By Rose Hoban
In the wake of mass shootings such as the one perpetrated in Orlando this past weekend, questions invariably arise about the best ways to prevent such events from happening again.
This week is no different. In fact, in the context of the heated presidential race, the questions came quickly and sharply, with presumptive Republican candidate Donald Trump quickly blaming “radical Islam” and Hillary Clinton and other Democratic leaders calling for more stringent restrictions on access to guns and assault weapons.
In the midst of this debate, the former wife of the shooter, Omar Mateen, told reporters that she believed her physically and emotionally abusive former husband was “bipolar” and described his “instability.”
It’s in this context that a study published last week by Duke University researcher Jeffrey Swanson becomes particularly poignant.
In his Health Affairs paper, Swanson examines 10 years of records of more than 81,000 people with mental health diagnoses being cared for in the public behavioral health systems of Florida’s two largest counties, Miami-Dade and Pinellas (the Tampa, St. Petersburg, Clearwater region). Researchers compared those documents with law enforcement, court, corrections and health-care records.
[pullquote_right]Between 2009-2011, 64 percent of male suicides in North Carolina and 40 percent of the female suicides used a firearm.[/pullquote_right]What Swanson and his co-authors found was that having a serious mental health problems — schizophrenia, bipolar disorder and depression — “contributes very little to the overall risk of interpersonal violence but is strongly linked to suicide.”Four percent
“The suicide rate in this population that we studied is about four times higher than the general population of adults in Florida in the same counties in the same years,” Swanson said last week in an interview with NC Health News.
Since 2007, Florida has maintained records of such behavioral health issues and listed them in an electronic database that gun sellers must use to see if a buyer is disqualified from purchasing a firearm.
[pullquote_left]Of the 1,914 violent deaths in North Carolina in 2013, 1,237 were suicides, making it the leading cause of injury death in the state.[/pullquote_left]Federal and Florida legislation limit gun purchases for people who have had “health-related adjudications,” which include involuntary commitment to an inpatient psychiatric hospital, mandatory outpatient treatment, a finding of incompetency to stand trial and “not guilty by reason of insanity,” or a finding of mental incapacity to manage one’s affairs.But most of the people who committed suicide were not on this list. Swanson found many people who shot and killed themselves had mental health problems that did not disqualify them from purchasing a gun.
“Seventy-two percent of them, on the day they used the gun to end their life, had they walked into a federally licensed firearm dealer to buy a gun, they were legal to do that, even with a perfect background check system,” Swanson said. “They did not have any mental health commitment record.”
Swanson also found 28 percent of people who committed suicide and 62 percent of violent crime arrests involved people not legally permitted to have a gun, primarily because of prior criminal convictions. But they had firearms anyway.
“I’d interpret that to be a problem with the criteria that we have for deciding who’s at risk,” he said.
Swanson concluded from his research that legislative bodies that try to create criteria for keeping people from using guns get it wrong.
He noted there’s not a lot of evidence that laws limiting gun ownership for people with specific mental health problems actually prevent violent crime. That’s in part because those people don’t commit a lot of violent gun crimes, and pose little risk of violence.
“If we cured depression, schizophrenia and bipolar disorder, our overall violence level would go down by only about 4 percent,” he said.
At the same time, those laws don’t prevent people with mental health issues from using firearms to commit suicide.
“We have suspected that those [disqualifying] criteria are both too broad and too narrow at the same time,” Swanson said.
Pistol permitting
[pullquote_right]In 2015, North Carolina had 531,876 searches on the NICS system.[/pullquote_right]Swanson said that in some ways North Carolina and Florida are “fairly similar” when it comes to firearm restrictiveness, in firearm fatality rate and in household gun possession rates.Under federal law, anyone who wants to buy a firearm from a federally licensed dealer is subject to review under the National Instant Criminal Background Check System (NICS). After dealers put a person’s information into the system, they get back a result of “proceed,” “denied,” or “delayed.”
If a person’s application has been delayed, he or she can wait three days and if nothing more comes up on the system, the person can proceed with the sale.
Florida has gone beyond federal law (and North Carolina) to make those temporary holds on gun ownership a reason for disqualifying people altogether.
Swanson said he doubted making temporary holds permanent really disqualifies many more people with behavioral health problems. Under the current system, “It turns out that all those people already have a history of involuntary commitment,” and they’re already in NICS.
“One in four of these gun eligible people who used a gun to take their own life had been identified, treated and evaluated in a mental health crisis, but [they] didn’t lose their ability to legally possess a gun,” Swanson said.
“If you put all the purchases into NICS it would be better,” said Becky Ceartas, head of North Carolinians Against Gun Violence. “The federal system only applies to federally licensed dealers.”
Ceartas said North Carolina’s pistol permitting system, which requires buyers to get a permit from their local sheriff before purchase, closes a lot of the loopholes present in other states.
Gatekeepers?
[pullquote_right]White males had higher suicide rates than other racial/ ethnic groups in North Carolina (28.3/100,000)[/pullquote_right]North Carolinians who want to get concealed-carry permits need mental health review by a doctor, as well as by their sheriff.Swanson said adding a physician’s review of the mental health risk to the pistol permitting process might catch a handful of additional people who go on to commit crimes. But it would likely catch more people who want to harm themselves, a result that occurred in New York State.
There, the state compelled mental health clinicians to report people who they felt posed a danger to law enforcement to report them to the gun registry database.
But that requirement puts practitioners in a bind.
“Clinicians have competing duties to their patients and also to society and confidentiality, which is the bedrock of the doctor-patient relationship,” Swanson said.
That’s been the concern of UNC-Chapel Hill family physician Adam Goldstein, who has researched North Carolina’s mental health review process for several years.
For a paper published in 2015, Goldstein surveyed 222 physicians across the state and found a wide variation in the physicians who would find a patient incompetent to qualify for a concealed-carry permit.
“Physicians most frequently chose mild dementia, post-traumatic stress disorder, and recent depression as conditions that would render a patient not competent to carry a concealed weapon,” reads the article abstract. “Male physicians and those owning a gun were more likely to deem a patient competent.”
But Goldstein concluded if doctors were to serve in this role, they need better training and clearer guidelines.
“‘Signing off’ occurred despite the fact that most physicians said they did not feel capable of assessing a patient’s physical competence to carry,” Goldstein wrote in the article. “And a sizeable minority said that they were not capable of assessing mental competence to carry.”
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