Court Ordered Medication Compliance

Court-Mandated, Long-Acting Antipsychotic Medication as a Condition of Supervised Release

​United States v. Holman, 532 F.3d 284


In this matter, the court must consider the consequences of its role to protect patients and the public v the importance of preserving a patient's civil liberties. Patient contends that enforcing medication compliance via long acting injection is an infringement on his civil liberties and that if the instant court ordered such its actions would "violate his constitutionally protected liberty interest in refusing the unwanted injections." The appellate court found that despite the objections that appellant raised, the history and nature of the patient's behaviour made him a danger to others and himself and thus outpatient medication compliance could be court ordered while remaining within the legal framework of due process requirements set forth in (in re Harper and Sell).

Patient at the time had been detained for several drug and weapons charges. During his detention, he alternated between compliance with treatment and medication and refusing oral and IM medication. He was diagnosed as schizoaffective bipolar type. When not medicated, his symptoms of mania and depression returned. After another period of refusing medication, patient was referred to a psychiatric detention center. There an involuntary medication treatment hearing was convened and the patient ordered to take oral risperidone. Patient was subsequently released from his detention facility. His treating psychiatrist provided patient with a supply of oral risperidone and instructions that patient should be given a depot injection of risperidone to prevent future noncompliance. Patient continued treatment for a period of time after his release. At the time the conditions of his release did not stipulate that he must partake in outpatient treatment of his condition. Soon after his parole officer filed a petition to request that the special conditions of patient's release include that he be medication compliant. The instant court convened and found granted the petition finding that patient be required to comply with treatment and all medications set forth by his outpatient psychiatrist. The order by the instant court mandated that the patient be treated specifically with depot risperidone. 

After the order was issued by the lower court, the patient left his residence without his medication, suspended contact with his family, and missed mandatory parole officer appointments. Patient was arrested several weeks later after found in an altered mental state. After his condition was treated and stabilized, patient appeared before the district court for a hearing regarding violation of his parole. The court sentenced patient to 11 months for violation and a subsequent 49 months of supervised released with prior special conditions set forth. 

After his second release, patient had violated the terms of his parole again by refusing his IM injection of risperidone. Another petition was filed alleging his noncompliance by his parole officer. Patient was arrested again and evaluated to determine capacity. The court found that he was incompetent and he was committed once more for treatment. The district court ordered that he be detained and released later with special conditions for release. The patient filed a timely appeal challenging the special conditions that the instant court set forth. Patient did not object to the mandatory treatment of his condition but did file an objection to the mandatory IM injection of risperidone. He contends that IM antipsychotics "generally have the potential for severe or even fatal side effects[2]; for [patient], the side effects of the injectable medications are more significant and unpleasant than those of oral medications. patient argues that the government failed to establish that the injections were medically necessary and that no less intrusive alternative would suffice, and [patient] therefore argues that the special condition of supervised release imposed by the district court violates his constitutionally protected liberty interest in refusing the unwanted injections".

This opinion follows.

The reviewing court addresses two main legal matters in their opinion; Sell v. United States, 539 U.S. 166 and U.S.C.A. § 3553(a) (d)(1). U.S.C.A. § 3553 (d) contends with the matter of whether special conditions may be applied and whether they are constitutionally overboard.  

The appellate court notes first and foremost that the local district courts are required to impose special conditions with each supervised release issued. These conditions can be set forth and enforced should they be:

(1) is reasonably related to the factors set forth in [18 U.S.C.A. § ] 3553(a)(1), (a)(2)(B), (a)(2)(C), and (a)(2)(D);
*288 (2) involves no greater deprivation of liberty than is reasonably necessary for the purposes set forth in section 3553(a)(2)(B), (a)(2)(C), and (a)(2)(D); and
(3) is consistent with any pertinent policy statements issued by the Sentencing Commission pursuant to 28 U.S.C. 994(a).

§ 3553(a) (d)(1) refers to the role of the defendant's criminal and mental history,  characteristics, and the nature and circumstances of originating offense for which the he was convicted. In addition, the court may consider the need to deter from future crime and the protection of the public. The court must also consider the need to provide the defendant with the appropriate medical care that fits within the previously mentioned framework. The courts are granted latitude with administration of these special conditions and the purpose of the reviewing court's opinion is to examine whether there was an abuse of discretion in applying § 5335 (d).

The court argues that this special condition fits the statutory requirements set forth in § 3583 (d) for the following reasons. The court notes that the patient's prior history of severe mental illness was poorly managed without medication. With the proper administration of medication, patient's symptoms were minimal and posed no risk to himself or others. The court noted patient's violent and disruptive behaviour off of his medication. Drawing from patient's extensive detentions and placement in prison psychiatric facilities, the court reasonably assumes that the special condition of medication compliance is appropriately related to the safety of the public and the treatment needs of the patient as mandated by the legislature.

