This post is co-authored by Paul Nestadt, M.D.
The major problem of violence among people with serious mental illness is not that they kill other people but that they kill themselves.
In 2013 there were about 16,000 homicides in the United States (1), of which perhaps 5 percent (800) were committed by people with serious mental illness (2). But there were about 41,000 suicides (3), of which roughly 90 percent (36,900) where committed by people with mental disorders (4). More than half used guns to take their lives. (5)
In addition, homicides overall are on the decline; they have fallen over 13 percent since 2000. Suicides have increased 20 percent. (6) Currently, suicide is the 10th leading cause of death in the United States overall and the second leading cause of death under the age of 40. (7)
It is understandable that the media and politicians focus primarily on mass murders instead of suicide. Most of us are more afraid that we will be killed than that we will take our own lives. And images of mad men storming into schools or movie theaters armed with automatic weapons intent on taking as many lives as they can are truly terrifying.
Politicians, whether they are for or against gun control, all seem to agree that keeping guns out of the hands of people with mental illness and fixing the American mental health "system" are key to reducing the incidence of homicide by people with serious mental illnesses.
The facts do not support this view. Yes, people with serious mental illness commit a very small portion of homicides, but they are usually not mass murders and they are usually not killings of strangers. Yes, people with serious mental illness commit mass murders of strangers on rare occasion, but the odds of a person with a serious mental illness doing so are extremely low. There's little reason to believe that the changes in mental health policy that are now under consideration would have more than an infinitesimal impact on rates of mass murder. (8)
But steps can be taken to reduce the rate of suicide in the United States.
Some efforts are underway. The federal and state governments fund a variety of outreach, education, and treatment initiatives -- albeit not generously. (9) And a National Suicide Prevention Lifeline -- 1-800-273-TALK -- connects people who are suicidal or very distressed to nearby resources.
Still the problem of suicide is growing. What else can be done?
Improved identification and treatment could make a difference
Treatment for mental illness and/or substance abuse does not guarantee that people will not take their own lives, but it does reduce the likelihood that they will. (10) So a key to dealing with the problem of suicide is increasing utilization of behavioral health services. This is not easy for a number of reasons including the vast shortage of qualified behavioral health providers and lack of adequate outreach and engagement efforts.
In addition, most people who take their own lives have seen primary health care providers within 30 days prior to their suicides. (11) Their providers were unable to recognize that they were at risk. If health care providers routinely screened for depression and substance abuse and were more skilled at diagnosis, treatment, follow up, and the development of individual safety plans, risk of suicide could be reduced. (12) This is also not easy since it requires a vast change in standard practice.
Identification of, and appropriate response to, substance abuse is particularly important. Substance abuse multiplies the risk of suicide 6 times because of its impact on mood, because it reduces impulse control, and because overdoses are the third leading mechanism of suicide after guns and hanging. (13)
Early intervention after a first psychotic break could make a difference
People with psychotic conditions, particularly schizophrenia, are at very high risk for suicide, especially when they are young (14) and feel hopeless about their future. Intervention at the first break tends to reduce recurrence of acute conditions and to reduce the disabling consequences of the illness. (15) It could reduce suicides as well.
Primary prevention may be possible
In addition to improving identification and treatment of people at risk of suicide currently, it would be valuable to reduce the future development of risk.
One critical step would be to reduce access to the means used to commit suicide, especially guns, which are used in over half of suicides in the United States. (16) This is contested by opponents of gun control who argue that suicide rates in some countries with gun control are higher than in the U.S. People in these countries use other means, such as insecticides (17). That is true, but there is also evidence that in the U.S. states with gun control measures have lower rates of suicide than states that do not. (18)
In general, preventing the development of suicide risk calls for addressing the social determinants that contribute to mental illness and substance abuse. These include unemployment, poverty, family violence, lack of safety, poor education, and more. (19)
Lack of social cohesion also appears to be a powerful contributor to high rates of suicide. Thomas Joiner, one of the nation's leading experts on suicide, developed an interpersonal theory of suicide (20) to explain the complex factors that contribute to decisions to kill oneself. This theory points to "thwarted belongingness" and "perceived burdensomeness" as major contributors. Of course it is not easy to build more supportive communities in areas of the United States with limited social cohesion, but this may be key to reducing suicide rates significantly.
Increased research is critical.
The steps outlined above are suggestive but not definitive. Far more research is needed to identify both effective interventions with people at current risk of suicide and to prevent the development of high risk conditions. Sadly, some of the needed research is blocked by opponents of gun control, who apparently fear that the findings of objective research will not support their views.
