By Michael B Friedman, Columbia University
Mass murders lead inevitably, if not entirely reasonably, to the question of what is wrong with the American mental health system and how it can be made better. This has happened most recently with the killings that took place in Isla Vista, California.
It is important to note that mass murders take place all over the world, not just in the US, and questions about the quality of mental health care should not be only about the state of the US mental health system.
Terrorism, revenge and madness
The vast majority of murders are also not committed by psychotic people, but by people who do not have major mental illnesses – they are frequently acts of terrorism or revenge, rather than acts of madness.
Indeed, people with major mental illness are far more likely to be victims of violence than perpetrators of it. Murders of strangers by psychotic people are statistically rare, about one per 14-15m population per year. In the US that results in about 20 such awful incidents per year compared to about 16,000 homicides and 38,000 suicides per year. Accurately identifying the specific 20 people with psychotic conditions who will commit murders in the next year from among the roughly 3m people with such conditions in the US is probably impossible.
Many advocates for the rights of people with mental illness have pointed to these facts with grave concern about the damage done by the perception that mentally people are violent when, in fact, the vast majority are not. Stigma of this kind keeps many people with serious mental illness away from treatment and results in barriers to their getting jobs, decent housing, and other services and amenities.
Still, it is perfectly understandable that when people with psychotic conditions sometimes commit mass murder (rare as it is), the question of what a mental health system should do to prevent such terrible events is raised. And proposals promising reductions in violence inevitably surface whenever an episode is publicised.
Stigma and the state of mental health
Some of these proposals are frankly offered by advocates of better care who are taking advantage of the publicity to bring attention to the indisputable fact that mental health systems in the US and elsewhere could, and should, be better. Some of us are appalled by this exploitation of horrible incidents because it increases stigma. Others believe that it is an essential advocacy strategy.
Many proposals are offered out of the sincere belief that they would reduce the incidence of murders by people with severe mental illnesses. These proposals tend to fall into six major categories: provide more mental health services to more people; increase outreach to people known to have serious mental illnesses who are not seeking care; change the balance of mental health services with increased emphasis on inpatient treatment; create “early warning systems” and increase the use of coercive interventions (involuntary treatment); change laws about confidentiality and civil liberties to make it easier to intervene when care is needed or dangerousness is suspected; and provide early intervention for children to reduce the number of people who will develop major mental illnesses as adults.
The need for more mental health services is indisputable. In the United States, more than half of people with serious mental illness do not get treatment at all. The question is which services should be increased: traditional treatment with its heavy emphasis on medication therapy or services designed to reach out to, and address the day-to-day needs of people with serious mental illnesses who do not get treatment. Would this result in fewer homicides by people with serious mental illness? Maybe, maybe not. But would certainly make life better for millions of people with serious mental illness as well as their family and friends.
Current policy emphasises mental health services in outpatient and community settings rather than in hospitals. A huge number of hospital beds in governmental psychiatric hospitals have been eliminated. In the US some psychiatric beds have been added to general hospitals to compensate for these reductions.
Is this enough? Given the large numbers of people with serious mental illness in prisons and other institutions, it seems clear that more residential services are essential. To what extent they should be in hospitals and other institutions and to what extent in community-based housing is open to debate. In addition, general hospitals are under great pressure to get people in and out fast. Should more time in hospitals be allowed or even required? That largely depends on what alternative services are available outside of hospitals.
Curtailing the rights of the many
Many advocates for improved mental health services believe that changing laws about involuntary inpatient and outpatient treatment, about confidentiality, and about civil liberties are necessary in order to make early identification of potential dangers possible and protect both the public and people with mental illness themselves from homicide and suicide. Current laws already limit confidentiality and civil liberties. The fundamental question here is how many totally innocent people’s rights would have to be curtailed further to get protection from the exceedingly few people with serious mental illness who will commit murders?
Finally, many advocates call for improved preventive services and early intervention for children who may become adults with serious mental illness. The question here is whether the technology of prevention is far enough advanced to make a significant difference in the incidence of violence in 25 years. It may be worth a shot, whether it has an impact on murders by people with serious mental illness or not.
The upshot is that, without doubt, mental health systems around the world need improving, and governments should pay far more attention to this than they do now. But will improvements result in fewer murders by people with serious mental illness? Without a definitive epidemiological study, we are not likely to know.
Michael B Friedman does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.