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DISTRICT OF COLUMBIA COURT OF APPEALS

No. 22-FM-0498

IN RE D.D., APPELLANT.

Appeal from the Superior Court

of the District of Columbia

(2021-MHE-001820)

(Hon. Darlene M. Soltys, Trial Judge)

(Argued May 16, 2023 Decided October 4, 2023*

)

Jennifer Williams, Public Defender Service, with whom Samia Fam and 

Shilpa S. Satoskar, Public Defender Service, were on the brief, for appellant.

Eric M. Levine, Assistant Attorney General, for appellee. Brian L. Schwalb,

Attorney General for the District of Columbia, Caroline S. Van Zile, Solicitor

General, Ashwin P. Phatak, Principal Deputy Solicitor General, and Thais-Lyn 

Trayer, Deputy Solicitor General, were on the brief for appellee.

Before BECKWITH and HOWARD, Associate Judges, and THOMPSON, Senior 

Judge.

 

* The decision in this case was originally issued as an unpublished 

Memorandum Opinion and Judgment. It is now being published upon the court’s 

grant of appellant’s motion to publish.
THOMPSON, Senior Judge: This matter is an appeal from an order authorizing 

involuntary civil commitment. Appellant D.D. is an 80-year-old woman who has 

been diagnosed with schizoaffective disorder, bipolar type. At the time of briefing 

and oral argument before this court, she remained an inpatient resident of Saint 

Elizabeths Hospital (the “Hospital”), a psychiatric hospital operated by the District 

of Columbia (the “District”) Department of Behavioral Health (“DBH”). After a 

bench trial in June 2022, the Superior Court found that D.D. was mentally ill, that 

her mental illness put her at risk of injuring herself, and that inpatient commitment 

was the least restrictive alternative in the best interests of D.D. and the public, and 

issued a written order on June 8, 2022, committing D.D. to DBH, for a period of 

one year, for inpatient treatment.1

 See D.C. Code § 21-545. On appeal, D.D. (who 

has remained at the Hospital on a voluntary basis following the expiration of the 

commitment order2

) contends that the court based its determinations and order on 

 

1 The order contemplates, however, that D.D. might be “discharged from the 

inpatient treatment to participate in an outpatient course of treatment” and directs 

that if she “subsequently fails to abide by the treatment regimen or if [her] mental 

condition . . . deteriorates, [she] may be returned to inpatient hospitalization.” 

2 D.D. has delusions about Mitt Romney and reportedly believes that he is 

arranging other housing for her. She has remained at St. Elizabeths awaiting that 

assistance, and she has rejected a housing alternative arranged by her courtappointed guardian.
3

insufficient evidence.3 Although we are not persuaded by all of D.D.’s arguments, 

we are concerned that the Superior Court ruled without awaiting what appears to 

have been then soon-to-be available information about D.D.’s possible 

neurological or neurocognitive condition, and we also are persuaded that the court 

(and the District) did not adequately explore less restrictive alternatives to acute 

inpatient commitment of D.D. We therefore vacate the commitment order insofar 

as it mandated inpatient commitment.4

I. The Evidence at Trial

The District’s chief witness at trial was Dr. Syed Zaidi, a psychiatrist at the 

Hospital, who at the time of trial had been D.D.’s attending psychiatrist for nearly 

 

3 The trial testimony established that D.D. is “in denial of her mental 

illness,” but her briefs on appeal do not explicitly deny that she has a mental illness 

and do not appear to challenge the trial court’s determination that she is mentally 

ill. 

4 The trial court’s commitment order expired on June 8, 2023. D.D.’s 

history of emergency hospitalizations creates “a reasonable expectation that the 

same complaining party would be subject to the same action again,” In re Morris, 

482 A.2d 369, 372 (D.C. 1984) (quoting Weinstein v. Bradford, 423 U.S. 147, 149 

(1975)), and the one-year limitation on the length of commitment orders, see D.C. 

