Opinion ID: 2561809
Heading Depth: 3
Heading Rank: 4

Heading: The Second Sell Factor: Whether Involuntary Medication Will Significantly Further the State's Interest

Text: ś 44 The inquiry into whether the administration of involuntary medication will significantly further the State's interests in rendering Ms. Barzee competent to stand trial requires us to consider two issues: (1) whether medication is substantially unlikely to have side effects that will interfere significantly with the defendant's ability to assist counsel in conducting atrial defense, and (2) whether medication is substantially likely to render the defendant competent. Sell v. United States, 539 U.S. at 181, 123 S.Ct. 2174 (emphasis added). Before we address each of these issues, we pause to discuss the meaning of the substantially likely or substantially unlikely standards in this context. ś 45 We read substantially likely within the context of the greater question that it is designed to address: whether the State's interest in a competent defendant will be significantly furthered through involuntary medication. This leads us to the conclusion that substantially likely requires the likelihood of restoration to be significant, rather than requiring merely some likelihood of restoration. This conclusion is in keeping with that reached by other courts that have considered the issue. In United States v. Gomes, 387 F.3d 157, 161-62 (2d Cir.2004), a seventy-percent chance at restoration to competence was considered substantially likely; in United States v. Ghane, 392 F.3d 317, 320 (8th Cir.2004), a ten percent chance of restoration, described as a glimmer of hope, was held to be inadequate to meet this standard. Other courts have determined that a chance of success that is simply more than a 50% chance of success does not suffice to meet this standard. United States v. Rivera-Morales, 365 F.Supp.2d 1139, 1141 (S.D.Cal.2005); see also People v. McDuffie, 144 Cal.App.4th 884, 50 Cal.Rptr.3d 794, 798 (2006) (holding that a fifty- to sixty-percent chance of improving did not meet the substantially likely standard). We agree; the substantially likely standard requires that the chance for restoration to competency be great. To the extent that such a likelihood can be quantified, it should reflect a probability of more than seventy percent. Likewise, in order for side effects to be considered substantially unlikely to interfere with a defendant's right, to a fair trial, any side effect that would impede a defendant's ability to assist in her defense must have a very low rate of occurrence.
ś 46 Many side effects can result from the administration of antipsychotic medications, but those side effects that can be quite severe and could impede Ms. Barzee's right to a fair trial are rare. Thus, we hold that the district court did not clearly err in concluding that antipsychotic medication is substantially unlikely to interfere with Ms. Barzee's right to a fair trial. ś 47 The side effects considered likely by Drs. Jeppson and Whitehead include fatigue; dry mouth; blurry vision; constipation; orthostatic hypotension; and metabolic syndrome, which would require monitoring for weight gain, lipid profile, cholesterol, and diabetes. According to Drs. Jeppson and Whitehead, those side effects would not interfere with Ms. Barzee's ability to assist in her defense, nor would they interfere with her abilities to consult with her attorneys, engage in reasoned choice of legal options, recall memories, or testify relevantly. Dr. Morris generally agreed with these likely side effects but added cardiac problems to the list and stated that weight gain is likely and could lead to other health problems. ś 48 The physicians also recognized other unlikely side effects that can occur and that could have profound effects on Ms. Barzee's ability to assist with her defense. Tardive dyskinesia creates tics, can be irreversible, and would impair Ms. Barzee's ability to assist defense counsel. According to Dr. Jeppson, tardive dyskinesia occurs in only one patient out of 200, and according to Dr. Whitehead, it occurs in two to five percent of patients with continuous exposure to antipsychotic medications, more often in women than men. Another unlikely side effect is increased risk of stroke, but this generally occurs only in older patients, not patients within Ms. Barzee's age group. Even though these side effects could dramatically impair Ms. Barzee's ability to assist with her defense, because of the low probabilities associated with them, the district court's conclusion that the side effects are substantially unlikely was not clear error. ś 49 Drs. Jeppson and Amador also recognized additional side effects that are of concern. Due to the nature of Ms. Barzee's psychotic disorder and the connection her delusions have to her identity, a medication that could possibly alter these fixed beliefs and insult her, identity may make Ms. Barzee vulnerable to depression, suicidal ideation, stress reaction, or posttraumatic stress disorder. These effects could significantly interfere with Ms. Barzee's ability to assist counsel. Because, as I will discuss below, I am persuaded that the drugs are unlikely to alter her fixed delusions, I consider these side effects associated with a crisis in her identity substantially unlikely. The majority does not agree with my conclusion that the drugs are unlikely to alter Ms. Barzee's fixed delusions, but similarly concludes that these side effects identified by Drs. Jeppson and Amador are substantially unlikely.
