diagnosis the government and the defense expert also agree that if that's your point it's to be involuntarily medicated it should be some type of anti psychotic medication what they disagree on is the whether it is in mr coy's best medical interest to be forced to take anti psychotic medication what to focus my argument today on the magistrate judge's report recommendation i'm looking at page forty of the positive and then finally the magistrate judge said that the statistics that dr sonny provided in his testimony were also positive in favor of competency restoration so going st to d experience and training when he testified at the cell hearing i'm referring to pages eight and nine he was asked to ringback outline his experience with amphetamine in psychosis and he testified that he had seen a number of cases over the past three years when pressed on how many cases he'd actually seen he said it was less than five when asked his success rate on those cases he said he couldn't recall whether any patient had been treated successfully and restored to competency he said well the clinical picture with that has been complicated that was his quote he said i treat the same way that i would treat a patient was when asked again have people been restored to competency based on the course of treatment that you have outlined for mr coit have been restored to compensate and again he had to stay i don't have that information because i just don't recall the specific cases now this was an expert that the government called that's a rd direct examination of dr gravity he knew that the issue in this case is whether you can successfully treat amphetamine into psychosis with delusional disorders that persist for over three years and he didn't bother to go back through his experience over the years and either look up or try to recall what the results were in those cases now he te and psychosis however after he gave the testimony that i just i'm essentially the government attorney then read to him the four or five conclusions that he had made in his report and asked after each one of them did i read that correctly is that your opinion and dr gravatt informed informed him that it was there was no explanation given in testimony as to how he arrived from looking at this i think that it's apparent that this is a generic document that the federal medical center in butler uses in all cases for defendants who suffer from psychosis this the appendix spends a lot of time discussing relevant information that pertains to schizophrenia which mr coit does not have he has as i said amphetamine into psychotic order disorder where a very small number so the sample size for these studies was very small have a stamp of sizes included in the cell appendix so the magistrate judge would have had that available to her but she didn't necessarily have available to her what was actually said in those studies that countered this generally ros picture that roughly seventy percent or more of all psychotic defendants can be restored to competency examiners in both the herbal study and in the cochrane study admitted that the their opinions may have been more or have been in favor of favorable treatment they were both retrospective studies meaning there were no patrol groups without bat you can't establish a cause and effect relationship between the anti psychotic medication and the restoration to compensate for the copper in study at mit's that because of the small sample size that future research should  of treatment or rare disorders like delusional disorders so what we have is a client with an extremely rare disorder but though that disorder the amphetamine induced psychosis is not addressed any of the five studies that are on page two of the cell a substantially likely in and then and yeah yeah i didn't see any case saying what is substantially likely or fifty percent is that over sixty percent the clear and convincing evidence standard tells us that you well i did not find any cases that actually answer that question but i think that when you're talking about overriding a defendant who has not been convicted of anything yet he's merely accused overriding his constitutional liberty interest you have to meet a high threshold now the cases that i've seen that have  referred to the studies that are listed in the cell appendix they're generally citing seventy percent or higher but there's no case that draws the equivalence and said well seventy percent is the number that must be reached resting that if the government hasn't ever treated a large number of people with a given condition and brought them back to competency that they cannot make the necessary showing because that rule would mean that people w unusual conditions are basically outside of the cell procedure and i wonder if that's the logical implication of your medication so there was a track record take for example you mean voluntarily if the person had been treated voluntarily for purposes of this incurred as i don't recall if it was voluntarily if i remember correctly he had a state case and he had been arrested on that he was sent to a hospital and he was treated for a period of time with anti psychotic medication so i think regardless of whether it's bollen terry or involuntary in the past that person has a proven track record he was responding favorably before and that's a good indicator for favorable response in future treatment other cases i think you have to compare another limiting principle would be compare the actual type of psychosis that the person pats schizophrenia is very different from methamphetamine ind pertain specifically to the facts of the underlying crime he is charged with so take for example another case that the government's i'm sorry i can't recall the name of it but that particular defendant's delusion was that the state of alaska he was charged with not registering as a sex offender the two did not particularly have anything to do to one with one another now he was found not competent but me ask you this question what i've heard you argue they're saying afternoon has to do primarily with the testimony of the government's expert but i haven't heard you like much reference to dr suddenly or saw me have you pronounce the name and so am i correct about that d i think that you're attacking the government's evidence and you're not this is not a question of consulted on reaching the treatment plan and if you look at dr cochrane's two reports in this case you'll see that he mentions consulting with a psychiatric pharmacist as well you thank you for your argument this courage mr wagner will hear from you may please the court david wagner for the united states like to jump right in where mr left off talking about mr so me and  shepard you're absolutely right he's a psychiatric pharmacist by statute in that eighteen us c or two hundred and forty seven a psychiatric pharmacist does not qualify to a pine on a dependent competency only a licensed psychologist or psychiatrist can do that but he stands to reason if dr sami can't can't determine whether or not boys competent he's also unqualified to determine whether medication is the standard he likely to restore him to competency i think his opinion can be discounted on that ground alone also remember he never met mr croy he reviewed only two of the or prior reports that had been generated he talked about his experience in the literature but he did not identify a single study that he was relying on and only positive just note that although mr coysh attacked the government studies that show the effectiveness of anti psychotic medication across a range of wide range of delusional disorders he has not produced one thing will study in this case that supports his position that the medication is unlikely to be successful anyways returning back in fact substantially supported the government's position in the case with dr so mean that is that he saw hundreds of patients treated we i don't really know what treated means but he used that term so i'll use that term quote unquote treated hundreds of patients with drug induced psychosis and thousands with schizophrenia is that of those hundreds and thousands of