Source: https://www.tdcaa.com/journal/drugs-dont-work-in-patients-who-dont-take-them/
Timestamp: 2019-04-25 20:07:32+00:00

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The world of mental health issues pervades both criminal and civil law. The great axiom of the day is that jails have become the de facto mental institutions. What so often causes detention in a jail facility for a Penal Code violation or in a mental health facility under a civil function is the fact that a mentally ill person has, for some reason, stopped taking her medication.
Medication for the mentally ill has advanced dramatically in the last 60 years, beginning with the first “magic bullet” medication for mental illness: Thorazine. More than 60 years ago, Time magazine called Thorazine the “wonder drug of 1954.” Its development and other early psychotic medications set the stage for the deinstitutionalization of the mentally ill. The proliferation of psychiatric medications has since exploded, with spending in the United States going from $400 million in 1987 to $40 billion today.
Pharmaceuticals as the magic bullet for mental illness is not a position everyone accepts. Personal liberty considerations always arise when there is a discussion of the government forcing medical treatment. On more than one occasion I have heard ad litem attorneys citing a book titled Anatomy of an Epidemic by Robert Whitaker, which questions why the number of people suffering from mental illness has skyrocketed in the last 50 years despite the advances in medications.1 The book suggests that the widespread use of psychiatric medications could actually be fueling the epidemic.
Once the application is filed, the patient is entitled to receive a copy of the physician’s application and notice of the hearing “immediately after the time of the hearing is set.”8 Further, the court must appoint an attorney who is knowledgeable in the subject area, and the patient is entitled to meet with the attorney “as soon as is practicable” to answer questions and prepare for the hearing.9 As with all mental health hearings, the patient has a right to be present at the hearing, but she may waive that right and allow the court to proceed on the application at the hearing.
If the court finds by clear and convincing evidence that the patient lacks capacity to make a decision regarding the proposed medication and that the proposed medication is in the patient’s best interest, the court may order that the medications be administered over the patient’s objection.10 The authorization, however, is limited to those classes of medication that the doctor requested in the application.11 The typical classes of medication, within which many individual medications fall, are antidepressants, antipsychotics, anxiolytics/sedatives/ hypnotics, and mood stabilizers.
• less intrusive treatments likely to secure the patient’s agreement to take the psychoactive medication.
This requires that any effort to administer psychiatric medication to an incompetent defendant who is refusing that medication must begin with an application to the probate court with proceedings in the Health and Safety Code. The provisions for the incompetent defendant in the probate court are slightly different from those for the civilly committed.
Like the civil proceeding, the physician providing mental health services to the incompetent defendant makes application to the probate court and, pursuant to Texas Health and Safety Code §574.106(a)(2), the probate court may issue an order to administer psychiatric medications to a person who “is in custody awaiting trial in a criminal proceeding” who has been ordered to receive mental health services as part of her competency restoration.
For the probate court to order administration of the medication, however, the court must find more than a lack of capacity and the patient’s best interest. The probate court must find by clear and convincing evidence that treatment with the proposed medication is in the defendant’s best interest and the defendant presents a danger to herself or others.15 The probate court analysis is conducted in the court’s capacity as guardian of wards of the state without regard to any specific interest of the State of Texas, which differs from what analysis comes in the later proceeding in the criminal court.
The requirement that the defendant be a danger to herself or others creates an added element of difficulty in obtaining an order to medicate. Many incompetent defendants are not actively psychotic but remain resistant to medication, which hinders their competence restoration. If the incompetent defendant is not a danger to herself or others, the probate court must deny the application.
The two-step process for incompetent defendants has its roots in the U.S. Supreme Court’s decision in Sell v. United States.19 In Sell, the Court held that the government may pursue forced medication requests but should evaluate the defendant’s dangerousness initially. If the defendant is not a danger to herself or others, then further inquiry should be made.
The focus in the criminal court proceeding is on weighing the State’s interest in bringing to trial someone accused of a “serious crime” against the defendant’s right to not be administered medication that will produce side effects that will interfere with her ability to assist in trial defense. Expert testimony from physicians on the effects of the medication, both beneficial and deleterious, is the key to success in this hearing.
Given the health and liberty issues at stake, it stands to reason that the procedures for securing an order to administer psychiatric medications over a patient or defendant’s objection are complex. Successfully securing the order, however, will result in shortened stays in inpatient mental health facilities and state hospitals, which is in everyone’s best interest.
1 Whitaker, R. (2010). Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. New York: Crown Publishers.
2 Osterberg L, Blaschke T. Adherence to medication. New England Journal of Medicine, 2005; 353(5):487–497.
3 See Kessler RC, Berglund PA, Bruce ML, et al. The prevalence and correlates of untreated serious mental illness. Health Services Research. 2001;36(6 Pt 1):987-1007.
4 25 Tex. Admin. Code §414.410.
5 See Sell v. United States, 539 U.S. 166, 123 S.Ct. 2174, 156 L.Ed.2d 197 (2003); Tex. Health & Safety Code §574.106; Tex. Crim. Proc. Code Art. 46B.086.
6 Tex. Health & Safety Code §574.104(a).
7 Tex. Health & Safety Code §574.106(a).
8 Tex. Health & Safety Code §574.103.
10 Tex. Health & Safety Code §574.106.
11 Tex. Health & Safety Code §574.106(h).
12 Tex. Health & Safety Code §574.106.
13 Tex. Health & Safety Code §574.110(a).
14 Tex. Crim. Proc. Code Art. 46B.086(a)(4).
15 Tex. Health & Safety Code §574.106(a-1)(2)(B)(ii).
16 Tex. Crim. Proc. Code Art. 46B.086(b).
17 Tex. Crim. Proc. Code Art. 46B.086(c).
18 Tex. Crim. Proc. Code Art. 46B.086(e).
19 539 U.S. 166, 123 S.Ct. 2174, 156 L.Ed.2d 197 (2003).
20 Tex. Crim. Proc. Code Art. 46B.086(d).
22 Sell, 539 U.S. at 185, 123 S.Ct. at 2187.

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