ś 50 For clarity's sake, I remind the reader that this portion of my opinion does not represent the view of the majority of the court. For the majority's conclusion on whether administration of antipsychotic medication is substantially likely to render Ms. Barzee competent to stand trial, please refer to Justice Durrant's separate opinion. ś 51 In order for the State to medicate Ms. Barzee, it is required to prove that the medication is substantially likely to make her competent based upon clear and convincing evidence. Utah Code Ann. § 77-15-6.5(6)(a) (Supp.2006); see also United States v. Bradley, 417 F.3d 1107, 1113-14 (10th Cir.2005). Clear and convincing evidence requires that the evidence place in the ultimate factfinder an abiding conviction that the truth of its factual contentions are highly probable. This would be true . . . only if the material it offered instantly tilted the evidentiary scales in the affirmative whets weighed against the evidence . . . offered in opposition. Colorado v. New Mexico, 467 U.S. 310, 316, 104 S.Ct. 2433, 81 L.Ed.2d 247 (1984) (internal quotation marks and citations omitted). I do not believe the State's evidence in this case rises to this standard. Further, I believe that the district court did not properly weigh all of the evidence presented within the framework of this high burden. Instead, the court ignored the testimony of the defense experts and relied exclusively on the testimony of Drs. Jeppson and Whitehead. It did not consider the evidence presented by the defense, but found the State witnesses to be in the best position to determine the likelihood of Ms. Barzee's restoration to competency and afforded complete deference to their opinions in abrogation of the court's duty to actually consider and weigh all the evidence presented, [14] Proper balancing does not simply require a court to pick one expert or one side to defer to, but instead requires that the evidence presented by each side is thoughtfully considered and weighed. See United States v. Valenzuela-Puentes, 479 F.3d 1220, 1228-29 (10th Cir.2007) (refusing to affirm the district court in a Sell hearing because competing testimony rebutted its conclusion that the defendant was substantially likely to be rendered competent with medication). The district court deferred to the opinions of the State witnesses based upon the purported familiarity that Drs. Jeppson and Whitehead had with Ms. Barzee. This reasoning is not supported by the evidence. First, Dr. Whitehead had only a single one-and-a-half-hour meeting with Ms. Barzee. The fact that he works in the same hospital where Ms. Barzee is committed does not establish that he is particularly familiar with her case. Second, while Dr. Jeppson is the psychiatrist assigned to Ms. Barzee's case, the record does not show that he in fact spent significantly more time with her than Dr. Amador. The district court stated that he had weekly meetings with Ms. Barzee; however, Dr. Jeppson testified that his meetings with her were on a weekly to monthly basis over a twenty-two-month period and that a lot of times these aren't 45-minute talks, I mean just a few minutes here and there. In addition, Ms. Barzee had not met with her treatment team for the ten months preceding the Medication Hearing. Dr. Amador visited with Ms. Barzee multiple times over the past few years, spending over fifteen total hours with her. Thus, the amount of time Dr. Amador spent with Ms. Barzee rivals the time she spent with Dr. Jeppson. My brief review of the record reveals that Drs. Jeppson and Whitehead clearly did not have a quantity or quality of information so superior to that of Drs. Morris and Amador such that their opinions should not even have been considered on the issue of Ms. Barzee's likelihood of restoration. However, that is what the district court did. I reject the notion that a treating physician's opinion can be looked to for the sole source of information when competing testimony, based on proper foundation, challenges the treating physician's conclusions. In this case, we should closely examine all of the witnesses' testimony and look to the foundation for that testimony in weighing its impact. In examining that testimony, I conclude that the defense experts, not the state hospital physicians, most carefully considered and relied on Ms. Barzee's particular condition and history. I am persuaded that the State witnesses lacked adequate foundation for their opinions in many respects, including a reliance on general statistics rather than statistics particular to the defendant, failure to rely on the DSM-IV, failure to recognize the effect of a particular diagnosis on restoration to competency, failure to consider the presentation of Ms. Barzee's particular symptoms, and the inability of medication to alter Ms. Barzee's fixed delusions. I will address each of these issues below.
