Quotes of the Day

In retrospect, it's easy to see the evidence that Tucson, Ariz., shooter Jared Loughner was mentally unstable. In his community-college classes, he would laugh randomly and loudly at nonevents. He would clench his fists and regularly pose strange, nonsensical questions to teachers and fellow students. "A lot of people didn't feel safe around him," a former classmate told Fox News.

Given these facts and the horrific turn of events at a Safeway supermarket on Jan. 8 that left six dead and 14 others injured, including Representative Gabrielle Giffords, who remains in critical condition, could anything have been done to prevent the violence? What signs that trouble lay ahead were missed? What signs were observed but ignored? In short, what can be done to prevent a potentially ill or unstable person from harming others?

In most states, including Arizona, it's predictably difficult to detain someone involuntarily due to mental illness. If he is not deemed an imminent danger to himself or others, as determined by a judge, in almost all cases, treatment will not come without the person in question admitting that they are ill and need help. Even then, there is no guarantee that help will come readily or swiftly.

"What you have is an obvious need for more capacity in the mental-health system," says Dr. Ken Duckworth, a Harvard professor, psychiatrist and medical director of the National Alliance on Mental Illness (NAMI). A need for more capacity is certainly true in Arizona. According to a 2005 report from the Treatment Advocacy Center, a nonprofit mental-health organization, the state had 5.9 publicly funded psychiatric beds per 100,000 people, compared with a national average of 17. In addition, NAMI gave the state's mental-health system a C in 2009, a step up from its D grade in 2006, but with vast room for improvement. Part of Arizona's low marks stem from its large Native American and foreign-born populations, which are harder to reach and treat, as well as the state's rapid overall population growth and rural regions, which are underserved by medical professionals. Still, the state was not an outlier. In 2009, NAMI gave just six states B grades, while 18 got Cs, 21 got Ds and six got Fs. None received an A.

Regardless of resources available, however, the problem with someone like Jared Loughner is that, without a court order, he would not have received treatment without a self-referral. It appears that his community college, which kicked him out, rightly protected its own population — at least one student and one teacher told the New York Times they feared Loughner would bring a gun to class — but left the rest of the community vulnerable. It would have been up to Loughner to seek treatment, a move many psychiatrically ill people would never make. "Most young people who develop a psychiatric illness — particularly a psychotic illness in which they've lost the ability to discern fantasy from reality — don't have a lot of insight into the fact that they are ill," says Duckworth. He points to a recent online NAMI survey that found that schizophrenics suffered an average of nine years between their onset of symptoms, which often first appear in the late teens and early 20s, and diagnosis.

Often, authorities can intervene only once the illness has taken a dramatic, if not criminal, turn. On the same weekend of the Giffords shooting, the FBI took John Troy Davis, 44, of Denver into custody for threatening the staff of Colorado Senator Michael Bennet. Davis had been a familiar voice to Bennet's office, often calling to complain about Social Security benefits. But on Jan. 6, he began to say things like, "I'm a schizophrenic and I need help," and "I'm just going to come down there and shoot you all." In a subsequent call, he claimed to have killed a woman to get the Senator's attention. He then said, "I may go terrorism." The FBI decided to move on the case.

Other than a public breakdown and a threat to order, however, institutions with some sense of guardianship over individuals, like schools, colleges and, perhaps, corporations, may be the only potential intervenors — though even then, their options are limited by law and by the efficiency of bureaucracies. "At an institution like a university, this [has become] an expected problem," Duckworth says of mental illness. He reports that mental-health professionals working in college settings are overwhelmed by the intensity of the illnesses they see and by the sheer numbers of students in need of treatment.

An investigation conducted after Cho Seung-Hui shot 32 people dead at his school, Virginia Tech, in 2007 found gaps in that state's mental-health system. Yet even proper execution of the state's existing laws might have prevented the tragedy, either by preventing Cho from buying a gun or by forcing him to receive outpatient treatment for his mental illness, which had been identified (in fact, Virginia Tech had him institutionalized briefly but did not follow up after his release). Officials fell down on both counts. "Even in states that have a more paternalistic leaning," says Duckworth, "it's frequently about not executing. There's a passive quality to [enforcement]." (Just this past December, the U.S. Department of Education issued a report saying Virginia Tech violated a federal law on the morning of the shooting by not doing more to warn students that a shooter was on the loose on campus. The university denies it acted improperly.)

In fact, Cho's case is closely analogous to Loughner's, and it is becoming clear that officials at Pima Community College could have noticed sooner that the student was dangerous and unstable. For at least 18 months prior to the Virginia Tech massacre, Cho had shown many disturbing signs: bizarre writings for classes that included revenge fantasies; the stalking of at least three women; near total silence, including with his roommates; and even involuntary commitment to a mental institution. Similarly, it seems that Pima Community College (and Loughner's classmates and instructors) didn't do enough to recognize at least six warning signs in Loughner:

1. For months, he showed a classic symptom of psychosis: disorganized thoughts and speech. He routinely made irrelevant and nonsensical comments in classes. On one test, according to the Washington Post, he wrote, "Eat + Sleep + Brush Teeth = Math." On another test, he wrote, "Mayhem Fest!!!"

2. He showed another symptom of psychosis, or at the very least, an inability to function in social situations. One example from the New York Times: he enthusiastically read a poem in class in which he discussed touching himself in the shower.

3. He showed signs of paranoia, telling a classmate that U.S. currency was worthless and that the government was seeking to control people through grammar. He also became interested in a concept he called "conscious dreaming" (a concept at the heart of the mind-bending thriller Inception).

4. He regularly smoked marijuana, and while there is only a small correlation between having a mental illness and committing violence, that correlation becomes much more significant when mental illness is combined with drug use, according to John Monahan, a professor of psychology at the University of Virginia School of Law.

5. Several classmates said Loughner scared them. One of them even wrote e-mails in June saying she was afraid he would bring a gun to class. A teacher worried every time he had his back to Loughner that the student would pull a gun on him.

6. Loughner had five contacts with campus police, although it is not clear what behavior led to those contacts.

Hindsight is perfect, of course, but all institutions need to monitor students and employees who are consistently acting strangely. There was arguably enough evidence for Pima authorities to go to a judge and have Loughner involuntarily committed to a mental hospital, as Virginia Tech did with Cho. At the very least, the college could have required Loughner to check in with a counselor on a daily or weekly basis.

• Kate Pickert and John Cloud