Case Summary: In re H.P., 2019 IL App (5th) 150302 (Opinion Filed July 1, 2019)

In this 5th district case, the court reversed an involuntary medication order, specifying for the first time that pursuant to the Mental Health Code (405 ILCS 5/2-107.1(a-5)(4)(D) (West 2014)) the “State must present evidence of known interactions between multiple medications in order to satisfy its statutory burden of demonstrating that the benefits of the proposed treatment outweigh the harm.” ¶¶ 1-2.

Randolph County had entered an involuntary treatment order authorizing the Chester Mental Health Center to administer twelve medications (six primary medications, as well as six alternatives) on H.P., a Chester patient. ¶ 5. In his appeal, H.P. argued that 1) the state failed to prove by clear and convincing evidence that benefits of the proposed treatment outweighed its potential risks because the doctor failed to testify about the benefits of using more than one antipsychotic medication, and that he did not present any testimony concerning potential drug interactions; 2) the state failed to prove that testing also ordered with the medication was essential for the safe treatment; 3) the order did not conform to the evidence presented concerning the medication dosage and the treatment administrators; and 4) that he was provided with ineffective assistance of counsel. ¶¶ 2, 27.

Mootness

Since the 90-day order expired, the court initially addressed mootness, finding that the “public interest” exception to mootness applied. ¶16-20. To support this qualification, it noted that the issue of the risks of drug interactions appears to be of first impression. ¶18. The court also held that this case is not a sufficiency of evidence appeal, noting “H.P.’s claims relate to the type of evidence the state must present to meet its statutory burden, rather than the weight of the evidence presented. This court has recognized that such questions have ‘broader implications than most sufficiency-of-the-evidence claims.’ ” ¶17.

Principles of Law Concerning Involuntary Medication and Standard of Review 

As a preliminary matter, the court noted that “Courts [have] recognized that any involuntary mental health treatment involves “a ‘massive curtailment of liberty.’ The involuntary administration of psychotropic medications is particularly intrusive. This is so for three reasons. First, involuntary medication constitutes an unwanted “intrusion[ ] into [a patient’s] body and mind.”…..Second, psychotropic medications carry a risk of “significant side effects.”….. Third, there is a potential for such medications to be misused—that is, there is a danger that they might be prescribed primarily to manage or control patients rather than to treat their illnesses.” (citations omitted). ¶20.

Because involuntary medication “implicates fundamental rights”, the court reviewed this appeal under the plain error doctrine and rejected the state’s forfeiture arguments. ¶ 27.  Further, since this matter was determined on the case’s merits the court then declined to consider H.P.’s ineffective assistance of counsel arguments. ¶ 27. 

Risks vs. Benefits of the Ordered Medication

One element the state must prove is that the proposed treatment’s benefits outweigh its risks. 405 ILCS 5/2-107.1(a-5)(4)(D) (West 2014). ¶ 23. As for the benefits element, the court found that the doctor’s testimony that each medication would treat different symptoms is sufficient proof concerning the drugs’ benefits.   ¶ 31.
As for the risks of the interactions of multiple ordered medications, courts have recognized the importance of protecting patients from the risks of interactions, but that no prior Illinois cases have addressed this precise question of what evidence the state must present of the risks arising from the medications’ interactions. ¶ 35. The fifth district appellate court held that evidence of the potential risks from medications interactions must be presented: “We believe that the possibility of harm resulting from drug interactions is a crucial consideration in determining whether the benefits of a proposed course of treatment outweigh the risk of harm. Without pertinent information on the possibility of such harm, courts do not have adequate information to make a meaningful determination. Thus, we now hold that the state must provide trial courts with expert testimony addressing known drug interactions in order to meet its statutory burden of proving that the benefits of the proposed treatment outweigh the harm.”  ¶ 36
In this case, because the state did not ask the doctor about any known interactions between the requested medications that he wanted to administer simultaneously, the state did not meet its burden. ¶ 36

Testing and Other Procedures

At trial, no testimony was presented as to the specific tests requested, the frequency of those tests or why they were essential for monitoring. ¶ 40   In the court’s determination, the doctor’s testimony that H.P. would be monitored by blood tests, was insufficient proof the requested tests were essential for the safe and effective administration of the treatment. ¶ 40 The state itself conceded this point on appeal. ¶ 40.

Dosages and Individuals Authorized to Administer Medications

The court found that at trial the state also presented insufficient evidence of the medications’ dosage or who would administer them, also warranting reversal. ¶ 42. Though the Code does not require the state to present this evidence, the court reaffirmed its precedent, including that of In re Christopher C., (2018 IL App (5th) 150301, ¶¶ 23-24) and found that the state must present some evidence of the medication dosages and who would administer it. ¶¶  43-47. Further, having the petition “made a part of the record” at trial at the state’s request, is insufficient to prove this, for it was not specifically entered into evidence for purposes of establishing the requested dosages. ¶ 45. As for who is to administer the treatment, the state at trial presented evidence for two doctors to administer the medication, but not for the others, therefore not satisfying this requirement. ¶ 48.

Order reversed.

Barbara Goeben is a staff attorney with the Illinois Guardianship and Advocacy Commission, Metro East Regional Office in Alton.