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United States v. Gamarra

United States District Court, District of Columbia

October 19, 2018




         The government moves to involuntarily medicate defendant Jean-Paul Gamarra, who suffers from mental illness, to render him competent to stand trial. Pursuant to Sell v. United States, the Court must determine whether "in light of the efficacy, the side effects, the possible alternatives, and the medical appropriateness of a particular course of antipsychotic drug treatment, [the government has] shown a need for that treatment sufficiently important to overcome the individual's protected interest in refusing it." 539 U.S. 166, 183 (2003). Upon consideration of the pleadings, the testimony presented at the Sell hearing before Magistrate Judge Deborah A. Robinson held on April 13, 18, and 20, 2018, [1] and the entire record herein, the Court will grant the government's motion.[2]


         Gamarra was arrested outside the White House on March 28, 2017, after approaching United States Secret Service Officers with a package that he claimed contained a detonator for a nuclear device. Gamarra, 308 F.Supp.3d at 231. He was indicted for threatening the President' in violation of 18 U.S.C. § 871 and threatening and conveying false information concerning the use of an explosive device in violation of 18 U.S.C. § 844(e). Id. at 232. The government represents that Gamarra's "threatening conduct caused a significant area of the District [of Columbia] to be closed to traffic and commerce for approximately an hour and forty minutes." Gov't's Mot. to Medicate Involuntarily Def. to Restore Competency [ECF No. 22] ("Gov't's Mot.") at 6. Gamarra was found to have a mental disease that rendered him incompetent to stand trial, and he was hospitalized at Federal Medical Center ("FMC") Butner for further evaluation pursuant to 18 U.S.C. § 4241(d). Gamarra, 308 F.Supp.3d at 232.[4]

         At FMC Butner, forensic psychologist Evan S. Du Bois, Psy.D., and predoctoral psychology intern Kelsey L. Laxton completed a forensic evaluation, ultimately concluding that Gamarra remained "not competent to proceed to trial" but that "his competency is likely to be restored with adherence to a medication regimen." Gov't's Ex. 2 ("Forensic Evaluation") at 14.[5]FMC Butner Staff Psychiatrist Dr. Logan Graddy provided a forensic addendum and treatment plan that similarly concluded that administration of antipsychotic medication was medically • appropriate, that other interventions were unlikely to be beneficial without medication, and that the benefits of medication would outweigh the risks. Gov't's Ex. 11 ("Forensic Add. and Treatment Plan") at 1, 3.

         The government orally moved to have defendant involuntarily medicated, and the . defendant opposed the motion. Magistrate Judge Robinson held a Sell hearing over three days in April 2018 at which Dr. Du Bois, Laxton, and Dr. Graddy testified for the government. The defendant did not present any witnesses.

         Dr. Du Bois, whom the court qualified as an expert in clinical forensic psychology, testified that, in his opinion and to a degree of professional certainty, Gamarra suffers from "schizophrenia, continuous," based on observations of delusional ideation, disorganized speech, and possible auditory hallucinations. 4/13/18 Hr'gTr. at 55:9-11; 58:3-10. Dr. Du Bois opined that Gamarra was not competent to stand trial because, although Gamarra exhibited a basic factual understanding of court proceedings in general, his understanding of his case and the charges against him were "rooted in his delusional beliefs, which were a result of his schizophrenia." Id. at 64:1-23. Dr. Du Bois further opined that Gamarra would have difficulty testifying because he "would have difficulty communicating clearly and organizing his thoughts and testimony" and because his mental illness made it possible he would incriminate himself. Id. at 64:24-65:14. Dr. Du Bois concluded that Gamarra's disorganized speech would also impair his ability to consult with . counsel. Id. at 65:15-25.

         Dr. Du Bois testified that he did not recommend individual therapy in place of antipsychotic medication because delusional beliefs, like those to which Gamarra ascribed, "often -don't respond to behavioral or therapy techniques." Id. at 94:24-95:11. He and Laxton "attempted to challenge some of [Gamarra's delusional] beliefs or introduce evidence that would oppose them, which is the recommended method for opposing or trying to change delusional beliefs, . . . [but this course of treatment was] not effective." Id., at 95:12-17.

