A friend's cell phone shows a picture of Aaron Alexis, suspect in the mass killing that left 12 dead Monday.Tim Sharp/Reuters
He suffered from paranoia, sleep problems and rage-related issues. He heard voices in his head. His family says that he had recently been treated for mental health problems, but they do not know if he received a diagnosis.
Aaron Alexis had issues. But the case of the 34-year-old, believed by police to be the gunman in Monday's mass shooting that left 12 people dead, is now raising other issues in the wake of the tragedy at the Washington Navy Yard.
Is a broken mental health care system to blame for the latest mass shooting? Or should we look at our gun laws?
It is not a new debate -- but it's raised every time there is a mass shooting.
That Alexis did not get all the help he needed seems obvious, but many health and legal experts caution that while the current state of mental health care in the United States is badly broken, poor gun laws are much more likely at fault for the Navy Yard massacre.
"These mass shootings are so statistically rare with or without mental illness," said Liza Gold, clinical professor of psychiatry at Georgetown University School of Medicine. "The problem of gun violence in this country is a public health epidemic. These have way more to do with lack of regulation of firearms and legality of firearms."
Despite the spate of mass shootings in recent years, D'Vera Cohn, who co-authored a May 2013 Pew Research Center report, said gun violence is down in the U.S. Compared with what it was in 1993 -- the peak of U.S. gun homicides -- the firearm homicide rate was 49 percent lower in 2010, and there were fewer deaths even though the nation's population grew.
"Many Americans are unaware of trends in gun violence," Cohn said. "We conducted a survey in conjunction with our report and found that most Americans -- 56 percent -- thought the number of crimes involving a gun is higher than it was 20 years ago."
Making a point that highlights the complexity of the issue, Georgetown's Gold said most patients with serious mental illness are not dangerous. Studies have demonstrated that they are responsible for only 3 to 5 percent of violence nationwide.
"When people with serious mental illness are dangerous, they are far more likely to be dangerous to themselves by suicide than to perform acts of mass violence," Gold said.
It is hard to say what factors are involved in shooting sprees such as the one on Monday, said Marvin Swartz, a professor of psychiatry and division head of Social and Community Psychiatry at Duke Medicine.
"You've got a confluence of factors," Swartz said. "There's been an alarming trend in reductions of funding for mental health from public payers and also from private payers."
Dramatic cuts in the number of state hospital beds over the past two decades, and reductions in state mental health budgets as well as community services, are all components -- but lax gun laws play a big role, he said.
"The big difference here, compared to other countries: access to guns," Swartz said.
"If you look at rates of crime across countries, we don't have any more crime than most other developed countries. But we have much higher rates of gun ownership and much higher rates of homicide and, to some extent, suicide."
Other developed countries are also doing a better job of providing mental health care, according to Eliot Sorel, a clinical professor of global health at the George Washington University School of Public Health and Health Services. He said the U.S. spends the largest amount per person per year on overall health -- more than $8,000.
"No other country comes near that, but we still have about 50 million people who aren't covered by health insurance," Sorel said.
Even though mental illness still carries a stigma globally, he said many developed nations are more successful than the U.S. at addressing the issue.
"The Scandinavian countries are doing a good job, France is doing a good job, Germany, Switzerland, the U.K. -- practically all of them," he said.
Sorel said one of the keys to managing mental illness is to identify problems as early as possible. About half of mental disorders exist by age 14, and 75 percent are present by age 24.
But with mental health not incorporated into primary care, if children do not see psychiatrists, then mental health conditions are not detected early enough and intervention is delayed.
And the longer you delay it, he said, the more complex and fractured the problem becomes.
"We're sitting on a bomb that ticks," said Sorel, who is a proponent of universal health care.
Janis Orlowski, the chief medical officer at Washington Hospital Center, where victims of the Navy Yard shooting were treated, has also spoken out about the need to have broader and more readily available mental health care available to individuals who need it.
"I think, as we take a look at this issue, it's not just the issue of gun violence, but it's how we deal with people who have mental health issues, and I look at violence as a health care issue," Orlowski told Al Jazeera.
To a certain extent, the federal government and states have addressed mental health issues in their gun laws, to help protect patients who may be a risk to themselves or others if they get hold of a firearm. But these measures are imperfect.
Adam Winkler, a professor at the UCLA School of Law, said there is a federal law that is meant to keep guns out of the hands of certain people referred to as "prohibited purchasers."
"Among the list of prohibited purchasers are those people who have a history of mental illness," Winkler said. "But it's pretty limited in some ways. And there's definitely wide variety among state laws."
The bottom line, say some experts, is that Americans' desire for individualism may get in the way of their best health interests. "I think it's the American culture, the value on individualism," Sorel said. "Everyone is expected to pull up from their own bootstraps."
Laura Cutilletta, a senior staff attorney with the Law Center to Prevent Gun Violence, expressed a similar view.
"I think other countries put more emphasis on community, and in the U.S. we tend to value the individual," she said. "However, we also have to strike the right balance between the individual and the health and safety of our communities. Without safe communities, we are actually denying thousands of Americans the right to live free of gun violence every year.
"The federal government and most of the states have clearly not found the right balance when it comes to gun laws," Cutilletta said.