Guest Blog – Addictions and Mental Illness: Five Years On, We Still Need To Stick Together

By: Angie Hamilton, Executive Director, Families for Addiction Recovery (FAR)

Once again, thanks Marvin Ross for this opportunity to respond to The Pitfalls of Supportive Housing, Part 1 and Part 2. This feels like déjà-vu. In 2017 I wrote Addictions and Mental Illness: We Need to Stick Together in response to  Addictions and Mental Illness Do Not Belong Together, Part 1 and Part Two.

David Ross, and everyone else living with mental illness, addiction or both, deserve a safe home and community. We have health laws and a Mental Health Act that are supposed to keep people with a “mental disorder” safe from themselves and others, and others safe from them. Sadly, these laws, as currently drafted and/or applied, are not keeping people safe.

It is not the job of those who are afflicted to fix these laws and how they are applied. It is the job of our governments, those who elect them, and the health care professionals who are responsible for interpreting and applying these laws. And there is growing recognition within the medical community that they have not been providing those with addiction the same protections under the Mental Health Act as those with other mental health conditions.

So, it is discouraging to see those who struggle with addiction being blamed and stigmatized for this sad state of affairs, especially by a psychiatrist. I have attached a response from two members of FAR’s Advisory Board, one an addiction medicine physician and the other a psychiatrist, which explain that addiction is a treatable chronic illness, like other mental health conditions. They also explain that concurrent conditions, where a person has an addiction and another mental health condition, are very common and that both conditions need to be treated together.

A recent Guest Essay in The New York Times by a member of their editorial board illustrates that:

• addiction is a pediatric illness;
• most continue to view it as a moral failing or lack of willpower;
• addiction psychiatry did not become a subspecialty until 1993;
• few psychiatrists are trained to treat addiction;
• a functioning, evidence-based system of care for addiction does not currently exist;
• those with concurrent conditions are less likely to get any treatment; and
• addiction receives only a fraction of the resources expended on other mental health conditions.

In Part Two, Dr. Dawson states that those with severe mental illness are vulnerable and easily victimized by “unscrupulous addicts and dealers”. Are those who also struggle with addiction not doubly vulnerable and at risk of being victimized? In fact, Marvin Ross refers to seven deaths at Parkdale Landing. One was natural causes. It is entirely possible that all of the other six deaths were of those struggling with addiction; three were suspected overdoses, two were suicides and one was murder, presumably of Michel, who used substances.

This raises a question about the state of our drug policies that further harm those with addiction. Decriminalization of the possession of drugs for personal use, together with strict regulation, would help address some of the concerns raised about supportive housing. The federal government has started down this path by decriminalizing possession of drugs for personal use in BC. Other jurisdictions will likely follow. Safer supply programs are an acknowledgement that one of the best ways to protect people who use illegal substances from overdosing is to ensure that they receive a regulated supply. In fact, it is the increased toxicity of the drug supply that has been identified as the cause of the increase in overdose deaths, not an increase in addiction.

Shockingly, acute drug toxicity has been the leading cause of death of Ontario youth aged 15-24 since 2017. This equates to roughly 1 in 4.5 deaths in this age group. The second leading cause of death is asphyxiation. Let that sink in.

Where we can agree is that those who struggle with a severe addiction and who are in early recovery are often not safe in the community where illegal and legal substances are easily accessible. A locked psych ward, however, is most likely not what they need. We need appropriate residential treatment facilities available on demand. Further, if they are not seeking treatment but meet the criteria of harm to self/others under the Mental Health Act, we need to amend that Act to ensure that a locked psych ward is not the only place that they can receive the care that they need. For example, for youth this could be a therapeutic boarding school.

Response from Dr. Mel Kahan, Addiction Medicine Physician

I am an addiction physician. I would like to address several errors in The Pitfalls of Supportive Housing, Part 2. The author states, “While we do not have a specific and effective treatment for addiction…” In fact, there are a number of highly effective treatments for addiction. For example, Opioid Agonist Treatment with methadone and buprenorphine has been shown to markedly reduce opioid use and its consequences, including overdose deaths, suicides and hospitalizations. Anti-craving medications such as naltrexone have been shown to improve drinking outcomes and reduce alcohol-related hospitalizations.

