The Kelly Case and Forced Psychiatric Medications

Oops, I started this and had to run. I thought it was saved to "draft" but it actually posted before it even got started! This time for real:

This is a ClinkShrink issue: pure forensics, but it has my attention for the moment, and it has broad implications for the treatment of psychiatric patients in Maryland who are violent when they are mentally ill.

If you want to read about the Kelly Case in the Baltimore Daily Record, CLICK HERE.

Okay, so in Maryland, a psychiatric inpatient can be forcibly restrained and forcibly medicated (by injection) if they are actively violent or threatening in a way that the facility staff and docs deem someone's imminent safety to be in peril. Such events are disturbing for everyone involved-- the patient is agitated, has often already struck or bitten someone, thrown an object or broken something, emotions are high, decisions are made quickly, things get intense. The medications administered are generally sedating and are short-acting. This is how it works for very acute situations.

Sometimes psychiatric inpatients are dangerous as a result of their psychiatric symptoms, but not imminently, and safety is a longer-term issue. These aren't people who are necessarily agitated or belligerent. If a dangerous patient is refusing to take medications, there is a legal mechanism to force them to take medicine-- in Maryland we call this a Medication Review Panel and it's a legal proceeding in which the patient gets to make his case and the psychiatrist gets to say why he thinks the patient needs to be medicated against their will. This is a more deliberate process, a legal proceeding.

I will tell you that the term "dangerous" is less narrowly defined. So someone who is hospitalized for depression who is not taking care of themselves such that a medical condition threatens their life (-- we're not talking about a sad diabetic who reaches for a piece of cake here, just to be clear on this). Most of the patients who come to Medication Review Panels have psychotic illnesses-- they are having hallucinations and/or are delusional, and they don't have the insight that they have an illness. Legally, someone can be as psychotic as they'd like and refuse treatment, the issue here is one of dangerousness for someone who is already committed to an inpatient unit. Other examples might include someone who is so psychotic they are too disorganized to care for themselves and leave lighted cigarettes lying around, or they believe that the devil has instructed them to kill people, or use your imagination. Roy and ClinkShrink might be better at generating examples. Let me also clarify that the dangerousness must be a result of mental illness, otherwise we're simply talking about criminals.

No one has thought too hard about the exact location as Where someone might be dangerous. Until the Kelly Case, that is.

I've never met Anthony Kelly, I don't know his diagnosis or his symptoms. He is a dangerous man and he has been confined to a hospital for the criminally insane (okay, Clink, a maximum security forensic facility) since 2002. Mr. Kelly was deemed too sick to stand trial for his crimes and he refused to take medication. At a hearing in 2005, an administrative law judge said Mr. Kelly could be forced to take medications, but the ruling was reversed on appeal by Baltimore City Circuit Court Judge Lynne A. Battaglia. Judge Battaglia said that since Mr. Kelly is dangerous only when he's outside the hospital, but not while he's in the confines of a maximally secure facility, so he can't be made to take medications.

To the surprise of Maryland psychiatrists, the Court of Appeals upheld this decision:

"Because there was no finding that Kelly is a danger to himself or others during his confinement in Perkins Hospital, a prerequisite to forcible administration of medication pursuant to Section 10- 708(g) [of the Health-General Article], we shall affirm the judgment of the Circuit Court of Baltimore City."

This means that a person who is mentally ill and dangerous can only be forced to take medication if they are dangerous WHILE they are in the hospital --even if they would be dangerous if they were not in the hospital.

Many psychiatrists who work on inpatient units are not happy about this because it means that if someone is mentally ill and dangerous outside the hospital, but not dangerous inside the hospital, they can't be treated and and they can't be released. Because they are dangerous, they must be kept in the hospital, perhaps indefinitely.

I don't work in an inpatient unit, but what I don't like about this ruling is the assumption that someone has a crystal ball that accurately says When and Where and Under What Circumstances someone with a severe psychiatric disorder that renders them dangerous will act. People elope from psychiatric units, they commit suicide on inpatient units, they assault other patients and staff members.

