By Valda Crowder, M.D.
“There were no red flags,” said Jacksonville Sheriff TK Waters during a news conference about a mass shooting in which a White gunman killed three Black people and himself in a Dollar General store.
With the facts that we know now, it is worth counting the number of warning signs. Hopefully, we can learn by examining missed indicators that the shooter was a danger to himself or others.
The first red flag is the definition of a warning. In 2017, the gunman had been declared a danger to himself and/or others and held for 72 hours. According to Sherriff Waters, the shooter had a Baker’s Act Petition, the involuntary commitment law in Florida. This law is one of many state statutes that allow police, social workers, and family members to require a person to receive emergency mental health services on a temporary and involuntary basis for 72 hours.
In many cases, people come to an emergency department where they are evaluated at all times of the day and night. As an emergency medicine physician, I examine the mental and physical health of these patients. My colleagues and I determine patients’ risk of potential harm to themselves and others. If a patient is deemed a risk, our signatures uphold or enforce the 72-hour involuntary detentions. It also may extend the detention for multiple 72-hour periods that last weeks.
A second red flag and a good question for the next news conference held by Sheriff Waters is: What happened to the shooter after his 72-hour hold? To prevent the next shooting, journalists and officials need to ask: How does the mental health system in the Jacksonville community provide follow-up care to someone who has just been released from an involuntary commitment?
Is it possible that a person be involuntarily committed for 72 hours and in the 73rd hour buy a lethal weapon? The answer is yes in Florida. A person who has been declared dangerous in one hour can buy a gun in the next hour. How does this make sense?
At the opposite end of the spectrum from Florida is Pennsylvania. In the Keystone State, a patient who has an involuntary 72-hour commitment is subject to a lifetime ban on possessing firearms. Does this state law discourage people from seeking emergency mental health services? That is possible. There is no nationwide standard.
Having signed hundreds of involuntary emergency mental health petitions during my 30-year medical career, I have not seen any meaningful mental health care in 72 hours. Extensions of these commitments are common. Frequently the first petition is the start of lengthy inpatient psychiatric admissions that permit mental health teams to properly diagnose, treat and stabilize patients.
Mental illness is more common than diabetes in the US. According to the National Institute of Mental Health, serious mental illness is defined as patients who because of their mental illness have difficulty completing daily activities, such as self-care, keeping employment or housing.
When these commitments abruptly end after only 72 hours, these individuals are at high risk to themselves and others. Among the 10.4 million Americans who have serious mental illness, 35 percent of these patients or 3.6 million Americans have not received any mental health treatment in the last year. These patients are 3 times more likely to be a perpetrator of violence and they are 11 times more likely to be a victim of violence. With mental health treatment, the risks go away completely.
Problem solved. Not so fast. Our mental health system is difficult to navigate, poorly staffed and poorly funded. In the U.S., 60 percent of counties lack a single psychiatrist. In rural areas, 80 percent of U.S. counties do not have a single psychiatrist. In Clay County – home of the Dollar Store gunman, the mental health system is worse and the third red flag. According to a county report, there are 22 percent fewer licensed clinical social workers, 71 percent fewer marriage and family therapists and 58 percent fewer licensed psychologists compared to the average in Florida. In addition to the challenge of finding a therapist, people have trouble finding inpatient beds for patients who are seriously mentally ill. Clay County has 45% few adult inpatient beds than the rest of State of Florida.
To paraphrase Fannie Lou Hammer, whether you are a medical doctor or not you ought to know that we are all in the same bag. Gun violence is a threat to anyone’s family or community. We need to stop making excuses that there were no red flags, or that the gun was purchased legally. Let us look at the red flags that are staring us in the face. Let us create a meaningful national standard for the various involuntary commitment rules.
Valda Crowder, MD, MBA, is a board-certified emergency medicine physician who serves as medical director of emergency medicine at UPMC Community Hospital in Harrisburg, Pennsylvania, and is director of the Health Committee for Black Women for Positive Change.