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PERSPECTIVES

Mental Illness, Mass Shootings, and the Future ofPsychiatric Research into American Gun Violence

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Jonathan M. Metzl, MD, PhD, Jennifer Piemonte, MS, and Tara McKay, PhD

Abstract: This article outlines a four-part strategy for future research in mental health and complementary disciplines thatwill broaden understanding of mass shootings and multi-victim gun homicides. First, researchers must abandon thestarting assumption that acts of mass violence are driven primarily by diagnosable psychopathology in isolated “lonewolf” individuals. The destructive motivations must be situated, instead, within larger social structures and culturalscripts. Second, mental health professionals and scholars must carefully scrutinize any apparent correlation of violencewith mental illness for evidence of racial bias in the official systems that define, measure, and record psychiatric diagno-ses, as well as those that enforce laws and impose criminal justice sanctions. Third, to better understand the role of firearmaccess in the occurrence and lethality of mass shootings, research should be guided by an overarching framework thatincorporates social, cultural, legal, and political, but also psychological, aspects of private gun ownership in theUnited States. Fourth, effective policies and interventions to reduce the incidence of mass shootings over time—and toprevent serious acts of violencemore generally—will require an expanded body of well-funded interdisciplinary researchthat is informed and implemented through the sustained engagement of researchers with affected communities and otherstakeholders in gun violence prevention. Emerging evidence that the coronavirus pandemic has produced a sharp in-crease both in civilian gun sales and in the social and psychological determinants of injurious behavior adds special ur-gency to this agenda.

Keywords: gun violence, mass shootings, mental illness, psychiatric research, racial justice

Indiscriminate shooting rampages in public places accountedfor approximately 0.5%of homicides in the United States in2019,1,2 yet an estimated 71% of adults experienced fear of

mass shootings as “a significant source of stress in their lives,”causing 1 out of 3 people to avoid certain public places, accord-ing to a national survey by the American Psychological Associ-ation.3,4 In their responses to heightened community concernsover the threat of mass shootings, numerous public officials inrecent years have pointed to “mental illness” as a simplified ex-planation for these terrifying acts of violence.5 The “derangedshooter” narrative resonates with a persistent (if largely false)belief amongmajorities of adults in the United States: the notionthat people diagnosed with serious psychiatric disorders such as

he Department of Medicine, Health, and Society (Drs. Metzl and), Vanderbilt University; Joint Program in Psychology and Women’snder Studies, University of Michigan (Ms. Piemonte).

l manuscript received 18 February 2020; revised manuscripts re-25 June and 6 October 2020, accepted for publication subject to revi-October 2020; revised manuscript received 2 November 2020.

pondence: Jonathan Metzl, MD, PhD, 300 Calhoun Hall, 2301ilt Place,Nashville, TN37235-1665. Email: [email protected]

ght © 2021 The Author(s). Published byWolters Kluwer Health, Inc. onf the President and Fellows of Harvard College. This is an open accessdistributed under the terms of the Creative Commons Attribution-Nonercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissi-ownload and share the work provided it is properly cited. The work cannotged in any way or used commercially without permission from the journal.

0.1097/HRP.0000000000000280

d Review of Psychiatry

schizophrenia are likely or very likely to be violent.6 This con-struction of the problem relies on an elastic and pejorativedefinition ofmental illness and places psychiatrists in an oftenunwelcome yet strategic spotlight.7

On the one hand, the public’s a priori definition of massshooters as seriously mentally ill invites and reinforces unrealisticexpectations that mental health experts should be able to predictandprevent acts ofmass violence. It tends to inspire public supportfor restrictive policies and interventions targeting psychiatric pa-tients.6 On the other hand, the “deranged shooter” story can givemental health professionals a powerful voice and audience—people look to them for answers and solutions—which trans-lates into opportunities to reframe the debate over what shouldactually be done about mass shootings in the United States.

What can psychiatrists and other mental health clinicians,researchers, and policy makers do to foster evidence-based solu-tions topreventmass shootings, and tomitigate thepopulation riskof firearm injuries in general, without adding to the burden ofstigma and social rejection that people who are recovering frommental illnesses may feel when others assume they are dangerous?