Code § 21-545(b)(2), means that “the challenged action [is] in its duration too 

short to be fully litigated prior to its cessation or expiration,” Morris, 482 A.2d 

at 372 (quoting Weinstein, 423 U.S. at 149). D.D.’s claim is thus “capable of 

repetition yet evading review,” and we are satisfied (and agree with the District)

that her appeal is not moot. Id. (quoting United States v. Edwards, 430 A.2d 1321, 

1324 n.2 (D.C. 1981) (en banc)).
4

two years.5 Without objection, the court accepted Dr. Zaidi as an expert in the 

treatment and diagnosis of mental illnesses. Dr. Zaidi summarized D.D.’s

symptoms of schizoaffective disorder bipolar type, stating that she displays 

“[i]rritability”; is “psychotic,” “delusional,” and “easily . . . agitated,” and has 

exhibited behavior that includes shouting vulgarities at other patients and calling 

them “prostitute[es],” “homosexual[s],” or other names.6

 Dr. Zaidi also described 

that D.D. has been verbally aggressive toward other patients; referring to D.D.’s

Hospital record, he recounted that another patient pushed D.D. after D.D. was 

“intrusive” towards her. Dr. Zaidi further testified that D.D. has said that she will 

not take her psychotropic medication if she is released from the Hospital. He 

opined that if she does not take her psychotropic medication, her delusions will 

become more intense and her aggressiveness more physical, and she will be 

“confused, agitated, [and] disorganized.” Dr. Zaidi also opined that if D.D. does 

 

5 Dr. Zaidi began treating D.D. on January 9, 2020, before taking medical 

leave from late March 2020 through the end of that year. He resumed his role as 

D.D.’s psychiatrist in January 2021 and continued in that capacity through trial. 

Before testifying, he reviewed D.D.’s hospitalization, admission, and incidentreport records and spoke to her case manager. 

6 Dr. Zaidi recounted that D.D. has “threaten[ed]” to harm him “every single 

time” he has asked to perform a full evaluation of her. 
5

not take her psychiatric medication—an injectable form of Abilify,7 which 

Hospital staff administer to her every four weeks, and which they sometimes have 

been able to administer only by applying physical restraint as authorized by D.D.’s 

guardian—she will not take her medication for hypertension. Dr. Zaidi testified 

that the effect of forgoing her medication for hypertension “is going to be stroke, 

heart attack, kidney failure, blindness,” and other health issues. 

Dr. Zaidi explained that he had originally recommended outpatient treatment 

for D.D., but changed his mind upon being informed that providers of outpatient 

services cannot administer the involuntary injections. He dismissed the possibility 

that group homes would be better equipped for the task because “it becomes 

very[,] very difficult”; the Hospital always has backup staff to assist, which he 

“guess[ed]” would not be the case in a group home. 

Jessica Bassil, a social worker at the Hospital since 2012, testified that she 

speaks with D.D. every day and that D.D. “is more disorganized and more verbally 

aggressive when she’s not on medication.” Ms. Bassil has been able to tell when 

D.D. is not adhering to her medications because of her demeanor: yelling, being 

disruptive, and waving her arms while turning red in the face. Ms. Bassil testified 

 

7 Dr. Zaidi testified that D.D. did not want to take oral medication, and she 

was tried on a different, less effective, injectable medication before her treatment 

team settled on the long-term injectable form of Abilify. 
6

that D.D. seeks out medical treatment when she thinks she needs it, but told the 

court that D.D. is very critical of psychiatry, is very adamantly against psychiatric 

treatment, and does not believe in psychotropic medications, which she calls 

“snake oil.”8

 Ms. Bassil acknowledged, however, that D.D. had “largely been 

compliant” with taking her injections because she understands that if she does not 

adhere to the psychotropic medications, the Hospital will not consider her for 

discharge. Ms. Bassil also described D.D. as having trouble remembering recent 

events.9

 

Nurse Stella Okeke testified that D.D. is verbally abusive toward her fellow 

patients when she interacts with them. She described D.D.’s insults and vulgar 

outbursts directed at fellow patients (and at staff who intervene), which may be 

occasioned by, for example, another patient bumping into her slightly while 

standing in line. Ms. Okeke also described what has occurred when D.D. resists 

injection of her psychotropic medication: D.D. “threaten[ed] to shoot and take 

people down and things like that,” was angry and “foaming at the mouth,” was 

 

8 D.D. is also concerned about the weight-gain side effect from her 

psychotropic medication and the cost of the (expensive) medication. 

