Mental illness, mass shootings, and the politics of American firearms

"The only friend I had was my gun": A mixed-methods study of gun culture in school shootings

Firearms are the leading cause of death for minors in the United States and US gun culture is often discussed as a reason behind the prevalence of school shootings. Yet, few studies systematically analyze if there is a connection between the two: Do school shooters show a distinct gun culture? This article studies gun culture in action in school shootings. It studies if school shooters show distinct meanings and practices around firearms prior to the shooting, as well as patterns in access to firearms. To do so, I analyze a full sample of US school shootings. Relying on publicly available court, police, and media data, I combine qualitative in-depth analyses with cross-case comparisons and descriptive statistics. Findings suggest most school shooters come from a social setting in which firearms are a crucial leisure activity and hold meanings of affection, friendship, and bonding. These meanings translate into practices: all school shooters had easy access to the firearms they used for the shooting. Findings contribute to research on firearms and youth violence, public health, as well as the sociology of culture.

Association between community violence exposure and teen parental firearm ownership: data from a nationally representative study

BACKGROUND

Firearm injuries are the leading cause of death for U.S. adolescents. Given the prevalence of firearm ownership in the U.S., particularly among parental figures in homes with children and teens, and the relationship between firearm access and injury outcomes, it is vital to shed light on potential parental motivations for keeping firearms in their homes. The purpose of this analysis was to examine whether exposure to community violence is associated with parental firearm ownership.

METHODS

Data from the Firearm Safety Among Children and Teens Consortium's National Survey (6/24/2020-7/24/2020) was examined. The survey sample comprised parents/caregivers of high-school-age teens (age 14-18). The survey examined various measures, including firearm ownership, storage, community violence exposure, and sociodemographic characteristics. Stepwise logistic regression was used to examine the association between community violence exposure and parental firearm ownership.

RESULTS

The study included 2,924 participants, with 45.1% identifying as male, 12.9% identifying as Hispanic, and 25.3% identifying as non-White. Among these participants, 43.1% reported firearm ownership, and 49.9% reported exposure to community violence. Regression models demonstrate that community violence exposure is associated with an increased likelihood of firearm ownership among parents/caregivers of high-school age teens (OR = 1.08, p < 0.05). Other significant predictors of firearm ownership among parents/caregivers included parent/caregiver age (OR = 0.99, p < 0.01), marital status (OR = 1.29, p < 0.05), and educational attainment (OR = 0.60, p < 0.001).

CONCLUSIONS

The findings supported the hypothesis that community violence exposure was associated with an increased likelihood of parental firearm ownership, even after adjusting for potential confounders. These findings contribute to the existing literature by shedding light on the possible contributing factors for firearm ownership among parents/caregivers of teens. Public health interventions focused on raising awareness about the risks of firearm access in households with youths, providing counseling on locked storage practices, and offering resources for accessing secure firearm storage options, such as rapid access storage, may contribute to reducing firearm access among youth. Additionally, community-based initiatives focused on violence prevention and addressing the root causes of community violence can help create safer environments, thereby reducing the perceived need for accessible firearms in the home by parents and caregivers.

Lessons of the Boom: A Playbook for Crisis Centers to Prevent, Survive, and Respond to Active Assailants, Targeted Violence, and Mass Violence

Modern crisis centers need to be prepared for mass shootings, active assailant incidents, and related forms of targeted violence. While crisis engagement has traditionally been seen as a "right of boom" or post-incident responder, crisis leaders need to prepare their teams to identify people at risk for violence, use tools like Behavioral Threat Assessment and Management to reduce risk in those persons, and prepare their teams for potential incidents in their community. Evidence suggests that acute stressors are a common proximal risk factor for severe violence implying a potential synergy for using crisis services as a tool for prevention of violence.

Fatal Firearm Violence Among American Indians and Alaska Natives

There is a dearth of population-based studies regarding firearm-related deaths and years of potential life lost among American Indians and Alaska Natives (AI/AN). Using the Centers for Disease Control and Prevention's (CDC) We Based Injury Statistics Query and Reporting System (WISQARS) data for the three most recent years (2018-2020), we analyzed the demographic characteristics of AI/ANs who succumbed to firearm violence. AI/ANs averaged almost 500 firearm-related deaths per year. The majority of these deaths were observed among individuals 20-39 years of age (53%), males (84.4%), and in the West (55.3%). A plurality of these firearm-related deaths were suicides (48.9%) followed by homicides (43.5%). During the 3-year study period, the age-adjusted firearm death rate increased almost 5 times the growth of the AI/AN population. Also, a staggering 67,050 years of potential life were lost before the age of 80 years (YPLL80) during this period. Firearm suicides were responsible for the largest proportion of YPLL80s (48.5%). Traditional legal interventions [e.g., child access prevention (CAP) laws and extreme risk protection orders (ERPO)], if expanded to more states could potentially help reduce AI/AN firearm mortality. None of the 10 states with the highest firearm mortality of AI/AN have ERPOs and 8 of the 10 do not have CAP laws. Also, a renewed focus on cultural continuity and indigenous protective factors is essential to ameliorate the level of firearm violence in AI/ANs.

The impact of racism on Black American mental health

Black individuals in the USA experience disparities in mental health that lead to unfavorable health outcomes and increased morbidity from mental illness due to centuries of racism. We emphasize the need to understand the roots of racial injustice to achieve racial equity. Historical factors such as European imperialism, enslavement, the myth of Black inferiority, and scientific racial classification have all perpetuated disparities, leading to the current underestimation, misdiagnosis, and inadequate treatment of mental illness in Black populations. Many of the issues discussed herein apply to Black people globally; however, our focus is on Black Americans and the inequities that result from the current US mental health system. We discuss the limitations of using the DSM-5 classification system and common epidemiological surveys, which do not capture or call for a comprehensive analysis of the systems producing mental health issues, to understand mental illness among Black Americans.

Measuring media-related health and mental health information acquisition among Latino adults in the United States

OBJECTIVES

We developed and evaluated new media-related health information acquisition measures for U.S.-based Latino populations.

