How often do we hear that a violent criminal was "mentally unstable?" Too often, should be the most appropriate answer.

Recently we heard the story out of Florida on Dec. 14 where Clay Duke, 56 and suffering from bipolar disorder, opened fire at a school board meeting, missing all the members before he shot and killed himself. Now there is Jared Loughner, 22, the suspect in Saturday's high-profile shooting in Arizona that left six dead and 14 wounded, including Congresswoman Gabrielle Giffords; it was said by the sheriff's office that he had exhibited signs of mental illness but seems to have gone without treatment. Other high profile mentally ill violent persons include John Hinckley, President Reagan's would-be assassin in 1981, or Charles Whitman, the gunman at the University of Texas in 1966.

These are high profile events in other states but they could happen here, too. How much we know about mental illness can also tell us how well prepared we are to deal with such a crisis.

Public opinion surveys suggest that many people think that mental illness and violence go hand in hand - a recent study found that 60 percent of Americans thought that those with schizophrenia and 32 percent that people with major depression are violent. The research does not support this perception. While most individuals with mental illness are not violent, a subset are. We need to ask: is this subset more violent than the general population and if so, why?

The January 2011 issue of the Harvard Mental Health Letter talks about how multiple factors contribute to violent behavior in the mentally ill. Violence is found in those with schizophrenia or bipolar disorders 3-4 times more often for those with a substance abuse disorder than for those without.

One finding was that after controlling for substance use, rates of violence may reflect factors common to a particular neighborhood rather than symptoms of a psychiatric disorder.

Another finding noted a shared genetic vulnerability or common elements of social environment, such as poverty and early exposure to violence, were at least partially responsible for violent behavior.

It is easy to suggest "families should take care of these ill folks," which would be nice if families were so supportive or capable of doing so; many are not.

It is also simplistic to suggest "they should be locked up and not let back out" as it would be very costly; how should it be paid for? Perhaps more importantly, what would this option say about our society and how we treat victims of mental illness?

Clearly, under certain circumstances, such as when public safety is at risk, detention may be necessary. However, this strategy need not be the first line of intervention. And allowing detention to be the first line of intervention allows for criminal behavior by the mentally ill to occur in the first place with the oft consequence of there being a victim. We all know high profile cases don't represent the norm, but there are many less serious and less prominent examples that are devastating nonetheless.

How should violence by the mentally ill be prevented? Substance abuse is a trigger for violence in the mentally ill more than for the ill who do not abuse.

Considering this, "research suggests that adequate treatment of mental illness and substance abuse may reduce rates of violence," stated the Harvard Mental Health Letter.

It is further noted that interventions should be long-term and include a range of psychosocial approaches, including cognitive behavioral therapy, conflict management and substance abuse treatment. In other words, we can't ignore mental illness or offer single-level approaches; this requires a sustained holistic approach.

All this sounds great, but if there is no public will for helping those afflicted by mental illness, there will be no public support and we won't do what is necessary to help prevent those with mental illness from becoming violent.

No one chooses to be mentally ill. Many of the causes are genetic and exacerbated by environmental stressors.

If you think life is hard for those living with or around mentally ill persons, just remember that life is even more difficult for those afflicted by mental illness. This becomes a collective problem when those afflicted go without help.

PAUL HEROUX of Attleboro can be reached at Paul_Heroux@hks11.harvard.edu.

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