9 Ms. Bassil testified that D.D. “does not recall any of the hearings that she 

participated in,” even when reviewing transcripts of the proceedings. She has 

forgotten about scheduled meetings even when reminded earlier in the day and has 

“often” requested and received office supplies, forgotten they had been provided, 

and requested them again. 
7

looking as if “her eyes [were] popping out,” and was “shaking” and “really upset,” 

such that “you can see her vein.” Her blood pressure was “dangerous,” “almost 

200 over something.” Ms. Okeke testified that “[i]t doesn’t really take D.D.[] 

anything to get frustrated.” 

Other witnesses described D.D.’s symptoms and behavior that precipitated 

her inpatient admissions. Azalech Tegene, a member of the DBH Community 

Response Team (“CRT”), testified about the events that led to D.D.’s first 

emergency hospitalization, which lasted from May 23 to September 24, 2018, after 

she was “FD 12’d” on May 8, 2018.10 On that day, a women’s shelter where she 

had been living for several months summoned the CRT for the second time in 

roughly two weeks because of her “extremely agitated” behavior. Ms. Tegene 

arrived to find D.D. “cursing[,] . . . yelling, [and] screaming,” calling the security 

guards “homosexuals[,] . . . bitches and whores and so forth.” A shelter 

representative expressed concern that shelter staff, most of whom are African 

Americans, might retaliate because D.D. was “provocative.” (The trial court 

sustained a hearsay objection to Ms. Tegene’s testimony about D.D.’s specific 

language, but let stand Ms. Tegene’s testimony that she was called to the shelter 

because of “provocative statements that were made.”) Ms. Tegene was “not able 

 

10 An FD 12 is an application for emergency hospitalization. See D.C. Code 

§ 21-521.
8

to de-escalate.” Additionally, D.D. had bruising and swelling on her face but 

refused to let emergency medical personnel examine her. All of this led 

Ms. Tegene to complete an FD 12. Upon arrival at the Comprehensive Psychiatric 

Emergency Program, D.D. remained agitated, and medical personnel registered her 

blood pressure as “very high.” From there, she was redirected to a hospital and 

admitted. 

D.D.’s second emergency hospitalization, from July 10 to 

November 25, 2019, followed an FD 12 completed by another CRT member, 

Patrick Awosika, on June 8, 2019. Responding to a call from Amtrak police, 

Mr. Awosika reported to Union Station, where he found D.D. lying in front of the 

building entrance, “yelling, cussing people out, calling them all kinds of names: 

bitch, motherfucker, I’ll fuck you, all kinds of things.” He introduced himself to 

D.D. and offered assistance, but she refused, “calling [the CRT members] all kinds 

of name[s]” and exhibiting “bizarre behavior.” Mr. Awosika wrote the FD 12 in 

part because of his fear that by calling people “all kinds of names,” D.D. might put 

herself in danger of retaliation. He observed that some passersby at Union Station 

who encountered D.D. during this episode “tried to call her names back.” 

D.D.’s third emergency hospitalization initiated by DBH began on 

December 26, 2019, following an FD 12 on December 10, 2019. Staff at the 

shelter, to which D.D. had returned after leaving the hospital, called emergency 
9

medical services because D.D. was complaining of a headache and body pain. 

Emergency personnel found her disorganized, confused, and unable to “talk 

much.” They wrote in the FD 12 that “she was not really able to care [for] herself” 

and “was deemed vulnerable . . . to be attacked by others.” 

In D.D.’s case, her counsel raised the possibility that some or all of her 

symptoms could stem not from her diagnosed psychiatric condition, but rather 

from a neurological or neurocognitive disorder. The testimony established that 

after an initial examination (which was limited because D.D. was unwilling to 

cooperate), the Hospital’s neuropsychiatric team sought to do further testing to 

investigate possible neurological or neurocognitive contributions to her condition. 

On cross-examination, Dr. Zaidi concurred that some of D.D.’s symptoms, 

including insensitivity to social standards and behavior “out of [the] acceptable 

social range,” may sometimes indicate such a neurological or neurocognitive 

disorder. He agreed that certain dementias are associated with both memory issues 

and paranoia, but said that memory issues do not “give you . . . delusion[s].” 

