Opinion ID: 182759
Heading Depth: 2
Heading Rank: 4

Heading: Government's Witnesses at Sell Hearing

Text: On September 8, 2009, the district court conducted the Sell hearing, during which counsel represented Diaz. [4] Addressing the court, Diaz personally stated that he retained sovereign immunity from the judicial proceedings, was not a citizen of the United States and did not adhere to the laws of the United States, and invoked his right against self-incrimination. The government responded that it had a strong and important interest in bringing Diaz's case to trial because of the violent nature of his crimestwo armed bank robberies and a felon-in-possession charge and because of its interest in a speedy trial. The government presented evidence on the Sell factors.
The government first called Dr. Pietz to testify. Dr. Pietz, a psychologist, is Diaz's primary clinician at Springfield medical center. Dr. Pietz opined that Diaz suffers from paranoid schizophrenia. On May 21, 2009, Diaz was re-admitted to Springfield medical center and, since being re-admitted, Diaz has refused to be interviewed by Dr. Pietz and has refused to take any medication. Diaz has also refused the staff's attempts to administer medication to him and refused to participate in therapy sessions or undergo any other type of treatment. Because Diaz would not take medicine, Springfield medical center conducted the due process hearing to determine whether they forcibly could medicate Diaz. After this hearing, Dr. Tomelleri found that (1) Diaz suffers from a mental illness that requires medication, but (2) Diaz is not dangerous to himself or others, and (3) thus the medical center staff could not forcibly medicate him. Dr. Pietz opined that the administration of anti-psychotic drugs is medically appropriate for Diaz because his condition will not improve and could deteriorate if he does not receive medication. Dr. Pietz pointed out that Diaz's condition has worsened over the past few years. Dr. Pietz concluded that there are no alternative treatments that would be effective in treating Diaz's disorder. The potential alternative treatment options are individual therapy, group therapy, or recreational therapy. However, Diaz is not a candidate for those types of treatments due to his demeanor, his refusal to cooperate with mental health professionals, and his inability to function in an open group population. Diaz was not offered opportunities to participate in individual or group therapy because those therapies were not an option so long as he was unmedicated and held in a locked unit. In any case, Dr. Pietz has no reason to believe that Diaz would participate in a competency restoration program or any other form of group therapy. While at USP Lewisburg, Diaz was offered an opportunity to participate in a program called the Challenge Program, designed to help inmates after they are released into society, but Diaz refused to participate. Dr. Pietz also explained that medical center staff had attempted to educate Diaz regarding the benefits of anti-psychotic medication, but that he had resisted these efforts. Dr. Pietz further testified that the medication that she and Dr. Robert Sarrazin, the medical center's chief of psychiatry, recommended for Diaz has a substantial likelihood of rendering Diaz competent to stand trial. For over 19 years, Dr. Pietz has treated individuals who were found to be incompetent to stand trial. Between 60% and 70% of these patients were restored to competency with medication. As for the individuals who did not attain competency, Dr. Pietz explained that some of those individuals suffered from cognitive defects, such as mental retardation, which rendered them unresponsive to medication. Dr. Pietz stated that if the medical staff cannot treat Diaz with medication, they will never be able to restore his competency to stand trial. Addressing the potential side effects of anti-psychotic medication, Dr. Pietz testified that such medication will likely improve Diaz's ability to think in a rational and organized manner and will likely decrease his paranoia and irritability. As a result, Dr. Pietz believes that anti-psychotic medication will assist Diaz in his cooperation with his attorney. On cross-examination, Dr. Pietz testified that she last saw Diaz approximately a month prior to testifying. When Diaz returned to Springfield medical center in May 2009, Diaz did converse with her at some length. However, toward the end of her more recent period of evaluation, Diaz typically would not speak to Dr. Pietz or would engage in only limited conversation and dismiss her. Despite the fact that Diaz is being held apart from the general prison population, Dr. Pietz does not believe that he is a danger to himself or to others, or that there are any other grounds on which to justify forced medication. [5] In Dr. Pietz's experience, it is very rare that, upon taking anti-psychotic medication, a patient's condition does not improve such that he becomes competent. Dr. Pietz does not believe that individual or group therapy is appropriate for Diaz because such therapy becomes useful only after a patient begins taking medication that corrects the chemical imbalance that causes psychosis, which is a biological condition. Dr. Pietz does not believe that Diaz is malingering. On re-direct, Dr. Pietz testified that, if Diaz is ordered to be forcibly medicated, she and Dr. Sarrazin will be his clinical team, and Dr. Sarrazin will write the prescription for the medication. In response to the court's questions, Dr. Pietz stated that to her knowledge, Diaz has never been medicated and she expects that he will likely not respond quickly to medication. Dr. Pietz stated that if Diaz is not restored to competency within four months, she will request an extension from the court to continue administering medication for another four months, and again at the end of eight months if Diaz is improving but is not yet restored to competency. If all avenues are exhausted and Diaz is not restored to competency, Dr. Pietz will return him to the court as incompetent.