Existing scientific evidence paints a complex—if incomplete—picture of the causes of mass shootings and other acts of se-rious violence. Until recently, a congressional ban on federalfunding for most gun-related research has prevented scientistsand scholars from conducting the full range of interdisciplinarystudies that would provide a better understanding of the prob-lem and point the way to effective solutions.8

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In what follows, we outline a four-part strategy for futureresearch in mental health and complementary disciplines thatwill broaden our understanding of these tragic events andhow to effectively prevent them.

First, researchers must abandon the starting assumptionthat acts of mass violence are driven primarily by diagnosablepsychopathology in isolated “lone wolf” individuals, andmust rather situate such destructive motivations within largersocial structures and cultural scripts. Second, mental healthprofessionals and scholars must carefully scrutinize any ap-parent correlation of violence with mental illness for evidenceof racial bias in the official systems that define, measure, andrecord psychiatric diagnoses, as well as those that enforcelaws and impose criminal justice sanctions. Third, to betterunderstand the role of firearm access in the occurrence and le-thality of mass shootings, research should be guided by anoverarching framework that incorporates social, cultural, le-gal, and political, but also psychological, aspects of privategun ownership in the United States; what is needed is asustained inquiry into how these dimensions might shapethe contours of gun violence as a broader public health prob-lem. Fourth, effective policies and interventions to reduce theincidence of mass shootings over time—and to prevent seri-ous acts of violence more generally—will require an ex-panded body of well-funded interdisciplinary research thatis informed and implemented through the sustained engage-ment of researchers with affected communities and otherstakeholders in gun violence prevention. Emerging evidencethat the coronavirus pandemic has produced a sharp increaseboth in civilian gun sales and in the social and psychologicaldeterminants of injurious behavior—especially inmarginalizedcommunities—adds special urgency to our agenda.9

Acts of mass murder implicate the psychologies of perpe-trators. A better understanding of the reasons behind theirbehaviors—a kind of “rationality within irrationality”10—re-mains important to the hope of preventing such crimes in thefuture.11 Retrospective analyses suggest that a nontrivial minor-ity of high-profile mass shooters demonstrated clinical symp-toms, including paranoia, depression, and delusions, at somepoint in their lives.12–14 Still, the assumption thatmass shootingsare driven solely or even primarily by diagnosable psychopa-thology stretches the limits ofmental health expertise. It also setsup a false expectation that advancing neuroscience and bettertherapies tomanage psychiatric symptomswill provide “the an-swer” to solving gun violence. There is no existing or forthcom-ing unified theory of impaired brain functioning or of cognitive,mood, or behavioral dysregulation that could adequately ex-plain mass shootings or multiple-victim gun homicides.

Symptoms of mental illness by themselves rarely cause vio-lent behavior and thus cannot reliably predict it. Certain psychi-atric symptoms, such as paranoid delusionswith hostile content,are highly nonspecific risk factors that may increase the relativeprobability of violence, especially in the presence of other cata-lyzing factors such as substance intoxication.15,16 Yet the abso-lute probability of serious violent acts in psychiatric patients

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with these “high risk” symptoms remains low. In general, fo-cusing on individual clinical factors alone leaves too muchunexplained, as it tends to ignore the important social con-texts surrounding mass shootings and multiple-victim homi-cides.17 To assume that gun violence is primarily a problemconfined to a perpetrator’s brain may impede inquiry into aranges of factors that could be crucial to a full understandingof mass shootings—factors such as the perpetrator’s sex,race, socioeconomic status, relationships, attitudes, personalhistory, the place where a shooting occurs and the perpetra-tor’s (dis)connection to it, and the ways in which local guncultures and unrestricted access to guns might create the con-ditions under which these events become more likely.

How canmental health research change the dominant nar-ratives surrounding mass shootings and multiple-victim ho-micides, and thus broaden debates about the communityeffects of gun violence? Our selective literature review and re-search agenda present a strategy for moving beyond the“diagnose-the-mass-shooter” framework to a perspectivethat emphasizes the multi-determined nature of gun trauma.In so doing, we advocate for broadening the scope of concernand the potential contribution of mental health experts andresearchers to include the larger gun-violence epidemic, rec-ognizing its structural dimensions as within their purview, es-pecially at the intersection with social science, public health,and other complementary disciplines.