Dr. Zaidi also agreed that patients with some neurological or neurocognitive 

conditions, such as Alzheimer’s disease, Parkinson’s disease, and dementia, may 

present with memory issues along with some symptoms also associated with 
10

schizoaffective disorder. He acknowledged that it would be “important” to rule out 

such a condition where symptoms overlap with those of a diagnosed illness.11 

At the end of the bench trial, the court determined that the government had 

proven, by clear and convincing evidence, the requirements for civil commitment. 

The trial court concluded that D.D.’s mental illness put her at risk of injuring 

herself, i.e., that she was “a danger to herself because she puts herself in harm’s 

way by the name-calling and her aggressive and hostile behavior towards 

others[,] . . . [which] would very likely induce violence and retaliation by others.” 

The court was also persuaded by Dr. Zaidi’s testimony that, if discharged, D.D. 

would stop taking her psychotropic medication, which would cause her to become 

disorganized, resulting in an inability to take her prescribed hypertension 

medication and putting her at risk of heart attack or stroke. The court further found 

that there was no less restrictive treatment available than involuntary inpatient 

commitment. 

 

11 D.D.’s counsel pressed Dr. Zaidi on the Hospital’s failure to have her 

tested for a neurological or neurocognitive disorder despite his acknowledgment

that it would be “important” to rule out such a condition where symptoms overlap 

with those of a diagnosed illness. Counsel highlighted Dr. Zaidi’s statement that, 

although he interacted with D.D. almost every day, he had not been able to 

complete a full examination of her due to her “yelling” and “threatening” him. 

Dr. Zaidi affirmed his confidence in the schizoaffective disorder diagnosis, 

explaining that evidence of a differential diagnosis (i.e., evidence of other possible 

conditions that could share the same symptoms) does not remove a primary 

diagnosis in the absence of testing that negates the primary diagnosis. 
11

II. The Applicable Legal Standards

A. The Statutory Requirements for Commitment

The District of Columbia’s involuntary civil commitment statute is a part of 

the “Hospitalization of Persons with Mental Illness Act,” D.C. Code §§ 21-501 to 

21-592, often called the “Ervin Act,” see, e.g., In re Macklin, 286 A.3d 547, 550 

(D.C. 2022); Tilley v. United States, 238 A.3d 961, 965 (D.C. 2020). In order to 

involuntarily commit an individual, the government must demonstrate that (1) “the 

person is mentally ill,” (2) “because of that mental illness, [she] is likely to injure 

h[er]self or others if not committed,” and (3) there is no “[less] restrictive 

alternative [to commitment] consistent with the best interests of the person and the 

public.” § 21-545(b)(2). The showing on the first two prongs must be made by 

clear and convincing evidence. In re Gaskins, 265 A.3d 997, 1001 (D.C. 2021) 

(citing Addington v. Texas, 441 U.S. 418, 425-26 (1979) (holding that because of 

the liberty interests at stake, there must be clear and convincing evidence to order 

an involuntary civil commitment)); In re Gaither, 626 A.2d 920, 925 (D.C. 1993) 

(“[A]t the disposition stage the trial court need not apply the clear and convincing 

evidence standard in determining the least restrictive form of treatment” because 

“[t]hat standard is applicable only at an earlier stage of a civil commitment 

proceeding, when the hospital must prove that the person for whom commitment is 

sought is mentally ill and likely to injure self or others.” (citation omitted)). The 
12

clear-and-convincing standard requires that the truth of the factual contentions 

supporting commitment be “‘highly probable’ or substantially more likely to be 

true than untrue.” Gaskins, 265 A.3d at 1002 (quoting Colorado v. New Mexico, 

467 U.S. 310, 316 (1984)). 

As to the statutory requirement that the court “order the form of commitment 

it believes is the least restrictive alternative consistent with the best interests of the 

person and the public,” In re Lanier, 905 A.2d 278, 284 (D.C. 2006) (quoting D.C. 

Code § 21-545(b)(2)), we will not disturb the trial court’s determination unless it 

was “plainly wrong or without evidence to support it,” id. (quoting D.C. Code § 

17-305(a)); see also In re Artis, 615 A.2d 1148, 1153 (D.C. 1992). 

