This month, President Barack Obama said it again.
In his speech on new gun control measures, Mr. Obama repeated the catchphrase of mental health advocates: "We acknowledge that someone with a mental illness is far more likely to be a victim of violent crime than the perpetrator."
Yet that statement seems to clash with the stories that people repeatedly face on nightly newscasts and front pages. Whether it is James Holmes at a Colorado movie theater, Seung-Hui Cho at Virginia Tech, or John Shick at a Pittsburgh psychiatric clinic, mass shootings often seem to involve young men with symptoms that match those of paranoid schizophrenia.
In the face of that, what is the truth about violence and mental illness?
Jeffrey Swanson, a psychiatry professor at Duke University and one of the world's leading experts on the subject, cited a study he helped lead in the late 1990s, looking at the overall incidence of violence in different parts of the country.
MYSTERIES OF THE MIND: SCHIZOPHRENIA
Final in a three-part series.
Schizophrenia involves hallucinations, delusions and cognitive deterioration. It can mean a lifetime of dependency for patients -- and in rare cases, it leads to frightening outbursts of violence.
The bottom line: After excluding people with substance abuse problems, only 7 percent of those with a serious mental illness -- schizophrenia, depression or bipolar disease -- had committed acts of violence, from shoving someone to shooting someone. But among the rest of the population, that rate was just 2 percent.
So, Dr. Swanson concluded, it all depends on how you describe it.
"The vast majority of people with mental illness are not violent," he said, "but you could take the same study and say people with mental illness are three times more likely to commit a violent act than others are."
Analyzing the numbers
Still, it does seem that a disproportionate number of mass shootings involve people with mental illness.
The first thing to note about that, Dr. Swanson said, is that mass shootings by definition are tragically dramatic, frightening and hard to fathom, yet also comprise only a tiny fraction of all homicides.
"Most murders are committed by people who are perfectly normal from a mental point of view," added John Csernansky, psychiatry chairman at Northwestern University. "So if an ordinary person shoots his business partner for money or his wife for infidelity, it doesn't hit the papers in the same way. If a person with schizophrenia commits an act of violence and that is driven by their delusion, it's more than likely going to be an act that doesn't make any sense."
Other research has shown violent people with mental illness may not differ that much from people who don't have a psychosis.
A study by University of Pittsburgh psychiatric researcher Edward Mulvey several years ago showed that people released from mental hospitals were no more violent in the year afterward than other people living in the same neighborhoods, as long as they weren't abusing drugs or alcohol.
And a 2002 study by the U.S. Secret Service on school shootings showed that most were not committed by someone with a diagnosed mental illness.
After looking at 41 school shooting perpetrators between 1974 and 2000, the agency found that only one-third of them had ever received a mental health evaluation. On the other hand, nearly 80 percent had experienced suicidal thoughts or attempted suicide, and more than half were "extremely depressed or desperate."
How schizophrenia contributes
Despite the nuanced results of these studies, there is no escaping the fact that some aspects of schizophrenia can contribute to mass shootings.
Dr. Csernansky thinks it's important to separate the paranoia that patients feel from the decision to purchase weapons and fire them at people.
Schizophrenia patients often feel that some outside power or person is controlling their thoughts. "Most patients who believe they can be influenced by others find that frightening. I think an ordinary person would find that frightening."
So the paranoia may make a schizophrenia patient scared and angry, he said, "but my theory is that the shooting response has little or nothing to do with schizophrenia."
"If you were to threaten 10 different people on the street, they might all react in different ways. One might punch you. Another might run away. Those are things that are determined by other aspects of who they are as people."
Orin Bolstad, a forensic psychologist in Oregon, thinks the type of schizophrenia someone has is a major influence on whether he will be violent.
Mr. Bolstad, best known for his interviews with Kip Kinkel, who as a teenager killed his parents and then two students at his high school in Springfield, Ore., said schizophrenic people involved in mass shootings usually have the paranoid form of the disease.
