Hello and welcome. I'm Dr. Benjamin Druss, Professor and Rosalind Carter Chair in Mental Health at the Rollins School of Public Health at Emory University and health systems expert for SMI Advisor. I am pleased that you are joining us for today's SMI Advisor webinar, Rare but Real Risk of Firearms and Treatment of Individuals with SMI, Basic Principles for Practitioners. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now, I'm very happy to introduce you to the faculty for today's webinar, Dr. Deborah Pinals. Dr. Pinals serves as the Director of the Program in Psychiatry, Law and Ethics and as a Clinical Professor of Psychiatry at the University of Michigan Medical School. She's a Clinical Adjunct Professor at the University of Michigan Law School. She's also the Medical Director of Behavioral Health and Forensic Program for the Michigan Department of Health and Human Services. She's board certified in psychiatry and forensic psychiatry and is board certified in addiction medicine. From 2008 to 2016, she was the Assistant Commissioner of Forensic Services. Between 2012 and 2014, she was the Interim State Medical Director for the Massachusetts Department of Mental Health. During her career, she has been a clinical psychiatrist in community mental health, inpatient settings, forensic and correctional facilities, emergency rooms, and court clinics. Please note that Dr. Charles Scott will not present during the live broadcast due to an unforeseen conflict. Dr. Scott's presentation will be delivered by Dr. Pinals. We would like to thank Dr. Scott for his contributions to the presentation. Dr. Pinals, we want to thank you for leading today's webinar. Thank you very much for that kind introduction. It is a pleasure to be here on SMI Advisor. We hope that this presentation today will help you meet some of your learning needs. I do want to thank my colleague, Dr. Scott, for helping prepare this presentation. I'm happy to cover for him given his unforeseen conflict. I want to start by saying that neither I nor Dr. Scott have financial relationships with commercial interests or conflicts to report with regard to this presentation. I'm hoping today that we're going to give you some knowledge and skills related to the ability to identify risks of firearm violence attributable to individuals with SMI, to describe the assessment of firearm suicide and violence risk for individuals with SMI, and to be able to discuss risk-based gun removal laws and restoration of firearms rights related to individuals with SMI. This is an evolving landscape and something that I think is very important for clinicians to understand. So let's get started. Let's start with objective one, identify risks of firearm violence attributable to individuals with SMI. What does the data show us? First of all, it's important to realize that in the United States, about 37% of the US population owns guns of some sort. If we look at a veteran-specific population, you're going to see an even higher percentage with 42% of veterans approximately owning personal guns. Also, we know that homicide is more common in areas where homes have firearms, and that's just something that's important to think about. We also know that with regard to suicide, half of suicides are completed with a firearm, and individuals with mental illness who own a gun are more likely to use it for suicide than they are for homicide, despite what people might think from the media. In terms of firearms and homicide, 67% of all homicides can be attributable to firearms usage. However, when we look at the population of individuals who engage in serious violence and those with mental illness, it's important to realize that mental illness accounts for only 3% to 5% of violence in the United States. Only a very small proportion of violence can be attributable to persons with mental illness. We know that 1% of discharged psychiatric patients from one particular very methodologically sound study, which I'll get into in a little bit, used guns towards strangers in their first year. Although it is a rare risk, it is still a real risk and something that clinicians should be knowledgeable about. The particular study that I just mentioned that cites that 1% figure comes from data that was collected for what's known as the MacArthur Violence and Mental Illness Study. In a paper published in Psychiatric Services, my colleagues and I reanalyzed that data specific to looking at firearms-related risk. What's important to realize is this was a study looking at civilly committed patients who were hospitalized across multiple cities and who were discharged and followed up every 10 weeks for about a year. When they were followed up, there was an analysis of whether those patients had engaged in aggressive or violent acts, which were those involving weapons or involving injury to others, or other aggressive acts. Then looking at how many were the violent acts among how many patients. What we did was we analyzed that data. If we looked at the total aggressive or violent acts, meaning more serious and less serious, there were about 3,276 acts that were noted in the follow-up period for about 1,000 patients. Most of those were not really significant violent acts. Most of those were what would be called other aggressive acts, 2,667. Of the more serious violent acts, among 951 patients, there were about 608 violent acts in total. Only 178 of those involved weapon threat or use, but only 67 of those involved firearms. It was more common that weapons were other things like knives. That's important, again, to realize that we're looking at a very narrow group of people. Most of the people that were involved in the firearm use were not those people with serious mental illness. They were people with other mental disorders who had histories of criminal justice involvement. When we looked at the data, the factors that contributed to gun violence, 2% of the 951 discharged patients committed a violent act that involved guns at follow-up. That was a total of 23 people. The slide before was really describing the acts of violence or aggression. Now we're looking at it from a person perspective. There were only 23 of the 951 people across multiple cities that engaged in violent act that involved a gun. 1% of those committed a violent act involving both a gun and a stranger. The thought that people are going to come from the psychiatric hospital and have a high proportion of people that will engage in gun violence towards strangers is really not the way the data bears out. The common diagnoses that were