The toll from gun violence at schools has only escalated in the 20 years since the jolting, horrific massacre at Columbine High.

By December 2019, at least 245 primary and secondary schools in the United States had experienced a shooting, killing 146 people and injuring 310, according to The Washington Post.

At least 245 primary and secondary schools in the United States have experienced a shooting — killing 146 people and injuring 310 — since the country's first mass school shooting at Columbine High School in April 1999.

Now, new Stanford-led research sounds an alarm to what was once a silent reckoning: the mental health impact to tens of thousands of surviving students who were attending schools where gunshots rang out.

A study has found that local exposure to fatal school shootings increased antidepressant use among youths.

Specifically, the average rate of antidepressant use among youths under age 20 rose by 21 percent in the local communities where fatal school shootings occurred, according to the study. And the rate increase – based on comparisons two years before the incident and two years after – persisted even in the third year out.

“There are articles that suggest school shootings are the new norm – they’re happening so frequently that we’re getting desensitized to them – and that maybe for the people who survive, they just go back to normal life because this is just life in America. But what our study shows is that does not appear to be the case,” said Maya Rossin-Slater, a core faculty member at Stanford Health Policy and faculty fellow at the Stanford Institute for Economic Policy Research (SIEPR). “There are real consequences on an important marker of mental health.”

The study is detailed in a working paper published Monday by the National Bureau of Economic Research. It was co-authored by Rossin-Slater, an assistant professor of health policy in the Stanford School of Medicine; Molly Schnell, a former postdoctoral fellow at SIEPR now an assistant professor at Northwestern University; Hannes Schwandt, an assistant professor at Northwestern and former visiting fellow at SIEPR; Sam Trejo, a Stanford doctoral candidate in economics and education; and Lindsey Uniat, a former predoctoral research fellow at SIEPR now a PhD student at Yale University.

Their collaborative research – accelerated by their simultaneous stints at SIEPR – is the largest study to date on the effects of school shootings on youth mental health.

The study comes as the issue of gun safety continues to stoke political wrangling and public debate. And the researchers say their findings suggest policymakers should take a wide lens to their decision-making process.

“When we think about the cost of school shootings, they’re often quantified in terms of the cost to the individuals who die or are injured, and their families,” Rossin-Slater noted. “Those costs are unfathomable and undeniable. But the reality is that there are many more students exposed to school shootings who survive. And the broad implication is to think about the cost not just to the direct victims but to those who are indirectly affected.”

A Driver for Antidepressant Use

More than 240,000 students have been exposed to school shootings in America since the mass shooting in Columbine in April 1999, according to The Washington Post  data used in the study. And the number of school shootings per year has been trending up since 2015.

Yet despite this “uniquely American phenomenon” – since 2009, over 50 times more school shootings have occurred in the U.S. than in Canada, Japan, Germany, Italy, France and the United Kingdom combined – little is known about the effects of such gun violence on the mental health of the nation’s youth, the study stated.

“We know that poor mental health in childhood can have negative consequences throughout life,” Schwandt said. “At the same time, children are known to show significant levels of resilience, so it really wasn’t clear what we would find as we started this project.”

The researchers examined 44 shootings at schools across the country between January 2008 and April 2013. They used a database that covered the near universe of prescriptions filled at U.S. retail pharmacies along with information on the address of the medical provider who prescribed each drug. They compared the antidepressant prescription rates of providers practicing in areas within a 5-mile radius of a school shooting to those practicing in areas 10-to-15 miles away, looking at two years prior and two to three years after the incident.

Of those 44 school shootings, 15 of them involved at least one death. The 44 shootings occurred in 10 states: Alabama, California, Connecticut, Florida, Nebraska, North Carolina, Ohio, South Carolina, Tennessee and Texas.

Researchers found a marked increase in the rate of antidepressant prescriptions for youths nearby, but only for the shootings that were fatal. They did not see a significant effect on prescriptions for youths exposed to non-fatal school shootings.

“The immediate impact on antidepressant use that we find, and its remarkable persistence over two, and even three years, certainly constitutes a stronger effect pattern than what we would have expected,” Schwandt said.

Meanwhile, adult antidepressant use did not appear to be significantly impacted by local exposure to school shootings.

Layers of Costs, More Unknowns

The researchers also analyzed whether the concentration of child mental health providers in areas affected by fatal school shootings made a difference in the antidepressant rates, and they drilled a further comparison between the prevalence of those who can prescribe drugs, such as psychiatrists and other medical doctors, and those who cannot prescribe drugs, such as psychologists and licensed social workers.

Increases in antidepressant rates were the same across areas with both high and low concentrations of prescribing doctors, the researchers found. But in areas with higher concentrations of non-prescribing mental health providers, the increases in antidepressant use were significantly smaller – indicating perhaps a greater reliance on non-pharmacological treatments or therapy for shooting-related trauma.

