The heartbreaking murders at Tantalus lookout of taxi driver Manh Nguyen, and Jason and Colleen Takamori have once again focused the attention of our community on the relationship between violence and severe mental illness.

While all crime attacks our personal sense of safety, extreme and seemingly random violence, such as in this case, is particularly difficult to comprehend. When the person suspected of a violent crime has had a history of treatment for mental illness or has a psychiatric diagnosis of "paranoid schizophrenia," as has been reported in this case, it provides an easy way for us to rationalize the outrageous.

Over time, the judicial system will attempt to understand whether mental illness was a factor in this crime, as has been inferred by some. That determination reflects the complex intersection of medicine, law, public safety, psychiatric disability and insanity. The legal processes involved are clearly outlined in statutes.

UNFORTUNATELY, WHILE THE PUBLIC IS

exposed to these court deliberations, it may become more fearful that people with psychiatric disabilities pose a serious risk to themselves and their families. This lends a heightened importance and urgency to understanding the relationship between violence and mental illness.

To review the complex relationship between violence and mental illness and decrease the risk of violence, it is important to review relevant concepts of mental illness, its treatment and recovery. Recovery from severe mental illness can follow several pathways, including full and complete recovery. Alternatively, the disability may be episodic or it can be ongoing.

In all cases, the goal of treatment is recovery — and to help individuals understand and manage their illness, in consultation with the formal treatment system when needed and through family education and friends when appropriate. An important part of treatment is recognition by the disabled individual or their support network when their condition is deteriorating, and seeking additional support and treatment.

Schizophrenia can be defined in layman's terms as a thought disorder that includes symptoms of delusions (a belief system that does not match reality), hallucinations (an auditory, visual or other sensory event that does not match reality), or psychosis (which can be thought of as a summary term for any combination of thoughts, actions, delusions or hallucinations that do not match reality).

The specific mental illness most often presumed to be most associated with violence is called "schizophrenia, paranoid type," which may include specific delusions and or hallucinations but does not typically represent complete deterioration in functioning in other areas. For example, a person who functions well but suffers from a delusion that his auto mechanic is secretly placing subliminal messages in his car radio to control his thoughts may be given this diagnosis and would be perceived as potentially dangerous if he also hears "command hallucinations" — a voice in his head commanding him to cause harm to the mechanic's place of business. Clearly, a person with these symptoms needs treatment.

Still, predicting violence — both among those with severe mental illness and those with no mental illness at all — is difficult and complicated at best. It's clear that individuals with severe mental illness who are taking their medications are not more dangerous than the general population. The MacArthur Foundation's study of violence and mental illness found that individuals with severe psychiatric disability engaged in treatment showed approximately the same incidence of violence as individuals without mental illness living in the same neighborhoods.

However, when such individuals were not involved in treatment, the rate of violence doubled. Significantly larger increases in violence occurred when individuals with mental illness also abused alcohol and other substances. Substance-abuse problems, lack of participation in treatment — particularly nonadherence to prescribed medication, and a lack of acknowledgement of need for treatment — are the factors that contribute to violence by individuals with psychiatric disabilities.

All this must be viewed in its greater context. A 2003 briefing paper from the Treatment Advocacy Center titled "Violent Behavior: One of the Consequences of Failing to Treat Severe Mental Illness" pointed out that the overall rate of violence by individuals with severe mental illness, including those who abuse drugs and refuse treatment, accounts for no more than 5 percent of the violence in the United States. This population-based rate cannot help us predict when a specific individual might become violent. However, a sensible rule of thumb is that an individual who is more ill (i.e., has a co-occurring substance-abuse disorder, has frequent delusions and hallucinations, refuses to seek treatment, does not acknowledge the presence of an illness, declines or stops taking medication) is at higher risk of committing a violent act and should be carefully watched.

On a similar note, individuals who are actively engaged in treatment do not abuse substances, understand personal triggers to their illness and have either a strong treatment system or social system to provide support, quick access to treatment, and early identification of episodic deterioration are far less likely to be violent.

As a community, there are practical steps that we can take to help further lower the low incidence of violence by individuals with psychiatric disabilities. It is the responsibility of each of us in Hawai'i to try to understand the mental health of our relatives and family members, our friends and neighbors, and especially those individuals who are socially isolated. When talking with these people, we should watch for the warning signs of psychiatric disability, which include confused thought that doesn't match reality, specific ideas or plans which seem inconsistent with typical views of reality, or the hearing of voices. When a suspicion of severe mental illness is present, it is important to help individuals seek treatment.

The Department of Health has a 24-hour, seven-days-a-week ACCESS Program. In emergency situations, crisis mobile outreach teams can be dispatched.

It is easy to jump to a quick conclusion that violence is related to mental illness when we hear news reports including information that a person has had mental health treatment or a mental health diagnosis. But it's important to recognize that appropriate treatment is the key to minimizing any possible relationship between mental illness and violence.

Unfortunately, many individuals with severe mental illness will not seek treatment because of a lack of awareness of their illness and lack of knowledge on how to access treatment, and because of the associated discrimination and negative perception of mental illness perpetuated by the media and other social institutions.

If we had the ability to change the stereotype of individuals with psychiatric disabilities from insanely unpredictable murderers to something more realistic, we would see the mentally ill as people who are shy, afraid, lonely and often victimized. Better yet, maybe we will begin to see they are people just like us.

Annette Crisanti, chairwoman of the Hawai'i Center for Evidence-Based Practices; Marya Grambs, executive director of the Mental Health Association in Hawai'i; and Marion Poirier, executive director of the O'ahu chapter of the National Alliance on Mental Illness, contributed to this report. They wrote this commentary for The Advertiser.