The author seems to believe that addiction is a lifestyle choice, not an illness or a disorder. On the contrary, there is strong evidence that genetic and neurological factors play a key role in the development of addiction. People with a strong family history of alcohol use disorder are far more likely to develop an alcohol use disorder themselves. This is, in part, because they have a different neurological response to alcohol – they have a higher tolerance to the effects of alcohol and they enjoy it more than the average person. Of course, psychological factors play an important role; people who have had a traumatic childhood are more likely to develop a substance use disorder. But this is also true for mental illnesses such as clinical depression.

Addiction is, at its root, a disorder of volition. Drugs of abuse “hijack” the brain’s reward pathway, causing the executive functions of the brain to drive the person to seek drugs. Other physiological processes, including tolerance and withdrawal, perpetuate and worsen addictive behaviours.

The author claims that the merging of addiction and mental health means reduced funding for mental health care and treatment. This is not true. Both mental illness and addiction treatments are dramatically underfunded relative to their impact on mortality, morbidity and health care utilization. Private donors and governments underfund mental illness and addiction treatments for the same reason: Stigma. Reducing funding for addiction treatment will not result in more funding for mental illness treatment, but it will severely harm the mentally ill. People with mental illnesses often use substances to control their symptoms, yet their substance use can worsen their symptoms and reduce compliance with treatment. Patients with both mental illness and addiction need effective, high-quality treatment of both disorders.

Mel Kahan, MD CCFP FRCPC

Medical Director

META:PHI program (Mentoring, Education and Clinical Tools for Addiction: Partners in Health Integration)

Response from Dr. Tony George, Psychiatrist

First, people with serious mental illness like schizophrenia, bipolar disorder, PTSD and chronic depression have high rates of addictions – cannabis, cocaine, opioids, alcohol thus worsen their psychiatric illness, and lead to poorer outcomes including quality of life. Therefore, treating these conditions together is essential, and thus it behooves us to build a mental health treatment system that embraces addictions as part of the mental disorder.

Moreover, there is substantial evidence to support the assertion that addiction (the negative psychosocial consequences of drug and alcohol misuse) has an involuntary component, which CAN be successfully treated by medications and behavioural supports (e.g., addiction counselling). This is especially true for serious addictions (e.g., opioid use disorder) and concurrent mental and addictive disorders. While there is a voluntary (choice) element to drug use, it is clearly overcome when this progresses to an addiction (e.g., a substance use disorder, as defined by the DSM-5 of the American Psychiatric Association).

Tony P. George, MD FRCPC

Professor of Psychiatry,

University of Toronto

Clinician-Scientist, CAMH

Scientific Advisor, Families for Addiction Recovery (FAR)

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The Mental Health Commission of Canada – Will it Ever go Away?

By Marvin Ross

Many of my former Huffington Post columns dealt with the problems of the Commission and its failure to advocate for the seriously mentally ill. Those blogs resulted in a senior member (name withheld), inviting me to lunch to try to convince me that I was being unreasonable and that I should give them time to prove themselves. They did not improve themselves and I was very pleased to see that the external review of the MHCC and similar organizations commissioned by the government recommended that the MHCC be dissolved.

That was in 2018. The report said “MHCC- Mental health is now “out of the shadows”. The integration of mental health care services into the core of Canadian health systems requires a different type of leadership, capable of driving a bottom-up approach in which patients and families, providers, researchers, and the broader mental health community come together to break down silos.”

Four years later, they are still with us demonstrating once again that once an organization locks onto the government funding tit, it is near impossible to get it off. This time I’m referring to their report on mental health and cannabis. It is pretty well established that cannabis can be very harmful in terms of causing psychosis and that it can be detrimental in other mental illnesses. More on that in a minute.

