VIOLENCE AND GENDER

Volume 3, Number 2, 2016

ª Mary Ann Liebert, Inc.
DOI: 10.1089/vio.2015.0045

Firearm Violence by the Mentally Ill:

Mental Health Professionals’ Perceptions and Practices

James H. Price, PhD, MPH1 and Jagdish Khubchandani, MBBS, PhD2

Abstract
Firearm violence is a significant cause of morbidity and premature mortality in the United States. The majority of suicides and
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homicides are committed with firearms. Considerable debate has occurred regarding firearm violence and mentally ill people.
Mental health professionals can play a central role in research, practice, and advocacy regarding firearm violence prevention
through a number of avenues. However, little is known about mental health professionals’ perceptions and practices regarding
firearm safety counseling in the mentally ill. Thus, the purposes of this investigation are to summarize the literature on firearm
violence by the mentally ill and to conduct a rigorous review of the available scientific literature on mental health profes-
sionals’ views and practices on firearm violence prevention. A total of nine studies were found that dealt with mental health
professionals’ attitudes and practices on firearm violence prevention. Findings have been summarized in the following
categories: mental health professionals training, screening for the presence of firearms, engagement in firearm safety coun-
seling, and perceptions regarding firearm violence in the United States. Mental health professionals need more training
regarding firearm issues if they are going to play a role in reducing firearm trauma by the mentally ill. Their impact will be
primarily on firearm suicides.

Introduction and 2012. In part, these unhealthy changes in the mental

health arena have contributed to inadequate care. For ex-

T he lifetime prevalence of major mental illness is

almost half (46%) of the U.S. adult population (Kessler
et al. 2005). In addition, about 9% of those adults will meet
the diagnostic criteria for a personality disorder (e.g., anti-
social, borderline, paranoid, or schizotypal) (Lenzenweger
et al. 2007). Individuals with personality disorders, espe-
cially antisocial personality disorder, make up more than
70% of the individuals in prisons (American Psychiatric
Association 2015). In 2014, almost 1 in 5 (18.1% or 43.6
million) adults aged 18 and older had some form of a mental
illness. Among those with a mental illness were 4.1% (9.8
million) of adults who had a serious and persistent mental
illness (e.g., bipolar disorder, major depression, schizo-
phrenia). Furthermore, about 1% of adults (2.4 million)
had a comorbid serious and persistent mental illness and
a substance use disorder (Center for Behavioral Health
Statistics and Quality 2015).
Unfortunately, mental healthcare expenditures are de-
creasing. As a percent of total healthcare expenditures,
mental health expenditures in 1986 were 9% of the total
expenditures, 7% of the total expenditures in 2014, and is
projected to be 6% in 2020 (Mark et al. 2014). States have
cut the number of mental health beds by 10% between 2009
ample, the majority of those with a mental disorder did not
receive care in the previous year, and if they did receive
care, only one-third received care that was considered ade-
quate based on evidence-based treatment guidelines (Wang
et al. 2005). In addition, the upstream determinants of
mental health, the social determinants, are chronic problems
that are not likely to have solutions in the foreseeable future.
The diminution of social determinants (e.g., discrimination,
poor education, poverty, housing instability, and adverse
childhood experiences) of mental illness is as central to
improving mental health as are the solutions to downstream
barriers (e.g., health insurance, accessible mental health
professionals, and accessible facilities and medications) to
mental health treatment (Compton and Shin 2015). In other
words, we can expect to continue to see millions of citizens
with inadequately treated mental health problems, some of
which will have gained access to firearms.
Some mental health problems cause some individuals to
act peculiar, especially if they are not receiving mental
healthcare. Additionally, Hollywood and the mass media
have, at times, depicted some individuals with serious mental
illness as violent ‘‘murderous maniacs’’ (McGinty et al.
2014a, 2014b). Because of the prevalence of various forms of

1
Department of Health and Recreation Professions, University of Toledo, Toledo, Ohio.