The government next called Dr. Robert Sarrazin, Chief of Psychiatry at Springfield medical center. Dr. Sarrazin has had hundreds of cases involving involuntary medication. Of these cases, a small number involved the specific question of involuntary medication to restore a patient to competency to stand trial. In this group of cases, between 75% and 80% of patients forcibly medicated attained competency to stand trial. Dr. Sarrazin assisted Dr. Pietz in treating Diaz by acting as the consulting psychiatrist in Diaz's case. Dr. Sarrazin personally evaluated Diaz between May 21 and June 12, 2009, primarily by observing his behavior. Dr. Sarrazin reviewed all of Diaz's previous records and his current chart and consulted with Dr. Pietz. Dr. Sarrazin met with Diaz on June 3, 2009 after the due process hearing conducted by Dr. Tomelleri. Based on his observations of Diaz, his consultation with Dr. Pietz, and his review of the reports, Dr. Sarrazin concluded that Diaz suffers from chronic paranoid schizophrenia. Dr. Sarrazin noted that Diaz was not very cooperative during the evaluation process and would refuse to speak with others or leave his cell for an evaluation. While at Springfield medical center, Diaz has refused to take medication. Dr. Sarrazin reviewed several studies addressing the use of medication to restore psychotic patients to competency. He summarized the results of these studies as follows: (1) a general 1992 study of 150 incompetent defendants in a state forensic hospital found that only 8 of these patients could not be restored to competency, yielding an approximate 95% success rate; (2) a 1993 study of 45 incompetent pre-trial defendants, suffering from psychotic disorders, found that 87% of these patients were restored to competency with involuntary psychotropic medication; (3) a 2007 study reviewing Ohio state psychiatric hospitalizations from 1995 to 1999 found that 75% of patients were restored to competency with involuntary medication; and (4) another 2007 study of 22 individuals diagnosed with delusional disorder (a psychotic disorder different from schizophrenia) found that 77% of the patients were restored to competency by the use of involuntary anti-psychotic medication. Based on this data, as well as his own experience with involuntary medication of patients, Dr. Sarrazin opined that it is substantially likely that Diaz will be restored to competency if given anti-psychotic medication. Dr. Sarrazin further testified that the American Psychiatric Association (APA) has promulgated practice guidelines and data addressing the treatment of schizophrenic patients. The APA data reported that 83% of first episode patients experience stable remission, by the end of one year of treatment, meaning their symptoms (such as hallucinations and confusion) decrease to the point that the individual can return to his or her normal activities. The end point of the APA data, Dr. Sarrazin stated, was that individuals get to this type of remission, rather than competency. The APA data showed, however, that between 10% and 30% of schizophrenic patients have little to no response to anti-psychotic medication, and that up to another 30% have only a partial response to medication, meaning they exhibit improvement in psychopathology but continue to have mild to severe residual hallucinations or delusions. The APA data did not address success rates in situations where competency, rather than remission, was the end point. Dr. Sarrazin also noted that, because Diaz has never taken anti-psychotic medication, there is no record of whether he previously had responded or not responded to medication. Dr. Sarrazin testified that, under the most optimistic view of the APA data, there is a 90% chance that anti-psychotic medication will restore Diaz to competency. Under the most pessimistic view of the APA data, there is a 30% chance that Diaz will not respond to medication at all, a 30% chance that Diaz will partially respond to the medication but will not attain competency, and a 40% chance that Diaz will respond to the medication and attain competency. Dr. Sarrazin explained that anti-psychotic medications improve cognitive thinking and lessen hallucinations in individuals who suffer from schizophrenia. As to side effects, Dr. Sarrazin testified that, although anti-psychotic medications can cause sedation, this side effect is usually a short-term condition and can be improved by shifting the timing of the medication or splitting the dosage. Dr. Sarrazin clarified that anti-psychotic medication likely will improve Diaz's cognition, and is unlikely to cause a decrease in Diaz's cognitive ability. According to Dr. Sarrazin, anti-psychotic medications can be classified as first-generation, or typical, medications, or as second-generation, or atypical, medications. Second-generation and first-generation medications are equally effective. However, second-generation medications are less likely to cause neuromuscular side effects than first-generation medications. The neuromuscular side effects at issue include stiffness, shakiness, and akathisia, which is an internal feeling of restlessness. These side effects can be controlled by administering supplemental medications, such as Benadryl or Cogentin. Neuromuscular side effects are associated with injections of a medication called Haldol (known generically as haloperidol decanoate, or simply haloperidol) and, as a result, Springfield medical center staff usually adds supplemental medication to Haldol to control these side effects. If the medical center staff administered an anti-psychotic medication to Diaz, they would closely monitor him for neuromuscular side effects, and if he displayed any acute neuromuscular side effects, a treatment plan was already laid out. If supplemental medications such as Benadryl or Artane are used with Haldol, Diaz would be monitored to ensure that those medications do not cause confusion as a side effect. Dr. Sarrazin further testified that patients who take a first-generation medication over a term of years may experience tardive dyskinesia and tardive dystonia, conditions where