The focus on mental illness in the wake of the Newtown, Connecticut, school massacre December 14 has left the mentally ill stigmatized, and at the same time ignored the fact that alcohol is connected to certain kinds of gun violence, especially suicide, ADAW has learned.

“One of the unfortunate consequences of the Newtown discussion has been the assumption that the problem of violence is a problem of mental illness,” said Paul Appelbaum, M.D., chair of the American Psychiatric Association’s Committee on Judicial Action. He noted that most people with mental illness never commit an act of violence, and in fact substance abuse is more of a risk. “But you don’t hear people saying everybody who drinks has no right to have a gun,” he told ADAW. Most frequently, the violence is directed at the drinker, in the form of suicide or suicide attempts, he said. But it is also implicated in intimate partner violence, especially murder-suicides. And the most lethal form of suicide is by firearm.

Alcohol and drug abuse are second only to mood disorders as the most frequent risk factors for suicidal behaviors, said Richard McKeon, Ph.D., branch chief for suicide prevention at the Substance Abuse and Mental Health Services Administration. In 2008, alcohol was a factor in about one-third of suicides reported in 16 states, he noted, citing Centers for Disease Control (CDC) data. “Having both a substance use disorder and a mental disorder, particularly a mood disorder, also has been found to increase suicide risk,” he told ADAW.

Guns are the most prevalent method of suicide in the United States. About half of the suicides in the United States in 2009 resulted from the use of firearms, said McKeon. “Psychological autopsy studies, other case control studies and ecologic studies have found that firearm access is a risk factor for suicide in the United States,” said McKeon. He noted that gun owners are no more likely than others to have a mental disorder or to attempt suicide. “Rather, the risk of a suicide death is higher among this population because individuals who attempt suicide by using firearms are more likely to die in their attempts than those who use less lethal methods,” he said.

There is a ban on federal gun research imposed by Congress, lobbied for by the National Rifle Association. So the CDC and other agencies have very little data they can share linking guns, alcohol and violence. But they can make some connections.

Disinhibitor

“Alcohol is a disinhibitor,” said Robert Freeman, Ph.D., health scientist administrator with the Division of Epidemiology and Prevention Research at the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The model that has the most consensus among alcohol researchers, regarding decision making, is that “when you’re intoxicated, the most salient cues are right in front of you, and you pay less attention to distant cues,” Freeman said. “If the cue right in front of you says, ‘Go,’ all the precautionary cues disappear.” This is known as the attention allocation model, and it is particularly important when looking at alcohol and aggression. “Drinking narrows your vision to what is right in front of you,” he said.

Alcohol does not increase aggression for all persons and in all situations, said Freeman. “But there are a lot of people out there with certain traits — lower levels of empathy, or higher levels of aggressivity, or lower levels of executive functioning, and when they drink, the executive functioning doesn’t rein in their impulses,” he said.

Little research

“I always thought someone should go through the guns and public health studies and pick out the studies that talk about alcohol,” said David Hemenway, Ph.D., director of the Harvard Injury Control Research Center and professor of health policy at the Harvard School of Public Health. “Clearly, drinking is a risk factor for being a shooter,” he told ADAW, adding that alcohol is also associated with student gun carrying. In addition, people who carry guns are more likely to be binge drinkers, he said. A 2001 study showed that households with a lifetime prevalence of alcohol abuse were twice as likely to experience gun violence.

But basically, very little is known about gun violence and drinking, said Hemenway. “We know nothing. Nobody has written this up well,” he said.

Suicides

One NIAAA researcher who is looking at the topic of suicide and alcohol is Mark S. Kaplan, Dr.PH., professor of community health at Portland State University. Guns play a prominent role in his research because the method is so lethal. For example, people who have attempted suicide but survived have said that they were happy to have survived, and even in the process of falling from a jump off a bridge, for example, regretted the act. But people under the influence of alcohol are not thinking clearly.

Kaplan is funded by a three-year NIAAA project on acute alcohol use and the means of suicide. He is using the CDC’s National Violent Death Reporting System (NVDRS), which includes reports on whether victims were intoxicated at the time of death.

There are about 30,000 gun deaths every year in the United States, and two-thirds are suicides, said Kaplan. His research analyzing the NVDRS has found that about 24 percent of the men and 17 percent of the women who died were intoxicated at the time of their deaths.

“There’s a strong relationship between alcohol use and the choice of method,” Kaplan told ADAW. Men who used firearms were 76 percent more likely, and women were 68 percent more likely, to be intoxicated than men and women who used other methods to commit suicide.

Kaplan said there are two theories for the connection between alcohol and suicide. One is that it is a form of behavioral disinhibition, and that people first intend to commit suicide and then start consuming alcohol to make the act easier. The other is that people binge drink and then, on impulse, commit suicide.

“The point we’re trying to make with our work is that alcohol appears to play an important role in the process of self-destruction,” said Kaplan.

“I’m in the injury field,” said Hemenway. “Alcohol is a risk factor for every injury you can think of.”

President Obama is calling for $20 million to expand NVDRS. For the CDC’s NVDRS, go to www.cdc.gov/mmwr/preview/mmwrhtml/ss6106a1.htm?s_cid=ss6106a1_w.

Bottom line

Alcohol reduces inhibitions and makes someone — who may be provoked — forget about everything except for what is in front of him. That may be a gun. Experts discuss the effects of alcohol on violence, as well as the need for more research.