Because [patient] has consistently demonstrated his inability to comply with a treatment plan centered on oral medication, the requirement that he take the medication by way of injection is the least intrusive way of furthering these important governmental purposes. The government therefore contends that the district court properly required as a special condition of supervised release that [patient] receive injections of prescribed antipsychotic medication.

Patient appeals stating that the special condition should be an extension of the sentencing process and play a direct role in the sentencing and not impose unnecessarily on his rights. By imposing these special conditions, the instant court unnecessarily deprived him of his civil liberties. 

The special condition at issue in this case implicates Holman's fundamental liberty interest in refusing to take medications that substantially change his personality and carry a significant risk of dangerous side-effects. [Patient] thus contends that the nature of the interest affected by the special condition requires us to scrutinize with more care the district court's decision to impose the condition.

The supreme court cites in its opinion the case of Sell v. United States, which found that the courts have "a constitutionally protected liberty interest in avoiding involuntary administration of antipsychotic drugs an interest that only an essential or overriding [governmental] interest might overcome."  The reviewing court notes that in this case, the instant court found that the extenuating governmental interest would be the protection of the public from potentially dangerous behaviour and that involuntary treatment would be the appropriate remedy. Even though involuntary treatment is constitutionally impermissible on its own absent a finding of an overriding justification or finding of medical necessity, the court found that the instant court had made an appropriate show of cause with patient's history and noncompliance. 

If the involuntary treatment order lies on the individual dangerousness to the public, the instant court must satisfy the due process clause through a show that with treatment is appropriate and is the least restrictive option. In other cases, the court must show that in leu of the facts of the case, bringing the matter to trial is sufficient enough. The court must show that involuntary treatment will significantly further its interest in the public and welfare of the patient by showing that "administration of the drugs is substantially likely to render the defendant competent to stand trial" but yet "substantially unlikely to have side effects that will interfere significantly with the defendant's ability to assist counsel in conducting a trial defense." 

The reviewing court found that the statute allowed for a looser association between the special conditions and the overall goal of sentencing. The court reminds again that the conditions of release be no more restrictive than reasonably necessary to reach the goal of sentencing. 

The reviewing court found that the instant court had imposed the special conditions to protect patient from himself and to protect the public. The record supports the court's finding though his psychiatric decompensation and behaviour off of medication. The court's interest in protecting the public and patient from himself overrode any civil liberty interests at stake and that the evidence proffered was enough to satisfy the previously discussed statutory requirements. In regards to the patient's dangerousness, the court found that the court's order was specific enough to address the patient's situation and circumstances. The court found that the order was not just a rubber stamp solution. Again the reviewing court notes the established incidents of patient being a danger to himself and others with his multiple arrests and erratic behaviour. The supreme court found that the instant court had met its burden of meeting the Sell criteria of advancing the government's interests in protecting the person and the public when issuing its medication order.

The record also established that involuntary treatment was medically appropriate given that patient had a long history of non compliance and refusal of IM injections. The patient treating physician opined that IM injections were the best route of administration given the patient's long history of noncompliance and risk of discontinuation. His treating doctor also opined that he was completely dependent on medication in order to function without impairment.

Based on the composite of information, the reviewing court found that the instant court did not abuse its discretion and that there was plenty of evidence that supports the imposition of the special conditions mandating the patient receive IM injections as part of his conditional release. Because the instant court decision fell within the due process requirements set forth by Sell  and § 3583 (d), the decision did not infringe upon any constitutional liberties. 
The special condition is reasonably related to the need to protect the public and the need to provide the defendant with appropriate medical care, see 18 U.S.C.A. § 3583(d); Dotson, 324 F.3d at 260, and the involuntary medication order involves no greater deprivation of liberty than is reasonably necessary to further these governmental interests.














Procedural Posture
After defendant was released from prison and began serving a term of supervised release, the U.S. District Court for the Eastern District of Virginia imposed as a special condition of supervised release a requirement that defendant participate in mental health treatment and take all prescribed medication, including intramuscular injections of an antipsychotic drug. Defendant sought review of the special condition of his supervised release.


Overview
Defendant's initial supervised release included a requirement that he receive mental health care and take his prescribed medications. Defendant violated the terms of his release by not taking his medications, and he was found wandering aimlessly and in a partially catatonic state. Thereafter, the conditions of release were modified to include as a special condition that defendant receive intramuscular injections of a certain drug. On appeal, defendant argued that requiring him to submit to the intramuscular injections violated his constitutionally protected liberty interest in avoiding the unwanted administration of antipsychotic drugs. In rejecting this argument, the court held that the district court's decision was consistent with the due process requirements set out by the U.S. Supreme Court in Harper and Sell as well as with 18 U.S.C.S. § 3583(d). In particular, the court found that the special condition was reasonably related to the need to protect the public and the need to provide defendant with appropriate medical care. The involuntary medication order involved no greater deprivation of liberty than was reasonably necessary to further these governmental interests.


Outcome
The court affirmed the district court's decision