Liz Szabo, USA TODAY
In the two months since the Newtown, Conn., school shooting, lawmakers across the country have been grappling with ways to prevent gun violence, including proposals to prevent more mentally ill people from buying guns.
New York state's sweeping gun-control law requires mental health professionals to report the names of patients likely to seriously harm themselves or others.
A Maryland state task force also recommended a proposal- ultimately rejected by the governor - requiring psychiatrists, teachers and others to report people who threaten "suicide or serious violence" to authorities.
These sorts of approaches are unlikely to make a dent in the more than 11,100 annual gun-related homicides and more than 55,500 serious injuries, health researchers say.
That's because the proposals follow the same approaches in the country's current mental health reporting laws, which are failing on several levels, says emergency medicine physician Garen Wintemute, director of the Violence Prevention Research Program at the University of California-Davis.
Federal law prevents people from legally purchasing guns if they have been judged "mentally defective" or if they have been involuntarily committed to a psychiatric hospital, Wintemute says. Such patients are supposed to be reported to the National Instant Criminal Background Check System, and barred from purchasing a gun.
That casts a wide but porous net - identifying lots of people with mental disorders who are not violent, while often missing the few who do pose a significant risk, says Jeffrey Swanson, a professor at Duke University School of Medicine.
Research shows that most mentally ill people aren't violent, although they are more likely than others to become the victims of crime. Only 3% to 5% of violent crime is due to mental illness, says Paul Appelbaum, a professor of psychiatry, medicine and law at the Columbia University College of Physicians and Surgeons in New York.
In spite of horrific events such as Newtown, the nation's overall "problem of gun violence is not due to mental illness," Appelbaum says.
Andrew Arulanandam, a spokesman for the National Rifle Association, says the gun rights organization has always supported laws preventing dangerous mentally ill people from owning guns.
"People who've been adjudicated as mentally defective or a danger to themselves or a danger to others should not have access to firearms," Arulanandam says.
"We've lamented after some of these high-profile shootings, involving some of these violently mentally ill people, that there were numerous warning signs that went unheeded or that people ignored," he says. "If a procedure is being put in place where people who are mentally ill with violent tendencies are on the verge of doing something, and there is a reporting mechanism, that is a step in the right direction."
Even under the best of circumstances, however, current mental health requirements won't intercept every unstable person, experts say.
About 40% of gun sales are conducted by unlicensed, private sellers, such as at gun shows and on the Internet - sellers who aren't required to perform background checks, Wintemute says.
And while state records are vital to the background check-system, states aren't legally required to submit them, Appelbaum says. A report from Mayors Against Illegal Guns found that 18 states have submitted fewer than 100 mental health records since 1999. One state, Rhode Island, never submitted any records at all.
That report lists a wide range of reasons why states fail to report patients to the database. In some cases, states haven't put a system in place for tracking those involuntarily committed, says Richard Bonnie, director of the Institute of Law, Psychiatry and Public Policy at the University of Virginia.
In perhaps the most infamous failing of the system, a judge ordered Virginia Tech student Seung Hui Cho to undergo involuntary outpatient treatment. Cho's name was never reported to the database, however, allowing him to legally buy guns that he used to kill 32 people and wound 17 others in 2007.
Federal regulations define "mentally defective" to include people who have been judged incompetent, who have had a guardian appointed for them, who have been judged unfit to stand trial or who have been found not guilty by reason of insanity, Appelbaum says.
But judges and mental health officials sometimes disagree over who qualifies as "mentally defective," a term that is outdated, insulting and ambiguous, Wintemute says.
And even under ideal circumstances, the gun database would miss many disturbed people, Appelbaum says.
"Trying to identify who is likely to be dangerous is an inherently flawed and hopeless strategy," Appelbaum says.
Some unstable people may commit their first act of violence before ever encountering the mental health system or appearing in court, Appelbaum says. Psychiatric conditions such as schizophrenia typically often don't appear until young adulthood. Other patients are clearly ill, suffering for years without being able to find help, he says.
One-third of those with severe mental illness, such as schizophrenia, receive no treatment, according to the Substance Abuse and Mental Health Services Administration. Two-thirds of those with mild or moderate mental health problems also get no treatment.
Public spending on mental health has dropped by $4 billion in four years, Appelbaum says.
"The state of the mental health system in this country is really pitiful," Appelbaum says. "Most people would not even dignify it with the term 'system.' "
By the time someone's name is added to the federal database, the person may already have guns in the home, Wintemute says.
He commends California's law, which allows police or special agents to remove guns from the homes of people whose names have been newly added to the database. Thousands of guns have been collected this way, he says.
Indiana also takes a "common-sense approach," Appelbaum says. Indiana law allows police to seize the weapons of someone whose behavior suggests "a likelihood of committing violent acts," whether or not the person is mentally ill, Appelbaum says.
"What's likely to be the most helpful intervention of all is likely to be the one that we seem least able to consider, which is to reduce the number of guns in circulation in this country, particularly those weapons that seem designed to kill large numbers of people," Appelbaum says.
Some doctors say reporting laws such as New York's are unnecessary.
Psychiatrists already have a professional duty to protect both their patients and potential victims, says Liza Gold, a forensic psychiatrist at the Georgetown University School of Medicine in Washington. Psychiatrists who fail in this duty can be sued for civil liability.
Requiring psychiatrists to report on their patients - by revealing confidential conversations - could cause more harm than good, Gold says. Some patients may be afraid to seek help if they think their conversations will no longer be private.
"Once you break confidentiality," Gold says, "you often lose your relationship with your patient."