"If you look at simple or disorganized schizophrenia," he said, "you're going to find that the violence rates are very low. If you look at those with paranoid schizophrenia, you'll find the violence rates are much higher."
Kinkel, who is serving a 115-year sentence for the 1998 killings, believed the Chinese were going to invade America, Mr. Bolstad said, and thought a local man he had angered was stalking him. He also heard angry, critical voices in his head, as well as voices that ordered him to do things.
People with the disease often feel they cannot refuse the "command voices."
After Kinkel killed his parents at their home, Mr. Bolstad said, "how do you explain why he then went to school and killed some students and injured many more? If you were to ask Kip why this happened, and I did, he looked at me angrily and said 'I had no choice.' "
The Kinkel case also demonstrates one other common problem: young men with paranoid schizophrenia are often adept at hiding their psychotic thoughts from others.
Kinkel was seeing a psychologist for depression before the shootings, but he told Mr. Bolstad that he never told his therapist about his hallucinations or delusions "because the therapist talks to my mother, and my mother talks to everyone, and soon no girl will want to go out with me."
Others with schizophrenia deny that they are mentally ill at all.
In a 1993 study, Columbia University researcher Xavier Amador found that nearly 60 percent of schizophrenic patients denied having a mental illness, a condition known as anosognosia.
"We all know what denial is and we're pretty good at that," added E. Fuller Torrey, a psychiatrist and reform advocate. "So it's difficult for most people to really understand anosognosia. These patients are simply unable to understand that there is anything wrong with them.
"I've had patients say, 'Doc, if you really want to help me, just call the CIA and stop them from putting these ideas into my head.' "
Pushing for more treatment
That lack of awareness is a major reason why Dr. Torrey has pushed for several years to strengthen state laws that would require people to get psychiatric treatment when they're a danger to themselves or others.
According to his Treatment Advocacy Center website, 44 states, including Pennsylvania, now have "assisted outpatient treatment" laws, which allow judges to force people to get treatment and take antipsychotic drugs if they have a history of refusing to take their medication.
One of the best of those statutes, he said, is New York's Kendra's Law, passed in 1999 after a mentally ill man not taking his medications pushed Kendra Webdale to her death in front of a New York subway train. The law allows judges to require people to get outpatient mental health treatment, and a recent study showed that those who were ordered into treatment were two-thirds less likely to be arrested than those not getting forced treatment.
Dr. Torrey, executive director of the Stanley Medical Research Institute in Chevy Chase, Md., said these laws are vital for the major chunk of schizophrenia patients who deny they are sick.
"The idea of people having a right to determine whether they are treated is fine for the 50 percent who know they are sick. They may decide not to be treated, but at least you assume they can make a rational decision. For the other 50 percent, you can't make that assumption."
The reluctance of some judges or hearing officers to force patients to get treatment also can be heartbreaking for family members of patients, added Ned Kalin, a University of Wisconsin psychiatrist.
"That's a real frustrating issue for families," he said, "because they often run into social agencies and laws that say unless the patient is imminently dangerous, he can decide on his own whether to seek treatment, but one of the problems of these illnesses is that your judgment is impaired."
From his experience in the state hospital system, psychologist Frederick Frese, who has schizophrenia himself, said he can recall many times when patients who were acting out were forced to take medication.
"And then I've had them say a week later, 'Why didn't you do that earlier? Couldn't you tell I was out of my mind?' "
Many mental health experts find Dr. Torrey's perspective too simplistic.
"Dr. Torrey is an advocate for benign paternalism for people who don't know they're ill," said Duke's Dr. Swanson, "but that is a bit of a caricature of the situation. That may be true of some people, but it oversimplifies the situation."
But Mr. Frese said he basically agrees with Dr. Torrey.
"My big motivation on this is that a large percentage of the people in prisons and jails are mentally ill, and that's gone up precipitously" since many state mental hospitals were shut down over the past 30 years, Mr. Frese said.
"Where else are you going to put them? 'No forced treatment from the psychiatric establishment' sounds wonderful, but in practice what that means, particularly if you're a minority male, is you're going to get forced treatment in the criminal justice system and you're going to be a victim of those predators in the jails."
