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The desperate and the dead: families in fear

Closing psychiatric hospitals seemed humane, but the state failed to build a system to replace them.

Families are living with the tragic consequences.

At least 17 parents with signs of mental illness allegedly killed their children from 2005 through 2015.


And at least 18 sons and daughters with signs of mental illness were accused of killing their parents.


But the toll of violence reaches far beyond family. From 2005 through 2015, 116 people in Massachusetts were accused of killing 139 victims.



By almost any measure, Massachusetts has lost the leadership role it once had in mental health care.

Nancy Chiero was making a cup of mint tea in the kitchen of her Uxbridge home that January morning.

It was a small, characteristically kind gesture toward her 35-year-old son, Lee, who had always worried her, and sometimes scared her, too. Also, unfathomably, it was a fatal one.

Lee’s life had been ruled by severe mental illness, the pattern of his repeated unravelings devastatingly familiar to his mother and family. A psychotic episode would send him to an emergency room. Once released, he would refuse to take his medications, the delusions would return, and the cycle would repeat. And repeat again.

Through it all, Nancy had remained devoted and unimaginably patient with him. There was no one else who would. He had been living in a basement bedroom of her home; he had nowhere else to go.

The cycle was repeating again now, in 2007, she could see, and in even more alarming form. Lee had been videotaping his conversations with her, suspecting her in a plot against him.

He suspected everyone. Lately, Lee had disconnected computers and even the electric power in the house to prevent his imagined enemies from spying. He made his mother drive him hours from home for grocery shopping to elude his pursuers. He’d come to believe he’d been abducted by aliens and abused by animals, and feared he would be again.

Finally, just before Christmas, Nancy had Lee rushed by ambulance to Boston’s Tufts New England Medical Center at the urging of his primary care doctor, who agreed that he had become dangerous. But at the hospital, Lee insisted he was fine and a Tufts psychiatrist released him after four days, concluding that he “did not seem to present a danger to himself and others.”

Now, alone in her kitchen, Nancy faced her son’s fevered imaginings armed only with a cup of tea. Mint is soothing, she said, adding that even animals took pleasure in the fragrant herb.

With little warning, Lee lunged at her, knocking her down the basement stairs, convinced that her casual comment referred to the animals that would sexually assault him after his abduction.

He pulled out the knife he carried for protection and began stabbing his mother in the eyes, demanding she confess.

“That’s what you get for following me around,” he said, ranting on, with his camcorder running.

Then, it was over.

In the sudden quiet Lee began to doubt that Nancy was really part of the conspiracy that had taken control of his life. She hadn’t confessed. And if the house was bugged, if his every move was being watched, why hadn’t anyone intervened? Why hadn’t anyone stopped him? Why was he suddenly so alone in the overwhelming silence of his mother’s home?

Lee Chiero speaks to his mother (left) in a video he made months before killing her. Ed Hopfmann/MetroWest Daily News
Lee Chiero speaks to his mother (left) in a video he made months before killing her.

In the instant of her death at the hands of her son — a deeply troubled man discharged without restrictions from hospital care — Nancy Chiero wasn’t merely failed by the state mental health care system. She was her son’s mental health care system — or at least the only one he could rely on.

In a state that prides itself on leadership in human services and compassionate government, it has come to this, a Spotlight Team investigation has found: threadbare policies, broken promises, short-sighted decisions, and persistent underfunding over decades. As a result, the seriously mentally ill, including those at greatest risk of harming others or themselves, are far too often left in the care of parents, police, prison guards, judges, shelter workers, and emergency room personnel — almost anyone, in fact, but professionals trained to deal with their needs.

Families of these sufferers find themselves up against obstacles that earlier generations didn’t have to face. Fifty years ago, Lee Chiero might have been treated — and locked away — in one of the public psychiatric hospitals that once dotted Massachusetts.

Today, nearly all of those institutions have been bulldozed or boarded up — and many had to be, having evolved into inhumane asylums for people who are, in the great majority, no threat to anyone. But the hospitals were not replaced with anything resembling a coherent care system, leaving thousands of people with serious mental illness to navigate a fragmented network of community services that puts an extraordinary burden on them to find help and to make sure they continue getting it.

Even those beset by the most ferocious inner demons, such as Lee Chiero, are routinely pinwheeled from hospital to hospital, therapist to therapist, court to court, jail to jail, then sent off into the world with little more than a vial of antipsychotic medications and a reminder to take them. Chiero was hospitalized at least 10 times in a half-dozen hospitals over two decades before he killed his mother.

“I can’t tell you how many emergency rooms we visited to try and get him in,” said his sister, Gina.

