After the Navy Yard Shooting: A Call to Action On Mental Illness

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.

32 replies »

  1. Ummm, I’ve gotten to know my neighbors pretty well over the years. And, I’d say none of them are irrationally afraid of anything. They grew up in a gun culture and just like shooting. That doesn’t bother me in the least. Would any of them use a gun to defend family and property? Absolutely…and MO has the most liberal castle doctrine in the US.

    The neighbor whose decisions make most nervous? Just bought his 17 yo high school student son at 465 hp Shelby Mustang, modified to be race track ready. In a neighborhood full of pedestrians and playing children, I’m more nervous about him than I am about any one of the dozens of gun owners.

    And, yes, it is the case that ” that upper income, successful, educated, in tact family units use guns less to solve their problems”…to paraphrase Samuel L. Jackson on gun control: he says that he grew up in the South, where guns were everywhere, but no one shot anyone else because everyone understood the value of life and the importance of gun safety. I don’t know how to teach (re-teach?) that value system.

  2. Was that a rhetorical question? “What’s your point? That there is an irrational fear in your neighborhood that not having a gun will leave you vulnerable?” or directed at someone, because I know that I clearly stated, I am against the use of guns, but it is an individual decision and it should not be taken away, because of misuse from anyone. We know that whether a criminal obtains one legally or the majority of the time illegally they are not going to sit and count the bullets.

    By putting laws in place that absolutely, make no common sense, because it doesn’t way on the average persons mind is a waste of time. Key word “Average Person” they are the people that obtain guns and go through the background check and purchase it legally.

  3. “t’s also interesting to me that in our area of largely professional/entrepreneurial families, I would say that there is an average of one firearm per household. It seems like no one owns just one gun. The violent crime rate in our city of 50,000 is one-fourth the national average, and the total number of murders committed this century is under a dozen. Just 35 miles to the east is the city of St. Louis, which is one of the poorest and most crime-ridden urban areas in the nation”

    What’s your point? That there is an irrational fear in your neighborhood that not having a gun will leave you vulnerable? Is it that upper income, successful, educated, in tact family units use guns less to solve their problems?

    The common denominator is GUNS in the wrong hands. The NRA opposes measures that weed out the “wrong hands” before the guns are accessed.

  4. I just researched more facts about the Virgina Tech Shooting and while there is evidence that the shooter may have been psychotic it is very hard to say because of the pre-meditation that was involved. When ever you pre-meditate an act you are thoughtfully thinking something out in sound mind and in the tape he sent NBC News which you can view below he clearly states how he pre meditated his act. As I stated above there was no clear psychiatric diagnosis that I am aware of and if some one were to show actual facts about mass gunmen and the correlation between mental illness and shootings then I would be more than happy to agree, but if this has been going on for so long as stated by Dr. Lieberman where are the factual statistics. You would think that research would be done on it.


    partial evidence to support something in psychiatry I believe is not a clear indication of an actual diagnosis. If you were to look at the DSM 5 I’m sure anyone could be fitted with a diagnosis in there. Looking at a cluster of symptoms without looking at the totality of circumstances, environment etc… is not giving a proper diagnosis. I in no way condone violent behavior and I am completely against the use of any firearms accept when used by authorized professionals who have the training, but it is an individual decision which I believe ultimately needs to be respected and laws need to be put in place that protect others from being hurt by the use of guns, but my county executive said and it was very wise, No Criminal or Mentally ill person is going to sit and count the bullets in a magazine or whatever its called. They are just going to act so by taking away other peoples liberties because of something that ultimately can not be stopped makes no sense!!!

  5. Thanks for this, Vik Khanna. It’s the first time I have seen the term deinstitutionalization in print for some time. It’s hard to speak of this subject without being accused of advocating some Dickensian dystopia. It was a movement of the Sixties with good intentions that, as Justice Thomas might say, went seriously awry.

    Having been identified as one of the “ignorant and uneducated” commenters in this thread I’m reluctant to say much more, but here is a six-year old link to something I wrote following the Virginia Tech shooting.


    After all this time the links I cited there no longer work, but the first is from a Washington Post Op-ed. now thirteen years old, subtitled “WE HAVE LOST EFFECTIVELY 93 PERCENT OF OUR STATE PSYCHIATRIC HOSPITAL BEDS SINCE 1955.”

