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Volume 357:105-110 July 12, 2007 Number 2 Next

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Since April 16, when Virginia Tech student Seung-Hui Cho gunned down 27 fellow students and 5 faculty members and injured 24 other people before taking his own life, some disturbing facts about his mental health history have emerged. At various points during Cho's college career, Virginia Tech police officers, professors, and students recognized that he was mentally troubled, but although state psychiatric evaluators once briefly committed him to a psychiatric hospital, it is unclear whether anyone from the school monitored him after his release. These discoveries have left investigators wondering whether the killings could have been prevented — and college mental health specialists debating the best way to keep other disturbed students from falling through the cracks.

Cho's rampage is the subject of several investigations: one by an independent panel appointed by Virginia's governor, one by the state police, and one by Virginia Tech itself. But some key details are already clear. As a junior in the fall of 2005, Cho became known for his silent and aloof manner, troubling behavior, and dark, disturbing writings. That semester, he took a creative writing course with the poet Nikki Giovanni in which he always sat silently, wearing reflective sunglasses and, despite requests to remove it, a cap pulled down over his face. His class writing consisted of a single poem about women's panties, which Giovanni considered intimidating, but he would not write anything else: week after week, when it was time to share his work, he read the same poem. Midway through the semester, Giovanni learned that Cho had been using his cell phone under his desk to photograph female students. She told him he could not remain in the class.

Around the same time, according to an inquiry by the state's inspector general for mental health services, Cho's suitemates wrote a letter to a resident adviser documenting his bizarre and threatening behavior, and the campus police met with Cho twice after receiving reports from female students that he had sent them unwanted e-mail or instant messages.¹ After his second meeting with the police, Cho sent an instant message to his suitemate saying "he might as well kill himself," and that student told his father, who reported it to the campus police. This time, the police asked Cho to speak to a counselor. He went with them voluntarily and spoke to an "emergency evaluator" from the state Department of Mental Health, who heard about his harassing behavior and learned from one of his suitemates that he referred to an imaginary twin brother. She had him admitted to the psychiatric hospital in nearby Radford, but the next day, a judge discharged him and ordered him to seek outpatient treatment. The police notified the school that he'd been hospitalized, and before he was discharged, the hospital had him schedule an appointment with the university counseling center, which received records of his diagnosis and the court order for treatment. Nevertheless, it's unclear whether he sought therapy or whether a member of the university staff followed up with him. (The university released Cho's counseling records to the governor's panel in mid-June after his parents gave their permission, but the panel will not disclose their contents.)

View larger version (55K): [in this window] [in a new window]   From David Knachel, Virginia Tech.

 
Close follow-up is particularly important after a psychiatric hospitalization, because the risk of suicide is high immediately after discharge.² Cho's short stay at the hospital, combined with the court order for outpatient care, would have been a signal to an alert clinician that he needed an in-depth diagnostic evaluation. Many colleges and universities have a protocol for evaluating students who are returning to school after being hospitalized or taking a medical leave for psychiatric care. Referred to as "screening" or "reentry," it's a task that experts say has grown in importance as the number of students with serious mental disorders — including eating disorders, bipolar disorder, and schizophrenia, disorders that often present for the first time in the teens or early 20s — has increased. Not so long ago, people with such conditions would have been unlikely to stay in college, but the availability of new psychotropic medications has enabled more mentally ill students to pursue higher education, and the courts have made it clear that mental illness and suicidal behavior and ideation aren't grounds for dismissal. When Richard Kadison, chief of mental health services at Harvard University, performs a screening, he speaks to the student and the outside therapist and sometimes puts a contract in place requiring the student to continue therapy. In the end, though the evaluation is confidential, the screening doctor or reentry team makes a recommendation to the dean about readmission.

Unfortunately, there was no clear way to screen Cho for reentry to Virginia Tech in the fall of 2005. The school's counseling center did not accept "involuntary or ordered referrals for treatment from any source," according to the inspector general's report, and even students with "thought disorders" were treated only if they were willing to be served. In addition, according to an article in the student newspaper that fall, the university was facing a crisis at its counseling center, whose only psychiatrist had left and hadn't been replaced. There is a profound shortage of psychiatrists in the college's "very poverty-stricken, rural, rugged area," explains psychiatrist Joe Frieben, who worked part-time at Virginia Tech this past year. The college newspaper reported that students requiring prescriptions for controlled medications might need to travel to Roanoke, 45 minutes away.³

View larger version (108K): [in this window] [in a new window]   From Josh Armstrong, Virginia Tech Photo.