This is the choice Massachusetts has made, a choice with deadly consequences.

  The state shuttered Westborough State Hospital in 2010 to erase a budget gap, one of many such hospital closures motivated by a desire to save money. The 600-acre campus was formerly known as the Westborough Insane Hospital. Suzanne Kreiter/Globe Staff
The state shuttered Westborough State Hospital in 2010 to erase a budget gap, one of many such hospital closures motivated by a desire to save money. The 600-acre campus was formerly known as the Westborough Insane Hospital.

The evidence is everywhere. In May, Arthur DaRosa fatally stabbed two people, one of them at a Taunton shopping mall, before an off-duty deputy sheriff shot him dead. DaRosa had been released from a hospital hours earlier, even though relatives said he had threatened to kill himself and said the devil was trying to poison the minds of his children. Three weeks later, the body of 24-year-old Tyler Hagmaier was pulled from the Connecticut River after he left a suicide note confessing to fatally stabbing a 76-year-old neighbor, for no apparent reason.

“He wasn’t evil. He wasn’t bad,” said Kristine Jelstrup, the daughter of Hagmaier’s victim, Vibeke Rasmussen. “He was mentally ill, and he didn’t get the help he needed.”

Such attacks have come to seem part of the grim staccato of modern life — at times random, often inexplicable, and now stunningly common.

Since 2005, more than 10 percent of all Massachusetts homicides in which a suspect is known were allegedly committed by people with a history of mental illness or its clear symptoms, the Spotlight Team determined by building the first-ever database of such cases. At least 139 people in this state have died violently at the hands of a person with a diagnosed mental illness or strong indications of one during this period.

And last year, the mayhem grew even more frequent, as 14 of the 95 homicides in the state with identified suspects — nearly 15 percent — were allegedly committed by people who were or appeared to be mentally ill.

Few have paid a higher price in this crisis than the loved ones of people with a serious, often undertreated, mental illness — the Nancy Chieros in our communities. At least 18 parents allegedly have been killed by their mentally ill children in Massachusetts since 2005, the Globe review found, and 21 children allegedly were killed by their mentally ill parents. In all, people with a history of mental illness have been accused of killing at least 79 relatives and significant others since 2005.

Often, these victims were the very people who tried the hardest to get help for their mentally ill loved ones. Nancy Chiero was so devoted to her son that she once handcuffed herself to Lee to bring him home off the streets.

Indeed, family members are often all that stand between seriously mentally ill people and disaster — making sure they keep appointments, take their medications, and have a place to stay, while remaining vigilant for the next crisis. At the same time, thousands of those without family members to stand by them are relegated to streets, shelters, prisons, and county jails. They crowd emergency room wards and hallways.

This is, of course, not just a state but a national crisis. However, it is worse here than most would imagine. Massachusetts spends less per capita on mental health care than any other New England state except Rhode Island, and much less than some states of comparable means and politics — such as New York, according to a Kaiser Family Foundation study. By this and other critical measures, Massachusetts has forfeited the leadership it once was known for in mental health care.

Marylou Sudders, the top official overseeing mental health care in the state, can’t even bring herself to call the state’s patchwork of emergency rooms, group homes, clinics, and therapists a “system,” admitting that mental health care in the state is both poorly organized and grossly underfunded. Though many individual care providers do excellent work, she said, they are islands with little surrounding support.

“Families are the primary caregivers, if the person is lucky to have a family and that family has stayed with them through their journey,” Sudders told the Globe.

A tearful and emotional Liz DaRosa, aunt of Arthur DaRosa, faces reporters after Arthur DaRosa stabbed four people, killing two, hours after he had sought treatment for a mental illness. Barry Chin/Globe Staff
A tearful and emotional Liz DaRosa, aunt of Arthur DaRosa, faces reporters after Arthur DaRosa stabbed four people, killing two, hours after he had sought treatment for a mental illness.

The result is not just a public health care crisis but a public safety crisis — one that is largely preventable. Studies show that people with a serious mental illness are no more prone to violence than anyone else — when they get the help they need. But when they do not, drifting away from therapy and medications, often into the grip of alcohol or drugs, the risk of violence sharply escalates.

In a multipart series that begins today, the Globe Spotlight Team examines the unintended consequences of 50 years of deinstitutionalization and its often appalling aftermath. It stands, for a state that sets a high standard for itself in human services, as a broken covenant with a population with great needs, spawning heartache and tragedy for nearly everyone involved, from besieged mothers and fathers to police officers who suddenly find themselves confronted by someone with a mental illness determined to commit “suicide by cop.”

