Mass shootings result in widespread psychological distress and trauma symptoms for survivors and members of the impacted community [1]. Research demonstrates that following a mass shooting, higher rates of psychological symptoms (eg, depressive symptoms, increased feelings of fear, and decreased perceptions of safety) are found in the immediately affected community [2]. While there is emerging evidence suggesting that mass shootings may have negative mental health consequences that reach beyond local communities to broader populations through indirect exposure (eg, conversations, media exposure) [2], information about immediate effects of mass shootings on broader public well-being is nearly absent in the literature. One study showed that teachers who had increased exposure to school shooting–related media had increased experiences of secondary trauma [3]. Advancing understanding of indirect exposure and resulting mental health–related issues will inform future public health response.

There are several challenges associated with studying the effects of indirect exposure to mass shootings using traditional survey methods. Mass shooting events are unpredictable low-base rate events. Scheduled data collection of longitudinal or repeated cross-sectional studies may not align with when mass shootings occur, leading to excessively inefficient and costly survey operations. Furthermore, prolonged periods between exposure and data collection may lead to recall bias [4], reducing the quality of responses and the ability to make strong inferences. Recently, alternative study designs have been used to address these methodological challenges. For example, studies have analyzed the content of social media posts before and after mass shooting events to show increases in expression of emotions in the general population [5,6].

Data from crisis lines provide a unique opportunity to examine real-time data on the widespread psychological effects of mass shootings. Crisis Text Line (CTL) is a not-for-profit company that provides 24/7 confidential crisis counseling via SMS text messaging and WhatsApp. The majority of texters served by CTL in the United States are younger than 25 years (76% aged <25 years) [7]. CTL provides rich data specifically focused on mental health–related crises in the moments that they occur. Previous studies have used time series research designs with deidentified CTL data to analyze changes in the number and types of crises due to exposure to 13 Reasons Why on Netflix [8], celebrity suicide deaths [9], and Hurricane Florence [10]. These prior investigations collectively demonstrate that poignant events that have widespread coverage on various media outlets (including social media) have measurable impact on the larger corpus of individuals texting CTL.

In this study, we investigated CTL’s anonymized conversations related to firearm violence, including mass shootings, suicide, and other firearm-related issues. To our knowledge, no existing study has examined firearm-related crises in CTL conversations or other crisis lines. We examined changes in the volume and composition of CTL firearm-related texts before and after the Robb Elementary School mass school shooting on May 24, 2022, in Uvalde, Texas. Based on previous investigations with deidentified CTL data and national events [8-10], we hypothesized that conversations mentioning firearms would increase in the days following the mass shooting. Because work has not examined the broader effects of indirect exposure to mass shootings on mental health, we did not have a specific hypothesis about how social and mental health–related stressors may change before and after a mass shooting event. The objective of this study was to provide direct evidence of the effects of mass shootings on the broader public’s mental health.

We observed a significant increase in the number of conversations mentioning firearms following the shooting at Robb Elementary School (Figure 1). The largest spike in conversations mentioning firearms occurred the day after the shooting (n=159), May 25, 2022, with volume reverting to within the 95% CI of forecasted volume 4 days after the shooting on May 28 (n=77).

Table 1 reports the frequency and proportions of issue tags for conversations in the immediate 4-day pre- and postevent period. For firearm conversations during the postevent period, the count of all issue tags increased, except for the “COVID-19” issue tag. To control for increases in tags post event, we examined the percentage of total firearm conversations in the pre- and postevent period that each unique tag was used. Comparing pre-event to postevent, the “grief” issue tag increased significantly in the days following the shooting (d=0.06; P=.03), while the proportions for the “isolation/loneliness” (d=–0.07; P=.04), “relationships” (d=–0.11; P<.001), and “suicide” (d=–0.14; P<.001) issue tags decreased in the days following the shooting.

