Involuntary Medication of a Defendant with Delusional Disorder Upheld Under Sell
In United States v. Dear, 104 F.4th 145 (10th Cir. 2024), the Tenth Circuit Court of Appeals reviewed a decision regarding the involuntary medication of a defendant with delusional disorder using the criteria from Sell v. United States, 539 U.S. 166 (2003) (Sell criteria). The appellate court upheld the ruling and found that the district court satisfactorily explained its decision to grant the order for involuntary medications. The appellate court determined that there was no clear error in the district court’s conclusion regarding the second prong of Sell, which specified that the proposed treatment was “substantially likely” to restore the defendant to competency.
Facts of the Case
On November 27, 2015, the indictment alleged that Robert Dear Jr. arrived at a Planned Parenthood Clinic in Colorado Springs, Colorado, armed with 12 guns, hundreds of rounds of ammunition, and propane tanks. His attack resulted in a five-hour standoff with police, multiple injuries, and the deaths of three people, including one member of law enforcement. Mr. Dear was arrested and he was later diagnosed with delusional disorder, persecutory type. Over the next four years, repeated evaluations affirmed that Mr. Dear was not competent to stand trial, and attempts to medicate him involuntarily in Colorado were unsuccessful or legally constrained. In 2019, his case moved to the federal courts, where he was indicted on 68 charges, and he was transferred to the Medical Center for Federal Prisoners (MCFP) in Missouri for a competency evaluation. The examining forensic psychologist, Lea Ann Preston Baecht, PhD, opined that Mr. Dear remained incompetent to proceed, but “he was substantially likely to be restored to competency through the administration of antipsychotics” (Dear, p 147).
Mr. Dear consistently refused pharmacological treatment, so a Sell hearing was held in August of 2022 to consider the use of involuntary medications. Dr. Preston Baecht and Robert Sarrazin, MD, Chief of Psychiatry at MCFP, testified for the government. They affirmed that, in their over 20-year tenure at the hospital, they successfully restored over 70 percent of patients with delusional disorder and “estimated a similar, over-70 percent chance that antipsychotics would restore [Mr. Dear] to competency” (Dear, p 148). They emphasized Mr. Dear’s prior level of functioning in society, cognitive abilities, and lack of failed treatment as positive prognostic factors. Richard Martinez, MD, forensic psychiatrist; William Morton, PharmD, psychiatric pharmacist; and George Woods, MD, neuropsychiatrist, testified for the defense and refuted the government experts’ review of the available literature on delusional disorder and response to medication and on the claim that Mr. Dear’s chance of restoration with medication was more than 70 percent. Although only Dr. Martinez personally evaluated Mr. Dear, all three experts opined that antipsychotic medications were unlikely to restore him to competency. They refuted the scientific literature cited by the government’s experts and added that both Mr. Dear’s negative symptoms and cognitive abilities were unlikely to be improved by medications. The district court ultimately ruled in favor of the government and granted the motion for involuntary medication. The court found that the government met its burden of proof under all four Sell criteria and issued a stay following Mr. Dear’s appeal.
Ruling and Reasoning
The Tenth Circuit affirmed the district court’s decision and emphasized that the lower court adequately explained its ruling regarding each of the Sell criteria and did not commit clear error. The second Sell prong, that involuntary medications were substantially likely to render the defendant competent to stand trial, was the central point of contention on appeal. Mr. Dear stated that the court committed legal error by having “failed to engage” in a thorough review of the evidence and did not provide adequate reasoning for its conclusion. The appellate court disagreed and, although not defining a particular standard, noted that case law advised that the required level of detail included some level of particularized findings. In United States v. Watson, 793 F.3d 416 (4th Cir. 2015), the court made the important finding that the government must show that in the particular defendant’s situation, not just in general, it is “substantially likely” that involuntary medications will restore competency. The appellate court found that the district court’s ruling was supported by “detailed factual findings” related to Mr. Dear’s diagnosis and proposed treatment.
