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State Court Ruling Could Complicate Treatment

"Alaska's patients and clinicians will be spending a great deal more time in court and less time in treatment," says leading forensic psychiatrist Paul Appelbaum, M.D., after a controversial court ruling.

An Alaska Supreme Court decision adds a new layer of judicial oversight in determining whether involuntary treatment of patients with psychiatric illness is in the patients' best interest.

The court ruled that state constitutional guarantees of liberty and privacy require an independent judicial determination of an incompetent mental patient's best interests before authorizing treatment of patients with psychotropic drugs.

"We hold that in future nonemergency cases a court may not permit a treatment facility to administer psychotropic drugs unless the court makes findings that comply with all applicable statutory requirements and, in addition, expressly finds by clear and convincing evidence that the proposed treatment is in the patient's best interests, and that no less-intrusive alternative is available," the court ruled in June in the case Faith Myers v. Alaska Psychiatric Institute.

According to a brief filed by lawyers representing the Alaska Psychiatric Institute (API), a state psychiatric facility, Faith Myers had been diagnosed with schizophrenia and had been hospitalized several times, including at API.

In recent years, Myers became convinced that her medications were causing her illness, and in 2000 she weaned herself off all medication, according to the state's brief. In January 2003, after a period of homelessness, she moved into an apartment.

"Her daughter, who visited several times, was alarmed by the apartment's condition, including its uncleanliness, garbage, piles of dirt and pinecones, clothing rather than food in the refrigerator, food left by her mother to feed wild animals, and items including a pillow, blanket, reading material, and food left in the dirt-floored, shared crawl-space under the apartment," according to the brief.

In time, the manager of the apartment requested Myers' family to remove her from the apartment, and in February 2003 she was involuntarily committed to API. Because treatment staff at API believed Myers was incapable of giving informed consent for medication, they filed a petition for court-ordered administration of medication with their involuntary commitment petition in late February 2003.

The court held a hearing on the petition on March 5 of that year and granted API the right to treat Myers involuntarily. The court's medication order was stayed pending appeal to the Alaska Supreme Court, and Myers was discharged from API without the medication order having been implemented, according to the state's brief.

"Perhaps most troubling was the court's reliance on legal literature summarizing the effects of antipsychotic medication from the 1970s."

Attorneys from the Law Project for Psychiatric Rights, an Anchorage-based group opposed to court-ordered psychiatric medication, argued on behalf of Myers that the court order violated her constitutional rights. The group also presented evidence, including testimony from two psychiatrists, stating that antipsychotic medication was not necessarily in the patient's interest.

"By requiring the least-intrusive alternative to forced psychiatric drugging, this decision has the potential to change the face of current psychiatric practice, dramatically improving the lives of people who now find themselves at the wrong end of a hypodermic needle," said Jim Gottstein, an attorney for the group representing Myers, in a statement following the ruling.

"For people who want to try nondrug approaches, the research is very clear that many will have much better long-term outcomes, including complete recovery, after being diagnosed with serious mental illness," Gottstein said. "This decision restores the rights of those people to pursue that potential."

But experts in forensic psychiatry maintain that the ruling adds a new and burdensome layer of legal oversight of medical decision making.

"Alaska law had previously limited involuntary treatment of committed patients to persons who were incompetent to make treatment decisions for themselves," Paul Appelbaum, M.D., chair of APA's Council on Psychiatry and Law, told Psychiatric News. "This ruling adds the requirement that, even for this group, it must be a judge and not a physician who determines that the proposed treatment is in the patient's best interests and represents the least-intrusive alternative."

Appelbaum said that other states, such as Massachusetts, have adopted a similar approach in which all treatment decisions—including alterations in medications and dosages—must have judicial approval.

"However, given that there are states that don't require judicial determinations of incapacity, much less approval of specific treatment plans, Alaska's new approach is at the far end of the spectrum of judicial oversight of involuntary treatment," Appelbaum said. "Perhaps most troubling was the court's reliance on legal literature summarizing the effects of antipsychotic medication from the 1970s, apparently without awareness of the subsequent introduction of a new generation of medications and of the substantial changes in treatment approaches since then.

"Alaska's patients and clinicians will be spending a great deal more time in court and less time in treatment," he said. "It is difficult to believe that judicial process will result in better choice of treatments."

Briefs filed by both sides and other related documents are posted at <http://psychrights.org/index.htm>.

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