Grand Rounds

Why we do the things we do

Remaining Rational in the Wake of Connecticut

The rising threat to patients with psychiatric illness

The recent horrific events in Connecticut have spawned a bizarre series of debates that glop together questions regarding how we can best care for our psychiatrically ill patients, and corresponding questions regarding how we can best care for our firearms.

As my colleagues and family will tell you, I am usually not at a loss for words.  Nevertheless, I have started this post about a hundred times and I can’t get beyond a seething and sickening discomfort that prevents further careful inquiry on my part.

That, of course, is a problem.  When I feel this strongly, I worry that I will not write responsibly.  So, let me begin with some basic facts. 

-The amount of psychiatric illness in every Western country is roughly the same.  I am happy to cite these studies in further communications.  You can also  wander around the World Health Organization and the World Psychiatric Association web sites to learn more about these numbers. 

-Given the relatively equal rates of psychiatric illness across all Western nations, it is frighteningly logically suspect and stupendously oversimplified to explain the clear increase in the United States of still thankfully rare mass shootings as purely a function of psychiatric illness.  In other words, if we were to suggest that an appropriate response to the issue of mass shootings involves more stringent institutionalization of those with psychiatric illness, we would be hard pressed to explain the orders of magnitude difference in this kind of violence in the United States when compared to other developed nations. 

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-The United States quite simply has substantially more mass shootings but the same percentage of psychiatrically suffering patients than any other nation.

-We have more firearms in our country than in any other comparably developed nation.  These statistics are also easily accessible. 

-An individual in the United States is about a hundred times more likely to die due to the discharge of a firearm than in any other Western nation.

These facts are not in dispute.  That’s why they’re called facts.  We could slice the statistics if we wanted to – some Western nations have more guns, some have less, and some Western nations more actively hospitalize and confine individuals with psychiatric illness, and some hospitalize these patients less. 

BUT – it is dangerously fallacious to suggest that we will address mass shootings by, as some pundits have recently suggested, more stringently confining psychiatrically ill patients for the protection of those around them.  If this argument were to hold any real weight, and especially in the absence of the necessary corresponding debates that surround firearms, then we’d see similar calls for the increasing confinement of psychiatrically ill patients in other Western nations. However, other comparable Western nations have proven and lasting records of more humane, less restrictive and better overall care of those people with psychiatric illness than the United States enjoys.  I know this from the research I’ve done on this topic, from attending international meetings addressing psychiatric health care policy, and from my experience as a physician and psychiatrist practicing in this country.  To this end, the logic of those who argue for greater overall restrictions on those with psychiatric illness is repulsive and frightening.

I grew up in an upper-middle class suburban neighborhood where guns were common.  In fact, I was one of the few guys on my high school football team who didn’t hunt.  It was not uncommon to see dads sitting on the front porch teaching their kids how to properly care for a shotgun or a rifle.  Though my family did not own a gun, I very much enjoyed firing .22 caliber rifles in summer camp.  I even won a few rifle tournaments.  I mention all of this to say that I am not, in principle, opposed to the ownership of firearms. 

But, as has been noted continually by multiple law enforcement agencies, by lawmakers, and by gun enthusiasts themselves, I also have yet to meet a hunter who sees or appreciates the sporting advantage of an automatic weapon with ammunition designed to inflict maximum damage.  Those weapons are not about hunting. Some will of course say here I am splitting hairs, but a gun that fires multiple rounds with maximum damage are really only made for killing multiple people as quickly as possible.  They certainly aren’t made for shooting ducks.

I also am hard pressed to suggest that an automatic firearm is the best option for self defense.  If that were the case, we'd have to imagine a country where men and women routinely walk the streets with military grade rifles strapped to their backs. I've seen photographs of settings like that, but never from anything resembling this nation.

So – that part is settled.  I don’t mind guns, but I mind the wanton availability, or even the carefully controlled availability, of the kinds of firearms implicated in recent mass shootings.  I think that I am not alone in this sentiment, either nationally or internationally.

Now, let’s turn to the most sickening part of this already horrific debate. A conservative estimate of the lifetime national prevalence of psychiatric illness is about 1 in 5.  Those aren’t numbers from some self-serving industry group – those are numbers from the World Health Organization.  If we trust the WHO to accurately warn us about infectious pandemics, than we ought also to trust the WHO to accurately depict for us the burden of psychiatric suffering.

But we also know this about the United States: 

We are the only Western nation to carve out our psychiatric care from the rest of our health care.   We are the only Western nation to erect clear and disproportionate barriers to psychiatric care for our psychiatrically suffering population.  Remember – the numbers are one in five.  We’re not talking about caring for some ill defined “them.”  We’re talking about our failure, as a civilized and ethical people, to care for “each other.”  We, the People, suffer psychiatric illness often and with great pain.  And yet, We, the People, continue to refuse easy access and quality care to those in need.  That’s inexcusable and embarrassing and infuriating.  I say this not as a psychiatrist, but as a citizen of this great country.  We can do better.

So, the solution to the presence of ample availability of automatic weapons designed to inflict maximum damage in minimal time is to LOCK UP one in five of our population?  No, some will angrily retort.  We only want to lock up the dangerous ones, they’ll say. 

O.K…We do in fact have retrospectively predictable data on who among those individuals with psychiatric illness is likely to be dangerous.  The retrospective data is in fact pretty solid.  The profiles are eerily similar.  But prospectively?  Are we prepared, in the Land of the Free, to take the number of people who have done no harm, who are incredibly unlikely to do harm, and who are subject to horrific neglect and prejudice when compared to individuals with similar ailments in other developed nations, and proactively “confine” them? 

That’s not my America.

As it stands, and this I know from my own research, doctors in the United States are statistically significantly more likely to under-treat, under-recognize and to just plain fail to take seriously psychiatric illness.  This kind of medical nihilism does not exist in any other discipline of medicine in the U.S., and though things are without question getting better, let us, PLEASE, not muddle the discussions that will be embarked upon with much pain and suffering as we move, hopefully, forward in our efforts to understand ourselves, warts and all, in the wake of what happened in Connecticut and elsewhere.

Get the assault weapons out of my country.  And focus on better clinical treatment - not confinement -  for the citizens of our Land.          

 

 

 

 

Steven Schlozman, M.D., is an Associate Director of Medical Student Education in Psychiatry for Harvard Medical School.

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