MEMORANDUM DECISION
                                                                     Aug 07 2015, 10:04 am
Pursuant to Ind. Appellate Rule 65(D), this
Memorandum Decision shall not be regarded as
precedent or cited before any court except for the
purpose of establishing the defense of res judicata,
collateral estoppel, or the law of the case.



ATTORNEY FOR APPELLANT                                   ATTORNEYS FOR APPELLEE
Stuart K. Baggerly                                       James L. Whitlatch
Bloomington, Indiana                                     Kathryn DeWeese
                                                         Bunger & Robertson
                                                         Bloomington, Indiana



                                             IN THE
    COURT OF APPEALS OF INDIANA

In Re the Involuntary                                    August 7, 2015
Commitment of                                            Court of Appeals Case No.
                                                         53A05-1501-MH-19
R.R.                                                     Appeal from the Monroe Circuit
                                                         Court
Appellant-Respondent,
                                                         The Honorable Stephen R. Galvin,
        v.                                               Judge

                                                         Cause No. 53C07-1412-MH-419
Indiana University Health
Bloomington Hospital,
Appellee-Petitioner




Bailey, Judge.




Court of Appeals of Indiana | Memorandum Decision 53A05-1501-MH-19 | August 7, 2015          Page 1 of 10
                                          Case Summary
[1]   R.R. appeals an order involuntarily committing her to IU Health Bloomington

      Hospital (“IU Health”) and authorizing injections of medication. She

      challenges the sufficiency of the evidence to support the determination that she

      is gravely disabled or to support forced medication. We affirm.



                            Facts and Procedural History
[2]   R.R. is a forty-nine-year-old woman who has been diagnosed as schizophrenic.

      On December 13, 2014, R.R. called for an ambulance to take her to a hospital

      emergency room. R.R. had experienced prolonged sleep deprivation after

      becoming upset with her son, which she described as “very devastating.” (Tr.

      at 21.) The ambulance call had been preceded by at least five recent calls from

      R.R. to police requesting safety checks. One of the responding officers had

      noted that R.R.’s house was “extremely unkept [sic] with a dog and eight cats,

      knee deep debris and trash and feces and the county may be taking action to

      condemn the house.” (Tr. at 29.)


[3]   On December 16, 2014, IU Health filed a petition for involuntary commitment,

      attaching the report of Dr. Carey Mayer (“Dr. Mayer”). Dr. Mayer opined that

      R.R. was suffering from a psychiatric disorder which substantially disturbs her

      thinking, feeling or behavior and impairs her ability to function. More

      specifically, he noted: “very psychotic, has paranoid delusions, and likely

      hallucinations, has very poor judgment, not taking meds.” (App. at 7.)


      Court of Appeals of Indiana | Memorandum Decision 53A05-1501-MH-19 | August 7, 2015   Page 2 of 10
[4]   A commitment hearing was conducted on December 19, 2014, at which Dr.

      Mayer and R.R. testified. Dr. Mayer testified that R.R. was “unable to ensure

      her own safety and shelter,” was hearing voices, and was “afraid of her home.”

      (Tr. at 7.) For example, R.R. believed that there were “people peeing down her

      chimney.” (Tr. at 7.) According to Dr. Mayer, R.R. had a history of non-

      compliance with medication and would best benefit from a newer atypical

      antipsychotic injection regimen. R.R. testified that she would take medication

      but she objected to injections for fear of side effects.


[5]   On the same day, the trial court issued an order finding R.R. to be gravely

      disabled and in need of commitment to an appropriate facility for a period

      expected to exceed ninety days. R.R. was committed to IU Health, with the

      additional grant of authority to IU Health “to treat with the following

      medication, unless Respondent does not specifically benefit from these

      medications: Invega sustenna.” (App. at 21.) R.R. appeals.



                                Discussion and Decision
[6]   In Indiana, an adult person may be civilly committed either voluntarily or

      involuntarily. T.K. v. Dept. of Veterans Affairs, 27 N.E.3d 271, 273 n.1 (Ind.

      2015). A “regular commitment” is for an indefinite period of time that may

      exceed ninety days. Id. (citing Ind. Code § 12-26-7 et seq.). To obtain an

      involuntary regular commitment of an individual, a petitioner must prove by

      clear and convincing evidence that: (1) the individual is mentally ill and either



      Court of Appeals of Indiana | Memorandum Decision 53A05-1501-MH-19 | August 7, 2015   Page 3 of 10
      dangerous or gravely disabled; and (2) detention or commitment of that

      individual is appropriate. I.C. § 12-26-2-5(e).


[7]   “[T]he purpose of civil commitment proceedings is dual: to protect the public

      and to ensure the rights of the person whose liberty is at stake.” In re

      Commitment of Roberts, 723 N.E.2d 474, 476 (Ind. Ct. App. 2000). The liberty

      interest at stake in such a proceeding goes beyond a loss of physical freedom;

      given the stigma and adverse social consequences of confinement, a proceeding

      for an involuntary civil commitment is subject to due process requirements.

