21CA1333 Peo in Interest of Houle 11-24-2021
COLORADO COURT OF APPEALS
Court of Appeals No. 21CA1333
Jefferson County District Court No. 20MH69
Honorable Meegan A. Miloud, Magistrate
The People of the State of Colorado,
Petitioner-Appellee,
In the Interest of Stephany Houle, a/k/a Angelica Penny Royal,
Respondent-Appellant.
ORDER REVERSED
Division IV
Opinion by JUDGE FREYRE
J. Jones and Tow, JJ., concur
NOT PUBLISHED PURSUANT TO C.A.R. 35(e)
Announced November 24, 2021
Kimberly S. Sorrells, County Attorney, Joan S. Heller, Assistant County
Attorney, Golden, Colorado, for Petitioner-Appellee
The Law Firm of John L. Rice, John L. Rice, Pueblo, Colorado, for Respondent-
Appellant
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¶ 1 Respondent, Stephany Houle, a/k/a Angelica Penny Royal,
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appeals the district court’s order authorizing the involuntary
administration of (1) the antipsychotic medications Clozaril and
Zyprexa; (2) the anti-anxiety medication Ativan; (3) the mood
stabilizers lithium and Depakote; and (4) the side effect medications
Inderal and Benadryl.
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We reverse the order authorizing the
involuntary administration of these medications.
I. Background
¶ 2 In February 2021, Ms. Penny Royal was admitted to the
Colorado Mental Health Institute at Fort Logan (CMHI-FL). Dr.
Ryan Moroze, a staff psychiatrist at CMHI-FL, began treating Ms.
Penny Royal shortly thereafter, and in July, the People petitioned
for an order authorizing the involuntary administration of
antipsychotic, anti-anxiety, mood stabilizing, and side effect
medications.
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The respondent testified that her full name is Angelica Penny-
Romanoff-Royal-Rafael. Because she does not identify as Stephany
Houle and she has declined to complete paperwork using her legal
name, we identify the respondent as Ms. Penny Royal in this
opinion. This is also consistent with the parties’ briefs.
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Ms. Penny Royal does not appeal the portion of the district court’s
order extending certification for short-term treatment.
2
¶ 3 The district court held an evidentiary hearing at which Dr.
Moroze and Ms. Penny Royal testified. Dr. Moroze was qualified
and accepted as an expert witness in the field of psychiatric
medication by stipulation. At the time of the hearing, Ms. Penny
Royal agreed to take nine of the requested medications, but she
objected to Clozaril, Zyprexa, Ativan, lithium, Depakote, Inderal,
and Benadryl.
¶ 4 Dr. Moroze testified that Ms. Penny Royal suffers from Bipolar
I disorder, current episode manic, with psychotic features. Ms.
Penny Royal’s symptoms include difficulty sleeping, distractibility,
pressured speech, mood dysregulation, occasional aggressive
behavior, grandiose and paranoid delusions, and auditory
hallucinations.
¶ 5 Dr. Moroze said that while some of Ms. Penny Royal’s
symptoms have modestly improved under the voluntary medication
regimen, many persist, and the medications she currently takes
have provided limited benefit or are not available in a therapeutic
dose sufficient to promote her discharge. He characterized her as
“stably unwell,” said she remains gravely disabled, and opined that
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without the involuntary medications, her prognosis is very poor
because she would likely be subject to a long-term hospital stay.
¶ 6 Additionally, Dr. Moroze explained that if Ms. Penny Royal is
released without the involuntary medications, she will likely be re-
hospitalized as has happened several times previously. He noted
that her previous failures to medicate while in the community
resulted in lengthier hospitalizations to stabilize her and said that
the longer her delusions persist, the more difficult it becomes to
obtain a positive outcome. Dr. Moroze also testified that he has no
records of Ms. Penny Royal’s claimed side effects to the involuntary
medications. Even so, he articulated an existing plan to mitigate
and monitor potential known side effects.
¶ 7 For her part, Ms. Penny Royal denied being “very sick,” as Dr.
Moroze described. She believes her symptoms stem from
“menstrual dysphoria.” She said that she has numerous side
effects from the involuntary medications including dental issues,
mucus in her lungs, excessive drowsiness, seizures, hives, and
nightmares based on her grandpa’s death.
