CME credit for this article is now expired. It appears here for informational purposes only.

At the end of this article, readers should be able to:

1. Describe the benefits of psychiatric advance directives (PADs) and the problems with their implementation.

2. Distinguish between the 3 types of PADs: the instructional directive, the proxy directive, and the combination directive.

3. Assess the limitations associated with PADs.

Psychiatric advance directives (PADs) are similar to medical advance directives except the focus is on mental health treatment decisions. PADs are increasing in favor among patients but are considerably underused compared with medical advance directives.

PADs were created as a result of several court cases from the 1970s and 1980s that focused on patient self-determination regarding medical and psychiatric care. These cases ultimately led to the Patient Self-Determination Act of 1990 (PSDA).

 This federal law requires Medicare and Medicaid providers to inform patients of state laws concerning advance directives; to ask whether the patient has an advance directive; and to inform the patient of his or her right to complete an advance directive. Since the PSDA was enacted, 25 states and the District of Columbia have added statutes to assist mentally ill persons in guiding their care when facing possible future decision-making incapacity.

PADs are a means to empower persons with mental illness by increasing autonomy and decreasing coercion in the treatment they receive. PADs allow an individual with mental illness, while competent, to describe early indicators of relapse; specify preferences for or against certain medications; weigh in on other treatment options that may or may not have worked previously; articulate acceptable trade-offs in treatment; give advance informed consent for treatment (including hospitalization when appropriate); and designate a surrogate to make future health care decisions on his or her behalf.

The specific aspects of a PAD differ from state to state, but they generally contain the following guidelines

• Choice of medications, route of administration, dosage limitations

• Preferences for a lengthier hospital stay versus more aggressive treatment considerations (or vice versa)

• Desires regarding unusual or experimental treatments

• Choices with respect to the use of nonpharmacological modalities (eg, electroconvulsive therapy)

• Designation of treatment setting and choice of physician

• Preferences regarding the management of emergency situations (eg, use of physical restraints, seclusion, chemical sedation)

• Plans for post-hospital discharge services and support services (eg, housing management)

PADs provide a means for patients to express their personal choices and make advance decisions about the treatment they want to receive during times of acute illness.

 PADs contribute to improved communication with providers, allow patients to have a role in their treatment, and allow for better relationships with family and caregivers. This can improve patient self-esteem, improve treatment compliance, and enhance the patient’s quality of life. Family members can better understand a patient’s illness, which may help them recognize early signs of illness.

There are 3 types of PADs: the instructional directive (eg, living wills), the proxy directive (eg, health care power of attorney), and the combination directive. Each type has its own strengths and weaknesses.

The strength of the instructional directive is that the patient’s wishes are written out clearly before he becomes incapacitated. The patient has a relative amount of reassurance that his wishes will be followed. This increases a sense of continued autonomy even in times of vulnerability. A weakness is that it might be too restrictive in scope and flexibility. A patient may be left with an outdated treatment regimen because the document has not been updated. In addition, unforeseen problems may arise for which solutions have not been clearly spelled out, thus leading to improvisation and potential conflicts between the patient, his family, and the physician.

The strength of the proxy directive is that it has more flexibility and it is easier to meet the changes or challenges that can arise during treatment. The patient appoints a surrogate that he knows and trusts, which enables a smoother transition of care if the patient loses decision-making capacity. However, a problem can occur if the surrogate’s decisions are not altruistic. In addition, there may not be a close family member or friend to serve as a proxy. In this case, a patient’s physician could serve as a proxy, but there is the potential for conflict of interest. Because the advance directive does not have the immediate oversight of a judge, some states explicitly forbid a psychiatrist to act as proxy.

The combined directive has all the strengths of the other two directives and minimizes the weaknesses of each. The proxy portion gives broad decision-making authority to the patient’s substitute decision maker, who can use the instructional portion of the directive as proof of the patient’s wishes.