      T.K., 27 N.E.3d at 273. To satisfy the requirements of due process, the facts

      justifying an involuntary commitment must be shown by clear and convincing

      evidence. Id. “Because everyone exhibits some abnormal conduct at one time

      or another, loss of liberty calls for a showing that the individual suffers from

      something more serious than is demonstrated by idiosyncratic behavior.” M.M.

      v. Clarian Health Partners, 826 N.E.2d 90, 97 (Ind. Ct. App. 2005), trans. denied.


[8]   When we review the sufficiency of the evidence supporting a determination

      made under the statutory requirement of clear and convincing evidence, we will

      consider only the probative evidence and the reasonable inferences supporting

      it, without weighing evidence or assessing witness credibility. T.K., 27 NE3d at

      273. We will affirm if a reasonable trier of fact could find the necessary

      elements proven by clear and convincing evidence. Id.


[9]   R.R. does not challenge the finding that she is mentally ill, pursuant to Indiana

      Code Section 12-7-2-130, which defines mental illness as a psychiatric disorder


      Court of Appeals of Indiana | Memorandum Decision 53A05-1501-MH-19 | August 7, 2015   Page 4 of 10
       that substantially disturbs an individual’s thinking, feeling, or behavior and

       impairs the individual’s ability to function. She argues that the trial court could

       not have found by clear and convincing evidence that she is gravely disabled.

       “Gravely disabled” is defined as:

               a condition in which an individual, as a result of mental illness, is in
               danger of coming to harm because the individual:
               (1) is unable to provide for that individual’s food, clothing, shelter, or
                   other essential human needs; or
               (2) has a substantial impairment or an obvious deterioration of that
                   individual’s judgment, reasoning, or behavior that results in the
                   individual’s inability to function independently.
       I.C. § 12-7-2-96.


[10]   R.R. asserts that she is able to provide for her essential needs and to function

       independently; she likens her circumstances to those of the appellant in T.K..

       There, our Indiana Supreme Court reversed a commitment order, finding that

       grave disability had not been shown by clear and convincing evidence, when

       the respondent rented his own home, lived by himself, held full-time

       employment, owned two vehicles, made no physical outbursts, destroyed no

       property, did not put himself or others in actual danger with idiosyncratic

       behavior, and was not at risk of suffering a lack of food, shelter, or clothing.

       T.K., 27 N.E.3d at 277.


[11]   Here, however, IU Health did not merely present evidence of idiosyncratic

       behavior. Dr. Mayer testified that R.R. has “paranoid delusions involving

       other people attacking her and doing things to her and threatening her and her

       loved ones.” (Tr. at 5.) According to Dr. Mayer’s testimony based upon a
       Court of Appeals of Indiana | Memorandum Decision 53A05-1501-MH-19 | August 7, 2015   Page 5 of 10
       review of R.R.’s mental health treatment, she has both a long history of

       hospitalizations and a history of non-compliance with her medication regime.

       As of the hearing date, R.R. continued to suffer from “internalized auditory

       hallucinations” although they had diminished with medication administered at

       the hospital. (Tr. at 13.)


[12]   R.R. had a residence where she lived with her son, but she felt afraid there and

       repeatedly summoned assistance. Her unsubstantiated concerns – such as fear

       that people were urinating down her chimney – caused her to make repeated

       emergency calls. One responder, who was both an EMT and a police officer,

       noted that R.R.’s house was covered with trash and feces such that

       condemnation of the property was expectable. Unlike the appellant in T.K.,

       R.R. was at risk of losing her shelter.


[13]   The evidence favorable to the commitment order establishes that R.R. suffers

       from a substantial impairment of her judgment resulting in an inability to

       function independently and that she is in danger of coming to harm because she

       is unable to provide for her essential needs. Accordingly, the “trial judge could

       have found by clear and convincing evidence” that R.R. was gravely disabled.

       T.K., 27 N.E.3d at 274.


[14]   R.R. also challenges the medication order. A patient possesses a liberty interest

       in freedom from unwarranted intrusions into his or her physical person and

       mind while he or she is within an institution. In re Mental Commitment of M.P.,




       Court of Appeals of Indiana | Memorandum Decision 53A05-1501-MH-19 | August 7, 2015   Page 6 of 10
510 N.E.2d 645, 646 (Ind. 1987). Accordingly, our supreme court has held that

