                     IN THE COURT OF APPEALS OF IOWA

                                    No. 18-0247
                              Filed October 10, 2018


IN THE MATTER OF M.B.,
Alleged to be Seriously Mentally Impaired,

M.B.,
     Respondent-Appellant.
________________________________________________________________


        Appeal from the Iowa District Court for Polk County, Eliza J. Ovrom, Judge.



        Respondent appeals the district court decision finding him to be seriously

mentally impaired. AFFIRMED.




        Alexander D. Smith of Parrish Kruidenier Dunn Boles Gribble Gentry Brown

& Bergmann, LLP, Des Moines, for appellant.

        Thomas J. Miller, Attorney General, and Gretchen Witte Kraemer, Special

Assistant Attorney General, for appellee State.




        Considered by Potterfield, P.J., and Bower and McDonald, JJ.
                                           2


BOWER, Judge.

       M.B. appeals the district court decision finding him to be seriously mentally

impaired. We find there is sufficient evidence in the record to show M.B. lacks

sufficient judgment to make responsible decisions with respect to his treatment

and is likely, if allowed to remain at liberty, to inflict physical injury on himself or

others. We affirm the decision of the district court.

       I.     Background Facts & Proceedings

       M.B. has been diagnosed with and treated for schizophrenia. He was in a

mental health program in the community. In late 2017, M.B. began refusing to take

his prescribed medication for his schizophrenia and his condition deteriorated. On

November 29, 2017, M.B. was outside his apartment yelling and screaming at his

neighbors, and police officers were called to the scene. He was later served with

a notice of eviction due to the incident.        M.B. refused assistance from his

caseworker and case manager, who filed affidavits alleging M.B. was seriously

mentally impaired and stating he was likely to harm himself or others when he was

not taking his medication.

       In December 2017, a physician’s report of examination by Dr. Ketan

Dhadphale found M.B. was mentally ill and unable to make responsible decisions

about his treatment due to impaired insight and judgment. Dr. Dhadphale reported

M.B. was likely to injure himself or others, noting as recent overt acts “yelling at

neighbors, previous history of aggressive behaviors.”

       M.B. asked for a continuance and remained in treatment. Dr. Ahmar Butt

examined M.B. in January 2018 and found M.B. could not make responsible

decisions about treatment, stating, “Pt has symptoms of psychosis/delusions, has
                                           3


poor insight/judgment, has been noncompliant with meds.” Dr. Butt stated M.B.

was likely to injure himself or others based on the recent overt acts of “Psychosis,

command hallucinations.” The report also stated M.B. was a “Potential danger to

self/others due to loss of touch with reality.”

       After a hearing, a magistrate found M.B. was seriously mentally impaired.

The magistrate noted M.B.’s “uncontrolled demeanor at trial” and his statements

he was hearing both God and the devil. The magistrate found, “Inpatient treatment

is the only safe setting for [M.B.] to deal with his paranoia and psychotic behavior.”

M.B. appealed the magistrate’s decision to the district court.

       A hearing was held in the district court on January 11, 2018. Dr. Butt

testified M.B. had schizophrenia and had symptoms of psychosis. M.B. told Dr.

Butt he heard voices telling “him positive things to do.” Dr. Butt testified,

              So I want to emphasize that the command hallucinations,
       when the voices tell people to do things, they could be dangerous
       per se. Because the voices tell people to do things, and it’s very—
       sometimes it’s very hard to resist to the voice’s command and people
       put themselves in danger.
              So I believe he is hearing command hallucinations, and he
       has delusional beliefs. That’s why I believe he does not have [the]
       capacity to make medical decisions.

Dr. Butt stated M.B. was likely to physically injure himself or others if allowed to

remain in the community because he “got agitated, irritable. Got angry.” He also

noted M.B.’s delusional beliefs. M.B. told Dr. Butt, “Doctor, you die. I hope you

die. And you should not lie down, Coward.” Dr. Butt also stated M.B. was a danger

to himself because he was not taking his medications. He stated M.B. needed to

stay in inpatient treatment until his symptoms were managed to an extent he could

be released to outpatient treatment.
                                          4


         M.B. testified he did not believe he needed any medication. When asked if

he had ever been physically aggressive, M.B. stated, “No, never aggressive;

always on defense. Has been a defensive thing. And it’s only been one time in

my life and then another time when I was in Polk County jail, but I didn’t hurt the

deputy.” M.B. testified his statement to Dr. Butt about dying was made “really on

a friendly basis.”

         The district court ruled M.B. was seriously mentally impaired.           In

determining M.B. lacked judgmental capacity, the court found, “Lacks judgment

concerning treatment. Voices telling him what to do. Does not believe he needs

psychiatric treatment or medication.”      The court found M.B.’s condition was

treatable. On the issue of dangerousness, the court stated:

                 Danger to self due to delusions and hearing voices. Likely to
         injure others. Came to treatment because agitated with others; upset
         and irritable. History of aggression in past. Told doctor today he
         hoped he would die. Not able to care for his own medical care if
         discharged. Would not take prescribed medications. Likely to suffer
         physical injury, physical debilitation or death within reasonably
         foreseeable future. Threatened with eviction due to actions when off
         meds.

