In 2007, Seung Hui Cho, the Virginia Tech shooter, slipped through the cracks of the state's mental health system. At just about every step, a system designed to catch bizarre behavior and get help to people such as Cho failed.
Now, as eerily familiar details emerge about the suspect in the recent Tucson shootings - whose behavior on an Arizona campus was widely noticed but never addressed by mental health professionals - the question on many minds in Virginia is: Has the system been fixed?
The answer, despite a massive overhaul of the state's mental health system in 2008 and an influx of $41 million, is no, according to state officials and mental health experts.
"Could someone like Seung Hui Cho fall through the cracks again? I definitely think so," said Aradhana A. "Bela" Sood, a child psychiatrist at Virginia Commonwealth University who sat on the panel established by then-Gov. Timothy M. Kaine (D) to investigate the Virginia Tech massacre.
Revisions recommended by that panel were implemented, the first such changes in 30 years, and Sood and other mental health experts said many of them were long overdue. Virginia colleges now have threat-assessment teams to better monitor students who exhibit troubling behavior. Restrictive standards that once made it difficult to force the seriously mentally ill into treatment have been eased. And information about students whose behavior raises concerns is easier to share without fear of violating privacy laws.
As a result, the National Alliance on Mental Illness bumped Virginia's score on mental health from a D in 2006 to a C in 2009.
But is the system fixed? "We've improved it, but the short answer is no. No way. Not even close," said Virginia Attorney General Ken Cuccinelli II (R), who as a lawyer represented clients in the mental health system and as a state senator pushed for reform. "It was really hard to get some very basic things changed until Virginia Tech. . . and frankly, there's a lot more we could do."
Richard Bonnie, who chairs the state Supreme Court's Commission on Mental Health Law Reform, said that despite the changes, gaping holes remain in the system.
"One of our greatest concerns is the lack of counseling services within the community colleges," he said. "Neither the preventive interventions nor the appropriate risk assessment and crisis interventions can be done if they don't have adequate mental health services."
Jared Lee Loughner - who has been indicted in the Tucson shooting rampage that killed six people and wounded 13 - attended a community college, Bonnie noted.
Jennifer Allman, director of student services for the Virginia Community College System, confirmed that the state's community colleges offer academic and career counseling but not mental health services. "Our procedure is not to offer mental health counseling," she said, "mainly because we don't have the resources to be able to do that."
Instead, she said, students whose behavior raises concerns are referred to local mental health agencies or community service boards.
Most troubling, Bonnie said, is the civil commitment process for the seriously mentally ill: the crack that Cho slipped through.
Although Cho's increasingly bizarre behavior - stalking girls, writing violent and disturbing short stories and poetry - frightened teachers and students and alarmed police, it wasn't until he threatened to commit suicide and a roommate's father called campus police that Cho was brought into the mental health system.
At that time, Virginia was one of four states to require that people demonstrate an "imminent danger" to themselves or others before they could be temporarily detained and involuntarily committed to a psychiatric hospital or required to get outpatient treatment. Cho was deemed a danger to himself because of his suicide threat, detained overnight and released the next morning with an order to get treatment.
But no one wrote a treatment plan, no one made sure that he got the treatment, and no one followed up when he showed up for an appointment at Virginia Tech's counseling center and abruptly left.
Because of the 2008 revisions, a magistrate may now detain for mental health evaluation a person who shows only a "substantial likelihood" that he might in the "near future" cause harm to himself or others. The law requires local community service boards to write treatment plans and make sure a mentally ill person gets the mandated care.
But mental health experts say many boards can't provide the services. So the mentally ill person is either hospitalized or dismissed.
Bonnie's commission said mandatory outpatient treatment - the least restrictive, most cost-effective treatment for a mentally ill person in crisis - is rarely used in the state.
Mary Ann Bergeron, who heads the Virginia Association of Community Services Boards, said part of the problem is funding. Although the state put an additional $41 million into the mental health system, state cutbacks then left some local community services boards with less money than they had before the changes - and a mandate to provide more services.
Sood said she has been shocked by the failure to improve Virginia's fragmented mental health system. "There's been a lot of rhetoric and not a whole lot has been done," she said. "We have made improvements, but it's in emergency and crisis care. It's not very sexy, but we should be concentrating on primary prevention and not waiting until a person becomes a crisis in the emergency room."