Reality-based mental health reform: preventing mass killings like the one in Newtown may be impossible. But there's plenty we can do to reduce violence by the mentally ill in general. And the tools are right there in Obamacare.

• Author: Pollack, Harold
• Position: Essay

In the aftermath of the massacre in Newtown, Connecticut, America is having a long-overdue national conversation about guns, mental health, and avoidable violence. The slaughter of elementary schoolchildren has a way of clarifying things.

Much of the conversation thus far has focused, quite rightly, on the guns. President Barack Obama has presented a package of valuable measures that closely match the recommendations of the nation's leading gun violence experts. If enacted into public policy and American law, the president's proposals, especially closing loopholes on background checks, have the potential to save many lives.

But there's a certain irony in the timing of this national conversation, and the way in which we are conducting it. High-profile mass shootings are relatively rare, resulting on average in a few dozen deaths a year; ordinary, clay-in, day-out gun crimes, on the other hand, wipe out more than 10,000 lives a year. Mass shootings are also quite difficult to prevent. I hope the sheer horror of Newtown catalyzes passage of a strong assault weapons ban, but the number of lives we will save through such a measure is likely to be modest. That's because the overwhelming majority of gun-related murders and injuries, whether by angry spouses or by professional criminals, aren't committed with assault weapons (defined, loosely, as semiautomatic firearms with military-style characteristics). Rifles and shotguns of all types, assault versions and not, together account for less than 12 percent of murders for which the type of gun is recorded; handguns account for the rest. The flow of ordinary crimes committed with ordinary weapons doesn't command the same attention, but it accounts for many more gun deaths.

A similar irony applies in the area of mental health. The Newtown massacre has elicited serious calls to do something to stop the violently prone mentally ill. Yet the fact is that very little of the violence perpetrated by people with mental illnesses takes the form of mass shootings. Much more common are cases in which deranged individuals commit assaults, muggings, and robberies, or cases in which individuals with mental illnesses commit crimes connected with the misuse of alcohol or illicit drugs. In many cases, the primary victims are not strangers, but the perpetrator's own loved ones and friends.

Just like those ordinary crimes committed with ordinary weapons, these individual acts of violence seldom make headlines. And of all the mentally ill likely to commit violence, mass shooters may be the hardest to identify in advance--in part because of the unusual, often idiosyncratic nature of such atrocities.

To be sure, in rare cases--often the cases that make headlines--mental health systems have failed to stop specific individuals who were already known to be dangerous. Seung-Hui Cho, the twenty-three-year-old who killed thirty-two people at Virginia Tech, had previously been found by a judge to be "an imminent danger to himself as a result of mental illness" and forced into outpatient mental health care. But things are usually far murkier. After an atrocity happens, one can often spot some ominous warning sign, some missed opportunity to intervene, dared Loughner displayed strange and scary tendencies before he shot Gabrielle Giffords and eighteen others. James Holmes saw three mental health professionals before he shot dozens of Aurora theatergoers. Such red flags generally appear brighter in retrospect, the dots easier to connect, than they do in real time. One rarely sees the equally red flags waved by tens of thousands of others who have struggled with mental illness or who have sought help for personal challenges who never subsequently hurt anyone. There is little in the biography of Adam Lanza that should have led law enforcement authorities to specifically identify him as a threat to public safety before the events in Newtown.

In a New York Times op-ed last December by Richard A. Friedman, Columbia University clinical psychiatrist Michael Stone noted that "most of these killers are young men who are not floridly psychotic. They tend to be paranoid loners who hold a grudge and are full of rage." They are damaged, but not disabled, by whatever impels them to hurt others. Indeed, they remain sufficiently lucid to plan and execute horrific crimes. Except...