2
Department of Physiology and Health Science, Ball State University, Muncie, Indiana.

92
 FIREARM VIOLENCE BY THE MENTALLY ILL
mental illnesses, it is logical to expect that some people who
commit serious crimes will have a mental illness. Violent
behavior of any type is only about twice as common in the
mentally ill as that found in individuals who never have a
mental illness, and the violence is usually directed toward
family members (Corrigan and Watson 2005; Frank and
McGuire 2011). The violence directed toward family and
friends seldom includes use of firearms. The violence men-
tally ill exhibit usually consists of shoving, kicking, hitting,
and throwing things. In contrast, individuals who abuse al-
cohol and other drugs have an increased rate of violence
seven times that of people who do not abuse drugs (Monahan
et al. 2001). A meta-analysis of schizophrenia and violence
found that the prevalence of violence in individuals with a
substance abuse diagnosis, but without psychosis, was similar
to individuals with a comorbid diagnosis of psychosis with
substance abuse (Fazel et al. 2009). In other words, having a
diagnosis of schizophrenia or other psychoses did not add
additional risk of being violent beyond what substance abuse
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alone conferred. In contrast, a meta-analysis by Large and
colleagues (2009) of the associations between homicide and a
diagnosis of schizophrenia found that about 6.5% of homi-
cides were by individuals with a diagnosis of schizophrenia.
This rate is higher than the prevalence of schizophrenia in
society (1%). About 40% of the homicides by those with a
diagnosis of schizophrenia occur during the first episode of
psychosis, before the individuals receive treatment (Nielssen
and Large 2010). As an example of treatment delay, the
average time between onset of first symptoms and initiation
of treatment for schizophrenics is a little more than 8 years
(National Alliance on Mental Illness 2008). Large et al.
(2009) did not clarify whether substance abuse was controlled
for in the studies included in their meta-analysis of homicide
and schizophrenia. Ultimately, if all violence, including gun
violence, by the mentally ill could be eliminated, 90–97% of
all violent behavior would continue to exist in the United
States (Swanson et al. 1990; Appelbaum 2013). In other
words, approximately 3–5% of firearm homicides are com-
mitted by the mentally ill.
Because of the increase in violence within a small seg-
ment of the mentally ill and some media portrayals of the
mentally ill, it is assumed by the public and politicians that
mental health professionals such as psychiatrists and psy-
chologists should be able to identify those patients who
have a propensity for acting violent in the future (Trestman
et al. 2016). A further assumption is that by reporting those
who are perceived as possibly violent in the future to the
appropriate authorities and providing the patients with ad-
equate treatment, we will be able to significantly reduce
future events of firearm violence. This reporting of indi-
viduals with mental illnesses to legal authorities is likely to
result in a large number of false positives (people who are
predicted incorrectly to be violent in the future but will not
be violent). This is where a form of social injustice is
magnified as these individuals will have some of their rights
curtailed (e.g., the right to purchase and own firearms).
Society seems willing to accept large numbers of false
positives as long as there are very few false negatives
(where some people become violent in the future but were
not predicted to do so by an assessment). A major reason for
much of the inaccuracies in assessing future violence by
patients is a lack of training in violence assessments. A na-
93
tional study of psychiatric residents found that one-third of
the residents received no training in assessing and managing
patients’ risk of violence, and of those who had training, one-
third of the individuals had training that was inadequate
(Schwartz and Park 1999). Also, a national study of psy-
chologists reported a median number of hours of formal
training in assessing and managing patient violence to be zero
(Guy et al. 1990). More recent research has found that mental
health professionals can be trained with structured risk as-
sessment inventories to slightly improve their prediction of
violent offending in the near future but that longer-term
predictors are not likely to improve much beyond chance
(Buchanan 2008; Teo et al. 2012). The characteristics most
likely to predict future violence include the following: young,
males, African American, history of engaging in substance
abuse (including alcohol), low socioeconomic status, per-
sonality disorders, and early life experiences with violence
(physical, sexual, and psychological) (Swanson et al. 2006).
