Mental Health Holds
Mental health holds can help people at risk of suicide or violence get into psychiatric care
A 5150 hold can bring someone at risk of harming themselves or others into mental health treatment, but should not be relied upon to prohibit them from accessing firearms.
In California, law enforcement officers and mental health professionals can place a patient on an emergency 72-hour hold, or “5150”, if, due to a mental illness, they are determined to pose a danger to themselves (DTS), a danger to others (DTO), or they are “gravely disabled” (GD).1 These holds are named after the part of California’s Welfare and Institutions code (section 5000 et seq.) covering the Lanterman-Petris-Short (LPS) Act, which regulates involuntary civil commitment in California. Though the law includes dangerousness as one of the criteria, 5150 holds are designed to connect people to mental health services, not to prevent community violence. A 5150 on its own does not trigger a firearm prohibition, so if there is concern for firearm-related harm, other interventions should be considered as an adjunct.
Mental Illness, Violence, and Suicide
Mental illness is the cause of relatively little interpersonal gun violence in the United States. Mass shootings, which are many Americans’ main concern about gun violence, are often assumed to be failures of the mental health system. However, researchers estimate that only a minority (perhaps 20%) of mass shooters have been diagnosed with a serious mental illness (SMI),2 and mass shootings comprise less than 1% of firearm deaths annually.3
Population studies have shown that people with SMI are somewhat more likely to commit violent acts than people without SMI, but the large majority are not violent towards others. Further, only a small proportion of violence that occurs in the general population can be attributed to serious mental illness alone; one frequently cited estimate is 4%. Most violence is attributed to other risk factors, such as substance abuse and a history of violent victimization.4 People with SMI are also more likely to be victims of violence than the general population.5
The association between suicide and mental illness, however, is much stronger. Almost half of suicide decedents have a diagnosis of a mental illness,6 although the majority of people with mental illness don’t die by suicide. Because firearms account for more than half of all suicides in the United States,3 clinicians who work in settings where they may encounter suicidal patients should consider firearm access when evaluating a patient who has a mental illness and risk factors for suicide.
Involuntary Psychiatric Holds and Firearm Prohibitions in California
The process of receiving involuntary psychiatric care may result in firearm removals and prohibitions at both the state and the federal level. Being placed on an emergency hold, being admitted to a psychiatric facility, and having a psychiatric commitment certified in court each affect a person’s right to have, own, or purchase a gun. Because of variations in the practices of local mental health systems and the resources available, these three events do not always happen in a specific order.
Emergency Psychiatric Holds
In California, a person can be placed on an involuntary psychiatric hold, or 5150, if, due to a mental illness, they are determined to pose a danger to themselves (DTS) or others (DTO), or if they are “gravely disabled” (GD), meaning they cannot provide for their own food, clothing, or shelter.1,7 Law enforcement and certified mental health professionals can place these holds, which are designed to get people with mental illness into treatment when they are unable to accept it of their own volition. Of note, psychiatric holds do not apply to people whose risk of dangerousness or grave disability is due to alcohol or drug use, dementia, intellectual disability, or antisocial behavior.
A 5150 hold itself does not confer a firearm prohibition but does allow for the temporary removal of weapons. If the 5150 is placed by law enforcement and the person is found to “own, have in his or her possession or under his or her control, any firearm whatsoever, or any other deadly weapon,” that weapon can be taken into custody. Law enforcement can petition for the weapon to be permanently removed, on the basis that returning the firearm (or other weapon) “would be likely to result in endangering the person or others.”8 However, if the court grants this petition, it does not affect the individual’s ability to own or purchase other firearms.
If a person detained on a 5150 is officially admitted to a designated inpatient facility for DTS or DTO, California law prohibits them from purchasing or owning a firearm for the next five years.9 Designated facilities are inpatient psychiatric hospitals specially certified by each county, and generally do not include emergency departments, crisis services units, or medical hospitals. Additionally, someone who is admitted for dangerousness twice within a one-year period is prohibited indefinitely under California law.10
People who do not meet criteria for admission may be released from their 5150 after an evaluation and will not incur a firearm prohibition. Additionally, people who are admitted on a hold that is only for GD are not prohibited by a psychiatric admission.
Firearm prohibitions may also result from a commitment hearing. These hearings usually happen a few days into a hospital admission, and allow the patient due process for their involuntary detention. Their mental health hold is reviewed by a legal official, usually a judge or hearing officer. If the official finds clear and convincing evidence that the person meets criteria to be involuntarily hospitalized, they are considered to have been “committed to a mental institution.” This is one of the prohibitory criteria laid out in the Gun Control Act and triggers an indefinite firearms prohibition at the federal level.11 If a person’s hold is written only for GD, they would not be prohibited until this point in the process, as state-level prohibitions on admission are for dangerousness only.
If the judge does not certify their commitment and instead releases them, an indefinite federal prohibition would not ensue (though a five-year state prohibition from an admission for dangerousness might still stand).