The court concluded M.B. should be committed for a complete psychiatric

evaluation and appropriate treatment. M.B. appeals the decision of the district

court.

         II.   Standard of Review

         Challenges to the sufficiency of the evidence in involuntary commitment

proceedings are reviewed for the correction of errors at law. In re B.B., 826 N.W.2d

425, 428 (Iowa 2013). An allegation of serious mental impairment must be proven

by clear and convincing evidence. Iowa Code § 229.13(1) (2017). “Clear and
                                            5


convincing evidence is less burdensome than evidence establishing proof beyond

a reasonable doubt, but more burdensome than a preponderance of the evidence.”

B.B., 826 N.W.2d at 428. “It means that there must be no serious or substantial

doubt about the correctness of a particular conclusion drawn from the evidence.”

Id.

       While the elements of serious mental impairment must be established by

clear and convincing evidence, the district court’s factual findings are binding on

appeal if they are supported by substantial evidence. In re J.P., 574 N.W.2d 340,

342 (Iowa 1998).        “Evidence is substantial if a reasonable trier of fact could

conclude the findings were established by clear and convincing evidence.” Id.

       III.    Merits

       In order to be considered seriously mentally impaired under section

229.1(20), there must be clear and convincing evidence the respondent (1) has a

mental illness; (2) lacks “sufficient judgment to make responsible decisions with

respect to the person’s hospitalization or treatment”; and (3) is likely, if allowed to

remain at liberty, to inflict physical injury on “the person’s self or others,” to inflict

serious emotional injury on those close to the person, or to be unable to satisfy the

person’s physical needs. Id. at 343 (quoting In re Foster, 426 N.W.2d 374, 376–

77 (Iowa 1988)).

       A.      M.B. does not dispute the first element, that he has a mental illness.

He claims there is not sufficient evidence in the record to support the court’s finding

on the second element, whether he lacked sufficient judgment to make responsible

decisions about his treatment. To demonstrate lack of judgmental capacity the

State must prove “the person is unable because of the alleged mental illness, to
                                           6


make a rational decision about treatment, whether the decision is to seek treatment

or not.” In re L.H., 890 N.W.2d 333, 340 (Iowa Ct. App. 2016) (quoting In re B.T.G.,

784 N.W.2d 792, 797 (Iowa Ct. App. 2010)).

       M.B. claims he had a rational reason to refuse to take medication—he was

worried about the side effects. At the hearing, M.B. testified about potential side

effects, but he also testified he did not believe he needed medication. Dr. Butt

testified M.B. was prescribed medication for his mental illness but had been

refusing to take the medication. He stated M.B.’s prescribed medication could

have side effects, which “could be anything from very minor thing that could affect

stomach upset to very serious thing that could be life-threatening.” Dr. Butt also

stated if M.B. was discharged without medications he would remain psychotic and

“may put himself and other people in danger.”

       We find there is substantial evidence in the record to support the district

court’s finding M.B. lacked sufficient judgment to make responsible decisions

about his medical treatment.

       B.     M.B. also claims there was not sufficient evidence to show he was

likely, if allowed to remain at liberty, to inflict physical injury on himself or others,

to inflict serious emotional injury on those close to him, or to be unable to satisfy

his physical needs. See J.P., 574 N.W.2d at 343. The term “likely” means

“probable or reasonably to be expected.” B.B., 826 N.W.2d at 433. The element

of dangerousness “requires a predictive judgment, ‘based on prior manifestations

but nevertheless ultimately grounded on future rather than past danger.’”             Id.

(quoting In re Oseing, 296 N.W.2d 797, 801 (Iowa 1980)). Additionally, “[t]his

element requires that the threat the patient poses to himself or others be evidenced
                                          7

by a ‘recent overt act, attempt, or threat.’” Id. (quoting In re Mohr, 383 N.W.2d 539,

542 (Iowa 1986)).

       Dr. Butt testified M.B. was likely to injure himself or others if he remained in

the community without treatment.         He stated without medication M.B. had

delusional beliefs and got agitated, irritable, and angry. M.B. had previous issues

with aggression, at one point putting a police officer in a wrestling hold. When

asked, “How certain are you that some harm will befall him or others because of

mental illness,” Dr. Butt responded:

              I am very certain because he has aggression in the past. He
       is here because of irritability and noncompliance with medication.
       And he currently has symptoms. And he has potential for agitation
       and aggression because he had in the past. So it is a likelihood that
       he could be a potential danger.

We additionally find M.B. had engaged in recent overt acts. On the day of the

hearing, M.B. told Dr. Butt, “Doctor, you die. I hope you die.” Also, M.B. had been

yelling and screaming at his neighbors, causing him to be evicted from his

apartment.

       We conclude there is sufficient evidence in the record to show M.B. was

likely to be a danger to himself or others if allowed to remain at liberty.

       We affirm the decision of the district court.

       AFFIRMED.