On that point, Dr. Swanson concurs.
"I think it's a national scandal that we've got more people with serious mental illness in our large city and county jails than we ever had in any asylum or that we currently have in a state psychiatric hospital," he said. "I think the causes for that are complex. You have people who are there because they are sick and didn't have access to treatment and ran afoul of the law, but you also have people who committed serious crimes who also have mental illness."
Will gun control help?
Most mental health experts agree with the Obama administration's new push for better gun control laws, but they are skeptical that will help prevent mass shootings.
"I think we can all agree that people who are psychotic shouldn't be able to go out and buy weapons," Dr. Torrey said, "but good luck if you think you can do anything about that. The gun lobby is very strong, and I think you'll make very little progress if you just focus on the guns."
Dr. Swanson noted that many mass shooters who were psychotic had never received treatment, so such gun laws would not have prevented those tragedies.
In addition, he said, these laws would cover some people who are not a threat.
Because mass shootings are so rare, it is almost impossible to predict who is likely to commit them, Dr. Swanson added. "If you look at all these incidents and you say what are the common characteristics, you get this profile of troubled young men, which matches a lot of other people in the population who never carry out such violent acts."
In a recent perspective article in the New England Journal of Medicine, two psychiatrists suggested that a common thread among mass shooters is their tendency to be socially isolated, which was particularly noticeable in the case of Adam Lanza, who killed 27 people, including 20 first-graders, in Newtown, Conn., shortly before Christmas. The horrific case prompted the latest call for more gun control.
But Dr. Swanson said even the issue of social contact can be complicated.
One study of schizophrenia patients showed that if those with milder forms of the disease interacted with more people, they were less likely to be violent, but in those with more severe illness, socializing "tended to provoke more conflict and fear and violent altercations with family members."
He makes one other point about gun violence and mental illness.
"If you examine government statistics and look at those who die from gunshots, nearly 60 percent are suicides, and suicides have more to do with mental illness than homicides do."
About this series
Every day, we are reminded of a mental disorder that affects our society.
Yet another mass shooting rips lives apart, and often the gunman has a history of mental illness. News reports document another athlete whose life has crumbled after repeated blows to the head.
A new statistical study raises the odds of a child being born with autism, or television commercials show depressed people barely able to get out of bed. And each month, there seems to be a new type of phobia to report.
They all have one thing in common: deep-rooted defects in the function of the brain that scientists are just beginning to understand.
Over the next year, the Pittsburgh Post-Gazette will explore five of these brain disorders: schizophrenia; chronic traumatic encephalopathy -- a form of brain deterioration affecting athletes and soldiers; autism; depression and phobias.
Number of people affected: 3.1 million in the United States, 1 percent of the population.
Onset: Late teens or early 20s for men; mid-20s for women.
Symptoms: Delusions (false beliefs); hallucinations (hearing voices); social withdrawal; poor thinking skills.
Derivation of term: From the Greek for "split mind," schizophrenia actually does not involve multiple personalities or other forms of split identities.
Where to get help: If you are concerned that you are experiencing symptoms of mental illness or have family members who are, you can contact these places: Western Psychiatric Institute and Clinic of UPMC has a call center for general inquiries and for scheduling outpatient appointments at 412-624-2000. The clinic, in partnership with Allegheny County, also offers the re:solve Crisis Network, which provides telephone, mobile, walk-in and residential behavioral health crisis services around the clock to any resident of the county at 1-888-7-YOU-CAN (1-888-796-8226). Help can be found at the West Penn Allegheny Health System by contacting www.wpahs.org/specialties/psychiatry, or calling 412-330-4000. Mercy Behavioral Health, part of the Pittsburgh Mercy Health System, has an around-the-clock toll free number, 1-877-637-2924, and also operates an around-the-clock crisis center at 264 South Ninth St., South Side. More information available at www.mercybehavioral.org
Mark Roth: email@example.com or 412-263-1130.