ś 52 Drs. Jeppson and Whitehead, the State experts, relied on their clinical experience at the state hospital in assessing the efficacy of medication on the restoration of Ms. Barzee's competence. Dr. Jeppson cited seventy- to eighty-percent restoration rates at the state hospital and concluded that there would be a seventy-five-percent chance of restoration with anybody. He stated that hopefully, [Ms. Barzee] would be restored to competency. Dr. Whitehead noted that the state hospital has a restoration rate of eighty percent, He stated that Ms. Barzee's case was nowhere close to a one hundred percent case for restoration, offering a gross estimate of seventy percent. He stated that a seventy-five-percent restoration rate exists for all psychotic disorders and opined that psychotic disorder not otherwise specified (PDNOS) may possibly have a higher rate. Dr. Amador's testimony, by contrast, cautioned against looking only to personal clinical experience in drawing conclusions about the efficacy of treatment because the types of patients in any particular treatment population may skew a practitioner's views on treatment generally. ś 53 I am not persuaded that the rates of restoration for the general population at the state hospital would have any bearing on Ms. Barzee's particular case without any showing that the population resembled Ms. Barzee. As the Court of Appeals for the Fourth Circuit has recognized, the general population tells us nothing of the response of a particular patient. United States v. Evans, 404 F.3d 227, 240-41 (4th Cir.2005) (refusing to rely on the state's evidence when there was no indication that the federal hospital staff had considered the defendant's particular medical condition in reaching conclusions). While Dr. Whitehead did opine that PDNOS patients may have higher rates of restoration than those with other psychotic disorders, he also stated that a particular diagnosis has little, if any, ramifications for treatment and that diagnosis does not have much bearing on restoration. [15] The district court looked at the success rate of the general population in the state hospital and compared it with the statistical data presented by defense experts, who identified a much lower rate of restoration for patients with symptoms similar to Ms. Barzee'sâ twenty percent for patients with delusional disorder, increasing to thirty or forty percent if other conditions, including schizophrenia, were considered. The court attributed the discrepancy, however, not to the individual symptoms and diagnoses of those similar patients, but to what the district court considered to be the expertise of the state hospital physicians. I find no basis for the court's conclusion that Utah's state hospital physicians are remarkably better than other psychiatrists at medicating and restoring incompetent patients. The fact that the rates for the general hospital population at the state hospital are identical to the rates reported by the Federal Bureau of Prisons' hospital system clearly indicates no special expertise on the part of Drs. Jeppson and Whitehead. Rather, the discrepancy between the conclusions of the State witnesses and those of the defense witnesses is explained by the fact that the State's witnesses based their opinions on the rates for general populations and saw little need to look at the particular symptomology of the defendant, while the defense experts refined their opinions to consider Ms. Barzee's particular characteristics. Thus, in my opinion, to the extent that the testimony of the State witnesses relied on the restoration rates for the general population at the state hospital, it should be given little, if any, weight. ś 54 Likewise, I reject the State witnesses' reliance on similar general statistics from the federal hospital system, but I am even more troubled by the State witnesses' use of those particular statistics. Citing a report issued by the Federal Bureau of Prisons, [16] Drs. Jeppson and Whitehead testified that the restoration rate for the general population at federal hospitals was seventy to eighty percent. As noted above, I have serious concerns with relying on statistics of the general population of a hospital. I also have concerns with the basic reliability of the federal statistics. Dr. Amador explained that the federal study was not peer reviewed; it was an unpublished, internal hospital report, and the patients were not broken down by diagnoses or symptoms. In fact, the physician who conducted the study did not even know the diagnoses of the patients involved in the study, nor did he know if any of the patients suffered from delusions similar to those suffered by Ms. Barzee. Those facts led Dr. Amador to conclude that the federal hospital data was completely useless in predicting whether medication would be successful in restoring Ms. Barzee to competency. Dr. Morris also testified that Ms. Barzee's poor prognostic factors must be taken into account because each case is individual and statistics for general populations are not predictive of Ms. Barzee's response. The rates identified for general populations were inconsistent with the rates found in studies cited by the defense experts, which were more focused and examine restoration of patients with symptoms mirroring those of Ms. Barzee. Thus, in my opinion, the statistics relied on by the State witnesses are entitled to little weight because the statistics do not account for the individual history and symptomology of Ms. Barzee. See United States v. Cruz Martinez, 436 F.Supp.2d 1157, 1162 (S.D.Cal. 2006) (noting that the court had serious doubts about the predictive value And applicability of the government's statistic regarding the likelihood of success when [i]t [was] not even clear that the statistic applie[d] to individuals in defendant's condition). ś 55 Today, the majority permits forcible medication of patients at the state hospital based primarily on the statistic that seventy to eighty percent of the general population at the state and federal hospitals were restored without regard to individual diagnosis and prognosis. Thus, every patient committed to the state hospital is substantially likely to be restored. Allowing this analytical charade renders the second part of the Sell test meaningless; such flawed logic does not, in my view, comport with common sense. The decision today allows courts to order forced administration of antipsychotic medication without regard to the individual symptoms and history of a particular patient. It allows courts to do so based on general statistics even when a multitude of evidence suggests that a particular patient with unique characteristics is not likely to be restored. The majority is not the first court to rely on general statistics, but I believe it is the first court to do so when the defense has presented evidence controverting the reliability of those statistics. See United States v. Dallas, 461 F.Supp.2d 1093, 1095, 1099-1100 (D.Neb. 2006) (refusing to rely on general statistics cited by government witnesses who did not take into account the symptoms and history of the particular defendant); United States v. Cruz-Martinez , 436 at 1161-62 (same); see also United States v. Gomes, 387 F.3d at 159, 161-62 (upholding the district court's conclusion that defendant was substantially likely to be restored based on the unchallenged testimony of government doctors who cited the seventy percent the Bureau of Prisons' success rate); United States v. Milliken, 2006 WL 2945957, at -10, 2006 U.S. Dist. LEXIS 82413, at 29-31 (M.D.Fla.2006) (relying on unchallenged testimony citing the Bureau of Prisons' seventy-six-percent success rate in restoring individuals to competence); United States v. Leveck-Amirmokri, 2005 WL 1009791, at , 2005 U.S. Dist. LEXIS 7610, at  (W.D.Tex.2005) (relying on physician's conclusion that medication fails to work only one time out of twenty when de fendant had provided no reason to doubt the government witnesses). I am troubled by the district court's decision in light of the evidence, but I am even more troubled that my colleagues are willing to undertake only highly deferential review of that decisionâ one that I believe should be recognized as clearly erroneous even under a deferential standard of review. In my opinion, when the State relies on statistics from the general population and competing testimony establishes that those statistics are inapplicable to a defendant with a particular history and particular symptoms, the general statistics are inapposite. When faced with competing evidence, general statistics cannot rise to the level of clear and convincing evidence that a patient is substantially likely to be restored. I believe this is the only reasonable conclusion that can be reached if the Sell test is to have continued validity in protecting the constitutional liberty interest in freedom from unwanted antipsychotic medication.