AN AGENDA FOR MENTAL HEALTH RESEARCHINTO MASS SHOOTINGS AND MULTIPLE-VICTIMGUN HOMICIDES

1. Move Beyond Simplistic Mass Shooter Profiling andMedia-Driven “Diagnose-the-Shooter” Formulations toSituate Destructive Motivations Within Larger SocialStructures and Cultural ScriptsPoliticians and media commentators often quickly label massshooters as “mentally ill” without defining the term and beforeany valid psychiatric history is known, simply on the basis ofthe aberrant nature of the crime itself: “What sane person coulddo such a thing?” Media-stylized accounts of the motivation ofmass shooters tend to rely onmisleading stereotypes of the inher-ent dangerousness of mental illness. When such accounts arewidely adopted as master explanations for shooting rampages,the easily recognizable features of the narrative can obscure therole of many other potentially important contributing factors.These might include the perpetrator’s stressful economic circum-stances and level of social disadvantage,maladaptive personalitydevelopment in response to early-life trauma, the psychologicalsequelae of domestic violence exposure, aggrieved resentmentand smoldering anger against individuals or groups perceivedto be hostile and threatening,18 and male gender and aberrantconstructions of masculinity—all enhanced by the disinhibitingeffects of substance intoxication and easy access to a semi-automatic firearm. These kinds of vectors and background con-ditions, often interacting with each other in complex ways, can

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be far more germane to comprehending a particular act of massviolence than a diagnosis of acute psychopathololgy.19

Recent studies suggest that approximately 25% of massmurderers had exhibited a mental illness, but most of themhad not appeared on the radar of either the mental health orlaw enforcement systems.13 Similarly, a Federal Bureau of In-vestigation (FBI) study of 63 active-shooter incidents between2000 and 2013 found that 25% of shooters were known tohave been diagnosed with a mental illness of some kind, rang-ing fromminor tomore serious disorders. The study concludedthat “formally diagnosed mental illness is not a very specificpredictor of violence of any type, let alone targeted violence.”12

These relatively weak associations highlight how mental ill-nesses in themselves rarely cause violent behavior and are notreliable predictors of multiple-victim gun crimes.16,20

In some sense, each mass shooting incident is unique. Sub-stance use comorbidity and a range of putative risk factorsranging from the shooter’s level of economic distress andhousing insecurity to politically extremist attitudes and ideol-ogy, to social isolation have been cited as stressors in analysesof mass shootings.21No single variable emerged as a commonfeature of mass shooters. Still, the “diagnose-the-shooter”narrative persists and furthers a number of stigmatizing ste-reotypes, such as the notion that persons with mental illnessresemble “ticking time bombs.”11,22 Representations of peo-ple with mental illness as being irrationally and unpredictablyviolent can have real adverse consequences, ranging fromcommunity resistance to the placement of housing and treat-ment facilities for people with mental illness in particularneighborhoods, to the escalation of tense interactions be-tween people with mental illness and law enforcement offi-cers, often resulting in avoidable arrests and incarcerationsand sometimes ending in fatal shootings by the police.23,24

Defining an appropriate role for mental health practi-tioners in preventing mass shootings is inherently difficult.While recent studies have found that the majority of massshooters did not show signs of acute psychosis or seriousmood disorder, the estimated prevalence of psychiatric disor-der is still higher among these perpetrators than in the generaladult population. As we have already suggested, there is someevidence that certain combinations of clinical symptoms andaffect patterns may temporarily increase risk of gun violence.Researchers have identified delusions, fixation, and perceivedpersecution as clinical symptoms that may precede violent be-havior.16,25 But does this implicate psychopathology in massshooting, and therefore call for psychiatric surveillance andrisk assessment to prevent at least some of these events?

Ironically in this context, disorders such as major depres-sion and schizophrenia are often marked by psychomotorslowing, negative affect, intellectual disorganization, socialisolation, and other symptom clusters that would seem to ren-der a person less likely to plan and implement a complex guncrime.18,26 It is perhaps not surprising, then, that some studieshave found that persons diagnosedwith these mental illnessesare less likely than non–mentally ill offenders to use firearms

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in violent crimes.27 Along these lines, Swanson and col-leagues28 found that adults with serious mental illnesses inpublic behavioral health systems in Florida were at least nomore likely than other adults in the general population to bearrested for a gun-related violent crime.

