Mandate treatment for the mentally ill

The least Massachusetts could have done to save Nancy Chiero was to compel her adult son, Lee, to take his medication.

It was hard enough for Nancy that Lee suffered from a mental illness so severe that he would search the basement ceiling in her Uxbridge home for secret cameras and microphones that never existed. Harder still was that the burden of managing his condition, which required medication that Lee routinely failed to take, fell mostly on her. In its latest investigation, the Globe Spotlight team revealed that, when the state dismantled its psychiatric hospital system over half a century — with the ostensible goal of allowing patients to flourish in community settings rather than languish in isolated madhouses — it didn’t really set up an alternative care system. In effect, Massachusetts left it up to law enforcement, emergency room personnel, and especially families to care for mentally ill patients, even those with a history of violent acts and noncompliance with medication regimens.

Since 2005, the Spotlight team found that, in more than 10 percent of Massachusetts homicides with a known suspect, that suspect had a history or clear signs of mental illness. At least 79 victims were relatives or significant others of mentally ill suspects. Nancy Chiero was one of them. Convinced she was part of a conspiracy, Lee stabbed her in the eyes, in 2007. She died. He videotaped it.

Let’s admit it: Lee Chiero was a terrible, terrible judge of his own medical needs. Nancy Chiero needed help. But in a wrongheaded conflation of cost-cutting and respect for mentally ill patients’ civil liberties, Massachusetts has minimized its intervention in cases like these, and is one of only four states without a law that gives the courts a clear path to compel mentally ill patients with a history of noncompliance to undergo medical treatment. Adopting such a law in Massachusetts would be far from a comprehensive response to the problems detailed in the Spotlight report, but it would make it far harder for the state to blow off any responsibility — at least before troubled patients are arrested or readmitted to a limited number of inpatient psychiatric facilities.

In other states, “assisted outpatient treatment” laws have been associated with better health outcomes for patients and lower costs for public agencies. Under these laws, caseworkers or the police regularly escort patients to receive required medications. According to a study in New York, patients who receive court-mandated outpatient treatment are less likely to be arrested, admitted to hospitals, or deemed at risk of suicide. A state that invests in the kind of treatment that the law mandates spends less than it would if patients are left a cycle of skipped medication, deteriorating mental health, and rehospitalization — or worse.

Nationally, many advocates for the mentally ill support assisted outpatient treatment. Others bristle at the euphemistic name — yes, “assisted” means “compulsory” — and at the infringement on patients’ free will. There’s a history here: States’ past tendency to warehouse patients in cold and sometimes abusive institutions justifies a heightened awareness of the potential for stigma, and a heightened suspicion of coercive approaches to treatment. Critics of the New York program have argued that it’s the additional resources that matter, not the court mandates, and that the state should offer more voluntary resources to the mentally ill. Locally, opponents of compulsory-treatment laws argue that certain legal guardianships can achieve similar results but with more protection for patients’ liberty.

In practice, guardianships with more cumbersome legal requirements are hard to pursue — especially for relatives who are struggling with the daily burdens of providing care. In practice, some patients don’t volunteer for treatment. In practice, the existence of a compulsory-treatment law puts more pressure on a state to deliver the right resources.

Massachusetts, usually to its credit, has a healthier respect for individual rights than most states. That’s one reason the Bay State is an outlier on this issue. But at this point, the bigger threat isn’t that the state runs roughshod over the rights of the mentally ill; it’s that the system has abandoned them and their patients to their fate.

Lee Chiero is now committed to Bridgewater State Hospital, a psychiatric facility controlled by the state Department of Correction. It’s too late to help his mother. But other patients and their families would benefit from a mandatory-treatment law.