ś 56 The DSM-IV is the authoritative tool for diagnosis in the field of mental health; however, Drs. Jeppson and Whitehead stated that the manual was of little or no use to their analysis of Ms. Barzee's case. Dr. Jeppson stated, I am not tied to DSM-IV  When asked about the characteristics of PDNOS, he responded that he had not reviewed that recently. I don't pack [the DSM-IV ] around. When Dr. Whitehead was asked about specific diagnoses and their implications for treatment decisions, he stated that diagnosis has little, if any, ramifications for treatment, despite extensive research cited by the defense experts suggesting that diagnosis and symptoms have significant ramifications for a patient's response to medication. Indeed, Dr. Amador testified that the difference in diagnosis at this particular hearing is relevant to predicting response to antipsychotic medication. The state hospital physicians' dismissal of the standard diagnostic system used in the field of psychiatry is perplexing in light of the important questions they were asked to address by the State in this case. While diagnosis may not be critical to the question of whether medication is medically appropriateâ because for any form of psychosis, drugs will almost undoubtedly be appropriateâ diagnosis is of utmost ,importance for predicting the effect of medication on a particular patient. In this case, the court was not asked to consider the likelihood of any psychotic patient being restored to competency through medication; instead, the court was to decide whether forcible medication was likely to restore Ms. Barzee to competence. I am at a loss to comprehend the State witnesses' disregard of the DSM-IV, an important and integral tool for diagnosis in the mental health arena. ś 57 Not only did the State witnesses disregard a basic tool of their trade, but Dr. Jeppson, without the aid of the DSM-IV, made a puzzling change in Ms. Barzee's diagnosis from delusional disorder to PDNOS. Three of the four witnesses at the Medication Hearing agreed that delusional disorder was a reasonable diagnosis for Ms. Barzee. Dr. Jeppson knew that Ms. Barzee had experienced referential thinking prior to his initial diagnosis of delusional disorder, [17] yet he pointed to no other factor explaining his subsequent change in diagnosis except her continued reports of referential thinking. [18] Although Dr. Jeppson testified that referential thinking was one of many changes influencing his decision, he failed to cite any other factor, and the factor he did identify was not even a change. He stated that he did not believe that referential thinking was part of the symptomology of delusional disorder pursuant to the DSM-IV â which he had not read recentlyâ but if it is, it is certainly a small part. While Dr. Jeppson eventually softened his assertion that referential thinking removes one from the diagnosis of delusional disorder, this assertion was flatly rebutted by other witnesses. Dr. Morris testified that delusional ideas of reference are simply one delusion of the delusional disorder and that the symptom does not remove one from a diagnosis of delusional disorder according to the DSM-IV. Dr. Amador, the co-chair for revising the DSM-IV section on psychotic disorders, stated that referential thinking as exhibited by Ms. Barzeeâ receiving messages from moviesâ did not remove her from the diagnosis of delusional disorder in the DSM-IV. Not surprisingly, the DSM-IV section on delusional disorder states, Ideas of reference (e.g., that random events are of special significance) are common in individuals with [delusional] disorder. Their interpretation of these events is usually consistent with the content of their delusional beliefs. DSM-IV 325-26. Thus, I am skeptical of Dr. Jeppson's change in diagnosis based on factors that apparently do not withstand the scrutiny of other mental health professionals and published professional standards. I am further troubled because the DSM-IV, the standard tool for diagnosing mental illness, appears to have been given little, if any, weight by Drs. Jeppson and Whitehead. Furthermore, in view of the DSM-IV's flat rejection of the notion that ideas of reference are not a symptom of delusional disorder, I find Dr. Jeppson's testimony unpersuasive. [19] ś 58 Equally perplexing is the change after two years of treatment from the more specific diagnosis of delusional disorder to the more general one of PDNOS. [20] Dr. Morris pointed out that there is no evidence that Ms. Barzee's condition is the product of substance abuse or a medical condition, and Dr. Whitehead noted that the chance that a medical condition was causing her symptoms was extremely unlikely. Thus, the remaining diagnoses beneath the umbrella definition of PDNOS, which are available to this particular patient, are schizophrenia and delusional disorder. [21] Only one initial evaluator, Dr. Cohn, suggested that schizophrenia was the appropriate diagnosis; all the other practitioners doubted the existence of symptoms as severe as Dr. Cohn's report suggested. Neither of the State witnesses at the Medication Hearing suggested that. Ms. Barzee met the criteria for schizophrenia or even opined that it might have been an appropriate diagnosis. Thus, while the boundaries between psychotic disorders may at times be fuzzy, according to Dr. Whitehead, the opinions of all the mental health professionals involved in this case persuade me that it is extremely likely that Ms. Barzee suffers from delusional disorder.
