Court Opinion

ID: 9901718
Source: CourtListenerOpinion
Date Created: 2023-11-22 15:02:13.770525+00
Date Added: 2024-06-11T09:21:38.124815
License: Public Domain

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              DISTRICT OF COLUMBIA COURT OF APPEALS

                                No. 22-FM-0498

                            IN RE D.D., APPELLANT.

                         Appeal from the Superior Court
                          of the District of Columbia
                             (2021-MHE-001820)
                      (Hon. Darlene M. Soltys, Trial Judge)

(Argued May 16, 2023                                  Decided October 4, 2023 *)

      Jennifer Williams, Public Defender Service, with whom Samia Fam and
Shilpa S. Satoskar, Public Defender Service, were on the brief, for appellant.

      Eric M. Levine, Assistant Attorney General, for appellee. Brian L. Schwalb,
Attorney General for the District of Columbia, Caroline S. Van Zile, Solicitor
General, Ashwin P. Phatak, Principal Deputy Solicitor General, and Thais-Lyn
Trayer, Deputy Solicitor General, were on the brief for appellee.
         Before BECKWITH and HOWARD, Associate Judges, and THOMPSON, Senior
Judge.

      *
         The decision in this case was originally issued as an unpublished
Memorandum Opinion and Judgment. It is now being published upon the court’s
grant of appellant’s motion to publish.
      THOMPSON, Senior Judge: This matter is an appeal from an order authorizing

involuntary civil commitment. Appellant D.D. is an 80-year-old woman who has

been diagnosed with schizoaffective disorder, bipolar type. At the time of briefing

and oral argument before this court, she remained an inpatient resident of Saint

Elizabeths Hospital (the “Hospital”), a psychiatric hospital operated by the District

of Columbia (the “District”) Department of Behavioral Health (“DBH”). After a

bench trial in June 2022, the Superior Court found that D.D. was mentally ill, that

her mental illness put her at risk of injuring herself, and that inpatient commitment

was the least restrictive alternative in the best interests of D.D. and the public, and

issued a written order on June 8, 2022, committing D.D. to DBH, for a period of

one year, for inpatient treatment. 1 See D.C. Code § 21-545. On appeal, D.D. (who

has remained at the Hospital on a voluntary basis following the expiration of the

commitment order 2) contends that the court based its determinations and order on

      1
         The order contemplates, however, that D.D. might be “discharged from the
inpatient treatment to participate in an outpatient course of treatment” and directs
that if she “subsequently fails to abide by the treatment regimen or if [her] mental
condition . . . deteriorates, [she] may be returned to inpatient hospitalization.”
      2
        D.D. has delusions about Mitt Romney and reportedly believes that he is
arranging other housing for her. She has remained at St. Elizabeths awaiting that
assistance, and she has rejected a housing alternative arranged by her court-
appointed guardian.
                                          3

insufficient evidence.3 Although we are not persuaded by all of D.D.’s arguments,

we are concerned that the Superior Court ruled without awaiting what appears to

have been then soon-to-be available information about D.D.’s possible

neurological or neurocognitive condition, and we also are persuaded that the court

(and the District) did not adequately explore less restrictive alternatives to acute

inpatient commitment of D.D. We therefore vacate the commitment order insofar

as it mandated inpatient commitment. 4

                                 I. The Evidence at Trial
      The District’s chief witness at trial was Dr. Syed Zaidi, a psychiatrist at the

Hospital, who at the time of trial had been D.D.’s attending psychiatrist for nearly

      3
          The trial testimony established that D.D. is “in denial of her mental
illness,” but her briefs on appeal do not explicitly deny that she has a mental illness
and do not appear to challenge the trial court’s determination that she is mentally
ill.
       4
          The trial court’s commitment order expired on June 8, 2023. D.D.’s
history of emergency hospitalizations creates “a reasonable expectation that the
same complaining party would be subject to the same action again,” In re Morris,
482 A.2d 369, 372 (D.C. 1984) (quoting Weinstein v. Bradford, 423 U.S. 147, 149
(1975)), and the one-year limitation on the length of commitment orders, see D.C.
Code § 21-545(b)(2), means that “the challenged action [is] in its duration too
short to be fully litigated prior to its cessation or expiration,” Morris, 482 A.2d
at 372 (quoting Weinstein, 423 U.S. at 149). D.D.’s claim is thus “capable of
repetition yet evading review,” and we are satisfied (and agree with the District)
that her appeal is not moot. Id. (quoting United States v. Edwards, 430 A.2d 1321,
1324 n.2 (D.C. 1981) (en banc)).
                                         4