Anthony Kelly remains in Clifton T. Perkins hospital, unmedicated, or so I understand. Outside the hospital, his illness presumably contributed to his actions such that he is in a hospital and not a prison for his crimes-- the rape of the women and the murder of two people including a child. He has presumably been a safe and non-violent patient on his unit, and he doesn't want medications. Psychotic patients have difficulty with reality testing, they can be unpredictable and some patients can be dangerous. I'm not sure how in the face of such heinous past actions that anyone can absolutely guarantee that a patient such as this might not suddenly attack another patient or a staff member even in the hospital.

While the Kelly Case has been a topic of discussion among psychiatrists in the state, all factual information for this blog post was taken from the article in the Baltimore Daily Record that I linked to above. Okay Clink, let's hear it.....

Sorry, no pic. I couldn't find one of Clifton T. Perkins Hospital and anything else seemed tacky for such a serious and disturbing topic.

Top 10 Podcasts from My Three Shrinks for 2007

Okay, this is my last Top 10 list. We served up over half a terabyte (!) of podcasts last year, producing just under 40 podcasts on My Three Shrinks. We had over 30,000 unique visitors, nearly 200,000 visits, and served up over 100,000 podcast downloads!

Here are the Top 10 downloaded podcasts in 2007:

RANK	DOWN- LOADS	PODCAST
1	10466	#24: Short version of Dr Phil prank on Dinah [Listen now]
2	7252	#1: Podcasting Makes You Potty [Listen now]
3	3572	#5: Sex, Lies, & Neuroeconomics [Listen now]
4	3534	#6: Advice on Manipulating Your Psychiatrist [Listen now]
5	3368	#13: Lost It In Space [Listen now]
6	3348	#21: Chris Kraft on Gender Issues [Listen now]
7	3343	#8: Positively Lost [Listen now]
8	3304	#10: Be Mine [Listen now]
9	3300	#17: Happy Anniversary! [Listen now]
10	3299	#12: Bilingual [Listen now]

Incidentally, none of the above generated the most comments. The two podcasts that stirred up the most comments (37 each) were #15: POTUS Reading and #18: Grand Rounds.

My Three Shrinks Podcast 40: Happy New Year!

[39] . . . [40] . . . [41] . . . [All]

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Happy New Year to all our readers and listeners. We really have our podcast sequence screwed up still. #39 is stuck on an inaccessible, corrupted, encrypted Filevault folder, thanks to Leopard's poor handling of Filevault on installation. I'm working on it. [Edit: #39 is now our BlogTalkRadio interview with Dr. Anonymous. -Roy]  Until then, here is #40, recorded on Dec 30 for release on New Year's Day. Joining us today is a guest psychologist, Barb.

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January 1, 2008: #40 Happy New Year!

Topics include:

• Roy's Leopard Troubles. All is not easy in Mac-land. WARNING: Do NOT install Leopard if you are using Filevault. Turn off your Filevault first (of course, if you have 60GB of files in your Filevault, you will need 60GB of empty hard drive space to decrypt it, not the 5GB which I have).
  
  
• New Year's Resolutions. We all discuss our resolutions (or lack thereof).
  
  
• Top 25 Posts of 2007. Check out the most viewed Shrink Rap posts of 2007.
  
  
• Roy's Favorite Searches of 2007. Also check out Roy's quirky list of top 10 weird and funny Google searches. (Hint: oompaloompas)
  
  
• Hanns-G 28-inch LCD Monitor. Roy got a new monitor. Clink has screen-envy.
  
  
• Q&A: Drug Interactions. Do multiple psychotropic drugs sometimes counteract each other?
  
  
• Q&A: Seasonal Affective Disorder (SAD). Long discussion about SAD, lightboxes, melatonin, depression, and suprachiasmatic nucleus.
  
  
• iTunes Reviews. We read some of the 20 reviews we have on iTunes. We are NOT related to the Shrink Rap Radio podcast (which is also very good and worth listening to, but not nearly as entertaining as we are, IMHO.)
  

The background song is Auld Lang Syne, performed by Knuckle Fingers Joe on the Honky Tonk Piano CD (listen on eMusic).

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Find show notes with links at: http://mythreeshrinks.com/. The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom). This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.