Only about 4% of the violence in the United States is com-
mitted by individuals who are mentally ill. The mentally ill
are more likely to be victims of violence than the perpetrators
of violence (Choe et al. 2008).
A health threat that has become intertwined with mental
illnesses is the pervasive threat of firearm violence. Accord-
ing to statistics from the Federal Bureau of Investigation
(FBI), in 2013, every 4 minutes an aggravated assault oc-
curred in the United States with a firearm, every 4.5 minutes a
robbery with a firearm occurred, every 25 minutes someone
committed suicide with a firearm, and every 58 minutes
someone was murdered with a firearm (Federal Bureau of
Investigation 2014). From 2010 to 2012, on average 32,529
people died from firearm trauma. Sixty-two percent of these
deaths were suicides, 35% were firearm homicides, and 2%
were unintentional firearm deaths (Fowler et al. 2015). At
least 90% of those who commit suicide have a mental health
problem (Nock et al. 2008). Approximately 70% of all ho-
micides are committed with a firearm, usually a handgun.
Firearm homicides in the United States are approximately 20
times greater than that found, on average, in other major
Western countries. It is estimated that there are 310 million
firearms in private hands in the United States (Bureau of
Alcohol, Tobacco, Firearms, and Explosives 2011). Numer-
ous research studies have confirmed that higher levels of
firearm ownership are associated with higher levels of firearm
assaults, firearm robberies, firearm suicides, and firearm ho-
micides (Stroebe 2013; Monuteaux et al. 2015).
An extremely rare form of homicide (less than 1% in a
typical year) is mass murder with firearms. However, these
rare events gain tremendous mass media attention and
overshadow the much larger numbers of individuals who are
murdered in less dramatic events. Mass murder events
usually occur after weeks or months of planning (Lankford
2015; Price et al. 2015, 2016). These are not situations in
which someone ‘‘snaps’’ (Swink 2010). The idea that
someone can just ‘‘snap’’ is the fictitious creation of Hol-
lywood movies and television shows. It is true that the
majority of mass murderers are mentally ill, and very often
they have a paranoid personality disorder that causes them
to be disgruntled with parts of their environments that they
perceive as unfair and for which they hold a grudge (Stone
2015). The mass media tends to emphasize the role that
mental illness played in the shooter who carried out the
 94
mass murder. Because of the media saturation of these
events as caused by mental illness, the public has reinforced
in their minds that all or most mentally ill are violent indi-
viduals. However, the vast majority of homicides, including
firearm homicides, are not committed by the mentally ill.
The federal response to restricting access to firearms by
people who possibly should not have them was to pass the
Gun Control Act of 1968 (Price and Norris 2008). It pro-
hibited several categories of individuals from purchasing
firearms. Among the categories was the mentally ill who were
defined as individuals who had been involuntarily commit-
ted to a mental hospital or those who were ‘‘adjudicated as
mentally defective.’’ It includes anyone legally identified as
incompetent to manage his or her own affairs, those accused
of being incompetent to stand trial for a crime, or individuals
acquitted of a crime by reason of insanity. Obviously, most
seriously mentally ill do not meet these criteria. Also, in 1993
the Brady Handgun Violence Prevention Act was passed by
Congress. This law added a national electronic registry,
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which resulted in the National Instant Criminal Background
Check System (NICS) in 1998 that is controlled by the FBI
(Price and Norris 2008). All states were encouraged to submit
records for the groups of individuals identified in the Gun
Control Act (1968) to the FBI. Unfortunately, many states
have reported very limited numbers of individuals because of
concerns about confidentiality and the costs associated with
making their records in electronic format to meet the needs of
the FBI. Thus, the NICS records are not complete for a va-
riety of reasons. It should also be noted that only the purchase
of firearms from federally licensed firearm dealers is required
to have background checks with NICS to see if the potential
purchaser is listed as a member of one of the banned cate-
gories of individuals. Unfortunately, about 40% of gun sales
occur at gun shows, flea markets, pawn shops, and private
sales (secondary market). These sales are not required to have
background checks with NICS because the dealers do not
have a federal firearm license. On January 5, 2016, President
Obama announced several new executive actions. One of
these actions was to reduce the size of the gun market that
does not conduct background checks on gun purchasers
(White House 2016).