Having a psychiatrist, team of mental health professionals, legal staff, or a facilitator versed in PADs able to interact with the patient increases the odds of compliance with a PAD. Although PADs are legal documents, consulting with an attorney to develop such a document may not always be feasible. A hospital team approach can decrease the time and expense in completing a PAD, although this is an area where additional research is needed. Psychiatrists could play a critical role in assisting patients in developing a PAD and facilitating their implementation in a timely and cost-effective manner.

When a patient is helped by hospital staff to fill out a PAD, the document is more likely to be completed.5 PAD software is available to facilitate the completion of a PAD. In a study that used the AD-Maker

 software, patients were 200 times more likely to complete a PAD.

 found that patients preferred to complete a PAD outside of the psychiatric ward or clinical setting and were more comfortable in an attorney’s office. Collaboration between hospital psychiatric and legal resources would likely allow more patients to have an advance directive. Although more research is needed, the best approach seems to be a collaboration between the patient, his proxy, his physician, and legal/hospital counsel.

Because of limited research, it is difficult to assess whether PADs are effective. One study showed that PADs are most useful in higher-functioning patients.

 This study found PADs were more likely to be accessed if the patient had an Axis II diagnosis or had a surrogate. During a crisis event, substance abuse/dependence or a history of prior outpatient involuntary commitment decreased a PAD being accessed by 4- and 6-fold, respectively. This is unfortunate because lower-functioning patients with prior involuntary commitments gain the most from a PAD to help guide effective treatment.

The solution to increasing the use of PADs is 3-fold: they need to be easily accessible; physicians need to be trained in their use and the surrounding legal issues; and health care bias about the legitimacy of PADs needs to end.

Swanson and colleagues8 found that PDAs were being completed by only 4% to 13% of patients. Srebnik and Russo

 found that a scant 20% were being accessed by providers. A useful tool is being wasted, and this does not bode well for the effective treatment of patients. To help mitigate this, some states have online registries or place symbols on drivers’ licenses to alert health care professionals that a patient has an advance directive. Organizations such as the Veteran’s Administration (VA) have PADs on file or use pop-up windows to alert providers when they access the patient’s electronic medical record.

 Another complicating factor is that most PADs are only available as a hard copy that needs to be carried by the patient. The potential consequences on patient confidentiality are dire should loss occur.

Psychiatrists who are viewed as advocates of a patient’s care and continued autonomy regardless of the patient’s decision-making capacity have a potentially unique responsibility to uphold a PAD. The biggest issue for providers when acknowledging PADs is provider bias and ignorance of the law. In one study, only 37% of physicians correctly answered a question about an aspect of North Carolina’s PAD statute; 50% of mental health providers thought the effect of a PAD would be a negative outcome for the care of the patient.

It is difficult to know when a PAD can be overridden. The state that has come closest to protecting a patient’s wishes by not overrriding a PAD is Vermont, where refusal of “usual treatments” is allowed for 45 days before a PAD is overridden in court. This 45-day period is set to provide enough time to allow the patient to improve before the PAD is overridden.

It was feared that in writing a PAD, patients would opt out of all psychotropics. Srebnik and colleagues5 found that 81% of patients with a PAD had included medications, and although 64% listed medications they would refuse, none rejected all psychotropics. These findings indicate that the risk of a patient opting out of all medication is minimal. States may want to look at legislation to minimize the worst case scenario. For example, Pennsylvania’s statute includes 3 provisions that protect physicians from legal liability and have legal oversight when a PAD is overridden by the courts to protect abuses of the further erosion of a patient’s autonomy.

One of the PSDA mandates requires that states and hospitals follow federal guidelines to make medical and educational forms easy for patients to understand. Mueller and colleagues

 showed that the literacy level of most advance directives was above the national average ability to read and comprehend. In fact, the average literacy level of the advance directives evaluated from each state was at a 12th grade level, thus potentially alienating 90 million individuals in the US whose reading level is below that of a high school graduate. Only 22 directives were at a 10th grade or lower reading level. Oregon’s was the most consumer-friendly, at a 7th grade level, but Utah’s living will and power of attorney forms were at a 19th and 18th grade level, respectively.

