United States Court of Appeals

For the Eighth Circuit 

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No. 20-1156

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United States of America

 Plaintiff - Appellee

v.

Matthew H. Coy

 Defendant - Appellant

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Appeal from United States District Court 

for the Western District of Missouri - Kansas City

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Submitted: January 12, 2021

 Filed: March 17, 2021 

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Before COLLOTON, WOLLMAN, and SHEPHERD, Circuit Judges. 

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SHEPHERD, Circuit Judge.

Matthew H. Coy, who suffers from amphetamine-induced psychotic disorder, 

with onset during intoxication, was charged with unlawful possession of a firearm 

by a convicted felon. The district court1 found Coy incompetent to stand trial, and 

1

The Honorable Gary A. Fenner, United States District Judge for the Western 

District of Missouri, adopting the report and recommendations of the Honorable 
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after Coy declined medication, the government moved to begin involuntary 

treatment under Sell v. United States, 539 U.S. 166 (2003). The district court granted 

the government’s motion, and Coy now appeals. Having “jurisdiction over 

interlocutory appeals of orders for involuntary medication under the collateral order 

doctrine,” United States v. Nicklas, 623 F.3d 1175, 1177 (8th Cir. 2010), we affirm.

I. 

After being charged by criminal complaint, Coy was indicted on two counts 

of unlawful possession of a firearm by a convicted felon, in violation of 18 U.S.C. 

§§ 922(g)(1) and 924(e)(1). Coy and his mother had an altercation, which resulted 

in a gunshot wound to Coy’s leg. Coy was treated at a medical center and was 

described as: having “an altered mental status”; “exhibiting delirium”; and 

“screaming random statements.” R. Doc. 36, at 5. While Coy was being treated, 

police found two firearms in his residence. Coy claims that his mother shot him as 

part of a large conspiracy aimed against him; his mother claims that Coy had taken 

methamphetamine, attacked her, and shot himself in his delirium.

Coy filed a motion for determination of competency. After a psychological 

evaluation, Dr. Jeremiah Dwyer, a forensic psychologist, noted that while Coy’s 

exam was largely unremarkable, Coy would be unable to assist in his trial due to his 

delusions regarding his mother, law enforcement, and medical personnel. The 

magistrate judge recommended that an order of incompetency be entered and that 

Coy be committed to the custody of the Attorney General for treatment at a federal 

medical center (FMC Butner) for four months, a recommendation which the district 

court adopted in full.

After the first ordered period at FMC Butner ended, Dr. Robert Cochrane, the 

primary psychologist, filed a report with the district court stating that Coy’s 

Lajuana M. Counts, United States Magistrate Judge for the Western District of 

Missouri.
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delusions had persisted, and the district court extended the treatment another four 

months. Shortly thereafter, Dr. Cochrane notified the district court that Coy had 

declined further medication, and the government requested authority to begin

involuntary treatment under Sell. The magistrate judge recommended that the 

district court enter a finding that there were important government interests at stake, 

the first element under Sell, based on the seriousness of Coy’s crime. The district 

court adopted the recommendation in full and ordered the staff of FMC Butner to 

prepare an “Addendum and Treatment Plan” to address the other Sell elements. 

The magistrate judge subsequently held an evidentiary hearing on the three 

remaining Sell elements. Dr. Logan Graddy, the chief psychiatrist at FMC Butner, 

submitted the requested “Addendum and Treatment Plan” (the Treatment Plan). In 

the Treatment Plan, Dr. Graddy determined that Coy suffered from amphetamineinduced psychotic disorder, with onset during intoxication, and that the disorder’s 

impact on Coy’s life was “moderate to severe.” R. Doc. 71, at 2. The Treatment 

Plan contained Dr. Graddy’s findings:

3. My opinions related to these matters: 

* * *

b. In regards to [element] 2:

 i. I have no opinion as to whether involuntary medication 

 will significantly further government/state interests.

ii. In my opinion, with reasonable medical certainty, 

involuntary medications are substantially likely to render 

Mr. Coy competent to stand trial. 

iii. In my opinion, with reasonable medical certainty, 

involuntary medication is substantially unlikely to have 

side effects that will interfere significantly with the 

defendant’s ability to assist counsel in conducting a trial 

defense.
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c. In regards to [element] 3:

i. I have no opinion as to whether involuntary medication 

is necessary to further government/state interests.

ii. In my opinion, alternative, less intrusive treatments are 

unlikely to achieve substantially the same results as 

involuntary medication.

iii. I have no opinion as to whether less intrusive means 

(court order backed by contempt order) will achieve 

substantially the same results as involuntary medication. 

d. In regards to [element] 4: It is my opinion that administering 

antipsychotic medication to Mr. Coy is medically appropriate. It 

is in his best medical interest in light of his medical condition.