seen amongst the individuals that did use a gun against a stranger were depression and especially substance use disorders. That's something that we talked about in a prior SMI advisor webinar on looking at violence risk assessment as a whole. Substance use disorders plays a huge role in these types of acts. As I mentioned before, the themes that were common amongst these 23 people involved that these were individuals who were cycling in and out of jails, often with multiple hospitalizations, but mostly with a high percentage of what we call criminogenic factors, which relate to antisocial personality disorders, substance use disorders, histories of childhood physical abuse, and parental arrest histories were also part of the picture. When we really look at the individuals who are coming in and out of hospitals, we do have to do careful risk assessments with everyone, but there are going to be individuals that are going to be at greater risk than others. Those might not include the individuals with SMI who would only be accountable for very small numbers of violent acts related to firearms compared to society as a whole. In another study looking at serious mental illness and firearms, there was a study looking at 255 recently discharged psychiatric patients and 497 census matched community residents. There was a total of 15% that reported firearms access altogether. The patient group, including those with major mental disorder and other mental disorders, were no more likely to perpetrate violence, but were significantly more likely to report suicidality. Violence is much more rare, but suicide risk cannot be ignored where firearms are concerned. What about guns, impulsive anger, and mental disorders? In a study looking at the National Comorbidity Study replication showing large numbers of individuals in the United States who self-reported patterns of impulsive, angry behavior, and also possessed firearms at home or carrying guns outside the home, there were associations of numerous common mental disorders and combinations of angry behavior with gun access. But only a minority of the at-risk individuals had histories of psychiatric hospitalization. So in other words, it's really important to look at our patients broadly and understand that of those with serious mental illness, firearm-related violence might be a real risk, but it would be extremely rare. Well, as clinicians working in general practices or working in emergency departments, however, where we see individuals with general impulsive, angry behavior who might have an associated mental disorder or some combination with gun access, there may be more of a risk to consider. What about mass violence, serious mental illness, and race? Some very difficult topics to discuss. Mental health professionals should scrutinize apparent correlation of violence with mental illness for evidence of racial bias in the official systems that define, measure, and record psychiatric diagnosis, as well as those that enforce laws and impose criminal justice sanctions. There are many concerns that mass shootings committed by individuals who are white are attributed to mental illness, where mass shootings committed by blacks are more likely attributed to gang violence or drive-by shootings. And so what we know is that there are lots of theories about what is happening in terms of violence, but we really need to look at how data has been collected and how it has been analyzed, because there's a lot of concern right now that there are a host of issues that lead to racial biases and conclusions that might be flawed in their thinking. Assessment considerations include that generally the use of firearm in violence amongst individuals with mental illness is, as I said before, what we call a low base rate event. That means it is a rare event, which makes it particularly difficult for clinicians because of its low frequency. Facts and circumstances of the particular individual may elevate risk, and that's where risk assessment comes into play. Rare events with individuals with fulminant psychosis should not be ignored, and we do see some of those situations, and certainly we see some of them reported in the media, but we don't want to make conclusions that all mass violence is associated with psychosis. That would be a flawed conclusion. So we have to pay attention to rare but real risk. Again, looking at the guns, impulsive anger, and mental disorders, as I said before, that when you look at self-report patterns, you're going to see individuals with impulsive angry behavior who also possess firearms at home or carry guns outside the home are going to be perhaps at greater risk. The associations of common mental disorders, as I said before, and angry behavior with gun access were not associated with serious mental illnesses like schizophrenia and bipolar disorder, just to put a finer point on what I had explained. Only a minority of the firearms at risk individuals had histories of psychiatric hospitalization, as I had explained. So that gives you some perspective on the data that looks at the association of firearm-related violence and serious mental illness. However, as I said, even though it's a rare but real risk, we have to be able to assess that risk and make treatment plans around that risk. So the next objective is to help you be able to describe the assessment of firearm suicide and violent risks for individuals with serious mental illness. One question you might be asking yourself is whether you have a duty to ask about firearms. In the legal sense, what is a duty? A duty is an obligation that if you fail to meet it can be attached to liability. When we look at negligence cases in the law, which are usually translated as malpractice cases to practitioners, there's four requirements to prove negligence. One is whether there is a duty to do something or to not do something, a dereliction of that duty that directly causes damages, and all four elements are required to prove that somebody was negligent. So the question of do I have a duty to ask about firearms, and if I fail to do so and a bad outcome ensues, can I be sued for negligence? Well, the truth of the matter is that anyone can be sued at any time, but the question that you really want to be asking yourself is how do I reduce my risk of being sued successfully and perhaps being sued at all? That leads us to thinking about the standard of care because the duty is going to be defined often by what is the standard of care. The standard of care is that a provider is required to exercise in both diagnosis