The objective of this investigation was to examine the effect of a mass shooting event on the broader public’s mental health. To do so, we examined the immediate effects of a widely publicized mass shooting in the United States on volume of mental health crisis text conversations that mentioned firearms. We also examined the psychosocial context of those text conversations by investigating changes in issue tags associated with firearm conversations as coded by the vCCs. Consistent with our hypothesis, we found that firearm-related crisis conversations following the Uvalde school shooting significantly increased. In addition to this main finding, we observed an increase in the proportion of grief-related conversations that mentioned firearms and a decrease in suicide-related conversations that mentioned firearms. We also observed a decrease in firearm conversations associated with relationships or feelings of isolation/loneliness following the Uvalde school shooting. Overall, we saw evidence that a widely publicized mass shooting influenced the broader public’s mental health beyond the specific location of the mass shooting event.

Our innovative methodological approach of analyzing real-time mental health crises through CTL conversations allowed us to address a critical gap in knowledge of the psychological effects of mass shootings on remote populations of individuals who are not directly exposed to the mass shooting event. Only a couple of prior studies have investigated the effects of mass shooting events on youth populations beyond the communities directly involved in these events, and these studies have mainly focused on youth expressions of emotion such as fear. However, our study findings may have the potential to have a significant impact on mental health crises (beyond general expressions of negative emotions) among the public. Interestingly, the increase in crisis conversation volume existed even when accounting for other mass shootings in the study period. It is possible that the Uvalde shooting has a particularly strong impact on users of CTL because school shootings (relative to other forms of mass shootings) appear to significantly affect youth mental health [17], and the CTL population is largely composed of youth [7]. Of course, other confounding factors such as the amount of media coverage or social media mentions may also be influential.

The increase in proportion of grief-related conversations, along with the decrease in suicide-related conversations, further suggest that firearm crisis conversations post event may be focused more on loss rather than suicide as is typically more common in firearm-related mental health crisis conversations. These findings are consistent with prior research showing that grief is a common reaction immediately following school shootings [18]. We also observed a decrease in firearm conversations associated with isolation and relationship issues. Although the data does not illustrate why this shift occurred, we speculate that an increase in social solidarity after the mass shooting event leads to fewer crises due to isolation and relationship factors. This possibility is consistent with prior studies suggesting that community members often reach out to provide more emotional support to one another after traumatic events [19]. Together, our results demonstrate that firearm-related mental health crisis conversations immediately following a mass shooting differ from typical firearm conversations in that they are more likely to be associated with grief issues and less likely to be associated with suicide, isolation, and relationship issues.

Several limitations of the study should be noted. First, we assume that the firearm conversations represent users that were not directly impacted by the Uvalde shooting (survivors, direct family members, etc) due to the relatively smaller number of people expected to incur direct versus indirect effects. Future studies should use geographic indicators to increase the chance of examining those directly related to a mass shooting event. Second, our study design does not address why the text volume associated with the Uvalde school shooting is greater than other mass shootings observed in the study period. Future research studying the magnitude of indirect impacts of mass shootings across different types of events could greatly enhance the literature, for example, the impact of school shootings compared to nonschool shootings. Additionally, this study does not attempt to quantify the impact of increased awareness of or referrals to CTL due to the Uvalde shooting. Lastly, issue tags were designated by the vCCs and thus relatively subjective. Future work could study the reliability of vCCs’ tagging to help better understand how mass shootings may be related to increases in firearm-related mental health crises. Overall, our findings support two main conclusions. First, the Uvalde, TX mass school shooting increased firearm-related text conversations at a national mental health crisis line even after factoring in the effects of other mass shootings that occurred proximally in time. Our findings provide some of the first data showing the real-time repercussions for the broader population exposed to school shooting events. Public health officials must recognize that the reverberations of school shootings on mental health extend beyond just the immediate community where the event takes place. Second, these firearm-related crises conversations may be most frequently related to grief. Thus, findings suggest that public health interventions that target feelings of grief may have the potential to reduce mental health crises immediately following a school mass shooting. Overall, the findings lay the foundation for future research on effective public mental health interventions that may be implemented after school mass shootings.