Meanwhile, those who try to improve this sorry picture are repeatedly thwarted by a state Legislature that routinely turns a deaf ear to calls for change. Earlier this year, a clutch of proposals by state Senator Kenneth J. Donnelly, including a plan to ensure that patients like Chiero take their medications, was sent to a committee for study, effectively killing it.

“We seem to be moving at a snail’s pace, if at all,” said Donnelly, an Arlington Democrat. “We send bills to study while our emergency departments, courts, and prisons take on more and more of the burden that comes when people can’t get the care they need and deserve.”

Mass shootings and other notorious crimes understandably draw the greatest scrutiny, but deadly violence by those with a mental illness is usually a more intimate affair, the Spotlight investigation found, an eruption between family members or friends that usually does not involve a gun.

In Massachusetts, homicides in which mentally ill individuals are accused are far more likely to involve the use of knives, ropes, or even bare hands than a firearm. A gun was the weapon of choice in only 16 percent of the cases analyzed by the Globe. Most of the time, those who turn violent are lashing out at friends, lovers, or family members, using whatever weapon is at hand.

The Spotlight Team investigation found that three key factors were often a prelude to murder by someone with a serious mental illness: lack of treatment, a failure to take prescribed medications, and the abuse of illegal drugs and alcohol, which is common among the mentally ill as they try to assuage their symptoms. Clinicians refer to it as “self-medicating.”

In many cases, it was impossible for the Globe to determine whether the perpetrators were off their medications or were acting under the influence of illegal drugs or alcohol. But there was evidence that 31 of the accused killers in the Globe’s tally were refusing to take prescribed psychiatric drugs, while 28 had a history of substance abuse. In only a handful of cases was there evidence that the accused were taking appropriate medication at the time of the crime.

Some perpetrators were never diagnosed or treated at all. They included Kerby Revelus, a young Milton man shot to death by police in 2009 after he had killed two of his sisters and was about to kill a third, and Li Rong Zhang, a Quincy woman found not guilty by reason of insanity after she was charged in 2011 with killing her 8-year-old son by locking him in a room with a smoking, charcoal-fueled hibachi.

Bianca Revelus, 5, and Samantha Revelus, 17, were killed by their brother, Kerby Revelus. Serafina Revelus, 9, (right) was stabbed but survived.
Bianca Revelus, 5, and Samantha Revelus, 17, were killed by their brother, Kerby Revelus. Serafina Revelus, 9, (right) was stabbed but survived.

The Globe’s findings on substance abuse and mental illness track pioneering research on the connection between mental illness and violence. One widely reviewed study, conducted over several years in the early 1990s, found that people with a mental illness are significantly more likely to use drugs and alcohol, and that those who do so are more likely to be violent than users without a mental illness.

“When first discharged, patients were twice as likely as their neighbors to be abusing substances,” the MacArthur Violence Risk Assessment Study found. “And alcohol and drugs raised the risk of violence for patients abusing them even more than for others.”

In the Spotlight review, the combination of mental illness and substance abuse also played a role in numerous fatal crashes. For instance, in 2013, Benjamin Shealey — who has been diagnosed with paranoid schizophrenia and was driving under the influence led police on a high-speed chase before running over and killing a 62-year-old man waiting for a bus in Chatham.

The firmly held belief that people with a serious mental illness are no more likely to be violent than others has fueled opposition to new laws that could help families like the Chieros, who struggle to persuade their mentally ill loved ones to accept treatment and take their medications.

For years, some advocates for people with a mental illness have helped block all attempts to require mentally ill people with a history or grave risk of violence to take their prescribed medications, to the point where Massachusetts is one of only four states without such a provision, a gap defended by the advocates as a matter of personal liberty.

“The right to refuse treatment is vital,” said Susan Fendell of the Mental Health Legal Advisors Committee, speaking against a mandatory outpatient treatment bill during a State House hearing last year.

But Lisa Dailey, an attorney for the Treatment Advocacy Center, a nonprofit group that advocates for such treatment for some people with mental illness, was just as adamant.

“This is a cruel and dangerous status quo,” she said.

A 15-year-old mental health patient waited for 11 days in the South Shore Hospital emergency room because of a statewide shortage of psychiatric beds. Suzanne Kreiter/Globe Staff
A 15-year-old mental health patient waited for 11 days in the South Shore Hospital emergency room because of a statewide shortage of psychiatric beds.

It was 8 a.m. on a January Monday, the busiest day of the week for the emergency department at South Shore Hospital in Weymouth. Patients suffering psychiatric and substance abuse crises occupied about a quarter of the 60 beds.