What just came to my attention is one of their reports called Amplifying Black Experiences in Cannabis and Mental Health Research. This is from their acknowledgement:

“In 2018, the Mental Health Commission of Canada (MHCC) received funding from Health Canada to explore the relationship between cannabis and mental health. As part of this work, between December 2020 and April 2021, it hosted a series of virtual dialogues with researchers, community organizations, service providers, and people with lived experience within Canada’s Black communities. The MHCC recognizes the disproportionate impacts that the criminalization of cannabis and other substances has had on racialized people in Canada, particularly members of Indigenous and Black communities.”

There is a lot of research on cannabis and mental illness but they were not doing that. They were having dialogues with people. I’m not sure if they noticed that the issue of criminalization of cannabis which concerns them ended when it was legalized in Canada in October 2018. I cannot believe how many legal pot shops exist on many blocks in my city. That is not an issue although the sociologist who did the study still feels that the Black community is traumatized by it.

There are ten main findings that came out of this “study” which you can read if you desire but the main one is that there is no single Black community in Canada. I don’t think that comes as a surprise to many. The original Black settlers in Ontario came via the Underground Railway whereas in Nova Scotia they came from Colonial America as either Slaves or Freemen. (see Lawrence Hill’s book and the TV series The Book of Negroes). More recently are the British Caribbean, French Haitians, Africans and Somalians.

Aside from the study was the very weird way they collected or tried to collect an evaluation of it. Someone sent me their e-mail soliciting discussion of the study so I took a look. An early question asked if we had seen the study which I hadn’t so I replied no. I was offered the chance to download it which I did, looked it over and returned to the survey. I was expecting to have a chance to answer questions about it but was given a choice – “back” or “submit”

Back I assumed meant going back to the screen that asked if I had seen the study so I picked submit. “Thank you for giving us your views”, I was told, “you may now close this window”. What!. I didn’t give my views! Someone else who took the same route as I did commented that she was “gobsmacked”.

Why did precious tax dollars go to fund this and the idiotic evaluation when so much needs to be done for those suffering from mental illness? Probably because no one really cares about the mentally ill.

As far back as 1969-70, Swedish researchers looked at the link between cannabis and schizophrenia on Swedish conscripts aged 18-20 (50,087 or 97% of that age group). They reported on drug use and a number of other factors while the researchers looked at hospital admissions for schizophrenia for the group. The researchers concluded that there was no doubt there was a causal link and that the more smoked, the greater the risk. A number of years later, Scottish researchers looked at all the studies on the topic between 1966 and the end of 2004 and agreed with the original findings.

The day I received the Commission “study”, I got my usual e-mail of interesting studies from Dr David Gratzer at the Centre for Addiction and Mental Health in Toronto with the latest research on cannabis and bipolar disorder and depression. The report was just published and is from the “Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force Report: A Systematic Review and Recommendations of Cannabis use in Bipolar Disorder and Major Depressive Disorder” .

This is Dr Gratzer’s summation of what he calls a very important study:

• The database review yielded 12,691 studies.
• With the elimination of duplications and review of the texts, they selected 56 studies: 23 on bipolar disorder, 21 on major depressive disorder, 11 on both diagnoses and 1 on treatment of comorbid cannabis use disorder and major depressive disorder.
• “Of those with cannabis use, 2,761 had bipolar disorder and 5,044 major depressive disorder.”
• Prevalence. “The lifetime prevalence of cannabis use was 52% – 71% and 6% – 50% in bipolar disorder and major depressive disorder, respectively.”
• Course. “Cannabis use was associated with worsening course and symptoms of both mood disorders, with more consistent associations in bipolar disorder than major depressive disorder: increased severity of depressive, manic and psychotic symptoms in bipolar disorder and depressive symptoms in major depressive disorder. Cannabis use was associated with increased suicidality and decreased functioning in both bipolar disorder and major depressive disorder.”
• Recommendation. “Considering the consistent signal for the deleterious effects of cannabis in BD and based on the clinical experience of experts, CANMAT provides a strong recommendation against CU use in this disorder. On the other hand, the inconsistency of the signal regarding the effects of cannabis in MDD contributes to a qualified level of recommendation against its use in this disorder”

In 2011, Gratzer also discussed another study of cannabis that appeared in the American Journal of Psychiatry. Here is a link to that study and to Dr Gratzer’s summation https://davidgratzer.com/reading-of-the-week/reading-of-the-week-cannabis-also-dr-jillian-horton-on-her-burnout-recovery-qt/

I highly recommend that you consider signing up for his regular weekly mailings summarizing the latest in good psychiatric research.

