It was a diagnosis -- depressed and imminently dangerous -- that in Virginia sends most people to a mental hospital.

But in the case of Seung-Hui Cho, a special justice took the rare step of ordering outpatient treatment instead. It was that decision in December 2005 that placed Cho into a system where oversight was viewed by many as inadequate long before he went on a shooting rampage on Virginia Tech's campus.

Cho never received the treatment ordered by the special justice, The Washington Post reported Monday, citing unnamed authorities who had seen his medical file.

Even if Cho had received outpatient treatment -- or was instead sent to a facility of some type -- it is impossible to say whether it would have averted the April 16 deaths of 33 professors and students, including Cho himself.

His was the worst of worst-case scenarios, but mental health advocates said the lack of follow-up treatment happens all too often.

"There is no follow-up," said Bill Farrington, president of the National Alliance on Mental Illness' Virginia chapter.

"The system did not work," Farrington said. "And for others like Cho, there are no teeth in the law to make it work."

On Dec. 13, 2005, Cho was taken to Carilion St. Albans Behavioral Health outside Radford after a roommate said he might be suicidal. The next day, after Cho was evaluated by a community services board worker and an independent doctor -- who differed on whether he was a danger to himself or others, and on whether he required hospitalization -- the special justice released him with the order to attend outpatient treatment.

In cases like Cho's, Virginia law assigns the local "community services board, behavioral health authority, or designated provider" to monitor whether court-ordered treatment is being kept up with. Failing to get treatment could trigger a competency hearing and inpatient commitment.

Richard Bonnie, director of the Institute of Law, Psychiatry and Public Policy at the University of Virginia and chairman of the state Commission on Mental Health Law Reform, said there appears to be "significant variation" in how monitoring and other aspects of outpatient commitment are handled in Virginia.

In the New River Valley, where Cho was evaluated, monitoring is up to whoever gets the outpatient referral, said Mike Wade, spokesman for the New River Valley Community Services Board.

Outpatient referrals such as Cho's are not numerous, Wade said, and the community services board gets most of them. But it did not get Cho's referral, Wade said.

Paul Barnett, the special justice who handled Cho's case, declined to comment on its details. But he said last month that St. Albans staff would have made an appointment somewhere for a patient like Cho. Carilion spokesman Eric Earnhart declined to comment on the case.

A request under the Freedom of Information Act for Cho's community services board records was denied.

Barnett said that any provider of mental health services -- and there are dozens in the New River Valley -- could receive an outpatient referral.

The Washington Post reported that Cho was likely referred to Tech's Cook Counseling Center. But Chris Flynn, director of the Cook center, said last month that to his knowledge, the center was not notified that Cho had been ordered to have counseling.

Calls to Flynn last week and Monday were not returned.

Wherever Cho was supposed to have gone, mental health advocates and state officials say it's unusual to order outpatient treatment for someone deemed to be an imminent danger to himself, as Cho was.

"I was a little surprised to see that," said Mary Zdanowicz, executive director of the Treatment Advocacy Center, a national nonprofit group dedicated to eliminating barriers to mental health treatment. "Much more often, it is an inpatient order.

"I think what happens is there are judges who look at imminent danger and say: 'Should I really order someone into the community ... and then they do something that comes back on me?' "

Current statistics are hard to come by. But a 1994 survey of special justices found that outpatient treatment was ordered in just 8 percent of the commitment hearings.

Involuntary inpatient commitment was the most frequent outcome, accounting for 53 percent of the commitment hearings, according to the survey by the state's Joint Legislative Audit and Review Commission.

Another 21 percent of the people involved in the commitment process agreed to be committed to a mental facility, the survey found, and 18 percent were released at the time of the hearing.

Like other observers of Virginia's mental health system, Jim Martinez, director of mental health services for the state Department of Mental Health, Mental Retardation and Substance Abuse Services, had no current statistics but agreed that outpatient treatment orders are in the minority "by a significant margin."

"I think that's partly because you have to meet a fairly high threshold of mental illness ... and there aren't a lot of community services that are set up to deal with those circumstances," Martinez said.

Martinez also said it can be hard to track compliance.

"If a treatment plan simply says see a psychologist every two or three months, there's not likely to be too much monitoring in between those visits," he said.

Cho's case also illustrates how hard it is in Virginia for the courts to even get involved in mental health treatment.

For someone to be committed or ordered to receive outpatient treatment, there must be proof that they are an "imminent danger" to themselves or others, or that their mental illness leaves them unable to care for themselves.

Virginia is one of just five states that uses "imminent danger" as the threshold for court-ordered treatment, according to the Treatment Advocacy Center. Other states have less restrictive language.

" 'Imminent danger' really creates a barrier for this [court-ordered treatment] being used more appropriately in Virginia," Zdanowicz said.

The wording of the law also implies that someone has to make a threat against themselves or others before they can be subjected to a commitment proceeding.

When English professors at Tech voiced concerns about the disturbing nature of Cho's writing and his antisocial behavior in the classroom, they concluded that they could not force him into counseling because he had made no direct threats.

"I saw that as a lost opportunity that is representative of what many families in Virginia are experiencing when they try to get help for a loved one," Zdanowicz said.

Like many areas of mental health, outpatient treatment and monitoring has long been hobbled by a lack of resources.

"Forget about gunshots and dormitories," said Paul Lombardo, a Georgia State law professor who spent 16 years on the University of Virginia's law and medicine faculties and helped craft some of Virginia's mental health laws. "We don't have the political will to spend the money for adequate mental health services."

"These are not new problems," Barnett agreed. "They are in a new context, a very unfortunate context."