Opinion ID: 2537785
Heading Depth: 4
Heading Rank: 2

Heading: Proceedings on administration of psychotropic medication

Text: On May 7 API moved for an expedited hearing on the medication petition, noting that under AS 47.30.839(e), a hearing is required on the patient's capacity to give or withhold informed consent within seventy-two hours of the petition. On May 9 (a Friday) the court notified the parties that it was going to hold an expedited hearing on the medication petition on May 12 (Monday). At the May 12 hearing on the medication petition, Gottstein objected to the expedited proceedings, saying the hearing was premature because to his knowledge Bigley had not yet been committed. It then emerged that Gottstein had not received notice of the court's May 5 commitment order. Gottstein also stated that he had yet to receive Bigley's medical chart despite earlier requests to API. He further argued that the API petition was defective because it did not provide adequate information about the proposal to medicate Bigley, such as the specific drugs, dosages, side effects, and benefits. He said that he needed this information to adequately prepare for the hearing. Gottstein also proposed that a pretrial or settlement conference be held for the purpose of crafting a plan that would allow for an alternative to Bigley taking the medication. The court decided to proceed with the hearing and allow API to present its case, but said that it would make additional hearing time available for Gottstein to respond if necessary. Early in the proceedings on the medication petition, Gottstein moved to dismiss, arguing that Bigley was competent earlier when he refused to take medications and that a less intrusive alternative existed of providing him support in the community to help him to function without medications. Gottstein also objected to the compressed schedule for the hearing, which he said would prevent him from adequately preparing his case. The court decided to allow API to proceed with its case, but asked Gottstein how much additional time he needed for his presentation and set aside additional time on May 14 for that purpose.
The court-appointed visitor, Marie Ann Vassar, testified she attempted to meet with Bigley that morning to assess his competence and found him extremely agitated, delusional, and unable or unwilling to cooperate in an assessment. She said there was no evidence of an advance directive with regard to psychotropic medication. She also said that the guardian supported the use of such medication. API presented the testimony of Dr. Lawrence Maile, director of API's forensic evaluation unit and its clinical director. He testified that he had treated Bigley on a number of prior occasions. He testified that Bigley's refusal to take medication was based on the delusional belief that API was trying to poison and kill him. Maile said that Bigley was not capable of having a rational conversation about the medications or understanding the proposed treatment. Bigley's counsel argued that on prior occasions, Bigley had while competent expressed opposition to taking medication and had ceased to take it after being discharged from the hospital, and that the court must abide by such statements of his preference. The court concluded that Bigley was not now competent and that there was no evidence of any prior occasions on which Bigley had, while competent, stated an opposition to being medicated in the future. Bigley's own demeanor in the courtroom apparently influenced the judge's determination that Bigley lacked capacity. In her findings, the judge observed that Bigley was quite agitated and maintained a running monologue throughout most of the court proceedings.
With respect to the determination of Bigley's best interests, the main subjects of the evidence were (i) the benefits that API claimed the treatment would provide and (ii) the harms that Bigley claimed would result from administering psychotropic medication.