¶ 8 At the end of the hearing, the district court found Dr. Moroze
both credible and persuasive. As relevant here, it found, by clear
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and convincing evidence, that Ms. Penny Royal suffers from a
mental illness and is not competent to effectively participate in
treatment decisions. It concluded that treatment is necessary to
prevent significant and long-term deterioration of Ms. Penny Royal’s
condition and that Ms. Penny Royal’s reported side effects can be
managed by CMHI-FL’s medical staff. Finally, the court found the
need for treatment is sufficiently compelling and overrides any
legitimate interest Ms. Penny Royal has in refusing the medications.
And it found that a less intrusive treatment alternative is not
available. The court granted the petition and entered an order
authorizing the involuntary administration of Clozaril, Zyprexa,
Ativan, lithium, Depakote, Inderal, and Benadryl. Ms. Penny Royal
challenges the sufficiency of the evidence supporting the court’s
order.
II. Legal Authority and Standard of Review
¶ 9 An involuntarily committed person retains the right to refuse
treatment. See People v. Medina, 705 P.2d 961, 971 (Colo. 1985).
Even so, a district court may authorize the involuntary
administration of medication to a patient if the People establish
each of the following elements by clear and convincing evidence: (1)
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the patient is incompetent to effectively participate in the treatment
decision; (2) treatment by antipsychotic medication is necessary to
prevent a significant and likely long-term deterioration in the
patient’s mental condition or to prevent the likelihood of the
patient’s causing serious harm to herself or others in the
institution; (3) a less intrusive treatment alternative is not available;
and (4) the patient’s need for treatment by antipsychotic medication
is sufficiently compelling to override the patient’s bona fide and
legitimate interest in refusing treatment. Id. at 973; People in
Interest of Strodtman, 293 P.3d 123, 131 (Colo. App. 2011). A
physician’s testimony alone may constitute clear and convincing
evidence sufficient to sustain an involuntary medication order. See
People v. Pflugbeil, 834 P.2d 843, 846-47 (Colo. App. 1992).
¶ 10 When, as here, a patient challenges the sufficiency of the
evidence supporting the district court’s findings on any of these
elements, we review the court’s conclusions of law de novo and
defer to its findings of fact if supported by record evidence. People
v. Marquardt, 2016 CO 4, ¶ 8. We view the record in the light most
favorable to the People, leaving the resolution of conflicts in the
testimony and determination of the credibility of the witnesses
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solely to the province of the fact finder. People v. Fuentes, 258 P.3d
320, 326 (Colo. App. 2011).
III. Analysis
¶ 11 Ms. Penny Royal challenges the sufficiency of the evidence for
the second and third Medina factors. Concerning factor two, she
argues that the evidence does not support the district court’s
findings that involuntary medication is necessary to prevent a
significant and long-term deterioration in her mental condition.
Because we agree with this contention, we need not address her
arguments concerning factor three.
¶ 12 The second Medina factor requires the court to consider one of
two alternative factors: if the proposed treatment is necessary either
(1) “to prevent a significant and likely long-term deterioration in the
patient’s mental condition” or (2) “to prevent the likelihood of the
patient’s causing serious harm to himself or others in the
institution.” 705 P.2d at 973. Here, the district court based its
order on the deterioration alternative. This alternative considers
“the patient’s actual need for the medication.” Id. Medina directs
courts to consider “the nature and gravity of the patient’s illness,
the extent to which the medication is essential to effective
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treatment, the prognosis without the medication, and whether the
failure to medicate will be more harmful to the patient than any
risks posed by the medication.” Id. But, as our supreme court
explained in Marquardt, ¶ 23, these considerations must all be
viewed through the lens of preventing deterioration, rather than
attaining improvement, of a respondent’s condition. The
deterioration factor cannot be met simply with evidence that
medication would have a positive impact on the patient’s condition
and potentially lead to a patient’s release from confinement. Id. at
¶¶ 25-26.
¶ 13 The district court found that the requested medications “are
necessary to prevent a significant and likely long-term
deterioration” in Ms. Penny Royal’s mental condition. It considered
the holding in Marquardt, but it distinguished this case by finding
that Ms. Penny Royal was unstable. The record, however, does not
support the district court’s finding on this issue.