Another issue is the question of how much capacity is needed to complete a PAD and how should its assessment be implemented. Srebnik and colleagues

 found that few statutes require capacity to be assessed before a PAD is created. This may reinforce the difficulty of upholding a PAD if the patient’s capacity was questionable. However, the law presumes decision-making capacity until otherwise shown, and there are no set criteria as to what to assess.

 used the criteria of the Competence Assessment Tool for Psychiatric Advance Directives (CAT-PAD) to assess competency. They argued that the CAT-PAD criteria were superior because they looked not only at capacity to make medical decisions but also at comprehension. Surprisingly, this study found assessing capacity may be unnecessary because patients in their 30s who had bipolar I disorder or schizophrenia still had the capacity to fill out their PAD. Others have used the Hopkins Com­petency Assessment Test. Backlar and colleagues

reported that 82% of individuals with severe mental illness could correctly understand key PAD concepts.

Patients view the PAD as their voice when they have none. Physicians and the courts agree to some extent but are given a large amount of leeway with involuntary commitment and compelling the use of medications. When can a court or physician, in good conscience, disobey a directive written in a patient’s legal document? Currently, where to draw this line is hotly debated. Ironically, a patient can have difficulty in overriding his own words in a PAD because of questions of capacity. Patients without treatment preferences in their PAD are subject to the proxy’s or physician’s clinical discernment.

 To help address this issue, some states, such as Washington, Hawaii, and Pennsylvania, have laws that allow for “tailored activation” of PADs, which permits an individual to define prospectively the point at which he has lost the capacity to make informed treatment decisions (eg, when delusional comments are made or a large amount of money is spent in a short time, indicating a manic episode).

 found that patients who specified a medication in their PAD were more likely to continue with that medication 12 months later compared with patients who did not have a PAD. Better medication adherence results in a decrease in emergency department visits and psychiatric admissions and improved quality of life. A patient who is experiencing a manic or psychotic episode can have difficulty communicating his wishes. The PAD helps guide the clinician to the most effective, expeditious, safe treatment that is in line with the patient’s wishes.

Research suggests that many hospitals do not have a system in place for PADs to be stored and easily accessed, which makes it difficult to implement and use them. Some states and private companies have attempted to reconcile this by making living will registries accessible to patients and physicians. But as of 2009, only 12 states and 1 private company, US Living Will Registry, had registries.

A VA hospital looked at possible blockades to using PADs.

 In spite of formal clinician training and readily available PADs, their use was limited to a fraction of actual cases. However, another study showed that physician education does make a difference; those who were more aware of the legal aspects of PADs were more likely to use them. Longitudinally, the longer PADs were used and brought to the attention of providers, the more often they were implemented.

It will take larger entities, such as hospitals and state governments, to make PADs more accessible and presented at a level that everyone can read and understand. In addition, clearer guidelines are needed on when a PAD can be overridden, to help in striking the best compromise for the patient and societal safety.

Much like the early legal battles in the 1970s and 1980s that led to an applicable advance directive document, a fair amount of time and contentious debate will be needed to allow mental health policies, local government procedures, and hospital policies to coalesce into an applicable and feasible process to fully implement PADs and their high degree of utility in patient care to positively affect quality of life.

Jether C. Farino, MD, has no disclosures to report.

Kaustubh G. Joshi, MD, has no disclosures to report.

Christine Wilder, MD, (peer/content reviewer) has no disclosures to report.

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http://icbbioethics.com/archives.php?entry=76

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 Backlar P, McFarland BH, Swanson JW, Mahler J. Consumer, provider, and informal caregiver opinions on psychiatric advance directives. 