METHODS

In 2021, a sample of U.S.-based Latino adults (N = 1574) self-completed a 20-min survey of health information acquisition measures across three language/cultural dimensions: Spanish media, Latino-tailored media in English, and general media in English. Socio-demographics were also ascertained. Means and standard deviations for the health acquisition measures were adjusted for age and sex and reported across nativity status.

RESULTS

The sample was diverse across age, gender, race, ethnicity, socioeconomic status, migration, and language competency. Internal consistency reliability of developed scales was excellent overall and within age, gender, race, ethnicity, and socioeconomic subgroups (Cronbach's alphas = 0.86-0.94). English media scales had higher means overall indicating higher prolonged quantity (i.e., dosage) than Spanish media scales. In contrast, standard deviations for Spanish media scales were higher overall indicating broader reach at lower doses than English media scales.

CONCLUSIONS

Findings suggest English-language media is popular among Latino populations overall. However, Spanish-language media retains broad reach through both passive and active exposure. Our findings demonstrate the value of including more nuanced measurement of health information acquisition such as the scales developed in this study to improve health promotion among Latino populations.

Portrayals of gun violence victimization and public support for firearm policies: an experimental analysis

Objectives

This study examines how characteristics of victims and types of incidents described in a media account of gun violence affect public support for three categories of policies that regulate firearms.

Methods

A randomized experiment with a sample of US public (N = 3410).

Results

Victim race, particularly if the victim was Black, was a strong predictor of less public support for all tested categories of firearm regulation. Respondents were less supportive of policies to address gun suicide or accidents and more supportive of policy solutions to mass shootings, compared to street-level gun homicides. Depictions of victim gender, mental illness, prior incarceration, and age were less salient to support across categories of firearm regulation, compared to race and type of incident.

Conclusions

Media coverage of gun violence has heterogenous effects on public support for firearm regulation and may influence support for policies aimed at reducing specific types of gun violence.

Effects of Mass Shootings on Mental Illness Stigma in the United States

Although the vast majority of people with mental illness (PWMI) are not violent, Americans tend to think they are more dangerous than the general population. Because negative media portrayals may contribute to stigma, we used time-series analyses to examine changes in the public's perceived dangerousness of PWMI around six mass shootings whose perpetrators were reported to have a mental illness. From 2011 to 2019, 38,094 U.S. participants completed an online study assessing implicit and explicit perceived dangerousness of PWMI. There were large, upward spikes in perceived dangerousness the week of the Sandy Hook mass shooting that were relatively short-lived. However, there was not a consistent pattern of effects for other events analyzed, and any other spikes observed were smaller. Effects tended to be larger for explicit versus implicit perceived dangerousness. Sandy Hook seemed to temporarily worsen perceived dangerousness of PWMI, but this pattern was not observed for other mass shootings.

Risk of violent behaviour in young people at clinical high risk for psychosis from the North American Prodrome Longitudinal Studies consortium

AIM

Although violent behaviour has been studied in schizophrenia, violence risk has received little attention in individuals at clinical high risk for psychosis (CHR). This manuscript aims to report and discuss the overall results of the Structured Assessment for Violence Risk in Youth (SAVRY) from the NAPLS-3 project to explore the risk of violence in CHR youth and to determine the relationship between SAVRY violence risk scores, psychosis risk symptoms, and global functioning. We hypothesized that CHR young people are at higher risk of violence as compared to healthy comparison participants due to a similarity between risk factors for psychosis and risk factors for violence, and that this risk is associated with greater severity of symptoms, poor functioning, and risk for conversion to psychosis.

METHODS

Participants from the North American Prodrome Longitudinal Study consortium phase 3 (NAPLS-3) included 684 CHR and 96 HC. Assessments included the Structural Assessment of Violence Risk in Youth (SAVRY), clinical and functional measures.

RESULTS

The majority of participants across groups were deemed to be at low risk for violence. There were significantly more CHR participants (29.8%) who had moderate or high scores on the SAVRY Summary Risk Rating compared to HC participants (3.1%). Low versus moderate-high SAVRY scores were associated with better social (p < .005) and role (p < .002) functioning and fewer positive (p < .002), negative (p < .002), disorganized (p < .01) and general symptoms (p < .002). CHR participants with higher SAVRY scores were more likely to be diagnosed with borderline personality disorder, ADHD and substance misuse. Among CHR, overall violence risk was not associated with conversion to psychosis. However, those who converted to psychosis scored lower on the protective factors index, primarily driven by less prosocial involvement and fewer resilient personality traits.

CONCLUSIONS

This is the first study to assess violence risk in CHR adolescents. Violence risk factors overlap with risk factors for psychosis in general, perhaps accounting for the association. These findings have implications for intervention efforts to reduce violence risk and bolster resiliency in CHR youth.

Exploring the nature and prevalence of targeted violence perpetrated by persons found not criminally responsible on account of mental disorder

Although mental illness has a demonstrated link with violence, the prevalence of targeted (planned and goal-directed) violence perpetrated by individuals with mental illness and its association with psychiatric symptoms is relatively unexplored. File information was compared for all 293 individuals found not criminally responsible due to mental illness in British Columbia between 2001 and 2005, of whom 19% had committed targeted violence. Most individuals with targeted offenses displayed at least one warning behavior before their offense (93%); all displayed delusions and approximately one third exhibited hallucinations. Compared to individuals who perpetrated non-targeted offenses, the individuals with targeted offenses displayed greater proportions of threats/criminal harassment, had female victims, displayed a psychotic disorder and/or personality disorder, and displayed delusions during the offense. This implies that severe psychiatric disorders do not preclude the perpetration of planned violence and suggests that exploring symptoms of mental illness that may be proximally indicative of targeted violence is important in preventing future acts.