API proposed to treat Bigley with risperidone, an anti-psychotic medication that API records indicate had been part of an effective regimen in the past, and which, at the hearing, API doctors said helped make Bigley calmer and more capable of rational interaction so that he could function in the community. Dr. Kahnaz Khari, a staff psychiatrist at API, testified that the use of this kind of medication was required by the standard of care of psychiatrists in this community. She said she believed it was in Bigley's best interests to receive the medications. Dr. Khari said it was likely Bigley would be injected since he refused to take the oral form of the drug. She also planned to administer a medication from the benzodiazepine family to calm Bigley down until the risperidone took effect. Dr. Khari conceded that Bigley was not likely to be compliant with medication after release. She said that as a result API favored giving him an injection that only has to be administered every two weeks: At least that keeps him stable for some short period. Dr. Khari said that she would expect that with medication Bigley might remain delusional, but with a lower level of intensity and a better ability to think rationally and engage with other people. She said that in the past, she had seen Bigley on medication and he was functioning better and living in an assisted living facility. [H]e was able to have more rational interaction, and he wasn't labile.... So I have seen him in a higher quality of living standard that he can have with the medication versus when he's not on medication. She testified that without the medication, she was concerned he would not be able to provide the care for himself, like not eating, not sleeping. Dr. Maile, the API clinical director, also testified that Bigley would benefit from the drugs. He testified that when Bigley took medications, he was a very different, pleasant man who is not threatening and not at risk to generate the harm from others by his perpetual threats to them. Without medication, he tends not to take care of himself. He doesn't eat, he doesn't drink, he doesn't seek appropriate medical care. Dr. Maile testified that when not on his medications, Bigley tended to threaten people. For example, he said that Bigley had recently threatened to slit Maile's throat and kill his staff and their children. Dr. Maile expressed concern that someone Bigley encountered on the street might react to such threats by harming Bigley. This concern that Bigley might provoke an assault on himself was later reinforced by testimony from other witnesses, including one of Bigley's own witnesses. The court-appointed visitor, Vassar, also testified that Bigley had in the past been helped by psychotropic drugs administered at API. She said that previously, there was a period, around 2003, 2004, or 2005, during which Bigley complied with the medication order as an outpatient, receiving medication every two weeks at API while living on his own in an apartment. She thought this period of stability had lasted a couple of years. API's medical director, Dr. Raymond Hopson, gave similar testimony. He said that when Bigley agreed to take medication, he was able to have suitable housing. And he was happy. He was not on the streets, and he was doing well at that time. However, in contrast to Vassar, Dr. Hopson said this recent period of stability under the influence of the medications had only lasted about six months. Dr. Hopson testified that without medications, Bigley was intermittently homeless and his dietary intake is questionable and that this affects his overall health. Bigley's witnesses portrayed the proposed treatment as just the latest in a repetitious cycle in which Bigley was committed and forcibly medicated without any real benefits. Dr. Grace Jackson, a psychiatrist called as an expert by Bigley, described the state's plan as business as usual. And that is to continue sort of the in and out cycle of hospitalizations, revamping previous or new treatment plans, and then discharging, and then sort of repeating that process over again as it might become necessary. API records indicate that even with medications, Bigley would remain delusional, although sometimes calmer. Paul Cornils, a program manager for CHOICES, a social services nonprofit that had worked with Bigley, testified that it was futile to medicate Bigley because he would stop taking the medication as soon as he was released. Cornils also said Bigley had not been helped by the medication, saying the only effect he observed was sedation. He testified that with medication, his delusions are as strong. His anger and aggression is still present, he just does not express them as strongly. He is less disturbing most of the time ... I have not noticed much difference except to say that his behavior is more socially acceptable when he's on medication. Cornils testified that there was no need for psychotropic medication and that providing Bigley with support and assistance would facilitate his return to a more stable, higher functioning state.
The court heard evidence relating both to the perils of psychotropic drugs generally, and the specific side effects such drugs could have on Bigley himself. Dr. Grace Jackson, the psychiatrist and author called by Bigley, testified as an expert witness about the harmful effects and lack of effectiveness of anti-psychotic drugs. Dr. Jackson conceded that psychotropic medication is widely accepted within the psychiatric community as an effective treatment for schizophrenia. However, she testified that the pharmaceutical industry had skewed and suppressed data showing the harms these drugs caused. She testified that the life expectancies of people taking drugs such as risperidone had shortened by as much as twenty to twenty-five years, that the drug caused many patients to be chemically brain injured, and contributed to an epidemic of dementia. She disputed the idea that risperidone was safer than the older drugs. She testified these drugs really should be called chemical lobotomizers rather than antipsychotics because they merely inhibit brain