What value is there to be derived from the money the Commission is spending on their work? Why does it still exist? Important questions to ask your government reps.

RIP June Conway-Beeby – Your Fight for the Families of Schizophrenics Will Continue

By Marvin Ross

https://pixabay.com/images/id-5356482/

It was not unexpected but long time advocate and pioneer for families, June Conway-Beeby, left us this week at the age of 92.

If I am not mistaken, June was one of the founders of what was Friends of Schizophrenics in Ontario which then became the Schizophrenia Society of Ontario. She was one of the first executive directors and despite having lost her son to the disease, she did not vary. According to her long time ally, Patricia Forsdyke from her presentation to the Ontario Legislation Committee:

“June Conway Beeby knows a lot about danger. Mathew, her young delusional son, drove two ordinary dinner knives through his eyes (and died as a result). June will tell you about danger. She is here today. When he was released from hospital she was told never to be alone with him when he was released from hospital because he was dangerous! Mathew was not taking his medication.”

June was 79 at the time and she showed up at the meeting. What I find remarkable is just how many mothers lose a child to schizophrenia but continue for years to advocate for improvements. I honestly do not know if I would.

When former SNL and SCTV star, Tony Rosato was in court in Kingston Ontario fighting his hospitalization for Capgras Syndrome, she was outside the court talking to the press about the failures of our system. She told the media that “there is no system in place that properly takes into account Rosato’s illness, diagnosed as Capgras syndrome” and “This poor soul needs treatment.”

She added that with treatment, people with the syndrome can get their lives back on track. Rosato has not had access to treatment, as he has been in jail two years awaiting a trial that finally began this week.

We all owe June a huge debt of gratitude and it is my wish that she never knew how her fought for organization has been corrupted into the Institute for Advances in Mental Health “designed to redesigning society for better mental health”.

Bankrupt Political Strategies for Improving Mental Illness Care – An Ontario Election Example

By Marvin Ross

The Canadian province of Ontario has just had an election for a new government in which all four parties running put forth their ideas on how we could improve services for the mentally ill. Unfortunately, most talk about mental health rather than illness and put forth strategies to increase the use of psychotherapy for essentially the worried well.

What appears below is my post election op ed critiquing the party platforms. The lesson for advocates is to reject the term mental health and to focus on illness. And while psychotherapy may be appropriate in some circumstances, it is not appropriate for illnesses. Medicine is based on the concept of triage where the most seriously ill or injured go first. In our world, the most seriously ill – those with schizophrenia bipolar, etc – are ignored

The election is over and the biggest losers are the mentally ill. The sad reality is that it did not matter who won as none of the parties offered a realistic solution.

Mental illnesses (unlike the vague mental health referred to by politicians) like schizophrenia, bipolar disorder, anxiety, severe depression are medical problems requiring prescribed medications, often hospitalizations and life long care. As explained by my fellow blogger, Dr. David Laing Dawson, “calling severe mental illness a “mental-health issue,” and addiction an “issue with substances” is ridiculous.

These “issues” become a new reality, he says, that allows us “to ignore the real reality of the jails and prisons filling with the mentally ill, the burgeoning homeless population, and the horrific struggle families go through trying to get psychiatric treatment for a family member who is mentally ill.”

In an op ed in here last year, I pointed out that Premier Doug Ford made no progress in mental illness services other than a report called Road Map to Wellness which has not accomplished much because of COVID-19, as explained by the minister responsible last year and confirmed recently by a staff member. The wait time for children’s services went from 18 months in 2018 to 40 months today.