a petitioner

        must demonstrate by clear and convincing evidence that: (1) a current
        and individual medical assessment of the patient’s condition has been
        made; (2) that it resulted in the honest belief of the psychiatrist that the
        medications will be of substantial benefit in treating the condition
        suffered, and not just in controlling the behavior of the individual; (3)
        and that the probable benefits from the proposed treatment outweigh
        the risk of harm to, and personal concerns of, the patient. At the
        hearing, the testimony of the psychiatrist responsible for the treatment
        of the individual requesting review must be presented and the patient
        may present contrary expertise.
        Equally basic to court sanctionable forced medications are the
        following three limiting elements. First, the court must determine that
        there has been an evaluation of each and every other form of treatment
        and that each and every alternative form of treatment has been
        specifically rejected. It must be plain that there exists no less restrictive
        alternative treatment and that the treatment selected is reasonable and
        is the one which restricts the patient’s liberty the least degree possible.
        Inherent in this standard is the possibility that, due to the patient’s
        objection, there may be no reasonable treatment available. This
        possibility is acceptable. The duty to provide treatment does not
        extend beyond reasonable methods. Second, the court must look to
        the cause of the commitment. Some handicapped persons cannot have
        their capacities increased by anti-psychotic medication. The drug
        therapy must be within the reasonable contemplation of the
        committing decree. And thirdly, the indefinite administration of these
        medications is not permissible. Many of these drugs have little or no
        curative value and their dangerousness increases with the period of
        ingestion. The court must curtail the time period within which they
        may be administered. If a patient does not substantially benefit from
        the medication, it should no longer be administered.
        If after the hearing brought about by the objecting patient has taken
        place, the court is convinced that the State has met its burden of proof
        of showing, by clear and convincing evidence, a professional judgment
        having the above recited qualities and characteristics, it should


Court of Appeals of Indiana | Memorandum Decision 53A05-1501-MH-19 | August 7, 2015   Page 7 of 10
               sanction the forced medication. If it is not so convinced, it should
               reject such treatment.
       Id. at 647-48.


[15]   Dr. Mayer explained that Invega Sustenna “addresses the underlying neuro

       biochemical imbalance that’s in the brain and therefore directly improves the

       patient’s functioning and reduces their symptoms.” (Tr. at 7-8). R.R. contends

       that she expressed willingness to take that medication orally. She argues that

       there was no testimony that each and every form of treatment other than

       injectable Invega Sustenna had been considered and rejected or that the

       injections represent the least restrictive treatment. Our review of the record

       reveals otherwise.


[16]   When asked about other forms of treatment, Dr. Mayer initially focused on the

       setting for treatment, as opposed to medication. He was concerned that R.R.,

       as an out-of-county patient, would not qualify for a transitional care facility that

       would otherwise be preferable to inpatient commitment. However, Dr. Mayer

       was then specifically asked:

               and so, has every other form, it seems like you’ve exhausted many,
               many forms of treatment and so have you looked at every form of
               treatment that would be possible for [R.R.] and ruled them out and
               decided that this recommended treatment then is the, is necessary?
       (Tr. at 19.) Dr. Mayer responded, “Yes.” (Tr. at 19.) Ideally, more

       elaboration upon Dr. Mayer’s evaluative processes might have been elicited at

       that juncture.




       Court of Appeals of Indiana | Memorandum Decision 53A05-1501-MH-19 | August 7, 2015   Page 8 of 10
[17]   Nonetheless, during the hearing, Dr. Mayer testified that R.R. “becomes very

       psychotic” when off her medication, oral medication had been prescribed for

       years, and R.R. had a history of non-compliance. (Tr. at 6.) R.R. testified that

       she took her medication regularly, specifically, heart medication, cholesterol

       medication, and Ambient (something she described as “kind of like my

       Risperdone was”). (Tr. at 22.) However, Dr. Mayer testified that R.R.’s liver

       enzyme evaluation had revealed some abnormalities, raising “a concern that

       she may have been taking the wrong medications and too much of them and

       not enough of the right ones.” (Tr. at 29.)


[18]   Dr. Mayer considered Invega Sustenna as “a very benign medication in that

       class” and specified that the benefits “far outweigh any of the risks.” (Tr. at 8.)

       Dr. Mayer opined that the risk of side effects was low and R.R. did not appear

       to be experiencing significant side effects from the oral form of medication

       given during her hospitalization. According to Dr. Mayer, injections would

       require limited occasions of intervention, as it required two injections, four days

       apart, and then would become only monthly. The hope was that R.R.’s

       estimated 60% improvement in auditory hallucinations with oral medication

       could be further improved to the “elimination of psychotic symptoms.” (Tr. at

       13.) The trial court did not order a particular medication in the absence of

       testimony of other alternatives; we find R.R.’s argument to be a request to

       reweigh the evidence presented in this regard.


[19]   R.R. also claims that there was no time limitation placed upon the

       administration of the medication. Again, we disagree with this contention.

       Court of Appeals of Indiana | Memorandum Decision 53A05-1501-MH-19 | August 7, 2015   Page 9 of 10
       Indiana Code Section 12-26-15-1(a) requires the annual review of commitment

       orders. In compliance therewith, the trial court ordered IU Health to submit a

       periodic report not later than December 19, 2015. By statute, the forced

       medication order is not indefinite. The time period of medication

       administration was curtailed and the order was subject to the limitation of

       discontinuance if R.R. did not specifically benefit from the medication.

       Sufficient evidence exists for the medication order.



                                               Conclusion
[20]   IU Health presented sufficient evidence such that the trial court could find by

       clear and convincing evidence that R.R. was gravely disabled. IU Health

       established the requisite proof to support the medication order.


[21]   Affirmed.


       Baker, J., and Mathias, J., concur.




       Court of Appeals of Indiana | Memorandum Decision 53A05-1501-MH-19 | August 7, 2015   Page 10 of 10
