October 24, 2021


 The tragic deaths of two American heroes.  

Was this heartbreaking event avoidable?   Many questions remain about the diagnosis and treatment of veteran Eddie Ray Routh, the convicted killer.   What is the difference between clinical and legal insanity?

As a mental health professional, that treated veterans and directed programs in the Department of Veterans Affairs, the above questions came to mind.   The first item that I would like to ascertain is what type of mental illness, if any, Mr. Routh had.   Some statements made suggest a severe mental illness, while others make a case of malingering.   I have not read or heard any convincing evidence of this person suffering from PTSD.   This is, in my mind, important because as this stress produced mental disorder was ignored for many years, I am afraid that at present is over diagnosed as justification of criminal kinds of behavior.   Exposure to combat, actual or not, can lead to many different mental illnesses other than PTSD.   Other psychosis as bipolar or schizophrenia, could be had before enlisting, not picked up, and come to the fore because of stress.   The fact that he was treated at mental hospitals, including the VA, plus the statements of his immediate family leads me to believe that Mr. Routh was indeed psychotic from Paranoid Schizophrenia.   Was this veteran well served by the Veterans Administration, specifically the Dallas VA hospital?   It pains me to conclude that he was not.   As I understand after admission for a severe illness, he was discharged after two weeks of treatment with six medications.   I also understand that his family pleaded for his continued acute treatment, and that the official records of his stay in that institution have not been made public.   Unfortunately, this follows a pattern of secrecy, and stonewalling that has been present for decades.   Because of this fact, I can’t give an objective account of what and why, but certainly I can write an educated guess.   If indeed the diagnosis of severe psychosis given to the veteran at admission was correct, it could not have been stabilized in two weeks, and if he did not suffer from a severe illness, six medications that include antipsychotics and mood elevators, among others is not appropriate as also the diagnosis of PTSD is not.   In any case, an immediate follow up, with either a transfer to a medium care facility, as a rehab and/or extensive outpatient follow up was indicated, if only for the reason of the family feedback.   There is a strong possibility that if a correct medical service and follow up would have been provided, the intervention made on his behalf by Mr. Kyle and Mr. Littlefield would not have been necessary, and the heartbreak for all three families avoided.

Legal insanity is extremely hard to prove even in clear cases of clinical psychosis.   The only parameter mentioned in this case was the ability to differentiate between “right and wrong” that started in the M’Naghten rule in 1843.   As this defense was judged to be too limiting, the “irresistible impulse” test was started and is now also used in most States in our country including Texas.   In 1843 Dr. Winslow described this test much better than what I could do, and then in 1844 was used for the first time in the United States.

“A person may be perfectly competent to draw a correct distinction

between right and wrong, and yet labour under a form

of insanity which ought unquestionably to protect him from legal

or moral responsibility. I allude to cases of insanity where the

patient is driven, by an irresistible impulse, to destroy, after

struggling, for some time, against the morbid desire, being, at

the same time, perfectly conscious that he is impelled to do what

is wrong both in the sight of God and man.”


In 1844 Abner Rogers was tried in Massachusetts for murder.”

The defense was insanity. Chief Justice Shaw of the Supreme Court,

who presided at the trial said;


“If then it is proved, to the satisfaction of the jury, that the

mind of the accused was in a diseased and unsound state, the question

will be, whether the disease existed to so high a degree, that

for the time being it overwhelmed the reason, conscience and

judgment, and whether the prisoner in committing the homicide,

acted from an irresistible and uncontrollable impulse: If so, then

the act was not the act of a voluntary agent, but the involuntary

act of the body, without the concurrence of a mind directing it.”




I wonder why the impulse test has not been mentioned by the pundits, because in my opinion it fits much better in this case, as it is in the cases when disorganized thinking produced by mental illness prevail.

All in all, a very tragic event.


Fernando Milanes MD

ACOS for Mental Health, Miami VA Hospital (Ret.)

Vice Chairman University of Miami, Mental Health Service (Ret.)