A study of individuals who were clinically fixated onharming members of Congress found that having a psychiatricdiagnosis alone was not associated with aggression or actualviolent behavior. More relevant predictors included the indi-vidual’s motives and means.29,30 The MacArthur ViolenceRisk Assessment Study31 identified a group of 100 repeatedlyviolent individuals in a sample of 1136 discharged psychiatricinpatients but found that psychosis immediately preceded only12%of violent incidents. The researchers concluded that “psy-chosis sometimes foreshadows violence for a fraction ofhigh-risk individuals, but violence prevention efforts shouldalso target factors like anger and social deviance.”32 In addi-tion, the MacArthur study found that only 2.4% of the studyparticipants engaged in any act of firearm-involved violence,defined to include brandishing or threatening someone with agun, over the 12-month follow-up period.31

A large U.S. study of schizophrenia patients in the commu-nity found that 5.4% of participants engaged in at least oneact of injurious violence during an 18-month follow-up pe-riod, but baseline symptoms of psychosis or depression didnot predict injurious violence. Rather, the significant predic-tors were severity of illicit drug use (hazard ratio = 2.93), re-cent violent victimization (hazard ratio = 3.52), childhoodsexual abuse (hazard ratio = 1.85), andmedication nonadher-ence (hazard ratio = 1.39).33 These findings would suggestthat the large majority of patients with schizophrenia do notengage in acts of serious violence, and even when they do,psychiatric symptoms alone do not provide a sufficient expla-nation for their violent behavior.

Still, “mental health” remains the focus of many existingregulations as well as proposed policies to prevent gun vio-lence in the community. Despite evidence that there is nostrong connection between gun crime and mental illness,2 fed-eral law since 1968 has prohibited firearm purchase or posses-sion by anyone with a record of involuntary civil commitmentto a psychiatric hospital or other mental health–related adjudi-cation.34 A few studies have suggested that this restriction pre-vents some violent crime—and gun crime, in particular—butits population-level impact is severely limited since very fewpatients are involuntarily committed.35,36 The vast majorityof violent gun crimes are perpetrated by people who wouldnever be committable to a psychiatric hospital, and the im-portant correlates of violent behavior tend to be the same inpsychiatric and nonpsychiatric populations—for example,being young, male, or socially disadvantaged, exposure totrauma in early life, and using drugs and alcohol to excess.Future research into mass shootings and other acts of seriousviolence should move beyond the diagnostic template thatlooks for psychopathology to adequately explain the perpe-trator’s behavior.

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2. Scrutinize any Apparent Correlation of Violence withMental Illness for Evidence of Racial Bias in the OfficialSystems That Define, Measure, and Record PsychiatricDiagnoses, as Well as Those That Enforce Laws and ImposeCriminal Justice SanctionsU.S. popular and political discourse frequently applies themental illness descriptor to white male shooters, but analysisof whiteness itself, or discussions of whiteness as a race or eth-nicity, are usually omitted from published studies about U.S.mass shootings.37–39 By contrast, race and ethnicity oftenplay a key role in accounts of mass shootings when the perpe-trator is not white. For example, after the 2007mass shootingat Virginia Tech University perpetrated by a college student ofKorean-American heritage, media outlets reported thatAsian-Americans experienced fear of retaliation and feltforced to issue an apology on behalf of their “group.”40

A content analysis of news documents covering massshootings from 2013 to 2015 found that white and Latinxmale perpetratorsweremore likely to have their crimes attrib-uted to mental illness than were shootings by black men.41

White men were qualitatively described as more sympatheticcharacters than black and Latinx men, who were more oftenlabeled as violent threats to public safety.41 Despite the popu-lar stereotype of mass shooters being white, statistically justover half (57%) of the perpetrators of FBI-defined massshootings since the early 1980s have been white, and the ma-jority of victims of mass shootings in recent years have beennonwhite individuals.42,43 When a mass shooting occursand the identified perpetrator is black, content analysis showsthat politicians’ press briefings, media reports, and researcharticles rarely mention mental health and illness in descrip-tions of the perpetrator. Rather, such incidents are more likelyto be described under rubrics such as “gang disputes,” “drive-by shootings,” or other forms of “urban” violence, often withlittle further elaboration on motives or effects.44,45

These white/black dichotomies in the definition of massshootings carry implications for resource allocation for study-ing these incidents and for potentially interrupting theircausal pathways and mitigating their harmful consequencesto individuals and communities. Defining urban violence asessentially out-of-range for our concern with mass shootingsmakes it much more difficult for researchers to discover theways in which these shootings, too—as commonplace as theyhave become in certain urban neighborhoods—can have pro-found and lasting psychological and community effects.46

Mass shootings in urban areas have received little attentionfrom mental health researchers, and the relatively few studieson this topic mostly amount to superficial, group-based com-parisons between urban and suburban perpetrators. For exam-ple, Knoll47 describes aspects of social identity in summarizinghow urban and suburban perpetrators seem to differ, citing anurban “honor culture” and strong, group-based “social hierar-chies” as the context for urbanmass violence, in contrast to theimage an isolated loner who commits amass shooting in a sub-urban public setting.

