This month, our nation experienced yet another tragedy when, authorities say, a shooter with a history of psychiatric symptoms opened fire at the Fort Lauderdale airport, killing five people and wounding eight others. Such events invariably lead to calls for better mental health services, usually for laws to make it easier to mandate people to get treatment.
Mass murders are defined as a shooting in a public place where four or more people are killed by a stranger. While more common then they once were, they remain rare events that account for roughly 1 percent of gun deaths, in contrast to suicide, which accounts for 60 percent of firearm fatalities. In approximately half of mass murders, the gunman has had a history of psychiatric illness. If the definition of mass murder is expanded to include domestic, workplace and gang killings, shootings done during the commission of another crime, or acts of terrorism, then the number of mass murders rises sharply and the percentage of gunmen with mental illness drops.
It seems that anyone who would kill with no obvious motive must be disturbed, and that is true — it's not normal to kill strangers. Mental illness, however, is about more than being disturbed, and is defined by the co-occurrence of symptoms that cluster together to meet criteria for specific disorders, such schizophrenia or bipolar disorder. When violence against strangers is caused by mental illness, it is generally the result of a psychotic state, one where the person has lost touch with reality and has delusional beliefs that motivate his behavior. According to news accounts, the man charged in the incident reportedly told the FBI the government had infiltrated his brain and was forcing him to visit ISIS websites, and one account described him as incoherent; these would be hallmark symptoms of paranoid psychosis.
The media is often comfortable chalking up a mass murder to "mental illness," as if that alone explains it, but the existence of a psychiatric disorder does not tell us anything useful when it comes to violence. In any given year, 20 percent of people will experience an episode of psychiatric illness, and over the course of a lifetime, half of us will meet the criteria for a mental disorder. With few exceptions, people with severe mental illnesses are too disorganized to gather the weaponry and enact these tragic deeds, and few such gunmen have been found to be so psychotic that their disorders fully account for their actions. In many instances, the gunman knows he is committing a crime and is remanded to prison and not to a forensic psychiatric facility for treatment. Psychiatric disorders account for only 4 percent of violent acts. Violence is much more clearly associated with substance abuse, anger and early exposure to violence than mental illness.
In the case of the Fort Lauderdale shooting, the media has reported that the suspected shooter had been violent with a girlfriend, the police had taken his gun, he was briefly hospitalized and released, and his gun was returned to him at a later date. It has only been days, however, and the reported details are scant. We can hope that a hospital would not have released a psychotic patient, and the police would not have returned a weapon to someone if it was known that the patient was at risk of becoming a mass murderer. Furthermore, we know nothing about the treatment the suspected gunman received or if follow up care was recommended.
Psychiatric care is usually doled out with a mentality of providing as little as possible. We have a shortage of both psychiatrists and beds, and treatment comes with a cost that insurers are hesitant to bear. Even when it is available, some patients won't engage for a variety of reasons, but every state has laws that permit the confinement of someone who is both mentally ill and dangerous. This assumes psychiatrists can accurately predict who will become dangerous, and that is not often not the case.
There are no simple answers. While mental illness causes a negligible number of people to become mass murderers, it does cause a tremendous amount of psychic torment, incarceration for nuisance crimes, homelessness and a profound loss of human potential. At the same time, involuntary treatment is not something that should be done lightly; it can be very traumatizing to patients and may include restraining and confining people in ways that linger and leave people less likely to seek care in the future. Finally, our treatments help many, but they are far from perfect as some patients have symptoms that don't respond and others have serious side effects. Psychiatric treatment is not a panacea for all of society's ills.
In the United States, half of all counties have no mental health professionals, and even in major cities, it can be very difficult for someone to get an appointment with a psychiatrist. For those sick enough to need hospitalization, the beds are so few that it's not uncommon for patients to have long waits in emergency departments, or to simply be denied admission. Often, insurance companies — and not psychiatrists — determine who gets those beds and how long a patient may remain in one. Psychiatry is the only field where the patient's condition must be life-threatening for insurers to approve inpatient care; we would tolerate this with no other form of illness.
Mass murder, like the one we saw in Fort Lauderdale, grabs the undivided attention of the media, and then ignites our own fears. The cure is not to round up every mentally ill person and force them into care, but it's also not to leave very ill people on their own to negotiate a system with so many barriers. It's time to refocus our attention toward making comprehensive psychiatric care available to all who are suffering.
Dr. Dinah Miller (firstname.lastname@example.org) is a psychiatrist in Baltimore. She is co-author, with Dr. Annette Hanson, of "Committed: The Battle Over Involuntary Psychiatric Care" (Johns Hopkins University Press, November, 2016).