Psychiatrists certainly do not know all the answers when it comes to the recent spate of school shootings, but we do know some of the most pressing questions. For example, is there a difference in the psychological makeup of adult shooters versus student, or juvenile, shooters? To what degree does untreated psychosis or depression play a part in the shooter's seemingly inexplicable behavior? How important is bullying in motivating some students to seek revenge on their peers? What are the earliest warning signs of an impending attack by an assailant of any age?
Without a psychiatric evaluation, it is impossible to reach any diagnostic conclusions about those involved in school shootings. However, publicly available information suggests some of the general characteristics of these individuals. In 1989, when 25-year-old Marc Lépine gunned down 14 women at Montreal's École Polytechnique, he apparently roamed the school shouting, "I hate feminists!" as he opened fire on female engineering students. In the recent Amish schoolhouse shooting, local police described the assailant—32-year-old Charles Carl Roberts—as having acted out of revenge for something that had happened to him 20 years ago. In both of these incidents, the shooters seem to have invested the victims with powerful symbolic significance. These killings appear to have been related more to the shooters' long-standing internal dynamics than to animus related directly to the victims' behavior.
In contrast to these "simmering symbolism" shootings, attacks by students on their classmates seem more closely tied to revenge against perceived mistreatment—and in particular, to feeling bullied or teased by classmates. The classic example is Eric Harris, 1 of the 2 attackers in the Columbine High School shootings in 1999. Harris reportedly left a suicide note stating, "Your children who have ridiculed me, who have chosen not to accept me, who have treated me like I am not worth their time, are dead."1 As Professor Dewey Cornell noted in testimony before the House Judiciary Committee, "These are young people who are outcasts from their peers. Often they are victims of bullying and teasing."2 Cornell has also identified depression as a factor that may drive these student-on-student attacks. Such "direct revenge" shootings may evolve over shorter periods than those carried out by persons with more deep-seated, symbolic conflicts.
There are many other scenarios and dynamics involved in school shootings, and rigid classification schemes are not helpful. Furthermore, as Cornell has noted, there is a risk of focusing too narrowly on school shootings rather than on understanding what drives violent attacks in a multitude of other settings. Indeed, some mental health professionals have pointed to undiagnosed and untreated mental disorders as risk factors for violent behavior. However, we need to tread carefully here: the notion that most individuals with psychiatric disorders are violent is a destructive myth. Only a small percentage of those with mental illnesses act out violently; indeed, many are themselves victims of violence.
However, some subgroups do have a higher-than-expected rate of violence. For example, Dr Marvin S. Swartz and colleagues3 have shown that alcohol(Drug information on alcohol) or other drug abuse problems, combined with poor adherence to medication, may increase the risk of violent behavior among persons with severe mental illnesses. It is imperative that psychiatrists offer comprehensive, affordable, and compassionate care to these persons.
We desperately need "distant early warning" indicators for troubled students. Often, these youngsters signal their murderous intentions clearly—on Internet chat lines or in direct statements to peers—but these red flags are frequently dismissed or ignored. We also need comprehensive school programs to address the all-too-common problems of teasing and bullying.
Finally—and this is a problem that extends beyond psychiatry into the realm of politics and policy—we need to examine the role of easy access to firearms as an exacerbating factor in school violence. Only when we bring to bear the full resources of doctors, parents, schools, and communities will we begin to reduce the plague of violence in our culture.