 
Although the student health service is in the same building as the counseling center, the two aren't integrated and don't share responsibility for patients or patient records. But though the school may have had an unusual gap in coverage, lapses in coordinating follow-up care are fairly common in college mental health. One reason is that on any given campus, mental health services may be minimal. Colleges and universities are regulated under the Higher Education Act, which "has absolutely no standards whatsoever for mental health," notes Joanna Locke, a program director at the Jed Foundation, a New York–based organization aimed at preventing campus suicides. And yet, U.S. colleges are full of stories of troubled students who become suicidal. A 1995 survey of 5000 undergraduates by the Centers for Disease Control and Prevention found that in the previous 12 months, 10.3% had seriously considered suicide, 6.7% had made a suicide plan, and 1.5% had attempted suicide, and the American College Health Association reported similar figures in 2006. Tales of successful suicides by students — which attract lawsuits and media attention — have prompted recent changes at some universities.

At the Massachusetts Institute of Technology (MIT), the mental health services were restructured after a highly publicized case: in 2000, sophomore Elizabeth Shin became the 12th student to commit suicide on campus in as many years. MIT counselors and psychiatrists had met with Shin, and she had been hospitalized while in school, but no one person seemed to have responsibility for overseeing her care. The school's mental health service was understaffed: between 1995 and 2000, the number of students seen by the service had increased by 50%, and the number hospitalized for psychiatric reasons had increased by 69%, but staffing levels hadn't increased.⁴ According to Alan Siegel, chief of MIT's mental health service, the service now ensures that any student who is in treatment has an assigned clinician who must track him or her if appointments are missed; students also have electronic medical records that are shared by the medical and counseling staffs. In addition, each member of the mental health staff is assigned to a dormitory to do outreach, which Siegel refers to as the "doc-in-the-dorm" program.

Outreach may be a campus mental health center's most important function, since only about 20% of students who take their own lives have ever been to their school's counseling center. The University of Illinois reduced its suicide rate by requiring students who threatened or attempted suicide to have a four-session mental health evaluation. Other strategies include "gatekeeper training" (teaching the people most likely to interact with students how to recognize suicidal ideation), hotlines, and eliminating access to lethal means by locking up chemicals, blocking off roof access in campus buildings, and ensuring that windows cannot be opened all the way. None of these ideas are novel, but none have been routinely implemented on college campuses.

At New York University (NYU), the impetus for change came after six students jumped or fell from high buildings to their deaths from the autumn of 2003 to the autumn of 2004. Henry Chung, the psychiatrist appointed in 2005 to integrate the school's mental health and medical services, was struck by the poor communication among members of the health staff. Doctors in the primary care center would refer a patient to the mental health center, he explained, "but have no idea whether they went" because of "the complete lack of a feedback loop" between the services. He encountered misinterpretations of privacy laws (see FERPA, HIPAA, and the Privacy of College Students) that kept mental health professionals from sharing with primary care doctors information about students' psychiatric problems. He also found that there was no mechanism for triage, so that even students with urgent clinical needs had to wait weeks for a counseling appointment — at which point some did not come. He hired more staff members — for 38,000 students, NYU now has three full-time psychiatrists — and instituted policies ensuring that any student seeking counseling was assessed over the phone within 48 hours. But his efforts to fold the two services together were met with "a lot of mistrust."

Psychologist Greg Eells, the director of Cornell University's counseling center and president-elect of the Association for University and College Counseling Center Directors, acknowledged that his field faces a clash of cultures between traditional counseling and the "medical model" of diagnosing psychopathology. Many campus counselors, said Eells, find it hard to think about combining their services with those of a medically run center because the training for the two is so different. And indeed, nearly 65% of college counseling centers have no relationship with the college health center. If students have complex problems requiring coordinated care, said Eells, "most of the time at most universities" there is no capacity for treating them.