Most had been there more than a day, some for several days. One patient had been kept waiting almost five days. All were “boarding” in the emergency room — stuck there because the state’s overtaxed mental health care system had no other place for them.

Hospitals across the state, often the first line of treatment in mental health emergencies, have become de facto psychiatric care centers, something they were never meant to be.

“You go into emergency medicine to take care of every patient, regardless of their ability to pay,” said Jason Tracy, the doctor in charge of South Shore’s emergency medical services. “This is a segment of society that is not being cared for right now.”

Mental health and substance abuse patients spend about 66,000 total “boarding hours” at South Shore every year, Tracy added, and the resultant strain on the system is as bad as it has ever been. In fiscal year 2015, 2,400 patients with mental health complaints came to the ER — an average of about six a day — along with another 2,130 patients with problems related primarily to drugs and alcohol.

Statewide, the number of ER boarders awaiting mental health care has escalated sharply, according to surveys conducted by the Massachusetts College of Emergency Physicians. Over the last five years, the surveys show, the number of mental health patients stuck in ERs jumped 23 percent while the number of hours they spent there shot up nearly 20 percent.

“It’s frustrating to see patients languish for days at a time waiting for inpatient beds,” said Dr. Jeffrey Hopkins, head of emergency room services at Milford Regional Medical Center and the president of the Massachusetts College of Emergency Physicians.

Not only are the general hospitals poorly equipped to handle the crush of mentally ill patients, but the acute demands often posed by patients in mental health crises limit how attentive doctors and nurses can be to everyone else in the ER, emergency department officials say. At the same time, hospitals must constantly weigh the costs of boarding psychiatric patients — often with limited reimbursement from insurers — against the risks of releasing them back to the streets.

South Shore Hospital public safety workers are called into the ER when a patient with mental illness becomes agitated. Another patient (left) waits in a hallway for a room. Suzanne Kreiter/Globe Staff
South Shore Hospital public safety workers are called into the ER when a patient with mental illness becomes agitated. Another patient (left) waits in a hallway for a room.

“You have no safe place to discharge them to; you have no bed to admit them to,” said Win Brown, president and CEO of Heywood Healthcare, which operates hospitals in Gardner and Athol.

The shortfall is so acute that Heywood routinely places mental health patients at Brattleboro Retreat, a psychiatric facility in southern Vermont, because there’s no suitable facility to care for them in Massachusetts.

The care gap yawns particularly wide for those in gravest need — those with a history of violence and those with critical medical needs in addition to psychiatric issues. Because so few hospitals are equipped to take them, they wait longer. In one case at South Shore Hospital last winter, a 46-year-old woman with a psychiatric disorder lingered for almost six days in the ER because she also needed supplemental oxygen. She was finally discharged not to a hospital but to her own home.

Patients who arrive with inadequate insurance coverage are especially vulnerable. At Tufts New England Medical Center, for example, when a psychiatric patient arrives, everything stops for a “wallet biopsy,” said Dr. Matthew Mostofi, the hospital’s vice chairman of emergency medicine.

Insurance coverage often dictates decisions about care for psychiatric patients and the facilities they may be referred to, Mostofi said. “Mental health patients are different,” he said. “They’re treated differently every step of the way.”

In practice, that means doctors often examine the patient’s insurance coverage and make decisions accordingly. Some might be allowed to remain in the hospital’s psychiatric unit, but others must be moved to less expensive facilities. And MassHealth patients — those with lower incomes who are receiving government assistance — have to be evaluated by a team of outside clinicians to determine whether they merit treatment at all.

Officials at Morton Hospital in Taunton last month suggested the outside evaluators were a factor in their much-criticized decision to release Arthur DaRosa shortly before he fatally stabbed two people and injured several others in Taunton. Morton, which is owned by for-profit Steward Health Care System, announced it would no longer use the state-run screening system after the tragedy.

The sharp focus by hospitals on money from insurance reimbursements shouldn’t come as any surprise. A 2015 report by Attorney General Maura Healey found that commercial and MassHealth insurance covered only 61 percent of the cost of delivering care to patients with mental health disorders and substance abuse problems.

Philip W. Johnston, a former state human services secretary who is now chairman of the board at the Blue Cross Blue Shield of Massachusetts Foundation, said insurance reimbursement rates are so low that some hospitals have cut beds reserved for mental health care or have eliminated their psychiatric units altogether.

“Hospital administrators concluded long ago that this is a money-losing proposition,” he said. “One of the most serious problems we face in mental health care in Massachusetts and around the country is patient dumping by financially strapped hospitals.”

