State Reporting Requirements for Involuntary Holds, Court-Ordered Guardianship, and the US National Firearm Background Check System

IMPORTANCE: Firearm violence is a leading cause of death in the US. There is broad public agreement that individuals at high risk of perpetrating violence should not be allowed to purchase or possess firearms. The National Instant Criminal Background Check System (NICS) is a national system intended to stop firearm purchases or possession by prohibited persons, but there is heterogeneity in how states interact with and report data to NICS. OBJECTIVE: To examine variability in state requirements for NICS reporting for mental health prohibitions. DESIGN AND SETTING: This cross-sectional study in the US reviewed current statutes for all 50 states and the District of Columbia (enacted through the 2021 legislative session) regarding reporting mental health prohibitions to NICS or state systems. Data were analyzed from October 2022 to April 2023. MAIN OUTCOMES AND MEASURES: For each state, the following were recorded: reliance on Federal Bureau of Investigation vs state point of contact for NICS checks; regulation requiring or allowing reporting to NICS for 3 hypothetical cases; and details on reporting responsibility and time frame. The number of NICS listings for adjudicated mental health reasons was obtained, and state rates per 1000 population were calculated. To compare states, we developed 3 hypothetical cases of individuals with risk of firearm violence, whether possibly temporary (involuntary commitment for decompensated psychosis, or involuntary short-term psychiatric hold for suicidal ideation) or chronic and progressive (court-appointed guardianship for dementia). RESULTS: A total of 39 states required and 5 allowed reporting to NICS for court-ordered, involuntary psychiatric hospitalization. Thirteen states required and 5 allowed reporting to NICS when a court determines an individual is mentally incompetent to manage their affairs (with or without guardianship). Two states required NICS reporting for short-term emergency psychiatric holds. Five states and the District of Columbia had no legislation explicitly requiring or allowing NICS reporting in the 3 scenarios. CONCLUSIONS AND RELEVANCE: In this cross-sectional study of state laws, there was substantial heterogeneity in NICS reporting requirements and lack of clarity around processes. This raises questions about the ability of NICS to be used to block firearm purchases or possession by individuals with court-identified high risk of perpetrating violence toward themselves or others.