Court-Mandated, Long-Acting Antipsychotic Medication as a Condition of Supervised Release
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* Bradley Freeman
* Richard L. Frierson

## The Fourth Circuit Court of Appeals Approves the Order of Forced Intramuscular Medication as a Condition of Release

In *United States v. Holman*, 532 F.3d 284 (4th Cir. 2008), the U.S. Court of Appeals for the Fourth Circuit upheld a district court ruling mandating involuntary long-acting antipsychotic medication as a condition of supervised release. In issuing its opinion, the court considered the interpretation of the Federal Sentencing Guidelines in light of *Washington v. Harper*, 494 U.S. 210 (1990), and *Sell v. United States*, 539 U.S. 166 (2003). In November 2008, the U.S. Supreme Court denied *certiorari* on appeal (*Holman v.* *United States*, 129 S. Ct. 522 (2008)).

#### Facts of the Case

Philip A. Holman pleaded guilty to various drugs and weapons charges in 1993 and 1996. While serving his sentence for the 1993 charges, he displayed symptoms that ultimately led to a diagnosis of schizoaffective disorder, bipolar type. During his time in prison, Mr. Holman vacillated in his compliance with treatment, including oral antipsychotic medication. Periods of treatment refusal lead to recurrence of his symptoms. In 1997, Mr. Holman was involuntarily committed to a psychiatric prison facility.

After several months of his noncompliance, prison officials convened an “involuntary medication hearing” in June of 2003, consistent with the due process provisions outlined in *Washington v. Harper*, and decided to allow involuntary medication of Mr. Holman with antipsychotic drugs. By late 2003, his condition deteriorated and he voiced suicidal and homicidal threats, prompting the administration of risperidone in its long-acting, injection formulation. While on injections and oral antipsychotic medication, he was released in September 2004 after serving his prison term. His prison psychiatrist recommended that he continue the injections “to prevent [him] from succumbing to the temptation to stop taking the tablets.” He was then treated in the community with oral risperidone.

The conditions of his supervised release did not require mental health treatment. Mr. Holman's probation officer filed a petition regarding the treatment, and in March 2005, the court ordered Mr. Holman to comply with his treatment plan, including all medication. The order specifically required the use of intramuscular injections of risperidone as recommended by his prison psychiatrist.

After the hearing but before the court order, Mr. Holman disappeared. After losing contact with his family for several weeks, he was found wandering aimlessly in a partially catatonic state and arrested. After his competence was restored, he was sentenced to 11 months for violating the terms of his conditional release. He was then released under the same supervised guidelines for 49 months. However, only a few months after his release Mr. Holman once again refused to take his prescribed medication, and his parole officer issued a petition regarding the violation. Mr. Holman was arrested, found incompetent, restored, and then given one year's imprisonment with 37 months of supervised release under the same conditions as those of the previous release.

Mr. Holman appealed his sentence, objecting to the required administration of long-acting, intramuscular, antipsychotic medication, but not to the other guidelines, including that he comply with oral antipsychotic medication. He argued against the medical necessity of the injections and that less intrusive alternatives would suffice. He purported that the special condition of the supervised release violated his constitutionally protected liberty interest in refusing the injections.

#### Ruling and Reasoning

The 4th Circuit Court of Appeals affirmed the ruling of the lower court. District courts are required to impose certain conditions with supervised release and are permitted to impose other measures under 18 U.S.C.A., § 3583(d). The district courts “have broad latitude” regarding implementing special conditions of supervised release and the appeals court, after examination, ruled that there was no abuse of discretion by the district court in this case. The court ruled that the record clearly reflects that Mr. Holman was a danger to himself and others when off his medication. The appeals court contended that the involuntary medication requirement (1) was reasonably related to the need to protect the public, (2) was providing Mr. Holman with effective and proper medical care, and (3) was the least intrusive way to further these important governmental purposes. Mr. Holman argued that application of the § 3583(d) requirements did not address his fundamental liberty interest in refusing dangerous, personality-altering medications.

The court weighed the strength of § 3583 against existing case law, especially *Sell v. United States. Sell* requires that an order for involuntary medication meet a compelling governmental interest, whereas § 3853 requires only a reasonable relationship to one of several sentencing goals. In addition, the statute requires that the condition of supervised release be no more restrictive than reasonably necessary, while *Sell* demands that the least intrusive means be utilized. Finally, the court ruled that the special condition of involuntary medication was consistent with the due process requirements set out by the U.S. Supreme Court in *Harper* and *Sell*.

#### Discussion

Under the Due Process Clauses of the Fifth and Fourteenth Amendments, individuals have a protected liberty interest in avoiding involuntary administration of antipsychotic drugs. While considering the constitutionality of involuntary medication, there is a governmental interest in the protection of the individual and others from the individual's dangerous behavior (*Riggins v. Nevada*, 504 U.S. 127, 134–5 (1992) and *Harper*, pp 225–6). Safety is a predominant reason to order involuntary medication; however, a nondangerous person can also be involuntarily medicated, such as to restore capacity to stand trial.

Mr. Holman's volatile behavior when noncompliant with medication led the appeals court to rule that he was a danger to himself and others and to affirm the order of the district court. The other option the court considered in disposition of Mr. Holman was imprisonment. This plan of action, however, continued to place him at a risk to himself and the staff of the facility, as evidenced by his behavior while incarcerated. Placing him in the least restrictive environment for treatment is mandated by *Sell*, which supports supervised release in lieu of incarceration. Before the onset of symptoms, Mr. Holman was charged with drugs and weapons violations in which he was convicted. It could be argued that even if optimally treated, he might still be dangerous to others based on his legal history.

This case represents an extension of legally recognized situations that constitutionally permit involuntary psychiatric medications. While *Harper* provides the requirements for involuntary medication in prison and *Sell* outlines the requirements for involuntary medication to restore competence to stand trial, the present case outlines the guidelines for involuntary medication as a condition of supervised release. If this expansion continues, future cases may examine the use of involuntary medication for potentially dangerous patients in nonforensic populations as a condition for outpatient treatment upon release from a psychiatric hospital.

*   American Academy of Psychiatry and the Law