slightly off-topic:betreffende Susan Lindauer (stem in begin van clip); die is aangeklaagd geweest voor werken in dienst van Saddam, maar was "mentally incompetent to stand trial". toen wilde men haar gedwongen behandelen met neuroleptica.
Goed om te zien dat de rechter de psychologen en psychiaters het respect geeft dat ze verdienen:
quote:
Susan Lindauer is charged in four counts with conspiring to act and acting as an unregistered agent of the government of Iraq, in particular the Iraq Intelligence Service ("IIS"), fromOctober 1999 until February 2004, and engaging in various forbidden financial transactionswith that government during that period, apparently in connection with her alleged role asagent of that government. At least a half dozen mental health professionals, including apsychologist and a psychiatrist retained by the defense, and several psychologists and psychiatrists employed, and one psychiatrist retained, by the government, have found hermentally incompetent to stand trial, due principally to delusions of grandiosity and paranoiathat make her unable to assist meaningfully in her own defense and understand the nature ofthe proceedings she faces. Defendant, but not her lawyer, has refused to accept thediagnosis and has refused to take psychotropic drugs that government physicians wish to administer in aid of rendering her competent to stand trial. The government has movedpursuant to Sell v. United States,
539 U.S. 166, 123 S.Ct. 2174, 156 L.Ed.2d 197 (2003)foran order compelling administration of such drugs. Lindauer, through and with the approval ofher lawyer, opposes the motion.
[..]
2.Evidence Bearing on Disputed Issue of Forced Medication
All the mental health professionals at the Carswell facility endorsed in their reports the idea of prescribing antipsychotic medication for defendant. Indeed, even Drs. Shadduck and Greg,
who hold Ph.D. degrees and accordingly are not, so far as I am aware, authorized to prescribe medication, nonetheless opined that "[a]ntipsychotic medications are the best treatment for symptoms of psychosis" (Shadduck Reports 12/13/05, 12/28/05 at 5) (see VasReport 12/19/05 at 2; Letter of William M. Pederson, M.D. to the Court, Jan. 19, 2006, at 1) Dr. Vas submitted the above-referenced two-page report, in which he concluded that it is medically necessary to treat defendant with antipsychotic medications, that they are"substantially likely" to render her competent, and that the side effects listed in his letter are rare and can be dealt with through "treatment strategies," and that in any event defendant does not to his knowledge suffer from any medical condition which would place her at substantial risk of developing any severe side effects. Dr. Vas also testified at the hearing, and did so with the same bland assurance and utter lack of substantiation. He stated in conclusory form his professional belief that "antipsychotics are medically necessary and appropriate and that, although there is a risk of various side effects, the risk of the side effects are rather rare and fairly easily managed" (5/4/06 Tr. 24), and specifically as to defendant, answered in the affirmative to the question, "[i]n your opinion, is involuntary administration of antipsychotic medication medically appropriate to treat Ms. Lindauer for her mental condition?" (Id.at 28) He recommended what are referred to as second generation or atypical antipsychotic medications that "are much more easily tolerated by patients, and we have some evidence that they have a less deleterious effect on cognition and help people think more rationally."
In the same broad fashion, he testified to experience with "people that . . . might complain of a side effect, and we try to alleviate side effects as much as we can and try to meet the treatment goals at the same time." (Id.at 25)
Similarly, and without elaboration, he testified that it was "extremely likely" that defendant would respond positively to antipsychotic medication, and added that "[t]here have been a few studies done that have been published in the literature which would indicate a restoration to competency that is above 80 percent, anywhere from 80 to 95 percent and that has included patients from various diagnostic categories and their response to particularly antipsychotic treatment." (Id.at 29
The government appears to have placed principal reliance on the testimony of its retained psychiatrist, Dr. Kleinman. He submitted an extensive initial report, cited above, that focused entirely on the diagnosis of defendant's condition. However, he submitted a later report that discussed treatment, and testified as well on the issue of forced antipsychotic medication. His second report described why he prefers his diagnosis to that of Dr. Goldstein, but stated also that even if defendant is diagnosed as suffering from delusional disorder, "second generation, i.e., `atypical', antipsychotic medication would reasonably likely—safely—help her." (Kleinman 4/7/06 Report at 10) Although the report supports that conclusion by quoting four studies that are optimistic as to the potential effectiveness of second generation antipsychotic medication in treating delusional disorder, all are anecdotal, which is to say none report on controlled studies. The most optimistic, dated in 1995, reports an overview of the literature that suggests "80.8% of patients show total or partial recovery" (id.at 15), but that conclusion is hemmed in with qualifications, as follows:
The authors are well aware that the outcome of this delusional disorder treatment overview is tentative. The existing literature has been investigated thoroughly, but its quality is extremely diverse, nomenclature is highly variable,and extended-case series are rare. The simplest details are often missing, suchas dosage schedules, side effects, duration of drug use, etc., as well as reasons for choosing or changing drugs. Duration of follow-up is extraordinarily variable.Another confounding factor in looking at outcome results with different treatments is that pimozide has generally become the first-choice treatment in recent years. Therefore, other neuroleptics tend to be employed in somewhat older studies. This may make their direct comparison even less reliable than otherwise
At the hearing, Dr. Kleinman came bearing a later report, published in February 2006, that reviewed the literature dating back to 1994 dealing with treatment of delusional disorder.(5/4/06 Tr. 79; GX 2) According to Dr. Kleinman, the new report concludes that the literature indicates "an effectiveness overall of various types of antipsychotic medication to be approaching 90 percent, in the high 80 percent." (Id.at 80) (emphasis added) The word"overall" here is significant, because Dr. Kleinman testified further as follows:
Q. And with respect to persecutory and grandiose types of delusion [the two types with which defendant is afflicted], what are the results as reported in the article?
