A meme that circulated recently on social media suggested that the days of going to our comedians for levity and our politicians for public policy are over. According to the post, we now get our belly laughs from Donald Trump and discussions of serious social issues from the likes of John Oliver.
As a physician treating the mentally ill and addicted, this was never more evident to me than on Sunday, when Oliver, on his HBO show "Last Week Tonight," addressed the sad state of mental health care in the United States. Oh sure, the British-born comic made the subject plenty funny -- the system, he said, is a "cluster f---, except that's an insult to cluster f---s" -- but he hit many nails directly on their heads.
Oliver reported that the inadequacy of the mental health system to meet the needs of an estimated 43.8 million mentally ill Americans, of which about 10 million, or roughly the population of Greece, suffer from serious psychiatric conditions, is not a subject that anyone wishes to discuss ... until there is a mass shooting, such as the recent tragedy in Roseburg, Oregon. "Perhaps the clearest sign of just how little we want to talk about mental health," Oliver said, "is that one of the only times it's actively brought up is, as we've seen yet again this week, in the aftermath of a mass shooting as a means of steering the conversation away from gun control."
While I will not address the pros and cons of gun control in the U.S., it is true that the three presidential candidates quoted in the segment certainly sounded gung-ho on the issue of treating the mentally ill. "Do we need to do a better job in mental health?" asked Mike Huckabee, former governor of Arkansas. "You bet we do." (Of course, Oliver then pointed out that Arkansas, under Huckabee, had received a D- grade from the National Alliance on Mental Illness for its treatment of the mentally ill.)
"It seems there is nothing like a mass shooting to suddenly spark political interest in mental health," Oliver said. He then pointed out that the aftermath of gun violence is perhaps the worst time to talk about mental health when you consider that the large majority of those with psychological disorders are not violent. In fact, media reports connecting violence to mental illness only increase the stigma directed toward the mentally ill. A 2013 study conducted by researchers at the Johns Hopkins Bloomberg School of Public Health found that news reports about a mass shooting immediately increased readers' negative impressions about people with mental illnesses, with more than half stating that those with serious mental illness were likely to be dangerous.
In a separate public opinion survey conducted by the same researchers, almost half of the respondents believed that people with serious mental illness are more dangerous than members of the general population and most said they were unwilling to have a person with a serious mental illness as a coworker or a neighbor.
'Treatment' Left to Jailers
How do we address the inadequacy of a mental health system in which, Oliver reports, there are 10 times more mentally ill people being "treated" in jails and prisons (2 million) than there are in state-funded psychiatric treatment?
A couple of possibilities were raised on "Last Week Tonight." Establishing more crisis intervention units within local police departments would be a good first step, since police are often the first to confront a person manifesting symptoms of serious mental illness, and these encounters can end badly. (Oliver cited one report demonstrating that half of the incidents in which police used deadly force were calls involving a mentally ill person.) Only 15 percent of all law enforcement jurisdictions have crisis intervention programs, let alone special units, and crisis intervention training is voluntary.
The report also addressed Assertive Community Treatment (ACT) programs, in which the mentally ill can continue living in the community with the assistance of social workers who help patients attend to their treatment and daily needs. Despite the success of these programs, and the fact that they largely pay for themselves, they are in danger in many states due to budget cuts and issues relating to Medicaid reimbursement.
So, if the need for better mental health care is anything more than a talking point to deflect attention away from gun control, there is plenty to discuss. Because, in reality, the two subjects have surprisingly little to do with each other.
Vast Majority of Mentally Ill Will Never Be Violent
Trump blamed mental illness for the tragic loss of life in Oregon. "This isn't guns; this is about mental illness," the leading GOP presidential candidate said on ABC's "This Week." "You have sick people in this country and throughout the world, and you're always going to have difficulty." And while on the face of it, you don't have to be a doctor to know that no one is his right mind would take the lives of nine innocent people, the vast majority of mentally ill people are not violent and never will be. Mental health disorders are much more strongly linked to self-harm than to violence against others.
Oliver cited "one study that found that fewer than 5 percent of 120,000 gun-related killings were committed by people diagnosed with mental illness." That comprehensive study was done by Vanderbilt University researchers Jonathan Metzl and Kenneth MacLeish, who analyzed data and literature linking guns and mental illness over 40 years. The researchers concluded that it's not the stereotypical "violent madman," the young, white, angry male, whom we need to fear.
"You're far more likely to be shot by your neighbor or your cousin or disgruntled brother-in-law than by some crazed stranger," said Metzl, the study's lead author. "[There's this] fear of the unknown stranger ... some crazy person who is going to come and shoot you. But if you look at the research ... you're far more likely to be shot by someone you know.
"We should set our gun policies based on the everyday shootings, not the sensational shootings," Metzl said. "The mentally ill across the board are 60 percent to 120 percent more likely than the average person to be the victims of violent crime, not the perpetrators. People with severe mental illness often are homeless or talking to themselves, odd in a certain kind of way, and they become targets. We need to pay much more attention to mental health systems. How do people get care? Do they have health insurance, is there follow-up, is there medication available to them?"
The clincher: "It's a failure of the system that becomes represented as a failure of the individual."
Think Risky Behavior, Not Mental Illness
What does predict gun violence? A history of violent behavior, a history of childhood abuse, substance use at the time of an emotionally charged event and the availability of a firearm are all better risk indicators for violent behavior than psychiatric diagnoses. In addition, substance abuse appears to be a major predictor of violence whether it occurs along with a concurrent mental illness or not.
Dr. Jeffrey Swanson, a professor of psychiatry and behavioral sciences at the Duke University School of Medicine and an expert on the connection between violence and mental illness, said in a recent interview with ProPublica, "the risk factors for a mass shooting are shared by a lot of people who aren't going to do it ... if you paint the picture of a young, isolated, delusional young man ... that probably describes thousands of other young men." He cites a 2001 study of mass shooters that found three out of four had no psychiatric history and only 6% were judged to have been psychotic at the time of the mass murder.
Swanson says that even if schizophrenia, bipolar disorder and depression were cured, violent crime in this nation would decrease by only about 4 percent.
So making the mentally ill scapegoats for gun violence may be convenient, but it's flat-out wrong and won't make anyone safer.