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National Resource Center on Psychiatric Advance Directives. http://www.NRC-PAD.org. Accessed December 20, 2012.

Articles

Demonstrating the importance of psychiatric advance directives and the benefits and obstacles involved in implementing them.

Psychiatric Advance Directives: What Psychiatrists Need to Know Now

Schizophrenia is a severe psychiatric disorder that affects approximately 

 The 12-month prevalence of substance use disorders (SUDs) among the general US population is approximately 12% for alcohol and 2% to 3% for illicit drugs.

 It is interesting to note that nearly 50% of people with schizophrenia also suffer from a comorbid substance-related illness during their lifetime.

 There are complex interactions between substance use and psychiatric disorders, 

Patients who receive a dual diagnosis-a psychiatric disorder and an SUD-are faced with serious challenges related to treatment and prognosis. Many clinicians focus solely on treating either the psychiatric illness or the SUD. This lack of integration of psychiatric and addiction treatment is a significant issue for dual-diagnosis patients; growing evidence suggests a 

Psychiatric illness appears to be a vulnerability factor for substance abuse, and because substance abuse can lead to an exacerbation of psychiatric symptoms, there is a critical need to understand the factors that influence both the onset and duration of substance abuse and psychiatric illness, particularly how they interact to influence prognosis.

Schizophrenia is characterized by the disturbance of cognition and sometimes behavioral and emotional processes. Positive symptoms of schizophrenia can include hallucinations, paranoia, and delusions, while negative symptoms can include blunted affect, cognitive deficits, social avoidance, and anhedonia. Reductions in brain volume typically occur in patients with schizophrenia (as a function of the illness, medications, or both), primarily in the prefrontal cortex (PFC) and temporal lobes, which may contribute to the cognitive deficits commonly seen in patients.

There are 4 central dopamine (DA) systems: mesolimbic, tuberoinfundibular, mesocortical, and nigrostriatal.

 The mesolimbic pathway projects from the ventral tegmental area and substantia nigra of the midbrain to the nucleus accumbens (NAc), olfactory tubercle, and amygdala.

The DA hypothesis may be insufficient to explain the complexity of schizophrenia. However, there is mounting evidence to support DA dysfunction in schizophrenia. In particular, schizophrenia appears to be associated with hyperactive subcortical mesolimbic DA pathways in the brain and deficient DA function in the PFC.

 Moreover, all effective antipsychotic medications are antagonists of the DA D

Mesocortical DA modulates working memory and executive function, and dysregulation of this pathway may underlie some of the positive and negative symptoms associated with schizophrenia.

 The nigrostriatal pathway extends from the substantia nigra to the dorsal striatum via the median forebrain bundle, and overactivity of striatal DA release may be a key factor in the development of schizophrenia (

DA influences motor activity and attention in humans and plays a critical role in stress.

 In animals that are subjected to stress, DA is released in the cortical and limbic areas of the brain and may exacerbate symptoms associated with schizophrenia that could be a result of too many demands on the already diminished population of dopamine neurons.

The DA system also plays a large role in the reward- and pleasure-seeking system, particularly the D

 receptors. Many drugs of abuse block the function of the DA transporter, resulting in a large increase of DA in the synapse and increased D

 receptor signaling that mediates the reward pathway, usually in the NAc.

 recently reported that striatal DA release is increased in patients with schizophrenia, primarily in the precommissural caudate, and reduced in the ventral striatum in individuals with addiction. They measured the change in amphetamine-induced D

 receptor availability in both dual-diagnosis schizophrenia patients and in schizophrenia-only patients using positron emission tomography. Dual-diagnosis patients reported greater increases in happiness and energy following drug administration, but amphetamine reduced D

 receptor availability across both groups.

Many hypotheses have been put forth to explain the link between substance abuse and schizophrenia. The two hypotheses that we discuss are the self-medication hypothesis (SMH) and the addiction vulnerability hypothesis (AVH).