The weaponization of medicine: Early psychosis in the Black community and the need for racially informed mental healthcare

There is a notable disparity between the observed prevalence of schizophrenia-spectrum disorders in racialized persons in the United States and Canada and White individuals in these same countries, with Black people being diagnosed at higher rates than other groups. The consequences thereof bring a progression of lifelong punitive societal implications, including reduced opportunities, substandard care, increased contact with the legal system, and criminalization. Other psychological conditions do not show such a wide racial gap as a schizophrenia-spectrum disorder diagnosis. New data show that the differences are not likely to be genetic, but rather societal in origin. Using real-life examples, we discuss how overdiagnoses are largely rooted in the racial biases of clinicians and compounded by higher rates of traumatizing stressors among Black people due to racism. The forgotten history of psychosis in psychology is highlighted to help explain disparities in light of the relevant historical context. We demonstrate how misunderstanding race confounds attempts to diagnose and treat schizophrenia-spectrum disorders in Black individuals. A lack of culturally informed clinicians exacerbates problems, and implicit biases prevent Black patients from receiving proper treatment from mainly White mental healthcare professionals, which can be observed as a lack of empathy. Finally, we consider the role of law enforcement as stereotypes combined with psychotic symptoms may put these patients in danger of police violence and premature mortality. Improving treatment outcomes requires an understanding of the role of psychology in perpetuating racism in healthcare and pathological stereotypes. Increased awareness and training can improve the plight of Black people with severe mental health disorders. Essential steps necessary at multiple levels to address these issues are discussed.

State-level education policies: Opportunities for secondary prevention of child maltreatment

BACKGROUND

Exposure to child maltreatment creates risk for adverse social, health, and economic outcomes across generations. The socioecological model posits the well-being of individuals, including children and youth, is shaped by the larger systems they exist in. Employing state-level policies to position school settings to effectively identify and intervene in instances of child maltreatment is an important secondary prevention opportunity.

OBJECTIVE

This study examines the relationship between state-level policies that call for school based trainings to promote the recognition of and response to child maltreatment, and states' annual rates of substantiated child maltreatment reports.

METHODS

Relevant policies were identified and abstracted to generate measures of policy presence and comprehensiveness. The National Child Abuse and Neglect Data System was used to derive rates of substantiated child maltreatment reports by state and year. Child maltreatment rates were the dependent variable and policy measures were the primary explanatory variables in a difference-in-differences (DD) model series with state-level clustering and year-fixed effects.

RESULTS

The DD model series suggest significant, positive relationships between the presence of policies calling for school-based recognition and response training and child abuse (IRR 1.140, p = 0.04) as well as child physical abuse outcomes (IRR 1.150, p = 0.05). Sensitivity analyses suggest the relationships between policy presence and abuse outcomes were stronger for children than for adolescents.

CONCLUSION

These findings suggest that related policies may be effective secondary prevention tools for child maltreatment.

Distinguishing lone from group actor terrorists: A comparison of attitudes, ideologies, motivations, and risks

The increasing recognition of the risks posed by lone-actor terrorists provides the impetus for understanding the psychosocial and ideological characteristics that distinguish lone from group actors. This study examines differences between lone and group actor terrorists in two domains: (i) attitudes toward terrorism, ideology, and motivation for terrorist acts; and (ii) empirically derived risk factors for terrorism. Using a cross-sectional research design and primary source data from 160 men convicted of terrorism in Iraq, this study applied bivariate and logistic regression analyses to assess group differences. It tested the hypothesis that there are no statistically significant differences between the groups. Bivariate analyses revealed that lone actors were less likely than group actors, to be unemployed, to cite personal or group benefit as the main motives for terrorist activity, and to believe that acts of terrorism achieved their goals. Regression analysis indicated that having an authoritarian father was the only factor that significantly predicted group membership, with group actors three times more likely to report this trait. Lone actors and group actors are almost indistinguishable except for certain differences in attitudes, motives, employment, and having an authoritarian father.

A Sequence Analysis of the Behaviors and Experiences of the Deadliest Public Mass Shooters

Researchers of public mass shooters are increasingly focusing on the pre-attack behaviors and experiences of these offenders. Varying in scope from consideration of individual factors to more generalized life course and threat assessment analyses, their scholarship has identified behavioral and experiential factors associated with public mass shooters. However, what is generally missing from this body of research is consideration of the order in which the offender encounters these factors, and prior related research has shown that analyzing sequences allows for insights not available from a catalogue of common characteristics. To address this shortcoming, we use a sample of offenders from 1999 to 2020 for whom the most detailed data is available and conduct a sequence analysis of their stressors, antisocial behaviors, mental health issues, and planning and preparation activities. We calculate proximity coefficients for each variable in relation to all others, capturing both local and distant connections between and among them. Our findings reveal relatively coherent phases in the lives of attackers, highlight the centrality of family problems and interest in past mass killings in the overall sequence, and provide new context to understanding the effect of mental health issues and firearms acquisition in the lives of offenders. A discussion of findings illustrates potential intervention points that may have been overlooked, as well suggestions for future research.

"Husband, father, coward, killer": The discursive reproduction of racial inequality in media accounts of mass shooters

Relying on more expansive criteria for defining "mass shootings" than much existing research, we examine a subset of a unique dataset incorporating 7,048 news documents covering 2,170 shootings in the United States between 2013 and 2019. We analyze the descriptive language used to describe incidents and perpetrators and discover significant racial disparities in representation. This research enables a critical examination of the explanatory frames utilized by news media to tell the public who mass shooters are and journalistic attempts to explain why they occur. Data were analyzed utilizing a mixed methods approach, relying on content analysis to inductively code emergent categories of descriptions of shooters and binary logistic regressions to analyze the preponderance of descriptive categories when comparing news articles reporting on shootings committed by differently racialized shooters. Our results confirm some recent research showing that mass shooters racialized as white are more likely to be described with kind and compassionate language. With our larger sample, however, we also find that mass shooters racialized as white are additionally more likely to be described with negative language as "bad" or "evil" in comparison to shooters of color. We discuss how these data demonstrate that media reports present a more complex picture of white mass shooters for the public than shooters of color.

