Raising Red Flags on Gun Violence

By Gail Saltz, M.D.

In one of the ever-growing number of mass shootings in the United States, a 33-year-old man killed eight people and injured seven others at a mall in Allen, Texas, in just four minutes with an AR-15-style rifle. The man, with ties to right-wing extremist groups, no known criminal record, and no recent psychiatric history, killed innocents between the ages of 5 to 61. Unfortunately, as is often the case in mass shootings, nothing in his public record kept him from legally purchasing the eight guns he took to the mall.

Following this and every other U.S. mass shooting, a loud flurry of arguing begins again. One group says it’s a gun-control problem, while the other says it’s a mental health issue. And yes, there are a lot of mental health problems in the U.S., but how they intersect with an out-of-control death-by-gun problem is complex. Psychiatrists possess unique information that can and should inform gun policy in this country.

Some Facts and Statistics about Mental Health and Guns

The U.S. has 25 times more gun homicides than other high-income countries. It’s also worth noting that 80% of murders occur by gun.

Further, while the U.S. has only 4% of the world’s population, it registers 35% of the world’s suicides by gun. More than 50% of suicides in this country are gun deaths. It turns out that guns are the most lethal means of all attempts to die by suicide, killing nine out of 10 people who attempt suicide by gun.

Many people who die by gun suicide have not seen a mental health professional at all and do not have a diagnosis. Yet, it’s fair to say that does not mean they don’t have a mental health problem. However, due to constitutionally protected civil liberties, no one can force those people to see a mental health professional or to get treatment that might avert death by suicide.

One exception is when a judge has affirmed a person to be an imminent danger to themselves or others and can mandate involuntary treatment. However, this scenario requires a person to admit they plan to kill themselves imminently—which doesn’t always happen.

More commonly, it is left to those around the suicidal person—family, friends, neighbors—to observe the signs that someone is thinking of killing themselves and to help remove access to the means of doing so. As it turns out, close to 50% of mass shooters and people who die by suicide have notified friends, family, or social media of their intentions ahead of time.

Red-Flag Laws

Such notifications are where red-flag laws come into play, although red-flag laws are on the books in only 19 U.S. states and Washington, DC. The laws enable someone who believes that someone they know is a risk for suicide, or homicide, to call the police and remove a gun.

This approach does involve due process in a civil court, because the decision to remove a firearm from a potentially suicidal person must be adjudicated and reassessed frequently before a judge.

Red-flag laws are one gun policy in which psychiatrists play a crucial role, notifying authorities when a patient is deemed at risk because they have access to a gun that should be removed. However, in most U.S. states, the laws do not exist. Consequently, psychiatrists could play a role in educating and informing policymakers, encouraging the adoption of red-flag laws in the 33 states that do not have any.

Age Limits to Purchase Guns

Between 18 and 21 is the peak age for commiting a violent offense with a gun. A disproportionate number of mass shootings are by men under the age of 22.

This is not at all surprising in light of what is known about human brain development: the brain is biologically immature and not fully developed until age 24 or 25. The teenage brain has high activity in an area called the amygdala. Amygdala activity, higher in teenage years than any time before or after, may play a role in the high impulsivity of teens.

In addition, another area of the brain that is not fully developed until age 24 or 25 is the prefrontal cortex. This area houses a person’s capacity for judgment and understanding the consequences of their actions, captured in the ability to say, “If I do this thing today, what will happen tomorrow? Maybe I need to suppress this impulse.”

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What do these brain facts mean? Teens and young adults can feel shame, anger, and a desire for revenge. What they cannot do as well as adults over the age of 24 is fully consider what acting on any of those feelings in the moment might mean for someone else or themselves after the moment is over. Given that they may be at the whims of an already overzealous impulsivity, this fact may explain why the number of teens and young adults responsible for mass shootings, homicides, and suicides remains disproportionally high.

Consider a teenage boy who is humiliated and seeking revenge but doesn’t have access to a gun. He might beat someone up, but they would not likely die. However, if he shoots them, they are likely to die. If the growing number of teens and young adults with depression or who feel hurt and ashamed cannot bear how they feel and they have access to a gun, an impulsive attempt to harm themselves in the moment will often be lethal.

To some degree, this reasoning lies beneath the decision to raise the legal drinking age to 21: An immature brain, if impaired by alcohol, puts its owner at an unacceptably high risk. The same goes for guns: Access to them puts its owner and others at risk.

Raising the age limit for gun ownership to 21 is another point point on which existing psychiatric knowledge and expertise can help inform gun policies.

Closing the Boyfriend Loophole

Another point on which psychiatrists can help inform gun policy is the five-fold increase in gun homicides by men who have committed intimate partner violence and who possess a gun. A history of domestic partner abuse is one of the few clear red flags identified in studies showing an increased likelihood of homicide by firearm.

U.S. women are 21 times more likely to be killed by a gun than women in any high-income country. In addition, more women die every year by gun at the hands of a domestic partner than from mass shootings. And many more women suffer post-traumatic stress disorder after having been threatened or shot at by their partner with a gun.

In some, but not all, states, red-flag laws allow gun removal from a person convicted of a misdemeanor or felony of domestic violence. However, by the time a woman has gone through the arduous process of having a court case and conviction against her domestic partner, many end up dead.

One solution would be to pass laws allowing a woman who has obtained a legal order of protection to trigger a due process procedure that would prevent her partner from having access to a gun. Closing this “boyfriend loophole” would save many women’s lives.

Background Checks with Waiting Periods

In about 80% of mass shootings, the shooter has told someone, in one way or another, of their intention. Frequently, they have acquired the gun shortly before the shooting.

That is why federal background checks with waiting periods would help keep people most at risk of committing a mass shooting—those having a prior conviction, a history of previous domestic violence, or a known history of serious psychiatric illness—from being able to acquire that weapon.

In addition, instituting wait times would mean more time for that individual to tip off someone somewhere about their intentions and for that observer to report it.

Finally, more time also permits the possibility that a person will interface with a mental health professional because most of them have thoughts of suicide via their mass shooting and would be able to get treatment that might avert catastrophe.

Are There Limits to Constitutional Rights?

Arguments against any form of gun control, including weapons of mass destruction such as automatic assault rifles, boil down to the second amendment of the U.S. Constitution granting the right to bear arms. However, written in 1789, our forefathers had yet to have any of the information available to them that the field of psychiatry has elucidated in the ensuing 234 years.

As with many laws and policies, even those based on constitutional rights, laws are needed to protect the health and well-being of the entire population based on science and health information we have today.

Gun deaths are the number one cause of death for children today. The number of gun deaths continues to rise every year. We are growing an entire generation of people traumatized by gun violence, adding to the already enormous number of people having mental health problems with insufficient clinicians and resources to treat them all.

Psychiatrists can play a role in the public health crisis of gun violence. That role is not limited to identifying and treating mentally ill people who should not have access to firearms, as they remain the vast minority. There is also a role to play in using today's psychiatric science to inform gun policies to save lives and prevent more children and adults from being traumatized and subsequently developing mental illnesses.

Gail Saltz, M.D., is a member of the Committee on Psychiatry and the Media at the Group for the Advancement of Psychiatry.