two years. 5 Without objection, the court accepted Dr. Zaidi as an expert in the

treatment and diagnosis of mental illnesses.         Dr. Zaidi summarized D.D.’s

symptoms of schizoaffective disorder bipolar type, stating that she displays

“[i]rritability”; is “psychotic,” “delusional,” and “easily . . . agitated,” and has

exhibited behavior that includes shouting vulgarities at other patients and calling

them “prostitute[es],” “homosexual[s],” or other names. 6 Dr. Zaidi also described

that D.D. has been verbally aggressive toward other patients; referring to D.D.’s

Hospital record, he recounted that another patient pushed D.D. after D.D. was

“intrusive” towards her. Dr. Zaidi further testified that D.D. has said that she will

not take her psychotropic medication if she is released from the Hospital. He

opined that if she does not take her psychotropic medication, her delusions will

become more intense and her aggressiveness more physical, and she will be

“confused, agitated, [and] disorganized.” Dr. Zaidi also opined that if D.D. does

      5
         Dr. Zaidi began treating D.D. on January 9, 2020, before taking medical
leave from late March 2020 through the end of that year. He resumed his role as
D.D.’s psychiatrist in January 2021 and continued in that capacity through trial.
Before testifying, he reviewed D.D.’s hospitalization, admission, and incident-
report records and spoke to her case manager.
      6
       Dr. Zaidi recounted that D.D. has “threaten[ed]” to harm him “every single
time” he has asked to perform a full evaluation of her.
                                          5

not take her psychiatric medication—an injectable form of Abilify, 7 which

Hospital staff administer to her every four weeks, and which they sometimes have

been able to administer only by applying physical restraint as authorized by D.D.’s

guardian—she will not take her medication for hypertension. Dr. Zaidi testified

that the effect of forgoing her medication for hypertension “is going to be stroke,

heart attack, kidney failure, blindness,” and other health issues.

      Dr. Zaidi explained that he had originally recommended outpatient treatment

for D.D., but changed his mind upon being informed that providers of outpatient

services cannot administer the involuntary injections. He dismissed the possibility

that group homes would be better equipped for the task because “it becomes

very[,] very difficult”; the Hospital always has backup staff to assist, which he

“guess[ed]” would not be the case in a group home.

      Jessica Bassil, a social worker at the Hospital since 2012, testified that she

speaks with D.D. every day and that D.D. “is more disorganized and more verbally

aggressive when she’s not on medication.” Ms. Bassil has been able to tell when

D.D. is not adhering to her medications because of her demeanor: yelling, being

disruptive, and waving her arms while turning red in the face. Ms. Bassil testified

      7
        Dr. Zaidi testified that D.D. did not want to take oral medication, and she
was tried on a different, less effective, injectable medication before her treatment
team settled on the long-term injectable form of Abilify.
                                         6

that D.D. seeks out medical treatment when she thinks she needs it, but told the

court that D.D. is very critical of psychiatry, is very adamantly against psychiatric

treatment, and does not believe in psychotropic medications, which she calls

“snake oil.”8 Ms. Bassil acknowledged, however, that D.D. had “largely been

compliant” with taking her injections because she understands that if she does not

adhere to the psychotropic medications, the Hospital will not consider her for

discharge. Ms. Bassil also described D.D. as having trouble remembering recent

events.9

      Nurse Stella Okeke testified that D.D. is verbally abusive toward her fellow

patients when she interacts with them. She described D.D.’s insults and vulgar

outbursts directed at fellow patients (and at staff who intervene), which may be

occasioned by, for example, another patient bumping into her slightly while

standing in line. Ms. Okeke also described what has occurred when D.D. resists

injection of her psychotropic medication: D.D. “threaten[ed] to shoot and take

people down and things like that,” was angry and “foaming at the mouth,” was

      8
        D.D. is also concerned about the weight-gain side effect from her
psychotropic medication and the cost of the (expensive) medication.
      9
        Ms. Bassil testified that D.D. “does not recall any of the hearings that she
participated in,” even when reviewing transcripts of the proceedings. She has
forgotten about scheduled meetings even when reminded earlier in the day and has
“often” requested and received office supplies, forgotten they had been provided,
and requested them again.
                                          7