and treatment that reasonable degree of knowledge and skill which is ordinarily possessed and exercised by other members of his or her profession in similar circumstances. So the standard of care is not defined by what is ideal care, but it is defined as what a provider is required to exercise in both diagnosis and treatment in terms of reasonable degree of knowledge and skill, and I'll just say it again, which is ordinarily possessed and exercised by other members of his or her profession in similar circumstances. So what does that mean with regard to firearms? In terms of risk assessments, it's going to mean that the standard of care does require that practitioners conduct relevant suicide and violence risk assessments. That's fairly clear from practice guidelines and from training that we have to do a relevant suicide and violence risk assessment. So what does that mean as we drill down further? For suicide risk assessment, just to do an overview, there are going to be suicide-specific screening questions that we're probably all fairly familiar with. Does the patient have current suicidal thoughts? Do they have current plans to commit suicide? Have they taken any steps or attempted to enact a plan? Do they have prior suicide attempts in their history? If so, what's been their most lethal suicide attempt, and do they have a family history of suicide, which might put them at greater risk? These might be the screening questions that you would ask all patients as you're doing your suicide risk assessment. Associated suicide risk screening questions include looking at whether they have current depression or anxiety or psychosis. Do they feel hopeless, which can be associated with increased suicide risk? What about homicidal ideation? Sometimes we see suicide risk associated with homicide risk. Do they have current symptoms like insomnia or substance use, which can really be something that's a risk factor for disinhibition and impulsivity? What about current psychosocial stressors that might contribute to that individual's suicide risk? Similarly, we recommend that there be violence risk assessment screening questions as well that are kind of parallel to the suicide risk assessment questions, but again, a lot of practitioners aren't trained as much on violence risk assessment, so they may not be as comfortable asking these questions, but they would include, do you have violent thoughts? Does the individual that you're seeing, your client or your patient, have current violent thoughts towards others? Do they have plans to commit an act of violence or multiple acts of violence? Have they taken any steps or attempted to enact violence? Rehearsals, for example, bringing a knife closer to their person, placing a knife in their sock because they're thinking about what they might have to do, so any steps or attempt to enact violence. How about any past history of violence? We know that past history of violence is a great predictor of future violence, although it's not the only factor that we look at in violence risk assessment, but is this a person who has engaged in a past history of violence? Which is, I reported that data looking at individuals who were revolving through the psychiatric hospitals with maybe not SMI but other mental disorders and criminal histories revolving through the criminal justice system and histories of complicated conduct-related disorder as children or trauma-related symptoms. Those were the individuals who may have had a history of engaging in violence and perhaps would have been more likely to engage in those firearm-related incidents that I described. What's the most violent act that a person has committed? That might be another specific screening question that we would recommend that you would ask. Associated violence risk screening questions include, again, some of the same things. Depression, anxiety, active psychosis, hopelessness, suicidal ideation, substance use. Do they have agitation or impulsivity? Again, getting to what I was talking about before, do they have current psychosocial stressors that are leading to anger and impulsivity? These would be associated violence risk screening questions that can be helpful to ask individuals to get the lay of the land as you're looking at their risk factors as a whole. And then we have to think about what does that mean once we've asked those general questions in terms of firearms related inquiry? What is the standard of care? Well, in 2010, the American Psychiatric Association Suicide Assessment Guidelines and the American Academy of Pediatrics, as well as numerous articles, book chapters, and other citations recommended an inquiry about firearms, particularly if you're doing a suicide and homicide risk assessment. So you would be asking those kinds of basic questions such as, do you have guns at home or any other place where you can access them? Can you get a gun easily? Remember that not all guns are gonna be legally acquired. In fact, many of the examples that we see of the use of firearms for violence relate to people with unregulated gun access. So we wanna ask that general question of can you get access to a gun? Another question you might ask is, do you intend to obtain or purchase a gun? Which gets at that intent. I had a patient once who was exhibiting paranoia about some neighbors. And although she did not initially speak about wanting to get a gun spontaneously, when I said, do you have any intention of obtaining or accessing anything to protect you from that neighbor, she did indicate that she had gone to purchase a gun. She hadn't purchased one yet, but she had been contemplating purchasing a gun, which raised my concerns about her increased risk. So that question of do you intend to obtain or purchase a gun can really be helpful to understand what people are thinking about and what they're trying to obtain a purchase or why they're trying to obtain or purchase a gun if the situation for them is changing. Other questions you might ask is, when did you obtain your gun? So again, it could be somebody that got a gun recently, purchased a gun, acquired a gun from somebody they know. Remember that the risk of suicide within the first week of gun purchase is 57 times higher than the general population. So we know that a newly acquired firearm can raise significant risk, and that's important to consider. Also, other specifics might include whether these are short guns, pistols, unlocked guns, or loaded guns. Are people keeping their guns at the ready able to be used without much preparation? And we're