Again, we find that the public and politicians un-
realistically expect mental health professionals to determine
which patients with a mental health problem are likely to be
involved in firearm violence in the future (Gold and Simon
2016). First, these expectations assume that mental health
professionals are trained in firearm violence issues associ-
ated with mental health problems. Second, it is assumed that
those who are trained are appropriately discussing with their
patients/clients firearm violence issues. Third, that mentally
ill people play a significant role in firearm violence. Thus,
there are two purposes to this article. First, we reviewed the
basic issues of firearm violence by the mentally ill. Second,
we conduct a systematic review of the research literature on
mental health professionals’ preparation and practices re-
garding firearm safety assessments of patients/clients.
Methods
Search strategy
Electronic searches were carried out in the following da-
tabases: PsychInfo, CINAHL, and PubMed. The search re-
PRICE AND KHUBCHANDANI
sults were limited to the peer-reviewed literature. The search
was not limited by year of publication. We did not search the
‘‘gray literature’’ (e.g., theses, technical reports, conference
proceedings, and official documents). These types of publi-
cations are often ephemeral and difficult to obtain. In addi-
tion, when articles were identified, their references were
also searched to help ensure that all possible articles were
found. An experienced medical librarian served as the advi-
sor for literature searches. Keywords such as ‘‘firearms,’’
‘‘guns,’’ ‘‘mental health,’’ ‘‘mental illness,’’ ‘‘psychiatric
nurses,’’ ‘‘social workers,’’ ‘‘psychologists,’’ ‘‘psychiatrists,’’
‘‘case managers,’’ ‘‘mental health administrators,’’ and
‘‘counselors’’ were searched. The order of keywords was
changed in repeated searches across databases to extract the
final pool of relevant studies.
Inclusion criteria
Articles were included for review if they explored the
perceptions and practices of U.S. mental health profes-
sionals. Only the specific mental health professionals pre-
viously mentioned were included in our review.
Search results
A total of 360 publications were identified. After repeated
filtration applying the inclusion criteria, most of the articles
were not relevant to our study because they were not pub-
lished in English, studies were conducted out of the United
States, studies did not relate to mental health professionals,
studies did not address firearm violence specifically and
dealt with violence in general, or they were opinion pieces
or commentaries. A total of 10 publications were identified
that met our criteria. One of the publications identified from
the hand search of articles’ references appeared to be from a
newsletter and could not be located by the researchers or the
medical librarian advisor. The newsletter article appeared to
be an article on psychologists and firearm safety counseling
(Sullivan 2004). No articles were located for mental health
case managers or mental health administrators and firearm
safety issues. Two independent investigators ( J.H.P. and
J.K.) reviewed the final pool of studies to reach a consensus
on inclusion of relevant articles. Discrepancies were sorted
out with discussion.
Results
A total of 9 studies on the perceptions and practices of
mental health professionals regarding firearm violence were
found. Four of the articles dealt with psychiatrists, two ar-
ticles from one study dealt with social workers, and one
article each examined clinical psychologists, college coun-
selors, and graduate psychiatric nurses.
Psychiatrists
The first study addressing psychiatrists was a random
sample of primarily Massachusetts psychiatrists who were
mailed a 38-item survey (Gallagher 2002). The study ab-
stract published as a presentation at a national conference
did not specify the sample size but did report a 42% re-
sponse rate. Most psychiatrists (85%) reported being com-
fortable with discussing issues regarding firearms with
suicidal patients, but only 37% believed that counseling
 FIREARM VIOLENCE BY THE MENTALLY ILL
would be effective in reducing suicide risks. Yet, 81% of the
respondents reported that they screened suicidal patients for
access to firearms. Few of the psychiatrists (23%) had been
trained to assess patient firearm access and 14% of the
psychiatrists had experienced a patient who committed
suicide with a firearm. A majority (52%) of the respondents
were interested in additional training regarding firearms and
suicide. Barriers to screening patients regarding firearm
access were lack of knowledge regarding resources or ef-
fective interventions (49%) and time constraints (25%).
