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In re Perruso

April 13, 2006

IN RE EDITH PERRUSO, APPELLANT


Appeal from the Superior Court of the District of Columbia (MH-524-01) (Hon. Lee F. Satterfield, Trial Judge).

The opinion of the court was delivered by: Terry, Senior Judge

Argued January 8, 2004

Before FARRELL, Associate Judge, and BELSON and TERRY, Senior Judges.*fn2

This is an appeal from a trial court order revoking appellant's outpatient commitment to Saint Elizabeths Hospital and committing her as an inpatient "for an indefinite period." We are satisfied that the order is amply supported by the evidence of record, and thus we affirm.

I.

In August 2001 appellant was civilly "committed to the Department of Mental Health for an indefinite period to participate in an outpatient course of treatment," pursuant to Super. Ct. Mental Health Rule 16.*fn3 The court noted in its order the conditional nature of this outpatient status, stating "[t]hat if the Respondent fails to abide by the treatment regimen or if the mental condition of the Respondent deteriorates, respondent may be returned to inpatient hospitalization."*fn4

About a year later, in August 2002, appellant was rehospitalized at Saint Elizabeths Hospital because of paranoid and delusional behavior. Appellant's refusal to take her medicine had caused her to become unstable and increasingly agitated, irritable, and confused. After the Department of Mental Health filed a timely notice of rehospitalization, the court found probable cause to keep her in the hospital pending the outcome of a full hearing.

Dr. Alican Dalkilic, appellant's treating psychiatrist, was the only witness at that hearing, which was held a few weeks later. He testified that appellant was brought to the hospital by the police after her case manager requested their aid because appellant had stopped taking her medication, started to become manic,*fn5 refused to let the ACT team*fn6 enter her home, and failed to attend an appointment with her treating psychiatrist. In addition, appellant became paranoid, stating that Dr. Hornett (one of her treating physicians), her case manager, and her guardian were "doing things behind her [back], trying to get into her bank accounts." She also asserted that "the nurses and doctors [were] trying to destroy her mind and poison her."

After appellant came to Dr. Dalkilic's ward, her paranoia and delusions "improved somewhat," but not enough to justify releasing her back into the community. The doctor stated that appellant's recent "marginal improvement" was directly connected to the resumption and adjustment of her medication following her readmission to the hospital in August 2002. According to Dr. Dalkilic, appellant's delusions become "very intense," causing changes in her behavior, when she stops taking her medication. In the past, appellant has demonstrated that she becomes "optimally stabilize[d]" only when she took her medications. On at least five such occasions she was released into the community, but she soon stopped taking her medications and had to be returned to the hospital.

Dr. Dalkilic described a "multi-disciplinary team" made up of a social worker, one or more nurses, a psychiatrist, and treating residents who collectively determine whether a patient is fit to become an outpatient again by considering her general psychiatric history, her ability to function in the community, her ability to care for herself with the proper food, clothing, and shelter, and her ability to adhere to any ongoing treatment regimen. In appellant's case, the doctor said, there was no direct evidence that she would harm anybody or put herself in danger. Appellant does not have a history of violence associated with her mental condition and probably would not be dangerous to others if released from the hospital in almost any condition. However, the doctor was unwilling to recommend her immediate release from the hospital because she acts on her delusions and thus "might very well put herself inadvertent[ly at] risk" of sustaining an injury "due to impaired judgment and psychotic behavior." Until she shows insight into her illness and recognizes that she must take her medication to prevent the delusions, Dr. Dalkilic opined, appellant should not be released.

At the time of the hearing, appellant was still suffering from delusions that impaired her judgment.*fn7 Dr. Dalkilic opined that she could put herself in danger by acting on those delusions. For example, the doctor cited a recent episode in which appellant left her apartment in the middle of the night without telling anyone where she was going. At other times, she randomly visited her neighbors' apartments because she thought they were spying on her. In addition, each time appellant has been released in the past,*fn8 she has stopped taking her medications at some point thereafter, thus making it necessary to hospitalize her again. Her failure to take her medications, the doctor said, led directly to increased delusions and hence an increased risk of hurting herself. Dr. Dalkilic urged the court to make sure that appellant would be stable and show insight into her disease before releasing her, so that she would have the optimal chance of remaining in outpatient status. Consequently, Dr. Dalkilic concluded that the least restrictive alternative for appellant would be inpatient hospitalization - at least for "another four to six weeks, until we optimally stabilize her."

The court stated that Mental Health Rule 16 required appellant's outpatient commitment to be permanently revoked to keep her in the hospital until she was optimally stable. "To accomplish the things that need to be accomplished for her to be safe at this time," the court said, revocation of her outpatient status was necessary because "she's not stable enough at this time to be released to outpatient treatment." The court concluded that revocation was "the least restrictive alternative" for appellant and urged her to "work with the doctors" so that she could go "back home soon." Finally, the court emphasized that no alternative other than revocation had been offered or proposed by either party. In the written order which followed, the court declared that appellant "continues to suffer from a mental illness," exhibiting "multiple symptoms," and that she "is currently in need of inpatient psychiatric hospitalization for an indefinite period, which is the least restrictive treatment alternative treatment for [her]."

II.

Appellant argues that the evidence was insufficient to meet the "clear and convincing evidence" standard of D.C. Code ยง 21-548 (a) (2005 Supp.), which must be met before a civilly committed outpatient "may be transferred to a more ...


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