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Meanwhile, a large body of research has focused on thelink between violence and mental illness in general, much ofit relying on data from the criminal justice system, forensic fa-cilities, state psychiatric hospitals, or other publically fundedsystems in the community. Due to the historical nexus of ra-cial discrimination and economic disadvantage—which hadled indirectly to entrenched disparities in arrest and incarcer-ation as well as to involvement with the public behavioralhealth system—individuals who are identified as violent (orat risk of violence) in official institutional settings tend to bedisproportionately people of color.48–50

These systems curate and disseminate the records of felonyconviction and involuntary civil commitment that are used todetermine that a person is ineligible to possess firearms underfederal or state law. Specifically, official agencies reportgun-disqualifying records to the FBI’s gun-purchase back-ground check database, with the result that racial disparitiesin the reporting institutions’ practices and policies tend to bereproduced in the implementation of firearm restrictions thatare applied to putatively risky categories of people.51 As oneexample, a large study of gun restrictions in a population ofadults with serious mental illnesses in Florida found thatblack individuals made up 15% of the surrounding popula-tion but 21% of the study group in the public behavioralhealth system, 31% of those disqualified from guns due to amental health adjudication, and 36% of those disqualifieddue to a criminal record.28,49

As a result of these entrenched selection effects, much ofwhat we know regarding the intersection of violence andmental illness extends only as far as people with mental ill-nesses who are socially and economically marginalized oruse public services. But this misleading picture is often usedto justify further institutionalization or incarceration that dis-proportionately affects people of color, producing an insidi-ous feedback loop between biased data and discriminatorypractice. Studies that are able to account for a range of socialcorrelates of violence inmultivariablemodels tend to find thatthe statistical association between violence and race is muchattenuated, as is the link between violence and mental illnessas defined in the official records of state agencies.31,52

In summary, racial bias can creep into available data anddistort our understanding ofmass shootings and other gun vi-olence, limiting the scope of what should be a broader andmore productive inquiry into the complex causes and effectsof gun-related injury and death. What, for instance, are thepsychologies that underlie shootings in areas of concentratedurban poverty, and what particular traumas emerge in theirwake?53,54 What are the traumatizing effects for young peo-ple who frequently hear gunshots or have seen shootings ordead bodies?55,56 How can mental health expertise be effec-tively deployed to address these more quotidian, but no lessproblematic, aspects of gun violence in the United States?

Reckoningwith the biases in its own framework can then aidmental health research to promote anti-racist work57—such ascollaborating with community-based violence interrupters,58

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imagining and advocating for structural change, and addressinghow gun victimization in black communities intersects withother unequal systems, including health care, education, andcommunity safety.46

3. Promote Awareness of the Social and PoliticalDeterminants of Firearm ViolenceTo better understand the role of firearm access in the occur-rence and lethality of mass shootings and other forms ofgun violence, research should be guided by an overarchingframework that incorporates not only social, cultural, andpolitical, but also psychological, aspects of private gun own-ership in the United States. Mental health researchers shouldplay a key role in a sustained collaborative inquiry into howthese dimensions might shape gun violence as a broader pub-lic health problem. Following the lead set by public healthscholarship, adopting such an approach would enable mentalhealth researchers to contribute productively to building in-terdisciplinary evidence for gun laws and policies that areboth effective and equitable, minimizing potentially adversecollateral consequences for at-risk individuals who are sub-ject to restrictions.59Mental health professionals and scholarscould have much to offer, for example, in the development ofbetter guidelines for restoring firearm rights to persons withgun-disqualifying records in their remote past.60