The Impact of Increasing Community-Directed State Mental Health Agency Expenditures on Violent Crime

Violent crime remains a prevalent threat to population health within the United States. States offer varying policy approaches to prevent violent crime and support behavioral health, such as community-based programs that include substance use disorder prevention and treatment. Using state mental health agency data, we construct a panel of U.S. states over nine years and apply an instrumental variables empirical model with state and time fixed effects to adjust for policy endogeneity, omitted variable bias, and time trends. We find that a 10% increase in community-directed state mental health agency expenditures yielded nearly a 4% reduction in violent crime rates. Larger magnitude reductions in violent crime rates were associated with the presence of gun control regulations and increases in the proportion of the population completing secondary education. Policymakers should consider the added benefit of violent crime reduction when considering budgetary allocations of community-directed state mental health agency expenditures.

Identification of medical and psychological indicators of trouble in adolescents to ensure the safety of the educational environment and the prevention of auto-and hetero-aggressive behavior

Introduction. Aggressive behavior of children and adolescents in the educational environment should be assessed differentially depending on the nature of its manifestation and the age of the student. Extreme variants of aggression, expressed in attacks on educational institutions, are multifactorial in nature and combine auto- and hetero-aggressive tendencies.

Goal. Identifying medical and psychological indicators of vulnerabilities in adolescents, warning of the possibility of their auto- and hetero-aggressive behavior, also in the educational environment.

Material and methods. Qualitative and descriptive analysis of the empirical material of complex forensic psychological and psychiatric examinations of minors with suicidal and hetero-aggressive behavior.

Results. Behavioral indicators and typological psychological features inherent in this category of adolescents are described. The order of work of specialists (teachers, school and clinical psychologists, social educators, psychiatrists) with adolescents displaying these behaviors is presented. Particular attention is paid to the clinical manifestations of mental disorders that can be found in such adolescents.

Conclusions. Prevention of auto- and hetero-aggressive behavior of adolescents in the educational environment, starting with the fixation of described behavioral indicators, requires the consistent involvement of various specialists in work with adolescents and their interdisciplinary and interdepartmental interaction.

Rapprochement and Reform: Overcoming Factionalism in Policy Making for Serious Mental Illness

This article traces the history of factionalism in policy making and advocacy for persons with serious mental illness from deinstitutionalization to the present. The authors draw on deliberative democratic theory to illustrate how factionalist advocacy causes advocates and policy makers to fail in their duties to represent and develop policy in support of people with serious mental illness. The authors discuss how this factionalism has bred distrust and undermined efforts to address the needs of people with serious mental illness. They propose the formation of a Public Mental Health Policy Commission, guided by principles of deliberative democracy, to overcome factionalism and to improve policy making to meet the needs of people with serious mental illness. The commission must include a diverse array of stakeholders, especially individuals with lived experience of serious mental illness.

State firearm laws and nonfatal firearm injury-related inpatient hospitalizations: A nationwide panel study

BACKGROUND

Firearm injury remains a major cause of morbidity and mortality in the United States. Because of prior lack of comprehensive data sources, there is a paucity of literature on nonfatal firearm injury. Associations have previously been shown between state-level firearm laws and firearm fatalities, but few studies have examined the effects of these laws on nonfatal firearm hospitalization rates. Our objective was to examine the relationship between state firearm laws and firearm injury-related hospitalization rates across all 50 states over a 17-year period.

METHODS

In this panel study design, we used fixed effects multivariate regression models to analyze the relationship between 12 laws and firearm state-level injury-related hospitalization rates from 2000 to 2016 using the RAND Corporation Inpatient Hospitalizations for Firearm Injury Database. We used difference-in-differences to determine the impact of law passage in a given state compared with those states without the law, controlling for state-level covariates. The main outcome measure was the change in annual firearm injury-related inpatient hospitalization rates after passage or repeal of a state-level firearm law.

RESULTS

Examining each law individually, passage of violent misdemeanor, permitting, firearm removal from domestic violence offenders, and 10-round limit laws were associated with significant firearm injury-related hospitalization rate reductions. Examining multiple laws in the same model, passage of violent misdemeanor laws was associated with a 19.9% (confidence interval, 11.6%-27.4%) reduction, and removal of firearms from domestic violence offenders was associated with a 17.0% (confidence interval, 9.9%-23.6%) reduction in hospitalization rates.

CONCLUSION

State laws related to preventing violent offenders from possessing firearms are associated with firearm injury-related hospitalization rate reductions. Given significant physical, mental, and social burdens of nonfatal firearm injury, determining the efficacy of firearm-related policy is critical to violence and injury prevention efforts.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level IV.

Public Perception of Gun Violence-related Headline Accuracy and the Credibility of Media Sources

The present study sought to determine the extent to which the message or messenger is more important for news media portrayal of gun violence prevention. Exploratory analyses also examined factors related to Fox News and MSNBC credibility. Participants (N = 3,500) were US adults matched to the 2010 US Census on several demographic variables. Two mock headlines were presented: "Gun violence is result of mental health problems" and "Storing firearms in a safe can help prevent suicides." Headlines were reported to be from either Fox News or MSNBC. Participants then rated accuracy of the headline and credibility of the news source. Headline content did not predict perceived accuracy of the headline. Perceived credibility of the messenger was associated with perceived accuracy for both mock headlines. Exploratory analyses indicated several demographic factors related to Fox News and MSNBC credibility. Regardless of the content of a headline, the degree to which participants perceived it as accurate was associated with how credible they believed the source to be. These findings highlight the importance of credible media portrayal of accurate information on gun violence prevention.

Explainable depression detection with multi-aspect features using a hybrid deep learning model on social media

The ability to explain why the model produced results in such a way is an important problem, especially in the medical domain. Model explainability is important for building trust by providing insight into the model prediction. However, most existing machine learning methods provide no explainability, which is worrying. For instance, in the task of automatic depression prediction, most machine learning models lead to predictions that are obscure to humans. In this work, we propose explainable Multi-Aspect Depression Detection with Hierarchical Attention Network MDHAN, for automatic detection of depressed users on social media and explain the model prediction. We have considered user posts augmented with additional features from Twitter. Specifically, we encode user posts using two levels of attention mechanisms applied at the tweet-level and word-level, calculate each tweet and words' importance, and capture semantic sequence features from the user timelines (posts). Our hierarchical attention model is developed in such a way that it can capture patterns that leads to explainable results. Our experiments show that MDHAN outperforms several popular and robust baseline methods, demonstrating the effectiveness of combining deep learning with multi-aspect features. We also show that our model helps improve predictive performance when detecting depression in users who are posting messages publicly on social media. MDHAN achieves excellent performance and ensures adequate evidence to explain the prediction.

