019) indicated that suicide rates are significantly underestimated, while ill-defined causes of death are used to misinterpret data related to suicide and self-harming behaviors [ 19 ].

According to Verbitskaya [ 21 ], 80% of publications in Russian have methodological issues or unacceptable research designs. Based on our analysis, many studies conducted or published in Russia have methodological flaws (e.g., incomparable populations, lack of standards, internationally approved scales, and different designs). An analysis of the literature published in Russian showed that many journals have no specific or evidence-based standards for the description and presentation of research results. Although these issues are not directly related to our assessment of men’s suicide rates, it is important to mention these flaws to facilitate positive changes in data reporting. No matter how much the data vary, male suicide mortality rates remain exceptionally high. 

Socioeconomic environment

Many experts agree that male suicide mortality rates are a consequence of social, economic, psychological, and demographic issues. Some of Russia’s cultural norms can be attributed to the nation’s tumultuous history, such as that of the former Soviet Union. With the fall of communism, the nation experienced social and economic hardships that adversely affected many Russians’ mental health. Some theorize that such monumental societal changes during that time have had long-term effects, persisting until the present day. However, there has been a downward trend in suicide rates over the last two decades because the nation has improved on many socioeconomic indicators [ 22 ]. The number of suicides correlates with social changes, such as resettlement, assimilation, and the destruction of the conventional social structure. 

Financial struggles can be attributed to increased suicidality in men. The three main economic indicators, which are GDP, unemployment rate, and consumer price index, are associated with suicidal ideas, suicide attempts, and suicides [ 23 ]. In the economic crises of the 1990s, unemployment and a decrease in personal income were directly correlated with growing suicide rates, especially among men [ 24 ]. Another study evaluated how certain socioeconomic factors influenced suicide patterns within Russia. The findings demonstrated a significant decline in the male suicide rate with the country’s improvement in economic indicators (e.g., income per capita, GRP growth rate, etc.). The study also evaluated the effects of marriage and divorce on suicide rates among men. Marriage has negative effects on suicide rates, while divorce has positive effects on suicide rates [ 25 ]. Russian men are more prone to relocate and tend to move to large cities to obtain employment and work on a shift basis. These difficulties have also led to the insufficient development of institutions expected to address these social issues [ 26 ]. 

Geographical aspects

People living in rural areas of Russia are at a greater risk of suicide than those living in urban areas or big cities. The strength of the connection between intoxication and suicide also depends on the geographical region in Russia. Specifically, the data show that rates increase from the south and west to the north and east of the country [ 24 ]. 

Not only are suicide rates significantly lower in the Northern Caucasus, but other factors also make it important to consider other psychosocial factors. For example, a higher proportion of Muslims in these regions results in a different cultural context in the Northern Caucasus than in the rest of Russia, plus religious differences and Islamic scriptures against suicide. Furthermore, the intersection of these cultural factors with social institutions means that several of the measures included here as controls are confounded with a location in this area.

Average alcohol consumption in central Russia is high with a relatively large proportion of unrecorded consumption ranging from almost zero to 21 liters [ 27 ]. The rates of heavy alcohol consumption (more than 40 g of pure alcohol per day) among men were the lowest in Kabardino-Balkaria and Karachay-Cherkessia (2.3 L of ethanol per adult/year) and the highest in Magadan region (24.3 L per adult/year) [ 28 ]. Alcohol consumption is lower in these regions, and wine products are more often consumed here than in the rest of the country, meaning that the preference for vodka is not as strong as elsewhere in Russia.

Cultural aspects

The Russian mentality is characterized by a man destined to serve the motherland, the army, and his family. Russian culture is rooted in rigid gender roles, and these norms are present even at the institutional level. In The ABC for Men, the author determined that Russia has over a dozen laws that discriminate against men. For example, Russian law supports the idea of motherhood among women, yet no laws exist that support fatherhood. Although there is no concept of "single father" in Russian law, the number of families consisting of single fathers with children is slowly growing in Russia (1.18% in 2002 vs. 1.27% in 2010. According to Russian law, these men are eligible for the same benefits as single mothers [ 29 , 30 , 31 ]. Russian legislators have attempted to pass several similar bills that, although unsuccessful, highlight the inequities between males and females.

Along these lines, men experience different expectations in terms of occupation. Women are not allowed to work certain jobs that are considered difficult or dangerous. Likewise, these occupations consist solely of male employees, allowing men easier access to suicide modalities at hazardous places of work. Such methods, such as pesticides or firearms, are more lethal. Not only this, but a man’s age of retirement is a full five years later than that of a woman [ 31 ]. These policies indicate Russian cultural pressures, which may adversely affect men’s mental health and suicide rates. Finally, 40-50 percent of all marriages in Russia will end in divorce or separation. High divorce rates may also contribute to the likelihood of higher suicide rates in this country [ 32 ].