After a 1995 murder–suicide in a Harvard dormitory and two task-force reviews of the school's mental heath service, Harvard provost Steven Hyman, a psychiatrist, was concerned about a similar issue: some students were seen at the university's freestanding counseling center and others at the university health service, and the two didn't always communicate. Harvard moved both services into a new department in 2004. Paul Barreira, the psychiatrist who chairs the department, acknowledged that the move was controversial and wouldn't have happened without the provost's strong support.

Raising the stature and visibility of the person in charge of mental health may be a prerequisite for transforming campus culture with regard to mental illness and for combating the stigma attached to it. Kerry Knox, a University of Rochester researcher who designed an effective suicide-prevention program for the Air Force, believes that a key factor in the program's success is its history of being championed by three-star and four-star generals.⁵ "That can make things happen," she notes. Knox is now working with MIT and five other universities to see whether parts of the Air Force program can be implemented on a university campus, but it's not clear who can act as a general in the academic setting.

Chris Flynn, director of Virginia Tech's counseling center — where one full-time psychiatrist is now available for the school's 27,000 students — said that the center has excellent communication with the student health service, and the dean runs a regular meeting that includes staff members from resident life, the disciplinary office, student health, student affairs, and the counseling center. But the people who knew Seung-Hui Cho best and were most concerned about his behavior starting in 2005 weren't at that meeting; they were in the English department, where Cho was a major and tended to write about violent themes, such as a child who attempted to murder his stepfather and a teacher who stalked students. Giovanni said that she would have liked the department faculty to have met to discuss him, "but we don't discuss students because we have so many issues . . . around privacy." She characterized such issues as "phony," and indeed some legal experts say that colleges are mistaken in interpreting student-confidentiality laws as prohibiting necessary discussions of students' work and behavior. Similarly, though college administrators may contact a student's family, many of them believe that privacy laws prohibit it. At Virginia Tech, it appears that no one told Cho's parents he had been admitted to a psychiatric hospital.

It is impossible to know what difference outpatient mental health care might have made for Cho. He could have fallen through the cracks even if a serious effort had been made to provide care, but given the state of the mental health service and intracampus communication in 2005, it appears that Virginia Tech was unable to make that effort. Apart from speeding tickets, Cho had no further involvement with the police from December 2005 until the day of the killings; rather than falling through the cracks, says Flynn, Cho "crawled into the cracks and hid there." But members of the governor's investigatory panel see it differently. "The counseling piece is a critical part in the college environment, and there truly was no counseling," said emergency physician Marcus Martin at the panel's meeting in Fairfax, Virginia, on June 11. It fell to a college senior to tell the student paper in August 2005 that the lack of services could mean "serious problems with students who may be depressed or suicidal" — it is not clear whether Tech's leaders were aware of the crisis.

Calling All Crisis Counselors

When classes resumed at Virginia Tech on a Monday morning a week after the shootings, psychologist Chris Flynn had been awake for hours. Flynn is something of an expert on crises, having been the counseling center director at Loyola University New Orleans when Hurricane Katrina struck. He intended to focus his resources on certain classes — those whose enrollees included the shooter or one of his victims, those whose professor had been murdered, and those involving someone who had requested a counselor's presence. He'd let psychologists and counselors throughout the country know that he needed professionally trained counselors — for what turned out to be nearly 300 classes.

That morning at about 5:45, three Ph.D. psychologists sat in Virginia Tech's stadium, writing the name and location of each class on a whiteboard, but no one was sure how they would provide counselors to all of them. Flynn headed to his office to pick up tip sheets from the American Psychological Association on managing distress in the aftermath of a tragedy (his staff had made 30,000 copies), and when he returned to Lane Stadium about 45 minutes later, he found 125 trained counselors from all over the country waiting in line to show their credentials and be registered, each donning a high-visibility purple armband. Some were directors of college counseling centers in the Southeast, others came from as far away as California, and the line kept getting longer.

All told, more than 300 volunteers showed up that day and the next, and Flynn's staff used them all, fanning them out across the campus to classrooms, hallways, and walking paths. Often, they spoke at the start of a class or at the end, and in one case they took over teaching a class session for a traumatized professor. They stayed 2 days, as requested, but Flynn plans to increase his staff before fall. The principal at Columbine High School in Colorado, the site of a 1999 mass shooting, has called and warned Flynn that the university's students will have a greater need for counseling for many years to come. At Columbine, the principal said, the numbers seen by counselors have never fallen back to their pretragedy level, and the school has seen a marked turnover of teachers and staff.

