A Path to Mental Health
A tortured young mind went on a deadly rampage two weeks ago, leaving families forever devastated, a campus weeping, and a nation mourning. In the aftermath, it is only natural, if not obligatory, to seek explanations and look for ways we can prevent or mitigate such tragedy. The problem is complex. But at the center is a human being desperate for psychiatric intervention. This catastrophic event, though rare, should be a wake-up call that we need to incorporate routine mental-health screening and prevention programs into adolescent medical care and school counseling. Such efforts could potentially thwart at least some of the psychopathy that underlies school shootings, since medicine now can help even the most severely ill. And they would also benefit the many young people struggling with far less extreme brain disorders.
The U.S. Secret Service, which studies "targeted violence," provides insight on the urgency of the need in its 2002 "Safe School Initiative" report: School attacks, instead of being the random impulsive acts of brawling rowdies, are well-planned events mostly carried out by a single student-who is not evil but mentally ill. Except for being male, the 41 attackers studied fit no profile of family background, race, ethnicity, or even academic performance. Many were A and B students. Few had a history of violent or criminal behavior. But their thoughts were of violence, and their behavior was often intimidating. They frequently expressed violent themes in their writings, in one instance portraying homicide and suicide as solutions to feelings of despair. The perpetrators often had telegraphed to other students and teachers their depression or desperation and either talked about or had attempted suicide. Feelings of persecution by others were common and led to festering resentment and anger.
Psychiatrists and psychologists recognize that these are red flags demanding medical intervention. Yet one of the most striking findings in the report was that the vast majority of these students never had a mental-health evaluation. No wonder only 17 percent were diagnosed with a psychiatric illness-it wasn't looked for. That alone points to a huge mental health gap: If the distress of these students didn't trigger medical attention, it's unlikely that less severe struggles that are seen in as many as 15 to 20 percent of other students will do so.
Still a chance. Yet the school years are a critical time in the development of minds and brains. In fact, the brain does not fully mature until late adolescence and early adulthood, when the prefrontal cortex undergoes the final stages of building and organization. This area controls impulses, moral reasoning, judgment, and rational thinking and accounts for that magical time parents yearn for when their emotion-driven teens morph into people capable of nuanced thinking. This is also the time when two major brain illnesses emerge-schizophrenia, a disorder marked by irrational thought, and bipolar or manic-depressive illness, a disorder of mood. Henry Nasrallah, a schizophrenia researcher at the University of Cincinnati, notes that the experiences of a 20-year-old student struggling with messages from within or perceived signals from without and putting the wrong meaning on other people's actions (and behaving accordingly) are all signs of an emerging schizophrenia. Rarely-and he stresses rarely-does it lead to violence. But when these illnesses erupt into psychoses, the patient loses touch with reality and displays bizarre and inexplicable behavior.
Only recently have we learned that these are neurodevelopmental disorders whose early signs might well be picked up in routine pediatric screening. For example, a classic behavior in a child that can precede psychosis later in life is speaking to almost no one, even family, says Nasrallah. Genes are known to confer vulnerability, but equally important is the environment. Stress or great disappointment can exacerbate symptoms; connecting with an adult in an ongoing relationship can do the opposite. Interventions like social-skills training combined with talk therapy and targeted medication can make a huge difference. Early treatment can lessen the frequency and intensity of psychotic episodes, leaving many patients with only the mildest of symptoms. And the younger the brain, the more malleable it is. The ultimate goal is to not only modify evolution of disease but keep it from arising in the first place. This is achievable, and the path to get there is becoming clear.
This story appears in the May 7, 2007 print edition of U.S. News & World Report.