THE PROGNOSIS

Mental illness is just one of many factors in why someone might open fire. 

But talking about the El Paso and Dayton tragedies in a nuanced way isn’t exactly one of President Trump’s strong suits. He largely blamed mental ailments for being the root cause of mass shootings, while backing away from an initial tweeted call for expanding background checks — a framing that only fanned the political flames around the issue of gun violence. 

“Mental illness and hatred pulls the trigger, not the gun,” Trump said yesterday, condemning the massacres at a Walmart in Texas and a strip of bars and restaurants in Ohio that left a total of 31 dead and dozens more injured.

“We must reform our mental health laws to better identify mentally disturbed individuals who may commit acts of violence and make sure those people not only get treatment, but, when necessary, involuntary confinement,” he said.

Democrats and gun control advocates protested that Trump was too quick to blame mental illness and ignoring the troubling issue of gun accessibility -- and feeding into the stigma already experienced by people with schizophrenia, bipolar disorder, severe depression or other serious conditions. Authorities are investigating the El Paso shooting as a case of domestic terrorism, as the gunman is believed to have posted an anti-immigrant manifesto online just before the attack. It's unknown whether the shooter was mentally ill.  

“Contrary to what many Republican politicians are quick to suggest, this isn’t a problem of video games, ‘evil’ and mental illness,” Peter Ambler, executive director of a gun violence prevention organization formed by former congresswoman Gabby Giffords (D-Ariz.), wrote in a CNN op-ed.

2020 hopeful Sen. Cory Booker (D-N.J.): 

From Sen. Chris Murphy (D-Conn.):

David Hogg, co-founder of gun control advocacy group March For Our Lives, formed by students at Marjory Stoneman Douglas High School: 

Sen. Elizabeth Warren (D-Mass.): 

But here’s the bottom line: Not every mass shooter is the same. In fact, it’s exceedingly hard to identify who might be prone to carry out mass gun violence and what life factors led them there. Some shooters, such as James Holmes (who attacked a movie theater in Aurora, Colo., in 2012), were diagnosed with a mental illness. Others, such as 2017 Las Vegas shooter Stephen Paddock, had no known illness.

And the El Paso attack -- which was followed by the shooting in Dayton -- extended a series of at least five fatal attacks over the past year motivated by racial or religious reasons, my colleague Greg Miller reports.

Footage from vigils where mourners remembered the victims of the attacks in El Paso and Dayton:

These nuances — which are getting short shrift in the political conversation — are underscored in two recent reports from the FBI and the Secret Service looking at the characteristics of shooters. Both agencies found that mental illness is often — but not always — a factor in mass shootings.

  • The Secret Service report looked at perpetrators of 2018 attacks in which at least three people were killed. It found that two-thirds of attackers experienced mental health symptoms, most commonly related to psychosis and depression. Nearly half had been diagnosed with or treated for a mental illness.
  • The FBI, which examined the pre-attack behaviors of active shooters between 2000 and 2013, found that one-fourth of active shooters were known to have been diagnosed with a mental illness. In 37 percent of the cases the agency wasn’t able to determine if a diagnosis had been given.
  • Of those diagnosed with mental illness, 12 shooters had a mood disorder, four were diagnosed with an anxiety disorder, three were diagnosed with a psychotic disorder, and two were diagnosed with a personality disorder.
  • The FBI also found that mental health was the top stressor experienced by the shooters. Sixty-two percent experienced mental health stressors, while 49 percent experienced stressors related to financial strain and 35 percent experienced stressors related to their jobs.

But both reports stressed that even when mental illness is a factor, it’s just one piece of the whole puzzle. Mass shootings happen when guns and people with particular tendencies or challenges come together.

Professors Jillian Peterson and James Densley, who have studied the life histories of mass shooters with funding from the Justice Department, write in the Los Angeles Times that the vast majority experienced early-childhood trauma and exposure to violence at a young age. Additionally, most shooters experienced some kind of identifiable crisis in the weeks leading up to the attack and had studied the actions of prior shooters and sought validation for their motives.

And data shows far more crimes are committed by people with no mental illness.