FERPA, HIPAA, and the Privacy of College Students

The laws and professional codes of conduct that protect a college student's right to privacy are so confusing that they have produced "massive misunderstanding," according to Peter Lake, director of the Center for Excellence in Higher Education Law and Policy at Stetson University. This claim is supported by a "Report to the President" issued by three Cabinet members in June. Confusion about federal and state privacy laws was a consistent theme in discussions that these officials held throughout the country in response to the Virginia Tech tragedy.

The Family Educational Rights and Privacy Act (FERPA), the college confidentiality law passed in 1974, is often interpreted as prohibiting faculty or staff members from sharing information about a student with one another or with family members unless there is an emergency, but Lake said this is a misinterpretation. FERPA was not intended to block communication between deans or professors, who may share students' academic records. It's also not aimed at blocking communication between universities and students' families, since it restricts only discussion of a student's academic record, not interactions about, say, strange behavior or illness. Yet Cabinet members "repeatedly heard reports of `information silos' within educational institutions . . . that impede appropriate information sharing."

College counseling centers may also claim that they are prevented by the Health Insurance Portability and Accountability Act (HIPAA) from sharing information about a student without the student's permission, but experts differ about whether and when HIPAA applies. The Cabinet members wrote that in their meetings "and in every breakout session, we heard differing interpretations and confusion about legal restrictions on the ability to share information about a person who may be a threat to self or others."

Most college mental health personnel follow standard medical confidentiality rules, which can be frustrating to parents and to faculty and staff members. But without a strict interpretation of confidentiality, many students might not seek care. "A large percentage of our students who come for counseling have had thoughts of suicide," said Mark Reed, director of Dartmouth College's Counseling and Health Resources Departments. "If they think, `If I whisper those words, I'm going to be kicked off campus,' that will prevent them from coming."

One answer for counseling centers is to find another person on campus who can communicate about a student more broadly. Class deans, who fill that role at Dartmouth, are free to communicate with family and faculty members. Though deans cannot know what is in the student's counseling or medical records, they can share their own concerns about a student's behavior or the concerns raised by others. Said Reed, "If family call us or the coach calls us, we'll say, `You're right to be concerned, and you may also want to share that with the dean.'" Information that comes to the dean from these other sources — not the school's health or mental health service — "is not HIPAA protected," explained Paul Appelbaum, director of the Division of Psychiatry, Law, and Ethics at Columbia University.

Another answer is to find legal counsel who can weigh the risks of breaching confidentiality against the risks of keeping it. At the University of Michigan, health care professionals have been reassured by university counsel that if a breach in confidentiality is required to preserve a student's life or mental health, the university will support them, "though it's done with great gravitas," said chief health officer Robert Winfield.

Both FERPA and HIPAA have exceptions for emergencies, but even the exceptions are confusing, and the Cabinet members found that people were generally unaware of these exceptions.

Perhaps, as Lake predicts, the Virginia Tech case will ultimately help to clarify the provisions of the privacy laws and allow crucial communication to take place.

Source Information

Dr. Shuchman is a national correspondent for the Journal.

An interview with Mark Reed, director of the Counseling and Health Resources Departments at Dartmouth College, can be heard at www.nejm.org.

References

1. Commonwealth of Virginia, Office of the Inspector General for Mental Health, Mental Retardation and Substance Abuse Services. Investigation of April 16, 2007 critical incident at Virginia Tech: preliminary report. No. 140-07. (Accessed June 20, 2007, at http://www.oig.virginia.gov.) 
2. Appleby L, Shaw J, Amos T, et al. Suicide within 12 months of contact with mental health services: national clinical survey. BMJ 1999;318:1235-1239. [Free Full Text]
3. Sutphin M. Psychiatric support lapses at Virginia Tech counseling center. The Collegiate Times. August 12, 2005.
4. Massachusetts Institute of Technology. MIT Mental Health Task Force report. November 6, 2001. (Accessed June 20, 2007, at http://web.mit.edu/chancellor/mhtf/.)
5. Knox KL, Litts DA, Talcott GW, Feig JC, Caine ED. Reduced risk for suicide and related adverse outcomes following exposure to a suicide prevention programme in the US Air Force: cohort study. BMJ 2003;327:1376-1380. [Free Full Text]

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