looking as if “her eyes [were] popping out,” and was “shaking” and “really upset,”

such that “you can see her vein.” Her blood pressure was “dangerous,” “almost

200 over something.” Ms. Okeke testified that “[i]t doesn’t really take D.D.[]

anything to get frustrated.”

      Other witnesses described D.D.’s symptoms and behavior that precipitated

her inpatient admissions. Azalech Tegene, a member of the DBH Community

Response Team (“CRT”), testified about the events that led to D.D.’s first

emergency hospitalization, which lasted from May 23 to September 24, 2018, after

she was “FD 12’d” on May 8, 2018. 10 On that day, a women’s shelter where she

had been living for several months summoned the CRT for the second time in

roughly two weeks because of her “extremely agitated” behavior. Ms. Tegene

arrived to find D.D. “cursing[,] . . . yelling, [and] screaming,” calling the security

guards “homosexuals[,] . . . bitches and whores and so forth.”             A shelter

representative expressed concern that shelter staff, most of whom are African

Americans, might retaliate because D.D. was “provocative.”          (The trial court

sustained a hearsay objection to Ms. Tegene’s testimony about D.D.’s specific

language, but let stand Ms. Tegene’s testimony that she was called to the shelter

because of “provocative statements that were made.”) Ms. Tegene was “not able

      10
        An FD 12 is an application for emergency hospitalization. See D.C. Code
§ 21-521.
                                         8

to de-escalate.” Additionally, D.D. had bruising and swelling on her face but

refused to let emergency medical personnel examine her.                All of this led

Ms. Tegene to complete an FD 12. Upon arrival at the Comprehensive Psychiatric

Emergency Program, D.D. remained agitated, and medical personnel registered her

blood pressure as “very high.” From there, she was redirected to a hospital and

admitted.

      D.D.’s     second    emergency         hospitalization,   from      July 10   to

November 25, 2019, followed an FD 12 completed by another CRT member,

Patrick Awosika, on June 8, 2019. Responding to a call from Amtrak police,

Mr. Awosika reported to Union Station, where he found D.D. lying in front of the

building entrance, “yelling, cussing people out, calling them all kinds of names:

bitch, motherfucker, I’ll fuck you, all kinds of things.” He introduced himself to

D.D. and offered assistance, but she refused, “calling [the CRT members] all kinds

of name[s]” and exhibiting “bizarre behavior.” Mr. Awosika wrote the FD 12 in

part because of his fear that by calling people “all kinds of names,” D.D. might put

herself in danger of retaliation. He observed that some passersby at Union Station

who encountered D.D. during this episode “tried to call her names back.”

      D.D.’s third emergency hospitalization initiated by DBH began on

December 26, 2019, following an FD 12 on December 10, 2019.               Staff at the

shelter, to which D.D. had returned after leaving the hospital, called emergency
                                         9

medical services because D.D. was complaining of a headache and body pain.

Emergency personnel found her disorganized, confused, and unable to “talk

much.” They wrote in the FD 12 that “she was not really able to care [for] herself”

and “was deemed vulnerable . . . to be attacked by others.”

      In D.D.’s case, her counsel raised the possibility that some or all of her

symptoms could stem not from her diagnosed psychiatric condition, but rather

from a neurological or neurocognitive disorder. The testimony established that

after an initial examination (which was limited because D.D. was unwilling to

cooperate), the Hospital’s neuropsychiatric team sought to do further testing to

investigate possible neurological or neurocognitive contributions to her condition.

      On cross-examination, Dr. Zaidi concurred that some of D.D.’s symptoms,

including insensitivity to social standards and behavior “out of [the] acceptable

social range,” may sometimes indicate such a neurological or neurocognitive

disorder. He agreed that certain dementias are associated with both memory issues

and paranoia, but said that memory issues do not “give you . . . delusion[s].”

