Garen J. Wintemute, MD, MPH; Veronica A. Pear, MPH; Julia P. Schleimer, MPH; Rocco Pallin, MPH; Sydney Sohl, BS; Nicole Kravitz-Wirtz, PhD; Elizabeth A. Tomsich, PhD
Financial Support: By grants from the Fund for a Safer Future (NVF FFSF UC Davis GA004701), The California Wellness Foundation (2014-255), and the Heising-Simons Foundation (2017-0447) and by the UC Davis Violence Prevention Research Program and the University of California Firearm Violence Research Center.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-2162.
Corresponding Author: Garen J. Wintemute, MD, MPH, Violence Prevention Research Program, Department of Emergency Medicine, UC Davis School of Medicine, 2315 Stockton Boulevard, Sacramento, CA 95817; e-mail, email@example.com.
Current Author Addresses: Drs. Wintemute, Kravitz-Wirtz, and Tomsich; Ms. Pear; Ms. Schleimer; Ms. Pallin; and Ms. Sohl: Violence Prevention Research Program, Department of Emergency Medicine, UC Davis School of Medicine, 2315 Stockton Boulevard, Sacramento, CA 95817.
Author Contributions: Conception and design: G.J. Wintemute.
Analysis and interpretation of the data: G.J. Wintemute, V.A. Pear, J.P. Schleimer, R. Pallin, S. Sohl, N. Kravitz-Wirtz, E.A. Tomsich.
Drafting of the article: G.J. Wintemute, E.A. Tomsich.
Critical revision of the article for important intellectual content: G.J. Wintemute, V.A. Pear, J.P. Schleimer, R. Pallin, S. Sohl, N. Kravitz-Wirtz.
Final approval of the article: G.J. Wintemute, V.A. Pear, J.P. Schleimer, R. Pallin, S. Sohl, N. Kravitz-Wirtz, E.A. Tomsich.
Obtaining of funding: G.J. Wintemute.
Administrative, technical, or logistic support: J.P. Schleimer, S. Sohl.
Collection and assembly of data: G.J. Wintemute, V.A. Pear, J.P. Schleimer, R. Pallin, S. Sohl, E.A. Tomsich.
Urgent, individualized interventions to reduce firearm access, such as extreme risk protection orders (ERPOs, colloquially known as “red flag” orders), provide a rapid, focused response when risk for imminent firearm violence is high. Studies to date suggest such interventions are most commonly used to prevent suicide and are effective. Authorizing legislation has often been enacted after public mass shootings but, to our knowledge, there have been only 2 reported cases of ERPO use in efforts to prevent mass shootings. California enacted the nation's first ERPO statute, which took effect in January 2016. The authors are evaluating that statute's implementation and effectiveness and are seeking to obtain court records for all 414 cases occurring in 2016 to 2018. Based on 159 records received thus far, this article presents an aggregate summary and individual histories for a preliminary series of 21 cases in which ERPOs were used in efforts to prevent mass shootings. Most subjects were male and non-Hispanic white; the mean age was 35 years. Most subjects made explicit threats and owned firearms. Four cases arose primarily in relation to medical or mental health conditions, and such conditions were noted in 4 others. Fifty-two firearms were recovered. As of early August 2019, none of the threatened shootings had occurred, and no other homicides or suicides by persons subject to the orders were identified. It is impossible to know whether violence would have occurred had ERPOs not been issued, and the authors make no claim of a causal relationship. Nonetheless, the cases suggest that this urgent, individualized intervention can play a role in efforts to prevent mass shootings, in health care settings and elsewhere. Further evaluation would be helpful.
Table 1. Characteristics and Outcomes of 21 Cases in Which GVROs Were Used in Efforts to Prevent Public Mass Shootings
Table 2. Summaries of 4 Representative Cases*
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In this video, Garen J. Wintemute, MD, MPH, offers additional insight into the article, "Extreme Risk Protection Orders Intended to Prevent Mass Shootings."
Crime Prevention Research Center
October 27, 2019
Counting the Unpredictable
With the link between mental illness and gun violence being hotly debated, mental health care professionals maintain they have little or no ability to predict who will become lethally violent. “...45 percent of the mass public shooters from January 1998 through June 2019 were seeing mental health care professionals within six months of their attacks.” (What type of gun control will actually make us safer? John R. Lott, Jr. President, Crime Prevention Research Center, Before the Pennsylvania State Senate Judiciary Committee September 24, 2019) While patients under direct treatment of mental health care experts cannot be accurately identified as potential killers, the authors do so by retrospective document review, counting “saves” attributable to Red Flag orders. With 38% of ERPO cases reviewed, 13% of those were counted as “saves” in prevention of mass murder. While the authors heavily caveat their ongoing work, the media and gun control advocates promote this work as proof that Red Flag laws work. While authors cannot held responsible for misinterpretation of preliminary results by partisan advocates, academic press offices rarely emphasize caveats in press packages provided under embargo until date of publication. Scrutiny of publications usually happens well after the news and social media have made such scrutiny a moot point.
Garen J. Wintemute, Veronica A. Pear, Julia P. Schleimer, Rocco Pallin, Nicole Kravitz-Wirtz, Elizabeth A. Tomsich
Violence Prevention Research Program, University of California Davis
October 30, 2019
Counting the Unpredictable--Authors' Response
As the commenter notes, we drew no inference of a causal relationship between the use of gun violence restraining orders and the non-occurrence of mass violence in the 21 cases we reported; the commenter is counting “saves,” not us. He appears to raise the larger question of the effectiveness of extreme risk protection orders (ERPOs). As we reported, three studies have found an association between use of ERPOs and reduced risk of suicide, with a number needed to treat of 10-20 for prevention of a fatality (1-3). These are very promising findings, and we look forward to further information on the outcomes of extreme risk protection orders in California and elsewhere.References1. Swanson J, Norko MA, Lin MH-J, et al. Implementation and effectiveness of Connecticut’s risk-based gun removal law: does it prevent suicides? Law Contemp Probl. 2017;80:179-208.2. Swanson JW, Easter MM, Alanis-Hirsch K, Belden CM, Norko MA, Robertson AG, et al.Criminal justice and suicide outcomes with Indiana’s risk-based gun seizure law. J Am AcadPsychiatry Law. 2019. Online publication ahead of print April 15. DOI:10.29158/JAAPL.003835-19.3. Kivisto AJ, Phalen PL. Effects of risk-based firearm seizure laws in Connecticut andIndiana on suicide rates, 1981–2015. Psych Serv Adv. 2018;69(8):855-862.
Wintemute GJ, Pear VA, Schleimer JP, et al. Extreme Risk Protection Orders Intended to Prevent Mass Shootings: A Case Series. Ann Intern Med. 2019;171:655–658. [Epub ahead of print 20 August 2019]. doi: https://doi.org/10.7326/M19-2162
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Published: Ann Intern Med. 2019;171(9):655-658.
Published at www.annals.org on 20 August 2019
Emergency Medicine, Endocrine and Metabolism, Fluid and Electrolyte Disorders, Nephrology, Prevention/Screening.
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