The researchers also found no evidence that the rise in antidepressant usage stemmed from mental health conditions that were previously undiagnosed prior to the shootings.

In totality, the researchers say the results in the study clearly pointed to an adverse impact from a fatal shooting on the mental health of youths in the local community. Furthermore, the results capture only a portion of the mental health consequences: Non-drug related treatments could have been undertaken as well.

“Increased incidence of poor mental health is at least part of the story,” Schnell said.

Though their analysis included only 44 schools and 15 fatal school shootings, Rossin-Slater noted how the trend of school shootings is growing. She believes the mental health impact found on the local communities they studied “can be generalizable to other communities’ experiences.”

That’s all the more reason why policymakers should consider the overall negative effects of school shootings, and how further research will be needed to gauge other societal consequences, the researchers said.

“Think of it as layers of costs,” Rossin-Slater said. And when it comes to evaluating gun violence at schools, “we think our numbers say, ‘Hey, these are costly things, and it’s costlier than we previously thought.’”

Stanford Health Policy’s Kathy McDonald — one of the nation’s leading experts in patient safety and health-care quality — has been named a distinguished professor at Johns Hopkins University, and will soon be leaving the Stanford Cardinal for the Hopkins Blue Jays.

McDonald, PhD, is the founding executive director of the Center for Primary Care and Outcomes Research at the Stanford School of Medicine and the Center for Health Policy in the Freeman Spogli Institute for International Studies (CHP/PCOR). She has spent 25 years at Stanford and says it’s tough to leave the Stanford Health Policy community, whose members are like family.

“CHP/PCOR has given me a community of close colleagues who care about each other and what we do together,” McDonald said. “And we’ve done a lot together over the years, much more than the usual academic products of grants, publications and courses. We have built a reputation for being ahead of the curve of health-system concerns. We also keep doing a fabulous job pushing the science envelope, and coming up with insights for everything from big policy to every day practice decisions, in the U.S. and abroad.”

McDonald soon heads East as the Bloomberg Distinguished Professor of Health Systems, Quality, and Safety. She will hold primary appointments in the Johns Hopkins schools of Nursing and Medicine and joint appointments in the Carey Business School and the Bloomberg School of Public Health, and affiliated with the Malone Center for Engineering in Healthcare. She will continue to explore what makes safe, affordable and high-quality health-care delivery systems, as well as the obstacles that prevent health organizations from achieving those goals.

McDonald told the Johns Hopkins University blog, the Hub, in a recent story that she intends to collaborate with faculty colleagues across the university and continue borrowing from other disciplines to optimize health-care delivery, just as she has done in her role at Stanford.

“All of us at CHP/PCOR owe Kathy an incredible debt,” said CHP/PCOR Director Doug Owens, who has worked alongside McDonald for more than a decade. “She helped found the centers, and we’ve benefited from her vision and extraordinary leadership for over 20 years. She is one of the top scholars in the nation in her areas of work, and her position at Johns Hopkins recognizes her exceptional accomplishments. We will miss Kathy greatly, but are thrilled with the opportunity she has to broaden her national leadership.”  

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For her PhD in health policy from the University of California, Berkeley, McDonald wrote her dissertation on diagnostic errors — an area McDonald believes is a critical blind spot of health-care providers. She was a member of the committee that issued a landmark report by the National Academy of Medicine, the medical arm of the National Academies of Sciences, which found that most Americans will get at least one faulty diagnosis in their lifetime. Despite dramatic improvements in patient safety in the last 20 years, the committee found, medical experts estimate that more than 12 million adults are misdiagnosed every year.

As Johns Hopkins pointed out in its release about her becoming the 46th Bloomberg Distinguished Professor, in addition to publishing more than 100 scholarly peer-reviewed studies and white papers, McDonald has published more than 40 government reports and developed tools for measuring patient safety and quality that have been used by private and public care providers alike. She was tapped by the federal Agency for Healthcare Research and Quality to create a series of reviews and seminal reports outlining practices for improving patient safety and health care quality, and also authored the Care Coordination Measures Atlas. 

Her research team also worked on a set of standardized health-care quality measurements called Quality Indicators for the agency, which can be used to analyze administrative data from hospitals to identify potential quality concerns and track changes over time.

Those Quality Indicators from the AHRQ were implemented at the Johns Hopkins Hospital in 2012. According to a case study published in May, McDonald and her team's Quality Indicators helped Johns Hopkins Hospital improve its postoperative ventilator procedures and reduce the incidence of perioperative pulmonary embolism, hemorrhage, and hematoma.

