                                   NO. 12-14-00166-CV

                          IN THE COURT OF APPEALS

               TWELFTH COURT OF APPEALS DISTRICT

                                      TYLER, TEXAS

THE STATE OF TEXAS FOR                            §      APPEAL FROM THE

THE BEST INTEREST AND                             §      COUNTY COURT AT LAW

PROTECTION OF A. W.                               §      CHEROKEE COUNTY, TEXAS

                                  MEMORANDUM OPINION
       A.W. appeals from an order authorizing the Texas Department of State Health Services
(the Department) to administer psychoactive medication-forensic. In one issue, A.W. asserts the
evidence is legally insufficient to support the trial court’s order. We affirm.


                                          BACKGROUND
       George Howland, M.D. signed an application for an order to administer psychoactive
medication-forensic to AW. In the application, Howland stated that A.W. was subject to an
order for inpatient mental health services issued under Chapter 46C (not guilty by reason of
insanity) of the Texas Code of Criminal Procedure. He testified that A.W. had been diagnosed
with schizophrenia, paranoid type, and requested the trial court to compel A.W. to take
psychoactive     medications      including     antidepressants,    anxoilytics/sedatives/hypnotics,
antipsychotics, and mood stabilizers.         According to Howland, A.W. refused to take the
medications voluntarily. In Howland’s opinion, A.W. lacked the capacity to make a decision
regarding administration of psychoactive medications because he feels he is “cured” from his
mental illness, has no insight into his mental illness, and has paranoid and delusional thoughts.
       Howland concluded that these medications were the proper course of treatment for A.W.
and that, if he were treated with the medications, his prognosis would be improved. Howland
believed that, if A.W. was not administered these medications, the consequences would be
continued lack of insight into his mental illness, irritable mood, and paranoid and delusional
thoughts.   Howland considered other medical alternatives to psychoactive medications, but
determined that those alternatives would not be as effective. He believed the benefits of the
psychoactive medications outweighed the risks in relation to present medical treatment and
A.W.’s best interest. Howland also considered less intrusive treatments likely to secure A.W.’s
agreement to take psychoactive medications.
       The trial court held a hearing on the application. At the close of the evidence, the trial
court granted the application. After considering all the evidence, including the application and
the expert testimony, the trial court found that the allegations in the application were true and
correct and supported by clear and convincing evidence. Further, the trial court found that
treatment with the proposed medications was in A.W.’s best interest and that A.W. lacked the
capacity to make a decision regarding administration of the medications.           The trial court
authorized the Department to administer psychoactive medications to A.W., including
antidepressants, antipsychotics, mood stabilizers, and anxiolytics/sedatives/hypnotics. This
appeal followed.


                                SUFFICIENCY OF THE EVIDENCE
       In his sole issue, A.W. argues that the evidence is legally insufficient to support the trial
court’s order to administer psychoactive medication-forensics. More specifically, A.W. contends
that the State failed to prove, by clear and convincing evidence, that he lacked the capacity to
make a decision regarding administration of medication.
Standard of Review
       In a legal sufficiency review where the burden of proof is clear and convincing evidence,
we must look at all the evidence in the light most favorable to the finding to determine whether a
reasonable trier of fact could have formed a firm belief or conviction that its findings were true.
In re J.F.C., 96 S.W.3d 256, 266 (Tex. 2002). We must assume that the fact finder settled
disputed facts in favor of its finding if a reasonable fact finder could do so and disregard all
evidence that a reasonable fact finder could have disbelieved or found incredible. Id. This does
not mean that we are required to ignore all evidence not supporting the finding because that
might bias a clear and convincing analysis. Id.




