We see it firsthand: red flag laws save lives

The Senate has reached an agreement on a bill to include support for the passage and implementation of red flag laws, properly known as extreme risk protection order (ERPO) laws, in states across the country. As a psychiatrist and an emergency physician in California, we are breathing sighs of relief. These orders fill a gap in our existing system – and when one of our patients falls through that gap, the consequences can be lethal. 

These civil orders are designed to prevent access to firearms by someone at imminent risk of harming themselves or others. They don’t require that a crime has been committed, or any mental health evaluation. If a judge determines a person to be at substantial risk of causing harm, their guns and ammunition can be temporarily removed, and new purchases can be blocked. 

Why isn’t this addressed by our current system? In most cases of mass shootings, the threats preceding them don’t constitute a crime, much less one that would result in a firearms prohibition. And though it seems incomprehensible that someone with excellent mental health would kill schoolchildren, most people who commit mass shootings don’t do so because of a psychiatric disorder. This gap between the criminal justice system and the mental health system often means that angry young men with violent revenge fantasies, white supremacist ideologies, or hatred for women can legally purchase semiautomatic weapons and all the ammunition they want. 

Most of these shooters do, however, exhibit warning signs, and nearly one-third of public mass violence is explicitly threatened before it happens. Persons considering suicide often exhibit warning signs, too. This is where extreme risk protection orders can fill the gap. 

In our practice, we see this often. Here’s a hypothetical case that reflects our real experience. A man comes into our ED with alcohol on his breath, saying that he wants to die and take other people with him. We put him on a psychiatric hold to evaluate his mental health. We hear about his recent divorce, the loss of his job where he hates his coworkers, his difficult relationship with his child, and the guns he has at home. We determine he is at risk of harming himself and potentially others in his life. But, when he wakes up in the ED the next morning, he claims his suicidal thoughts were just due to the alcohol, and that he is fine now. 

Alcohol abuse is not a mental illness for which we can hospitalize someone against their will, and he has not committed a crime. Without the option of an extreme risk protection order, we have to let this man go home to his guns, his alcohol, and his rage, fully aware of the harm he might soon cause.   

Situations like these are why we helped to get an ERPO bill passed in California. That law emerged, in part, due to a knowledge that psychiatry and emergency medicine share with law enforcement – there are dangerous people who make known their intentions to commit violence or attempt suicide, but for whom, absent ERPOs, nothing can be done to separate them from the means to convert intention into action.  

The law that came into being has filled that gap in California and provided a model for legislation in 16 additional states. Due process requirements are observed every step of the way. Now, when we encounter a patient like the one we describe above, we can work to have a petition submitted and, if a judge approves it, help ensure that he won’t harm himself or anyone else.   

Our research shows that ERPOs have been used to intervene in many cases where mass violence was threatened or planned, and none of those threatened incidents has occurred. Other studies (see here and here) have shown that, in cases of threatened suicide, a life is saved for every 10 to 20 orders issued. That is a highly effective treatment for a potentially fatal condition. 

As physicians, we have many tools available to save lives. Extreme risk protection orders are one we wish were widely available to protect our patients and people beyond the emergency department who are in danger. 

Amy Barnhorst, MD is an emergency psychiatrist and the director of the BulletPoints Project. Garen Wintemute, MD, MPH, is an emergency medicine physician and the director of the California Center for Firearm Violence Prevention at UC Davis.