Mental illness and guns

If you believe that early intervention by mental health professionals in the lives of people with serious psychiatric disorders will prevent future mass shootings like the ones in Newtown, Conn., or Tucson, Ariz., you probably are in for a disappointment: The truth is that no public health effort can prevent such tragedies entirely. That's because only a tiny fraction of the millions of Americans who suffer from serious mental illnesses will ever become violent, and there is no way of predicting who will be. Inevitably, some people fall through the cracks of even the best designed public mental health programs.

That doesn't mean that a Maryland initiative to create a new center to identify and treat people with psychotic symptoms early in the course of their illnesses is not urgently needed, however. Founded with a $1.2 million appropriation from the state this year, the Center for Excellence on Early Intervention for Serious Mental Illness aims to catch the earliest signs of psychosis in people suffering from serious chronic mental disorders and to intervene before those conditions create havoc in the lives of patients and their families. That not only will help many people with serious mental disorders, it's also good public health policy.

The recent, widely publicized mass shootings involving people suffering from mental illness have reignited a long-running debate over gun control laws in this country. But they have also brutally exposed the flaws in the nation's public mental health system. Time and again we hear stories of people who were clearly having mental difficulties, yet no one took notice or did anything to help them. That's a reflection of society's neglect and ignorance of mental health issues even in cases where someone obviously is ill. In a society more aware of mental health issues it would be incumbent on anyone who sees a family member, friend or colleague suddenly start behaving strangely to at least get that person evaluated and potentially have them hospitalized before something worse happens.

It must be said that something worse is hardly ever a homicide, much less the kind of mass shooting that makes national headlines. Such incidents are extremely rare. Much more common are suicides or violent but non-fatal encounters with relatives or law-enforcement officials that can profoundly disrupt the lives of mentally ill people and cause them to lose their jobs, their homes and their ability to lead independent lives. That's why Maryland's initiative aims to address the problem at the most critical time, which is when the earliest symptoms of psychosis appear or the person suffers his or her first psychotic episode. At that stage of the illness, health professionals have very good treatment options available.

It's somewhat ironic that the National Rifle Association, in attempting to deflect attention away from the easy availability of guns by focusing on the mental health issues behind some recent mass shooters, has become one of the greatest allies of mental health advocates. This despite the fact that fewer than 5 percent of homicides are committed by people who are psychotic. When it comes to mass shootings, that proportion rises, but only to about 30 percent.

What's needed is greater public awareness of how to recognize the signs that someone is slipping over the edge. Many people knew the young man accused of shooting former Rep. Gabriel Giffords and others in Tucson had been acting strangely in the months leading up to that incident. The college he attended had kicked him out of school and demanded a letter certifying he had visited a mental health professional before he could return. Yet school officials never required him to be evaluated nor did they notify anyone else of his condition. In the case of the Aurora shooter, a school psychiatrist did raise an alarm, but then the young man dropped out of school and the authorities failed to follow up on his case. Because he no longer was a student there they took the position that he was no longer their problem.

These are complicated and difficult issues for which there are no easy solutions. The one thing we can be reasonably sure of is that Maryland's initiative, while it may help many people with serious mental disorders, isn't going to make us safer from attacks by deranged people. The only thing that will do that is a more rational gun control policy that makes it far more difficult than it is today for firearms to fall into the wrong hands, be they those of criminals, mentally ill people, children or careless adults.

But in cases involving serious mental illness, early intervention remains the key. Assisted outpatient treatment could make a big difference, but Maryland, unlike states such as New York, doesn't have a law allowing judges to require that people with mental illnesses continue outpatient treatment after a hospitalization or one that allows heath care providers to take them back into custody and re-evaluate them after their release. Such laws have been shown to be effective in reducing the incidence of homelessness, arrests and jail time among the chronically mentally ill. The bottom line is that we need a more compassionate but also more aggressive policy in intervening early in the lives of people with serious mental illnesses. When people get to the point where they spiral out of control because of an untreated mental health condition, it's often too late.

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