This weekend, The Baltimore Sun reported a fire and deadly shooting in Woodlawn, Maryland. The fire was at the home of a 56-year-old man who for years claimed that the federal government surveilled him. He accused neighbors of being involved in this government surveillance. The neighbors recounted that he would sometimes march up and down the sidewalk with a gun or yell accusations from his porch through a bullhorn. On Saturday, authorities say the man attacked four people, killing three of them, before he was killed himself by Baltimore County Police officers.
That’s the day we ran out of time to intervene in the man’s behavior. But if we want to prevent another such occurrence, we must take inventory of the tools we have available, determine whether they were used in this case, and if they weren’t, how we can ensure that they’re implemented in the future.
While we will learn more about this case as the forensic examination continues, current information reads just like psychiatric clinical cases from my time in emergency psychiatry- or psychosis- clinic. There is some chance we might learn that the man was truly being surveilled by the federal government. Nevertheless, given the prevalence of psychotic disorders and the consistency of this man’s apparent paranoia over the years, there is a possibility that he had psychiatric illness. For most patients, this is treatable and may require emergency psychiatric evaluation to initiate treatment.
When I encountered these people in clinics, emergency departments or psychiatric inpatient units — I have been in position to directly treat and mitigate psychiatric conditions. The concern is for community members who do not make it to treatment before some damage is done. May 8 may be an example of the latter.
From the information available, it seems a Petition for Emergency Evaluation could have been requested for this man at different points over the years. Health care providers and police officers sometimes call this an “EP.” Under Maryland law, the EP can be requested based on observations that are concerning for someone having a mental disorder and presenting a danger to life and safety of others or themselves. The petition can be requested by clinical professionals, peace officers or “any other interested person.” Once the petition is given to a peace officer, the petitioned will be detained by police and brought to an Emergency Medical facility. Once at the facility, two psychiatrists (or one psychiatrist and one psychologist) must evaluate the detainee for possible involuntary psychiatric admission. Once the potential patient is involuntarily detained, providers can use antipsychotic medications to safely treat the paranoid delusions.
The next tool to prevent harm is the Extreme Risk Protection Order (ERPO). The ERPO is a mechanism to remove firearms from the possession of people who pose “an immediate and present danger of causing personal injury to self or others by having firearms.” In addition, the person of concern cannot purchase or possess other firearms. Spouses, partners, family members, cohabitants, law enforcement, and clinical professionals can petition for the ERPO. Regarding the May 8 events, a petition for ERPO may have been appropriate, based on the reports of potential paranoid delusions and brandishing a weapon in front of neighbors. When needed, ERPOs have a contingency plan to initiate an EP as well.
Finally, Maryland’s Mobile Crisis Teams (MCTs) are available to respond to “mental, behavioral or emotional crises.” These teams include licensed mental health professionals alongside specially trained police officers in plain clothes. This would contrast with uniformed officers arriving to a mental health crisis and ready to use deadly force. Before the May 8 fire, there may have been opportunities to engage a MCT on the case. The concerns of neighbors were clear as one told The Sun that man was “like a ticking bomb” for a significant time. In contrast, neighbors who experienced the May 8 event felt calls to police had been fruitless: “I was like, ‘Do you all want him to commit a crime before you guys come out to help us?’ and they [police] said, ‘Yes, that is the Maryland law.’ "
The May 8 fire and shooting is still under investigation, and we may learn that EPs, ERPOs, and MCTs were engaged at some point. But given how threatening the man was in the community, and in possession of a gun on May 8, I do not find it likely that the EP, ERPO or MCT were currently engaged for him.
This leads to my greater concern, that many Maryland residents may not know their rights to initiate these clinical interventions. ERPO was only recently passed in 2018, and MCTs have diffused across the state in recent years. Researchers at Johns Hopkins found that 70% of their surveyed house staff (physicians in training) had little to no knowledge of ERPO. After ERPO was briefly described to them, over 90% said they believe they have seen patients who would have qualified for an ERPO.
While Baltimore’s venerable medical institutions train their house staff to understand and utilize ERPO, it is probably time for all of Maryland’s residents to become familiar with EPs, ERPO and MCTs. These interventions will only protect communities if they are initiated correctly. Then, perhaps, we will have less stories like the fire and shooting of May 8.
Arkaprava Deb (ArkaDeb.Baltimore@gmail.com) is a psychiatrist and preventive medicine physician working in Baltimore City. He is also the Director of Public Psychiatry Education at SUNY Downstate College of Medicine and Director of Psychiatric Services at The Door in New York City.