ś 59 If in fact Ms. Barzee suffers from delusional disorder, the prognosis for restoration is poor. Dr. Nielsen, an initial evaluator, opined that if Ms. Barzee suffered from delusional disorder, her condition was refractory and rarely treatable with medication. Dr. Jeppson explained that he had treated very few patients with delusional disorder. He admitted that delusional disorder is more refractory to treatment than schizophrenia, but was unsure if it is the most refractory of psychotic disorders. Dr. Amador considered the specific diagnosis of delusional disorder when he opined that Ms. Barzee had a twenty-percent chance of restoration, noting that delusional disorder is harder to treat than other psychotic disorders. He based this opinion on research and his clinical experience. Dr. Whitehead discounted the literature and research upon which Dr. Amador relied, calling it traditional clinical lore and claiming that it would be an error to say that a delusional disorder is refractory to medication because the jury is out on that. He stated that very, little research has been conducted on delusional disordered patients because the diagnosis is so rare. He admitted to seeing only four or five cases of delusional disorder over the course of his career. Dr. Whitehead cited one study that suggested an eighty percent response rate to medications for people with delusional disorder. However, it is unclear how the presence of a response to medication equates to restoration to competency, especially when the experts agree that Ms. Barzee's delusions would persist even if medication was administered. Moreover, Dr. Whitehead relied on the information reported by the federal hospital study; he testified that eighty percent of the delusional patients in that study were restored and that five to ten delusional patients were involved in the study. That information, however, was unequivocally rebutted by Dr. Amador, who explained to the court that he spoke directly with the physician who conducted the study and that that physician did not know the diagnoses of the patients involved. Thus, Dr. Whitehead's testimony about the presence of delusional patients in the federal study appears to be without foundation. Despite Dr. Whitehead's opposition to looking to dogmatic conclusions based on research on delusional disorders because it is rare, I am persuaded by Dr. Arnador's review of the relevant scientific literature and his conclusions based on numerous studies that find delusional disorder refractory to medication even though some therapeutic effect may occur with medication for any psychotic disorder. [22] The State had the burden of proving by clear and convincing evidence that Ms. Barzee was substantially likely to become competent through the administration of antipsychotic medication. In my opinion, the high threshold of this burden has not been met. If delusional disorder is the appropriate diagnosis, the evidence presented fails to establish that medication is substantially likely to render Ms. Barzee competent.
ś 60 If Ms. Barzee suffers from PDNOS or another, variety of psychotic disorder, her specific symptoms also lead to the conclusion that restoration to competency is unlikely. The Court of Appeals for the Fourth Circuit recognized that in order to determine whether a patient is substantially likely to be restored to competence, a mental health professional must consider the  particular mental and physical condition of the patient. Evans, 404 F.3d at 240-41; see also United States v. Baldovinos, 434 F.3d 233, 240 n. 5 (4th Cir.2006) (recognizing that Sell requires an exacting focus on the personal characteristics of the individual defendant); United States v. Valenzuela-Puentes, 479 F.3d 1220, 1229 (10th Cir.2007) (remanding the case to the trial court with instructions to specifically consider the particular symptoms and characteristics of the defendant). Thus, in analyzing the opinions of the experts in this case, I believe we must look closely at the factors each expert considered in reaching his conclusion with regard to Ms. Barzee's likely response to antipsychotic medication. In doing so, it becomes clear that the defense experts were the only witnesses in this case who gave due consideration to Ms. Barzee's history and symptoms. Although Dr. Jeppson referred to Ms. Barzee's gender as a positive factor for restoration (without citing authority for his assertion), he and Dr. Whitehead essentially dismissed all of the specific facts apparent in Ms. Barzee's illness. [23] The most notable of the features particular to Ms. Barzee is the duration of her untreated psychosis, a period in excess of ten years and possibly as much as thirteen years. She also exhibits grandiose delusions and some persecutory delusions as well as delusional ideas of reference or referential thinking. Further, Ms. Barzee does not believe that she is mentally ill. In addition, no positive prognostic factors, such as family history or past successful treatment with medication, exist in Ms. Barzee's case. See United States v. Archuleta, 218 F. App'x 754, 756 (10th Cir.2007) (relying on previous restoration with antipsychotic drugs and well-documented history of resolution of his psychotic symptoms as a result of medication in concluding that the defendant was substantially likely to be restored (internal quotation marks omitted)); United States v. Morris, 2005 WL 348306, at -4, 2005 U.S. Dist. LEXIS 38785, at -14, 20 (D.Del. 2005) (holding that defendant was substantially likely to be rendered competent based on past history of positive response to antipsychotic medication). ś 61 First, Drs. Morris and Amador opined that a duration of untreated psychosis in excess of one year significantly decreased the likelihood that a patient will respond to medication. [24] In Ms. Barzee's case, her psychosis has impacted her functioning and behavior for at least ten years and possibly as much as thirteen years. Dr. Morris stated that duration of untreated psychosis as a predictor of response to medication was not a novel idea in psychiatry. The longer a patient is illâ even more than six months to a yearâ the chances of improvement with medication significantly decrease over time. Dr. Morris cited his experience and the current literature, referring to numerous studies, for the very well established proposition that duration of untreated psychosis is an important factor in