More than half of extreme risk protection orders in one state filed because of self-harm concerns

“Red flag laws” regarding firearms seemed to help protect patients with mental health issues from self-harm, researchers reported; however, other experts cautioned that such extreme risk protection orders (EPROs) should not be seen as a mental health intervention.

A 29-month descriptive study of EPROs in Washington state found that about 64% of ERPOs were filed because of concerns about self-harm, according to Ali Rowhani-Rahbar, MD, MPH, PhD, of the University of Washington in Seattle, and co-authors.

“Suicide attempts with a firearm are fatal in approximately 90% of cases…this is clearly relevant to clinicians who take care of patients at high risk for self-harm as well as their family members or those who live with such individuals,” they wrote in the Annals of Internal Medicine.

Under an ERPO, a petitioner can request restricting firearm access for individuals, or “respondents,” who pose harm to themselves or others, Rowhani-Rahbar’s group explained. Washington state enacted its ERPO law in Dec. 2016 and, since May 2020, 19 states plus the District of Columbia have enacted ERPOs or similar risk-based firearm restriction laws.

Not surprisingly, gun rights groups have lobbied hard against ERPOs, claiming that they “might negatively affect defensive gun use, hunting and recreation, and gun sales if firearms are denied to law-abiding citizens,” according to a RAND review.

The current study authors found that from 2016 through May 10, 2019, 237 EPROs were filed in their state — 67 were for concern of the respondent’s risk of self-harm, while 84 were for concern of the respondent’s risk of harm to both self and others and 86 were for concern of the respondent’s risk of harm to others.

In an editorial accompanying the study, Shannon Frattaroli, PhD, MPH, and Nathan A. Irvin, MD, MSHPR, both of Johns Hopkins School Of Medicine in Baltimore, called the findings “interesting,” and noted that they “suggest that ERPOs are being used as a response to different types of violence, and often for persons who have a history of dangerous behaviors that are associated with future violence.”

However, they emphasized that the inclusion of petitioner-reported respondents’ history for treatment of mental illness does not mean that EPROs are a mental health intervention.

According to the study, petitioner-reported prior diagnosis of a mental health condition and substance misuse for the respondent were seen in 40% and 47% of cases, respectively. Also, on the basis of petitioner reports, 39% of respondents had a history of an inpatient mental health encounter and 9% had a history of an outpatient mental health encounter only.

“Of all respondents, 62% had a history of suicidal ideation or attempt according to the petitioner,” Rowhani-Rahbar and co-authors stated.

Frattaroli and Irvin stressed that EPROs are supposed to be issued on the basis of dangerous behaviors, not mental illness diagnoses, although the latter was deemed the “best indicators of future violence risk” by the Consortium for Risk-Based Firearm Policy when ERPOs were being crafted.

“We urge readers to interpret the findings concerning respondents’ history of mental health treatment with caution, and encourage future researchers to include information about dangerous behaviors when collecting ERPO data and designing studies to evaluate the impact of ERPOs,” they wrote.

For an ERPO to be put in place, evidence in support of the petition is presented to a judge. If the latter finds in favor of the petitioner, an order is issued for the respondent to surrender their firearms, according to the authors. A full hearing must be held within 14 days of the original order, where both parties must appear before a judge, and a determination is made if the EPRO is to be granted for 1 year.

If the petition is denied, the firearms are released to the respondent, and the petitioner cannot refile the petition, although they can file a revision, reconsideration, or appeal.

If the EPRO is granted, the petitioner may also request renewal of the EPRO within 105 days prior its expiration, if they believe the respondent continues to pose a danger to self or others.

Rowhani-Rahbar’s group found that out of 39 counties in Washington, 16 did not have any EPRO filings during the study period. Of all ERPOs, 87% were filed by law enforcement and 81% were granted. Of these, three cases were terminated after 4, 6 and 7 months from the time they went into effect.

Most respondents were male (82%), non-Hispanic white (86%), and between ages 25 to 44 years (48%), they said.

They also reported that 641 firearms were removed from 64% of the respondents as part of the orders, with handguns as the most common type of firearm removed.

“Of the EPROs that were not granted, 56% were dismissed because the petitioner or both parties did not appear at the full hearing and 42% were denied owing to a lack of preponderance of evidence,” they explained.

The authors also noted that 24% of the respondents had a prior domestic violence perpetration while 37% had a history of arrest, conviction, or incarceration.

The courts ordered mental health evaluation in 30% of the cases, they stated, and 29% received treatment during the year after firearm seizure.

Study limitations included inconsistent filing of ERPO forms, missing information from forms, and the fact that the level of detail on petitions varied from jurisdiction to jurisdiction. Also, law enforcement records were not reviewed.

“Future studies similar to ours that examine the scope and reasons for filing ERPOs; characteristics of petitioners and respondents; and areas of improvements in the process of granting, serving, and enforcing ERPOs in other states will set the stage for subsequent evaluation of the effectiveness of these laws in reducing firearm-related injury and harm,” the authors stated.

Frattaroli and Irvin pointed out that the country is now “openly grappling with racism and police abuse of power…For those who are calling for reform, we suggest that the ERPO offers an example of a different role for law enforcement that may inform part of a comprehensive path forward,” as red-flag laws are “prevention oriented…require judicial oversight…[and are] more therapeutic than punitive.”

“The goal of ERPOs is to reduce the risk for lethality by temporarily removing firearms if violence is imminent,” they stated. “In most instances, no crime has been committed; no punishment is being sought, and as demonstrated in this article, many respondents actually received health care as part of the process.”

  1. Approximately 64% of extreme risk protection orders (ERPOs) were filed owing to concerns about self-harm, and suicide attempts with a firearm are fatal in approximately 90% of cases, according to a 29-month descriptive study of EPROs in Washington state.

  2. EPROs should not be seen as a mental health intervention, but they are “prevention oriented… require judicial oversight… [and are] more therapeutic than punitive.”

Shalmali Pal, Contributing Writer, BreakingMED™

The study was supported by the state of Washington.

Rowhani-Rahbar reported support from the state of Washington, the NIH, the U.S. Department of Justice, Arnold Ventures, and the city of Seattle.

Frattoroli reported being a member of the Consortium for Risk-based Firearm Policy that developed the ERPO recommendation. Irvin reported no relationships relevant to the contents of this paper to disclose.

Cat ID: 151

Topic ID: 88,151,281,585,730,192,151,925