B. Standard of Review

D.D. challenges the sufficiency of the evidence in support of the trial court’s 

order. Our standard of review for such challenges is “well settled.” In re Perruso, 

896 A.2d 255, 259 (D.C. 2006).

In examining a claim of insufficiency, the applicable 

standard of review is whether there is any substantial 

evidence which will support the conclusion reached by 

the trier of fact below. This court must view the 

evidence in the light most favorable to the government 

and give full weight to the factfinder’s ability to weigh 

the evidence, determine the credibility of witnesses, and 

draw justifiable inferences. When a case is heard by a 

judge sitting without a jury . . . the judgment will not be 

overturned unless it appears that the judgment is plainly 

wrong or without evidence to support it.
13

Gaskins, 265 A.3d at 1001 (alteration in original) (citations and internal quotation 

marks omitted) (first quoting In re Artis, 615 A.2d at 1152; and then quoting

Perruso, 896 A.2d at 259).

III. Analysis

To commit a mentally deficient person under the Act, it is necessary for the 

government to prove, first, “that the individual involved suffers from a mental 

illness.” In re Alexander, 372 F.2d 925, 927 (D.C. Cir. 1967). As noted above, 

although witnesses testified that D.D. does not believe she has a mental illness and 

although at trial D.D. challenged the diagnosis of schizoaffective disorder bipolar 

type, her briefs do not deny that she suffers from a mental illness. In light of 

Dr. Zaidi’s testimony about her diagnosis of schizoaffective disorder bipolar type, 

we discern no reason to question the sufficiency of the basis for the trial court’s 

finding that D.D. suffers from a mental illness.12 

Focusing on the second prong of the Ervin Act test (“because of that mental 

illness, [she] is likely to injure h[er]self or others if not committed,” D.C. Code 

§ 21-545(b)(2)), D.D. argues, however, that the government failed to present 

sufficient evidence to prove that D.D. is likely to injure herself by provoking 

 

12 Cf. Perruso, 896 A.2d at 261 (“The court was certainly entitled to rely on 

the [psychiatrist’s] opinion [about whether the individual is mentally ill] in making 

its ruling.”). 
14

retaliation from others who may be targets of her name-calling and vulgarities. 

Because of other aspects of the record (discussed infra) that we find dispositive, 

we need not decide whether the evidence supported a finding by clear and 

convincing evidence that D.D. was a danger to herself because of her conduct that 

might trigger retaliation. Nor, for the same reason, need we resolve whether 

substantial evidence supported the trial court’s finding that D.D. would be a danger 

to herself if discharged from the Hospital because she would refuse psychotropic 

medication, become confused and disorganized, and therefore fail to take 

medication for her “dangerous[ly]” high blood pressure and put herself at risk of 

heart attack or stroke.

13 What we find dispositive is the record as it relates to the 

 

13 We do acknowledge that the risk related to D.D.’s hypertension is 

somewhat attenuated; that her trial counsel’s cross-examinations raised questions 

about whether her inpatient hospitalization and agitation in response to involuntary 

injections is a principal trigger for her blood pressure spikes; and that the District’s

theory of injury to herself perhaps tests the boundaries of what counts as an 

“injury” as contemplated by the statute. To be sure, we have found in other cases 

that a person’s medical risks supported findings that the person’s mental illness put 

her at risk of injuring herself. See, e.g., In re Artis, 615 A.2d at 1149-50, 1152 

(concluding that the evidence was “ampl[e]” to support the decision that Ms. Artis

was likely to injure herself if not hospitalized where it showed, inter alia, that she 

“refused to maintain a diet necessary to control her elevated blood pressure and 

diabetes” and “refused to self-administer her [needed daily regimen of] prescribed 

insulin despite several attempts at instruction by hospital staff”); id. at 1151 n.1 (“It 

is precisely the union of mental illness with the inability of a person to adequately 

care for herself that raises the inference of ‘danger’ and ‘injury’ to self and triggers 

the statutory provisions.”); In re Gahan, 531 A.2d 661, 665 (D.C. 1987) (finding 

ample evidence to support commitment where the government showed that “if 

permitted to remain at liberty, Gahan would be a danger to herself,” specifically by 
15

statutory requirement that there be no “[less] restrictive alternative [to 

commitment] consistent with the best interests of the person and the public.” D.C. 

Code § 21-545(b)(2). On the record before us, we are persuaded that the trial 

court’s findings as to this requirement were not supported by substantial evidence. 