Dr. Zaidi also agreed that patients with some neurological or neurocognitive

conditions, such as Alzheimer’s disease, Parkinson’s disease, and dementia, may

present with memory issues along with some symptoms also associated with
                                         10

schizoaffective disorder. He acknowledged that it would be “important” to rule out

such a condition where symptoms overlap with those of a diagnosed illness. 11

      At the end of the bench trial, the court determined that the government had

proven, by clear and convincing evidence, the requirements for civil commitment.

The trial court concluded that D.D.’s mental illness put her at risk of injuring

herself, i.e., that she was “a danger to herself because she puts herself in harm’s

way by the name-calling and her aggressive and hostile behavior towards

others[,] . . . [which] would very likely induce violence and retaliation by others.”

The court was also persuaded by Dr. Zaidi’s testimony that, if discharged, D.D.

would stop taking her psychotropic medication, which would cause her to become

disorganized, resulting in an inability to take her prescribed hypertension

medication and putting her at risk of heart attack or stroke. The court further found

that there was no less restrictive treatment available than involuntary inpatient

commitment.

      11
          D.D.’s counsel pressed Dr. Zaidi on the Hospital’s failure to have her
tested for a neurological or neurocognitive disorder despite his acknowledgment
that it would be “important” to rule out such a condition where symptoms overlap
with those of a diagnosed illness. Counsel highlighted Dr. Zaidi’s statement that,
although he interacted with D.D. almost every day, he had not been able to
complete a full examination of her due to her “yelling” and “threatening” him.
Dr. Zaidi affirmed his confidence in the schizoaffective disorder diagnosis,
explaining that evidence of a differential diagnosis (i.e., evidence of other possible
conditions that could share the same symptoms) does not remove a primary
diagnosis in the absence of testing that negates the primary diagnosis.
                                          11

                       II. The Applicable Legal Standards

               A. The Statutory Requirements for Commitment

      The District of Columbia’s involuntary civil commitment statute is a part of

the “Hospitalization of Persons with Mental Illness Act,” D.C. Code §§ 21-501 to

21-592, often called the “Ervin Act,” see, e.g., In re Macklin, 286 A.3d 547, 550

(D.C. 2022); Tilley v. United States, 238 A.3d 961, 965 (D.C. 2020). In order to

involuntarily commit an individual, the government must demonstrate that (1) “the

person is mentally ill,” (2) “because of that mental illness, [she] is likely to injure

h[er]self or others if not committed,” and (3) there is no “[less] restrictive

alternative [to commitment] consistent with the best interests of the person and the

public.” § 21-545(b)(2). The showing on the first two prongs must be made by

clear and convincing evidence. In re Gaskins, 265 A.3d 997, 1001 (D.C. 2021)

(citing Addington v. Texas, 441 U.S. 418, 425-26 (1979) (holding that because of

the liberty interests at stake, there must be clear and convincing evidence to order

an involuntary civil commitment)); In re Gaither, 626 A.2d 920, 925 (D.C. 1993)

(“[A]t the disposition stage the trial court need not apply the clear and convincing

evidence standard in determining the least restrictive form of treatment” because

“[t]hat standard is applicable only at an earlier stage of a civil commitment

proceeding, when the hospital must prove that the person for whom commitment is

sought is mentally ill and likely to injure self or others.” (citation omitted)). The
                                           12

clear-and-convincing standard requires that the truth of the factual contentions

supporting commitment be “‘highly probable’ or substantially more likely to be

true than untrue.” Gaskins, 265 A.3d at 1002 (quoting Colorado v. New Mexico,

467 U.S. 310, 316 (1984)).

      As to the statutory requirement that the court “order the form of commitment

it believes is the least restrictive alternative consistent with the best interests of the

person and the public,” In re Lanier, 905 A.2d 278, 284 (D.C. 2006) (quoting D.C.

Code § 21-545(b)(2)), we will not disturb the trial court’s determination unless it

was “plainly wrong or without evidence to support it,” id. (quoting D.C. Code §

17-305(a)); see also In re Artis, 615 A.2d 1148, 1153 (D.C. 1992).