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Order to Administer Psychoactive Medication
       A trial court may issue an order authorizing the administration of one or more classes of
psychoactive medications to a patient who is under a court order to receive inpatient mental
health services. TEX. HEALTH & SAFETY CODE ANN. § 574.106(a) (West 2010). The court may
issue an order if it finds by clear and convincing evidence after the hearing that (1) the patient
lacks the capacity to make a decision regarding the administration of the proposed medication,
and (2) treatment with the proposed medication is in the best interest of the patient.              Id.
§ 574.106(a-1). “Clear and convincing evidence” means the measure or degree of proof that will
produce in the mind of the trier of fact a firm belief or conviction as to the truth of the allegations
sought to be established. State v. Addington, 588 S.W.2d 569, 570 (Tex. 1979). “Capacity”
means a patient’s ability to (1) understand the nature and consequence of a proposed treatment,
including the benefits, risks, and alternatives to the proposed treatment, and (2) make a decision
whether to undergo the proposed treatment. TEX. HEALTH & SAFETY CODE ANN. § 574.101(1)
(West 2010).
       In making its findings, the trial court must consider (1) the patient’s expressed
preferences regarding treatment with psychoactive medication, (2) the patient’s religious beliefs,
(3) the risks and benefits, from the perspective of the patient, of taking psychoactive medication,
(4) the consequences to the patient if the psychoactive medication is not administered, (5) the
prognosis for the patient if the patient is treated with psychoactive medication, (6) alternative,
less intrusive treatments that are likely to produce the same results as treatment with
psychoactive medication, and (7) less intrusive treatments likely to secure the patient’s
agreement to take the psychoactive medication.             TEX. HEALTH & SAFETY CODE ANN.
§ 574.106(b) (West 2010).
Hearing on Application
       At the hearing on the application, Howland testified that he had been A.W.’s treating
physician for the past two years. A.W. was subject to an order for court ordered inpatient mental
health services under Chapter 46C of the Texas Code of Criminal Procedure, and the underlying
charge was the murder of his parents.            Howland said that A.W. was suffering from
schizophrenia, paranoid type. He wanted access to have A.W. take psychoactive medications
including antidepressants, anxoilytics/sedatives/hypnotics, antipsychotics, and mood stabilizers.
He believed that these medications would improve A.W.’s moods, and his delusional and



                                                  3
paranoid thoughts. If A.W. did not take these medications, his prognosis was poor. According to
Howland, A.W. needs medications to treat his schizophrenia. In his opinion, if someone has a
diagnosis of schizophrenia and has committed a crime as “heinous” as the one A.W. committed,
then that person needs to be on medication for the rest of his life.
        Howland believed A.W. lacked the capacity to make a decision regarding the use of
medications. A.W. refused to accept medication voluntarily for the past two years because he
did not believe he needed medications, that medications had not helped him get out of the
hospital in the past, and that he had been cured with steroids. Howland stated that he had not
known steroids to cure mental illnesses. He tried to explain to A.W. in the past two years the
reasons for the medications and their potential risks and benefits. However, he said, A.W. did
not understand because he lacks insight about his mental illness and did not believe he was
mentally ill.
        Howland testified that A.W.’s symptoms included paranoid thoughts and delusional ideas
about certain issues. A.W. believed that people on the unit were stealing his coffee even though
the hospital staff could not find any evidence of theft. He also believed that the State would pay
for his placement when he left the hospital even though the staff attempted to explain to him
multiple times that the contrary was true.        Howland attributed A.W.’s misunderstandings
regarding state regulations to his mental illness, explaining that such a fixed, false belief was
delusional. Howland explained that the week before the hearing, the treatment team decided to
move A.W. to a locked unit because he showed increased mood instability and heightened
psychotic symptoms, and had not been sleeping well. Over the past three or four months, A.W.’s
moods had worsened, leading to several incidents where he would become upset and scream at
the staff. At one point, Howland said, A.W. got very upset and raised his voice at a supervisor
because he did not get some additional items he wanted while shopping. The staff became
fearful of him. Howland said that A.W.’s actions indicated a rigid thought process and that his
responses to the staff’s explanations were not reasonable.
        Howland testified that he would give A.W. the least amount of medications to treat his
symptoms, that he was aware of medications that A.W. had concerns about, and that he would
avoid them.     A.W. never expressed any constitutional or religious reasons for refusing
medications, but merely told Howland that he had taken medications in the past and they did not
help him get out of the hospital. None of A.W.’s medical conditions would conflict or pose



