Several weeks before Aaron Alexis killed 12 people at Washington Navy Yard in September, he told police in Rhode Island that he heard voices emanating from hotel walls. Years earlier, he accused strangers in public places of laughing at him and randomly shot at the tires of a car owned by construction workers near his home.
One of the most tragic and frustrating aspects of Alexis’ case, and that of many other mass shooters, is how their earliest symptoms of mental illness seemed to slip through the system.
Untreated mental illness doesn’t usually erupt in violence, of course. More commonly, delusions, manias, and paranoias simply emerge in adolescence and quietly build, potentially making it hard for their host to function normally in later years. Often, people with schizophrenia or bipolar disorder don’t recognize their symptoms until it’s too late, causing them to depend on treatment with aggressive doses of anti-psychotic medications, which themselves can cause mental fogginess and extreme lethargy, for their entire lives.
But a four-year project from the National Institutes of Mental Health, wrapping up this summer, aims to change that. It attempts to intercept serious mental illnesses when their symptoms first crop up, allowing these patients to return to normalcy quickly—and, the NIMH hopes, permanently.
“The time between the onset of psychotic symptoms and when appropriate treatment is initiated is a critical period,” said Robert Heinssen, a schizophrenia expert who launched the RAISE project. "With what’s called ‘the duration of untreated psychosis,’ the longer it is, the more likely it is you're going to have an unfavorable outcome.”
Psychosis is a symptom, and sometimes a precursor, of schizophrenia and bipolar disorder, commonly considered two of the most debilitating mental illnesses. People experiencing psychosis might believe things that aren’t true, hear voices, or start making profoundly bad decisions.
Writing in Harper’s in 2010, Rachel Aviv describes Anna, a woman whose mother had schizophrenia and for whom the prospect of her own, eventual psychotic break had loomed throughout childhood. After 20-some years of lucidity, one day while walking through an academic building Anna noticed that, “a bust of Plato, which she had never noticed before, seemed to be calling out to her.” She soon began to develop strange ideas, such as that the world was "made up of gasses," and began "blowing on books to see whether they would disintegrate."
“We don't know exactly whether that's going to be schizophrenia, bipolar, major depression with a psychotic feature, or whether it's a brief psychosis that's going to resolve,” said Heinssen. “It's a way station in a process that can take several turns.”
Not everyone who experiences psychotic episodes will go on to develop schizophrenia, but among those who do, the consequences are tragic. Roughly 73 to 90 percent of people with schizophrenia are unemployed. Some recover, but many live in halfway houses, with family, or on the street. One in 10 people with schizophrenia kill themselves, and about 15 percent of people in prison have serious mental illnesses.
And unlike degenerative brain diseases, such as dementia, schizophrenia seems to strike people in the prime of their lives.
“This is a disease that starts in late adolescence, just when people should be becoming independent, and instead they're becoming entirely dependent and disabled,” NIMH director Thomas Insel told me. “It strikes people who seem gifted and might have been on a path to do great things. And all of a sudden, they are wrapped up in delusions that are just so frightening.”
At their worst, serious mental illnesses can drive the people they afflict to hurt others. Though the majority of people who experience psychosis never commit crimes, 38 of the perpetrators in 62 recent mass shootings analyzed by Mother Jones showed signs of mental illness.
Today in the U.S., treatment for psychosis usually only occurs when the person’s symptoms become alarming enough attract the attention of their family, friends, or authorities, and the patients get hospitalized.
From there, “usually someone just sees a psychiatrist, and sometimes they decide not to see a psychiatrist because they may not think they're sick,” Insel explained. Then, if they have another psychotic episode, “People come into the hospital for a brief time, they get medication, it makes the voices go away, they decide they're better, and they go about their business. But they still have schizophrenia, and they get rehospitalized or they end up in jail, where they don't get optimal medical psychiatric care. It's an awful roller coaster for the first few years.”
This path, however, neglects the critical window of time between when the symptoms first occur—when Anna first heard the bust speaking to her—and when medication or therapy is administered.
When treated soon after their first sign of psychosis, individuals are more likely to avoid relapse and hospitalization, studies from Europe and elsewhere have shown.
According to Aviv’s research, there are only about 60 existing clinics that focus on early psychosis intervention, and only about a third focus on the prodrome stage, the time when patients first start to imagine things but before they start to believe that their false beliefs are real.