the patient experiences abnormal movements of the mouth and tongue and, sometimes, other parts of the body. Patients taking second-generation anti-psychotic medications experience these side effects at a rate of 2%, or 5% in a population of elderly patients. Individuals on long-term treatment with first-generation anti-psychotic medications experience tardive dystonia at a rate of 1%-2%. Dr. Sarrazin also discussed metabolic side effects. Second-generation anti-psychotic medications can cause elevated blood-sugar levels or diabetes. Springfield medical center monitors patients' blood-sugar levels and weight on a monthly basis, and monitors patients' lipid, cholesterol, and hemoglobin [6] levels once every three months. If a patient experiences an increase in his blood-sugar level, the medical staff responds by altering the patient's diet or changing his anti-psychotic medication. The medical center would likely administer to Diaz medications called Geodon or Abilify, because these medications have a lower association with heightened blood-sugar levels. Dr. Sarrazin further testified that, on rare occasions, anti-psychotic medications can cause serious or even fatal side effects. On exceedingly rare occasions, and even more rare in second-generation anti-psychotics, a patient can suffer from neuroleptic malignant syndrome, which causes a patient to become rigid, have an elevated body temperature, and, without treatment, experience muscle deterioration and kidney damage. If not treated promptly, this condition poses a 10% to 20% mortality rate. Dr. Sarrazin explained that the medical center monitors patients for symptoms of this condition. In addition, some first-generation medications, including Mellaril, can cause a patient to have an irregular heartbeat that, in turn, can cause sudden death. The medical center avoids prescribing these medications, and closely monitors patients who take these medications. Dr. Sarrazin also mentioned that some anti-psychotic medications have side effects, such as light-headedness, constipation, and trouble with urination. These side effects can be managed by lowering the dosage and selecting medications that have a lower risk of these side effects. Dr. Sarrazin has been successful in reducing or eliminating side effects. Dr. Sarrazin then discussed data regarding the efficacy of psychotherapy for treating individuals with schizophrenia. Dr. Sarrazin opined that individual psychotherapy without medication is not an effective treatment option for Diaz, and that the preferred treatment for schizophrenia is anti-psychotic medication. Once a patient begins taking medication, however, psychotherapy is useful primarily to encourage the patient to continue to take his medicine, and it may be helpful for Diaz once he begins taking medication. Dr. Sarrazin reiterated that anti-psychotic medication is medically appropriate for the treatment of schizophrenia as it is the treatment of choice and the gold standard for treating patients with the disease. Dr. Sarrazin opined that the administration of anti-psychotic medicine to Diaz will likely render him competent to stand trial and will be unlikely to cause side effects that would interfere significantly with Diaz's ability to assist counsel in conducting his defense. Because Diaz is not currently on any medications, Dr. Sarrazin is not concerned about any drug interactions. Dr. Sarrazin and Dr. Pietz created a treatment plan for Diaz. Dr. Sarrazin would administer to Diaz, on a daily basis, one of these medications: (1) 15 to 60 mg of Abilify, (2) 80 to 320 mg of Geodon, (3) 2 to 12 mg of Risperdal, or (4) 2 to 40 mg of Haldol. Each medication is a second-generation medication, with the exception of Haldol, a first-generation medication. Dr. Sarrazin would first attempt to administer orally a second-generation medication to Diaz, starting with low doses and increasing the dosage slowly to lessen side effects while monitoring Diaz closely. They would administer Haldol only if Diaz were to refuse to take medication voluntarily by swallowing a pill, thus making it necessary to use an injectable medication. Dr. Sarrazin testified that, in commencing Diaz's treatment, medical center staff plan to show Diaz a copy of the court's order for involuntary medication and ask him to comply with the order. If Diaz refuses to comply, the staff forcibly will inject Diaz with his medication. Dr. Sarrazin will prescribe the lowest dosage possible in order to treat Diaz effectively. If Diaz becomes agitated or combative when receiving medication, the staff will inject him with a dose of 2 milligrams of Lorazepam, which will calm him down so that he can be safely released from restraints. Dr. Sarrazin verified that the government requested a four-month period in which to restore Diaz to competency. Because Diaz is going to be involuntarily medicated, the period of time may need to be six or eight months before Diaz can be effectively restored to competency. Diaz will continue to receive involuntary treatment to maintain his competency until the conclusion of all pretrial and trial proceedings. Dr. Sarrazin believes that anti-psychotic medication has a substantial probability of rendering Diaz competent to stand trial. If Diaz indicates that he will cooperate with oral medication, the staff will switch from injecting his medication to oral medication. On cross-examination, Dr. Sarrazin conceded that, because Dr. Pietz has other patients for whom she is the primary clinician, she has been unable to spend all of her working hours focused on establishing a relationship with Diaz and convincing him to take his medication. Dr. Sarrazin does not believe that Diaz is malingering. If Diaz is malingering, the medication will have no effect on his fabrication of symptoms. Dr. Sarrazin does not believe that physically forcing a patient to take medication will have long-lasting psychological effects on the patient. On re-direct examination, Dr. Sarrazin reiterated that treatment with anti-psychotic medications is medically appropriate for Diaz, and that Diaz will not regain competency without medication.