predicting response to medication. Dr. Amador similarly identified Ms. Barzee's lengthy duration of untreated psychosis as a poor prognostic factor. Dr. Amador based this conclusion on his experience and on the research reported in the relevant scientific literature; in fact, he had personally participated in peer review of approximately fifteen articles on this specific subject. He stated that after one year of psychosis without treatment, there is typically no response for the negative or positive symptoms of a psychotic disorder, [25] nor is there a response for social functioning. Dr. Amador opined that Ms. Barzee's lengthy duration of untreated psychosis was a significant factor . . . [that] reduce[d] her chances of responding to antipsychotic medication and also reduced the chances that her delusions will cease. Contrary to the testimony of the defense experts, Dr. Whitehead stated that the duration of untreated psychosis was an important variable, but that it should not be overstated. He later said it was only a small to moderate factor in predicting response to treatment. He did not address the numerous studies cited by the defense, but pointed to studies from the 1950s and one study from 2005 where the duration of untreated psychosis impacted treatment of only negative symptomsâ not Ms. Barzee's most prominent positive symptom of grandiose delusions. Similarly, Dr. Jeppson, while admitting that duration of untreated psychosis was definitely a factor in predicting response, did not think that the duration of Ms. Barzee's disorder had implications for her response to medication. He did admit, however, that patients experiencing their first episode of psychosis would probably respond better, but that he would have to read on whether duration of untreated psychosis impacts the prognosis for response to medication. He opined that just because a newly psychotic patient may respond more favorably to medication, that does not mean that someone who has [suffered from psychosis] for ten or eleven years is not going to respond. Dr. Whitehead made a similar statement in his testimony, suggesting that illness untreated for one day may not respond to medication while illness untreated for decades may respond. He also stated that the state hospital had had success in treating patients with previously untreated illness in excess of one year. However, he did not state that the hospital had ever successfully treated anyone with untreated psychosis to the extent of Ms. Barzee's, and I find no support in the record for the district court's conclusion that the state hospital physicians somehow have expertise in restoring delusional patients with a significant delay from the onset of psychosis to initial treatment. While I recognize that some patients with a lengthy duration of untreated psychosis may in fact respond to medication, [26] the overwhelming evidence from the empirical research presented at the Medication Hearing identified duration of untreated psychosis as a factor negatively impacting the response to administration of antipsychotic medication. The speculation that an individual patient with years of untreated psychosis may respond favorably does not meet the clear and convincing standard of the State's burden to prove that this particular patient is substantially likely to be restored to competency by forced medication. [27] The evidence presented at the hearing establishes that it is not substantially likely that someone with ten to thirteen years of untreated psychosis will respond to medication at all, much less be rendered competent. ś 62 Second, the presence of grandiose delusions, Ms. Barzee's primary competency impairing symptom, was also identified as a poor prognostic factor for psychotic patients' response to medication. In his initial review, Dr. Nielsen pointed out that symptoms of a delusional nature do not respond favorably to medication. Dr. Morris stated that the prominent delusion affecting Ms. Barzee's competency is her leave it to the Lord grandiose delusion. He stated that grandiose delusions are more difficult to treat than other delusions, such as persecutory delusions, which Ms. Barzee also exhibited to a lesser extent. Dr. Amador explained that grandiose delusions permeate an individual's personality and self-esteem and impede treatment of nonmood-related psychosis generally when compared to other types of delusions. His conclusion that grandiose delusions are refractory to treatment was informed by his clinical experience and by the relevant scientific research. Dr. Whitehead opined differently; he stated that grandiose delusions were not particularly refractory and cautioned not to look to the dogmatic conclusions of research with delusional disordered patients. He stated that Ms. Barzee exhibited positive symptoms, [28] and he then relied on research suggesting an eighty-percent response rate to medication for psychotic patients generally who suffer from positive symptoms. However, Dr. Whitehead did not identify whether this research referred to hallucinations or delusions or if it focused on grandiose delusions specifically. Similarly, Dr. Jeppson (without citing any authority) opined that positive symptoms and lack of negative symptoms suggested a better prognosis. As noted above, the research highlighted by defense experts concluded that the impact of medication was less favorable for grandiose delusions than for other types of delusions, hallucinations, and disorganized thinking. Dr. Jeppson again attempted to rebut the testimony of defense witnesses by focusing on the idea that an individual patient with grandiose delusions may respond to medication, stating that he had seen people who think they are Jesus respond to medication. Again, I am unpersuaded by a single, particular example that would appear to contradict the findings of a substantial amount of research. I recognize, and all the testimony supports, the fact that some individuals who suffer from grandiose delusions will respond to medication, but this does not inform the court as to Ms. Barzee. Even if only one percent of patients responded to medication, examples would exist, but the court should not extrapolate from the experience of one patient, or a handful of patients, the notion that Ms. Barzee will respond to medication. ś 63 Third, Drs. Amador and Jeppson identified Ms. Barzee's lack of insight into her illness as a significant symptom of