Since December 14, 2012, when Adam Lanza entered Sandy Hook Elementary School in Newtown, Connecticut, intent on taking the lives of innocent children and the adults tasked with protecting them, the topic of gun control in the United States has returned to the forefront. Some professional organizations, such as the American Academy of Pediatrics (AAP), have made their stance clear. In a letter to President Obama, AAP President Thomas K. McInerny, MD, FAAP, wrote:
“New federal firearms legislation that bans assault weapon sales and the sales of high-capacity magazines, strengthens mandatory waiting periods and background checks for all gun purchases, and promotes strict gun safety policies is a necessary first step. Next, the federal government must take action to improve access to services that meet the mental health and developmental needs of infants, children, and adolescents, and ensures that children and families exposed to violence have access to a medical home and other community supports.”
That “first step” is the central, divisive issue in the debate between gun control advocates and supporters of the Second Amendment, such as the National Rifle Association (NRA). But it is the next step—improving mental health services (and not only for children)—that may actually represent the crux of the matter. The risk is that, as both sides dig in their heels and try to out-shout each other, the nation will either miss or misuse an opportunity to address a complicated and unwieldy problem.
What Is Really At Issue
One week after the shooting at Sandy Hook, NRA executive Wayne LaPierre raised the idea of a “national database” of the mentally ill as one means of stemming gun violence. His comments also raised hackles, as some considered them a diversionary tactic and others worried that the mentally ill would become scapegoats in the debate.
As with all emotionally wrought topics, the intersection between violence and mental illness is complicated and controversial. Even setting aside personal positions on gun control leaves a realm of clinical uncertainty. There are no easy answers.
True psychiatric illness involves cognitive distortion (eg, the paranoia and hallucinations of schizophrenia). That positive symptomatology distinguishes mental illness from sociopathy, which entails a personality or a moral dysfunction.
“We know what neurotransmitters are involved in cognitive processes, and we can treat them,” says Cindy Parsons, DNP, ARNP-BC, FAANP, Associate Professor of Nursing, College of Natural and Health Science, University of Tampa, Florida. “When it comes to moral compasses being off-kilter, we don’t have a tried-and-true methodology that gives us even some hopefulness in terms of improvement. With Columbine and Sandy Hook, these young people were not so much paranoid about the world—they didn’t have a clear perspective on right and wrong.”
Currently, there is no treatment for antisocial personality disorder (which is diagnosed in those older than 18; in younger persons, it is known as conduct disorder). In fact, sociopathy—a particularly severe form of antisocial personality disorder—has not been a true classification in the Diagnostic and Statistical Manual of Mental Disorders. That will change this May, however, when DSM-V is published.
“Our ‘ticking time-bombs’ are probably our young people,” says Parsons. “How are we teaching young people to manage stress or conflict? We don’t. That’s not something we educate them on in school; we assume that families are educating them.”
Catherine R. Judd, MS, PA-C, who practices in Parkland Health and Hospital System’s Jail Health Program at the Dallas County Jail, recalls kids she encountered in the juvenile system. Many of them had been involved in vandalism, theft, animal cruelty, destruction of property, and arson—all criteria for a diagnosis of conduct disorder.
By contrast, “a lot of the seriously mentally ill people we see here in jail, their charges have nothing to do with weapons,” she says. “Their charges are criminal trespassing, stealing bologna out of the 7-11 because they’re hungry, urinating behind lampposts, hanging out under bridges, being ‘used’ by the real thieves to fence the copper they’re stealing off air conditioners, or to cash that ‘hot’ check.”
That isn’t to suggest that persons with mental illness are never violent. But are they necessarily more likely to be violent than those without a psychiatric diagnosis? And furthermore, who is determining that risk? These are just some of the concerns that Don St. John, MA, PA-C, who practices in adult outpatient psychiatry at the University of Iowa, has pondered since the subject of gun violence and the mentally ill has garnered renewed attention.
“If we define mental illness as ‘a DSM diagnosis,’ 25% of the population has had some kind of mental illness, lifetime prevalence,” he points out. “And the vast majority of people with a DSM-diagnosed mental illness are not at risk for doing anything like this.”