Because of variations in each county’s system and practices, these court hearings may happen days or even weeks after the 5150 was originally applied. Many patients are treated and discharged before reaching that point, regardless of how ill or potentially dangerous they were on initial presentation. Those with more chronic psychiatric illness but lower potential for suicide or violence may be more likely to remain in the hospital until their hearing. Thus, the commitment hearing is not a particularly useful threshold in the mental health system for prohibiting dangerous people from owning firearms. A Florida study found that though nearly three-quarters of people with serious mental illness who died by firearm suicide had no mental health-related firearm prohibitions, more than half of them had been on a non-disqualifying emergency psychiatric hold.12
Other Mental Health-Related Prohibitions
An inpatient hospitalization is not the only way a person in the mental health system can become prohibited from owning firearms in California. People who are placed on a mental health conservatorship by a court or ordered to involuntary outpatient treatment (in California, under Laura’s Law13) are also prohibited. Through the criminal court system, a person who is found incompetent to stand trial or not guilty by reason of insanity, or who is adjudicated as a mentally disordered sex offender, is also prohibited. These all fall under the criterion of “adjudicated as a mental defective” in the federal Gun Control Act (GCA).11 California follows these same criteria for state-level prohibitions.14
What You Can Do
If a clinician suspects that someone poses a risk of harm to themself or someone else and is not certified to file a 5150, they can involve someone who is able to, usually an emergency mental health provider or a law enforcement officer. That person will decide, particularly in cases of threats to others, if a psychiatric hold is merited. However, while the 5150 may result in temporary removal of weapons, it does not trigger a firearm prohibition at the state or federal level and should not be relied upon to remove firearm access in the long term.
If no one is available to write a 5150 application, physicians and other licensed staff who provide emergency medical care in general acute care hospitals can place a patient on a 1799 hold to detain the person for 24 hours. If the patient’s status does not improve, they may be evaluated for a 5150 once a professional is available. A 1799 does not include any provisions for firearm removal or prohibition.15
Thus, if ongoing access to firearms is a concern (e.g., the person’s suicidality or thoughts of harming others are expected to continue), the clinician should consider other methods of reducing access to lethal means. If the patient is willing to collaborate, safe storage or temporary transfer may be appropriate; if not, and there is an imminent risk, civil protective orders can be used as an adjunct to a mental health hold.16
Click to view references
- What role does serious mental illness play in mass shootings, and how should we address it? Criminology & Public Policy.
- Web-based Injury Statistics Query and Reporting System (WISQARS) [online].
- Mental illness and reduction of gun violence and suicide: bringing epidemiologic research to policy. Annals of Epidemiology.
- Perpetration of violence, violent victimization, and severe mental illness: balancing public health concerns. Psychiatric Services.
- Suicide rising across the US.
- Gun violence, mental illness, and laws that prohibit gun possession: evidence from two Florida counties. Health Affairs.
- Gun Violence Restraining Orders: Alternative or Adjunct to Mental Health‐Based Restrictions on Firearms?. Behavioral Sciences and the Law.
Learn more about potential interventions
If guns are kept in the home, storing them safely can prevent firearm injury.
Storing guns outside the home when someone is at risk can be lifesaving.
Protective orders can remove firearms from dangerous situations.
For more information, see these peer-reviewed articles.
Barnhorst, A., & Kagawa, R. M. C. (2018). Access to firearms: When and how do mental health clients become prohibited from owning guns? Psychological Services.
Swanson, J. W., McGinty, E. E., Fazel, S., et al. (2015). Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Annals of Epidemiology.
Traylor, A., Price, J. H., Telljohann, S. K., et al. (2010). Clinical Psychologists’ Firearm Risk Management Perceptions and Practices. Journal of Community Health.
Norris, D. M., Price, M., Gutheil, T., et al. (2006). Firearm Laws, Patients, and the Roles of Psychiatrists. American Journal of Psychiatry.
Simon, R. I. (2006). The myth of “imminent” violence in psychiatry and the law. University of Cincinnati Law Review.
Sherman, M. E., Burns, K., Ignelzi, J., et al. (2001). Firearms Risk Management in Psychiatric Care. Psychiatric Services.
Additional Resources on Mental Health Holds
Access to firearms: When and how do mental health clients become prohibited from owning guns?
A review of three clinical cases examining firearm legislation as it pertains to firearm ownership in people with mental illness.Peer-Reviewed Article
APA: Position Statement on Firearm Access, Acts of Violence and the Relationship to Mental Illness and Mental Health Services
The American Psychiatric Association's statement highlights the need to reduce morbidity and mortality related to firearm violence and lists its positions on numerous issues related to firearm ownership.External Resource
Care of the Psychiatric Patient in the Emergency Department – A Review of the Literature
A reference tool and guide, developed by the American College of Emergency Physicians (ACEP), evaluating best practices for management and care of psychiatric patients admitted to the emergency department.