The timing of opportunities to prevent mass shootings: a study of mental health contacts, work and school problems, and firearms acquisition

Although it is important to know what public mass shooters have in common, it is also helpful to understand when different variables were present on their pathways to violence. This study explored the timing of key life events for the deadliest public mass shooters in the United States since Columbine (N = 14). Using data from official reports and supplementary sources, we found perpetrators' mental health contacts often began more than a decade before their mass shootings, and often ended more than a year before their attacks. Mental illness was typically a constant in their lives, not something that automatically caused them to attack. While treatment may help prevent some mass shootings, mental health professionals have limited influence over patients they have not recently seen. In turn, perpetrators' work and school problems also typically began long before their mass shootings, but these issues continued closer to their attacks. Employers and educators may therefore have an opportunity to intervene later in the process. Firearms acquisition often occurred in the final stages, after perpetrators were already interested in mass murder. Red flag laws and ERPOs which prohibit sales to explicitly dangerous individuals may therefore help reduce the prevalence of these attacks.

The Influence of New York's SAFE Act on Individuals Seeking Mental Health Treatment

Responding to mass shootings, some states have passed gun removal laws (e.g., NYS' SAFE Act), requiring that mental health professionals report patients who might potentially harm themselves/others. The purpose of this study was to assess whether knowledge of the SAFE Act impacts patients' mental health treatment-seeking and symptom-reporting behaviors. Patients at two mental health centers were surveyed during 2014-2018. Participants were asked if they would be concerned about being reported to county government, likelihood of seeking mental health treatment, and willingness to report mental health symptoms/behaviors given the SAFE Act's provisions. 228 patients (71.5% response rate) completed questionnaires. About 18% were concerned about being reported to county government, 9% would be less likely to seek mental health treatment, and about 23% would be less willing to report mental health symptoms/behaviors. Although these behaviors were not affected for most participants, there was a small minority who were concerned and less willing to report mental health symptoms/behaviors.

Evidence for the Technical Adequacy of the Risk Assessment and Distress Recovery: Examining Risks While Avoiding Profiling Youth With Mental Health Difficulties

This study examined the psychometric properties of the Risk Assessment and Distress Recovery (RADR) Scale—a new self-report psychological screening tool for high school students that explores risk factors related to mental health characteristics of students who have engaged in school violence. The sample consisted of 1093 high school students from all four regions of the United States. A four-factor model consisting of coping skills, depression, suicidal ideation, and narcissism demonstrated good fit. Results of confirmatory factor analysis and measurement invariance, as well as internal consistency estimates, provide initial evidence for reliability and validity of the RADR. Exploratory analyses between the RADR and characteristics of past school shooters are also presented. Students with disabilities self-reported significantly greater risks for mental health concerns across all four constructs, with small (.15) to large (.80) effect sizes.

Structural competency and the future of firearm research

In this critical literature review we develop a five-part agenda for pandemic-era research into mass shootings and multiple-victim homicides that promotes understanding the psychologies of individual shooters within larger structures and systems. We show how the momentous events set in motion by the COVID-19 virus, and the structural drivers of inequity and racism that its spread exposed, challenge mental health research on gun trauma to better account for broader terrains of race and place, as well as the tensions, politics, and assumptions that surround guns in the U.S. more broadly. Doing so will broaden mental-health interventions into epidemics of U.S. gun trauma, and challenge mental health research better recognize structural biases inherent in its own purview. We frame the agenda through the rubric of structural competency, an emerging framework that systematically trains health care professionals and others to recognize ways that institutions, neighborhood conditions, market forces, public policies, and health care delivery systems shape symptoms and diseases. Developing a structural framework around research into U.S. gun violence addresses the risks, traumas, meanings, and consequences that firearms represent for all communities-and highlights the importance of a renewed focus on mental health and safety for communities of color. Recognizing how gun violence reflects and encapsulates structures helps mental health experts address common sense gun policies within broader contexts-by fighting against structural racism or racially inflected gun policies for instance, or against economic policies that undermine access to mental health care more broadly.

Mental illness and the risk of self- and other-directed aggression: Results from the National Survey on Drug Use and Health

Aggression and mental illness have been classically interlinked, often causing controversy and debate. Previous studies have shown that mental illness can be a risk factor to self- and other-directed aggression. However, these associations have rarely been simultaneously studied within the same population. Therefore, we aimed to study whether psychiatric disorders differentially increase the likelihood of one subtype of aggression over the other. We used the publicly available data of the National Survey on Drug Use and Health (NSDUH) from 2008 through 2014, for a total sample of 270,227 adult respondents. We designed our independent variable according to three categories: no mental illness (NMI), low or moderate (LMMI) and serious (SMI). We constructed regression models to estimate the odds ratios for those having a mental illness committing (a) a subtype of aggression over the past year compared with no aggression and (b) other-directed compared to self-directed aggression. We found that most respondents with mental illness reported no past-year aggression of any type. However, respondents with mental illness had higher odds of perpetrating all subtypes of aggression. Additionally, respondents with LMMI and SMI were respectively 1.7 and 3 times more likely to engage in self- rather than other-directed aggression. Future research should focus on identifying accurate and reliable predictors of self- and other-directed aggression among individuals with mental illness.

Association of Conflict-Affected Environment on Ethiopian Students' Mental Health and Its Correlates During COVID-19 Era

BACKGROUND

Ethiopia has seen the largest number of conflict-induced displacement. Mental disturbance has been identified as a major public health concern among conflict-affected people, including students. Due to the effect of continuous unfold of the COVID-19 epidemic in the conflicted affected setting, the mental health problem tends to be increased. This creates a double burden for students from conflict affected setting after school re-opening. As a result, the goal of this research was to evaluate the mental health impact and its correlates in students from conflict affected setting, Ethiopia.