A. Well, there is a total of 15 reported cases of persecutory delusions and there are a little bit more than 50 percent, eight [of] fifteen, are reported to be improved. None are reported to be recovered entirely, and there were no patients specifically with grandiose delusions. Moreover, Dr. Kleinman acknowledged a substantial ambiguity even in the "overall" figure,when he noted that the report showed elsewhere that a "positive response to medication treatment occurred in nearly 50 percent." (Id.at 81) He speculated that the apparent contradiction between the 50 percent and 90 percent figures could have occurred because at one point recovered and improved patients had been lumped together to generate the 90 percent statistic, but the author did not explain what was meant by "positive response" in nearly 50 percent of the cases. Dr. Kleinman conceded that this explanation was "not an entirely satisfactory one." (Id.) He offered for guidance also an article describing a single success in treating delusional disorder with Risperidone (GX 3), a second generation or atypical antipsychotic medication (5/4/06 Tr. at 83-84). However, the last sentence of the conclusion in that article reads as follows: "A controlled clinical trial of Risperidone in the treatment of patients with delusional disorder is warranted." (Id.at 85) Dr. Kleinman explained the absence of evidence from controlled clinical studies by pointing out that delusional disorders are generally rarer than schizophrenic disorders, and accordingly it is difficult to obtain data with respect to delusional disorders and resources are directed more at the schizophrenic disorders. (Id.at 86) Later, he agreed that controlled studies are a"more desirable source of data for making treatment decisions." (Id.at 90) Despite the absence of controlled studies, and the "critical eye" with which case studies must be approached, he answered "Yes" to inquiries as to whether "involuntary administration of antipsychotic medication [is] medically appropriate to treat Ms. Lindauer's symptoms" and whether such treatment would "improve Ms. Lindauer's chances to be restored to mental competency to stand trial." (Id.at 87)That was as strong an endorsement as he gave to involuntary medication.
It bears mention here that initially, when he was not responding to leading questions, he testified simply that "there is only one type of treatment that holds any promise of diminishing . . . the psychotic disorder not otherwise specified and that is antipsychotic medicine." (5/4/06 Tr. 63) That testimony says nothing about the likelihood that such treatment would succeed, but only that it is the sole treatment that could succeed in treating what he characterized as "a condition very much worthy of treatment." (Id.at 89) Dr. Goldstein, defendant's retained psychiatrist, explained his preference for the diagnosis of delusional disorder, mixed type over psychotic disorder not otherwise specified (5/9/06 Tr. 6,32-33), but readily noted that from the standpoint of treatment, the two defined "a distinction without a difference." (Id.at 28)He reviewed the weaknesses of the paper Dr. Kleinman had brought to the hearing, GX 2,including not only that there were no controlled studies but also that, there aren't many articles where someone says I treated six patients with this illness and none of them got better. Those kind of papers are generally not published. So there's a kind of skewing of the literature towards only writing about things where you have a favorable outcome.
Dr. Kleinman spoke principally of the likely effect of unsuccessful treatment on defendant's relationship with her lawyer, and said it was by no means certain that relationship would deteriorate because the relationship continued intact at the time of the hearing (5/4/06 Tr. at 68), although he conceded that an"extreme" reaction would be for her to "become very angry at him and reject him."
As to physical side effects, Dr. Kleinman agreed that certain of such side effects were possible, but emphasized that monitoring and screening of patients could mitigate or prevent the onset of such symptoms (5/4/06 Tr. 71-73, 92), although he agreed that a physician charged with monitoring a large number of patients would have a harder time monitoring each patient effectively (id.at 92). Dr. Goldstein relied on a pharmacology text (DX D) to project various percentages of physical side effects, principally including EPS, or extrapyramidal syndrome, which encompasses various degrees of muscular disorder and pseudo-Parkinsonism, with tremors, rigidity, and other involuntary muscular phenomena.(5/9/06 Tr. at 21) Such phenomena became more likely as the dosage increased, reaching 25 percent for Risperidone at a 16 mg level (DX D), which he said is considered a high incidence. (5/9/06 Tr. at 22;see also DX C) He testified that the recorded incidence of neurologic malignant syndrome, or NMS, in patients taking these medications is 2 percent,with 20 percent mortality in patients suffering NMS, a death rate of 4 per 1,000. (4/9/06 Tr.24)