The second study of psychiatrists was of practitioners in
Ohio (n = 205; 60% response rate). Nearly half (45%) had
never thought seriously about discussing firearm safety is-
sues with patients (Price et al. 2007). The respondents did
perceive firearm safety issues to be much greater (32%) or
slightly greater (37%) for the mentally ill than patients in
general. The psychiatrists perceived that, if they discussed
firearm safety issues with their patients, approximately 42%
of their patients would comply with storing their guns
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locked away and unloaded, and only 26% would remove
firearms from their homes if the psychiatrist so re-
commended. One-fourth of the respondents reported that
they had a routine system for identifying which of their
patients owned firearms. The majority (54%) of the psy-
chiatrists had not received any information on counseling
patients regarding firearm issues. Psychiatrists who had re-
ceived information on issues of firearm safety were over 13
times more likely to counsel patients regarding firearms than
psychiatrists who had not received information on this topic.
The third study with psychiatrists was a national study of
psychiatric residency training directors (n = 115; 64% re-
sponse rate). The vast majority (79%) had not seriously
thought about providing firearm injury prevention training
to their residents (Price et al. 2010). However, more than
half (55%) reported that their residency’s training practices
included screening patients for firearm ownership. The
residency directors perceived there to be important benefits
to providing firearm injury prevention training to their res-
idents, including increased safety of practicing psychiatrists
(57%), reduced mortality from firearm suicides by patients
and/or family members (51%), and increased attention by
mental health clinics toward firearm trauma prevention
(48%). A plurality of directors (30%) thought that their
residents would not be able to address issues of firearm
injury prevention, and another 29% were unsure about the
firearm safety skills of their residents.
The fourth study of psychiatrists was a national survey of
residency directors’ perceptions of firearm access by the
mentally ill (Price et al. 2014). The membership of the
American Association of Directors was surveyed, and 72
(56%) responded. Almost one-fourth (23.6%) of directors
thought that access to firearms should not be prohibited for
anyone with a serious mental illness. All of the directors
believed that persons with mental illness could circumvent
the NICS and obtain firearms from family members. The
vast majority (90.3%) of directors indicated that they had
patients who should not possess firearms but have never
been adjudicated or institutionalized for a mental illness.
The majority (69.4%) thought that rather than restricting
access to firearms by the seriously mentally ill, providing
more resources for treatment of the mentally ill would be
more effective in reducing firearm violence by this group of
95
patients. Residency directors (56.9%) believed that all states
should be required to submit mental health records to NICS.
A plurality (44.4%) of directors did not believe that patients
with mental illnesses would avoid treatment if they knew
they would be reported to NICS. Also noteworthy was that a
plurality of directors (40.3%) would not be willing to be
involved in a legal system that required psychiatrists to
certify their patients as acceptable/not acceptable to pur-
chase firearms.
Clinical psychologists
A national random sample of clinical psychologists was
drawn from the American Psychological Association mem-
bership list by Traylor and colleagues (2010). A total of 339
responded (62%) to a survey regarding discussion of fire-
arm risk management with patients who had mental health
problems. The majority (78.5%) of psychologists perceived
firearm safety issues as a greater issue for those with mental
health problems than for the general population. However,
most respondents did not have a routine system for identi-
fying patients with access to firearms. Approximately half
(51.6%) reported that they initiated anticipatory guidance on
firearm safety if patients were assessed as being at risk for
self-harm or harm to others. About one-fourth (24.5%) had
never seriously thought about talking with their patients
about firearm safety issues. Only 57% of the respondents
counseled all or most of their suicidal patients regarding
firearm safety issues. Slightly more than one-third (36.6%)
never discussed the dangers of firearms with their patients.
