This blog was stimulated by the confluence of several events at the end of May and beginning of June. I was asked by the parent of a patient about my experience as the expert witness in the 1972 Prosenjit Poddar trial which became the Tarasoff case. The rules derived from that California Supreme Court case still govern the disclosure psychiatrists and other mental health workers must make when a patient is threatening harm to someone in the community. A few days after discussing this case, a young Californian, Roger Elliot, killed six people near Santa Barbara. About two weeks later 60 Minutes had an extended piece on mass murderers. In the past I have avoided high profile topics like this in these blogs; however, I decided to make an exception in this matter because I have had some experience as an expert in certain murder defenses and there are substantial debatable public health and safety issues which need airing.
A cardinal distinction that psychiatrists draw when evaluating any patient or perpetrator is whether the individual is psychotic. This broad term is often defined as "loss of contact with reality", and typically includes hallucinations, delusions, inability to think clearly, drawing incorrect conclusions which cannot be corrected even when clear contradictory information is presented. Some recent examples include James Holmes who thought he was "The Joker" and killed twelve people at a Colorado theater; Anders Breivik thought he was the future ruler of Norway, Europe's Perfect Knight and killed seventy-seven people in Norway; and Seung-Hui Cho who thought he was Jesus Christ and said he vacationed with Vladimir Putin in North Carolina. He killed thirty-two at Virginia Tech. Psychosis can be caused by a psychiatric illness, substances, or medical illness.
About 2.7 to 3 million people in the United States population of approximately 317 million people suffer from severe mental illnesses and about one in seven commit murder. Of this number about 50% are psychotic. The remaining 50% are motivated by anger, jealousy, revenge, or attention secured by being a "copy cat." These numbers exclude war, terrorism, and gang activity.
There are a number of features that distinguish psychotic killers from non-psychotic killers. The psychotic killer usually acts alone, rarely tries to flee from the authorities, and is usually killed at the scene either by suicide or "suicide by cop." They are generally not under the influence of alcohol or drugs, are Caucasian and older than thirty, often unemployed, and usually telegraph their plans verbally, in writing, or on the internet. When looking back at their lives, they often demonstrate a fluctuating level of functioning from superior to impaired. Their actions are not usually impulsive but planned and they often know that they are behaving illegally. The individuals at greatest risk are family, friends, neighbors and mental health workers.
There are about 20 instances of psychotic mass murder in the United States each year. This rate has been stable for the last forty years. This is both a public health and safety problem. The public debate about prevention in the United States is almost exclusively focused on gun control. In my view this is too narrow a focus. I think a comprehensive strategy needs to be considered beyond guns because they are generally available and plentiful. Furthermore they are not always the instrument used in these tragedies. In addition, a significant number of psychotic perpetrators have been in contact with the mental health system but have been ineffectively treated. This shouts out loud and clear to me that the system needs reform. Such reform would perforce require a reappraisal of the balance between individual freedom and involuntary treatment or commitment. Once the public debate has taken place, community leaders should shepherd the changes into law. Follow up for patients discharged from psychiatric units needs study and improvement. Certain treatment modalities, long acting injections for certain patients, need to be discussed and guidelines for their use changed so as to increase medication compliance in very problematic patients. Finally, it strikes me as inappropriate to task the police with evaluating the mental state of individuals in the community. These evaluation when done properly require a working knowledge of psychiatric conditions, physiological responses to legal and illegal substances, and the impact of social circumstances on the individual in question. These evaluations should be performed by well-trained and experienced mental health professionals if the community interest is maximum accuracy and minimum errors.