May, 2007. Media coverage regularly gravitates to sensational, lurid, or tragic events, giving the impression that catastrophes are far more prevalent than they really are. However, when devastating loss of human lives relentlessly persists in Iraq, more and more of us are directly or indirectly affected, with family and friends among those who are lost. But when an almost unimaginable tragedy strikes a college campus, such as the recent tragedy at Virginia Tech, all of us are deeply affected. How could this happen? How safe is my college-age child, grandchild, sibling, family member? In psychiatry, we are in the business of trying to understand human behavior, provide advice, prescribe treatment, and suggest prevention strategies, yet we are humbled by an eruption of violent behavior of this magnitude. Those of us in the behavioral health field, with ferocious intensity and curiosity, devour every emerging detail about the perpetrator. We anticipate that there might be a history of abuse or neglect, severe trauma, a fragmented and unstable family, or a pattern of substance abuse, but no such data have emerged, at least so far. What does emerge is an unfolding story of a painfully isolated young man, who walled himself off from his family and the world, despite efforts by many to reach out and try to bring him out of his shell.
The Monday-morning quarterbackers, ubiquitous experts suddenly filled with wisdom, appear on all of the major networks, sending up the usual flags-shouldn't someone have seen this sooner, surely it was obvious that this man was a powder keg about to blow, shouldn't he have been involuntarily hospitalized, aren't people who are mentally ill dangerous? And of course these are all crucial issues, riddled with a mix of known facts and remarkable fears, prejudices, and misinformation. But we in the field must do what we can to underscore what we do know and where we are falling short. We know more and more about risk factors, gene-environment interactions, and warning signs of dangerous behavior, either to oneself or to others. We won't be able to predict every outcome, no more than medicine can predict the future for an individual patient whose family history shows a high risk of cancer. But we need to ask more questions, screen more college students, and intervene more definitively when danger seems a real possibility. A tall order for us all, but one we must embrace.
In this issue of the Journal, Currier et al. and Daniel et al. present data comparing the use of aripiprazole with haloperidol and placebo to treat agitation in the emergency setting, complementing the November, 2005 Supplement on the Treatment of Behavioral Emergencies. Although agitation is not always prominent when violence is near, as in the recent Virginia tragedy, it often precedes loss of behavioral control. The success that psychiatric hospitals have had throughout the country in reducing the incidence of restraint and seclusion has been remarkable, and it reflects patient-centered engagement, better advanced planning, and judicious, preferably voluntary, use of medications to provide relief to patients experiencing escalating agitation. Interventions such as these serve as guides to help us partner with our patients to look for other ways to help them sustain self-control. Meanwhile, society must increase its efforts to curb violence unrelated to mental illness, to make our world a safer place.
John Oldham, MD