WHAT IS ALREADY KNOWN ON THIS TOPIC

There is significant morbidity and mortality from gun-violence in the USA, with over 20 000 injuries and 9956 deaths resulting from firearms between the 1 January and the 1 October 2015.1 Individuals who have been involuntarily hospitalised are prohibited from possessing guns under US law. This exclusion fails to prevent those predisposed to angry and impulsive behaviour that have not been involuntarily hospitalised, from having access to firearms. This article argues that angry and impulsive behaviour carries an intrinsic risk of violence. Some offences, which may correlate with angry and impulsive behaviour, such as convictions for violent misdemeanours and driving offences, do not exclude individuals from possessing and carrying firearms in the USA. This paper highlights the issue of a potentially large number of individuals with significant risk factors for violence, who also have free access to firearms.

What this paper adds

• This paper challenges current gun restriction laws in the USA. It highlights a large group of potentially ‘high-risk’ individuals for violence, who have unrestricted access to guns. This is contrasted with a relatively low number of people who have been involuntarily hospitalised for mental disorders and thus excluded from gun possession.

• It proposes an expansion of restriction from gun access to those convicted of minor offences, which may correlate with angry and impulsive behaviour and therefore increase risk of violence.

Limitations

• It is uncertain how precisely self-reported angry and impulsive behaviour, measured by this paper, is associated actual risk of violence. This study did not attempt to examine completed acts of interpersonal violence.

• The paper relies on the assumption that individuals with self-reported angry and impulsive behaviour have a relatively higher number of previous convictions.

• A questionnaire was devised to measure angry and impulsive behaviour. The validity and reliability of this is uncertain.

What next in research

Research could focus on testing whether there is a link between self-reported angry and impulsive behaviour and gun violence. This could take the form of a prospective or retrospective cohort study where patients and general population controls are tested for these exposures and then followed up for violence, either using registry data (which has the advantage of longer follow-up times) or self-reported violence questionnaires (which has the advantage of capturing violence that does not lead to arrest or conviction).3

Do these results change your clinical practice and why?

The article makes an argument for revising US laws on gun restriction. It highlights that only a small number of individuals are unable to own guns based the legally sanctioned restriction of having been hospitalised involuntarily due to a mental disorder. In contrast, there are likely to be large numbers of individuals with significant risk factors for violence, such as impulsivity and substance abuse, who can access guns in an unrestricted way. The paper potentially impacts on clinical practice by reinforcing the importance of assessing for angry and impulsive behaviour in clinical risk assessment.