The knife murder at Charlotte, North Carolina, of a Ukrainian refugee, Iryna Zarutskak, by an apparent schizophrenic has raised the recurring and obvious questions about how to ensure dangerous persons are not walking the streets — or, in this case, using public transit.

Yet tougher laws or augmenting local police or similar proposals miss a larger point. It is time to deal with the thousands of untreated seriously mentally ill persons by returning to a system we once had across the country: adequate public and private mental hospitals to institutionalize those in need of treatment — and from whom we need protection. A movement of “reinstitutionalization” — rolling back the deinstitutionalization that began in the 1960s — is not only necessary but practical.

An expanded system of institutional care would not have to be nearly as extensive as that which was phased out. In the past, mental institutions were accused of being hellholes that in effect “warehoused” patients in unsafe conditions. A much smaller system could focus narrowly on those who suffer from the most serious mental illnesses, including schizophrenia.

At its height, the state-based system of mental hospitals comprised a stunning 500,000 beds. In most states, such hospitals were the largest single budget item.

But beginning with a Life magazine photo essay exposé, a reform wave built against these institutions. The psychiatrist Thomas Szasz propounded the idea of the “myth of mental illness,” and the documentary filmmaker Frederick Wiseman released “Titicut Follies,” about the conditions inside a Massachusetts mental hospital.  Federal law followed — including the decision that Medicaid not provide funding for institutional care. Homeless schizophrenics became a feature of our cities, under bridges and in encampments

To be sure, not all schizophrenics become violent. Neither, though, can we easily predict who will do so and when. That story has been powerfully told by Jonathan Rosen in his book “The Best Minds” — about a brilliant friend who, after apparently recovering from a schizophrenic break, killed his wife. Without doubt, however, all who are at risk of harming themselves or others deserve treatment, whether voluntarily or not.

The institutions that once housed dangerous mentally ill individuals need not be replaced bed-for-bed. Mental hospitals were shelters of last resort for a diverse population we would not house in such facilities today, reports the historian Gerald Grob in “Mental Illness and American Society: 1875–1940,” a definitive history. They included those in the last stages of syphilitic dementia, tuberculosis, and so-called senile dementia. They were, too, dumping grounds for the elderly poor — before the advent of Medicare and Medicaid and the now widespread “memory units” in long-term care facilities.

The Treatment Advocacy Center, founded by the psychiatrist E. Fuller Torrey, has estimated there may be 169,000 mentally ill untreated persons living on America’s streets. At one point, California alone had 50,000 mental hospital beds. A 2025 National Institutes of Health study concludes that “across the US there is a shortage of inpatient psychiatric beds, with only 28.4 beds per 100,000 population; this is more than 30 beds fewer than the optimal level of 60 beds per 100,000 that is supported in the literature.” Areas with racial minority populations, per the study, had the fewest.

To provide the compassionate treatment the seriously mentally ill need, the concerns of civil libertarians must be de-emphasized. That means restoring involuntary commitment — including at the request of family members for adults — as a feature of our health care system. 

I saw this work in my own family.  My grandparents were burdened with the care of my grandfather’s brother — my great uncle — who, following a teenage arrest, suffered an apparent schizophrenic break at an Ohio jail. He would go on to spend the rest of his life at the Lima State Hospital, which, prior to construction of the Pentagon, was the largest poured concrete structure in the world.  

He suffered from the delusion that he was a playwright — and perhaps with modern treatments he might have been released to become one. At least, though, he did not cower in the cold and rain on a Cleveland street — nor threaten my grandparents and my mother. He was visited regularly by a Toledo rabbi.

Involuntary commitment need not — and is not — be an issue that leads to a political divide. The University of Pennsylvania Medical School psychiatrist, Ezekiel Emanuel, famously a key architect of ObamaCare, has written, “Reforms that ignore the importance of expanding [asylums] will fail mental health patients who cannot live alone, cannot care for themselves, or are a danger to themselves and others.” 

So it once was — and should be again.