         Laxton, who was qualified as an expert in clinical forensic psychology without objection, [6]testified that, in her opinion and based on a reasonable degree of professional certainty, Gamarra suffers from "schizophrenia, continuous," and was not competent to stand trial. Id. at 13:10-15, . 18:8-19, 20:12-18. In particular, Laxton testified that while Gamarra had a factual understanding of the court proceedings, including an understanding of basic legal terminology and concepts, he had "some difficulty rationally understanding the proceedings against him, especially the potential consequences of his case." Id. at 21:6-22. She explained that Gamarra's understanding of the charges against him and his defenses to those charges were themselves rooted within his delusional belief system. Id. at 22:23-23:10. As a consequence, she opined that Gamarra lacked capacity to testify because his condition made it difficult for him to communicate "in a clear and coherent way . . . without discussing further his delusional belief systems" and because he would "likely . . . incriminate himself without realizing that he was doing so." Id. at 23:14-24:8. For essentially the same reasons, Laxton concluded that Gamarra also lacked capacity to consult with counsel. Id. at 24:9-19. In addition, Laxton noted that Gamarra's delusional beliefs around electric waves, computers, and telephones would affect his competency to stand trial; for example, "in the courtroom, he thought that the presence of the telephone would be detrimental to him or his case or even have some physical impact on [the] judge . . . ." Id. at 22:6-22.

         Laxton also testified that, in her opinion, administration of antipsychotic medication was a "key piece" of Gamarra's treatment plan that would be "necessary to get [Gamarra's] symptoms in control to a point that he would be competent to stand trial," and it was "unlikely" that Gamarra's condition would improve without medication. Id. at 37:10-38:9. Though staff had "encouraged Mr. Gamarra to take medications," Laxton explained that Gamarra refused to take antipsychotic medications at various times while at Butner because of his beliefs that "he had ... died previously taking another medication," "that he does not have a mental illness and does not need those medications," and that his religion prohibited taking what he believed were addictive medications. Id. at 26:21-27:10; 37:20. Ms. Laxton observed, however, that during her examination Gamarra communicated more clearly on medication and that this improvement was corroborated by reports from Gamarra's family (and Gamarra himself) that antipsychotic medication improved Gamarra's condition. Id. at 27:23-28:18. Gamarra's family members reported that he was "highly intelligent and functioned well when he [had] complied with medications" in the past. Id. at 28:4-8. Laxton herself observed that Gamarra "communicated slightly better" during the brief periods at FMC Butner when he was "more compliant with [prescribed antipsychotic] medication." Id. at 28:16-18.

         Dr. Graddy, whom the court qualified as an expert in the field of forensic psychiatry, testified that, in his opinion and based on a reasonable degree of medical certainty, Gamarra suffers from "schizophrenia, multiple episodes, currently in[ an ]active episode." Id. at 112:2-11; 114:8- 15. Dr. Graddy did not meet Gamarra in person, but he "reviewed the full record" before making his diagnosis. Id. at 114:8-115:10. His diagnosis, in contrast to Dr. Du Bois and Laxton's diagnosis of "schizophrenia, continuous," was based on his observation that "Gamarra has gotten better in the past on medications, significantly better, such that I have classified him as having multiple distinct episodes rather than one continuous episode." Id. at 115:19-25.[7]

         Dr. Graddy noted several studies indicating that antipsychotic medications restored competency in more than seventy-five percent of defendants suffering from schizophrenia and other psychotic disorders. Of particular relevance, Dr. Graddy cited a 2012 study in which 62 of 81 defendants diagnosed with schizophrenia were restored to competency with antipsychotic medications, for a restoration rate of approximately 76%. See 4/18/18 Hr'g Tr. at 40:20-41:18 (discussing Gov't's Ex. 10 at 3). Although Dr. Graddy did not directly evaluate Gamarra's competency, Dr. Graddy noted that Gamarra "appears ... to be consistent with other ... defendants who did regain their competency when treated with antipsychotic medication" and that this conclusion was "stronger" because Gamarra "has documented improvement on antipsychotic medication in the past." 4/13/18 Hr'g Tr. at 116:1-11. Dr. Graddy testified that antipsychotic medications "are generally safe and effective" and that "patients with schizophrenia or schizoaffective disorder ... need medications to improve" because "[o]ther treatments are not very effective for these conditions." Id. at 118:11-24. Dr. Graddy did not believe that other, less-invasive treatments would be effective. Id. at 121:10-13; 143:4-8. Dr. Graddy stated that he would propose beginning Gamarra's treatment with the antipsychotic medication risperidone because it "is a medicine he took in the past" that he "appeared to tolerate . . . well" and that had been documented to "improv[e] ... his mental state." Id. at 123:15-18.