Ford did establish a new bureaucracy called the Centre of Excellence for Mental Health and Addictions “as a central engine to design, manage, and co-ordinate the mental-health and addictions system.” Most of what they have done is to arrange for psychotherapy sessions for people, including internet sessions and supports for stressed health-care workers.

I don’t want to knock psychotherapy, but serious mental illnesses require much more than talk therapy. The Polish psychologist and critic of psychotherapy, Tomasz Witkowski, in his forthcoming book, “Fads, Fakes, and Frauds,”points out that there are 45 theoretical schools explaining the functioning of our psyche and that in psychotherapy there are over 600 different (often conflicting) modalities. So, when politicians push psychotherapy, which school and which modalities do they favour? I suspect they have no idea.

To be fair, the Tories did set up four new mobile clinics in hard to reach communities and they are working on the establishment of early psychosis programs.

The Liberal platform we can discount. In 2010, they released the results of an all-party committee consultation on improving mental health and addictions based on extensive consultations and expert submissions from across the entire province and then failed to act on almost all of them.

The NDP wanted to make mental health part of OHIP (Ontario’s public health plan), which it already is. Mental illnesses are covered by OHIP as treatment is provided by medical doctors and hospital stays. Andrea Horwath focused most of her efforts on counselling in order to help people stressed by the COVID pandemic when the main problem is the lack of timely services for illnesses.

The Greens were a little more realistic in advocating for supportive housing with extensive supports, reducing wait times and increasing spending on mental illnesses from seven per cent of the health budget to 10 per cent. According to the Canadian Institute for Health Information, we spend less than most countries in the OECD with France at 15 per cent and the UK at 13 per cent. They, too, pushed for more psychotherapy but the bottom line is no one had any realistic strategies to improve services.

We will all continue to suffer as a result.

My Review of the forthcoming book “Fads, Fakes, and Frauds”

Psychology Gone Wrong

Marvin Ross, medical writer/publisher, author ofAnti-Psychiatry and the UN Assault on the Mentally Illand blogger at Mind You Reflection on Mental Illness, Mental Health and Life wrote a short review of my new forthcoming book Fads, Fakes and Frauds: Exploding Myths in Culture, Science and Psychotherapy.

“In 2015, I had the pleasure of favourably reviewing Psychology Gone Wrong: The Dark Side of Science and Therapy by Tomasz Witkowski and Maciej Zatonski. Since then, I’ve been anxiously waiting for him to write more. His latest book, Fads, Fakes, and Frauds, has been worth the wait. Since 2015, the amount of disinformation has increased considerably and, thanks to the Internet, that disinformation is spreading faster than ever before.

We tend to take at face value much of what we are told by “experts” without ever looking at the evidence and governments buy-in and fund all manner of strategies that…

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Putin was Predictable

By Dr. David Laing Dawson

I watched Fareed’s Zakaria’s Putin documentary on CNN the other night. He ends the narrative by suggesting we not look for clinical explanations but rather make a moral judgement of the man. And then he uses the word “evil”.

During the documentary we got to see Vlad singing in English, “I found my thrill on Blueberry Hill”, and George W. Bush and Donald Trump praising Vlad’s intellect and honesty.

But it occurred to me that two character traits would be essential and necessary from the start for anyone interested in becoming a dictator, and these two traits would have to exist in extreme form to enable someone to succeed in such a position. And they would be, of course, narcissism and psychopathy. It is easy to understand the meaning of “narcissism”, and in this instance “psychopathy” would mean lacking the capacity for guilt or empathy and having the capacity for ruthlessness.

Now usually a degree of empathy is necessary for any social success, but it can be replaced by, or substituted by, cleverness, intellect, scheming and manipulation. Hence the ability to charm George W. Bush without actually experiencing any empathy for anyone.

And thus rather than thinking of Vlad as a man who was good but went bad, so to speak, it would be more useful to think of any and all dictators as being, by the very fact of their achievements, narcissistic psychopaths. And thus realizing where they are predictably going to lead their countries when either their power and control are threatened or they simply grow older and bolder.