“There is lots of data to support the conclusion that people with mental illness have somewhat elevated risks for violence,” Paul Appelbaum, former president of the American Psychiatric Association, told me. “But it’s also true that they account for a very small proportion of the overall violence in our society.”

Fewer than 5 percent of the 120,000 gun-related killings in the U.S. between 2001 and 2010 were carried out by people diagnosed with mental illness, according to the National Center for Health Statistics. Other researchers have estimated that fewer than 3 to 5 percent of crimes involve people with mental illness.

“Diagnosed mental illness is not a very specific predictor of violence of any type, let alone targeted violence,” the FBI report says. “In short, declarations that all active shooters must simply be mentally ill are misleading and unhelpful.”

That message is also coming from leading health provider associations, who have intensified calls for action on gun restrictions and warned not to make assumptions about the mental health of shooters after last year's attacks at a Pittsburgh synagogue, a country-music bar in California and a hospital in Chicago, our researcher Paulina Firozi wrote in December.

The American Psychological Association: 

The American Medical Association:

Cynthia Cox, vice president at the Kaiser Family Foundation:

AHH, OOF and OUCH

AHH: The president is considering options to take executive action to address gun violence in order to bypass lawmakers, Politico’s Gabby Orr reports.  What exactly the president is considering is not clear, but White House officials say Trump and Attorney General William P. Barr are “resolved” to act.

“Trump has increasingly relied on his executive authority to address issues that have stained his administration, including the gun violence epidemic,” Gabby writes.

The president has “abandoned previous efforts to address gun violence in the wake of mass shootings, in addition to proposing solutions — such as arming schoolteachers — that a majority of congressional Democrats have already declared dead on arrival," she writes. "It’s a pattern that some Republicans said they expect the president to follow once more, as he grapples with using executive authority without upsetting influential groups like the NRA or jeopardizing his support among gun rights advocates who helped elect him in 2016.”

— But there is potential for compromise on at least one idea for gun-control legislation, our Post colleague Amber Phillips writes. So-called red-flag laws could allow family members to request that judges temporarily block individuals who are mentally ill or may pose a risk to themselves or others from having a firearm.

It helps that there’s bipartisan support for such a measure. Sen. Lindsey Graham (R-S.C.), who has argued that it’s a practical solution to keeping firearms out of wrong people’s hands, announced yesterday that he and Sen. Richard Blumenthal (D-Conn.) plan to introduce a bipartisan measure to incentivize states to pass red-flag laws. In a statement, Graham said the president is supportive of the proposal.

Trump referred to these laws during his Monday remarks, saying the "the monster in the Parkland high school in Florida had many red flags against him, and yet nobody took decisive action. Nobody did anything. Why not?...[W]e must make sure that those judged to pose a grave risk to public safety do not have access to firearms, and that, if they do, those firearms can be taken through rapid due process. That is why I have called for red flag laws, also known as extreme risk protection orders."

"Many of these shootings involved individuals who showed signs of violent behavior that are either ignored or not followed up," Graham said in a statement. "State Red Flag laws will provide the tools for law enforcement to do something about many of these situations before it’s too late.”

According to the Giffords gun control organization, seventeen states and the District of Columbia already have red-flag laws in place. 

“One reason Republicans like this proposal is because it doesn’t create a federal law restricting gun access. It creates grants to help states set up these laws, and each state can adjust the restrictions to what it believes is best,” Amber writes. “Congress hasn’t passed a law limiting people’s access to guns in more than two decades, since it created a national federal background check system in 1993.”

OOF: The main pharmaceutical lobbying firm in Canada wrote a memo urging the Canadian government to act early to push back on plans by the Trump administration to eventually import lower-cost drugs.

A memo by Innovative Medicines Canada was drafted before the announcement last week from the U.S. government that it was taking steps that could eventually lead to the importation of some drugs from Canada, Reuters’s Allison Martell reports

In one early version of these talking points, the group said the Canadian government should not wait for drug shortages to respond to U.S. plans and suggested it prohibit all drug exports “unless otherwise permitted by regulation.” The documented added that “reliance on reactive measures after shortages occur may pose a risk to Canadian patients.” The group told Reuters in a statement an export ban is “not part of our current positioning shared with our members. That said, we believe the government has tools that could be used to prevent shortages.”

