Every time the country is shaken by a tragic mass shooting and the loss of innocent lives, mental illness and its role in the actions of the mass shooter come under scrutiny.

Mental illness again became a central theme after the mass shooting in Maine on Oct. 25, 2023, in which records suggest that the shooter had a history of serious mental health issues. Months before the tragedy, the family of gunman Robert Card, as well as Army Reserve staffers, had contacted law enforcement expressing high levels of concern about his mental health and noting his access to guns.

Since 1999, 19 states along with the District of Columbia have passed legislation, commonly known as red flag laws, that allow law enforcement and other people in a person’s life to petition for removal of firearms when there are imminent safety concerns about a gun owner. However, reports suggest that this law is rarely used.

Maine, though, has what’s known as a yellow flag law. It requires reporting to local law enforcement that a person poses an imminent threat, but it then relies on the police to take the person into custody, order a mental health evaluation and request a court order to have that person’s guns removed. The yellow flag law was not used in Card’s case.

The relationship between mental illness and guns, and risk mitigation, is complicated. Specifically, there is no clear and uniform consensus on who should determine when to restrict access to firearms – should it be a psychiatrist, an independent forensic psychiatrist, a committee of psychiatrists or a judge? The majority of people with mental illness do not seek treatment.

In that light, it might make sense to mandate a psychiatric examination into the background check process for purchasing a gun. As severe mental illness can start at any point in life, will gun owners need periodic psychiatric assessment, akin to a vision exam for renewing a driver’s license? If so, who will pay for the visits?

I am a trauma psychiatrist who regularly deals with the outcome of gun violence, whether in victims or first responders. In my book “Afraid: Understanding the Purpose of Fear and Harnessing the Power of Anxiety,” I have examined mental health issues related to gun violence and the social consequences of mass shootings.

The term “mental illness” covers a wide range of conditions, and there are more than 200 diagnoses listed in the most recent version of the Diagnostic Statistical Manual of Mental Disorders, which is the gold standard for psychiatric diagnosis in the U.S. Mental illness includes diverse conditions like phobias, social anxiety disorder, post-traumatic stress disorder, hair-picking disorder, gambling disorder, schizophrenia, dementia, various forms of depression and personality disorders, such as antisocial personality disorder.

Mental illnesses are also very common: Nearly 1 in 5 people experience clinical depression during their lives; 1 in 5 people experience an anxiety disorder; 1 in 100 experience schizophrenia; and nearly 8 in 100 of the general population experiences PTSD. People with higher exposure to trauma, such as veterans and first responders, have higher rates of PTSD, up to about 30%.

So when suggesting that gun access should be restricted for people with mental illness, does that mean all of these conditions? Or just some, or some in defined circumstances? For example, should all veterans with PTSD or those with social anxiety disorder have their guns removed? Neither of these conditions is known to commonly impair judgment.

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