patients only ten or twelve maintain their delusion in spite of absence from the drug in treatment presumably referring to the drug that created this psychosis so in other words of the people he had seen a minuscule percentage were not effectively treated by anti psychotic medication and there's some there's some back and forth in the brief the american psychiatric association unlike doctors so he is qualified by statute to a pine on whether someone is competent or not unlike doctors only he spent approximately two hours personally with boy evaluating him in person unlike doctors so many he consulted with other professionals treating mr coit including the nurse practitioner clinical pharmacist and dr cochrane unlike dr soni he pointed to particular stud effectiveness of and i think otic medication in treating psychotic disorders clinical settings in other words is fully aware of more studies than are just just the ones that are particularly cited in his appendix and was relying on them what about the fact that and i know that's why he doesn't have to be more precise does does the government have to put on evidence is more particularized in order to meet its burden absolutely not because other because if if if if if there's a defendant with a very peculiar condition and there's no not a large body of data about how the medication works for that condition the government expert a medical doctor can talk about how in is training and experience the medication that works for one sort of condition is likely to work for another and that's basically i think exactly what dr gravity doing here we understand we're out we're understand where's the best place in his coit and i would note that in the statement of purpose for that appendix they talked about it being designed for this particular patient so i do think there was some thought put into whether the points were relevant to you mr corey in particular and then all the rest of it about how he gave individualized attention to mr croy how he studied the prior reports that had been written about mr croy how he consulted with others all these individual considerations support his opinion that mr coit particular disorder even though we might not have in the record a study that says thousands of people with this disorder were treated and how it was effective because dr gregory has the experience and can understand how chemistry works positive disorders were he was able to say with a reasonable degree of medical certainty that the medication is substantially likely to be effective well in journey place where he makes the statement that you kind of attributed to him that that he thinks he can transfer his experience with related or similar conditions to this condition i can't recall that he said that specifically but i think that i think if you you read it as more fulsome than that does he actually give the basis for his opinion absolutely i mean one of the bases is his individualized evaluation of mr croy and other base the base and other bases is consultation with others treating mr croy other bases is his understanding of the literature about how and i think i take medication works for a wide range of psychotic disorders these are all reliable bases for his opinion to address delusions such as the ones that mr quaid has he said that quote him human induced psychosis has been found to be effectively treated through the use and i think i take medication even if it may take longer to treat delusional thinking  other symptoms dr cochrane also similarly pined that mr croy has a quote treatment responsive illness and does not have co morbid conditions or extenuating circumstances that would mitigate a positive treatment response so all of the medical professionals were competent to do a pint on whether mr with whether mr coe is competent have agreed that the medication is substantially likely to work out all to point the court to its prior opinion in united states versus oslo united states versus mackey and united states versus curtis and basically what those opinions say is for this particular factor the district court can rely on a competent experts testimony about whether the medication is substantially likely to work and it's not clear for a district court to credit an expert's credible testimony you know i think i think that's exactly what the district  oh i'm sorry good shepherd you have something yes i do can you hear me i can hear you get up at one thing i know that it is that dr  d the pelham but it was it was for two hours that's the that's the number that i recall from the from what i've read  what about that is that up is that a significant time period is really thing the record that tells us if that that is a typical amount of time for a expert or a doctor to treat or personally interview a patient in this situation i think to directly answer question no there  no testimony on an addict that point however there is no testimony to the contrary certainly and remember and keep in mind that in addition to personally evaluating mr croy dr greg he reviewed all the reports that had been generated or and he consulted with the individuals who were treating mr corey so i think those things combine two hours in two hours is a fairly significant amount of time and i think that combined with all the baseline knowledge he had from the written fact that he had treated a low number of people with this particular disorder and recalling the moment what the outcome was i don't think discredits his testimony in anything approaching a material way and i don't believe the district court didn't either category or was he strictly relying on judge i think what he was relying on with his general understanding of the disorder and how it relates to other disorders that he has experience treating and that the studies that he was relying on i think just because just because mr mr quinn happens to have a civic what appears to be fairly unusual longstanding disorder that causes him to have the delusion that doesn't mean that it is necessarily materially different from other patients with other psychosis or not i think the fact that the fact that the studies that were that are in the record support that and i think i take medication is effective across a range of disorders no reason to believe that  delusions anti psychotic treatments and as courts have been recognizing more recently the literatures simply did not support that position name or that's an outdated you will study that cochrane study that were that that was in the record or the district court that this medication is medically inappropriate dr somi was asked if it's his patient was willing and anxious to try any kind of medication which would give them that medication and he said yes i think we can conclude that soami would not be willing to give a patient medication that he did not think were in their medical best interest so in that point it seems to me it's fair to say that the expert testimony w also there's evidence in the record about all the things that all the issues that mr corey was experiencing dr grabby that is symptoms were moderately severe and the impact of the disorder on his life is moderate to severe and a medication which means that all right thank you for your argument will give you two minutes for a bottle if you'd like to reply you'll have to turn on your microphone  eighty the prognosis is clearly good individuals treated for st psychotic episodes typically respond favorably once correct medication and dose of stablish but if you go to the cell appendix document seventy one dash one top of tape or the rd paragraph says patients repeats this same principle st psychotic episode are comparatively easier to treat but what he is quoting from here what this type of situation requires informed consent knowing all of the possible side effects that you might face even those that are rare but which can cause death you still aren't willing and want to be  medication and finally just because it's hard to prove we don't give the government cut them some slack because it's difficult they still bear the burden of their parents in evidence thank you very much all right thank you to both counsel