OBJECTIVE

To assess the association of conflict-affected environment on Ethiopian students' mental health and its correlates during COVID-19 era.

METHODS

From April 1 to 30, 2021, an institutional-based cross-sectional survey was undertaken. A total sample of 795 students were participated through a systematic random sampling technique. The Kessler Psychological Distress Scale was used to assess mental distress (K10). The correlation between outcome and explanatory variables was investigated using bivariate and multivariate logistic regression analyses.

RESULTS

A total of 795 people were examined, with a 100% response rate. Mental distress was reported about 59.4% with a 95% CI of 57% to 62.9%. Conflicted related sexual abuse (AOR = 4.1, 95% CI 2.37 to 6.94), witnessed shooting (AOR = 3.49, 95% CI 2.7 to 5.89), threat to security and safety (AOR = 2.23, 95% CI 1.29 to 3.87), being female (AOR = 3.01, 95% CI 1.61 to 5.44), and poor academic performance (AOR = 2.1, 95% CI 1.08 to 4.08) were found to be substantially correlated.

CONCLUSION

Students from conflict-affected areas are at high risk of mental distress. Therefore, the ministry of health, ministry of education of Ethiopia and humanitarian organizations should work collaboratively in providing consistent school-based psychosocial support and appropriate intervention for students.

Gendered Massacres: Examining the Effects of Cultural and Structural Gender Inequality on the Incidence of Mass Public Shootings

With nearly 97% of incidents within the past 40 years committed by men, mass public shootings are a gendered social problem. Yet, empirical research on this phenomenon largely neglects gender hierarchy and cultural factors as predictors, in favor of individual- and event-level characteristics. Despite calls from scholars to place masculinity and threats to patriarchal hegemony at the center of analyses, no empirical studies to our knowledge have examined the role of gender inequality in mass public shootings. The findings indicate that gender inequality, structural and ideological, are important predictors of mass public shootings and that future research should continue to investigate such violence from a gendered lens.

Australian Mass Shootings: An Analysis of Incidents and Offenders

Mass shooting events are relatively underresearched, and most study comes from the United States. Despite significant international interest, little is known about other countries' experiences of these events. The current study examines Australian mass shooting incidents and offenders, with emphasis on mental illness, life strains, and offenders' life histories. Australia had 14 mass shootings between 1964 and 2014. Most offenders experienced acute life stressors and/or chronic strains leading up to the event; however, diagnosed mental illness was less commonly documented. These observations provide new information about mass shooting incidents and offenders, and can help to inform international policy development.

Prevalence and context of firearms-related problems in child protective service investigations

BACKGROUND

Despite the significance of firearm safety, we need additional data to understand the prevalence and context surrounding firearm-related problems within the child welfare system.

OBJECTIVE

Estimate proportion of cases reporting a firearm-related problem during case initiation and the contexts in which these problems exist.

SAMPLE AND SETTING

75,809 caseworker-written investigation summaries that represented all substantiated referrals of maltreatment in Michigan from 2015 to 2017.

METHODS

We developed an expert dictionary of firearm-related terms to search investigation summaries. We retrieved summaries that contained any of the terms to confirm whether a firearm was present (construct accurate) and whether it posed a threat to the child. Finally, we coded summaries that contained firearm-related problems to identify contexts in which problems exist.

RESULTS

Of the 75,809 substantiated cases, the dictionary flagged 2397 cases that used a firearm term (3.2 %), with a construct accuracy rate of 96 %. Among construct accurate cases, 79 % contained a firearm-related problem. The most common intent for a firearm-related problem was violence against a person (45 %). The co-occurrence of domestic violence and/or substance use with a firearm-related problem was high (41 % and 48 %, respectively). 49 % of summaries that contained a firearm-related problem did not provide information regarding storage.

CONCLUSION

When caseworkers document a firearm within investigative summaries, a firearm-related risk to the child likely exists. Improved documentation of firearms and storage practices among investigated families may better identify families needing firearm-related services.

Using search engine data to gauge public interest in mental health, politics and violence in the context of mass shootings

Despite significant potential for providing insight to private perceptions and behaviors, search engine data has yet to be utilized as a means of gauging the U.S. public’s interest and understanding of mental health in the context of gun violence and politics. An analysis of Google Trends revealed that Mental health searches increased in volume starting in the beginning of the current decade. Notably, both “mental health” and “gun(s)” were searched with greater frequency the week after the mass shooting events occurred. Related searches after the event also observed a significant increase in interest in mental health and gun regulation, legal reform, mass shootings, and gun(s). Results suggest that the American public’s perception of mental illness increasingly incorporates associations with themes of violence and politics, which becomes more apparent surrounding mass shooting events. Future studies are needed to determine implications for stigmatization of vulnerable groups, and possible relations to media coverage.

A systematic review of the causes and prevention strategies in reducing gun violence in the United States

BACKGROUND

Approximately 100 lives are lost each day as a result of gun violence in the United States (US) with civilian mass shootings increasing annually. The gun violence rate in the US is almost 20 times higher than other comparable developed countries and has the most gun ownership per capita of any nation in the world. Understanding the causes and risk factors are paramount in understanding gun violence and reducing its incidence.

METHODS

A literature search of all published articles relating to gun violence and mass shootings in the US was conducted using the Medline and PMC databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used in conducting this study. Rayyan statistical software was utilized for analysis. Statistical significant was defined as p < .05.

RESULTS

Of the initial 2304 eligible manuscripts identified, 22 fulfilled our selection criteria. A variety of common causal and contributory factors were identified including but not limited to mental illness, suicidal ideation, intimate partner violence, socioeconomic status, community distress, family life, childhood trauma, current or previous substance abuse, and firearm access.

CONCLUSION

Gun violence is pervasive and multi-factorial. Interventions aimed at reducing gun violence should be targeted towards the most common risk factors cited in the literature such as access, violent behavioral tendencies due to past exposure or substance abuse, and mental illness including suicidal ideation.

