Firearm purchase restrictions for people with certain mental health conditions

Evidence Rating  
Expert Opinion
Evidence rating: Expert Opinion

Strategies with this rating are recommended by credible, impartial experts but have limited research documenting effects; further research, often with stronger designs, is needed to confirm effects.

Health Factors  
Decision Makers

Federal law requires licensed firearm dealers to conduct background checks of potential firearm purchasers’ records via the National Instant Criminal Background Check System (NICS). The system includes felony and fugitive status; history of diagnosed, serious mental health conditions; court restraining orders; misdemeanor convictions for domestic violence; unlawful drug use; and undocumented immigration status, all of which are federal criteria to prohibit firearm sales. States can pass laws with provisions that match those of the federal law; however, state officials may be unable to enforce federal background checks provisions if they aren’t included in state law. States can also expand restrictions on firearm purchases by requiring the collection and review of a broader set of disqualifying criteria (e.g., in-state criminal records of violent misdemeanor convictions, juvenile court records, and history of substance abuse or mental health issues) and applying such criteria to all firearm sales. Specifically, states can establish additional disqualifying criteria for people with certain mental health conditions, such as involuntary outpatient commitment, that disqualify them from being eligible to purchase firearms while also requiring that mental health records are reported to NICS. Background checks for broader disqualifying criteria can be adopted along with other efforts to strengthen background checks, such as universal background checks and regulations that require licenses to purchase or own firearms1, 2.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Reduced gun violence

Potential Benefits

Our evidence rating is not based on these outcomes, but these benefits may also be possible:

  • Reduced homicide

  • Reduced suicide

What does the research say about effectiveness? This strategy is rated expert opinion.

Firearm purchase restrictions for people with certain mental health conditions are a suggested strategy to reduce gun violence3. However, additional evidence is needed to confirm effects4.

Available evidence indicates that requiring additional background checks of mental health records can decrease firearm suicide and overall homicide rates more than checks that only include criminal history5. States that report mental health records to the National Instant Criminal Background Check System (NICS) have lower rates of firearm suicides than other states, but no difference in the rates of firearm homicides6. Increasing restrictions to keep firearms from people with certain mental health conditions is associated with decreases in firearm suicides, even after accounting for state variations in available health care resources7. A Florida-based study indicates that background checks which include mental health records may prevent violent crime, such as homicides and aggravated assault, by prohibiting firearm purchases from individuals with records of disqualifying mental health conditions8.

Overall, states that require background checks that include additional purchase disqualification criteria (e.g., certain mental health conditions, driving under the influence (DUI) convictions, domestic violence restraining orders, other misdemeanor convictions, etc.) appear to have lower rates of firearm homicides and suicides than other states9. It is unclear if background checks that include records of disqualifying mental health conditions can reduce mass shootings; there appears to be a weak association between serious mental health conditions and mass shootings10, 11.

Experts recommend expanding and refining legal criteria that prohibits firearm purchase, possession, and access to better account for potential threats and suicide risks, along with continued state reporting of firearm purchase disqualifying data to the NICS database6, 12, 13. Other recommendations include providing greater access to mental health services, funding crisis services for people with and without mental health conditions, and cautions against stigmatizing people with serious mental health conditions9, 11.

How could this strategy advance health equity? This strategy is rated inconclusive impact on disparities.

It is unclear what impact firearm purchase restrictions for people with certain mental health conditions may have on disparities in gun violence. Associating mental health with firearm violence may stigmatize people with ongoing or a history of serious mental health conditions11. A mental health condition is one of the risk factors for committing gun violence; however, firearm suicides or homicides among people with a serious mental health condition remains relatively rare16.

What is the relevant historical background?

The first gun control policy was passed by a European colony in 1619, which banned the sale or gift of firearms to Native Americans. This was a controversial policy because firearm trading was profitable and Native Americans were sometimes allies against colonial adversaries17. The addition of the Bill of Rights to the U.S. Constitution in 1791 included the Second Amendment, which states that, “A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed”18. The varied interpretations of the Second Amendment have shaped firearm regulations ever since it was ratified.