her psychosis. Dr. Amador has specific experience with psychotic patients who do not believe they are mentally ill. He has conducted research on treatment response with these particular individuals, and he has coauthored approximately fifty peer reviewed articles on the topic of involuntary medication of individuals who do not recognize that they are mentally ill. Based on his experience and research, he identified this symptom as a factor that would have a negative impact on Ms. Barzee's response to medication, stating that it will take many years [for a patient] to ever understand there is an illness. ś 64 Taking into account the poor prognostic factors and the absence of positive factors, Dr. Morris concluded that medication is unlikely to resolve Ms. Barzee's delusions to the point of restoration of competency. He stated, I am of the opinion that it is unlikely that she is going to make any kind of significant response to medication. Based on that, it is even more unlikely that she is going to be restored to competency. Dr. Amador's conclusion was identical. Their reasoning is persuasive because of the specificity with which they analyzed Ms. Barzee's condition and because of the foundations upon which they based their opinionsâ not statistics derived from a general psychiatric population, but rather from research tied to the specific characteristics exhibited by Ms. Barzee. Accordingly, even setting aside the witnesses' disputes about diagnosis, I am still persuaded that medication is unlikely to restore Ms. Barzee to competence.
ś 65 It is important to understand why Ms. Barzee is incompetent to stand trial in order to determine whether restoration is substantially likely. Prior to the Medication Hearing, Drs. Kovnick, Cohn, Berge, and Nielsen evaluated Ms. Barzee for the sole purpose of determining whether she was competent. Those professionals concluded that Ms. Barzee's primary area of incompetency was her inability to engage in reasoned choice of legal strategies and options. Drs. Kovnick, Cohn, Berge, and Nielsen all agreed that Ms. Barzee showed severe impairment in this capacity because her religious delusions, and not her best interests, drove her decision-making process. Ms. Barzee told Dr. Kovnick that to fight for her life during this court process would be not allowing God to put her through the suffering that he feels is required of her. All of the professionals agree that Ms. Barzee's delusions currently make her incompetent to stand trial, and the district court concluded that she was incompetent on three separate occasions prior to the Medication Hearing. [29] Within the framework of Ms. Barzee's specific impairment, I cannot conclude that medication is likely to render her competent to stand trial. ś 66 Because they did not take into account the changes that must occur for Ms. Barzee to be rendered competent, the State witnesses' conclusions that medication will actually restore her to competency do not persuade me. The State focused on, and the district court was persuaded by, the witnesses' conclusion that, with the aid of medication, Ms. Barzee would be less preoccupied with her delusions and talk about them less. That conclusion ignores the actual cause of Ms. Barzee's incompetency: in order for Ms. Barzee to be rendered competent, her, delusions must be eliminated. As long as she has the delusions, regardless of whether they dominate her conversation, they will impact her ability to engage in the reasoned choice of legal strategies and options. If Ms. Barzee talks less often about God directing her life, but continues to experience the delusion that she is subject to God's direction and that her participation in the legal proceedings would go against God, she will lack the capacity to engage in reasoned choice of legal strategies and options. This will be true even if it is masked by a medication-induced ability to talk less about the delusions. The delusions will nonetheless continue to drive her decision-making process. ś 67 My conclusion is derived directly from the generally uncontroverted testimony presented at the Medication Hearing. Dr. Morris stated that Ms. Barzee's delusions influence her competency because they inhibit her ability to weigh legal strategies. He stressed that the grandiose delusions become predominant when it comes to Ms. Barzee's strategy in legal proceedings. Dr. Jeppson stated that Ms. Barzee will continue to have delusions even if medicated, but that with medication, she will focus on them or talk about them less, and the medication [will] hopefully diminish the strength or maybe the intensity of the delusion. Dr. Morris agreed, with Dr. Jeppson's assessment, testifying that there is a poor prognosis for ending her delusion with medication and that she might talk less about the delusion and not focus on it as much. Dr. Amador also agreed with Dr. Jeppson on this point, stating that while medication may make Ms. Barzee feel less pressure to discuss her delusions, there is a high likelihood that the fundamental delusional beliefs aren't going to change; she may talk about her case, but that will not change the fact that she believes God is directing everything, and thus, the delusions will continue to, influence her decisions and behavior. According to Dr. Amador, in order to render Ms. Barzee competent, medication would have to reduce the certainty of Ms. Barzee's beliefs, not merely her discussion of those beliefs, and it was Dr. Amador's opinion that medication would not impact Ms. Barzee's certainty. [30] Even Dr. Cohn, who believed Ms. Barzee suffered from schizophrenia, which generally responds more favorably to medication than delusional disorder, opined that it was unclear whether Ms. Barzee's deeply entrenched, delusional belief would be impacted by medication because those symptoms are most refractory to pharmacological intervention. ś 68 At the Medication Hearing, the district court judge stated that she was not concerned with eliminating Ms. Barzee's delusions; rather, she was concerned with restoring Ms. Barzee to competency. I conclude that, in Ms. Barzee's case, the continued presence of delusions would constitute continued incompetence because her inability to make reasoned choices about her legal predicament, for example, her incompetence, is driven by fixed delusions that, even Dr. Jeppson admits, will continue despite the administration of antipsychotic medication.