gonna talk a little bit more about that. In addition, of course, in any risk assessment, you're gonna wanna do a routine psychiatric evaluation so that you're really understanding what's going on for this individual. And that would include getting a history that encompasses a biopsychosocial formulation, a current mental status exam, and then getting varied sources of information to understand how elevated the risk might be. So that would include asking the individual themselves. We know from prior studies that self-report is actually fairly reliable. Speaking to collateral sources of information, like people who know the individual, can add to the database that helps you formulate your risk assessment, as well as looking at past records or case files that might be available to you to understand what's going on for this person. In addition, Dr. Lisa Aniker and I posited in 2016 that we might wanna think about firearms-related risk assessment on a two-tier level. And the tier one level would be the questions that we would ask in terms of a general risk assessment to anyone that we're seeing in clinical practice, where those relevant risk assessment questions are gonna be needed. And that includes what I've already mentioned, which is firearms ownership, firearms access, how accessible is that firearm? Is it stored and locked away with somebody else with the key that the person can't access? Also, where is the ammunition stored? Is the ammunition stored separate from the firearm so that it would take additional steps to get the firearm loaded and ready to use? Does somebody else have the ammunition? These are important questions to ask because when we think about people who are engaging in either suicide or violence, but again, in particular, with suicide, the more distant the means is, the less the potential risk. So if the person has their firearm stored in a locked area that's hard to access, and if it's a family member that has it and the person doesn't have the key, that might present a lower risk than the person who keeps the firearm locked and loaded under their pillow. So asking these types of tier one questions. And also in a tier one question, is there a social support network that can assist with firearms safety? For example, a family member. Is the family member on the side of helping that person reduce their access or is the family member on the side of helping them increase their access? And these are gonna be questions that you're gonna wanna understand in terms of what is the support network to mitigate potential risk. Now, if the tier one questions lead you to have additional concerns, then we would recommend what we call tier two questions, which really try and get at a more sophisticated type of risk assessment formulation. Because firearms have taken on a lot of meaning for people. For example, people who grow up in a military culture or are law enforcement officers where suicide risk actually is high, still might be very comfortable and acculturated with firearms. And their firearm might have specific meaning to them. And I'll talk about that in a moment. But how comfortable are these individuals with guns? Because when you're talking about what you're gonna do in terms of risk mitigation, that might matter. Also, how much time is the person spending with their gun? Somebody who's got a lot of violent fantasies or suicide thoughts might be spending increased time with their gun. Might be practicing shooting, might be loading and unloading their gun. And taking those steps and really spending a lot of time with their gun could be a sign and is likely a sign that there might be something going on that increases their risk. Similarly, these violent fantasies that people might have associated with the gun. How much time are people spending really fantasizing, writing out their fantasies about how they might use their gun for violence? Also, what's the psychodynamic attachment to the gun? There is a lot that can go in to the psychological psychodynamic attachments with firearms. We certainly see this in individuals who, for example, who are in the law enforcement community or who have military training, who might think that they're less of a person if their gun is removed. And so they may not be a risk right now and removing their gun might elevate their risk. And so we have to really think carefully about psychodynamic attachments to guns and work with individuals around that. Also, hobby and recreational use can be really important to people. And so what does that mean to take that away from them? And we have to be careful about any of our own political views about firearms. That is not something that should enter into this assessment. What we really should be looking at is, is this individual somebody for whom firearm related risk is high and for whom risk mitigation would include removal of that firearm or helping them to get themselves to a safer place. Their peer and family views will also be relevant in that conversation. So now that we've got that understanding of thinking about the aspects of firearm related risk assessment, which can be both basic and then nuanced, we wanna discuss risk-based gun removal laws. And then the question of restoration of firearms rights related to individuals with SMI who may have had their firearms removed. Well, what are risk-based gun removal laws? Many of you may have seen this in recent media reports as being proposed by various politicians. Many states have enacted these types of laws, but let me just tell you what they are. They are known by different names. Some states call them gun violence restraining orders. Others call them risk-based gun removal laws. Others might label them dangerous persons firearm seizure laws or ERPOs. Some states call them extreme risk protection orders or even the term red flag laws have been used. The premise of risk-based gun removal laws is that persons with firearms may be dangerous for many reasons. It may be unrelated to mental illness, but yet they may pose a danger. And people around these individuals might see them as becoming increasingly dangerous, but not know what to do or not have any legal way of doing anything to have that firearm removed from that potentially dangerous individual. So citizens concerned about persons presenting with imminent danger related to their firearm, have premised on this idea that they should be able to have a remedy to have that person's firearm removed. Imagine if you're in a neighborhood and you see your neighbor waving around their firearm and being