 The SMH posits that drugs of abuse relieve psychological suffering and that a person’s preference for a particular drug involves some degree of psychopharmacological specificity.

 By contrast, the AVH suggests that the of schizophrenia may increase vulnerability to drug reward and reinforcement, thus promoting concurrent expression of these disorders.

The SMH entails relief of negative symptoms, such as anhedonia, depression, blunted affect, and neurocognitive deficits.

 This hypothesis claims that drug addiction is a secondary process, or a reaction, to schizophrenia; the dysfunctional leads to aversive symptoms and to self-medication. Khantzian

 suggested that “it is not so much a psychiatric condition that one self-medicates, but a wide range of subjective symptoms and states of distress that may or may not be associated with a psychiatric disorder.”

People with schizophrenia may be targeting the negative symptoms and/or motor adverse effects of antipsychotic medications. The SMH explains comorbid drug addiction through a negative reinforcement model, in which drugs may serve to reduce aversive symptoms associated with the psychiatric disorder.

Over the past few decades, the SMH has drawn criticism. Since support for the SMH has focused on subjective, self-report measures, many researchers question the validity of this hypothesis. Amelioration of negative symptoms and adverse effects of medication is among the reasons Khantzian provides for individuals with schizophrenia who use drugs.

 Tobacco use is common in patients with schizophrenia, and nicotine may alter nicotinic acetylcholine receptor abnormalities in schizophrenia.

The effects of smoking abstinence on visuospatial working memory (VSWM; a cognitive process dependent in part on prefrontal DA) were examined in smokers with schizophrenia and smokers without schizophrenia (controls).

 Smoking abstinence in the schizophrenia group was associated with a decreased VSWM; in the control quitters, VSWM improved. The findings indicate that nicotine may have beneficial effects on cognition in smokers with schizophrenia. Although these data appear to support the SMH, it is important to note that cognition is subconscious and an individual with schizophrenia is unlikely to describe the effects of smoking on such unconscious processes.

Another shortcoming of the SMH is that when dual-diagnosis patients stop using their drug of choice, their psychiatric symptoms improve or remain unchanged rather than worsen after drug withdrawal is complete.

 Moreover, findings from prospective clinical trials suggest that patients with schizophrenia who quit smoking have no significant changes in positive and negative symptoms.

 Results from a retrospective study show that smokers with schizophrenia significantly decreased their reported daily cigarette use when they switched from neuroleptics to the atypical antipsychotic clozapine.

 If the SMH were supported, it would be expected that smokers would not decrease their daily smoking in response to medication (and may in fact increase smoking), since the SMH suggests that individuals use drugs to relieve medication adverse effects.

The AVH differs from the SMH in that it does not assume there are any beneficial (or detrimental) reasons for comorbid drug addiction. While the SMH posits that dual-diagnosis patients become addicted to relieve deficits, such as mood and anxiety symptoms, the AVH claims that dual-diagnosis patients become addicted to drugs despite the negative consequences of the drug.

With its focus on the common pathophysiology of addiction and schizophrenia, the AVH does not rely on the positive aspects of a drug as mediating the addictive process. The AVH suggests that addiction and schizophrenia are primary disease symptoms with common abnormalities. In addition, environmental influences can have a strong effect on the development of either one of the comorbid diseases. The combination of environmental and genetic influences may predispose an individual to a comorbid drug addiction, often before prodromal psychotic symptoms appear.

Animal studies provide some of the best data with respect to modeling the comorbidity process; neo-natal ventral hippocampal lesions (NVHLs) in rats mimic symptoms similar to those of schizophrenia.

 Rats with NVHLs responded more actively to an initial cocaine injection than did controls, and they had greater patterns of behavioral sensitivity after 7 days of injections.

 Such altered patterns of behavioral sensitization may result from abnormal present in schizophrenia, which promotes greater vulnerability to addiction.

