APA Weighs in on Forced Medication Issue in Loughner Case

Nancy A. Melville

August 09, 2011

August 9, 2011 — As the issue of schizophrenia and its treatment takes center stage in the case against Jared Lee Loughner, the American Psychiatric Association (APA) and the American Academy of Psychiatry and the Law (AAPL) have become involved, filing a brief in the case to address arguments over Loughner's forced medication.

Loughner, the accused gunman in the Tucson, Arizona, shootings that killed 6 people and injured 13 others, including Rep. Gabrielle Giffords, has been diagnosed with schizophrenia and declared incompetent to stand trial.

Dr. Paul S. Appelbaum

While he is being held in a federal prison hospital in Springfield, Missouri, the 9th Circuit Court of Appeals this month permitted prison authorities to continue to forcibly administer antipsychotic medications amid reports that Loughner's condition was deteriorating and he was posing a danger to himself and to others.

The action only came after defense attorneys were earlier granted a request to restrict forcible medication to sedatives, arguing that the antipsychotic medications posed the risk for "irreparable physiological harm" and potentially caused chemical changes to the brain that can have "serious, even fatal side effects" — assessments that many psychiatrists would dispute.

Those, and other wayward arguments, prompted the APA and AAPL response, which sought to specifically address 2 key issues. The first was to set the record straight on the nature of schizophrenia and its medications, explained Paul S. Appelbaum, MD, chair of APA's Committee on Judicial Action.

Distorted Argument

In their order temporarily halting Loughner's medication, the court used language and cited earlier opinions that used language which significantly distorted the purpose of fact and risk-benefit ratio of antipsychotic medications.

"In their order temporarily halting Loughner's medication, the court used language and cited earlier opinions that used language which significantly distorted the purpose of fact and risk-benefit ratio of antipsychotic medications."

"When a court, particularly an important court like the 9th Circuit Court of Appeals, is writing about psychiatric illness and treatments, the APA has a strong interest in making sure they have an accurate set of facts to work from," said Dr. Appelbaum, who is the Elizabeth K. Dollard Professor of Psychiatry, Medicine & Law and director of the Division of Law, Ethics, and Psychiatry at Columbia University in New York.

"So one of the major motivations for our brief was to put before the court, without taking sides, a set of accurate facts about schizophrenia and its treatment."

The second key issue the brief addressed was the importance of permitting authorities who have custody of a defendant to make decisions of forcible medication without having to go through a time-consuming judicial hearing on the matter.

Loughner's attorneys have argued that their client still retains more rights to such proceedings than prisoners because he is not yet a convicted criminal. When the court considers their appeal later this month, it will address whether the landmark ruling of Washington v. Harper, which permits forced medication of prisoners who are a danger to themselves or others, indeed applies to a pre-trial detainee like Loughner.

The APA/AAPL brief argues that existing standards do include pre-trial detainees in those circumstances.

Sedatives Only

When prison hospital authorities overrode the court orders not to forcibly medicate Loughner with antipsychotics in July, they argued that Loughner had stopped eating and sleeping; was pacing his cell; and had been talking about death, including his own suicide.

"When people are deemed to be dangerous, the importance of being able to institute treatment promptly is paramount, lest the prisoner or detainee harms others or himself," Dr. Appelbaum told Medscape Medical News.

"The notion of requiring a court hearing halfway across the country, which may not take place for days or weeks and then possibly be subject to appeal and further delay is threatening to the safety of the detainee and the staff and really compromises the role of the psychiatrist there who must stand by helplessly while these procedures take place," he added.

"So our second interest is in trying to keep these kinds of decisions outside of the court and within the facility where they can be made in a more timely and reasonable fashion."

The defense's request to allow the forced medication only of sedatives, as opposed to antipsychotics, is in line with their strategy to keep Loughner off of death row – at the expense of keeping him in a psychotic state.

The defense's request to allow the forced medication only of sedatives, as opposed to antipsychotics, is in line with their strategy to keep Loughner off of death row, at the expense of keeping him in a psychotic state, Dr. Appelbaum noted.

"One often sees defense teams, particularly in capital cases, use this strategy of attempting to block all efforts of treatment of their clients," Dr. Appelbaum said.

"As long as Loughner is kept psychotic, he can't be brought to trial and the defense clearly thinks it is in his best interest to remain psychotic rather than being tried, which I would suggest is a debatable proposition in its own right."

Unprecedented Ruling

Dr. Appelbaum added that he is not aware of any other cases in which a court allowed a dangerous, schizophrenic prisoner being held before a trial to be denied treatment with antipsychotic medications.

"Maybe there have been cases, but the defense would certainly have pointed them out if they existed, and they didn't."

We meanwhile emphasized in our brief that to only barely sedate the patient with medication in the hope of controlling dangerousness is simply bad medical treatment.

"We meanwhile emphasized in our brief that to only barely sedate the patient with medication in the hope of controlling dangerousness is simply bad medical treatment."

While she could not address Loughner's case specifically, psychiatrist Carol A. Tamminga, MD, said that patients provided the optimal treatment of schizophrenia can indeed see their condition become manageable.

"In general, if someone comes to a hospital with a florid acute psychosis, treatment is possible," said Dr. Tamminga, professor and chairman of the University of Texas Southwestern Medical Center's Department of Psychiatry in Dallas.

"Antipsychotic medications generally calm psychotic symptoms, a process which begins at a gradual pace once medications begin and can continue over the next several weeks, until improvement is optimal."

Optimal improvement can take several months, and even if symptoms remain, they often, but not always, become manageable, she said.

"Even if mild psychotic symptoms continue, patients do not often act on them, once their treatment has begun.  There is a very general expectation that about one third of patients will improve considerably, about one third will improve moderately, and then a final third do not improve even adequately. "

Dr. Appelbaum has disclosed no relevant financial relationships. Dr. Tamminga consults for pharmaceutical companies including Lilly and Sunovion.

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