Factors Associated with U.S. Military Women Keeping Guns or Weapons Nearby for Personal Security Following Deployment

Background: The relationship between postdeployment health characteristics and U.S. military women and women Veteran's gun/weapons use for personal safety outside of military is not well understood. The purpose of this exploratory study was to determine if Operation Enduring and Iraqi Freedom era military women and women Veterans keep guns/weapons nearby for personal security outside of military duties postdeployment and factors associated with this. Methods: A Midwestern community sample of US Army and Air Force currently serving Military women and women Veterans (N = 978) who had deployed to Iraq/Afghanistan (I/A) or outside of the United States completed telephone interviews (March 2010 to December 2011) querying sociodemographic and military characteristics, combat and gender-based trauma, and guns/weapons use postdeployment. Data were analyzed in June 2019 with chi-square, Fisher's Exact test, and odds ratios. A classification tree analysis identified subgroups with the greatest proportion of keeping guns/weapons nearby for security. Results: One-fifth of participants reported having guns/weapons nearby to feel secure. Women more likely to report this were younger, patrolled their homes for security (age adjusted odds ratio [aOR] 7.0); experienced combat (aOR 3.0-4.9) or gender-based traumas (aOR 1.9-2.0); self-reported mental health conditions (aOR 1.5-4.3), including post-traumatic stress disorder (PTSD; aOR 4.3); or relied on friends/family for housing (aOR 4.8). Most had seen a provider in the preceding year. The classification tree found women patrolling their homes, PTSD positive, and injured/wounded in I/A had the largest proportion of women keeping guns/weapons nearby for security. Conclusions: Keeping gun/weapons nearby for personal self-defense is a potential marker for complex postdeployment readjustment conditions and an overlooked public health concern. Provider recognition and assessment of women's postdeployment fears and safety-related activities are essential to address military women and women Veterans and their families' safety in this high-risk population.

Simulating the Suicide Prevention Effects of Firearms Restrictions Based on Psychiatric Hospitalization and Treatment Records: Social Benefits and Unintended Adverse Consequences

Objectives. To estimate the number of lives saved from firearms suicide with expansions of gun restrictions based on mental health compared with the number who would be unnecessarily restricted. Methods. Agent-based models simulated effects on suicide mortality resulting from 5-year ownership disqualifications in New York City for individuals with any psychiatric hospitalization and, more broadly, anyone receiving psychiatric treatment. Results. Restrictions based on New York State Office of Mental Health-identified psychiatric hospitalizations reduced suicide among those hospitalized by 85.1% (95% credible interval = 36.5%, 100.0%). Disqualifications for anyone receiving psychiatric treatment reduced firearm suicide rates among those affected and in the population; however, 244 820 people were prohibited from firearm ownership who would not have died from firearm suicide even without the policy. Conclusions. In this simulation, denying firearm access to individuals in psychiatric treatment reduces firearm suicide among those groups but largely will not affect population rates. Broad and unfeasible disqualification criteria would needlessly restrict millions at low risk, with potential consequences for civil rights, increased stigma, and discouraged help seeking.

Introduction to the Special Issue on Migration Problems in the US and Their Implications for Group Work

In this introduction I provide an overview of this Special Issue on migration problems at the southwestern border of the United States. These problems are framed against the rising world-wide tide of anti-immigrant rhetoric and the ascendance of right-wing nationalist leaders. I maintain that, from a group dynamic perspective, we in the US are witnessing the emergence of an authoritarian fight group leader (Bion, 1961) who has capitalized on the systematic arousal and manipulation of our most primitive fears, and who encourages the use of developmentally regressive projective mechanisms that permit us to disown, externalize and deposit into the "other" all that is bad or destructive. A series of critical interrelated questions is posed for group therapists to consider in order to respond effectively to the challenges we face. I explain the context in which this volume took shape and offer a set of guidelines for how to address these problems. In addition, I review more recent developments regarding how our government is responding to this situation, and explore the linkages between the "immigration crisis", racism, White nationalism and violence. I then describe the articles that comprise this Special Issue, acknowledging that these contributions depart from the more typically neutral and "objective" pieces published in a professional journal, and represent an amalgam of both professional and more personal statements that emanate from deeply held ethical principles and humanitarian concerns. I conclude by inviting our readers to share their reactions to this volume and to the concept that is advanced of the group therapist as a potential social change advocate.

Rescuers at Risk: Posttraumatic Stress Symptoms Among Police Officers, Fire Fighters, Ambulance Personnel, and Emergency and Psychiatric Nurses

Emergency personnel and rescue workers may be at a risk of posttraumatic stress symptoms (PTSS) due to exposure to trauma and work-related stressors. Though rescuers of different professions are often engaged in the same type of emergency, they have different tasks and responsibilities and receive different training in coping with traumatic events and stress; hence, we speculated that the salience of identified risk factors for PTSS vary across their respective professions. The present cross-sectional survey aimed to identify influencing variables on PTSS, well-being, and suicidal ideation that can act differently across professions of rescue workers and emergency personnel. In this anonymous online study, data from 1,002 rescue workers and emergency personnel in Switzerland, were collected: 499 police officers, 239 firefighters, 97 ambulance personnel, and 85 emergency and 82 psychiatric nurses. PTSS, coping strategies, well-being, suicidal ideation, previously experienced and work-related trauma, and self-efficacy were measured and analyzed using multiple regression and structural equation modeling (SEM). The prevalence of suspected posttraumatic stress disorder varied across the professions, ranged from 8% (firefighters) to 22% (psychiatric nurses), and was associated with psychological strain and suicidal ideation. The SEM showed that dysfunctional coping strategies, self-efficacy, previously experienced and work-related trauma, years on job, and female sex explained up to 78% of PTSS and that PTSS itself explained up to 68% of the psychological strain experienced in the different professions. Independent of the profession, dysfunctional coping such as alcohol use, avoidance, and distraction, as well as work-related trauma were the most robust predictors of PTSS. However, while self-efficacy was a risk factor for police officers, firefighters and ambulance personnel, it was a protective factor for emergency and psychiatric nurses. Furthermore, female sex was only a risk factor for ambulance personnel and emergency nurses. In agreement with prior research, emergency personnel and rescuers exhibited enhanced prevalence of PTSS and suspected PTSD, leading to significant psychological strain and suicidal ideation. However, risk factors varied across the professions. Thus, the development of profession-specific trainings to improve self-efficacy and coping with work-related stressors to reduce PTSS, and enhance quality of life, is needed for individuals in such high-risk professions. Clinical Trial Registration: ClinicalTrials.gov Nr. NCT03842553.