increasingly angry about some situation at work. There may be a cause to want that person to not have that firearm, but because of important second amendment rights, without a basis to remove those laws, to remove those guns, there may not be an availability to do so. So many states have enacted these risk-based gun removal laws. The early adopters that these were based on were Connecticut, Indiana, Washington, and California, which allowed individuals, again, who had concerns about acute risk to call police or notify court. And what the American Psychiatric Association has stated about these laws is that these are less stigmatizing because these laws don't require this to be based on mental illness. And when we know that most firearms violence is not attributable to mental illness, it's really important to keep that message strong and that still realizing that individuals may have acute moments where they're more at risk, unrelated to their mental illness or related to something in mental illness that may be going on for them, such as acute depression and suicidality. And so what happens is there can be a petition to the police or to court, and then an investigation regarding the threat to self or others that warrant immediate firearm removal by police as a safety measure. And so the way this works, and I'd like to acknowledge Dr. Reena Kapoor, who led a work group for the American Psychiatric Association Council on Psychiatry and Law in putting this together. But the typical framework that we see in these risk-based gun removal laws is that the individual reports the concern about firearm access to police or court, the police go and investigate the concern, and then the individual may be referred for a mental health evaluation. They may also be arrested if there's illegal behavior. They may have firearm possession and or purchase temporarily restricted if the imminent risk is found, after which a court hearing can be held regarding further restrictions of firearm access. Firearms, however, can be returned if criteria are not ultimately met at that court hearing. But if the criteria are met, the firearms can be restricted from that individual, usually for an additional period, such as a year. And that's how these laws typically work. The Indiana Code, for example, that was passed in 2006, talked about a warrant being issued to search and seize a firearm when an individual presented imminent dangerousness to self or others, and they either had a mental illness and had not been consistent with taking their medication or was subject of documented evidence that would give rise to a reasonable belief that the individual had a propensity for violence or emotionally unstable conduct. And again, what many people thought was positive about that law is that it was not solely hinging on mental illness as the strategy for public safety. A recent discharge from a mental health facility or being on medications for a mental illness alone do not, in that law, by themselves, equal dangerousness. What the data shows for these states that have enacted these laws is that most firearms are removed related to suicide concerns by others. So it is seen as a mechanism to help reduce suicide risk. Calls have usually been made by acquaintances or family members who have increasing concern about the individual. And that, although it's not gonna solve all the problems related to firearms-related violence, this is seen as a public health approach that may be one angle to reduce firearm-related mortality and give due process rights still to individuals who, due to Second Amendment, feel that it's important for them to have their firearms. The advantages, again, of the risk-based gun removal laws are that they focus on dangerousness as a whole rather than diagnosis, and that there are registries that focusing on purchasing, whether an individual can purchase a firearm. However, at the time of purchase, there may not be a crisis. So you may have somebody that's had a gun in their possession for 20 years. They've been fine. Now they're suddenly acutely depressed and suicidal. And these laws allow action at the time of a crisis. They supplement legal options for mental health professionals. Mental health professionals may not be named in these bills as the people that can remove the firearms, but the mental health professionals, like yourselves, can actually help family and friends who will have increased leverage to persuade patients to voluntarily surrender their weapons. And you can help family and friends know that these laws exist to help them get those firearms removed, or to actually say, look, I don't wanna have to go to court or go to the police. If you voluntarily surrender your gun, it may be easier. It can provide a way to reach individuals who do not seek psychiatric assistance, but for whom suicide or violence risk might otherwise go undetected. So in other words, it allows for that public health prevention strategy. Generally, what we say in terms of guidance for psychiatrists and other practitioners is that we have to assess a patient's risk. We always have to assess whether hospitalization or some kind of emergency assessment is gonna be needed first. If these firearm removal laws exist in the state, then a family or friend could be encouraged to take temporary possession of the weapons or to contact police for removal of that firearm. Or the clinician can consider emergency exception to confidentiality to ask the police directly to intervene and have firearms removed if they come across a patient for whom they think the firearm should be removed. If clinicians are not specifically named in the bill, in the laws allowing that communication to occur, there could be the emergency exception to confidentiality that allows that direct communication to police if suicide risk is at play. If violence risk is at play, there may be other laws that allow notification to police. Risk-based removal of guns does not confer immunity from liability for breach of confidentiality, however. So we have to really attend to when we are letting others know about an individual's firearm and think about and perhaps consult with risk management. It's always better if patients voluntarily disclose information and that we have justification documented if there was a breach of confidentiality, that there was an emergency exception or that there was a breach of confidentiality because of other duties, such as the duty to protect third parties from harm when there may be violence. From risk management perspective, you want to ask