         In addition, Dr. Graddy opined that medication would be "medically appropriate," particularly since "he appears ... to be a patient who does get better with treatment." Id. at 120:11-19. Dr. Graddy explained that antipsychotic medication is the course of treatment he would recommend to Gamarra "if he were to come and see me with this complaint in the community" or "[i]f his family were to approach me" seeking advice on treatment. Id. at 122:11-23. He also noted that antipsychotic medications were prescribed to Gamarra "every time he's gone into the hospital." Id. Dr. Graddy also highlighted that he considered risperidone "one of our best medications" for treating patients with schizophrenia-type diagnoses, even in light of the potential risk of side effects. 4/20/18 Hr'g Tr. at 43:1-12.

         As to potential side effects, Dr. Graddy testified that antipsychotic medications are known to have a significant risk of serious side effects, including acute dystonic reactions (involuntary muscle contractions), parkinsonism (characterized by muscle rigidity, tremors, and decreased spontaneous facial expressions), dyskinesias (characterized by involuntary grimacing, tongue movements, rapid blinking, and rapid limb movement), and akathisia (uncomfortable inner restlessness). 4/18/18 Hr'g Tr. 22:15-24:6; 31:22-32:16; 38:6-40:19. Dr. Graddy testified that various studies suggested that the reaction rates for antipsychotic medications generally ranged from two to ten percent for dystonic reactions, up to fifty percent for parkinsonism, up to thirty-two percent for dyskinesias, and up to thirty percent for akathisia. Id. at 24:23-25:1; 33:7-25; 39:3-9; 40:6-11.

         He opined, however, that if Gamarra were medicated, any side effects that Gamarra might experience would be closely monitored and managed by medical staff, either by adjusting the dosage of antipsychotic medication, prescribing a different antipsychotic medication, or by treating the side effects with other medications. 4/13/18 Hr'g Tr. at 122:24-123:25. Dr. Graddy acknowledged that Gamarra's medical records noted that he had "complained of some neuromuscular symptoms," particularly "stiffness," in response to risperidone, which a treating physician would "watch closely if we have to treat him with that" medication. 4/20/18 Hr'g Tr. at 36:19-37:3. But because negative reactions tend to "occur early in treatment" and would be noted by medical providers, Dr. Graddy believed the risk of Gamarra experiencing, for example, a dystonic reaction while taking risperidone to be "fairly low since he's tolerated [this] medicine in the past." Id. at 25:12-16; 28:2-4; 4/20/18 Hr'g Tr. at 36:7-13; see also 4/20/18 Hr'g Tr. 19:22- 20:2 (Dr. Graddy explaining his use of past medical records in recommending medication to patients). Furthermore, any side effects from the medication would be "very unlikely to cause him to not be able to be competent" to stand trial. 4/13/18 Hr'g Tr. at 120:20-7. In all, despite the risks of side effects, Dr. Graddy stated that "from a medical perspective, benefits of treatment, in my opinion, outweigh the risks." Id. at 120:16-19.


         "Although an individual has a constitutionally protected interest in avoiding involuntary .

         medication, that interest can be overcome by an 'essential' or 'overriding' state interest in some circumstances." United States v. Dillon, 943 F.Supp.2d 30, 34 (D.D.C. 2013), affd. 738 F.3d 284 (D.C. Cir. 2013) (quoting Sell, 539 U.S. at 179-80). The Supreme Court in Sell "prescribed a detailed, four-part inquiry for district courts to undertake prior to authorizing involuntary medication to restore defendants to competency." United States v. Dillon, 738 F.3d 284, 290 (D.C. Cir. 2013). Pursuant to Sell,

a court may order the administration of medication to render a mentally ill defendant competent to stand trial on criminal charges if:
(1) doing so advances an important government interest, such as bringing to trial an individual accused of a serious crime;
(2) the medication is substantially likely to render defendant competent to stand trial[] and substantially unlikely to have side effects that will interfere significantly with defendant's ability to ...

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