Child and adolescent suicidality in Russia

Across all post-Soviet countries, Russia has one of the highest rates of child and adolescent suicide [ 33 ]. Parental neglect, such as physical, sexual, or emotional abuse in childhood (PSEA), is very common in Russian families. The link between PSEA and the risk of suicide throughout life has been confirmed by published research data [ 34 ]. 

According to multiple reports, Russia has often outstripped Europe when it comes to teen suicide rates [ 35 ]. The adolescent suicide rates (specifically between ages 15-34) have steadily increased since 1996, more so than the older age groups. Suicide among young Russian males is four times more common than among young females (32.8 per 100,000 people versus 7.6 in 2004), and it occurs among ever-younger males, some in their early teens [ 36 ]. Although younger groups have had consistently lower suicide rates than middle-aged and older adults, young Russian men have attempted suicide almost twice as often as female youth since 1989. According to reports, almost 4,000 teen suicide attempts were registered in Russia annually, and as many as 1,500 of them resulted in death. In 2016, an ominous report by journalist Galina Mursaliyeva in the Russian newspaper Novaya Gazeta surfaced, which brought to light the presence of online “death groups” on the social media platform  vk.com , which influenced countless teenagers to commit suicide worldwide [ 37 ], the biggest proportion of which were Russian teenagers.

In turn, the administrations’ knee-jerk reactions to increasing internet censorship did little to address the situation. There was a 14% spike in emergency room trips for potential suicides by children and adolescents in 2018 compared to 2017 (692 in 2017 versus 788 in 2018), according to findings reported by state officials [ 38 ]. Local media reports estimated that adolescent suicide rates remained relatively unchanged in 2018-2019. Interestingly, local experts noted that increasingly more Russian teenagers wanted to participate in or “supervise” online suicide games in 2020-2021 [ 39 ].

The underlying conditions that deem these children more susceptible to suicidal ideations are social isolation, a dysfunctional family system (e.g. families with interpersonal conflicts, misbehavior, child abuse or neglect), increased social isolation due to stigma surrounding mental health, an inability to relate to the opposite sex, and intolerance toward LGBTQ+ youth [ 40 , 41 ]. Additionally, decreased attention by caregivers to a child’s emotional needs has been the norm for a long time.

Multiple support groups, such as Your Territory and Deti 404, have since emerged on  Vk.com  to give teenagers a platform to express their frustrations with a skilled support network that provides counseling and mental health support [ 40 ].

Mental health and stigma

Studies of the relationship between psychopathology, substance abuse, and suicide consistently indicate that around 70% of people who die from suicide suffer from an identifiable mental disorder before death. Episodes of major depression associated with a major depressive disorder or bipolar disorder account for at least half of suicide cases [ 42 ]. The prevalence of affective disorders in Russia ranges from 30-40%. The majority of cases remain underdiagnosed and undertreated [ 43 ]. Among suicides, there are usually many factors that can increase underlying risks or interact with depression and increase suicide risk, such as alcohol- and drug-related disorders, which are more common in men [ 44 ].

In almost all regions across the country, men consistently live shorter lives than women. Especially among middle-aged Russian men, high alcohol consumption and ongoing mental health problems contributed to gender differences in all-cause mortality [ 45 ]. 

In Russia, there is a stigma associated with mental health and consequent suicide. Many Russians consider mental health disorders to be self-inflicted and do not believe in treatment. This stigma can extend to a suicidal individual’s friends, family, and mental health professionals. 

Binge drinking is commonplace among Slavic nations, with Russia being one of them. Suicides among men in Russia are specifically associated with high rates of alcoholism. Russia’s cultural pressures also affect the physical health of the country’s men. Men are discouraged from coping with life stressors in healthy ways, and many men turn to drinking or smoking to cope [ 31 ]. Data have shown that many Russian men drink alcohol to cope with stress, unemployment, depression - in situations in which they would otherwise have difficulty coping. High levels of alcoholism in Russia existed before the collapse of the Soviet Union. However, a sharp rise began in the early 1990s and has risen to one of the highest worldwide. Local officials have estimated that alcohol consumption is up to 15 liters per person per year, while consumption in the European Union and the United States is between 7 and 10 liters [ 31 ].

Vodka accounts for roughly 75% of the nation’s alcohol consumption, and approximately one-third of Russian men report binge drinking vodka at least once monthly [ 46 ]. While inebriated, individuals are more susceptible to existing mental health issues and maybe likelier to act on suicidal thoughts. It was shown that life expectancy decreased by 12% between 1990 and 1994, which was directly related to alcohol mortality [ 24 ]. Researchers estimate that 61% of male suicides in Russia involve alcohol, compared to 22% of deaths worldwide that involve alcohol [ 47 ].