yourself, can the gun be removed? If so, who will be removing it? Where will the gun go? Will it be retrieved? Can you get callback confirmation from the patient or the patient's family that the gun was removed? How willing is the patient to relinquish the gun? If they're not willing, why? Does that increase the risk and maybe lead to a different decision like hospitalization until this can get sorted out? Where are any weapons stored so that you get all of them? Are all guns removed or any hidden elsewhere? Does having a gun ever decrease risk or illness? For example, if that individual really has some attachment, is there a reason why having the gun can decrease their risk because you're not escalating their sense of shame? But that's something you really have to think about in your clinical assessment. And what is the role of firearm safety, education and counseling, which I think has a very important role. And I think the work we've done is really recommended that you continue to counsel your patients about firearm safety and what we do know about the risk of increased suicide and violence amongst firearm owners. The framework for firearm limitations related to persons with serious mental illness was something also that was put together as a resource document by Dr. Grace Lee in 2020 that's available to the public. This American Psychiatric Association resource document asked the question of what do I do if my patient asked for their gun to be restored if it's been removed? And remember there is a second amendment general right to bear arms. However, there can be disqualifying conditions or prohibitors for the purchase and transfer of certain firearms, such as if the person's had felony convictions, domestic violence, restraining orders against them or adjudications like civil commitment pertaining to mental illness or guardianship for that matter. And then there also can be these post removal related to a risk-based gun removal as I've already explained. So there's many reasons why people might be disqualified from purchasing or transferring firearms, or having, and there may be reasons why guns have been removed, but then there may be the request to have guns returned. So when the patient asks, doctor, can I have my gun back? What are some general considerations to think about? First of all, if they're asking you to write a letter, you wanna make sure that you have knowledge about the subject and have time to take this on and understand what your resource limitations might be to be able to take on this task. Remember, there is no shield from liability for the letters that are written that indicate that an individual can have their gun back. So you may wanna limit the scope of your response. You also may wanna think about the therapeutic relationship when a patient is really pressuring or really wants a letter saying that they can have their gun back, you want to handle that delicately if you don't feel comfortable writing that gun, that letter. And there's no obligation that you have to write that letter. So you might want to consult liberally before you engage on that, in that activity. However, if as a clinician, you choose to write a note for the patient that says something related that they would use then to promote having their firearm restored to them, you want to consider a few different options and approaches. One is writing a very narrow statement, basically just saying, this is my patient and they're currently in treatment for whatever they're in treatment for, and their symptoms are currently stable. In that kind of narrow statement, you're not making any risk prediction or risk analysis. You're just stating the facts. The patient or the client can then take that letter to the decision maker about whether their firearm is restored and use that as they see fit. You could write a more broad statement with a more complete historical and current analysis, including a risk assessment, but be sure you would want to make sure that you acknowledge the limitations of that risk assessment, including that that risk assessment cannot take into account future changes, such as if the patient becomes depressed again, or they have a divorce or something happens in their life that puts them at greater risk. You wouldn't want to write a letter that says that they can have their gun back and that they will forevermore never be at risk again. That would be something that we couldn't predict. So you really want to be careful about the limitations of what you can say, even when you're making a broader statement. So in summary, firearms and mass violence are rare events, fortunately, even though we hear about them in the media, and we may have false perceptions about them. However, firearm risk assessment is important when treating persons with SMI, especially as we're thinking about suicide. But violence can occur even though it is a rare risk. Risk assessments related to firearms can be critical in overall risk assessment activities. Considerations regarding firearm risk increasing with co-occurring substance use, criminal histories, impulsivity, anger, and histories of childhood adverse events are really important to think about, as all of those may increase risk even more than the SMI. Risk-based gun removal laws are emerging and have emerged in many states and may help provide clinicians with one additional tool to help leverage gun removal in those situations where you may see that your patient or client is at greater risk. And psychiatrists and other practitioners working with persons with SMI should be familiar with firearms risk assessment and risk management. And I hope that this presentation today helped familiarize yourself with that. So thank you for your attention. Thanks so much, Dr. Pinals. Really interesting, useful presentation on such an important topic. Before we shift into Q&A, I do want to take a moment and let you know that SMI Advisor is accessible from your mobile device. You can use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and you can even submit questions directly to our team of SMI experts. You can download the app at smiadvisor.org forward slash app. So it looks like we have a few questions that are beginning to come in. So we have one, Dr. Pinals, asking, what's the risk level of someone with a mental illness who isn't taking their medications compared to someone without a mental illness or someone with mental illness who has been taking medication? How do we think about that as a criterion for assessing risk? I think that's a great question. In general, where