R. Doc. 71, at 5-6 (footnote omitted). The Treatment Plan further noted that Coy 

had voluntarily taken antipsychotic medication while at FMC Butner but that he 

“ha[d] been reluctant to take the medications at sufficient doses or for a sufficient 

period of time to treat his disorder.” R. Doc. 71, at 3. Coy’s reluctance stemmed 

from his belief that “the treatment team was trying to poison him or part of the 

conspiracy against him.” R. Doc. 71, at 4. 

 Dr. Graddy also submitted an appendix of studies to the Treatment Plan, the 

purpose of which was “to provide the [district c]ourt [with] helpful scientific 

information to be used in weighing the potential risks and benefits of a trial of 

treatment.” R. Doc. 71-1, at 1. The appendix largely referenced schizophrenia, but 

it also included data on other psychotic disorders, such as delusional disorder. The 

appendix summarized the data, stating: “[T]he effectiveness of antipsychotic 

medication in treating schizophrenia and related psychotic disorders has been 

repeatedly demonstrated in published professional literature for nearly 50 years, and 

is considered an essential element in the treatment of these conditions.” R. Doc. 71-

1, at 3. The appendix further discussed the myriad side effects associated with 

antipsychotic medications and outlined the proposed monitoring procedures FMC 
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Butner would take and the responses the clinic would implement should such side 

effects manifest. 

At the evidentiary hearing, Dr. Graddy testified on behalf of the government

and adopted the Treatment Plan as his direct testimony. He testified that he was 

board certified in general psychiatry and addiction medication and was a 

distinguished fellow in the American Psychiatric Association. Dr. Graddy testified 

that in compiling the Treatment Plan he had relied on his correspondence with Coy’s 

nurse practitioner, a clinical pharmacist, and Dr. Cochrane (the primary 

psychologist), in addition to his own observations of Coy, which totaled about two 

hours. Dr. Graddy testified that he had experience treating individuals with 

conditions similar to Coy’s. While he was unable to recall these patients’ specific 

outcomes, Dr. Graddy noted that he had treated amphetamine-induced psychotic 

disorder similar to schizophrenia. On cross-examination, Dr. Graddy acknowledged 

that Coy had claimed that he had experienced side effects from the voluntarilyaccepted antipsychotic medication, but Dr. Graddy was unable to state whether Coy 

actually experienced those side effects.

To rebut Dr. Graddy, Coy called Dr. Roger Sommi, a psychiatric pharmacist 

who serves as a professor of psychiatry and pharmacy, to testify. Dr. Sommi 

testified that in his academic role he conducted research and made drug therapy 

recommendations to psychiatrists. While Dr. Sommi testified that he had worked

with “hundreds” of patients that had a condition similar to Coy’s, see R. Doc. 81, at 

26, he admitted that he had not met with Coy personally and was merely basing his 

opinions on Coy’s medical records. Based on Dr. Graddy’s diagnosis, Dr. Sommi 

opined that there was a “low probability” that antipsychotic medication would 

alleviate Coy’s delusions given their persisting nature. R. Doc. 81, at 28. Dr. Sommi 

acknowledged that if Coy was willing, he would likely take the same approach as 

Dr. Graddy. On cross-examination, Dr. Sommi admitted that there was a possibility 

that the Treatment Plan could render Coy competent. He also testified that, in a 

clinical setting, the opinion of a psychiatrist or nurse practitioner would prevail over 

his as a psychiatric pharmacist if a disagreement as to a patient’s treatment arose. 
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The magistrate judge subsequently issued a report and recommendation, 

recommending Coy’s involuntary medication. The magistrate judge relied on 

Dr. Graddy’s testimony, which was based on his personal interactions with Coy, in 

finding that involuntary medication was substantially likely to restore Coy to 

competency and that any resulting side effects could be managed with medication. 

The magistrate judge noted that while Dr. Sommi was less optimistic about the 

viability of the Treatment Plan, portions of Dr. Sommi’s testimony were supportive 

of Dr. Graddy’s proposed plan. The magistrate judge referenced the appendix of 

studies with approval. The magistrate judge also found that the Treatment Plan 

included sufficient flexibility to adequately accommodate any side effects such that 

the Treatment Plan was medically appropriate for Coy. The district court adopted 

the report and recommendation in full and ordered the commencement of Coy’s 

involuntary medication. Coy appeals.

II. 