In the brains of individuals addicted to drugs, the NAc is in an activated state, whereby DA inputs to the NAc are increased. DA inhibits hippocampal and PFC glutamatergic input and decreases NAc GABAergic outflow to the ventral pallidum and thalamus. In this disinhibited state, the reward circuitry is dysfunctional, and DA levels continue to rise, producing increased drug reinforcement.

Developmental abnormalities in both the hippocampal and PFC circuitry in schizophrenia may impair projections to the NAc. This results in hyperresponsiveness to basal and drug-stimulated DA release.

 Therefore, the abnormal underlying schizophrenia can result in dysfunctional basal DA and GABA resting states similar to those of an addicted individual. This process increases the vulnerability of patients with schizophrenia to drug addiction. Furthermore, the individual with schizophrenia may be more sensitive to the rewarding and reinforcing properties of addictive drugs because of excessive mesolimbic functioning.

One observation that supports the AVH is that generally the onset of drug abuse occurs before the onset of psychiatric symptoms, consistent with a common in schizophrenia and addictions.

 A study of 45,570 Swedish conscripts supports the AVH-the risk of schizophrenia among cannabis users was elevated 6-fold compared with non-users.

It is possible that cannabis may induce schizophrenia per se, but a more likely explanation is that individuals with a predisposition to schizophrenia are more likely to use cannabis, as a function of the common underlying both disorders.

Identifying reasons for comorbid drug addiction in schizophrenia has been difficult. Many theories have been proposed to try to explain the root cause of drug addiction in patients with schizophrenia, but no one theory has been put forth that encompasses all aspects of drug addiction in these patients. The SMH falls short by assuming that drug addiction in schizophrenia operates on a negative reinforcement model. Nonetheless, it is clear that the prognosis for schizophrenia is much better when patients achieve drug abstinence, including in the domains of depression, quality of life, and community integration.

Clearly, more research on the interrelationships between substance use disorders and schizophrenia is needed to support or refute the SMH or the AVH-and to establish the sequence of onset of the comorbid disorders. In other words, which came first, the chicken or egg? The answer to this question may have important implications for how we assess and treat people with drug addiction and schizophrenia.

This work was supported in part by operating grants from the Canadian Institutes of Health Research (CIHR, MOP#115145) and the Ontario Mental Health Foundation to Dr George, and by the Chair in Addiction Psychiatry at the University of Toronto to Dr George.

Ms Bridgman is a fourth-year undergraduate student in neuroscience and psychology at the University of Toronto; Dr Ouellet-Plamondon is a Fellow in Schizophrenia and Addiction Psychiatry at the Centre for Addiction and Mental Health in Toronto and the department of psychiatry at the University of Toronto; Ms Morozova is a fourth-year undergraduate student in psychology at the University of Toronto; and Dr George is Professor and Co-Director of the division of brain and therapeutics in the department of psychiatry at the University of Toronto, and Chief of the schizophrenia division at the Centre for Addiction and Mental Health. Ms Bridgman reports no conflicts of interest concerning the subject matter of this article. Dr George reports that he is on the Data Monitoring Committee for Novartis, has received investigator-initiated contract support from Pfizer Canada, is on the Speakers Bureau for Pfizer Inc, and is a Member of the Grant Review Committees for the National Institutes of Health and the Canadian Institutes of Health Research.

A systematic review of the prevalence of schizophrenia

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It is clear that the prognosis for schizophrenia is much better when patients achieve drug abstinence, including in the domains of depression, quality of life, and community integration.

Understanding the Neurobiological Basis of Drug Abuse: Comorbidity in Schizophrenia

Mass murder-the killing of 4 or more people at one location within one event-is a rare but appalling tragedy. The body of research on mass shootings is relatively small and hampered by the low base rate, questionable methods, and lack of data regarding thwarted events. Mass shootings are not new, but since the 1990s, they have taken on a different quality. This quality has been affected by cultural shift, social media, and enhanced media coverage.

