MEMORANDUM OPINION
JOHN
D. BATES UNITED STATES DISTRICT JUDGE
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]
BACKGROUND[3]
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.
DISCUSSION
"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 ...