 “In Sell v. United States, the United States Supreme Court considered 

longstanding precedent regarding a defendant’s constitutional right to refuse medical 

treatment.” United States v. Curtis, 749 F.3d 732, 735 (8th Cir. 2014) (citing Sell, 

539 U.S. at 177-80). “[T]he Supreme Court concluded that the government may 

administer antipsychotic drugs involuntarily to render a mentally ill criminal 

defendant competent to stand trial for serious, but nonviolent, crimes.” United States 

v. Mackey, 717 F.3d 569, 573 (8th Cir. 2013). “The [Supreme] Court articulated a 

four-[element] test for determining the circumstances in which the government may 

obtain a court order to involuntarily medicate a defendant to render him competent 

to stand trial.” Curtis, 749 F.3d at 735. Those elements are: “(1) that an important 

governmental interest is at stake; (2) that involuntary medication will significantly 

further that governmental interest; (3) that involuntary medication is necessary to 

further that interest; and (4) that administration of the drugs is medically 

appropriate.” Mackey, 717 F.3d at 573. 
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Coy challenges the district court’s findings only as to the second and fourth 

Sell elements, which the government must prove by clear and convincing evidence. 

See id. As these Sell elements are factual in nature, see United States v. Fazio, 599 

F.3d 835, 839-40 (8th Cir. 2010), we review the district court’s determinations for 

clear error, id. at 840; see also Mackey, 717 F.3d at 573. “Under the clear-error 

standard of review, this [C]ourt may not reverse the findings of the district court 

simply because it would have weighed the evidence differently or decided the case 

differently if sitting as the trier of fact.” Schaub v. VonWald, 638 F.3d 905, 920 (8th 

Cir. 2011) (citing Anderson v. City of Bessemer City, 470 U.S. 564, 573 (1985)). 

“This [C]ourt will affirm ‘the district court’s account of the evidence’ if it is 

‘plausible in light of the record viewed in its entirety.’” United States v. Dico, Inc., 

920 F.3d 1174, 1178 (8th Cir. 2019) (quoting Schaub, 638 F.3d at 915).

A.

To satisfy the second Sell element, “the court must conclude that involuntary 

medication will significantly further” the state interests as articulated under the first 

Sell element. Sell, 539 U.S. at 181. To do so, “the government must establish by 

clear and convincing evidence that involuntary medication is both (1) ‘substantially 

likely to render the defendant competent to stand trial’ and (2) ‘substantially unlikely 

to have side effects that will interfere significantly with the defendant’s ability to 

assist counsel in conducting a trial defense.’” Curtis, 749 F.3d at 735 (quoting Sell, 

539 U.S. at 181).

Coy argues that the government failed to provide evidence specifically

tailored to his condition to show that antipsychotic medication was substantially 

likely to render him competent to stand trial. Specifically, he points to Dr. Graddy’s 

alleged inexperience with amphetamine-induced delusional disorder (relative to 

Dr. Sommi’s experience) and Dr. Graddy’s inability to recall outcomes of patients 

who were similar to Coy. Coy also argues that the appendix of studies focuses 

broadly on schizophrenia and delusional disorders, whereas Dr. Sommi testified that 
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Coy falls into a rare subgroup that maintains persisting delusions that are unaffected 

by antipsychotic medication. 

While an individual’s history with the proposed medication and studies 

tailored to the individual’s specific mental illness are beneficial in determining the 

efficacy of the proposed treatment plan, we have never held that such minutely 

calibrated evidence is necessary for the government to carry its burden under the 

second Sell element. Such a requirement would virtually bar the government from 

involuntarily medicating a defendant with a rare, understudied mental illness even 

though a physician, based on his or her experience with similar illnesses, would 

opine with reasonable medical certainty that involuntary medication would render 

the defendant competent. Instead, the bar is no higher than what the Supreme Court 

set out in Sell: the government must show that the proposed treatment plan is 

“substantially likely to render the defendant competent to stand trial.” 539 U.S. at 

181. The government, however, is free to choose the means by which it carries that 

burden. 

Even so, the record establishes that Coy’s Treatment Plan was individually 

tailored to him. Dr. Graddy authored the Treatment Plan after personally observing 

Coy, reviewing his medical history, and consulting the medical care team that had 

been overseeing Coy’s treatment at FMC Butner. Coy ultimately faults the district 

court for favoring Dr. Graddy’s testimony over Dr. Sommi’s. Nothing in the record 

indicates that the district court’s acceptance of Dr. Graddy’s testimony was clear 

error. See Fazio, 599 F.3d at 841. While Dr. Sommi may have had significant 

interaction with individuals with substance-induced delusional disorder, he did not 

make an in-person assessment of Coy. He contested the efficacy of the Treatment 

Plan but admitted that if Coy was willing to be medicated, Dr. Graddy’s approach 

was the proper way to proceed. And, as Dr. Sommi acknowledged, if the two doctors 

were both serving on the team treating Coy, Dr. Graddy’s opinion would control

under the law. To the extent that conflicts existed between the opinions of the 

experts, the district court “is entitled to resolve such evidentiary conflicts.” Id. Once 

the district court accepted Dr. Graddy’s medical opinion that the Treatment Plan was 
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substantially likely to restore Coy to competency for trial, the government met its 

burden. See id.