Improving American behavioral health policy is essential
Critics of the American behavioral health "system" are certainly right that it needs vast improvement. But to focus on improvements that are of doubtful value in reducing rare acts of homicide by people with serious mental illness is a mistake.
Comprehensive reform is a very complex matter (21), but when it comes to the relationship between violence and mental illness, the suicide epidemic, not rare instances of mass murder, should be the major focus.
(1) U.S. Centers for Disease Control (CDC). "Fatal Injury Reports." http://www.cdc.gov/injury/wisqars/fatal_injury_reports.html
(2) Metzl, JM. "Mental Illness, Mass Shootings, and the Politics of American Firearms" in American Journal of Public Health, February 2015. http://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2014.302242
(3) U.S. Centers for Disease Control (CDC). "Fatal Injury Reports." http://www.cdc.gov/injury/wisqars/fatal_injury_reports.html
(4) Hyde, PS. "Suicide: The Challenges and Opportunities Behind the Public Health Problem." U.S. Substance Abuse and Mental Health Administration (SAMHSA). July 27, 2011. http://store.samhsa.gov/shin/content//SMA11-PHYDE072711/SMA11-PHYDE072711.pdf
(5) U.S. Centers for Disease Control (CDC). "Fatal Injury Reports." http://www.cdc.gov/injury/wisqars/fatal_injury_reports.html
(6) U.S. Centers for Disease Control (CDC). "Fatal Injury Reports." http://www.cdc.gov/injury/wisqars/fatal_injury_reports.html
(7) U.S. Centers for Disease Control (CDC). "Leading Causes of Death 1999-2013" http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html
(8) Metzl, JM. "Mental Illness, Mass Shootings, and the Politics of American Firearms" in American Journal of Public Health, February 2015. http://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2014.302242
(9) U.S. Substance Abuse and Mental Health Administration (SAMHSA). "Suicide Prevention". 10/29/2015. http://www.samhsa.gov/suicide-prevention
(10) American Suicide Prevention Foundation. "Treatment." https://www.afsp.org/preventing-suicide/treatment
(11) Louma, MA et al. "Contact With Mental Health and Primary Care Providers Prior To Suicide" in American Journal of Psychiatry, July 2002. http://www.researchgate.net/profile/Jason_Luoma/publication/11331338_Contact_with_mental_health_and_primary_care_providers_before_suicide_A_review_of_the_evidence/links/00b4952c5f12b45cef000000.pdf
(12) Sederer, LI. "How Doctors Think About Suicide Prevention" on The Huffington Post. 8/4/2015. http://www.huffingtonpost.com/lloyd-i-sederer-md/how-doctors-think-suicide-prevention_b_7917772.html
(13) Erinoff, Lynda; Compton, Wilson M.; Volkow, Nora D. "Drug abuse and suicidal behavior". Drug and Alcohol Dependence, December 2004. http://dx.doi.org/10.1016/j.drugalcdep.2004.08.001
(14) Kayhee, H. and Taylor, M. "Suicide and Schizophrenia: A Systematic Review of Rates and Risk Factors" in Journal of Psychopharmacology, November 2010. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951591/
(15) Harris, MG et al. "Impact of a Specialized Early Psychosis Treatment Programme on Suicide. Retrospective Cohort Study" in Early Intervention Psychiatry, February 2011. http://www.ncbi.nlm.nih.gov/pubmed/21352126
(16) CDC. "Fatality Injury Reports." http://www.cdc.gov/injury/wisqars/fatal_injury_reports.html
(17) World Health Organization. "Preventing Suicide: A Global Imperative." 2014. http://www.who.int/mental_health/suicide-prevention/world_report_2014/en/
(18) Harvard Injury Control Research Center. "Suicide." 2015. http://www.hsph.harvard.edu/hicrc/firearms-research/gun-ownership-and-use/
(19) Sederer, L.I. "The Social Determinants of Mental Health" in Psychiatric Services In Advance, November 2015. http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201500232?journalCode=ps
(20) Joiner T. et al. Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients. American Psychiatric Association, 2009. http://www.apa.org/pubs/books/4317175.aspx
(21) Friedman, M. B. "Improving Mental Health Policy: No Simple Answers" in Harvard Health Policy Review, Fall 2015. http://hhpronline.org/improving-american-mental-health-policy-no-simple-answers/
Michael B. Friedman, MSW is Adjunct Associate Professor at Columbia University School of Social Work. He can be reached at firstname.lastname@example.org. Paul Nestadt, MD is a psychiatrist and fellow of psychiatric epidemiology at Johns Hopkins. He can be reached at email@example.com.