While the existing research is hampered by methodological problems, certain psychosocial factors are consistent (eg, problems with self-esteem, a persecutory/paranoid outlook, narcissism, depression, suicidality, social rejection). The problem of focusing too heavily on these factors is that too many false positives result. The reality is that “no consistent and reliable profile of school shooters exists, and most researchers and clinicians would agree that predicting violent behavior is a slippery slope.”

In an excellent review of school-associated homicides in kindergarten through 12th grade, Flannery and colleagues

 noted that “a need remains for researchers and commentators to examine other factors beyond the individual that may explain school shootings, including culture, the social ecology of the school, or other community factors.” For example, there are differences between urban and suburban school shootings-some acts are related to threats to the perpetrator’s social identity.

 Suburban and rural shootings may be characterized by social alienation, whereas urban incidents may be associated with a general inner-city tolerance of violence. The issues of social marginalization and familial dysfunction are other common findings.

 noted that peer groups played a role in facilitating school shootings; they sought to study whether adolescents who had expressed an online threat of a school massacre differed from those who had expressed a threat offline. Those who expressed their threats online were more likely to have been bullied and depressed, more often made threats with clear intention, and more often were prepared. In contrast, those who expressed threats offline were more likely to have problems with impulse control and to have shown delinquent behavior before the threats.

In another study, Lindberg and colleagues

 attempted to characterize adolescent copycats who had threatened to carry out a school massacre. A majority of these copycats were found to have a history of mental health treatment, depressive symptoms, suicidal ideas, and impulse control problems. The prevalence of pervasive developmental disorders was high.

The assertion that severe mental ill-ness is to be blamed for mass shootings is a distraction. In reality, research shows that “even if one assumes that the association between severe mental illness and recorded violent crime is entirely causal . . . the overall contribution of patients with severe mental illness [is a mere 5%].”

Given that both prediction and profiling are unhelpful, what are we left with? Most authorities recommend a careful threat assessment approach. The problem is that these endeavors are complicated and time-consuming and need to be done by well-trained professionals working as a multidisciplinary threat assessment team. The process also relies on a thorough psychiatric evalua-tion, which is a resource that is in short supply. Flannery and colleagues

 give the sensible advice that “particular attention should also be paid to a youngster’s access to or fascination with firearms and the presence of writings or drawings with violent themes,” as well as dysfunctional peer relationships, including bullying.

In response to the Sandy Hook tragedy, the Interdisciplinary Group on Preventing School and Community Violence provided a rational set of recommendations.

 The key element of their recommendations is improved communication. Their report states that “the most effective way to prevent many acts of violence targeted at schools is by maintaining close communication and trust with students and others in the community, so that threats will be reported and can be investigated by responsible authorities.” They recommend that schools develop “channels of efficient, user-friendly communication,” so that “community members, students, and staff members feel comfortable bringing concerns regarding safety to the attention of school administrators.”

Third parties, such as other students and family members, may have pre-offense knowledge or significant concerns because potential perpetrators often “leak” their intent. The National Alliance for Mental Illness, which has offices all over the country, is a good resource for friends or family who suspect that a problem is brewing.

In response to the plea by Flannery and colleagues

 to examine other factors that contribute to mass shootings, particularly cultural and social ones, it is impossible to avoid the issues of narcissism and media responsibility. Narcissism is the classic American pathology, but there is concern that it may be proliferating “virally” and gaining momentum. In their excellent work 

 note that while crime has dropped overall since the 1990s as a result of a variety of factors, crimes due to narcissism or a wounded ego are directly relevant to mass shootings.

 laid out an impressive overview of how the “civilizing process” has reduced violence among homo sapiens over the centuries. Indeed, this was also seen by Freud,

 who noted that civilization itself required a strenuous renunciation of biological impulses. Pinker now wonders if we might have reached a point of limited returns-we no longer hack and impale each other at the drop of a hat, instead we seek further and comparatively smaller gains that are more difficult to appreciate and achieve. Those harder to achieve gains may arguably lie in the realm of facing and somehow attenuating the problem of narcissism.