    (I furnished a second link thinking it would make it past moderation but it didn’t so it will likely appear later.)

  6. Thanks for this, Vik Khanna. It’s the first time I have seen the term deinstitutionalization in print for some time. It’s hard to speak of this subject without being accused of advocating some Dickensian dystopia. It was a movement of the Sixties with good intentions that, as Justice Thomas might say, went seriously awry.

    Having been identified as one of the “ignorant and uneducated” commenters in this thread I’m reluctant to say much more, but here is a six-year old link to something I put together following the Virginia Tech shooting.


    After all this time the links I cited there no longer work, but the first is from a Washington Post Op-ed. now thirteen years old, subtitled “WE HAVE LOST EFFECTIVELY 93 PERCENT OF OUR STATE PSYCHIATRIC HOSPITAL BEDS SINCE 1955.”

    (Here is the link without the dots. If two links appear in a comment it gets put into a moderation queue and may not appear for a day or so.)

  7. Just to highlight my educational background and a little work experience, I graduated cum laude with my bachelors of science degree in criminal justice, I have worked in a county jail, worked as a social work intern in a substance abuse program with paroles, clients that were on probation, TASC Clients, Clients who were incarcerated for murder and other violent offenses all who had co-existing disorders or just a substance abuse diagnosis. During my time as a social work intern I not only did intakes, I did full biopsychosocials, had my own individual clients, co-faciliated substance abuse groups, facilitated my own substance abuse groups and much more. I can personally attest to the fact that, yes some people ( clients) do have a mental illness which directly correlate with a violent history, but it was very rare. It usually involved the co-occuring disorder which led to the violent act.

    Also it had to do with the way you treat your clients. I sat in a group one day that I was facilitating and one of my clients began speaking about how they had used over that past weekend and another client who wasn’t mine immediately said why are you saying that your going to get into trouble. I said no he isn’t. I explained that everyone with this disease slips, especially in the beginning and if my clients are up front with me and don’t lie I am more than willing to work with them and their probation officers, parolee officers etc.. to work on a treatment plan that will help them achieve sobriety and long term goals that help them live a healthy life style, but I said if I see that the behavior is consistently manipulative or is a harm to themselves or anyone else than I will be forced to take some other action.

    What I am saying is people are able to be rehabilitated when given respect, treated with dignity and guidelines are set and enforced. I’m not saying all people, but I read all these comments from ignorant, uneducated people saying lock them up for life. Is that solving the problem or adding to it? Ultimately someone has to pay for a person to be locked up for life and it ‘s going to come down to the tax payers.

  8. Platon20 is on to something. Overall, I like Dr. Lieberman’s piece, mostly because it focuses the attention where it belongs, on both mental health diagnostics and therapeutics.

    In 1986, just out of graduate school (and the experience of working as a physician assistant in the Baltimore City Jail and Maryland SuperMax Penitentiary), I because advisor on health policy to sitting Attorney General and gubernatorial candidate Stephen H. Sachs. Although he lost the race, one health policy aspect I did not advise on because he had already committed to a particular stand, was that of deinstitutionalization of the mentally ill. Sachs was a virtual hero to advocates. I remember talking to him about it and questioning what was going to happen to all these people, and, quite frankly, he effectively said, well, we’ll figure it out. Obviously, we have no succeeded in doing so. And, I can attest, that when you do intake histories and physicals of people entering the penal system, sometimes for very violent offenses, there is no question that there is something quite different about them. It might be true that each of us is capable of great violence, but most of us don’t commit crimes, even with access to weaponry.

    Where I live now, in western St. Louis County, the gun culture abounds. At social gatherings people talk about their new guns, accessories, and accomplishments at the range in the same casual tone that they do their golf game. No one bats an eyelash. It’s the first time I’ve every lived in a state where guns are out in the open, so to speak, and in the times I’ve gone shooting, it’s been great fun.

    It’s also interesting to me that in our area of largely professional/entrepreneurial families, I would say that there is an average of one firearm per household. It seems like no one owns just one gun. The violent crime rate in our city of 50,000 is one-fourth the national average, and the total number of murders committed this century is under a dozen. Just 35 miles to the east is the city of St. Louis, which is one of the poorest and most crime-ridden urban areas in the nation.

    I am not ascribing causation, but there is surely something at play that goes beyond the right-left talking points of “it’s the crazies” or “it’s the NRA.”

