Va. Tech Tragedy Spurs Examination of Commitment, Campus MH

The killing of 32 students and professors at Virginia Tech University on April 16 opened a wide-ranging, if not always focused, debate about civil commitment and the availability of psychiatric services on campuses around the country.

“Some universities and colleges are extraordinarily underserved,” Jerald Kay, M.D., professor and chair of psychiatry at Wright State University in Dayton, Ohio, told Psychiatric News. Kay is also chair of APA's Corresponding Committee on Mental Health on College and University Campuses. “A significant number of students who need treatment don't go for it, either due to stigma or lack of access.”

The prevalence of psychological problems among college youth is relatively widespread, said Bruce Cohen, M.D., an associate professor of psychiatry and neurobehavioral sciences at the University of Virginia in Charlottesville and director of its forensic psychiatry residency training program, in an interview. The spring 2006 National College Health Assessment, produced by the American College Health Association, said that 45 percent of students surveyed felt so depressed at some point in the school year that they found it hard to function. Nine percent had experienced suicidal ideation, and 1.3 percent had attempted suicide.

Over the course of a year at his own university, said Cohen, 40 to 60 students might be hospitalized for acute depression, bipolar disorder, or other serious psychiatric problems.

“Colleges report higher utilization of mental health services as students who were diagnosed in high school or junior high school enter with psychiatric problems,” said another forensic psychiatrist, Paul Appelbaum, M.D., the Elizabeth K. Dollard Professor of Psychiatry, Medicine and Law and director of the Division of Psychiatry, Law and Ethics at Columbia University College of Physicians and Surgeons in New York. “Trying to block [these students'] attendance would probably constitute a violation of the Americans With Disabilities Act.”

However, colleges may have slightly more leverage over students than other institutions, said Appelbaum. In general, persons over the age of 18 may not be compelled to undergo treatment. However, under some circumstances it can be justified on educational grounds; colleges may be able to require that a student undergo evaluation or remain in treatment as a condition of staying in school.

Some observers have also complained that federal privacy laws or court rulings restrict dissemination of information about potentially dangerous students and that wider knowledge of the psychiatric history of Seung-Hui Cho, the Virginia Tech gunman, might have led to treatment or restraint and prevented the tragedy. But Appelbaum noted that both the Health Insurance Portability and Accountability Act, which governs health records, and the Family Educational Rights and Privacy Act, which covers educational records, contain exceptions to the usual confidentiality standards in cases of emergencies and allow information to be disclosed to parents or third parties.

Systemwide Problems Revealed

Civil outpatient commitment laws vary state by state. Under civil commitment rules in Virginia, a person can voluntarily present to a community services board or a hospital emergency room, said Cohen. They can also be brought in by the police under an emergency custody order. A magistrate can order the person held for 48 hours in the hospital and then must conduct a formal hearing to decide the restrictiveness of the setting and any need for treatment.

According to Cohen, Cho had threatened suicide and was taken for evaluation in December 2005. Although he met the criteria for commitment, the court found that he could be managed in an outpatient setting. Virginia statute requires“ imminent” danger to self or others for confinement, a higher standard than in most states. Over a year had passed from the time of his commitment hearing to the killings, so that even in retrospect the standard was met.

“Imminent danger” may seem clear at first thought, but, asked Appelbaum, “what is 'imminent?' An hour, a day, a week?”

One reason that outpatient commitment is not widely used is that the criteria (like “imminence”) are the same for both inpatients and outpatients, said Richard Bonnie, J.D., the John S. Battle professor of law, professor of psychiatric medicine, and director of the University of Virginia Institute of Law, Psychiatry, and Public Policy, in an interview.

“Someone who meets those criteria needs intensive intervention, which usually means hospitalization,” said Bonnie. “Whatever criteria are used, however, if an alternative to hospitalization in the community is sought, then you'd think it would be intensive and aggressive treatment. But there are big gaps in the service system— the services are not there.”

Magistrates may order treatment, but some do so with hope as their only tool to enforce the patient's compliance.

In theory, the judge's orders are supposed to include provisions for the police, the hospital, or the community services board about what to do if the patient does not appear as directed for treatment.

Apparently, such follow-up did not occur in Cho's case. In fact, Cho's case was not typical of outpatient actions in general, said Appelbaum.“ Typically, the patient is directed to a particular facility or entity with required follow-up. Some states require a treatment plan in advance of release.”

Cho's case was an “unusual failure” of the mental health system, but it points to a structural problem with outpatient commitment systems—there are no teeth in the system, Appelbaum said. But what happened in Virginia also reflects that no outpatient statute provides the authority to treat someone against his or her will. A judge may order compliance, but if the patient refuses treatment, the courts have limited recourse.

One of the problems in Virginia and probably other states is that outpatient commitment is a locally administered process, and little information is collected statewide to permit analysis of its frequency and outcomes, said Bonnie.

Last summer, the state's chief justice appointed a 30-member commission (including Bonnie) to study mental health law reform in Virginia. To record at least some data on outpatient commitment, the month of May was arbitrarily chosen as the time in which every case in the state was to be documented. Bonnie hopes that information gleaned from the documentation will inform the commission's discussions on improving the state's outpatient commitment system. Whatever the details, said Bonnie, services must be available, protocols must be arranged with willing providers, and the law must be modified regarding the criteria for and expectations of commitment.

College Protocols Needed

Back on the nation's campuses, much work remains to provide mental health services to students who need them.

“As more young people arrive at college with prior psychiatric diagnoses, many of them on medications, we don't want to penalize students with disabilities,” said Kay. “Colleges want to establish protection from liability and at the same time give students the benefits they need. We need national guidelines to help colleges respond to students who are disturbed.”

Students who need help should get it, and that means lessening the stigma that drives people away from treatment, he said. The University of Michigan has instituted a program using everything from posters to radio and TV spots to raise awareness of mental illness on campus.

Second, colleges and universities must have adequate funds and clinicians. Right now, resources vary widely. Universities usually offer counseling services, and some have psychiatrists on staff, but they may also refer students to a contract psychiatrist or community sources of care depending on the type and intensity of care needed.

Also, not all colleges require that all students—especially graduate students— have health insurance, and not all health insurance covers students when they go off campus for treatment, especially mental health treatment.

As for the wider aspects of the Virginia Tech case, Appelbaum pointed out that people with serious mental illness contribute to 3 percent of the violence in the U.S. Some in Congress have called for funding to update the national instant-check background system to include people adjudged mentally ill and prevent their purchasing firearms.

“If 97 percent of violent acts are committed by the non-mentally ill, targeting them as a matter of policy is a peculiar thing to do,” he said. ▪