With the Army's disclosure that Army Spc. Ivan Lopez was being evaluated for post-traumatic stress disorder before he went on a shooting rampage Wednesday, there were once again questions about whether the Army could have prevented the violence at Fort Hood.
Experts in mental health say (even as more facts about Lopez emerge) that it's highly unlikely the violence could have been predicted. Just raising that question, psychologists and psychiatrists say, shows how much Americans misunderstand the link between mental illness and violence.
One national survey in 2006 found that most Americans — 60 percent — believed people with schizophrenia were likely to be violent. But the vast majority of people with psychiatric disorders are not violent. In fact, another study found they are far more likely to be the victims of violence, and that 1 in 4 experience violence every year.
Dr. Carl Bell, a psychiatrist at the University of Illinois at Chicago, says being able to predict who will be violent in advance "is impossible."
"The reality," Bell says, "is that prediction of violence is only useful in an immediate clinical situation: Someone comes in and says, 'I'm going to kill myself.' Then you take their word for it, and can predict violence in the short term. But you cannot use that to predict violence in the long term."
Army officials said Thursday that Lopez had seen a psychiatrist in the past month, but there were no indications that he was suicidal.
Dr. Thomas Grieger, a clinical and forensic psychiatrist who worked in military hospitals for three decades, says that one reason violence is so hard to predict is because it is so rare. "Acts of extreme violence and acts against yourself — suicide attempts — are so infrequent that it really becomes almost impossible to predict when any individual or situation is going to escalate to that," Grieger says. "So many factors come to play: interpersonal relationships, difficulty in the workplace, issues at home, career issues and true mental health issues like depression, bipolar disorder or psychosis."
Medications are another complicating factor — which ones and whether a soldier was taking them. For many troops back from deployment, multiple medications are prescribed to deal with pain, mental health issues and other problems. Army officials say Lopez had been prescribed Ambien, a drug to help him sleep, and other medications to treat anxiety and depression.
Still, there are a few factors that are more likely than others to be present among people who do become violent. The best predictor of future violence is whether a person with a psychiatric illness has been arrested or acted violently in the past. And people with substance abuse problems, on top of mental illness, are also at a greater risk of committing violence.
Bell says there's growing study of "mass murder preceding suicide." In these cases, someone who goes on a shooting spree wants to die, but wants to do so in a way that gets a lot of attention.
"There's a huge dynamic in suicide where people get angry because they're hurt," Bell says. "They say, 'I'll fix you. I will kill myself and I'll get even with you.' What better way to get even (and make a big splash) than to kill a bunch of people before you kill yourself?" It's been reported that Lopez shot himself, bringing his shooting spree to an end, after he was confronted by a police officer.
This was the second mass shooting at Fort Hood in less than five years. Last year, Maj. Nidal Hasan, an Army psychiatrist, was sentenced to death for killing 13 people and wounding 32 others in the November 2009 shooting that remains the worst mass murder at a military installation.
It's more reasonable to question whether the Army could have prevented Hasan's violence — but not because of mental illness. The FBI had seen email that Hasan had sent to the website of terrorist Anwar al-Awlaki, expressing his own sympathy toward suicide bombers.
And, as my NPR colleague Daniel Zwerdling reported, Hasan's supervisor at Walter Reed Army Medical Center was so concerned about Hasan's "pattern of poor judgment and a lack of professionalism" that he wrote a memo sharply criticizing the doctor. That kind of document could have ended a military career.
But instead, the Army — with a shortage of psychiatrists and a flood of soldiers returning from Iraq and Afghanistan with mental health problems — kept Hasan working.
After the 2009 shootings, the Pentagon commissioned a report on how to prevent a repeat of the shootings. The report made 47 recommendations for how to improve security. One was to improve training so that military personnel could better "identify contributing factors and behavioral indicators of potentially violent actors." Another was simply to realize that its own soldiers could be a threat. Another was to find ways to restrict the carrying of personal firearms on military bases. Lopez, it's been reported, died of a self-inflicted gunshot wound from a .45-caliber Smith & Wesson semiautomatic pistol. The gun, according to media reports, was purchased at the same Killeen, Texas, store where Hasan bought his pistol.