But the insurance industry bridles at the idea that its reimbursements are deficient, saying that providers are paid adequately and that hospitals overall have fared better than insurers in recent years.

“We’ve got plans that, in aggregate, have lost money,” said Lora Pellegrini, president and CEO of the Massachusetts Association of Health Plans. “So where’s the money going to come from? Are we willing to pay more? . . . We have the highest health costs in the nation.”

Pallbearers carry the casket of Patricia Slavin into Holy Family Catholic Church in Taunton. Slavin was stabbed to death by Arthur DaRosa hours after he had sought treatment for a mental illness. Jonathan Wiggs/Globe Staff
Pallbearers carry the casket of Patricia Slavin into Holy Family Catholic Church in Taunton. Slavin was stabbed to death by Arthur DaRosa hours after he had sought treatment for a mental illness.

Still, the Spotlight Team identified four mental health patients who committed or attempted murder within a month of being released from hospitals, including Lee Chiero and Carol Kingsley, a Somerville woman who stabbed three police officers the day she was released from Cambridge Hospital before being shot to death herself by an officer.

The other two were released from hospitals owned by Steward Health Care: DaRosa and Tu Nguyen, who stabbed an elderly neighbor to death in front of the neighbor’s 8-year-old granddaughter in 2012, just three weeks after Carney Hospital in Dorchester let him go.

Relatives of the victim, Mary Miller, filed a wrongful death lawsuit against the hospital, noting that Carney decided to release Nguyen even though he had assaulted a psychiatrist and was being checked for his safety every five minutes. A judge had approved holding Nguyen involuntarily for up to six months, but the hospital let him go after just 23 days over the objections of Nguyen’s family. The hospital even advised family members to take out a restraining order against him to keep him away.

“Clearly he was still a danger,” said Chester Tennyson Jr., the attorney representing Miller’s family.

Lawyers for Steward Health have asked a judge to reject the lawsuit, arguing that clinicians had no duty to warn Nguyen’s neighbors that he was dangerous. “While federal law does not allow us to comment on the details of the lawsuit in question, we are confident that it will be dismissed,” said Ryan Boxill, vice president of behavioral health at the company.

Boxill also said Steward has bolstered its commitment to providing inpatient mental health care, “even as other providers have reduced their mental health bed counts and services, resulting in unacceptable wait periods for mental health beds and a domino effect across the entire state.”

Exactly what happened to Lee Chiero on Halloween 1999, when he was 27 years old, is still largely a mystery. He claimed he was drugged, gagged, and raped in his Milford apartment. And when his mother responded to his terrified call, she found him curled on his couch in the fetal position and took him home — convinced that something disturbing must have happened to him — and then to Milford Regional Hospital.

By that time, the slight, olive-complexioned man with a soft, round face had traveled a long, winding road marked with episodes of petty crime, drug and alcohol abuse, and serious mental illness. And he wasn’t heading for anything better.

According to psychiatric records, the first of his 10 hospitalizations came when he was just 12 years old, for “out of control behavior.” By the time he turned 16, he had dropped out of school and was using marijuana, cocaine, and alcohol — “everything I could get my hands on,” as he put it during an interview with a psychiatrist.

Lee Chiero listens to testimony at a recommitment hearing at Bridgewater State Hospital in 2015. John Tlumacki/Globe Staff
Lee Chiero listens to testimony at a recommitment hearing at Bridgewater State Hospital in 2015.

When he was 22, Lee was charged with making annoying phone calls to three young women. A short time later, he drove an unregistered car at an off-duty police officer and was charged with assault and battery with a dangerous weapon, leading to the first of three jail sentences.

But it was on Halloween night in 1999 that Lee’s delusions began to take on all-consuming qualities, including fantasies that both he and his mother had been drugged and raped by hospital doctors. The inner visions varied from day to day, but were invariably terrifying to Lee.

“His story changed a lot,” his sister, Gina, later recalled, during a court hearing. “He thought it was the police. He thought it was the doctors. He thought it was the Mafia. He thought it was people with Halloween masks. There were a lot of different scenarios.”

During an interview with a psychiatrist after yet another arrest on assault and battery charges, Lee said he recalled a time when emergency room staff at Milford sedated him so that doctors could sexually assault him. “That drug was so powerful I ain’t never seen anything like that as long as I live,” he said, becoming distraught at the memory. There is no evidence of any such episode, according to reports later compiled by outside psychiatrists, but Chiero’s delusions were, to him, plain, appalling fact.

