Court Opinion

ID: 5178015
Source: CourtListenerOpinion
Date Created: 2022-01-06 01:18:47.482798+00
Date Added: 2024-06-11T08:26:26.846775
License: Public Domain

JUDGE CASEBOLT,
concurring part and dissenting in part.
1 23 I fully concur with the majority's conclusion that the principles articulated in People v. Medina, 705 P.2d 961, 973 (Colo.1985), apply in determining whether an increase in medication dosage over a respondent's objection may be ordered by a court I part company with the majority, however, in its determination that the trial court misapplied the "deterioration" element set forth in Medina in finding that the increase for respondent, Larry Wayne Marquardt, was necessary to prevent a significant and likely long-term deterioration in his mental condition. In my view, the majority interprets that factor in too restrictive a manner and without sufficient regard for the full test that Medina directs. Accordingly, I respectfully. dissent from the majority's reversal of the trial court's order authorizing an increase in the dosage of the medication Marquardt was voluntarily taking.
T24 In Medina, the court articulated a four-part test for trial courts to apply in determining whether to order the administration of antipsychotic medication against the 'wishes of a mentally ill person. The pertinent part of the test that is at issue here is whether the proposed treatment is "necessary to prevent a significant 'and likely long-term deterioration in the patient's mental condition." Id. The majority holds. that the trial court's interpretation and application of that standard to the facts is erroncous. But in doing so, the majority falls to consider the complete test:
The[ ] determin[ation] whether the proposed treatment is necessary ... to prevent a significant and likely long-term deterioration in the patient's mental condition.... involves a consideration of two alternative factors, 'The first is the patient's actual need for lthe medication. [The court should foeus on the nature and gravity of the patlent’s illness, the extent to which the medication is essential to effective treatment, the prognosis without the medication, and whether the failure to medicate will be more harmful to the patient than any risks posed by the medication. The alternative factor involves the issue of physical safety.
1d.
125 The majority, in my view, fails to recognize and apply the noted factors and instead views "deterioration" in isolation, noting that Marquardt is stable on his current dosage. It also holds that the deterioration *658factor does not include the ability to order medication solely to improve a patient's condition or his participation in treatment,. In doing so, the majority ignores the nature and gravity of Marquardt's illness, the extent to which the increased dosage is essential to his effective treatment, and his prognosis without the increased dosage. It also fails to consider whether the failure to medicate Marquardt will be more harmful than the risks posed by the medication. Employing those elements here, the following evidence supports the trial court's conclusion that the increased dosage was necessary to prevent. a significant long-term deterioration in Mar-quardt's mental health. |
1 26 The treating psychiatrist tendered an affidavit to the court, which included a copy of his seventeen-page psychiatric assessment. In the affidavit, the psychiatrist opined that all the information submitted.. "documents clearly that [Marquardt] is continuing to deteriorate in his level of functioning, using his considerable intelligence to work against any treatment plans. that mean to change his thinking. He is profoundly mistrustful of treatment professionals." The psychiatrist went on to state that Marquardt's "medication has been only partially effective in stabilizing his psychosis and reducing his violence and threats.... I am now trying to determine whether Saphris will be effective in controlling his illness and cannot do so until I raise his dosage above his current dosage." The psychiatrist documented his consultation with a clinical pharmacist and noted that half of the patients at the Colorado Mental Health Institute in Pueblo (CMHIP) who were taking Saphris found a ten milligram dose a day effective in helping control the illness and the other half required fifteen or twenty mxlhgrams a day before it became effective.
127 The psychiatrist then set forth his diagnosis of Marquardt and discussed how the current ten milligram dose of Saphris was not controlling Marquardt's condition:
Mr. Marquardt is showing Perseeutory Delusions along with Grandiose Delusions 'that prevent him from learning from reality experience and teaching. He also previ-. ously: showed command auditory hallucinations that were part of his Instant Offense and which are, now, partially controlled with his current dose of Saphris. He believes he can make the same judgments physicians make, by virtue of his readings. Indeed, he denies he has a mental illness and cannot grasp that medications can prevent his illness from leading to violence.
