Should John Shick have been involuntarily committed for a psychiatric evaluation in the weeks and months before he shot and killed one person and injured five at Western Psychiatric Institute and Clinic of UPMC on March 8?
It's one of the main questions at the heart of Allegheny County District Attorney Stephen A. Zappala Jr.'s ongoing investigation in the horrific incident that ended when Mr. Shick was shot and killed by a University of Pittsburgh police sergeant.
To Mr. Zappala it's an easy call.
"Quite frankly, it appears that in February it should have become a police matter in terms of an involuntary commitment and he should have been taken to an emergency room on that basis," Mr. Zappala said Wednesday.
He was referring to incidents on Feb. 10 and Feb. 20 when Mr. Shick walked into UPMC Shadyside hospital with a bat and was "menacing" people, incidents so upsetting to his primary care physician that the doctor refused to see him anymore. The doctor also tried to have him involuntarily committed.
The doctor began the "302 commitment" process, as it's called in reference to the state statute that guides the law. But the effort was scuttled when Mr. Shick was uncooperative with a mobile psychiatric unit that was sent to his home. The psychiatric unit then tried to interview the hospital employees who were threatened, but they had left work for the day and the issue was left with the primary care physician to follow up. It's not known if the doctor ever did follow-up.
A spokeswoman for the Pennsylvania Department of Public Welfare, which has oversight authority on 302 commitments, said on Friday that the department is reviewing the February incidents involving Mr. Shick to see if the process was handled properly by everyone involved.
UPMC maintains the bat incidents aren't as bad as they sound and were handled properly.
"He had a bat. He was using it as a cane. Never made any menacing moves, threatening behavior," UPMC spokesman Paul Wood said. "Security was called because of his erratic behavior. But at no time did he make a threat, brandish the bat as a weapon."
Mr. Shick tapped the bat on the floor and wandered around the lobby talking, according to the account of security guards contained in an internal report, according to Mr. Wood.
Mike Manko, spokesman for the district attorney's office, said it stands by its description of Mr. Shick's actions at the hospital as "menacing."
"We're comfortable with what we said on Wednesday," Mr. Manko said.
Mr. Wood said that nothing Mr. Shick did merited calling police or attempting to have him involuntarily committed, a decision that was made by both doctors and security.
Mr. Wood would not respond to questions asking why Mr. Shick's primary care physician started the 302 commitment process based on the incidents.
Pennsylvania state law allows a person to be involuntarily committed for up to five days if the person is shown to be a danger to himself or others.
Any person -- a family member, co-worker, friend or others -- can become an initial "petitioner" if he or she has witnessed the dangerousness of the person. The petitioner has to sign a 302 form requesting that someone be involuntarily committed. A designated county health representative -- in Allegheny County it is a mental health professional in the Office of Behavioral Health -- approves the petition.
Approving the petition allows law enforcement or an ambulance crew to forcibly take the person to the nearest emergency room where a physician must do an evaluation within two hours to determine if the person will stay for up to five days for treatment. At the end of that time a longer stay can be requested as well.
But in addition to allowing any petitioner to begin the process, the 302 law also gives unique power to police and physicians to approve an involuntary commitment on their own, allowing them to have a person taken to an emergency room for an evaluation without a review by the county authorities first, as a regular petitioner would.
Pittsburgh police never had a chance to use that power, though, because they were never notified of Mr. Shick's incidents with a bat in February at UPMC Shadyside.
But being able to say how any one incident should have been handled is difficult, said Kim Welch, manager for Emergency and Community Integrated Services in the county's Office of Behavioral Health, because how the law plays out day to day "is complicated."
The 302 law "is really about a balance between safety, health and someone's rights," she said. "The vast majority of the time we believe the process works.
"But ideally, we'd be able to engage someone before it becomes necessary to use a 302," she said.
And that has been happening in Allegheny County over the last five years, county officials believe.
The number of 302 commitments in the county have decreased steadily since 2007, from 4,456 in 2007 to 3,795 last year, for a 12 percent overall reduction. The county is on pace this year to fall still lower, with 631 through the end of February so far this year.
The reduced number of 302 commitments "is a very good thing," said Patricia Valentine, executive deputy director for Integrated Program Services in the county's Department of Human Services.
She traces the decrease to a series of programs that were created beginning in 2007 as the county was anticipating the closure of Mayview State Hospital in 2008, which was going to mean hundreds of more people needed care in the community.
"We were able to develop a lot of services to reach out to people in creative ways that we weren't before -- and earlier," she said.
Among those are the county's nine community treatment teams, which each treat about 100 clients in the community, visiting them where they live and ensuring they're getting any help they need or just making sure they've taken their medication.
One of the other changes the county made in 2007 was to change how its 24-hour crisis system responded to calls of concern. Previously, the county had a consortium of seven different psychiatric hospitals that rotated the duties of responding to calls.
Starting in 2007, the county contracted with Western Psych to be the sole provider of those services, which led to creation of the re:solve Crisis Network by UPMC, which provides 24-hour coverage for emergency psychiatric services.
It was because of that change that in February when Mr. Shick's primary care physician at UPMC called to say Mr. Shick should be committed, it was a re:solve mobile psychiatric unit that responded to his home, and later UPMC Shadyside.
Though some critics believe the system is still problematic, and could fail to reach the people it needs to if cuts are made by the state this year, Barry Fisher, a Pittsburgh-area psychiatrist, believes the changes that began in 2007 have improved the system -- including 302 commitments.
"Recent events notwithstanding," Dr. Fisher said, "I think overall we're doing a better job of treating folks. We're getting people in and working with them in a more collaborative manner."
Harriet Baum, former executive director of NAMI Southwestern Pennsylvania, an advocacy group for mental health clients and their families, said, however, that even if the system managed to commit Mr. Shick, it may not have been a panacea.
"In involuntary commitments, many people really resent it and are angry about it and are often not likely to follow the recommendations when they get out," she said.
If some of the other services available to Mr. Shick, including the outpatient visits he had with a Western Psych doctor in November, had worked, it may have been the difference.
"People are more likely to buy into the process if they're part of it," she said.
One out-of-state expert on forensic psychiatry who has studied mass shooters like Mr. Shick, however, believes that the system both here and nationally has a major flaw.
"Mental health professionals don't ask about homicidal fantasies enough," said Michael Welner, a forensic psychiatrist in New York and founder of The Forensic Panel consultants group. "We ask about suicidal thoughts, but not homicidal."
Among other cases he has consulted on, Dr. Welner was previously hired by Mr. Zappala's office to analyze and interview serial killers Richard Baumhammers and Ronald Taylor.
Asking about homicidal thoughts is important, Dr. Welner said, because "mass shooters aren't people who just snap; they're people who have fantasized about it for a long time. They're at a juncture in their life where their sense of failure and emasculation seems permanent to them."
Mr. Zappala said that he has evidence that Mr. Shick had been planning his attack for a month.
In that time, Dr. Welner said, Mr. Shick's anger likely grew to encompass not only his UPMC doctors whom he felt had not given him proper care, but everyone else, even random employees in a psychiatric hospital where he was once treated.
"You have to be resentful of everyone in order to kill anyone," Dr. Welner said.
Jonathan D. Silver contributed to this report. Sean D. Hamill: email@example.com or 412-263-2579.