Lee’s release from Milford underscored a bitter theme for his mother: Despite multiple attempts over two decades, she was never able to find a hospital that would hold her son long enough to persuade him to faithfully take his medications and accept the psychotherapy he so desperately needed.

Over the next year, Lee was hospitalized at MetroWest Medical Center in Natick four times and was diagnosed alternately with paranoid schizophrenia and a personality disorder. But the hospital never held him for an extended period — always just long enough for the crisis of the moment to ease before he was back in his mother’s care.

Part of the problem, Lee’s sister would explain, was that her brother had become increasingly adept at concealing his paranoid delusions from doctors and other clinicians.

“He could hide it from professionals,” she said, during a court hearing after her mother was killed. “He’s been in and out of mental health institutions and he can pull it together. . . . He’s very smart, he’s very likeable, and he’s believable.”

Lee Chiero’s sister, Gina, testifies at his murder trial in Worcester Superior Court in 2009. Mark Fisette/MetroWest Daily News
Lee Chiero’s sister, Gina, testifies at his murder trial in Worcester Superior Court in 2009.

Then, one night in December 2001, Lee walked into a restaurant and pulled a knife on two men he believed were taunting him. As a consequence, he was sentenced to 30 days behind bars and three years of probation by a judge who ordered him to take his medications and see a therapist or risk being sent back to jail.

It was a disappointment for his family, but it also proved a blessing in disguise. Finally there was something beyond their own exhortations to persuade him to follow a treatment plan that could be effective.

“Clearly, treatment for alcohol and drug use as well as consistent treatment with psychiatric medication is necessary for him to remain in his moderate risk category,” wrote a psychiatrist, Dr. Judith Gallen Edersheim, in a sentencing evaluation, referring to Lee’s risk for future violence.

During his three years on probation, Lee led a relatively stable life, boarding in a basement bedroom in his mother’s home where Nancy could keep an eye on him. But in 2005, once his probation ended and the threat of jail disappeared, Lee stopped taking his medications and stopped checking in with his therapist.

Increasingly isolated with his deepening paranoid delusions, he came to believe that agents working for an imaginary force he called Asosa had repeatedly kidnapped him, possibly by making their way through the basement bulkhead. At her wits’ end, Nancy had police take her son to Milford Regional in November 2005 with a request that he be involuntarily committed, but hospital officials let him go less than a day later.

Back home, Lee continued to deteriorate and act out. He defecated on the food tray Nancy used to bring him his meals, and in her washing machine. He also began removing the panels of the basement’s hung ceiling, obsessively searching for bugging equipment and cameras.

Throughout 2006, Lee came to suspect that a growing number of family members were joining the conspiracy against him, a list that eventually included his mother. It was a frightening development that Nancy Chiero initially hid from other members of her family, because she didn’t want to alarm them, but her situation was clearly growing more perilous.

Once, Lee hit Nancy with his cane, demanding she admit that she and her boyfriend had joined forces with the “Asosa” conspiracy. Another time, Nancy woke up in the middle of the night and found Lee holding a knife to her throat.

A video of Nancy Chiero, made months before she was killed, is shown to the jury during Lee Chiero’s murder trial. Ed Hopfmann/MetroWest Daily News
A video of Nancy Chiero, made months before she was killed, is shown to the jury during Lee Chiero’s murder trial.

After escaping from her son and spending the rest of the night in her car, waiting for her boyfriend to return from work, Nancy decided that she would try again to have Lee involuntarily committed. So in early December of 2006 she called police, who took a knife away from Lee and brought him back to Milford Regional. There, once again, Lee managed to conceal his delusions and persuaded doctors to release him — this time within just an hour and a half.

Officials at Milford Regional would not comment on the Chiero case, citing federal patient privacy provisions. Lee’s sister, however, said she later learned that her mother had not told Milford clinicians that Lee had threatened her with a knife because she feared he would be imprisoned. But as Lee’s bizarre behavior escalated, Gina insisted that Nancy try again and, this time, tell the whole truth about Lee’s threats.

Finally, just before Christmas, Nancy called Lee’s primary care physician, who arranged for Lee to be taken by ambulance to the emergency room at Tufts New England Medical Center in downtown Boston, which maintains a locked psychiatric ward, marking the third time in a little more than a year that Nancy had tried to have her son involuntarily committed.

Once again, Lee insisted there was nothing wrong with him, and, in the end, Tufts clinicians said they found both Nancy and her son believable — even though their stories differed in almost every respect. Hospital staff never attempted to contact others in the family, such as Gina or Nancy’s longtime boyfriend, who could have backed up Nancy’s version of events. And after four days they let Lee go.