  9. – Since you seem to be such an expert on delusions, there are three types what are they?

    – Please cite your resources

    – Because of ignorant, uneducated people like yourself and that’s putting it nicely the stigma associated to mental illness is no less today then it was when President Obama held the conference on Mental Health.

    – The mass shootings that have taken place ( almost all) have been pre-meditated. In order to pre meditate anything you need to be of sound mind. A delusional person is not of sound mind. If you actually did your research on the mass shootings, all accept for about two and one being the most recent ( the DC Shooter) were confirmed delusional. The others were found competent to stand trial because it was pre-meditated.

    – To comment on your comment about violence your right about previous violent behavior being an indicator for future violent behavior, but absolutely wrong with your statistics. What do you see everyday on the news? Stories about gun violence. Your going to tell me that ninety-seven percent are paranoid – delusional people. ( BS) It’s all about nature vs. nurture. Look that up.

  10. Predicting who will commit violence is not some enigmatic mystery that nobody can figure out.

    Consider these facts:

    1. 82 percent of all violent crime is perpetuated by somebody who had a previous history of violent acts

    2. Of all killers who were labeled mentally ill after the fact, ninety seven percent had a history of both delusions and previous history of violent acts.

    Now, advocates of the mentally ill say that 90 percent of mentally ill persons are nonviolent. And they are RIGHT about that. The vast majority pose no threat whatsoever. But where the mental health advocates are WRONG is that we cant predict who is violent. That is a load of BS. As stated above, its pretty easy to figure out who the high risk groups are.

    We need to reinstate instutionalization. The reason why we got it wrong 50 years ago was not because we had institutions, its because we tried to warehosue EVERYBODY in the same institution, regardless of risk level. That was just stupid. You would have 50 something housewives w/ depression institutionalized with stone cold psychotic killers. Sheer lunacy.

    We need to build institutions and ONLY put the DELUSIONAL, VIOLENT persons in there. That is an easy screen to weed out the 90 percent of everybody else who wouldnt hurt a fly (i.e. most crazy homeless persons who talk about seeing Elvis but have never been aggressive or violent).

    People with a h/o violence due to mental illness get locked up, for life. They can get mental healthcare inside their prison cell. They should NEVER be let out, ever. Why? Because juts about every single one of these people are paranoid delusionals, and they will NEVER adhere long term to a medication regimen that will keep their demons at bay.

  11. Very well stated, it’s always much more complicated than one issue like money and guns.

    I’m not against psychiatry at all, medication has saved my life. I take it everyday. In fact, I have a medication box just for two medications. I suffer from Major Depression. I am a fierce Mental Health Advocate, but I try to look at everything as they have taught me while taking classes for my masters of social work as an entire picture, not just a snapshot. In Social Work it’s called the Person in Environment Perspective. Which simply means the person and correlation between their entire environment. Now in psychiatry I believe and I am not a doctor but am a patient the same should be done. You need to look at the symptoms, where they are coming from, why they are being displayed etc.. and not jump to a conclusion based upon a cluster of symptoms just displayed and not looked into.

    Now I never thought in a thousand years, but was told because I do have a big mouth that one day I may come up against a psychiatrist who will challenge me. That day came on February 21, 2013 when I was admitted into New York Presbyterian Hospital and you can read about it if you wish on the link I posted above. The issue that stands is the psychiatrist didn’t like that I was questioning her authority, recommendations and medication regimens so since she had the power to bring me before a judge she did so. Now I had the pleasure of speaking with yesterday at a National Alliance of Mental Illness fundraiser a board member and I explained the entire story and to her she understood what the hospital did wrong, but presented to an uneducated audience you would think I actually am “crazy”. What was so said, was this board member had a son who actually suffered from a fixed delusion and schizophrenia and she fought so hard to get her son treatment for years and here I am with a diagnosis that I have had for many years and is even in my chart “Major Depression” and a psychiatrist who is wasting her time because she doesn’t want to choke up her pride and their are parents out their trying to protect their children and the community because they are aware of what this illness is and a psychiatrist who could be helping but is wasting her time, traumatizing me in the meantime, taking up the courts time, committing perjury, creating false documentation and providing false testimony at a hearing. What is worse is that you have testimony from a psychiatrist in front of a judge and cross examination from my attorney actually showing through the psychiatrists own words that she was caught in lies on the stand and I was sent back to be forcibly medicated.

