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
"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
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
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
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
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
"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
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
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
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.
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
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
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