Opinion ID: 3033156
Heading Depth: 2
Heading Rank: 2

Heading: Grape’s Sell Hearing

Text: On June 26, 2007, the District Court held a Sell hearing to determine whether it could authorize the involuntary medication of Grape. The Government presented Dr. Pietz and Dr. Sarrazin as witnesses via video conference from Springfield. Grape also appeared via video conference from Springfield. Grape presented no witnesses. Dr. Pietz testified that over the course of a few months, she saw Grape several times a week. She believed Grape suffers from paranoid schizophrenia, as demonstrated through his auditory hallucinations, responses to internal stimuli, 3 Washington v. Harper allows the involuntary administration of drugs to a prisoner with serious mental illness under limited circumstances if: (1) the inmate is dangerous to himself or others, and (2) the treatment is in the inmate’s “medical interest.” 494 U.S. 210, 227 (1990). 7 inappropriate display of emotion, and paranoia. Further, she disputed the prior diagnoses that Grape was malingering, testifying that he was unable to maintain a logical thought process, or showed “cognitive slippage,” which is very difficult for a patient to fake, and that he may pretend his mental illness is less severe than it is. Dr. Pietz testified that Grape would benefit from taking antipsychotic medicine for his schizophrenia to “stabilize his mood[,] . . . [diminish his] attending to internal stimuli, . . . and restore his competency.” However, Dr. Pietz deferred to Dr. Sarrazin on the specific plan for medicating Grape. Dr. Pietz admitted that she believed that if Grape were not in custody, he could present a danger to himself or others. She agreed that his mental state declined during his stay in Springfield, that his symptoms would likely stay consistent without medication, and that residing in a locked unit would have adverse effects on his mental condition. Dr. Sarrazin testified second and, given his limited meetings with Grape, relied heavily on Dr. Pietz’s observations in reaching his conclusions. Dr. Sarrazin believed that Grape suffers from paranoid schizophrenia and antisocial personality disorder, though he had not seen him hallucinate or respond to internal stimuli, and that Grape’s condition did not improve between his February 2007 evaluation and the June 2007 Sell hearing. Dr. Sarrazin testified in detail about medicating Grape, and opined that “there is a substantial probability that with antipsychotic medications . . . Grape will be restored to competency to stand trial.” Specifically, Dr. Sarrazin hoped medication would help treat Grape’s symptoms of disorganized, delusional, and psychotic thought. 8 Dr. Sarrazin reviewed the different types of antipsychotic medications available for Grape generally, comparing first- and second-generation medicines.4 He described the treatment available to Grape if he were to voluntarily accept oral medication, expressing a preference for prescribing oral secondgeneration antipsychotics. However, presuming that Grape would continue to refuse medical treatment, Dr. Sarrazin proposed a plan for his involuntary medication. He recommended treating Grape with a first-generation antipsychotic medication called haloperidol,5 which is available in oral, and short- and long-acting injectable forms. If Grape refused to take the oral medicine, Dr. Sarrazin proposed starting with a short-acting injectable form, which he would administer daily, not to exceed a week at the maximum. He hoped that once medicated and “de-escalate[d]” after taking the shortacting injectable drug, Grape would choose to cooperate and take his medicine orally from that point. Because haloperidol also comes in long-acting injectable form, Dr. Sarrazin would inject Grape with that if the first week of daily short-acting injections did not render him cooperative. Other oral antipsychotic medications could be administered while the long- 4 Dr. Sarrazin testified that antipsychotic medicines come in two broad categories right now – first-generation and secondgeneration medication. First-generation antipsychotic medication has existed for many years, compared with the relatively new second-generation medicines. 5 Haloperidol’s nongeneric trade name, used interchangeably in the record, is Haldol. 9 acting injectable medication was still potent. Dr. Sarrazin believed Grape would have to be medicated for a minimum of four to six months. Practically, the forcible medication would happen in the following manner. Medical center nursing staff would first give Grape a chance to take medicine orally; if he refused, they would administer the medicine via an injection. To do so, the nurses would restrain Grape’s hands through his food slot, open his cell door, inject him with the medication, leave the cell, and then remove the handcuffs through the food slot. If Grape refused to submit to hand restraints, the nurses would come with a lieutenant, and even a four-cell boot team if necessary. The lieutenant and boot team would open the door and restrain Grape’s hands and legs, the nurses would then enter and give the injection (usually in the buttocks), someone from the medical staff would examine Grape for injury, and then the team would leave. A lieutenant would videotape the entire event according to procedure. Dr. Sarrazin believed “the medications would not have side effects that would significantly inhibit [Grape’s] ability to be competent for his trial, [or] to interact with his attorney.” If possible side effects such as sedation, lightheadedness, or others occurred, the doctors would no longer deem Grape competent to proceed with his trial and would make changes to his treatment. Other potential side effects include: extrapyramidal side effects (“EPS”), which involve feelings of stiffness; feeling as though one’s feet must keep moving (tardive dyskinesia); dry mouth; diabetes or changes in blood glucose levels; involuntary movements of the tongue and mouth; or neuroleptic malignant 10 syndrome, a more serious side effect that affects less than one percent of those treated and causes the body not to be able to regulate its own temperature. These side effects, especially neuroleptic malignant syndrome, EPS or stiffness, and tardive dyskinesia, which could be permanent, are less common in second-generation antipsychotics than in first-generation medicines such as haloperidol. Dr. Sarrazin said Grape would be monitored closely for any of these side effects and believed no alternative or less intrusive treatment would be effective in treating him; counseling or therapy would not have been effective at this stage. Dr. Sarrazin testified that the Bureau of Prisons has approximately a 70% success rate in restoring forcibly medicated defendants to competency, and that the numbers at Springfield roughly mirror that statistic, estimating a 70 to 75% success rate for his facility. However, Dr. Sarrazin acknowledged that the success rate in restoring patients to competency “is a little bit lower for people that have to be forcibly medicated than for people who do not,” including individuals who are “uncooperative with our treatment and . . . [those] more seriously mentally ill[, including those who] do not believe they are mentally ill,” such as Grape. Overall, Dr. Sarrazin testified that his proposed method of treatment is medically appropriate for Grape, that this treatment is in Grape’s “best medical interests,” and that his condition would “most likely” continue to deteriorate, and would not improve, absent medication. On cross examination, Dr. Sarrazin agreed that Grape could potentially cause harm to others if he were placed among 11 the open population at the medical facility. He also conceded that Grape repeatedly threatened Dr. Pietz and that if Grape were released onto the street, he could harm a member of the public at large. However, Dr. Sarrazin emphasized that he had no way of knowing whether Grape would be civilly committed if he could not be restored to competence. The District Court filed its opinion on September 6, 2007, granting the Government’s request to involuntarily medicate Grape in order to restore him to competency to stand trial. Grape timely filed his notice of appeal to the District Court’s order.