“Our final impression was that it seemed unlikely that Mr. Chiero’s mother was fabricating these allegations; however, Mr. Chiero’s behavior and attitude did not seem to present a danger to himself and others and his unwillingness to be forward with us limited our treatment options,” said the discharge summary signed by Dr. Edward Silberman, the supervising psychiatrist.

Because their stories were in conflict, Tufts clinicians recommended that Nancy and her son live apart. And so, with Nancy footing the bill, Lee soon relocated to a hotel.

But within a month, he was back in the basement bedroom. Then, on the evening of Jan. 14, 2007, Gina checked in with her mother by phone and learned for the first time that Lee had come to believe that Nancy had joined the “Asosa” conspiracy.

“So I asked her, what does that mean, Mom?” Gina recalled. “Are you afraid? Are you going to be OK?”

Less than 24 hours later, Nancy Chiero was dead.

Nancy and Lee’s devastating story might have had a very different ending if they had made their home just a couple of hours away, in New York State. There, people who are severely mentally ill and have a history of violence, or threatening violence, may be required to undergo outpatient treatment under a court order or face involuntary hospitalization.

In this, New York is like 45 other states, and Massachusetts is among the outliers, along with Connecticut, Maryland, and Tennessee. The New York law and those enacted in other states are designed to cope with “revolving door” mental health patients who are potentially violent or suicidal and land in emergency rooms after psychotic episodes, then refuse to take prescribed medications or see a therapist.

It is called Kendra’s Law, named for Kendra Webdale, a young woman who died in 1999 after being pushed in front of a moving New York City subway by a man with untreated schizophrenia. The law has been in effect for more than 15 years, and studies show it has improved the quality of life for mental health patients with extreme maladies such as schizophrenia and bipolar disorder while saving taxpayer money through reduced hospital visits.

While other states have similar provisions, most experts regard New York’s as among the most successful, in part because the state has robustly funded programs for patients receiving court-ordered treatment and has increased general spending on outpatient mental health programs.

In addition, Kendra’s Law, unlike other similar statutes, requires every county in the state to consider requests to investigate whether a person with a serious mental illness meets the criteria for mandatory outpatient treatment, and to operate a program providing court-ordered care to those who do. “New York remains the only state that created a true mandate,” said Brian Stettin, who helped write the law while working for then-New York Attorney General Eliot Spitzer and is now policy director for the Treatment Advocacy Center.

Stettin said he began his work shortly after Spitzer took office and Webdale was killed. “I was asked to find out what flaw in New York law had allowed someone who was obviously a ticking time bomb to be out walking about,” he said.

About 2,800 mental health patients are enrolled in New York’s Assisted Outpatient Treatment program, or AOT, and their families are among its biggest supporters.

Among them are Michael Biasotti, a former New Windsor, N.Y., police chief, and his wife, Barbara, a school psychologist. The Biasottis struggled for years to get treatment for Barbara Biasotti's daughter, a typical revolving door mental health patient who lived for a time on the streets of the Bronx and was hospitalized on more than 20 occasions.

“If a father who’s a police chief and a mother who’s a psychologist can’t get treatment for their daughter, you know we’re in trouble,” said Michael Biasotti, recalling the days before his wife’s daughter was enrolled in New York’s AOT program.

Barbara Biasotti said the program is essential to her daughter’s well-being because she suffers from anosognosia, a term used to describe mental health patients with severe disorders who lack awareness that they are ill.

“She’ll say, ‘There’s nothing wrong with me. It’s those meds that made me crazy,’ ” Barbara Biasotti said. Without the treatment program, Biasotti added, “She’d be homeless or in jail.”

Still, mandatory outpatient treatment laws are no guaranteed remedy, especially when, as in several other states, their enactment is not accompanied by state funding or specially tailored programs.

A candlelight vigil was held after the April 2007 shootings on the Virginia Tech campus in Blacksburg, Va. Charles Dharapak/Associated Press
A candlelight vigil was held after the April 2007 shootings on the Virginia Tech campus in Blacksburg, Va.

For instance, the Virginia Tech student who killed 32 people and injured 17 others in a 2007 shooting rampage had been previously ordered to undergo outpatient treatment that he never received. The tragedy, said the authors of a Duke University study hailing Kendra’s Law, “is a grim reminder that passing a law alone does not necessarily mean that needed services are provided to persons with severe mental illness in the community.”

In Massachusetts, supporters of a mandatory outpatient treatment law have run into ardent opposition from civil rights activists and mental health patients who say that no one suffering from a mental illness should ever be coerced into receiving treatment.