The appellate court upheld the district court’s decision to give more weight to the government’s experts, finding no legal error. The court noted that the government’s experts directly evaluated Mr. Dear, unlike the defense experts. Mr. Dear argued that the court failed to explain why the defense’s opinions were discounted and claimed the government confused credibility with the weight of expert testimony. The appellate court clarified that the district court did not find the government’s experts more credible; rather, the court reasonably assigned more weight to their testimony based on their years of clinical experience and personal interactions with and observations of Mr. Dear.
In his appeal, Mr. Dear argued that his duration of long-untreated psychosis (DUP), age, and cognitive condition made it unlikely that medication would restore his competency. But government expert Dr. Preston Baecht testified that research did not clearly link prolonged DUP to poor outcomes and shared her success treating patients with similar histories. (Of note, at no time in the hearing did the defense raise concerns that a nonprescribing psychologist was the primary expert for the government on questions pertaining to the efficacy of psychotropic medication in restoration treatment.) Similar reasoning applied to age and cognition. Although defense expert Dr. Woods described concern for Mr. Dear’s cognitive limitations, his opinion carried less weight because he never evaluated Mr. Dear. The government’s experts countered that Mr. Dear, in his 60s, showed no cognitive impairment or signs of dementia. The court also addressed Mr. Dear’s criticism of the scientific literature on treating delusional disorder with antipsychotics and acknowledged the flaws in both historical and modern studies. The appellate court emphasized that the district court’s decision relied primarily on the government experts’ experience in restoration treatment and personal interactions with Mr. Dear, placing considerably less importance on the disputes in the scientific literature.
The appellate court found no clear error in the district court’s weighing of expert testimony and finding that involuntary medications were substantially likely to restore Mr. Dear to competency. Thus, the appellate court affirmed the district court’s order to involuntarily medicate Mr. Dear.
Discussion
The Tenth Circuit Court’s ruling in Dear provides insight into how one appellate court resolved conflicting expert testimony on the question of whether antipsychotic medication was “substantially likely” to restore Mr. Dear to competency. The appellate court upheld the district court’s decision to forcibly medicate Mr. Dear by the weight given to expert testimony, testimony that was informed by ambiguous scientific literature and genuine disagreement about the ability to estimate the probability of restoration in this defendant’s particular circumstances. Given the limitations of research and the intrinsic uncertainty about how any individual with a primary delusional disorder may respond to antipsychotic medication, this court concluded that the government’s experts carried greater weight, not credibility, providing the court a pathway to a difficult decision.
The court reasoned that, because of their greater institutional experience with patients diagnosed with delusional disorder and particularly their experience with Mr. Dear, those experts warranted greater consideration. The court adopted this view despite conflicting testimony about Mr. Dear’s cognitive status and the government experts’ discounting that DUP was relevant in Mr. Dear’s case. The professional confidence in predicting a greater than 70 percent chance of restoration apparently was persuasive to the court, if not to the experts testifying against the involuntary treatment of Mr. Dear.
Several factors were not considered in the court’s reasoning. The court did not acknowledge how independent evaluators provide a crucial check on institutional and treater bias, considerations important when making decisions involving the introduction of unwanted invasive medical treatment. In addition, although the government’s interest in prosecuting Mr. Dear was not in dispute, the horrific nature of the violence and its impact on choosing between an opportunity for prosecution versus indefinite civil commitment can be unspoken factors at play in such cases.
For forensic psychiatrists involved in Sell proceedings, courts heavily rely on expert testimony involving probabilistic statements about responses to medication in situations where the scientific literature is thin, and the experience of experts can be limited, but overvalued. Ethically, forensic psychiatrists are aware of the problem when one wears “two hats” and may have a conflict of interest. In Dear, it appears the role of the treater weighed persuasively in the decision of the court, contrary to what research and experience has taught about potential conflicts of interest and bias when a treater is asked to opine on a controversial and difficult matter.
- © 2025 American Academy of Psychiatry and the Law
