Wednesday, January 09, 2008

The Kelly Case and Forced Psychiatric Medications

Oops, I started this and had to run. I thought it was saved to "draft" but it actually posted before it even got started! This time for real:

This is a ClinkShrink issue: pure forensics, but it has my attention for the moment, and it has broad implications for the treatment of psychiatric patients in Maryland who are violent when they are mentally ill.

If you want to read about the Kelly Case in the
Baltimore Daily Record, CLICK HERE.

Okay, so in Maryland, a psychiatric inpatient can be forcibly restrained and forcibly medicated (by injection) if they are actively violent or threatening in a way that the facility staff and docs deem someone's imminent safety to be in peril. Such events are disturbing for everyone involved-- the patient is agitated, has often already struck or bitten someone, thrown an object or broken something, emotions are high, decisions are made quickly, things get intense. The medications administered are generally sedating and are short-acting. This is how it works for very acute situations.

Sometimes psychiatric inpatients are dangerous as a result of their psychiatric symptoms, but not imminently, and safety is a longer-term issue. These aren't people who are necessarily agitated or belligerent. If a dangerous patient is refusing to take medications, there is a legal mechanism to force them to take medicine-- in Maryland we call this a Medication Review Panel and it's a legal proceeding in which the patient gets to make his case and the psychiatrist gets to say why he thinks the patient needs to be medicated against their will. This is a more deliberate process, a legal proceeding.

I will tell you that the term "dangerous" is less narrowly defined. So someone who is hospitalized for depression who is not taking care of themselves such that a medical condition threatens their life (-- we're not talking about a sad diabetic who reaches for a piece of cake here, just to be clear on this). Most of the patients who come to Medication Review Panels have psychotic illnesses-- they are having hallucinations and/or are delusional, and they don't have the insight that they have an illness. Legally, someone can be as psychotic as they'd like and refuse treatment, the issue here is one of
dangerousness for someone who is already committed to an inpatient unit. Other examples might include someone who is so psychotic they are too disorganized to care for themselves and leave lighted cigarettes lying around, or they believe that the devil has instructed them to kill people, or use your imagination. Roy and ClinkShrink might be better at generating examples. Let me also clarify that the dangerousness must be a result of mental illness, otherwise we're simply talking about criminals.

No one has thought too hard about the exact location as Where someone might be dangerous. Until the Kelly Case, that is.

I've never met Anthony Kelly, I don't know his diagnosis or his symptoms. He is a dangerous man and he has been confined to a hospital for the criminally insane (okay, Clink, a maximum security forensic facility) since 2002. Mr. Kelly was deemed too sick to stand trial for his crimes and he refused to take medication. At a hearing in 2005, an administrative law judge said Mr. Kelly could be forced to take medications, but the ruling was reversed on appeal by Baltimore City Circuit Court Judge Lynne A. Battaglia. Judge Battaglia said that since Mr. Kelly is dangerous only when he's outside the hospital, but not while he's in the confines of a maximally secure facility, so he can't be made to take medications.

To the surprise of Maryland psychiatrists, the Court of Appeals upheld this decision:

"Because there was no finding that Kelly is a danger to himself or others during his confinement in Perkins Hospital, a prerequisite to forcible administration of medication pursuant to Section 10- 708(g) [of the Health-General Article], we shall affirm the judgment of the Circuit Court of Baltimore City."

This means that a person who is mentally ill and dangerous can only be forced to take medication if they are dangerous WHILE they are in the hospital --even if they would be dangerous if they were not in the hospital.

Many psychiatrists who work on inpatient units are not happy about this because it means that if someone is mentally ill and dangerous outside the hospital, but not dangerous inside the hospital, they can't be treated and and they can't be released. Because they are dangerous, they must be kept in the hospital, perhaps indefinitely.

I don't work in an inpatient unit, but what I don't like about this ruling is the assumption that someone has a crystal ball that accurately says When and Where and Under What Circumstances someone with a severe psychiatric disorder that renders them dangerous will act. People elope from psychiatric units, they commit suicide on inpatient units, they assault other patients and staff members.

Anthony Kelly remains in Clifton T. Perkins hospital, unmedicated, or so I understand. Outside the hospital, his illness presumably contributed to his actions such that he is in a hospital and not a prison for his crimes-- the rape of the women and the murder of two people including a child. He has presumably been a safe and non-violent patient on his unit, and he doesn't want medications. Psychotic patients have difficulty with reality testing, they can be unpredictable and some patients can be dangerous. I'm not sure how in the face of such heinous past actions that anyone can absolutely guarantee that a patient such as this might not suddenly attack another patient or a staff member even in the hospital.

While the Kelly Case has been a topic of discussion among psychiatrists in the state, all factual information for this blog post was taken from the article in the Baltimore Daily Record that I linked to above. Okay Clink, let's hear it.....

Sorry, no pic. I couldn't find one of Clifton T. Perkins Hospital and anything else seemed tacky for such a serious and disturbing topic.