                               B. Standard of Review

      D.D. challenges the sufficiency of the evidence in support of the trial court’s

order. Our standard of review for such challenges is “well settled.” In re Perruso,

896 A.2d 255, 259 (D.C. 2006).

             In examining a claim of insufficiency, the applicable
             standard of review is whether there is any substantial
             evidence which will support the conclusion reached by
             the trier of fact below. This court must view the
             evidence in the light most favorable to the government
             and give full weight to the factfinder’s ability to weigh
             the evidence, determine the credibility of witnesses, and
             draw justifiable inferences. When a case is heard by a
             judge sitting without a jury . . . the judgment will not be
             overturned unless it appears that the judgment is plainly
             wrong or without evidence to support it.
                                         13

Gaskins, 265 A.3d at 1001 (alteration in original) (citations and internal quotation

marks omitted) (first quoting In re Artis, 615 A.2d at 1152; and then quoting

Perruso, 896 A.2d at 259).

                                   III. Analysis

      To commit a mentally deficient person under the Act, it is necessary for the

government to prove, first, “that the individual involved suffers from a mental

illness.” In re Alexander, 372 F.2d 925, 927 (D.C. Cir. 1967). As noted above,

although witnesses testified that D.D. does not believe she has a mental illness and

although at trial D.D. challenged the diagnosis of schizoaffective disorder bipolar

type, her briefs do not deny that she suffers from a mental illness. In light of

Dr. Zaidi’s testimony about her diagnosis of schizoaffective disorder bipolar type,

we discern no reason to question the sufficiency of the basis for the trial court’s

finding that D.D. suffers from a mental illness.12

      Focusing on the second prong of the Ervin Act test (“because of that mental

illness, [she] is likely to injure h[er]self or others if not committed,” D.C. Code

§ 21-545(b)(2)), D.D. argues, however, that the government failed to present

sufficient evidence to prove that D.D. is likely to injure herself by provoking

      12
          Cf. Perruso, 896 A.2d at 261 (“The court was certainly entitled to rely on
the [psychiatrist’s] opinion [about whether the individual is mentally ill] in making
its ruling.”).
                                           14

retaliation from others who may be targets of her name-calling and vulgarities.

Because of other aspects of the record (discussed infra) that we find dispositive,

we need not decide whether the evidence supported a finding by clear and

convincing evidence that D.D. was a danger to herself because of her conduct that

might trigger retaliation. Nor, for the same reason, need we resolve whether

substantial evidence supported the trial court’s finding that D.D. would be a danger

to herself if discharged from the Hospital because she would refuse psychotropic

medication, become confused and disorganized, and therefore fail to take

medication for her “dangerous[ly]” high blood pressure and put herself at risk of

heart attack or stroke. 13 What we find dispositive is the record as it relates to the

      13
          We do acknowledge that the risk related to D.D.’s hypertension is
somewhat attenuated; that her trial counsel’s cross-examinations raised questions
about whether her inpatient hospitalization and agitation in response to involuntary
injections is a principal trigger for her blood pressure spikes; and that the District’s
theory of injury to herself perhaps tests the boundaries of what counts as an
“injury” as contemplated by the statute. To be sure, we have found in other cases
that a person’s medical risks supported findings that the person’s mental illness put
her at risk of injuring herself. See, e.g., In re Artis, 615 A.2d at 1149-50, 1152
(concluding that the evidence was “ampl[e]” to support the decision that Ms. Artis
was likely to injure herself if not hospitalized where it showed, inter alia, that she
“refused to maintain a diet necessary to control her elevated blood pressure and
diabetes” and “refused to self-administer her [needed daily regimen of] prescribed
insulin despite several attempts at instruction by hospital staff”); id. at 1151 n.1 (“It
is precisely the union of mental illness with the inability of a person to adequately
care for herself that raises the inference of ‘danger’ and ‘injury’ to self and triggers
the statutory provisions.”); In re Gahan, 531 A.2d 661, 665 (D.C. 1987) (finding
ample evidence to support commitment where the government showed that “if
permitted to remain at liberty, Gahan would be a danger to herself,” specifically by
                                         15

statutory requirement that there be no “[less] restrictive alternative [to

commitment] consistent with the best interests of the person and the public.” D.C.

Code § 21-545(b)(2). On the record before us, we are persuaded that the trial

court’s findings as to this requirement were not supported by substantial evidence.