Narcissism and social rejection are risk factors that work in tandem to cause aggressive behavior, and these have certainly been described in the histories of mass shooters. Twenge and Campbell

 note that “given the upswing in the narcissistic values of American culture since the 90s, it may be no coincidence that mass shootings became a national plague around the same time.” Extensive media attention in the 1990s may have provided a script and unwitting adulation of those who would seek an impatient route to their entitled respect. This hints at a deeper societal pathology-a culture that has “grown more focused on self-admiration and more enamored with celebrity and fame.” One might argue that we hold celebrity as the single greatest achievement of life-one that should be attained by any means.

It becomes difficult to deny that the media coverage given to mass shooting perpetrators has sent the message that committing a spectacular act of murder or killing is a great way to get attention. A study confirms that perpetrators who were captured alive were influenced by previous, heavily publicized cases of mass shooting.

 The news media has always been in the business of searching for “the right sort of madness” to capture the public’s imagination.

 This may involve exploiting violent and tragic acts and/or overemphasizing the alleged role of mental illness. A universal media reporting code has been recommended that would cover the tragedy yet reduce the impact of the copycat effect.

 Most recommendations involve ensuring that the perpetrator is neither glorified nor demonized and generally avoiding much emphasis on the perpetrator.

There are countries in which mass shootings are quite rare. Brazil has had only one major school shooting. The Scandinavian countries and Thailand are other examples of cultures with both a large social safety net and social structures that “buffer against narcissism.”

 And so the question is inevitable-can we see past the distracters, such as mental illness, violent video games, and armed teachers, and grasp the roots of the problem? Freud

 once observed that “those who love have, so to speak, pawned a part of their narcissism.” Can we, as a society, pawn part of ours?

Flannery DJ, Modzeleski W, Kretschmar JM. Violence and school shootings. 

 Flannery DJ, Singer MI, Wester K. Violence exposure, psychological trauma, and suicide risk in a community sample of dangerously violent adolescents. 

Brown RP, Osterman LL, Barnes CD. School violence and the culture of honor. 

Rampage: The Social Roots of School Shootings.

 Lindberg N, Oksanen A, Sailas E, Kaltiala-Heino R. Adolescents expressing school massacre threats online: something to be extremely worried about?

 Lindberg N, Sailas E, Kaltiala-Heino R. The copycat phenomenon after two Finnish school shootings: an adolescent psychiatric perspective. BMC Psychiatry. 2012;12:91.

 Fazel S, Grann M. The population impact of severe mental illness on violent crime. 

 Interdisciplinary Group on Preventing School and Community Violence. A Call for More Effective Prevention of Violence. http://curry.virginia.edu/articles/sandyhookshooting. Accessed January 17, 2013.

 Small J, Foster B. Mother speaks out about son accused of plotting to shoot up theater in Bolivar. http://www.kspr.com/news/kspr-mother-of-man-accused-of-plotting-to-shoot-up-bolivar-theater-speaks-out-20121120,0,7523945.story. Accessed January 17, 2013.

 National Alliance on Mental Illness. http://www.nami.org. Accessed January 17, 2013.

The Narcissism Epidemic: Living in the Age of Entitlement. 

 Pinker S. The Better Angels of Our Nature: Why Violence Has Declined. New York: Viking Penguin; 2011.

 Reprint ed. New York: WW Norton & Company, Inc; 2010.

The news media has always been in the business of searching for "the right sort of madness" to capture the public's imagination.

Psychiatric Times Vol 30 No 2

Psychiatric Advance Directives: What Psychiatrists Need to Know Now

Understanding the Neurobiological Basis of Drug Abuse: Comorbidity in Schizophrenia

Mass Shootings: Research and Lessons

Panic Attacks and Suicide

From Boxes to Baskets

Ape With the Bone