I am not an historian but a survey of the strongmen dictators who have arisen in my lifetime seems to bear this out.

The democratically elected governments of our world tolerate, enable, and even support these dictators for economic or strategic reasons in fair weather times. But all of them, at some point, either wage a killing purge of dissidents or particular ethnic groups within their own countries, or decide the time is right to expand their realms and go to war. Some do both.

They are also, by definition, grandiose, so they usually, eventually overstep, but still the damage is done.

• Hitler, Mao, and Stalin, each responsible for 10 to 20 million deaths.
• Saddam, emboldened, decides to kill off his Kurdish minority and then annex Kuwait.
• Pol Pot, a couple of million deaths purging his own country.
• Slobodan Milosevic, bolstered by the west as a “peacemaker”, attempts to create a Serbian empire by war and genocide.

etc. etc. etc. etc.

But if there is a point to these observations it is that we should never support, embolden, encourage, appease or enable any dictator. By the very nature of these men they will, sooner or later, commit atrocities.

Only in fiction do High School Chemistry teachers become psychopathic drug lords. Only in fiction do professional hit men have soft spots for children and little dogs. Only in fiction do psychopaths give up their life of crime and devote their remaining years to good works and charity. And only in fiction might a successful, ruthless dictator, decide that, really, he should help transition his country to a healthy inclusive democracy with an independent judiciary and a free press – and be a good friend to his neighbours.

Medical Assistance in Dying and the Mentally Ill – Canada’s Shame

By Marvin Ross

It is known as MAID and something that I have always supported. It became legal in Canada in 2016 with the proviso that the patient must be suffering and must have a condition that will result in his or her death. That death does not have to be imminent like in the next week or month but is foreseeable. ALS is a good example of that. In my opinion, it is humane and it is logical and, frankly, it is something I would chose to do if faced with intractable pain and suffering leading to death in the very near term. We end the suffering of our pets when they are old, in pain and terminal so why not us?

Unfortunately, the rules around MAID are being extended to remove the provision of “reasonably foreseeable and terminal”. This opens the door to people who are ill and suffering but who do not think they are getting proper treatment for their problems or for whom the treatments available are not deemed to be acceptable. They can end their lives at the government’s expense. The most damning denunciation of these policies first appeared in the London Spectator and in the Australian Spectator with the headline “why is Canada euthanizing the poor?”.

We have now reached a situation where people who have disabilities are deciding and being approved for assisted death because we do not provide them with the proper care and supports they deserve as human beings and as citizens of a wealthy first world country.

Two women in Ontario with multiple chemical sensitivities trying to live on the obscene disability payments of $1169 a month (well below the poverty line) were approved for death simply because the support we as a society give to the disabled is so inadequate that death is a viable alternative. To put that Ontario disability payment into perspective, when the Canadian government established payments for people who lost their jobs because of Covid, they paid them $2000 a month arguing that was the minimum amount people needed to exist.

David Lepofsky, disability advocate and Visiting Professor of Disability Rights at the Osgoode Hall Law School is quoted in the above article saying “We’ve now gone on to basically solving the deficiencies in our social safety net through this horrific backdoor, not that anybody meant it that way, but that’s what it’s turned into.” Devorah Kobluk, a senior policy analyst with the Income Security Advocacy Centre in Toronto, part of Legal Aid Ontario added “With the right support, I have no doubt people with disabilities can live well in society. We all want people with disabilities to know that their lives have value.”

Canadaland reported last year about a number of people who are planning to apply for MAID when their money runs out and they can no longer afford to live and pay for their care. They said:

“In Canada right now, there are people choosing medically-assisted death, not because their illnesses are killing them or the pain is unbearable, but because they can’t afford the cost of managing that pain and getting the care they need to live with dignity.”