      The record raises more than uninformed speculation that D.D.’s danger-

productive outbursts could be the result of a neurological condition such as

dementia rather than the result of her diagnosed psychiatric condition.           As

described above, the Hospital’s neuropsychiatric team recommended further

testing to investigate possible neurological or neurocognitive contributions to

D.D.’s condition.    They opined after a limited examination of D.D. that “in

addition to the psychiatric issues, it’s a possibility . . . that she might have some

single neurological event, or some neuropsychiatric even[t].” As also described

above, Dr. Zaidi concurred that some of D.D.’s symptoms, such as her insensitivity

to social standards, could indicate such a neurological or neurocognitive disorder.

Further, he agreed that patients with some neurological or neurocognitive

conditions, such as Alzheimer’s disease, Parkinson’s disease, and dementia, may

have symptoms like those caused by schizoaffective disorder, including irritability

“not eating and . . . becoming severely dehydrated,” triggering “numerous other
medical problems that can come from that”). We need not decide, however,
whether D.D.’s medical risk is distinguishable from the risks at issue in those
cases.
                                         16

and agitation. And he acknowledged that it would be “important” to rule out such

a neurological/neurocognitive condition.

      Given the foregoing testimony, we are concerned about the timeline:

Dr. Zaidi’s testimony on June 1, 2022, that D.D. was scheduled for an MRI (part of

the recommended further testing) the day after his testimony, followed by a

representation by D.D.’s counsel on June 8, 2022 (immediately after the court

stated that it would grant the government’s petition), that the results of the MRI

were “abnormal” but had not yet been interpreted by or discussed with

neurologists.   In light of the trial court’s having received those signals of a

possibility that additional relevant evidence would soon become available, we are

unable to uphold the court’s adherence to its decision to order D.D.’s inpatient

commitment without waiting for an explanation of the test results (which might

have suggested that a memory care or dementia facility, for example, could meet

D.D.’s needs).14

      A second, related basis for reversal is this: insofar as the trial court’s order

authorized inpatient commitment of D.D., the record does not support that

inpatient commitment was the least restrictive alternative consistent with the best

      14
          We recognize that D.D.’s counsel explicitly lodged no objection to
proceeding to disposition on June 8, but we conclude that the trial court’s
finalizing its inpatient commitment ruling without awaiting a fuller explanation of
the MRI results was a plainly erroneous exercise of discretion.
                                         17

interests of D.D. and the public.       The government’s petition for inpatient

commitment was based almost entirely on the need for D.D. to receive involuntary

injections of her current psychotropic medication. Dr. Zaidi confirmed that he had

initially recommended her commitment to outpatient treatment, but modified his

position because he had come to understand that there was “no mechanism to

involuntarily administer [Ms.] D. her psychotropic medication if she is discharged

into the community.” But Dr. Zaidi did not “know for sure” whether a nursing

home, for example, would be able to administer involuntary injections, and he “just

guess[ed]” that a nursing home would not have the number of staff available to

restrain D.D. if she were to physically resist treatment. He agreed that “it could be

explored” whether a memory care or dementia unit would be able to administer

involuntary medications.

      “[I]t is the state’s burden to demonstrate the existence and unsuitability of

various treatment alternatives, not respondent’s, and it is the trial court’s

responsibility to ensure that the state meets this burden.” In re Stokes, 546 A.2d

356, 361 (D.C. 1988) (emphasizing that the trial court must play a “role . . . in

searching for treatment alternatives”). Here, neither the District’s nor the trial

court’s exploration of possible alternatives to inpatient hospitalization for D.D.

appears to have been particularly searching. We acknowledge that some evidence

was presented about the possible non-viability of certain alternatives.            A
                                          18

representative of one provider of “the most intensive outpatient services available

in the District” testified to the effect that her organization could not perform

involuntary injections. Ms. Bassil testified that D.D. has refused to discuss being

discharged to group housing or to a long-term-care or assisted living facility, and

D.D. herself told the court that the suggestion that she be placed in a nursing home

was “appalling.” Further, Dr. Zaidi explained that in light of COVID-19, bringing

