The recent tragedy in Tucson was a topic of sobering discussion in academic departments of psychiatry, psychology and social work throughout the United States. Henry A. Nasrallah, MD, Professor and Director, Schizophrenia Program, and Stephen M. Strakowski, MD, the Dr. Stanley & Mickey Kaplan Professor and Chairman of the Department of Psychiatry and Behavioral Neuroscience at the University of Cincinnati College of Medicine, offer their thoughts in the following essay. Drs. Nasrallah and Strakowski are affiliated with the Mood Disorders Program at the UC Neuroscience Institute.

By Henry A. Nasrallah, MD Stephen M. Strakowski, MD

The tragic recent events and loss of life in Tucson due to the violent acts of what appears to be a seriously mentally ill young man have shocked our nation and triggered much grief, anger and finger-pointing.  Random events like these tend to strike us as senseless and difficult to comprehend.

As information about the 22-year-old shooter is released, a picture of a seriously ill individual has emerged, with evidence of bizarre behavior, thought disorder, and emotional impairment that has been longstanding.  As with the public reaction to the Virginia Tech mass killings four years ago, the most frequent question begging for answer was – “why was this sick young man not referred for treatment despite numerous prior episodes of bizarre and threatening behavior in multiple venues?”

The answers to that question are multiple and reflect our country’s general lack of interest in mental health issues (except briefly following gruesome events such as the one in Tucson).  Although mental illness afflicts up to 25 percent of the U.S. population, most individuals with psychiatric disorders do not seek help for reasons that include:

1. Lack of awareness that they have an illness, related to inadequate public education
2. Lack of mental health services that could provide help promptly
3. Social stigma that persists about mental illness and is perpetuated by the media
4. Longstanding discrimination by insurance providers towards mental disorders that makes it much more difficult and expensive to receive treatment compared to other “physical” medical disorders
5. Arcane restrictions about guiding people into treatment and disclosing information about potential dangerousness. These restrictions limit interventions that teachers, police and other professionals can recommend and can even preclude requests for help from the family. We often sadly observe that because of those legal constraints, our patients with mental illness die “with their rights on!”

Despite being one of the most developed countries in the world, the United States gravely neglects its citizens who suffer from mental illness. The vast majority of psychiatric hospitals have been closed, and even psychiatric wards in general hospitals have typically been downsized or converted to more lucrative medical or surgical specialties where insurance reimbursement is far more profitable.

Public health statistics suggest that urban centers should have 40-60 acute inpatient beds for every 100,000 of its population, but most cities have a fraction of these actually available. An alarming number of patients with psychotic disorders such as schizophrenia and bipolar disorder are being warehoused in prisons instead of cared for in hospitals.  States are more willing to construct and/or expand jails and prisons than to build or expand mental health facilities.

It is a great source of pain to those of us who care for people suffering from psychiatric disorders to see them transformed from “patients” to “criminals.” The vast majority of psychiatric patients never commit violent crime, but their erratic behavior in public or their exploitation by seasoned criminals often lands them in jail.  The suicide rate among persons with schizophrenia, bipolar disorder or a major depression far exceeds the homicide rate, but the media coverage of acts of violence by a mentally ill individual is logarithmically greater than the coverage of death from self-inflicted injuries.

Opportunities for prevention of serious behavioral decompensation, like that which occurred in Arizona, are repeatedly wasted.  Psychiatric research has long established that adolescence and early adulthood are the most likely times in life for the onset of serious psychiatric disorders such as schizophrenia, bipolar disorder, major depression, anxiety disorders, and substance abuse.  Consequently, high school and college years offer the greatest opportunities for early detection and intervention, which could ameliorate the negative outcomes of these evolving mental disorders.

Yet many students who develop psychiatric disorders are not identified until their illness becomes severe and their symptoms are serious and threatening to self and others. A systematic screening of all students between 14 and 24 for early warning signs could reap tremendous benefits in terms of prevention and/or pre-emptive treatment as well as decreasing the suffering of these individuals, their families and our society.

Pediatricians and family physicians can begin this process by incorporating a routine “mental-health checkup” with the annual physical exam of children, adolescent and adult patients. With more thoughtful and enlightened intervention with our young people, we could prevent tragedies like the one that occurred in Tucson.