If you have about an hour to spare, I highly recommend that you listen to this podcast with Toronto psychiatrist Dr Sonu Gaind. As the promo states:

“He’s grown alarmed since Canada stopped requiring a reasonably foreseeable death for euthanasia, as he tells Anthony in this week’s episode. People who are poor, lonely or battling mental illnesses, who’s lives might get better with help, are being offered a lethal injection instead. And children could be next. What once threatened to be euthanasia’s slippery slope, says Gaind, has turned out to be a cliff.”

We should all be disgusted with these changes but how did they come about? Well, it was either Dr Gaind or Dr Stefanie Green, president of the Canadian Association of MAiD Assessors and Providers, and/or Dr. Naheed Dosani, a palliative care physician and health justice activist discussing the issues with Dr Brain Goldman on his CBC radio show, White Coat Black Art who provided this explanation.

The disabled community in Quebec filed an appeal against the MAID legislation with the Quebec courts claiming discrimination against the disabled for not being included in the assisted death legislation brought in by the Federal Canadian government. The one judge who heard the appeal (yes, one judge only) ruled in their favour and ordered the Canadian government to revise the legislation. Normally, when something like this happens, the Justice Minister will appeal and the issue will go to the Supreme Court of Canada for review. That court is comprised of nine justices and, unlike the US, they are not politically motivated. That did not happen. The Justice Minister did not appeal.

That Justice Minister then and now is the Honourable David Lametti who I can only assume was asleep at the time and forgot to file an appeal.

Thanks to that failure, we will soon be putting to death people who should be able to live a reasonable life with the supports they need. But, one injection to prematurely end their lives is a lot cheaper.

Mass Killing and Mental Illness

By Dr David Laing Dawson

Two serious online Psychiatric journals recently implored us to not “equate mass killing with mental illness.”

While the impulse to avoid further stigmatizing mental illness with the burden of mass murder is admirable, simply labeling these killers as bad, evil, amoral, racist, or, as one of the authors called them, “terrorists”, is not in the least helpful.

The information I have on the mass killings of the past 30 years is limited to that which is eventually revealed in the public media, but it is enough, I think, to make these judgements:

For the older men (40’s, 50’s, 60’s) the pattern is often one of a psychotic depression. Failure, a loss of relationship/job, long standing grievances and obsessions, blaming, nihilism, depression, despair, anger and suicide. They shoot up the doctor’s office, the emergency room, the post office, the place of recent employment, the extended family, the perceived cause of their pain and failure, and then themselves.

For the younger men (late teens, early twenties) the pattern is one of a developing psychotic illness like schizophrenia: social isolation, imposed by personality, disability, or illness, failures, grievances, seeking meaning and explanation in the wrong places, finding one, a simple satisfying explanation for all that is wrong, one that also provides a cause or source.

Plus that moment of slipping from obsession to delusion, a delusion in which the young man developing a psychotic illness now believes he is a major player, that he must act to ….., that he has been chosen for……., that he must die in a grand gesture for…..and then be remembered for….

I have been there many times in the past 50 years when young men reached that point. Fortunately not one had access to handguns or AR 15’s. And usually, almost always, the organizing principles, the delusions they arrive at, are only harmful to themselves and their families.

One decided he was Hitler’s illegitimate son. One stabbed his father who was “possessed by evil”. One decided to don the robes of Christ and preach to the masses as he wandered the continent. One did decide to borrow his uncle’s hunting rifle to kill the kids at school who had bullied him, but his right arm froze. Another unfurled a flag on the roof of the police station. Another jumped off a school roof, commanded to do this, to save the world. Another sought the home address of his nurse counselor so that he might kill her and rid the world of evil. Another stopped talking, went mute, lest his words cause more floods and famine. More than a few have come to the conclusion that the police and/or the government are controlling them, have implanted chips in them, listen to them, watch them day and night. Some have wondered if I am part of this evil cabal. And many, in the last 15 years, have fallen down the rabbit hole of internet conspiracy theories.

But none had easy access to weapons of mass killing.

So yes, in both those age groups, at the expected age of onset, mental illness is often a factor, along with easily attainable weapons. And of these two factors the latter is far more amenable to prevention.