somebody presents risk that is related to mental illness, non-adherence to medication can increase that risk. But you'd have to really understand what medication is it that the patient is not taking, what symptoms is it trying to treat, why are they not taking their medication. So I would say that it should set off a further discussion with the patient to understand what is going on with them that is making them not take their medicine and then also are symptoms emerging that we need to be worried about. Non-adherence to medication can increase risk generally. Whether it increases also the risk specific to firearms is another question too, because if it's an individual that has no access to firearms and no interest in firearms, then obviously that's kind of a separate issue. Great. Thanks so much. We have a second question that is about less imminently lethal forms of weapons that might be used like knives or ropes. How do you think about those when you're assessing someone's risk of violence when you've mitigated some of the other risks by limiting access to firearms? Yeah, I think that's also a really great question. I mean, as a forensic psychiatrist, I've done a lot of evaluations of people where they've been arrested on charges, say, of assault and battery with a dangerous weapon. And the dangerous weapon, by law, can be anything other than your bare hands or your bare feet. So it could be a shoe, it could be, I saw one with a sandwich when a man threw a sandwich at his father. I saw, but then you also have knives and bats and ropes, as the questioner asked. So, when we look at the data and the research, looking at aggression broadly, and what is a weapon broadly, people may think differently about different types of weapons. So I think that's one of the first things you have to think about. I mean, there's going to be things like frying pans and knives are ubiquitous, and those are unfortunately commonly used in domestic sorts of violence situations. And you're not going to be able to restrict access to frying pans and knives. So, I mean, if you have somebody who's under increased monitoring or support with SMI because of significant functional impairments and risk-related behaviors, then there may be ways to limit access to some of those things, or at least have staff around them to help support their success and non-use of those items. At the same time, I think what's really important is the basic risk assessment. You know, really understanding what is going on with this patient. Are they having increased in psychotic symptoms? Are they increasingly agitated or impulsive? Are they engaging in substance use where they may be more likely to be impulsive? That is where you're going to want to focus your risk assessment, because any one of those other weapons could be used when symptoms are emerging. And so you really want to look at the person's total symptom picture and their history to formulate a plan that will mitigate risk the best it can, knowing that the idea of some type of weapon can be available broadly. And so we want to mitigate risk by other means, making sure the symptomatic patient is stabilized on medication, making sure social supports are as strong as they can be, helping people express their frustration and anger to understand why they're getting, you know, to understand what's making them upset and try and address that. Great. Thank you so much. We have a question that's following up on your discussion about kind of visibility in the media. There have been obviously so many episodes of shootings that receive a lot of media attention. And, you know, what kind of advice do you have for clinicians to communicate with their patients if they're asking about it with other clinicians or even with the media when they're approached about this issue? Well, one thing I would say is that we want to really be careful about not overstating things that might be overstated in the media. I mean, we know that serious mental illness does not account for most of the mass shootings that are reported. There may be other things going on for individuals, disgruntlement, anger, other things that may be going on. But serious mental illness is so heavily stigmatized that this is one of our biggest challenges, to try not to have people automatically assume that individuals with SMI are at risk of mass shootings. So that's one thing that I would suggest that we do. The other thing is, you know, I think it is important for people working with individuals with serious mental illness to get some kind of baseline assessment of risk, to understand what is going on for this individual and what is going on with stressors, and to continue to support them and treat them in a way that's holistic. So that if there are moments when there may be more crisis or more risk, that we can help anticipate that, help anticipate how to build coping strategies that are more pro-social and help people work with their symptoms of mental illness so that nobody gets hurt along the way and that we reduce the risk of suicide. So I think it's that sort of rare but real conversation that you have to have with people. I like that phrase because I think you can help people understand these are rare risks, but we don't want to miss something if we can help. And that includes talking to family members as well, understanding that person's history, and helping support them so that if they do have concerns, also if this is a person that does have periodic crisis that involves some aggression or violence, you know, what's the crisis plan? What's the safety plan? What's the number that they call if there's an emergency? Is there a local crisis line that they can use that will bring supports to that person? You know, so building in safety planning is going to be important for patients that do have chronic risks. Great, thank you. Perhaps just sort of building on that point with one last question. I mean, you mentioned these risk-based gun removal laws, which are, you know, which are fairly nuanced in how they approach risk assessment. There are also laws, or at least frequently discussions about laws, that might be less nuanced, prohibiting entire groups of people with mental illness from owning guns. And I'm just wondering if as part of the framework that you mentioned, the LEAD-EL framework or other frameworks, you know, how APA or other organizations are thinking about the broader prohibitions against gun ownership among people with mental illnesses? Yeah, that's a great question. I mean, we at the APA have done a lot