1 28 The psychiatrist then opined that the increase in dosage was necessary to prevent the significant and long-term deterioration in Marquardt's mental condition and to prevent the likelihood of causing serious harm to others in the institution, He concluded the affidavit by noting that he had advised Marquardt that if he did fot take the medications, the adverse effects would be dangerous behavior, paranoid delusions of persecution and grandiosity, personality deterioration, institutionalization, and inability to gain discharge to the community.
129 At the hearing, the psychiatrist noted that Marquardt had. been admitted to CMHIP with a thirty-year mental illness and aA hlstory of violence, and that his latest incident involving violence was an attack upon his mother, which had precipitated an attempted ' murder charge. According to Marquardt, she had been harassing him, and "he glot] electronic transmissions that tell him that his members of his family are harassing him." He had been adjudicated not guilty by reason of insanity. The psychiatrist also noted that Marquardt had previously been hospitalized, but had been able to be discharged when he was court-ordered to take medication. '
€30 The psychiatrist testified that Mar-quardt had accepted a ten-milligram dose of Saphris, but opined that this dosage was "subtherapeutic, because he's 'only partially responding to this medication. And he's been on it for many months," He further testified that he did not believe Marquardt had reached therapeutic benefit from the current dose because "he continues to deny that he is mentally ill," He opined, based on the psychiatric assessment, his affidavit, and the other reports he had viewed and submitted, that in the absence of the ability to treat Marquardt with Saphris up to twenty milligrams per day, Marquardt would have a *659significant and likely long-term deterioration in his mental condition because "there has been continuous de-compensation and deterioration over time, in this patient."
1] 31 During eross-examination, the psychiatrist testified that Marquardt's illness was "only going to get worse, the longer it goes untreated. And this treatment that he's got now is partially effective. ... He takes medications just because he doesn't want to have to deal with the voices. And the ... medication does make the voices go away.. So he stays only on that level. And his delusions prevent him from going any further in admitting that he is ill."
[ 32 Upon completion of cross-examination, the court questioned the psychiatrist, asking, "You'd indicated that he had not deteriorated since he's been here. Do you have any reason to believe that he's going to deteriorate further, if he doesn't have the increase in medication?" The witness responded:
[Mly view is that he arrived in a deteriorated condition. And he is so intelligent that he is able to function reasonably well, while in a hospital, under protected structure, and that the structure helps him function. But his level of function is still not where it needs to be, for him to be moved forward, or to benefit from the groups that he's going to, and learning what he needs to know, in order to eventually be released. And so, the deterioration is manifested by continuing delusions of persecution and grandiosity that control his thinking, while the hallucinations appear to be absent at this point. The delusions are still present, And that is the sign of deterioration I am concerned about.
When the court inquired, "But there's no evidence that he's going to get worse, than he is, right now?" the witness replied, "I can't say that he's going to get. worse at this point, He may be able to hold it together."
1388 The majority relies upon these latter statements responding to the court's questions for its conclusion that the court misinterpreted and misapplied the "deterioration" portion of the Medina test. But considering the nature and gravity of Marquardt's illness, the extent to which the increase in medication is essential to his effective treatment, his prognosis without the medlcatlon, and that the failure to increase the dosage will likely be more harmful to Marquardt than the slight risk of tardive dyskinesia, in my view the court correctly interpreted and applied the deterioration factor. Indeed, when considering the issue of physical safety, which is another factor in the deterioration test, the psychiatrist's testimony supports the view that Marquardt may be a greater risk to the physical safety of others in CMHIP on the lower dose of medication.
[ 34 In sum, the majority's conclusion fails to consider all the Medina "deterioration" elements, and could lead to unintended consequences. Essentially if, as here, a treating psychiatrist starts a patient on a dosage of medication that fails to yield optimal therapeutic results, the majority's understanding of the "deterioration" eriterion could prevent any increase in the chosen medication dosage. I do not view that interpretation to be sound,
135 Although the majority does not (and need not) discuss the remaining Medina factors, I conclude that the People presented sufficient clear and convincing evidence to satisfy the remaining factors. Therefore, I respectfully dissent from the majority's reversal of the order.