Through the early 1930s, there was wide variation in state gun laws: major forms of state gun policies addressed hunting, militia, and gun carrying restrictions, with less attention given to firearm sale bans17. The National Firearms Act was passed in 1934 to control firearm transactions and possession of unregistered firearms, in recognition of increased crime rates and public safety concerns19. Since then, federal firearm legislation has moved forward in regulating firearm owners and dealers, but there have still been gaps in gun laws. For example, the Gun Control Act of 1968 (GCA) created a federal firearm licensing system for dealers and prohibited firearm sales and possession for felons and other unlawful individuals; yet some restrictions were removed by the Firearm Owners’ Protection Act of 198619, 20. The Brady Bill in 1993 established a background check system for gun purchases21; however, loopholes remained that allowed prohibited purchasers to access firearms. Loopholes include incomplete background check databases with missing records and a lack of criteria to disqualify firearm purchases (e.g., recent conviction for a violent misdemeanor, a mental health condition that poses a risk to themself or others)2, 22, 23. Gun rights advocacy groups, such as the National Rifle Association (NRA) and the National Shooting Sports Foundation (NSSF), have been successful at lobbying against firearm regulations and encouraging states to pass preemption laws that prevent local governments from implementing local gun control policies21, 24.

Although the health impacts of firearms are well documented, Congress prohibited federal research dollars from being used for gun violence and injury prevention research from 1996-202025. In 2021, approximately 48,900 people died from firearm-related injuries in the U.S., including firearm homicides (43%) and suicides (54%). Firearm homicide and suicide rates have increased over time; 80% of total homicides and 55% of total suicides in 2021 involved a firearm26.

Equity Considerations
  • Who is at a greater risk of death by firearms in your community? How can background check laws help increase their safety?
  • What are objective, nondiscriminatory ways to enforce background check laws? Which organizations and entities are required to report mental health records to background check systems?
  • How do preemption laws impact your ability to enact firearm background check laws in your state?
  • Are there resources available for people with mental health conditions in your community? Are they affordable?
Implementation Examples

As of January 2021, 35 states and Washington, D.C. have laws prohibiting the purchase of firearms by people with a history of certain mental health conditions. The mental health-related prohibition criteria varies by state: 11 states adopted the same standards as the federal law (i.e., persons with an adjudicated mental health condition or a history of involuntary commitment to any mental institution), while 11 other states have narrower criteria (i.e., people with a history of commitment to a psychiatric institution). Some states apply a broader disqualifying criteria, including prohibitions against people with a history of voluntary commitment to psychiatric hospitals (California, Connecticut, Illinois, Maryland, and Washington, D.C.) and people ordered to attend outpatient treatment (Arizona, Michigan, Oregon, and Virginia)3.

The National Instant Criminal Background Check System (NICS) Improvement Amendments Act of 2007 (NIAA) created a federal grant program to incentivize states to report firearm-disqualifying mental health conditions and protection and restraining orders, along with other criminal history, to the federal background check data system. In fiscal year 2022, 16 states received grants.10, 14.

Most states prevent local governments from enacting firearm laws via state preemption legislation; as of October 2022, five states (Connecticut, Hawaii, Massachusetts, New Jersey, and New York) allow local governments to enact firearm laws15.

Implementation Resources

Resources with a focus on equity.

Everytown-State gun law strength - Everytown for Gun Safety Support Fund (Everytown). 2022 Everytown gun law rankings.

RAND-Firearm law database - Cherney S, Morral AR, Schell TL, Smucker S, Hoch E. RAND state firearm law database. Santa Monica: RAND Corporation; 2022.

GLC-Prohibition - Giffords Law Center (GLC). Firearm prohibitions.

JHCGPR - Johns Hopkins Center for Gun Policy and Research (JHCGPR). Reducing gun-related injuries and deaths.

US DOJ-ATF - U.S. Department of Justice (U.S. DOJ). Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF).


* Journal subscription may be required for access.