A study byReeping and colleagues61 found that stateswithmore permissive gun laws and higher rates of gun ownershipalso tend to have higher rates of mass shootings. But do thesepatterns mean that gun laws are effective, or do they reflectthe intersectionality of other social and economic differencesamong states? Research by Steadman,31 Tuason,62 and otherssuggests that serious acts of violence attributed to “mental ill-ness” often are more robustly associated with socioeconomicfactors that may also be indirectly linked to mental illness, in-cluding unemployment, insecure housing, histories of trauma,or lack of access to care.63 Perhaps the broader determinants ofpopulation well-being, illness, injury, and death can indepen-dently affect all of the following: cultural attitudes towardgun ownership; responses to social conflict; policies and lawsconcerning gun access; the motivations of a mass shooter;and the probability of being able to carry out an act of mass vi-olence.64 Understanding such potential connections throughinterdisciplinary research that includes a trained mental healthlens could help to both reduce gun violence and improve otherdimensions of population well-being over time.

4. Use Community Engagement to Expand the Scope andImpact of Research to Prevent Mass Shootings and OtherGun ViolenceEffective policies and interventions to reduce the incidence ofmass shootings and other acts of serious violence will requirean expanded body of well-funded interdisciplinary researchthat is informed and implemented through the sustained en-gagement of researchers with affected communities and otherstakeholders. Within the mental health community, persons

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with lived experience as well as some family members and ad-vocates have been loath to engage with gun violence preven-tion efforts in the past, due to the perception that theseefforts play upon the public’s exaggerated fear of people withmental illnesses and thus exacerbate the stigma and scorn thatmentally ill individuals feel from others.65

In reality, people in the communitywho are recovering fromseriousmental illnesses often havemore to fear fromother peo-ple. Like other vulnerable populations,54,66,67 persons diag-nosed with mental illnesses are statistically more likely to bevictims than perpetrators of violent crime.18,68,69 They repre-sent between 25% and 58% of those shot and killed by policeofficers each year,70,71 and there is an apparent interaction be-tween race andmental illness when citizens are shot by law en-forcement officers. A recent study found that when police shotand killed people in the line of duty, their explanatory reportsapplied the label of “mental illness” more than twice as oftento white individuals as to black individuals (32% vs. 15%).72

These findings suggest the need for community-engagedresearch to explore how perceptions and potential biases sur-rounding mental illness and firearms intersect with those thatinvolve race, gender, and class.73 Such research could help todismantle the stigmatizing assumption that mental illnesscauses violence, clearing the way for larger debates aboutcommunity safety and resource allocation. This step couldbe important because studies have found that people who as-sociate mental illness with danger are less likely to support al-locating funds to community services and programs designedfor individuals with mental illness.74–77

Future research should determine what are the best practicesfor engaging communities in gun violence prevention, and shouldbetter promote existing efforts in that regard. For instance, fol-lowing the Sandy Hook shooting, the Interdisciplinary Groupon Preventing School and Community Violence recommendeddeveloping channels of communication between schools andsurrounding communities.78 Their report highlights “chan-nels of efficient, user-friendly communication” and empha-sizes the importance of ongoing dialogue between differentcommunity stakeholders such as students, parents, healthcare providers, security and safety officers, and school admin-istrators.78 Community-engaged mental health researcherswho are focused on broadening the discussion and inquiry intowhy mass shootings occur may occupy a strategic position forinforming and fostering such dialogue among stakeholders.

DISCUSSIONIt is important to move beyond a preoccupation with deter-mining the mental health status of mass shooters and, moregenerally, with the question whether “the mentally ill” areprone to gun violence. This preoccupation has served to limitthe important role that mental health expertise could actuallyplay in addressing broader questions involving the balancebetween the perceived benefits of gun ownership and the riskthat guns may pose in the hands of some persons at certaintimes—all in the interest of promoting the well-being of

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individuals and society. The ability to acquire reliable data onthe causes and consequences of gun violence was seriously ham-pered by a decades-long federal ban on funding for gun-relatedresearch at the Centers for Disease Control and Prevention.That ban, which prohibited any studies that could have beenperceived as promoting gun control, had a chilling effect on allfederal research funding aimed at preventing gun violence. Butnow that the ban has been at least nominally lifted and somenew federal funds have been appropriated for such research atthe CDC and National Institutes of Health, the time has comefor mental health experts and researchers to join other scholarsin complementary disciplines and seize the opportunity to buildthe next generation of research to prevent violence. Theymust develop broad conceptual frameworks and creativemethodologies to study gun violence as the persistent andmultifaceted public health crisis that it is, and to insist on alevel of public investment commensurate with the humanand societal cost that gun violence exacts.