The perceived barriers to discussing firearm safety issues
with patients were that the majority of patients would not
need such a discussion (73%), patients did not request such
information (35%), and lack of personal expertise on the
subject (22%). Yet, a majority thought that firearm safety
counseling would reduce the number of suicide attempts and
suicides (58%), and would reduce the number of accidental
firearm injuries and deaths (54%), and a plurality thought it
would reduce the number of homicides in patients and/or
their families (42.5%). The majority of psychologists (54%)
indicated that they had received information on firearm
safety issues, and 20% received their information from mass
media.
College counselors
A national survey of college counseling center directors
examined the use of firearm safety counseling with student
clients who used college counseling centers, and 213 (59%)
of the directors responded (Price et al. 2009). The majority
of counselors (57%) perceived firearm ownership safety
issues to be considerably or slightly greater for college
counseling center clients than for the general college pop-
ulation. Yet, only 17% routinely kept records on whether
repeat clients owned or had access to firearms, and only 6%
reported regularly discussing firearm safety issues with their
clients. One-third (34%) had never seriously thought about
providing anticipatory guidance on firearm safety to their
clients. Few responding counselors thought that discussing
firearm safety issues with clients would reduce suicides on
campus (39%) or reduce campus homicides (22%). Only a
third (32%) of the counselors provided anticipatory guid-
ance on firearm safety to suicidal clients. The limited
 96
engagement with patients regarding providing firearm safety
guidance may be because 54% reported having never re-
ceived any training on firearm safety issues and 49% indi-
cated that they had no expertise on this topic. Of those who
did have some training on the topic, 15% indicated that they
received their information from the mass media.
Social workers
A statewide (Ohio) survey of licensed social workers
(n = 697, 28% response rate) resulted in two articles from this
sample. The initial article reported that 34% of the respon-
dents routinely assessed firearm ownership and access in their
clients and 15% routinely counseled their clients on firearm
safety (Slovak et al. 2008). In addition, only 24% of the
social workers reported receiving training for firearm safety
counseling. If a social worker had firearm safety training, he
or she was two and a half times more likely than those
without such training to routinely assess firearm ownership
and access by their clients and almost five times more likely
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to engage in firearm safety counseling. They also reported
that female social workers were 65% and 75% more likely
than male social workers to engage in such assessments and
counseling on firearms. The second article from this sample
reported that almost 1 in 5 social workers (18.6%) desired
more training on counseling about firearms (Slovak and
Brewer 2010). Additionally, social workers who had prior
firearm counseling training were 91% more likely than those
without training to have a positive stance toward assessment
and counseling of clients regarding firearm safety.
Psychiatric nurses
A national study of all (n = 85) graduate psychiatric nursing
programs assessed the prevalence of firearm injury prevention
training in these programs (Khubchandani et al. 2011). A total
of 64 program directors (75%) responded to the survey. The
vast majority (87%) had not seriously thought about providing
firearm injury prevention training to their students. Less than
half (44%) of the directors reported that they had nurses rou-
tinely screen their patients for firearm ownership. Yet, most
directors agreed that there were benefits to providing firearm
injury prevention training, including increased safety of prac-
ticing psychiatric nurses (73%), reduced firearm suicide mor-
tality in patients (59%), and reduced firearm homicides by
patients (55%). There were also several perceived key barriers
to providing such training to nursing students: lack of faculty
expertise on firearm injury prevention (64%), lack of profes-
sional guidelines on what must be covered (52%), and lack of
standardized teaching materials for nurses (50%). A little more
than one-third (34%) of the directors perceived firearm own-
ership to be more dangerous for the mentally ill than for society
members in general. Finally, of the 9% of these programs that
were currently training nurses on firearm injury prevention, the
median number of hours of training was 2 and the maximum
was 8 hours.