“The lobby group’s efforts so far suggest industry is eager to derail the Trump administration’s plan,” Allison writes. “IMC’s members include major drug companies based in the United States and abroad, and large-scale shipments of cheap drugs from Canada could lower their profits.”

OUCH: States are pushing back on an effort from cities to make way for a national settlement of opioid lawsuits. A hearing is scheduled in Cleveland today for the proposal by lawyers for nearly 2,000 cities and counties that would allow for all 34,000 towns, cities and counties to vote on settlement offers that would guarantee payouts for the voting communities but would mean they couldn’t bring any more lawsuits forward, the New York Times’s Jan Hoffman reports.

But a bipartisan group of 39 state attorneys general argue states should be the ones to help determine the settlement agreements. “Rather than myriad cities and counties, they contend, it is the states, through law enforcement and regulatory authority, that can efficiently wrest a high-impact national agreement,” Jan reports. “They maintain that this plan goes behind the backs of the states pursuing cases brought by their own attorneys general, who are elected or appointed. By contrast, local governments are using private lawyers, who work on contingency fees. The states also fear that the plan would corral money for the cities and counties that they should control.”

The cities and counties also want this plan to make up for what happened with the 1998 Big Tobacco settlement, after which a large part of the $250 billion payout deal between five cigarette manufacturers and 46 states “went to discretionary funds of state legislatures. Especially in the wake of the 2008 financial crisis, hefty amounts were redirected to balancing budgets and fixing potholes, rather than to local prevention and treatment programs.”

HEALTH ON THE HILL

— Sen. Rand Paul (R-Ky.) said he had a surgery to remove a part of his lung because of injuries related to a 2017 attack by his neighbor.

He said the procedure would “limit my August activities” but added that he is planning to return to Washington in September after the recess.

Neighbor Rene Boucher “pleaded guilty to attacking Paul and was sentenced to 30 days in jail. Paul has also filed a lawsuit against Boucher over the incident,” our Post colleague John Wagner writes. “Earlier this year, Paul traveled to Ontario, Canada, to have hernia surgery, which he said was also related to the 2017 assault.”

— Kentucky’s other senator, Senate Majority Leader Mitch McConnell (R-Ky.), was also briefly sidelined over the weekend. He fractured his shoulder and was briefly hospitalized after a fall outside his Louisville home, as our colleague Paul Kane writes.

“This morning, Leader McConnell tripped at home on his outside patio and suffered a fractured shoulder. He has been treated, released, and is working from home in Louisville,” McConnell spokesman David Popp said in a statement on Sunday.

— And here are a few more good reads: 

Health
Studies of mass shooters find a fraction have mental health issues, and there's little to no evidence for a link to video games.
William Wan and Lindsey Bever
TRUMP TEMPERATURE
The president expected to travel to Texas and Ohio in wake of shootings.
Politico
AGENCY ALERT
The CMS on Monday issued new guidance for states and Medicaid managed care programs to change up their Medicaid drug utilization review programs by the end of this year.
Modern Healthcare
MEDICAL MISSIVES
The United States recorded eight new measles cases last week, taking the total f...
Reuters
Health
“All it takes is one 2-year-old slobbering kid” to set off the next chain of infection, New York City’s health commissioner says.
Lena Sun
INDUSTRY RX
Known as “authorized generics,” in-house spinoffs of brand-name drugs quietly undermine the competition.
Kaiser Health News
Duodenoscopes have sickened hundreds of patients in hospital outbreaks. Now some experts are demanding the devices be redesigned or taken off the market.
New York Times
REPRODUCTIVE WARS
Alabama Attorney General Steve Marshall recommended the state’s abortion ban law should be granted a preliminary injunction.
AL.com
STATE SCAN
DAYBOOK

Coming Up

  • Stat hosts an online chat on vaccine hesitancy on Wednesday.
  • The Centers for Disease Control and Prevention hosts a seminar on “Genomics, Big Data and Data Science in Public Health” on Friday.
SUGAR RUSH

From The Post's Fact Checker: Has the Trump administration prosecuted a record number of firearm offenses?