Dr. Daniel B. Fisher, a psychiatrist who is himself in recovery from schizophrenia, was among those who testified against the idea at a 2015 legislative hearing.

“We don’t need more coercive tools,” he said. “We need more voluntary tools.”

Marylou Sudders, the former Massachusetts mental health commissioner who is now serving as the state’s health and human services secretary, has opposed a mandatory outpatient treatment law for many years, saying the state already provides a legal avenue for court-ordered mental health treatment, known as a Rogers Guardianship. Sudders has also said the state should increase funding for outpatient mental health care before considering a mandatory outpatient treatment law.

But many advocates for mental health care changes say that seeking a Rogers Guardianship from a probate court can be time consuming, and that the provisions of the guardianship can be difficult to enforce. It is a cumbersome and often unworkable alternative to a true mandatory treatment law, they say.

The state’s outlier status as one of only four without a mandatory outpatient treatment law also means it is missing out on the chance to win new federal funding under a program that will grant up to $1 million a year for up to four years to local jurisdictions launching new Assisted Outpatient Treatment programs.

Meanwhile, the debate between supporters and opponents of mandatory outpatient treatment remains an impassioned one. Michael Biasotti, in a Globe interview, accused patient advocates who oppose mandatory outpatient treatment of seeking to deprive his wife’s daughter of her civil liberties, by denying her treatment that keeps her from returning to a life on the street.

“I feel those people are trying to kill her,” he said. “That would be the outcome.”

After Lee Chiero killed his mother, he used her car to flee west, across the New York border. But his paranoia had long ago rendered him incapable of coping with strangers. So within 24 hours he returned to Massachusetts with a hand injury and checked himself into Newton-Wellesley Hospital, where a nurse recognized him from a TV news report and called police.

The officers found him carrying six of the 28 videos he had made to persuade the world that the “Asosa” conspiracy against him was real — including one that recorded him killing his mother as he shouted his deranged accusations.

The videos proved to be decisive evidence. Lee was found not guilty of first-degree murder by reason of insanity, one of the few instances where a Massachusetts jury has reached that verdict.

After the trial, his sister, Gina, sued Tufts for discharging her brother without accurately assessing his dangerousness. She received an undisclosed settlement that was listed by the state Board of Registration in Medicine as “above average” for psychiatrists who are successfully sued. And Lee was committed to Bridgewater State Hospital, where today he is taking his medications and receiving psychotherapy, apparently with favorable results.

During a recommitment hearing last year, held in a cinder-block room behind the chain-link fencing and razor wire that surround the facility, Lee Chiero’s lawyer argued that Lee is ready to be transferred to the Worcester Recovery Center and Hospital, a recently opened state mental health facility that was designed to make up for beds lost when other inpatient facilities were closed.

That would have been a big step back toward life in the outside world, despite all the grim evidence of his incapacity to manage for long on his own. But a district court judge disagreed, ruling that “failure to retain Chiero in strict security would create a likelihood of serious harm.”

The ruling came as a relief to Gina. But the saga of her brother’s mental illness is a continuing heartache.

At the hearing, Lee sat at the end of a long table in his prison-issued jeans and blue work shirt and watched from behind a pair of horn-rimmed glasses as his sister testified for the state.

At one point, Gina fought back tears as she struggled to recount her mother’s devotion to her son.

Lee was crying, too. And when the state’s attorney asked Gina if she had spoken with her brother before the hearing, she replied, “I have. We actually started talking again.”

 Defense attorney Keith Halpern (back to camera) hugs Lee Chiero’s sister after Chiero was found not guilty by reason of insanity. Ken McGagh/MetroWest Daily News
Defense attorney Keith Halpern (back to camera) hugs Lee Chiero’s sister after Chiero was found not guilty by reason of insanity.

About this story

The Globe compiled its list of killings by people with signs of mental illness from news clippings, court records, and interviews with families, prosecutors, and defense attorneys. The Globe included cases where reporters found that the accused had some indication of mental illness, such as being diagnosed with a mental disorder, spending time in a psychiatric hospital, taking psychiatric medication, acting suicidal, or being found unfit for trial or not guilty by reason of insanity.

However, defendants’ full medical records are typically confidential and experts sometimes offered conflicting opinions about whether they thought the suspects were mentally ill. In addition, the presence of a mental illness does not necessarily mean a defendant could not tell right from wrong. In many cases, courts found that people were still guilty of murder, even when there were indications they were suffering from a mental illness. In addition to these cases, there are almost certainly others in which mental illness went undiagnosed or an assailant’s mental health history was not publicized or known.

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