    Now if in fact I did have ” Schizo-affective disorder” as this psychiatrist stated then I wouldn’t be functioning right now on an anti-depressant, which is administered by a psychiatrist. I wouldn’t be voluntarily going to therapy twice a week and living on my own in the community as I have been since I was 18 years old just fine.

    Now how does this relate to insurance, well I have medicare and while the psychiatrist was busy wasting my time, damaging me more, which thankfully I have a very strong support network, wasting the courts time etc… I would have been discharged within a week, week and a half instead of three weeks and medicare wouldn’t have been billed thousands of dollars fraudulently. This is not the first time this doctor has done this, I know that for a fact!

    So you see it’s not all about getting money, but I have to pay and, my deductible for medicare, which was fraudulently charged by an overzealous doctor and eventually it trickles down to the taxpayer.
    BTW, that wasn’t even a slither of what actually happened during my three week long stay at New York Presbyterian Hospital.

  12. Everyone should have an advocate, but its always about a middle party (usually a judge) trying to find the truth in one side of the argument – a very difficult task in mental illness and open to tragic mistake.

    We have deinstitutionalized the mentally ill but now rely on the police to administer treatment by arrest and incarceration, or worse by gun fire, but there is no way to force patients in open society to take their meds or see a professional.

    My take on insurance companies and treatment coverage is that they never wanted to pay because they could not determine an end to treatment like physical disease – the risk was open ended. I think forcing insurance to pay is a good thing because mental health professionals want very large incomes and mental health is, to a large part, the root of society’s problems. Add that to the free access to guns and the outcomes are predictable. But that’s life in an NRA world.

    But you are right that open ended payments can be abused, and its scary that a person might be institutionalized for the money. I’m not sure how founded that fear is, anymore than the fear of not owning a gun will put you at risk.

  13. Sorry for the grammatical errors :), it’s early. Let me explain. With anything you always want somebody providing some oversight to make sure that everyone is doing their jobs. With that being said, if the insurance companies are no longer allowed to do reviews and they do have qualified RN’s doing these reviews then it gives psychiatrists the ability to keep patients past the time they need to be in the hospital. We all know that if you are articulate, especially in psychiatry where it’s all about documenting then you can continuously document reasons why a patient needs to be in the hospital.

    Now I’m sure your asking why would a psychiatrist want to keep any patient in the hospital after they are ready to go, but let me educate you.

    I’ll be happy to answer any questions!

  14. “this gives them free rein to do it without any one overseeing what their doing.”

    Who would you trust to do the overseeing?

  15. The pressing issue here is that a psychiatrist who is the head of the AMERICAN PSYCHIATRIC ASSOCIATION and CHIEF PSYCHIATRIST of Columbia Presbyterian in New York City is adding to the stigma of Mental illness and putting out false information.

    This is a big problem! Why is he doing it, for his own gain if you’ve ever read other articles written by him he has a dire need to get the Mental Health Parity Act passed. Now I haven’t followed the Mental Health Parity Act as of late, but if you read what is in it, basically what it’s stating is that insurance companies no longer have any control over how long patients stay in a psychiatric hospital and doctors “simply because their doctors ( psychiatrists) can keep a patient because they have the education and experience. Now this seems logical, but when you have corrupt psychiatrists draining medicare and medicaid the two state funded programs already this gives them free rein to do it without any one overseeing what their doing.

    Now you take a mentally ill patient who can’t advocate for themselves which is usually most and psychiatrists like Dr. Lieberman profit from all of this and taxpayers ultimately get the bill.

  16. “This is a cultural sickness”

    The cultural sickness is guns and the “crazies” are in the NRA.

  17. Thank you, Ms. Pierce, for your response. If my use of the word “crazy” was offensive, I apologize. It’s a careless layman’s term like geek, cancer victim, freak or queer with no clinically accurate definition, which I have heard used casually and unselfconsciously by a number of people in those respective categories.

    My comment is to urge everyday people to recognize their role in resolving what appears to be a uniquely American phenomenon, multiple instances of killing by deranged individuals. If social workers, medical professionals and policy makers had a remedy the problem it would have been solved long before now. This is a cultural sickness and we all have a role in finding a solution.

