The Navy Yard shooting in Washington, D.C. has once again confronted us with the issues of guns and mental illness, but what we really should address is the inadequacy of mental health care in the United States. Since 2009 there have been 21 mass shootings and the perpetrators in over half of these were suffering from or suspected to have a serious mental illness like schizophrenia, bipolar disorder and depression. (The other killers with no signs of mental illness were ideological zealots, disgruntled employees and disaffected loners.)
After each incident there is a great hue and cry, and calls for action but no substantive action is taken. Our reflexive approach has repeatedly failed to provide care in a timely fashion to individuals in need. As a country, we continue to ignore the growing public health need for greater access and a more proactive approach to mental health care. It is time that we say enough is enough and do something to prevent future tragedies.
When you strip away the hype and politics, the causal factors in these horrific incidents are clear and solvable. Yet we’ve lacked the social and political will to fashion and apply the solution.
The plain truth of the matter is that we do not provide adequate services to the 26% of the U.S. population with mental illness. The scope of and access to mental health services available to most people are limited and fragmented. Moreover, insurance coverage is all too often lacking and discriminatory. Consequently, we do not provide the level and quality of care of which physicians and health care providers are capable. It is the equivalent of knowing that a woman has breast cancer but not offering the indicated treatment options of surgery, radiation and chemotherapy. The result is that many people go untreated or inadequately treated.
Most simply suffer but many end up in jail. Our penal system has become the largest institutional provider of mental health care in the country. A very small number, (but any in this case is too many), left to the mercy of their symptoms, are impelled to violence directed at their family, co-workers or innocent strangers. In such rare but shocking instances as at the Washington Navy Yard they take the form of mass carnage.
This can and must change. We are not in a situation in which we have to wait for some research breakthrough discovering the cause of these illnesses or next miracle drug. We have the knowledge and means to prevent these seemingly senseless crimes.
For starters, we must bolster the front line of engagement for people with mental health problems so that preventive efforts are on par with other health conditions. We encourage routine screenings for physical ailments such as tuberculosis, diabetes and hypertension, and vaccinate for infections. There’s no reason we cannot develop a similar proactive public health strategy for mental health.
Rather than waiting for people with symptoms of mental illness to seek help, which they all too often delay or never do, we should engage them proactively in school systems, the work-place or through their primary care providers. As former Congressman Patrick Kennedy has said why shouldn’t people have “a check-up from the neck-up” along with their annual physical exams.
Perhaps our greatest challenge will be overcoming the stigma of mental illness as well as some individuals’ lack of confidence in psychiatric diagnosis and treatment. However, we must be willing to confront both and deal with the accompanying fears and misperceptions. Otherwise, we risk more heartbreaking consequences of illnesses that go untreated and violent death and injury as a consequence.
The first concrete step that offers the prospect of improving the quality and availability of mental health care is the adoption of final rules for a bill passed and signed into law almost five years ago: the Mental Health Parity and Addictions Equity Act. This will allow for the law’s true implementation and enforcement and will close loopholes that have kept people from receiving benefits and desperately needed care.
Combined with the likely impact of the Patient Protection and Affordable Care Act, final rules will clear the way for improved mental health care access nationwide and, in so doing, will reduce the stigma that often prevents people from seeking help or sticking with treatment.
In his recent book, American Psychosis, the mental health advocate E. Fuller Torrey writes that “at least one third of the homeless and 20% of the incarcerated” are mentally ill and that “our public (mental health) facilities are overrun by untreated individuals”. The recent spate of mass shootings is a tragic and preventable consequence of our failed policy.
Jeffrey A. Lieberman, MD is the President of the American Psychiatric Association. He is psychiatrist-in-chief at NewYork-Presbyterian Hospital/Columbia University Medical Center and chair of the Department of Psychiatry at Columbia University College of Physicians and Surgeons.