Future trends 

Russia is witnessing extremely high male suicide rates. As the high suicide rate among Russian males is multifaceted, it can be difficult to develop effective solutions. Current thinking suggests that access to mental health services can lessen suicide rates. Considering all the difficulties, the transition of primarily descriptive results to specialized suicide prevention programs among men turned out to be a challenging task that requires complex medical and social approaches [ 48 - 50 ].

In the last two decades, the Russian Federation has introduced many measures that have yielded tangible results. In the early 2000s, the state became fully involved in the control of the alcohol market [ 46 ]. In 2006, Russia implemented an alcohol policy to control the alcohol market and contain alcohol-related poisonings. President Putin implemented the law in January 2006, which regulated the volume and quality of alcohol products. The patterns thereafter revealed important learnings as to how alcohol consumption affects suicide rates. One study determined that the 2006 policy yielded a 9% decrease in male suicide mortality. This translates into 40, 000 male lives saved yearly from suicide by restricting alcohol [ 24 ]. 

The WHO published data that, in 2003, both alcohol-related mortality and the amount of alcohol consumed per year decreased significantly [ 51 ]. In this way, the mortality of men has decreased by as much as 40%, while men’s life expectancy has increased from 57 to 68 years over the past 15 years [ 51 ]. In the early stages of the COVID-19 crisis, local experts suggested that the pandemic might lead to an increase in suicide among Russians. Official data released by Rosstat suggested that for the entire year 2020, the standardized mortality ratio due to suicides dropped by 4.1%. However, WHO experts concluded that suicide mortality in Russia is worse than officially reported. According to their report, “Suicide Worldwide in 2019: Global Health Estimates,” the suicide rates (per 100 000) were 25.1 (crude suicide rate) and 21.6 (age-standardized suicide rate), or at least twice as high as the official data [ 52 ]. Given these discrepancies in the data, it is almost impossible to predict future tendencies in men’s suicide mortality. Algorithms used to estimate suicide mortality in men are no longer valid since the data are often inaccurate.

Several effective suicide prevention programs have been implemented in Russia. For example, school- and college-based suicide prevention programs [ 53 - 55 ] have proven effective in reducing the number of suicide attempts among students. Programs aimed at meeting the needs of elderly people from high-risk groups were less effective due to the questionable design of those interventions [ 56 ], none of which have been implemented since 2019. 

Laws that prevent access to a particular method, be they stricter firearm control laws, restriction of access and use of blister packs of pills, lockable pesticide boxes, or bridge barriers (often in combination with a crisis intervention telephone hotline), may affect the suicide rate, even if some adjustments to those methods may occur over time [ 57 ].

While Russia, unlike the United States, does not have anything like the Second Amendment in its Constitution, it does provide its citizens with the constitutional right to self-defense. Additionally, background checks before the ownership of guns are more rigorous and consider an individual’s medical and psychological history [ 58 ]. Despite stricter laws, certain individuals could easily bypass background checks either via corrupt measures or obtain firearms via illegal channels, which is a huge market. This problem was brought to the fore, especially after the mass shooting incident in the Russian city of Kazan in May 2021, when a 19-year-old went on a shooting spree, killing nine people and injuring 23. The authorities quickly passed stricter gun control laws, which included more stringent background checks and control over illegal gun trafficking [ 59 ].

The country also saw a spate of physician deaths during the COVID-19 pandemic, in which two healthcare workers died, and one suffered serious injuries due to falling from a building. While the cause of death is still a matter of speculation, it brought into light a system underequipped to deal with the pandemic due to a short supply of equipment and manpower. Reports also highlight the apathy of the hospital administration in dealing with the sudden spike of COVID-19 cases and caring for healthcare workers, many of whom worked tirelessly even after becoming symptomatic [ 60 ].

Conclusions

Although the suicide statistics in Russia are profound, the suicide rate may be even higher than what has been reported. One of the biggest drivers of male suicidality in Russia is the country’s cultural norms. Russia remains very rooted in tradition, and within this tradition lies unique societal pressures. Cultural and psychosocial aspects of the Russian male experience, such as gender norms, low quality of life, and alcohol consumption, are likely key contributors to the country’s high suicide rates.

Our analysis of official reports and secondary sources in Russia also confirmed that there are too many publications of poor-quality study design and statistical analysis. Finally, continuous improvement of public health policy and fundamental and translational research can contribute to reducing the future suicide rate among the male population in Russia.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained or waived by all participants in this study

Animal Ethics

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

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