The record raises more than uninformed speculation that D.D.’s dangerproductive outbursts could be the result of a neurological condition such as 

dementia rather than the result of her diagnosed psychiatric condition. As 

described above, the Hospital’s neuropsychiatric team recommended further 

testing to investigate possible neurological or neurocognitive contributions to 

D.D.’s condition. They opined after a limited examination of D.D. that “in 

addition to the psychiatric issues, it’s a possibility . . . that she might have some 

single neurological event, or some neuropsychiatric even[t].” As also described 

above, Dr. Zaidi concurred that some of D.D.’s symptoms, such as her insensitivity 

to social standards, could indicate such a neurological or neurocognitive disorder. 

Further, he agreed that patients with some neurological or neurocognitive 

conditions, such as Alzheimer’s disease, Parkinson’s disease, and dementia, may 

have symptoms like those caused by schizoaffective disorder, including irritability 

 

“not eating and . . . becoming severely dehydrated,” triggering “numerous other 

medical problems that can come from that”). We need not decide, however, 

whether D.D.’s medical risk is distinguishable from the risks at issue in those 

cases. 
16

and agitation. And he acknowledged that it would be “important” to rule out such 

a neurological/neurocognitive condition. 

Given the foregoing testimony, we are concerned about the timeline: 

Dr. Zaidi’s testimony on June 1, 2022, that D.D. was scheduled for an MRI (part of 

the recommended further testing) the day after his testimony, followed by a 

representation by D.D.’s counsel on June 8, 2022 (immediately after the court 

stated that it would grant the government’s petition), that the results of the MRI 

were “abnormal” but had not yet been interpreted by or discussed with 

neurologists. In light of the trial court’s having received those signals of a 

possibility that additional relevant evidence would soon become available, we are 

unable to uphold the court’s adherence to its decision to order D.D.’s inpatient 

commitment without waiting for an explanation of the test results (which might 

have suggested that a memory care or dementia facility, for example, could meet 

D.D.’s needs).14

A second, related basis for reversal is this: insofar as the trial court’s order 

authorized inpatient commitment of D.D., the record does not support that 

inpatient commitment was the least restrictive alternative consistent with the best 

 

14 We recognize that D.D.’s counsel explicitly lodged no objection to 

proceeding to disposition on June 8, but we conclude that the trial court’s 

finalizing its inpatient commitment ruling without awaiting a fuller explanation of 

the MRI results was a plainly erroneous exercise of discretion.
17

interests of D.D. and the public. The government’s petition for inpatient 

commitment was based almost entirely on the need for D.D. to receive involuntary 

injections of her current psychotropic medication. Dr. Zaidi confirmed that he had 

initially recommended her commitment to outpatient treatment, but modified his 

position because he had come to understand that there was “no mechanism to 

involuntarily administer [Ms.] D. her psychotropic medication if she is discharged 

into the community.” But Dr. Zaidi did not “know for sure” whether a nursing 

home, for example, would be able to administer involuntary injections, and he “just 

guess[ed]” that a nursing home would not have the number of staff available to 

restrain D.D. if she were to physically resist treatment. He agreed that “it could be 

explored” whether a memory care or dementia unit would be able to administer 

involuntary medications. 

“[I]t is the state’s burden to demonstrate the existence and unsuitability of 

various treatment alternatives, not respondent’s, and it is the trial court’s 

responsibility to ensure that the state meets this burden.” In re Stokes, 546 A.2d 

356, 361 (D.C. 1988) (emphasizing that the trial court must play a “role . . . in 

searching for treatment alternatives”). Here, neither the District’s nor the trial 

court’s exploration of possible alternatives to inpatient hospitalization for D.D. 

appears to have been particularly searching. We acknowledge that some evidence 

was presented about the possible non-viability of certain alternatives. A 
18

representative of one provider of “the most intensive outpatient services available 

in the District” testified to the effect that her organization could not perform 

involuntary injections. Ms. Bassil testified that D.D. has refused to discuss being 

discharged to group housing or to a long-term-care or assisted living facility, and 

D.D. herself told the court that the suggestion that she be placed in a nursing home 

was “appalling.” Further, Dr. Zaidi explained that in light of COVID-19, bringing 