D.D. to the Hospital for injections might not be feasible.          But, as we have

emphasized before, “[t]he statutory scheme in this jurisdiction does not limit the

court in a commitment proceeding to a polarized choice between indefinite

hospitalization and unconditional release: it makes the entire spectrum of

services . . . available, including outpatient treatment, foster care, halfway houses,

day hospitals, nursing homes, and others.” Id. at 360 (alterations in original)

(internal quotation marks omitted) (quoting In re Mills, 467 A.2d 971, 974-75

(D.C. 1983).15     The government did not show why one of those (or other)

      15
          See also In re Plummer, 608 A.2d 741, 749 (D.C. 1992) (Rogers, C.J.,
concurring) (explaining that the statutory scheme “has been construed to impose a
duty upon the courts to explore alternatives both within the mental hospital . . . and
outside the hospital, . . . and to require that the courts select the least restrictive
alternative which would serve the purposes of the commitment” (alterations in
original) (quoting In re Mills, 467 A.2d at 974-75)); cf. Lessard v. Schmidt, 349 F.
Supp. 1078, 1096 (E.D. Wis. 1972) (holding that the Constitution compelled the
state to establish the unsuitability of numerous alternatives to involuntary full-time
hospitalization before commitment could be ordered, including “voluntary or
court-ordered out-patient treatment, day treatment in a hospital, night treatment in
                                         19

alternatives could not be used in conjunction with, as necessary, administration of

D.D.’s injectable psychotropic medication by Hospital staff.16 See id. at 363-64

(observing, in vacating inpatient commitment order, that a dual-diagnosis program

specifically tailored to Stokes’s needs, which had already resulted in her making

improvements, had not been made available to her prior to initiation of the

a hospital, placement in the custody of a friend or relative, placement in a nursing
home, referral to a community mental health clinic, and home health aide
services”), vacated and remanded on other grounds, 414 U.S. 473 (1974).

      16
         In its January 25, 2022, Report and Recommendation to the trial court, the
Commission on Mental Health (the “Commission”) referred to D.D.’s “potential
[d]ementia” and also noted Dr. Zaidi’s testimony before the Commission stating
that it was not clear that D.D. has dementia but “acknowledg[ing] that elderly
patients who have [d]ementia have increased risks on [D.D.’s prescribed]
medication.” The Commission recommended, in a bolded and underscored
passage, “[t]hat the [trial court] order D.D.to undergo a medication review . . . to
determine if another medication regime can better address her symptoms and risk
of side effects, given her diagnosed and potential neurological conditions,” and
added that the review would “explore whether other medications could improve
her condition and enable her safe outplacement to the community.”
      We recognize that in determining its recommendations, the Commission is
not subject to a clear-and-convincing-evidence or other standard-of-proof
requirement. See In re Holmes, 422 A.2d 969, 971 (D.C. 1980). We also
recognize that, unlike in cases where the person whose commitment is
recommended has not made a timely demand for a trial, the statute does not
contemplate that the trial court’s decision is to be made “on the basis of the report
of the Commission, or on such further evidence in addition to the report as the
court requires.” D.C. Code § 21-545(a). We therefore cite the Commission’s
report (which, at oral argument, was analogized to a charging document) not as
evidence, but only as context for our observation that no evidence of a medication
review was presented at trial.
                                         20

proceeding to revoke her outpatient status, and that her doctor did not explain why

she “could not remain as an outpatient temporarily in lieu of indefinite inpatient

status”).

                                    IV. Conclusion

      A commitment order necessarily authorizes a substantial deprivation of

liberty and, accordingly, the government must justify the extent of that deprivation

with sufficient evidence. On the record before us, the government failed to meet

its burden of showing that inpatient commitment is necessary for D.D. to receive

appropriate treatment. Accordingly, we vacate the order of the Superior Court

ordering inpatient commitment. 17

                                        So ordered.

      17
          The District filed a supplementary appendix that contains (in addition to
some documents that were already part of the record) documents relating to D.D.’s
2020 commitment trial and February 14, 2020, Commission recommendation, and
portions of the District’s brief cite those extra-record materials. D.D. has moved to
strike the supplemental appendix and brief. Because we have resolved the issues
presented without referring to or relying on those materials, we now deny as moot
both the motion to supplement the record and the motion to strike.