The record further supports the district court’s finding that any side effects 

resulting from involuntary medication were substantially unlikely to interfere with 

Coy’s ability to participate in his defense. Dr. Graddy testified that such interference 

was substantially unlikely. The appendix of studies outlined in detail the probability 

of various side effects and the ability to treat them through other medications. 

Dr. Sommi further opined on the possibility of certain side effects, but he did not 

dispute that those side effects could be managed through the means set forth in the 

appendix. Therefore, the government met its burden in demonstrating that the 

Treatment Plan was substantially unlikely to produce side effects that would 

significantly inhibit Coy’s ability to participate in his defense. Accordingly, we find 

that the district court did not clearly err in finding that the Treatment Plan will

significantly further the important state interests.

B. 

To satisfy the fourth Sell element, “the government [must] prove by clear and 

convincing evidence that ‘administration of the drugs is medically appropriate, i.e., 

in the patient’s best medical interest in light of his medical condition.’” Curtis, 749 

F.3d at 737 (quoting Sell, 539 U.S. at 181). This element “requires the district court 

to consider all of the circumstances relevant to the particular defendant and to 

consider the entirety of the consequences of the proposed involuntary medication.” 

Id. Accordingly, the district court must refrain from a myopic analysis consisting 

only of the defendant’s health at trial but must additionally consider relevant 

circumstances such as “[the defendant]’s need for long-term treatment and [his] 

current quality of life.” Id. 

While Dr. Graddy testified that the Treatment Plan was in Coy’s best interest, 

Coy argues that “[h]is quality of life is not significantly diminished by his delusional 

beliefs.” Appellant’s Br. 42. Even if we agree with Coy that his quality of life is 
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not significantly diminished by delusions, that does not render clearly erroneous the 

district court’s finding that antipsychotic medication is in Coy’s best interest. See

Schaub, 638 F.3d at 920. Of course, the alleviation of a delusion, even for the sake 

of trial, is nonetheless beneficial to Coy. See Mackey, 717 F.3d at 576 (finding that 

involuntary medication “would allow the patient—who was not showering, 

recreating, or communicating with staff—to ‘have a better quality of life and to kind 

of move forward’” in addition to restoring his competency to stand trial); see also

United States v. James, 959 F.3d 660, 668 (5th Cir. 2020) (rejecting the argument 

that “the government’s interest in restoring [the defendant] to competency is entirely 

separate from [the defendant’s] medical interest”). In Coy’s case, it was his delusion 

that allegedly brought about the altercation with his mother and a gunshot wound to 

his leg. Thus, by seeking to alleviate Coy’s delusions, the Treatment Plan serves not 

only the government’s interest but also Coy’s in that it seeks to allow him to function 

in society without the looming fear of a widespread conspiracy against him. See

James, 959 F.3d at 668. 

Coy’s position is that if, as he argued above, antipsychotic medication is 

ineffective against his persisting delusions, then the Treatment Plan will subject him 

to the risk of side effects without any benefit of returning him to competency. Unlike 

the defendant in United States v. Mackey, “who was not showering, recreating, or 

communicating with staff,” see 717 F.3d at 576, Coy apparently functioned quite 

normally while institutionalized, R. Doc. 51, at 6. Thus, Coy argues that 

antipsychotic drugs would only risk further disrupting his life. However, having 

found that the district court did not err in determining that involuntary medication 

was substantially likely to render Coy competent, we must reject his argument. 

Further, Dr. Graddy determined that the magnitude of the symptoms of Coy’s 

disorder is “moderate to severe,” and that “[t]he overall magnitude of the impact of 

the disorder on his life is moderate to severe.” R. Doc. 71, at 2. The magistrate 

judge also approvingly noted the flexibility of the Treatment Plan, which would 

allow the treatment team to properly respond to the effects of the medication, 

especially undesired side effects that might arise. Accordingly, we find that the 
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district court did not clearly err in finding that involuntary medication is medically 

appropriate for Coy.

III. 

The order of the district court is affirmed.

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