Firearm violence in the USA: a frank discussion on an American public health crisis-The Kansas City Firearm Violence Symposium

Kansas City is a microcosm for USA. Although Kansas City shows a relatively diverse population, it is one that is segregated along the lines of race and income. This is an inequity that is common to all cities across the country. With this inequity comes unequal opportunity to survive and to thrive. Firearm violence is a core component of this societal inequity. In this article, we present the proceedings of the 2019 Kansas City Firearm Violence Symposium, where distinguished experts in trauma convened to share their experience, evidence and voices of gun violence-directly and indirectly. There were discussions on topics such as the human toll of gun violence, the role of structural violence in its perpetuation, the intersectional nature of race with both violence and medical care, and guidance on measures that could be taken to advocate for the reduction and elimination of gun violence. This was a symposium that started a country-wide conversation between academia, healthcare, survivors and the community on the most pressing public health crisis facing USA today.

State Legislators' Support for Behavioral Health Parity Laws: The Influence of Mutable and Fixed Factors at Multiple Levels

Policy Points When communicating with state legislators, advocates for state behavioral health parity laws should emphasize that the laws do not increase insurance premiums. Legislators' opinions about the impacts of state behavioral health parity laws and the effectiveness of behavioral health treatment have more influence on support for the laws than do their political party affiliation or state-level contextual factors. Reducing legislators' stigma toward people with mental illness could increase their support for state behavioral health parity laws CONTEXT: Comprehensive state behavioral health parity legislation (C-SBHPL) is an evidence-based policy that improves access and adherence to behavioral health treatments. However, adoption of C-SBHPL by state legislators is low. Little is known about how C-SBHPL evidence might be most effectively disseminated to legislators or how legislators' fixed characteristics (eg, ideology), mutable characteristics (eg, beliefs about the policy's impact), and state-level contextual factors might influence their support for behavioral health policies. The purpose of our study is (1) to describe the associations between legislators' fixed and mutable characteristics, state-level contextual factors, and support for C-SBHPL; and (2) to identify the mutable characteristics of legislators independently associated with C-SBHPL support.

METHODS

We conducted a multimodal (post mail, email, telephone) survey of US state legislators in 2017 (N = 475). The dependent variable was strong support for C-SBHPL, and the independent variables included legislators' fixed and mutable characteristics and state-level contextual factors. We conducted multivariable, multilevel (legislator, state) logistic regression.

FINDINGS

Thirty-nine percent of the legislators strongly supported C-SBHPL. After adjustment, the strongest predictors of C-SBHPL support were beliefs that C-SBHPL increases access to behavioral health treatments (aOR = 5.85; 95% CI = 2.41, 14.20) and does not increase insurance premiums (aOR = 2.70; 95% CI = 1.24, 5.90). Stigma toward people with mental illness was inversely associated with support (aOR = 0.86; 95% CI = 0.78, 0.95). After adjustment, ideology was the only fixed characteristic significantly associated with support for C-SBHPL. State-level contextual factors did not moderate associations between mutable characteristics and support for C-SBHPL.

CONCLUSIONS

Legislators' mutable characteristics are stronger predictors of C-SBHPL support than are most of their fixed characteristics and all state-level contextual factors, and thus should be targeted by dissemination efforts.

Income inequality and mass shootings in the United States

Background

Mass shootings are an increasingly common phenomenon in the United States. However, there is little research on whether the recent growth of income inequality is associated with this rise of mass shootings. We thus build on our prior research to explore the connection between income inequality and mass shootings across counties in the United States.

Methods

We assemble a panel dataset of 3144 counties during the years 1990 to 2015. Socioeconomic data are extracted from the U.S. Bureau of the Census. Mass shootings data are from three databases that compile its information from the Federal Bureau of Investigation and media sources, respectively. These data are analyzed using random effects negative binomial regressions, while controlling for seven additional predictors of crime.

Results

Counties experiencing a one standard deviation growth of income inequality witnessed 0.43 more mass shootings when using the definition of three or more victim injuries (incidence rate ratio [IRR] = 1.43; 95% confidence interval [CI] = 1.24, 1.66; P < .001) and 0.57 more mass shootings when using the designation of four or more victim deaths (IRR = 1.57; 95% CI = 1.26, 1.96; P < .001).

Conclusions

Counties with growing levels of income inequality are more likely to experience mass shootings. We assert that one possibility for this finding is that income inequality fosters an environment of anger and resentment that ultimately leads to violence.

Methodological limitations in the measurement and statistical modeling of violence among adults with mental illness

OBJECTIVES

Methodological limitations of extant research hinder the development of effective violence risk screening, assessment, and management strategies for adults with mental illness. This study quantifies the effects of three common limitations: (a) insensitive measurement of violence that results in violence classification with high levels of information bias, (b) use of cross-sectional data, and (c) use of data lacking spatiotemporal contiguity.

METHODS

We utilize secondary data (N = 3,000 participants; N = 10,017 observations) and parametric and nonparametric bootstrap simulation methodologies.

RESULTS

Not utilizing self-reported violence data increases information bias. Furthermore, cross-sectional data that exclude self-reported violence produce biased associations between substance use and psychiatric symptoms and violence. Associations between baseline variables and subsequent violence attenuate over longer time lags and, when paired with high levels of violence information bias, result in fewer significant effects than should be present. Moreover, the true direction of the simulated relationship of some significant effects is reversed.

CONCLUSIONS

Our findings suggest that the validity of conclusions from some extant research on violence among adults with mental illness should be questioned. Efforts are needed to improve both the measurement of violence, through inclusion of self-report, and the statistical modeling of violence, using lagged rather than nonlagged models with improved spatiotemporal contiguity.