¶ 14 While Dr. Moroze’s petition stated that involuntary
medications were necessary to “prevent further psychiatric
decompensation,” his testimony never connected the requested
medications to the prevention of Ms. Penny Royal’s long-term
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deterioration. Indeed, when asked on cross-examination whether
Ms. Penny Royal’s current medical condition was deteriorating, Dr.
Moroze stated, “It is not deteriorating from that point; however, it’s
not improving where she has that.” (Emphasis added.)
¶ 15 Nor does the evidence demonstrate that Ms. Penny Royal’s
condition was deteriorating. Dr. Moroze testified that Ms. Penny
Royal was tolerating the voluntary medications well and that she
had experienced modest improvement under the current medication
regimen. When Ms. Penny Royal was transferred to CMHI-FL, “she
used fewer racial slurs, her speech ha[d] been slightly less
pressured and more interruptible, and she . . . needed less
redirection from staff in order to follow the policies and procedures.”
She also needed less supervision when completing hygiene
activities. Although she continues to suffer delusions and is unable
to connect the need for medication to her mental illness, Dr. Moroze
testified that Ms. Penny Royal is “stably unwell.” In light of this
testimony, Ms. Penny Royal’s history of mental illness alone is not
enough to support the district court’s finding that she is unstable.
See id. at ¶ 21 (“A patient’s history of mental illness is insufficient
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to support an assumption that his condition will deteriorate further
when he is, in fact, stable.”).
¶ 16 As in Marquardt, the record here does not show a significant
risk that Ms. Penny Royal’s condition would deteriorate without the
requested medication, but instead shows that Ms. Penny Royal
would not improve to the point of justifying discharge. Dr. Moroze
testified that the involuntary medications are necessary to improve
Ms. Penny Royal’s mental condition and to promote her discharge.
In particular, he prescribed Clozaril and Zyprexa (antipsychotics)
because Loxitane does not provide “a significant benefit in terms of
promoting her discharge and alleviating symptoms.” He also
prescribed Depakote because Ms. Penny Royal had been previously
discharged while taking Depakote in combination with Zyprexa.
¶ 17 Additionally, Ms. Penny Royal agreed to take and was taking
the mood stabilizers Lamictal and Trileptal. Dr. Moroze requested
lithium and Depakote because the Lamictal and Trileptal are “not
enough to affect in terms of decreasing her mood dysregulation and
alleviating manic symptoms.” (Emphasis added.) Finally, although
Ms. Penny Royal agreed to take and was taking Clorazepam
(Klonopin), a benzodiazepine antianxiety medication similar to
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Ativan, Dr. Moroze requested Ativan because it is available in a
shorter acting, injectable form that can be administered if Ms.
Penny Royal refuses to take Clorazepam or “in an emergent period
of mood dysregulation or aggressive behavior, which she has
demonstrated in the past.” Overall, Dr. Moroze opined that Ms.
Penny Royal’s prognosis in the absence of the involuntary
medications was “very poor” because, without significant
improvement in her delusions and symptoms, Ms. Penny Royal
would “likely be relegated to a longer stay at the hospital.”
¶ 18 The district court was “pleased to hear that there ha[d] been
some improvement,” but it ordered the involuntary medication “to
make sure [Ms. Penny Royal] can be healthy enough to discharge.”
However, the court does not have the authority “to order medication
solely to improve or expedite a patient’s participation in treatment
or likelihood of release.” People in Interest of Marquardt, 2014 COA
57, ¶ 20, aff’d, 2016 CO 4. And, “[f]orcing patients to accept
medication based on an abstract, future possibility would render
their right to bodily integrity illusory,” even where the patient has a
history of violent actions. Marquardt, 2016 CO 4, ¶¶ 19, 21.
Because insufficient evidence supports the involuntary
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administration of Depakote and lithium, insufficient evidence
necessarily exists to support the involuntary administration of
Inderal and Benadryl, medications designed to counteract the side
effects of Depakote and lithium.
¶ 19 We conclude that the district court applied an incorrect legal
standard and, therefore, erred by ordering the involuntary
administration of medication to Ms. Penny Royal. See id. at ¶¶ 25-
26.
IV. Conclusion
¶ 20 The district court’s order authorizing the involuntary
administration of Clozaril, Zyprexa, Ativan, lithium, Depakote,
Inderal, and Benadryl is reversed.
JUDGE J. JONES and JUDGE TOW concur.