Four Months After the Massacre, Lessons to Be Learned

In the course of 15 years as an inpatient psychiatrist in an academic hospital in Manhattan, I have hospitalized many acutely suicidal or psychotic college students and taught many more psychiatry trainees about the signs of impending suicidal and dangerous behavior.

Watching television coverage of the worst murder on a college campus in American history, I saw what my wife, Lisa, a clinical psychologist, termed an astounding lack of public knowledge about mental illness and its relationship to dangerousness. This applied mostly to the mass media, but also to college faculty and administration and to law enforcement agencies.

Usually only untreated or under-treated psychosis or mood disorders can result in violence and suicide. To the extent that it can be deduced from the public record and using only general psychiatric knowledge, Seung-Hui Cho at the time of his mass murder-suicide was acutely psychotic and had a long history of mental illness.

Although Cho's diagnosis will never be known definitively, the signs of progressive mental illness were there: He was odd as a small child, and in high school he had difficulty talking and was isolated and laughed at. By 2005 he had developed bizarre and paranoid behavior (wearing shades, whispering, latency of speech, asking students to call him a question mark). Finally, several weeks or days prior to the mass murders, his sleep had decreased at the onset of the last and fatal episode of his illness.

In all likelihood, if he were properly diagnosed and treated in 2005 or even during the week preceding his bizarre murderous rampage, he would have become one of millions of Americans who are under treatment for chronic psychiatric illness and remain perfectly nonviolent. The tragedy was that neither his family, nor his fellow students, nor the faculty recognized that Cho was mentally ill and in dire need of treatment.

Taking Responsibility

Whose responsibility is it to help an acutely mentally ill student get proper help? The majority of first episodes of schizophrenia and of bipolar mood disorders occur in very young men and women of college age. Is it their responsibility to understand what is happening to them and to diagnose themselves?

In the words of my endocrinologist friend Len Poretsky, expecting a student with mental illness to know when to call for help is like expecting a student with appendicitis to operate on him or herself.

Thus the responsibility of helping students with mental illness to get proper treatment should lie with others, i.e. with college administration and with students' families.

Teaching the school or college staff how to help mentally ill students is no different than teaching them how to administer CPR or to recognize signs of child abuse. To think otherwise would be to stigmatize and discriminate against students with mental illness, be it depression or schizophrenia.

Moreover, if a student were suffering from a life-threatening medical illness, even with HIPAA regulations, their families would have been contacted. With suicidal students, unless they are deemed to be an imminent danger to themselves or others, privacy regulations prohibit family notification.

Steps to Prevent a Tragedy

This state of affairs is dangerous and unacceptable. Therefore I would like to propose the following solutions that would untangle the current maze of legal and ethical issues that prevents colleges from helping students with mental illness get proper treatment.

As a condition for matriculation, require all students to sign a confidentiality waiver in case of any suicidal or violent ideation, as determined by student mental health (the imminent likelihood of danger of violent behavior is impossible to establish with any semblance of certainty).

Institute mandatory teaching and dormitory staff training in recognizing signs and symptoms of the three most common psychiatric illnesses that may lead to suicidal or violent behavior: schizophrenia, bipolar disorder and major depression. Training should include recognition of suicidal ideation and violent intent and should not take more than three to four hours.

Using a business model that mandates an evaluation by employee health for anybody who disrupts the work environment, require college staff to refer students with signs and symptoms of serious mental illness for an evaluation by student mental health services. Cooperation with mental health evaluation should not be optional if the student wishes to remain matriculated.

Allow student mental heath services to contact the families of all students with active suicidal and homicidal thoughts, even those that do not threaten to kill themselves or hurt somebody else in the near future.

With the advent of modern psychopharmacology, many more bright and highly functional students with mental illness will attend college. Therefore the issue of how to deal with mental illness on campus will become ever more important.

The stakes are very high and involve our children's lives.

At first glance the approach I have proposed may seem overprotective and excessively limiting of personal freedoms. But in reality it is less restrictive than those used by most business or nonprofit institutions. If implemented, it will save many student lives and reduce or eliminate the stigma of mental illness in the process.

Dr. Igor Galynker is director of the Bipolar Family Treatment Center and associate chairman for research at the Department of Psychiatry at Beth Israel Medical Center in New York.