Evidence of Medication Noncompliance Is Not Admissible to Show Voluntary Inducement of a Mental State
In State v. Wierson, 916 S.E.2d 389 (Ga. 2025), the Supreme Court of Georgia examined whether voluntary medication noncompliance is relevant and admissible in a criminal responsibility trial. The court ruled that evidence of Michelle Wierson’s medication noncompliance was not admissible to demonstrate that she “voluntarily” induced her lack of mental state or delusional compulsion. The statutory insanity defense is available without regard to consideration of medication noncompliance.
Facts of the Case
Ms. Wierson was charged with vehicular homicide and reckless driving after she allegedly drove at high speeds and crashed into another car, resulting in a passenger’s death. At jail after her arrest, she was noted to be in a “manic state” and sent to an outside mental health facility for evaluation and treatment. The treating psychiatrist noted that Ms. Wierson was prescribed at least four medications, but there was evidence that she had stopped taking some of the medications weeks before the vehicle collision. After her release, two independent psychiatrists evaluated Ms. Wierson for her legal case and determined that, on the day of the accident, Ms. Wierson was experiencing religious delusions that she had to speed to rescue her daughter and God was driving her car. Both psychiatrists agreed that Ms. Wierson was unable to distinguish right from wrong at the time of the crash and experienced a delusional compulsion. Ms. Wierson filed a notice of intent to plead not guilty by reason of insanity according to Georgia’s insanity statutes (O.C.G.A. § 16-3-2 (2018), O.C.G.A. § 16-3-3 (2018)).
The state filed a motion in limine to admit evidence that Ms. Wierson was not taking her prescribed medications, arguing that Ms. Wierson voluntarily contributed to her mental state. Ms. Wierson’s team countered this. Initially, the trial court granted the state’s motion, but this was later reversed by the court of appeals, which held that whether she took medications or not was not relevant to her insanity defense.
The state had initially relied on a previous case, Bailey v. State, 291 S.E.2d 704 (Ga. 1982), in which a person with paranoid schizophrenia entered a stressful situation against medical advice and killed two people and that the “delusional compulsion” aspect of the insanity defense was not available to the defendant, as he had brought on the delusions voluntarily. In Bailey, the court had concluded that statutory insanity defenses were not available to a defendant who “intentionally” or “voluntarily” brought about the relevant mental state. The state argued that Ms. Wierson had similarly brought on her delusions through medication noncompliance. The court of appeals disagreed with the state.
The Supreme Court of Georgia granted review to address whether evidence of medication noncompliance is relevant to whether Georgia’s statutory defenses of insanity were available to the defendant and to reconsider Bailey.
Ruling and Reasoning
The Supreme Court of Georgia agreed with the court of appeals that Ms. Wierson’s medication noncompliance was not relevant as evidence for her insanity defense. The court also overruled Bailey’s holding that created an exception to the insanity defense.
The court examined the plain text of Georgia’s statutory insanity defense, which states that a person is not criminally responsible if, “at the time of the act, omission, or negligence constituting the crime, the person did not have mental capacity to distinguish between right and wrong in relation to such act, omission, or negligence” (O.C.G.A. § 16-3-2). The court noted that this defense and historical Georgia law had no mention of the cause of the mental state, emphasizing the importance of the defendant’s mental state at the time of the crime with no mention of how the state came to be. The court found that the insanity defense is available to even people who voluntarily bring about their mental state. Even if Ms. Wierson stopped taking her medication, her medication noncompliance was not relevant to her ability to use this defense.
The Georgia Supreme Court reviewed its prior decision in Bailey, which had analogized voluntary inducement of a delusion with voluntary intoxication. In Bailey, the court said that the insanity defense was not available to the defendant in that case because he “brought that delusion about with as much premeditation as a chronic alcoholic who, in the same circumstances, might have prepared himself for the impending confrontation by imbibing alcohol to excess” (Bailey, p 707). Compared with the insanity defense, the intoxication defense affords protections for persons who commit a crime because of involuntary intoxication, but voluntary intoxication “shall not be an excuse for any criminal act or omission” (Bailey, p 707, citing O.C.G.A. § 16-3-4 (c) (2024)). The Bailey decision suggested that the statutory insanity defenses would not be available to those who “intentionally” or “voluntarily” induced the relevant mental state.
In reviewing Bailey, the Supreme Court of Georgia considered whether to follow the past decision. The court discussed the definition of holding, concluding that the holding of a judicial decision is more than just based on facts but instead also on the reasoning necessary for the decision. Distinguishing its ruling from the court of appeals in Wierson, the court concluded that Bailey must be overruled, as the Bailey case did not interpret the insanity statute correctly and instead cited an exception only found in the statutory intoxication defense.
In application to Ms. Wierson’s case, the Georgia Supreme Court found that Ms. Wierson properly put forth two psychiatric reports with opinions that she lacked the mental capacity to tell right from wrong and also experienced a delusional compulsion at the time of the vehicle collision. The court said that an argument that Ms. Wierson failed to take her medications fails because that is not a basis for rendering unavailable the statutory insanity defenses. The court added that the decision does not foreclose admission of evidence of medication noncompliance for all purposes, but whether that evidence might be relevant for another purpose is not currently before the court. The judgment of the court of appeals was affirmed.
Discussion
In Wierson, the Georgia Supreme Court affirmed that evidence that a defendant “voluntarily” or “intentionally” brought about the defendant’s mental state at the time of a crime, specifically through medication noncompliance, was not relevant in the insanity defense. The court overturned a previous case that had transmuted an exception to the insanity defense from statutes on voluntary intoxication.
For forensic experts, this case underscores the complexity of considerations involved when a patient with psychosis is noncompliant with psychiatric medication. In an amicus brief to the Georgia Supreme Court in Wierson, the American Academy of Psychiatry and the Law and other health organizations explained the inherent challenges in defining medication noncompliance and determination of whether a person’s noncompliance with medications is the proximate cause of a criminal act (Amici Curiae Brief Am. Psych. Association, AAPL, and Ga. Psych. Phys. Assoc., State v. Wierson, 916 S.E.2d 389 (Ga. 2025)). For patients on multiple medications, such as Ms. Wierson, it is likely impossible to say that missing any one medication is directly linked to the state of mind at the time of the crime.
Clinicians recognize that patients’ reasons for medication noncompliance are complex (Semahegan A, Torpey K, Manu A, et al. Psychotropic medication non-adherence and its associated factors among patients with major psychiatric disorders: A systematic review and meta-analysis. Syst Rev. 2020; 9(1):17). Some patients may stop them because of debilitating side effects, and lack of insight in needing medications is a well known symptom of many mental diagnoses. Costs and lack of access to health care are structural barriers that further complicate the ability to take prescribed medications.
For psychiatrists, it is also difficult to ascertain whether patients are taking all the medications exactly as prescribed, as symptoms do not always correspond linearly with medication use. Furthermore, taking medications exactly as prescribed does not mean that a patient will be mentally stable, as psychiatric symptoms can fluctuate with the course of the disease, even if patients remain on the same medication for years. Given this level of uncertainty around medication compliance, forensic evaluators should recognize that experts cannot reliably assess and determine to what degree a person’s noncompliance led to the person’s mental state.
- © 2025 American Academy of Psychiatry and the Law