ś 69 The testimony of the defense experts, which is founded on empirical research documented in the relevant scientific literature, peer-reviewed studies, DSM-IV diagnoses, and clinical experience, is highly persuasive. Unlike the physicians from the state hospital, Drs. Amador and Morris focused on Ms. Barzee's particular symptoms when rendering their opinions. I conclude that the district court's deference to the State witnesses was not justified by the evidence. The State witnesses' clinical experience and general statistical data do not outweigh the focused analyses of the defense witnesses. The district court was in error in its statement that the statistical data . . . is neither as authoritative or weighty as the testimony of Ethel actual treating physician. The statistical data that was particular to Ms. Barzee's symptoms and history was the most authoritative and weighty information that was provided to the district court. Anecdotal evidence based on limited clinical experience cannot be used to extrapolate information about Ms. Barzee. Nor can statistics derived from psychotic patients generally be applied to Ms. Barzee without a showing of similarities in disorder, symptoms, and history. When numerous studies rebut a particular practitioner's limited and possibly inapposite experience, the information grounded in empirical research is the most authoritative and weighty evidence; it should not have been disregarded here. ś 70 I believe that Ms. Barzee is not substantially likely to be rendered competent to stand trial through the forced administration of antipsychotic medication. This conclusion is based on the weight of the evidence presented at trial, which persuades me that someone with Ms. Barzee's particular symptoms and history is unlikely to respond to medication, much less be rendered competent. Thus, in my view, the State's interest in bringing Ms. Barzee to trial will not be significantly furthered by involuntarily medicating her. ś 71 In conclusion, I do not doubt that medication is the appropriate medical treatment for Ms. Barzee. As Dr. Whitehead pointed out, antipsychotic medication is the cornerstone of treatment for all psychotic disorders and has been for the past fifty years. I empathize with Dr. Morris' statement that the inability to treat psychotic patients is very frustrating when treatment providers know there is no way patients are going to get better without medication. I also recognize the concerns expressed by Dr. Jeppson, that Ms. Barzee is unlikely to make any progress without medication and that the state hospital is simply warehousing her without treatment or care, which is not in her best medical interest. ś 72 However, this case involves the State's ability to involuntarily medicate a criminal defendant for the sole purpose of rendering her competent to stand trial. This court is not charged with determining what is best for Ms. Barzee from a mental health standpoint,â if that were the case, there would be little need for the judicial branch to exercise any authority in these matters. This court's duty is to determine whether Ms. Barzee's constitutional liberty interest in freedom from unwanted medication can be overcome by the State's interest in rendering her competent to stand trial. Unless the State's interest is highly likely to be furthered by the intrusion upon Ms. Barzee's liberty, this court cannot allow the State to forcibly medicate her with antipsychotic drugs. ś 73 I agree with Dr. Whitehead's testimony that predicting the treatment effect is often difficult. I feel that when this court is faced with such a difficult task that implicates the constitutional guarantee of liberty, we must carefully scrutinize the evidence to ensure that the State has met its high evidentiary burden. In this case, I cannot conclude that the State proved by clear and convincing evidence that Ms. Barzee, given her specific disorder, history, and symptoms, is substantially likely to be rendered competent through the involuntary administration of antipsychotic medication. The district court overlooked a multitude of compelling evidence in favor of the State witnesses' presumed expertise and familiarity. This purported expertise and familiarity does not hold up to a review of the evidence presented. Reliance upon the evidence of the State witnesses in this caseâ general statistics without regard to the individual characteristics of a defendant's disorderâ undermines the constitutional right to freedom from unwanted antipsychotic medication, a significant right that the Supreme Court has recognized on numerous occasions. ś 74 I cannot conclude that the State may constitutionally involuntarily medicate Ms. Barzee solely in an attempt to restore her to competence for trial when it has failed to prove that medication is substantially likely to accomplish that end. Therefore, I conclude that the State has failed to meet its burden in overcoming Ms. Barzee's liberty interest in freedom from unwanted antipsychotic medication. I would reverse the order of the district court.