1 GLC-Prohibition - Giffords Law Center (GLC). Firearm prohibitions.

2 Everytown-Prohibition - Everytown for Gun Safety Support Fund (Everytown). Prohibit people with dangerous histories from having guns.

3 RAND-Mental health - RAND Corporation. The effects of prohibitions associated with mental illness. 2023.

4 RAND-Gun policy research - RAND Corporation. Gun policy research review.

5 Sen 2012 - Sen B, Panjamapirom A. State background checks for gun purchase and firearm deaths: An exploratory study. Preventive Medicine. 2012;55(4):346-350.

6 Vars 2022 - Vars F, Meadows B, Edwards G. Slipping through the cracks? The impact of reporting mental health records to the national firearm background check system. Journal of Economic Behavior & Organization. 2022;195:52-74.

7 Choi 2020a - Choi KR, Saadi A, Takada S, et al. Longitudinal associations between healthcare resources, policy, and firearm-related suicide and homicide from 2012 to 2016. Journal of General Internal Medicine. 2020;35:2043-2049.

8 Swanson 2016 - Swanson JW, Easter MM, Robertson AG, et al. Gun violence, mental illness, and laws that prohibit gun possession: Evidence from two Florida counties. Health Affairs. 2016;35(6):1067-1075.

9 Smith 2020a - Smith J, Spiegler J. Explaining gun deaths: Gun control, mental illness, and policymaking in the American states. Policy Studies Journal. 2020;48(1):235-256.

10 Silver 2018 - Silver J, Fisher W, Horgan J. Public mass murderers and federal mental health background checks. Law & Policy. 2018;40(2):133-147.

11 Skeem 2020 - Skeem J, Mulvey E. What role does serious mental illness play in mass shootings, and how should we address it? Criminology & Public Policy. 2020;19(1):85-108.

12 Swanson 2021 - Swanson JW. Preventing suicide through better firearm safety policy in the United States. Psychiatric Services. 2021;72(2):174-179.

13 Wintemute 2019 - Wintemute GJ. Background checks for firearm purchases: Problem areas and recommendations to improve effectiveness. Health Affairs. 2019;38(10):1702-1710.

14 US DOJ-Goggins 2016 - Goggins B, Gallegos A. State progress in record reporting for firearm-related background checks: Mental health submissions. U.S. Department of Justice, Office of Justice Program, Bureau of Justice Statistics (BJS). 2016.

15 LawAtlas-State preemption - LawAtlas. State preemption laws in 12 domains.

16 RAND-Ramchand 2021 - Ramchand R, Ayer L. Is mental illness a risk factor for gun violence? Santa Monica: RAND Corporation; 2021.

17 Spitzer 2017 - Spitzer R. Gun law history in the United States and Second Amendment rights. Law and Contemporary Problems. 2017;80(2):55-83.

18 CONAN-Second Amendment - The Constitution Annotated (CONAN). Second Amendment: Right to bear arms.

19 ATF-NFA - Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF). National Firearms Act (NFA).

20 US DOJ-Gun violence 2001 - U.S. Department of Justice (U.S. DOJ). Gun violence reduction: National integrated firearms violence reduction strategy. Appendix C. History of federal firearms laws in the United States. 2001.

21 GLC-Gun lobby - Giffords Law Center (GLC). The gun lobby.

22 Everytown-Loopholes - Everytown. Undeniable: How long-standing loopholes in the background check system have been exacerbated by COVID-19. 2021.

23 CAP-Parsons 2020 - Parsons C, Bhatia R. Dangerous gaps in gun laws exposed by the coronavirus gun sale surge. Washington, D.C.: Center for American Progress (CAP); 2020.

24 Montez 2020 - Montez JK. US state polarization, policymaking power, and population health. Milbank Quarterly. 2020;98(4):1033-1052.

25 APA-Weir 2021 - Weir K. A thaw in the freeze on federal funding for gun violence and injury prevention research. American Psychological Association (APA). 2021.

26 Pew-Gramlich 2023 - Gramlich J. What the data says about gun deaths in the U.S. Washington, D.C.: Pew Research Center; 2023.

Date Last Updated