The majority of killers involved in recent mass shootings had encounters with the mental healthcare system before they committed their acts of violence, with some even being legally compelled to seek help.

Few seemed surprised when it came out over the weekend that James Holmes, 24, who allegedly killed 12 and wounded 58 others at a movie theater shooting in Aurora, Colo., had been seeing a psychiatrist with the University of Colorado’s mental health services program.

In such cases, many are quick to question whether the treating psychiatrist — in this case Lynne Fenton, MD, director of the University’s student mental health services — missed any red flags that could have prevented such a massacre.

At least one news report claims that about 6 weeks before the movie theater rampage, Fenton alerted the school’s threat-assessment program that Holmes was potentially dangerous, but he was lost to follow-up after dropping out of the university on June 10.

If that report is confirmed, Fenton’s experience appears to be the exception rather than the rule, since such warning signs aren’t easy to detect.

Detecting danger

Moreover, even if a client’s behavior sets off alarm bells for a clinician he or she may not have many options. For example, some states require a substantial amount of evidence before a patient can be detained against his or her will.

“Patients typically qualify for an involuntary commitment if they meet one of three criteria,” Paul Appelbaum, MD, professor of psychiatry, medicine, and law at Columbia University, told MedPage Today. “They’re a risk to themselves, a risk to others, or they’re gravely disabled and can’t meet the basic needs of food, clothing, and shelter.”

While that’s the “general framework,” Appelbaum said, the standards vary from state to state, with most agreeing that a clear action or physical threat would qualify a patient for involuntary commitment.

But in some areas, a simple verbal threat — even if the psychiatrist believes the patient is likely to act on it — wouldn’t necessarily make a patient qualify for commitment.

“There’s considerable variability in how much evidence is needed and how concrete that evidence needs to be,” he said.

Nor is a psychiatrist usually the first person to make the referral for an involuntary commitment, Appelbaum noted: “Most cases come out of the hospital emergency department or inpatient units,” with police officers detaining the patient and following up with psychiatric services for an official assessment.

“Only a small percentage come from the private setting, and that can be difficult,” Appelbaum said. “The average psychiatrist is not set up to take physical custody or restraint of a patient who does not want to be hospitalized.”

Instead, he said, a psychiatrist will typically raise the idea of voluntary hospitalization with the patient. If that doesn’t work, the doctor then reaches out to family of the patient or to police depending on how immediate the threat is.

Though it again varies by state, in general involuntary commitment requires the sign-off of at least one psychiatrist who has examined the patient on a petition filed with the court before that person can be hospitalized.

Commitment no guarantee

And an involuntary commitment isn’t guaranteed to prevent catastrophe, case in point: Virginia Tech shooter Seung-Hui Cho.

Cho, who killed 32 people and wounded 17 others, had been detained in December 2005 after two female classmates said they received threatening messages from him.

A local mental health service board determined that Cho was a danger to himself and transferred him to a psychiatric hospital. An evaluation there found him mentally ill but not a threat to himself or others, so a judge set him free after ordering that he receive outpatient counseling.

Cho never followed through on the order. Two-and-a-half years later, he went on a campus rampage.

A similar situation occurred with John Shick, the shooter who killed one and wounded five in a psychiatric ward at the University of Pittsburgh Medical Center last March.

Shick had also been involuntarily committed in Portland, Ore., in 2010 after assaulting a police officer and speaking incoherently.

According to reports, Shick had become increasingly hostile to physicians and staff at UPMC, where he was being treated for what he insisted was pancreatitis — though clinicians said he did not have the disease.

His primary care physician at UPMC tried to have Shick involuntarily committed, but when police showed up at his door, Shick refused to speak with them, and ultimately they gave up.

Shick had also sent emails to several clinicians around the country complaining about his treatment at UPMC just weeks before the attack.

One of those doctors, Brennan Spiegel, MD, of the University of California Los Angeles, has been quoted in news reports saying the email presented typical warning signs that UPMC clinicians should have been concerned about.

Sources at the University of Pittsburgh Medical Center told MedPage Today that they couldn’t discuss details of the case given that an investigation into the handling of these red flags is ongoing.

Whether or not spotting the potential for danger has any impact on preventing disasters, Appelbaum said rates of involuntary commitment are likely to rise after the Colorado shooting.

“After highly publicized acts of violence by a mentally ill person, involuntary commitment rates tend to go up,” he said. “Both physicians and the courts tend to be responsive to the salience of risk presented by these cases.”

Kristina Fiore is a staff writer at MedPage Today, where this article was originally published.