Mass Shootings, Mental Health, and the Antidepressant Myth

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Every time tragedy strikes in the form of a mass shooting, the same refrain echoes through the media and public debate: mental illness must be to blame. Worse yet, psychiatry as a field gets painted as complicit, accused of flooding the population with dangerous antidepressants that supposedly turn ordinary people into killers.¹

Let me be clear: I am not here to diagnose anyone from afar. But as an inpatient psychiatrist who has treated many dangerous and antisocial individuals, including those transferred from jails and prisons, I cannot ignore the distorted public narrative. Silence only ensures that politicians, pundits, and internet influencers will continue to frame these tragedies in ways that stigmatize patients and vilify psychiatry.

The Criminal Insanity Myth

The legal standard for insanity in most US states is the McNaughton rule, established in 1843. It asks whether the defendant, at the time of the act, was suffering from a “defect of reason, from disease of the mind,” such that they either did not know the nature and quality of the act, or, if they did, they did not know it was wrong.² This standard distinguishes true psychotic delusions—for example, believing one is killing an alien rather than a human being—from acts carried out with awareness and intent.

Case after case demonstrates that mass shooters knew exactly what they were doing. They stockpiled weapons, surveilled schools and theaters, wrote manifestos, and sometimes broadcasted their intentions online. These actions are incompatible with a state of psychotic unawareness, and juries know it. Insanity defenses succeed in fewer than 1% of felony cases, and have even lower success rates in homicide trials.³ To reflexively call these perpetrators mentally ill deepens the stigma against patients with schizophrenia, bipolar disorder, or major depressive disorder, people who are far more likely to be victims than perpetrators of violence.⁴

The Planning Speaks for Itself

Perhaps the most compelling evidence that mass shooters are not psychotic is the meticulous documentation they leave behind. Diaries, videos, and manifestos reveal not disorganized thought but carefully articulated resentment, grievance, and rage. Many bask in anticipation of the violence, seeking validation from online communities. Dylann Roof, who perpetrated the Charleston church shooting in 2015, posted a manifesto on his website The Last Rhodesian claiming to have been radicalized after looking up “black on white crime” which led him to further investigate white supremacist websites. There are many similar examples.

By contrast, violence driven by psychosis is typically disorganized, sudden, and paranoia-fueled. It lacks foresight and coherence. Psychosis is chaotic. Mass shootings are deliberate.

Psychopathy, Not Schizophrenia

The psychiatric profile of many mass shooters fits psychopathy or antisocial personality disorder more closely than schizophrenia. Forensic psychiatry research, including analyses of perpetrators such as Anders Breivik in Norway and US shooters like Eric Harris at Columbine, highlights traits such as⁵:

• Lack of empathy
• Grandiose self-perceptions
• Manipulation and deception
• Cold, calculated planning

Schizophrenia, by contrast, involves hallucinations, delusions, and impaired reality testing. While patients may act violently under paranoid delusions, their actions are rarely sustained or strategically organized.⁶ Psychopathy, though, enables just that: functioning within society while harboring a ruthless disregard for human life.

The Irony of the Public Narrative

Here is where the hypocrisy burns: as a society, we scapegoat psychiatry when violence erupts, blaming antidepressants or “overmedication,” yet we underfund the very system meant to help those truly suffering. We close community clinics, cut psychiatric beds, and stigmatize treatment.

Meanwhile, antidepressants are portrayed as if they are the trigger behind mass shootings, despite large epidemiologic studies showing no causal link between selective serotonin reuptake inhibitors use and violent crime at the population level.⁷

The result is a narrative that misleads the public, blames the wrong culprits, and ignores the true drivers of violence: grievance, entitlement, radicalization, and access to weapons.

The Hard Truth

It is comforting to believe that mass shooters must be insane. If they are alien, “other,” then we can avoid confronting the unsettling truth: these are individuals who often appear normal, who walk among us, but who harbor resentment, hatred, and the willingness to kill.

That realization should shake us more than any headline about antidepressants ever could.

A Call to Action

If psychiatrists fail to challenge the narrative, others including politicians and pundits will continue to tie our field to mass shootings, cementing stigma and distracting from real solutions. It is our responsibility to reclaim the truth: psychiatric illness does not explain mass shootings, and blaming our field only undermines care for those who desperately need it.

Dr Rossi is an inpatient and consultation liaison psychiatrist who also performs electroconvulsive therapy services at AtlantiCare Regional Medical Center in Pomona, New Jersey. He currently serves on the board of the New Jersey Psychiatric Association, where he has worked on advocacy projects, including enhancing access to collaborative care in the state.

References

1. Healy D, Herxheimer A, Menkes DB. Antidepressants and violence: problems at the interface of medicine and law. PLoS Med. 2006;3(9):e372.

2. Simon RJ, Ahn-Redding H. The Insanity Defense, the World Over. Lexington Books; 2016.

3. Callahan L, Steadman HJ, McGreevy MA, et al. The volume and characteristics of insanity defense pleas: an eight-state study. Bull Am Acad Psychiatry Law. 1991;19(4):331-338.

4. Stuart H. Violence and mental illness: an overview. World Psychiatry. 2003;2(2):121-124.

5. Melle I. The Breivik case and what psychiatrists can learn from it. World Psychiatry. 2013;12(1):16-21.

6. Rueve ME, Welton RS. Violence and mental illness. Psychiatry (Edgmont). 2008;5(5):34-48.

7. Lagerberg T, Fazel S, Molero Y, et al. Associations between selective serotonin reuptake inhibitors and violent crime in adolescents, young, and older adults - a Swedish register-based study. Eur Neuropsychopharmacol. 2020;36:1-9.