Discussion
We have found in our review of mental health profes-
sionals and firearm safety issues with patients that mental
health professionals need more training regarding firearm
issues if they are going to have a role to play in reducing
PRICE AND KHUBCHANDANI
firearm trauma by the mentally ill. The firearm trauma most
likely to be reduced in the mentally ill is firearm suicides. The
majority of the mental health professionals do not screen their
clients for firearms and do not provide safety counseling to
their clients but believe that firearm safety issues are greater
for mentally ill people. This in part could be because of a lack
of training in graduate programs and lack of information for
those who are practicing professionals.
There are several reasons why mental health professionals
should be rigorously trained in the area of firearm safety issues
(clinical, legal, ethical, advocacy, and research) (Thompson
et al. 2012; Price et al. 2015, 2016). First, better clinical practice
would be a likely outcome of professional training, given that
mental health professionals have to conduct violence risk as-
sessments, safety counseling, and ensuring the safety of
themselves, hospital/clinic staff, patients, family members, and
society in general. For example, psychiatrists may collaborate
with law enforcement officers to help remove guns from dan-
gerous clients (Melamed et al. 2011; McGinty et al. 2014a,
2014b; Candilis et al. 2015). This type of effort needs training
in both law and medicine as it relates to firearms. Second,
mental health professionals have to be aware of various legal
issues surrounding firearms and clients. Examples would in-
clude knowledge of Family Educational Rights and Privacy
Act (FERPA), Health Insurance Portability and Accountability
Act (HIPAA), confidentiality, and consent terms and condi-
tions while considering firearm safety for patients and disclo-
sures about firearms to relevant agencies (Swanson 2013;
Candilis et al. 2015). Also, mental health professionals need to
be aware of NICS, and state and federal reporting guidelines
(Price and Norris 2008; Appelbaum and Swanson 2010). These
issues can be included in graduate training curricula for mental
health professionals nationwide. Third, mental health profes-
sionals need training so that they can be an expert counsel for
patient rights, possession, purchase, transfer of guns, and ap-
peals processes when required to do so (Norris et al. 2006).
Another example would be the provision of legal advice on
type and duration of gun restriction for certain clients, which
requires sound clinical judgment and knowledge of laws re-
garding firearms. Finally, with adequate training, health pro-
fessionals have ample opportunities to be involved in research
and advocacy regarding firearms and mental health issues
(Khubchandani et al. 2009; Price et al. 2013, 2015, 2016;
Weinberger et al. 2015). Specially, mental health professionals
can work with law enforcement officers and policy makers for
evidence-based policy making on public safety, consensus
building for policies and practices on gun restrictions and gun
laws reform, research the effectiveness of current laws and
regulations, and gauge and respond to the publics’ perceptions
of mental illness, gun rights, and violence (Barry et al. 2013).
Our review of the relevant literature also indicates a wide
variety of reasons why the seriously mentally ill will con-
tinue, for the foreseeable future, to have access to firearms
(Price et al. 2014; Swanson et al. 2015). The weak links in
maintaining access to firearms by the seriously mentally ill
include the following:
 There is limited support by mental health professionals
to report categories of patients/clients to the NCIS.
The American Psychiatric Association (APA) is not
supportive of this type of reporting. This makes the
NICS data incomplete.
 FIREARM VIOLENCE BY THE MENTALLY ILL
 Most states have not been very responsive to reporting
mentally ill patients to NICS. The federal government
cannot mandate states to report individuals to NICS.
Thus, the data collected by NICS are inadequate.
 There is often a long lag period between onset of
symptoms of mental illness and obtaining treatment.
Therefore, a significant segment of the mentally ill
would not come to the attention of mental health pro-
fessionals and would not be included in NICS even if
states are better at reporting the mentally ill to NICS.
 The ubiquitous nature of firearms in the United States
means that the mentally ill (and everyone else) will
likely have relatives and friends with firearms. Ac-
cess to firearms is not difficult in the United States
even if a person is banned by NICS criteria. About 4
in 10 Americans report having a gun at home (Drake
2013).
 The secondary gun market sells 40% of the firearms.
This market is not currently required to check with NICS
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before they sell a firearm. This market makes firearms
readily available to NICS-banned purchasers, including
those with a serious and persistent mental illness.