                                                  4
additional dangers if Howland prescribed psychoactive medications. In fact, he met with the
hospital’s clinical psychiatric pharmacist who reviewed A.W.’s record. They found several
medications that A.W. had not taken that they believed were good choices and might help him
remain in the HOPE unit.1 If A.W. experienced an adverse side effect to the medications, he
would look at other options. However, he said, A.W. refused those medications.
         A.W. testified that he did not need psychotropic medications because he evidenced no
signs of psychosis or mental illness. He had been on the HOPE unit for three years, although he
admitted that he had been moved to a locked unit recently. While on the HOPE unit, he worked
in the warehouse and his responsibilities included helping with the inventory, receiving and
stocking items, and cleaning the warehouse. A.W.’s warehouse supervisor testified that A.W.
had never exhibited any behavior that caused him to become fearful or concerned that he might
need medications. He stated that he had never had a complaint about A.W. and would hire him
if he were another person looking for a job.
         A.W. testified that at one point, he had asked the judge in Jefferson County what it would
take to get out of the hospital, and the judge told A.W. that he needed to take psychotropic
medications.      A.W. stated that he and his physician at the time instituted a regime of
psychotropic medications in an attempt to get him out of the hospital. But taking psychoactive
medications did not make any difference to the judge in Jefferson County. Instead, A.W. said,
these medications harmed his health. He admitted that he had been in a hospital for twenty-six
years and that he had been medicated for fifteen years.
         A.W. stated that he was allergic to some psychoactive medications including Clozaril,
Seroquel, Respirdal, Invega, Zafress, and Abilify. Some of his reactions included low white
blood cell count, shaking, and blurred vision. A.W. said that he suffered strokes in 1991 and
1993, and testified that these medications were not recommended for someone with a history of
strokes. He was fearful of possible negative reactions from these medications. Further, A.W.
said, he had previously taken the two medications recommended by Howland and the hospital’s
clinical psychiatric pharmacist. These medications caused him to suffer bad side effects.



         1
           From testimony at the hearing, this appears to be a unit at the Hospital where the patients are not on one-
on-one observation, are not on psychotropic medication if they are able to stay in control of their moods and
psychotic symptoms, and are allowed to have the staff shop at stores for them. Howland also testified that patients
are not on court-ordered medications in the HOPE unit.


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Analysis
         The evidence showed that A.W. lacked the capacity to make a decision regarding
administration of psychoactive medications because he believed he was “cured,” by steroids in
the past, had no insight into his mental illness, did not believe he was mentally ill, did not believe
he needed medications, and had paranoid and delusional thoughts. Howland testified regarding
A.W.’s recent behavior including his delusional ideas about state regulations, paranoid beliefs
that his coffee was being stolen, increased mood instability, and heightened psychotic symptoms.
His behavior caused the treatment team to move A.W. to a locked unit the week before the
hearing.
         A.W. was concerned about taking psychoactive medications because of his history of
allergies and strokes. From Howland’s testimony, it is apparent that he took into account A.W.’s
past experiences with psychoactive medications when he prescribed the medications in
consultation with the hospital’s clinical psychiatric pharmacist. See In re E.K., No. 12-06-
00407-CV, 2007 WL 1492104, at *4 (Tex. App.—Tyler May 23, 2007, no pet.) (mem. op.); In
re D.H., No. 12-04-00181-CV, 2004 WL 2820896, at *4 (Tex. App.—Tyler Dec. 8, 2004, no
pet.) (mem. op.). The trial court is not required to defer to A.W.’s preferences, but must consider
them. See TEX. HEALTH & SAFETY CODE ANN. § 574.106(b).
         Considering all the evidence in the light most favorable to the findings, we conclude a
reasonable trier of fact could have formed a firm belief or conviction that A.W. lacked the
capacity to make a decision regarding administration of the proposed medications and that
treatment with the proposed medications were in his best interest. See TEX. HEALTH & SAFETY
CODE ANN. § 574.106(a-1); In re J.F.C., 96 S.W.3d at 266. Therefore, the evidence is legally
sufficient to support the trial court’s order. See id. Accordingly, we overrule A.W.’s sole issue.


                                                    DISPOSITION
         Having overruled A.W.’s sole issue, we affirm the trial court’s order.
                                                                  BRIAN HOYLE
                                                                     Justice
Opinion delivered October 30, 2014.
Panel consisted of Worthen, C.J., Griffith, J., and Hoyle, J.

                                                    (PUBLISH)




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                                      COURT OF APPEALS

      TWELFTH COURT OF APPEALS DISTRICT OF TEXAS

                                               JUDGMENT

                                             OCTOBER 30, 2014


                                             NO. 12-14-00166-CV


                              THE STATE OF TEXAS FOR THE
                         BEST INTEREST AND PROTECTION OF A. W.


                                   Appeal from the County Court at Law
                              of Cherokee County, Texas (Tr.Ct.No. 40,982)

                          THIS CAUSE came to be heard on the appellate record and briefs filed
herein, and the same being considered, it is the opinion of this court that there was no error in the
trial court’s order.
                          It is therefore ORDERED, ADJUDGED and DECREED that the trial
court’s order to administer psychoactive medication-forensic of the court below be in all things
affirmed, and that this decision be certified to the court below for observance.
                       Brian Hoyle, Justice.
                       Panel consisted of Worthen, C.J., Griffith, J., and Hoyle, J.