  18. My first response will be to the ignorant comment made by John Ballard.
    -Please define Crazy
    – The Statistics stated in Dr. Jeffrey Lieberman’s Article are not true. In an article titled Newtown, Conn Shooting: Timeline of Mass Killings Since Columbine they cite ONE person who supposedly has a mental illness and was released from jail, and committed a mass shooting. However, the media or investigators who are in charge of investigating the horrific acts up until the DC Shooter this past week or so when it occured has never released intimate details about a mass shooters psychiatric history so definitively. Anyone can say a relative had a mental illness, but in fact if something so tragic occured and they did have a SEVERE MENTAL ILLNESS, you better believe just like the DC SHOOTER the Investigators and Media would have their hands on it.
    – The fact of the matter is, is that not only are you, but Dr. Jefferey Lieberman which is absolutely dispicable that he is a psychiatrist and adding to the stigma of mental illness by releasing statistics or so called facts that are not true!!!

    – Before you get on your high horse and speak about CRAZY PEOPLE do some research and educate yourself so you don’t seem like such an ignorant and uneducated person such as the psychiatrist that wrote this article and that is nicely putting it.

    Now the resource that I took this from is


    Do some reading and if your not satisfied with what I posted maybe google it a little more the same goes for Dr. Jeffrey Lieberman.

  19. The Second Amendment distorts all thinking and argument pertaining to rational regulation of lethal weaponry. It’s a serious (and now dangerous) anachronism. I proffer one lone (albeit Quixotic) vote to get rid of it. I’ve managed to live 67 years thus far without need of it.

    That is NOT to advocate a blanket ban on private ownership of firearms, just a shifting of burden of proof.

    And, everyone can please spare the Perfectionism Fallacy pushback.

  20. RELATED: If the story which broke last week about Nevada authorities putting the mentally ill on buses to San Francisco and Los Angeles, with a sandwich lunch, some spending money and a few days of medication is true — which it seems to be — California needs to file a lawsuit against Nevada seeking damages and the Feds need to get involved. http://nyti.ms/18KkEuG

    We also need to determine how many other states are engaged in similar schemes. I’ve heard stories about this in enough parts of the country to believe that it is common practice .. .

  21. Tax bullets and guns to pay for mental illness treatment.

    But again this will be blocked by the power hungary fascists in the NRA.

    “The first truth is that the liberty of a democracy is not safe if the people tolerate the growth of private power to a point where it becomes stronger than their democratic state itself. That, in its essence, is fascism — ownership of government by an individual, by a group, or by any other controlling private power. ”

    Franklin D. Roosevelt, April 29, 1938.

  22. Several realities about crazy people have been apparent for years.

    –Crazy people can legally buy and use firearms. That crap about “When guns are outlawed only outlaws will have guns” is plainly wrong, as this most recent example illustrates.
    –Community mental health resources and aftercare are not preventing crazy people from killing others.
    –Deinstitutionalization, which started about forty years ago, is as much a failure as the so-called War on Drugs. It is time for a reality check for both.
    –Everyone I know has personal knowledge of somebody who is crazy. Not eccentric or strange or a loner or with special needs, but out and out card-carrying crazy. Most crazy people are harmless but a relatively small minority are dangerous and are candidates for civil commitment. There are not enough professionals to prevent these crazy people from killing others so it is the responsibility of everyone to take seriously the responsibility to protect themselves and those they care about against the harm that will result if crazy people are not managed properly.

    In the same way that society has learned to confront overt racism, smoking and drunk driving, it is time for a movement to raise the awareness and responsibility of everyone to be more alert to potentially crazy people who need professional attention. Yes, we still have racists, smokers and drunks among us, but those qualities are no longer as acceptable as they were just a few years ago. It’s time for ordinary folks to wake up to the dangers of crazy people. As in the case of child abductions and the dangers of fire, there are not enough professionals to fight the problem without help from the public.

    And anyone who thinks this is not about healthcare reform needs to go back and read the memo again.
    Here’s the link. http://accidentalblogger.typepad.com/accidental_blogger/2012/09/deinstitutionalization-john-ballard.html
    I’m getting tired of writing about this. Again. And again. And again…

  23. “My concern is the amount of mental problems in the general population and the lack of investment in this field. When I mentioned investment I don’t mean SSRI or analogues I mean effective psychotherapy and in some cases prescribed medications.”

  24. I am deeply sympathetic to your cause. I am a bit skeptical about the numbers you cite though. Can you cite your source for the 26%? Can we assume this is the conservative estimate?