In 2020, I was asked to review a submission for AJN’s Viewpoint column. Reviewers are not told who the author of a work is, nor are authors informed who is reviewing their submission. But I hadn’t gone very far when I knew exactly who the author was and what she was writing about.

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In my career I have read and been moved by many articles and first-person accounts, but this time was different. Each word took me closer into what I realized was a very personal viewpoint on an unimaginable national tragedy.

The author of the article was Arlene Holmes, a nurse and mother who was writing about her son James, who on July 20, 2012, opened fire on movie theater patrons in Aurora, Colorado, killing 12 and wounding 70. (Her article, “Why a Nurse (and Mother) Didn’t Know,” was eventually accepted and published in AJN‘s June 2020 issue.)

Asking the same questions over and over.

After completing the review of this article, the questions I asked myself were the same ones I ask each time we hear of such tragic events happening at the hands of someone who has a mental illness:

What could have been done to change the outcome and prevent such tragedies from happening? Why wasn’t something done by someone at some point along the way to change the direction the person and situation were headed in before it was too late?

Increasing awareness.

Who better than someone who has lived the experience to share an emic (insider) perspective? I reached out to Arlene to ask her to join me in getting the word out about increasing our awareness of mental health and illness and to offer some suggestions about what we need to know and do. She does so in my Mental Health Matters column (free until Oct. 7) in this month’s issue of AJN.

Being aware of the signs and symptoms of any disorder or disease is only the first step. Imagine being in a restaurant when another diner clutches his chest and complains of pain up his left arm. Do we look on and say, “Yes, those are the signs of a heart attack,” and then go back to finishing our meal?

Or imagine being at the mall and having the store clerk suddenly complain of a major headache and noticing she is slurring her speech and the left side of her face has started to droop. Is it enough to tell the clerk she might be having a stroke based on your knowledge of those symptoms and then take your items to be rung up by another cashier?

Absolutely not to both of those scenarios. We would step in and render care and call for help.

Unfortunately, such rapid intervention is usually not the case with mental health. With many of the cases we have seen in the past and will see again in the future, somewhere along the line there were clues and indications that, had these been followed up on, might have prevented a tragedy.

Nine critical warning signs.

In this month’s column, we review some of the things worth paying attention to, and Arlene shares important information about what nurses need to know and do. While most people who have mental health issues are not violent, it is important to consider that, at times, behavior can become violent.

The following nine critical warning signs of violence, compiled by the national nonprofit organization Sandy Hook Promise, should certainly be a call for action on the part of anyone who witnesses them, especially in combination. They indicate a person may be in crisis or in need of help sooner rather than later:

  1. Sudden withdrawal from friends, family, and activities (including online or via social media)
  2. Bullying, especially if targeted towards differences in race, religion, gender, or sexual orientation
  3. Excessive irritability and unusual quickness to anger
  4. Experiencing chronic loneliness or social isolation
  5. Expressing persistent thoughts of harming themselves or someone else
  6. Making direct threats toward a place, another person, or themselves
  7. Bragging about access to guns or weapons
  8. Recruiting accomplices or audiences for an attack
  9. Directly expressing a threat as a plan

The above is not an exhaustive list. Too often we find ourselves doing and asking questions after the harm has been done. Perhaps if we acted sooner, we wouldn’t need to ask why. Although it’s too late to change the course of events for past tragedies and acts of violence, it’s not too late to be the person who, armed with the knowledge that something is amiss, can make a difference in preventing a future tragedy.

Donna Sabella is a psychiatric mental health NP, a professor at the Pennsylvania College of Health Sciences in Lancaster, and the coordinator of AJN’s Mental Health Matters column.