D.D. to the Hospital for injections might not be feasible. But, as we have 

emphasized before, “[t]he statutory scheme in this jurisdiction does not limit the 

court in a commitment proceeding to a polarized choice between indefinite 

hospitalization and unconditional release: it makes the entire spectrum of 

services . . . available, including outpatient treatment, foster care, halfway houses, 

day hospitals, nursing homes, and others.” Id. at 360 (alterations in original) 

(internal quotation marks omitted) (quoting In re Mills, 467 A.2d 971, 974-75 

(D.C. 1983).15 The government did not show why one of those (or other) 

 

15 See also In re Plummer, 608 A.2d 741, 749 (D.C. 1992) (Rogers, C.J., 

concurring) (explaining that the statutory scheme “has been construed to impose a 

duty upon the courts to explore alternatives both within the mental hospital . . . and 

outside the hospital, . . . and to require that the courts select the least restrictive 

alternative which would serve the purposes of the commitment” (alterations in 

original) (quoting In re Mills, 467 A.2d at 974-75)); cf. Lessard v. Schmidt, 349 F. 

Supp. 1078, 1096 (E.D. Wis. 1972) (holding that the Constitution compelled the 

state to establish the unsuitability of numerous alternatives to involuntary full-time 

hospitalization before commitment could be ordered, including “voluntary or 

court-ordered out-patient treatment, day treatment in a hospital, night treatment in 
19

alternatives could not be used in conjunction with, as necessary, administration of 

D.D.’s injectable psychotropic medication by Hospital staff.16 See id. at 363-64 

(observing, in vacating inpatient commitment order, that a dual-diagnosis program 

specifically tailored to Stokes’s needs, which had already resulted in her making 

improvements, had not been made available to her prior to initiation of the 

 

a hospital, placement in the custody of a friend or relative, placement in a nursing 

home, referral to a community mental health clinic, and home health aide 

services”), vacated and remanded on other grounds, 414 U.S. 473 (1974).

16 In its January 25, 2022, Report and Recommendation to the trial court, the 

Commission on Mental Health (the “Commission”) referred to D.D.’s “potential 

[d]ementia” and also noted Dr. Zaidi’s testimony before the Commission stating 

that it was not clear that D.D. has dementia but “acknowledg[ing] that elderly 

patients who have [d]ementia have increased risks on [D.D.’s prescribed] 

medication.” The Commission recommended, in a bolded and underscored 

passage, “[t]hat the [trial court] order D.D.to undergo a medication review . . . to 

determine if another medication regime can better address her symptoms and risk 

of side effects, given her diagnosed and potential neurological conditions,” and 

added that the review would “explore whether other medications could improve 

her condition and enable her safe outplacement to the community.” 

We recognize that in determining its recommendations, the Commission is

not subject to a clear-and-convincing-evidence or other standard-of-proof 

requirement. See In re Holmes, 422 A.2d 969, 971 (D.C. 1980). We also 

recognize that, unlike in cases where the person whose commitment is 

recommended has not made a timely demand for a trial, the statute does not 

contemplate that the trial court’s decision is to be made “on the basis of the report 

of the Commission, or on such further evidence in addition to the report as the 

court requires.” D.C. Code § 21-545(a). We therefore cite the Commission’s 

report (which, at oral argument, was analogized to a charging document) not as 

evidence, but only as context for our observation that no evidence of a medication 

review was presented at trial.
20

proceeding to revoke her outpatient status, and that her doctor did not explain why 

she “could not remain as an outpatient temporarily in lieu of indefinite inpatient 

status”).

IV. Conclusion

A commitment order necessarily authorizes a substantial deprivation of 

liberty and, accordingly, the government must justify the extent of that deprivation 

with sufficient evidence. On the record before us, the government failed to meet 

its burden of showing that inpatient commitment is necessary for D.D. to receive 

appropriate treatment. Accordingly, we vacate the order of the Superior Court 

ordering inpatient commitment.17

So ordered.

 

17 The District filed a supplementary appendix that contains (in addition to 

some documents that were already part of the record) documents relating to D.D.’s 

2020 commitment trial and February 14, 2020, Commission recommendation, and 

portions of the District’s brief cite those extra-record materials. D.D. has moved to 

strike the supplemental appendix and brief. Because we have resolved the issues 

presented without referring to or relying on those materials, we now deny as moot 

both the motion to supplement the record and the motion to strike.