The reviewed literature makes clear that a diagnosis of amental illness alone is an negligible factor in any effort to ex-plain, predict, and prevent mass shootings or other acts of se-rious gun violence. These tragic events have many individualand social determinants—from trauma history to substancedependence, from unemployment and insecure housing tothe proliferation of guns in the community—that may inter-act with each other in complex ways. Public mass shootingsare still rare events when considered at the population level,notwithstanding a fearful public’s perception of their fre-quency and salience; these will always be exceedingly difficultevents to study, predict, and prevent. Filling in the gaps inknowledge about these events requires a better understandingof the cultures and contexts that surround guns in America, inaddition to a focus on specific shootings. More broadly,preventing gun-related injuries and deaths is a collective, so-cial responsibility. Psychiatry stands to be an agent of changein promoting interventions and solutions for improving thehealth of a community, rather than narrowly addressing themost sensationalized manifestations of gun violence.

This body of research becomes more salient as gun owner-ship emerges as an important theme in narratives surroundingAmerica’s responses to the COVID-19 pandemic and thereckoning with racism in the aftermath of the killing ofGeorge Floyd.79 Unprecedented surges in gun ownership,80

weapons brandished in the lobbies of statehouses,81 andarmed presence at protests and counter-protests across thecountry82 have marked the American pandemic moment.Mental health experts have also warned of a “perfect storm” forsuicide risk that is especially concentrated in COVID-distressedcommunities, with a sharp increase in the socioeconomicand psychological determinants of self-injurious behavior co-inciding with an influx of guns, the most lethal of suicidemethods. And while these trends may heighten the risk ofgun-related morbidity and mortality linked to mental illness,they also illuminate gaps, blind spots, and omissions in men-tal health expertise: we need to know more.

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Just like mortality rates from the novel coronavirus, socialvulnerabilities and inequities that contribute to gun traumahave been exposed and exacerbated by the shift in resourcesaway from communities that were already at risk. Recentmultiple-victim shootings in cities like Baltimore andPhiladelphia were all the more lethal because first respondersand emergency roomswere already deployed to capacity withCOVID-19 treatment instead.83–85

Future research will need to address ways in which U.S.gun trauma has morphed in relation to the changing struc-tures surrounding human interactions.86 For instance, thepossibilities that previously public gun violence is shiftingduring the pandemic to private spaces or that it involvesnew or different victims are developments that heighten theurgency of recalibrating risk assessment and mounting inter-ventions that can reach people where they reside.

Again, people who are already within the mental healthsystem do not represent the highest-risk groups for manytypes of gun violence, such as intimate partner shootingsand other stress-induced and alcohol-fueled tragedies that in-creasingly occur in private residences during the pandemic.87

Calling the police is not always the most realistic or desiredfirst step in these delicate situations; mental health expertsmight, instead, need to develop new networks through part-nerships with organizations, technology platforms, and ser-vices that reach individuals in threatening circumstances.Here, for instance, mental health knowledge tailored to thesesituations could be adapted and disseminated by social mediacompanies, first responders, employment boards, or other de-livery services.18

By reframing and broadening their approach tomass-casualtyshootings, mental health professionals and researchers couldmove mental health expertise to the fore in promoting firearmsafety in schools, workplaces, and public gatherings, and amongand between differing communities in post-pandemic America.88

Moving beyond diagnostic frameworks and the futile quest to“foresee” mass shootings will allow mental health research tomore fully address how mass shootings and multiple-victimhomicides occur within broader systems and frameworks. Do-ing so could broaden our understanding of gun violence andpoint the way to fair and effective policy solutions that couldsavemany lives, while respecting both the rights of gun ownersand the dignity of persons affected by mental illness.89

Declaration of interest: The authors report no conflicts of in-terest. The authors alone are responsible for the content andwriting of the article.

This article and the research behind it would not have beenpossible without the exceptional support of Jeffrey Swanson,PhD. His enthusiasm and exacting attention to detail havebeen an inspiration, and our findings reflect his ongoing en-couragement, generosity, and breadth of knowledge.

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89. Medical Director Institute. Mass violence in America: causes,impacts and solutions. 2019. https://ncvc.dspacedirect.org/handle/20.500.11990/1528

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