As gunfire reverberated in the streets surrounding our building last Friday morning, employees across Brigham and Women’s Hospital turned the hallways dark, locked office doors, and sheltered in place alongside frightened patients and colleagues. The tragic events that unfolded that morning left one hospital valet team member injured and another man dead.
While details of the incident are still emerging, early media reports suggest at the heart of this tragedy lies an individual battling a serious and chronic mental illness — schizoaffective disorder.
Schizoaffective disorder is a disease of the brain, a chronic condition that often requires lifelong medication to treat. During acute episodes, patients experience mood fluctuations and psychosis, including hallucinations, paranoia, and disorganized thinking. A less well-known symptom of this disorder is anosognosia, or the lack of awareness and insight into their illness. This lack of insight is a reason many individuals refuse or stop taking their medications.
The parents of the man killed in this incident described their son as “a very sensitive boy with a gentle soul” and said that “he was probably scared and off his meds or something.” They noted that their son was only symptomatic during lapses in treatment. He was not a patient at Brigham and Women’s Hospital. But in Boston and across the state, we are left wondering why so many individuals are unable to stay on medications that ensure their safety and well-being.
In rare instances when a person with mental illness commits a violent crime, it is commonly because the person stopped taking vital medications. In these potentially dangerous moments, psychiatric treatment providers step in to procure medications through filing a request with the courts. However, this process is anything but easy in Massachusetts.
The Commonwealth’s mental health statutes consider antipsychotic medications — used to treat conditions such as psychosis, mania, and paranoia — as “extraordinary measures.” This label differentiates these medications from virtually all others that doctors prescribe. Such a distinction creates challenges for doctors, mental health facilities, families, and communities in caring for patients in their most vulnerable moments, often when they lack the insight to make decisions for themselves.
The law that remains most problematic in the treatment of these illnesses is the Rogers Guardianship statute. This law requires a separate adversarial court proceeding in order to treat a patient with antipsychotic medication outside of emergency situations, even after that patient has been found dangerous enough — to themselves or others — to be civilly committed by the court to a hospital. The intention of the statute — to preserve a patient’s right to refuse medication — is well-meaning. However, in practice, it falls short in recognizing that a patient’s refusal of medication may reflect their underlying disease state. Paradoxically and poignantly, it is a symptom of psychotic illness to believe you do not have an illness.
Rogers Guardianship proceedings are fraught with challenges. When they occur within a psychiatric hospital via the district court, the approved antipsychotic treatment plan lasts only during the hospital admission. The patient is free to discontinue medications at the time of discharge. In the community, the treatment plans authorized in probate courts last for one year and then expire, obliging the process to be repeated. Further complicating matters, the law requires a court-appointed guardian to manage the antipsychotic medication decision-making. The process of identifying a guardian and scheduling a court hearing can be delayed for months, or even years. As a consequence, patients with mental illness often go untreated for long stretches of time while awaiting hearings and approvals. And even if the Rogers Guardianship is authorized, there are few protocols in place to ensure that a patient take medication for his or her condition.
Delays to treatment have a serious impact on patients suffering from psychotic illness. Studies show that untreated disease leads to persistent brain dysfunction and cognitive decline. Some patients develop refractory mental illness and risk of suicide or violence. Procedural delay can lead to suffering, increased disability, homelessness, and incarceration. Though the law treats it differently, untreated psychotic illness is not unlike untreated heart failure or liver disease, with the same damaging consequences.
There are solutions to this problem. To start, the state can explore outpatient commitment laws that mandate treatment for those in need outside hospital walls and protocols to ensure the order is followed. Massachusetts is one of only three states in the country (along with Connecticut and Maryland) that do not have such laws. Other solutions include pursuing expedited court hearings or a reexamination of the Rogers statute. It will take lawmakers, doctors, hospital and community health administrators, the courts, public defenders, and even correctional institutions to come together around best practices to prevent gaps in life-saving and community-preserving treatment for the acutely mentally ill. While this coordinated effort may be challenging, it is essential to help avoid tragedies like the one that transpired last week.
Dr. Jhilam Biswas is director of the Psychiatry, Law and Society Program at Brigham and Women’s Hospital and a forensic psychiatrist at Bridgewater State Hospital.