of work writing position statements and resource documents about firearms and mental illness, and really trying to educate the public and ourselves about the fact that some of these registries, you know, some of the registry laws which do prohibit purchase of firearms based on an adjudication of mental illness, that's in the federal law, you know, so a civil commitment or a guardianship, for example, could put somebody, would put somebody on the list that they would be prohibited from purchasing, and states have been working to increase their ability to report that data so that when people look them up, they would see that. But a lot of that is, can be very, it's very broad and can be very stigmatizing and may not deal with the actual risk that the individual poses. And that's why some of the resource guides and position statements that we've talked about really focus on if, you know, developing laws that allow people to, society to deal with risk when it presents, rather than, you know, considering broad categories of people, like people with mental illness who, and then perpetually calling them at risk. That can be, that can be problematic, and although the federal law is pretty clear, some states have passed even broader laws that limit what persons with mental illness can have access to. So I think we have to be careful about you know, some of the, some of the problems that come with that in terms of, you know, everybody wants a safer society, but we want smart solutions to get there and not those that stigmatize persons with mental illness and would potentially reduce people's willingness to come in for treatment. Thanks so much. Again, really thoughtful and interesting note to end a great presentation. So I want to point people to a resource that SMI Advisor has available. If you have follow up questions about this or any other topic related to evidence-based care for SMI, our clinical experts are available for online consultations. Any mental health clinician can submit a question and receive a response from one of our expert teams. Consultations are free and confidential. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health to the opioid epidemic. Thank you again for joining us. Until next time, take care. Thank you for participating in today's free course from SMI Advisor. We know that you may have additional questions on this topic, and SMI Advisor is here to help. Education is only one of the free resources that SMI Advisor offers. Let's briefly review all SMI Advisor has to offer on this topic and many others. We'll start at the SMI Advisor website and show you how you can use our free and evidence-based resources. SMI Advisor's mission is to advance the use of a person-centered approach to care that ensures people who have serious mental illness find the treatment and support they need. We offer several services specifically for clinicians. This includes access to education, consultations, and more. These services help you make evidence-based treatment decisions. Click on consult request and submit questions to our national experts on bipolar disorder, major depression, and schizophrenia. Receive guidance within one business day. It only takes two minutes to submit a question, and it is completely confidential and free to use. This service is available to all mental health clinicians, peer specialists, and mental health administrators. Ask us about psychopharmacology, recovery supports, patient and family engagement, comorbidities, and more. You can visit our online knowledge base to find hundreds of evidence-based answers and resources on serious mental illness. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Harvard, Emory, NAMI, University of Texas at Austin, and more. Browse by key topics or search for a specific keyword in the search bar. Access our free education catalog to find more than 100 free courses on topics related to serious mental illness. You can search the education catalog by topic, format, or credit type to find courses that fit your needs. SMI Advisor also offers live webinars each month that let you learn about evidence-based practices and participate in live Q&A with faculty. Check out our education catalog often to find new courses and earn continuing education credits. For individuals, families, friends, people who have questions, or people who care for someone with serious mental illness, SMI Advisor offers access to resources and answers from our national network of experts. The individuals and families section of our website contains an array of evidence-based resources on a variety of topics. This is a great place to refer individuals in your care for information about their conditions. They can choose from a list of important questions that individuals who have SMI typically ask. SMI Advisor worked with experts from the National Alliance on Mental Illness to develop these important questions and many of the resources in this section. Watch videos on important topics around SMI, such as what to know about a new diagnosis. They can also find dozens of fact sheets, infographics, and links to other important resources. To access even more evidence-based resources for individuals and families, visit our online knowledge base. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Mental Health America, National Alliance on Mental Illness, and more. Browse by key topics and select view all to uncover a list of resources on each topic. SMI Advisor offers a smartphone app that lets you access all of the same features on our website in an easy-to-use, mobile-friendly format. You can download the app for both Apple and Android devices. Submit questions. Browse courses and access clinical rating scales that you can use in your practice with individuals who have SMI. SMI Advisor also created My Mental Health Crisis Plan, a smartphone app that helps individuals in your care to create a crisis plan. The app is available on both Apple and Android devices. It helps people prepare in case of a mental health crisis. They can make their treatment preferences known and specify who should be contacted and who should make decisions on their behalf. The app even guides individuals through the process to turn their crisis plan into a psychiatric advance directive. Thank you for your interest in SMI Advisor. Access our free education, consultations, and more on smiadvisor.org at any time.

Dr. Deborah Pinals

firearms

serious mental illness

SMI

risk assessments

firearm-related violence

suicide

gun violence

screening questions

risk-based gun removal laws