activity to reduce annoying behaviors. She testified that five to twenty percent of patients on risperidone will develop tardive dyskinesia symptoms in the first years of use. [3] She said she did not know if Bigley had tardive dyskinesia, but that he was at high risk of it if placed on risperidone. She also testified there was a high likelihood he is simply just going to die in the next five years if he is placed back on risperidone. In sharp contrast to the API doctors, Dr. Jackson believed that Bigley's recent decline in mental health had been caused not by his refusal to take medications, but to the contrary was the result of damage done by excessive medication. Dr. Jackson concluded that continuing with anti-psychotic medication for Bigley would be very unwise. Bigley also introduced an affidavit from Robert Whitaker, a journalist and author, describing evidence of the harmful effects and lack of efficacy of psychotropic drugs. And he introduced an affidavit from Ronald Bassman, Ph.D., an advocate and researcher who has been treated with psychotropic drugs for his own schizophrenia and now opposes their use. Dr. Hopson of API disputed the assertion that treatment with anti-psychotics increases the likelihood of chronic mental illness. Dr. Hopson testified that Dr. Jackson's views were not in the mainstream of clinical practice in the Anchorage area. He said Alaska used treatment guidelines known as the Texas Medication Algorithm Project (TMAP) used in about half the states, which recommend anti-psychotic medications if the symptoms of schizophrenia interfere with daily functioning. He said it would be remiss not to treat someone like Bigley with such medications. API did not dispute that Bigley has experienced some unpleasant side effects from psychotropic drugs in the past. Records from a 1981 hospitalization, when he was being treated with the drug Haldol, report extrapyramidal symptoms (EPS), i.e. movement disorders. [4] More recently, during a 2007 hospitalization, his medications caused nausea and vomiting. Dr. Maile noted that Bigley had complained of some side effects from anti-psychotic medication such as sleepiness and weight gain. The visitor said Bigley had complained of side effects of erectile dysfunction and sleepiness, as well as a belief that the injections had altered the shape of his buttocks. Both Dr. Maile and the visitor said they were not aware of Bigley having experienced the side effect of tardive dyskenisia. [5] However, the court later found, based on grounds that are not stated, that Bigley did in fact suffer from this condition as the result of years of treatment with anti-psychotic medications. [6] Dr. Khari testified that the drug now at issue, risperidone, could have side effects such as sedation, hypertension, tardive dyskinesia, EPS, and hyperprolactinemia. [7] She said risperidone was a newer kind of anti-psychotic with fewer side effects, but could have similar side effects to the older drugs at higher doses. She testified that in Bigley's case, the only side effects observed in the past from risperidone were weight gain and sedation.
Before the hearing, Bigley's counsel had filed a Motion for Less Intrusive Alternative with the court. In it he proposed that Bigley be allowed to come and go from API as he wishes, including being given food, good sleeping conditions, laundry and toiletry items as reasonably requested. ... If placed at API involuntarily, he proposed that Bigley be allowed out on passes with escort. Furthermore, the proposed alternative called for API to procure and pay for a reasonably nice apartment that is available to Mr. Bigley should he choose to use it. Finally, he proposed that API make sufficient staff available to be with Mr. Bigley to enable him to be successful in the community. (Emphasis in original.) In support of this motion, Bigley offered affidavits from Ronald Bassman, Ph.D., Robert Whitaker, and an affidavit and testimony from Paul Cornils. The affidavit from Whitaker, a journalist who writes about science and medicine, criticized the efficacy and side effects of psychotropic drugs, and argued that recovery rates are superior without them. The affidavit of Ronald Bassman described research supporting the efficacy of recovery from schizophrenia without drugs. A report submitted by Dr. Jackson also described non-drug treatment strategies and summarized studies supporting their efficacy. Most directly relevant was the affidavit of Paul Cornils of CHOICES, because Cornils has worked with Bigley and specifically endorsed Bigley's proposed alternative, describing in some detail a theory of how Bigley could be better treated without psychotropic drugs. Cornils testified that his organization could provide case management and rehabilitative services in the community for someone in Bigley's condition. He thought that Bigley could be supported in the community without medication with the help of a twenty-four hours-a-day personal care attendant, which, over time, might be reduced to less than twenty-four hours. Although Cornils objected to API's use of coercion to treat Bigley, he conceded that CHOICES lacked the funding to provide the kind of support Bigley needed. He also testified that CHOICES would not normally work with a patient who was refusing to take medication against his physician's recommendations, which could preclude CHOICES from working with Bigley. And he testified that a psychiatrist treating Bigley without medications would run a liability risk: [T]he psychiatrist would ultimately be held responsible for the behavior because he is ultimately overseeing the treatment. ... API's Dr. Hopson agreed that the services recommended by Cornils would be valuable and that finding housing for Bigley should be a high priority. However, he said that the approach of treating Bigley without medication had been tried multiple times and failed because in each instance he was evicted from the housing due to his behavior. It had become difficult for his guardian to place him anywhere because they know Mr. Bigley, and they know ... the difficulties they are going to encounter.