 There are tens of thousands of seriously mentally ill
individuals who do not meet the current criteria for
being reported to NICS. Those who wish to purchase a
handgun will be required to complete the Bureau of
Alcohol, Tobacco, Firearms and Explosives (ATF)
form (Form 4473) that has only one mental health
question, ‘‘Have you ever been adjudicated mentally
defective or have you ever been committed to a mental
institution? Yes or No.’’ The vast majority of mentally
ill could answer ‘‘No’’ to this question. However, many
of these individuals should not have access to firearms.
 The number of seriously mentally ill will continue to be
in the general population and a very small portion of
such individuals will seek access to firearms. The re-
ductions in the number of mentally ill individuals will
occur only when the social determinants of mental ill-
ness are adequately addressed.
It should also be noted that, even if all seriously mentally
ill individuals are excluded from firearm access, it would
likely have a minor effect on firearm homicides. It is likely
that at least 95% of all firearm homicides would continue to
occur. However, excluding firearm access to mentally ill
individuals who might commit suicide would likely reduce
firearm suicides by 90%. There are a number of recom-
mendations if implemented could reduce firearm violence in
the United States (Thompson et al. 2009, 2011; Price et al.
2013, 2015, 2016; Pinals et al. 2015; Swanson et al. 2015;
Weinberger et al. 2015). Recommendations to help reduce
firearm violence would include:
 Eliminate firearm access for those individuals with
multiple driving under the influence (DUI) convictions
(e.g., report to NICS).
 Eliminate firearm access for individuals convicted of
violent misdemeanors.
 Eliminate firearm access for individuals who have a
temporary restraining order for domestic violence.
 Eliminate firearm access for those convicted of a con-
trolled substance crime.
97
 Require background checks for all firearm purchases
(including private sales).
 Require safe storage of all firearms and periodic safety
training for gun owners.
 Individuals assessed as being potentially violent should
be reported to NICS regardless if they have a mental
illness diagnosis or not.
 Increase research and professional training on the
causes of firearm violence and how to reduce the risks.
 Mechanisms need to be in place to restore the rights to
have firearms when appropriate for those who have
been disqualified to purchase or possess them.
Finally, we would like to add a few recommendations that
specifically relate to the mental health arena (Price et al.
2007, 2009, 2010, 2014; Thompson et al. 2012):
 Increase funding for early identification and treatment
of mental disorders and substance abuse disorders.
 Assure the rights of mental health professionals to make
appropriate inquiries of patients regarding firearms.
 The APA and the American Psychological Association
need to delineate standardized training for graduate
education for psychiatrists and psychologists on vio-
lence and, more specifically, on firearm violence.
 The APA and the American Psychological Association
should invest more resources to develop better assess-
ment tools to identify potential near-term violence in
patients/clients.
 The APA and the American Psychological Association
need to increase training opportunities for mental health
professionals who are already practicing and who seek
additional training on firearm violence.
 The ATF Form 4473 needs to be modified, and more
mental health questions need to be added to better
identify those who may need to be banned from pur-
chasing firearms.
In conclusion, we found that mental health professionals
need more training to practice firearm safety counseling, and
also there is a need for continued research on how to predict
violent behaviors in the near future so that individuals ex-
hibiting such behaviors could be prevented from having un-
restricted access to firearms. Mental health professionals
should play a role in helping formulate evidence-based gun
policies that do not stigmatize individuals with mental ill-
nesses. The large majority of people with mental disorders do
not engage in violence against others, and most violent be-
havior, including firearm homicides, is attributable to factors
other than mental illness. We have delineated a variety of
actions that, if implemented, could have a profound effect on
reducing violence, including firearm violence that specifically
affects those with mental health problems (firearm suicides).
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Jagdish Khubchandani, MBBS, PhD
Department of Physiology and Health Science
Ball State University
2000 W. Riverside Avenue
Muncie, IN 47306
E-mail: jkhubchandan@bsu.edu