“Kathryn McDonald’s ideas have improved the lives of the patients, including here at Johns Hopkins,” said Paul B. Rothman, CEO of Johns Hopkins Medicine. “We’re thrilled to welcome her to Johns Hopkins, where she can help us continue to develop and innovate health care delivery, here and across the country.” 

McDonald is also the principal investigator of a project at the Society to Improve Diagnosis in Medicine that is addressing ways that a patient’s age, race and gender — particularly women, young adults and African-Americans — may contribute to errors in medical diagnoses and disparities in patient outcomes. And she’ll continue to examine how the growing time constraints on clinicians — conducting patient consults faster, logging results in EMRs sooner, keeping up with regulatory changes — are impacting patient safety as the shortage of health professionals sgrows larger each year in the United States.

In a study published last year in the American Public Health Association journal, Medicare Care, McDonald and her colleagues wrote that despite concerns about the impact of growing time pressures on clinicians and the delivery of health care, “scant evidence exists about types of time stress, the organizational factors that shape such stressors in routine care settings, and consequences for patients and practitioners alike.” 

Focusing on Quality of Care for Patients, Best Practices for Clinicians

“Kathryn McDonald is a pioneer in bringing systematic and evidence-based approaches to the study of health care delivery,” Patricia Davidson, dean of the Johns Hopkin’s School of Nursing, told the Hub. “She has a track record of collaboration and innovation across disciplines and will bring with her new insights into the best practices for measuring health care outcomes to ensure patient safety for all people.”

McDonald told the Hub she believes it’s important to look at health care from a patient-centered point of view, where it’s often the easiest place to spot trends.

“There's a shift happening right now,” she said. “More people are accessing different entry points for health care, and we need to think about their journey to staying healthy or dealing with a health crisis.”

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California vaccine laws are among the toughest in the nation, particularly since the state did away with the personal belief and religious exemption in 2015 following a measles outbreak that began in Disneyland. 

Governor Gavin Newsom signed a new law in September that gives the state stronger powers to reject suspicious medical exemptions for vaccines.

But both laws are complicated, and antivaccination parents and advocates continue to resist. Some mothers — most of them white, well-educated and affluent — refuse to vaccinate their children as they believe they should be the ones who make the medical decisions for their children; some parents don’t believe vaccines are safe.

Stanford Health Policy’s Michelle Mello, a professor of law and professor of medicine, writes in this Annals of Internal Medicine editorial that California’s experience is a cautionary tale about what happens when vaccination exemption laws have holes.

“The key lesson from California and beyond, therefore, is not that laws tightening vaccination exemptions are unhelpful, but that suboptimal policy design and political compromises may keep them from achieving all they can,” Mello writes in the editorial, which accompanies a wide-ranging assessment of exemptions from vaccination in California by Paul Delamater at the Carolina Population Center.

Delamater, an assistant professor of geography at the University of North Carolina at Chapel Hill, and a team at Yale University found that although the 2015 California law eliminating personal belief exemptions improved overall rates of vaccination in the state, its projected impact would be less than anticipated due to substitution of medical exemptions and other loopholes.

“Lawmakers should anticipate that antivaccination groups will mobilize to assist parents in identifying ways to get around new requirements,” Mello writes. In California’s case, the legislature had to go back to the drawing board to patch the holes, again confronting bitter resistance. Antivaxxers were so incensed by the new law that they threw blood on California senators during the final night of the legislative debate on Sept. 13.

“Avoiding repeated skirmishes requires getting it right the first time,” Mello writes. She recommends that laws narrowing vaccination exemptions include five key provisions:

1.     They should require that medical exemptions come from a pediatrician or family physician whom the child sees for regular care. 

“The physician evaluating whether a child has a medical condition that precludes vaccination should be someone who has been treating the child and is trained in a relevant specialty—not the anesthesiologist who lives next door or the physician hundreds of miles away who offers exemptions on the internet,” Mello said.

2.     They should limit the justifications for medical exemptions to valid, recognized contraindications to immunization.

3.     They should provide for review of medical exemptions by the department of health, as well as action against physicians who do not provide a specific and valid clinical rationale.

4.     The laws should clearly task the department of health — not schools — with reviewing exemptions.

5.     They should avoid grandfather clauses that allow children with existing conditions to forgo their vaccines. 

“Other states can also learn from what California did right,” Mello writes, such as jettisoning personal belief exemptions of all kinds and applying the rules to private schools and daycare centers as well as public ones.

California also makes public an expansive list of required immunizations and makes annual data on school-level exemption rates public.

“In the wake of the recent measles outbreak, state legislatures have been active in considering how to ensure that their laws are up to the challenge of preventing future outbreaks,” Mello writes in the editorial. “To be dispirited about the prospects for legal reform to help improve immunization rates is an empirical mistake. 

“The devil, as Delameter and colleagues show, is in the details.”