United States District Court, N.D. Georgia, Atlanta Division
ORINDA D. EVANS, District Judge.
This criminal action comes before the Court on Mark Joshua Ruark's objections [Doc. 132] to the Non-Final Report and Recommendation ("R&R") of United States Magistrate Judge Gerrilyn G. Brill [Doc. 130], which recommends that the Government's Motion [Doc. 102] for involuntary medication be granted. For the following reasons, Ruark's objections [Doc. 132] are OVERRULED, the R&R [Doc. 130] is ADOPTED IN FULL, and the Government's Motion [Doc. 102] is GRANTED.
Defendant objects to several statements in the statement of facts, each of which is noted and reviewed de novo. The remainder of the R&R's statement of facts is uncontested and, not being clearly erroneous, is adopted by this Order and summarized below.
Defendant Mark Joshua Ruark is charged with bank robbery, Hobbs Act robbery, two counts of carrying a firearm during a crime of violence, and possession of a firearm by a convicted felon. Ruark suffers from schizophrenia and has been declared incompetent to stand trial. Ruark has refused to take his prescribed antipsychotic medications,  so the Government has moved for an order directing that he be involuntarily medicated [Doc. 102].
A. Initial Proceedings and Competency Determination
On April 13, 2010, a federal grand jury returned a five-count indictment against Ruark. Immediately following the indictment, Ruark was brought into federal custody on a writ, and Judge Brill ordered that he be detained. Ruark has remained in custody since that time. The trial in this case originally was set for January of 2011 but later was continued. In February 2011, Ruark filed notice of his intent to raise an insanity defense.
In May 2011, the defense moved for an order declaring Ruark incompetent to stand trial. This motion was based on the evaluation of a psychiatrist, Dr. Bhushan S. Agharkar, who concluded that Ruark was suffering from schizophrenia. Following a competency hearing, both sides agreed that Ruark was not fit to stand trial, and Judge Brill entered an order to that effect. Judge Brill directed that Ruark be remanded to the custody of the Attorney General for medical treatment. Ruark was transferred to the Medical Center for Federal Prisoners in Springfield, Missouri ("Springfield"). On February 25, 2013, the Government moved for an order directing that Ruark be involuntarily medicated.
B. The Sell Hearing
The Government's Motion prompted Judge Brill to hold a Sell hearing, which was conducted in two stages. During the first part of the hearing, which took place on May 20, 2013, the Government presented testimony from Dr. Lea Ann Preston-Baecht, a staff psychologist at Springfield, and Dr. Robert Sarrazin, the chief of psychiatry at Springfield. During the second part of the hearing, on November 5 and 6, 2013, defense counsel was given the opportunity to cross-examine both Dr. Preston-Baecht and Dr. Sarrazin in person. Defense counsel also presented testimony from Dr. Gabriella Ramirez-Laon, a clinical psychologist at the United States Penitentiary in Atlanta ("USP Atlanta").
1. Dr. Preston-Baecht's Testimony
Dr. Preston-Baecht has worked as a staff psychologist at Springfield since 2000 and has extensive experience evaluating inmates and testifying as a forensic psychologist in federal court proceedings, including thirty or forty involuntary medication hearings. In her experience, somewhere between 75% and 80% of involuntarily medicated defendants are restored to competency.
Dr. Preston-Baecht evaluated Ruark when he first arrived at Springfield and concluded that his overall presentation "was consistent with someone who was paranoid of others." She reviewed Ruark's mental health records from the Bureau of Prisons ("BOP"), which indicated that he had been taking Geodon, an antipsychotic medication, while housed at USP Atlanta. Later, Ruark was given a different antipsychotic medication, Zyprexa.
Based on his records and the interview, Dr. Preston-Baecht diagnosed paranoid schizophrenia. She saw Ruark on a regular basis during his time at Springfield and convinced him to resume taking Geodon for a period of time. The medication appeared to calm him, but did not completely alleviate his paranoia. Ruark stopped taking the drug after two months because he believed that it had weakened his immune system, causing him to catch a cold.
According to Dr. Preston-Baecht, Ruark had not taken the Geodon long enough or in a high enough dose for it to be fully effective. Upon her encouragement, Ruark resumed the Geodon in August 2012, but soon stopped and refused to take it for the rest of his stay at Springfield.
Dr. Preston-Baecht thereafter requested an administrative hearing on whether Ruark could be involuntarily medicated on grounds of disability or dangerousness. The hearing officer denied the request on grounds that Ruark, although suffering from a psychotic disorder, did not pose a danger to himself or others.
According to Dr. Preston-Baecht, alternative forms of treatment are not likely to restore Ruark to competency. Although Springfield does have a competency restoration group, the purpose of which is to explain how the criminal justice system works,  she testified that Ruark is "a bright young man who understands how the court system works." In her opinion, his "level of paranoia interferes with his ability to rationally apply that information to his own case." She believed that counseling or psychotherapy would also be ineffective because paranoid schizophrenia has a biological basis requiring medication. Without treatment, Dr. Preston-Baecht believed that Ruark would not be able to testify relevantly, communicate with his counsel, or make well-reasoned decisions regarding his case.
Dr. Preston-Braecht testified that antipsychotic medication is the generally accepted standard for treating schizophrenia and is medically appropriate in Ruark's case. These drugs often take four to eight months to fully restore a patient to competency.
On cross-examination, Dr. Preston-Baecht recognized that USP Atlanta's treatment notes show that Ruark has done "fairly well" since returning from Springfield and does not show signs of a psychotic disorder. She believed, however, that Ruark was being guarded to avoid being labeled mentally ill and involuntarily medicated. In her experience, mentally ill patients commonly behave this way; individuals with paranoid schizophrenia are capable of higher functioning and can appear normal when their delusions are not implicated. She also recognized that civil commitment is sometimes an alternative to involuntary medication.
2. Dr. Sarrazin
Dr. Sarrazin has served as chief of psychiatry at Springfield since 2004, is trained as a medical doctor, has performed hundreds of psychiatric evaluations, and has frequently testified in involuntary medication hearings. Where medication was ordered, between 75% and 80% of his clients were restored to competency.
Dr. Sarrazin's written report discusses several studies regarding the effectiveness of involuntary medication in schizophrenic prisoners. The results are summarized as follows:
(1) a general 1992 study of 150 incompetent defendants in a state forensic hospital found that only 8 of these patients could not be restored to competency, yielding an approximate 95% success rate; (2) a 1993 study of 45 incompetent pre-trial defendants, suffering from psychotic disorders, found that 87% of these patients were restored to competency with involuntary psychotropic medication; (3) a 2007 study reviewing Ohio state psychiatric hospitalizations from 1995 to 1999 found that 75% of patients were restored to competency with involuntary medication; and (4) another 2007 study of 22 individuals diagnosed with delusional disorder (a psychotic disorder different from schizophrenia) found that 77% of the patients were restored to competency by the use of involuntary anti-psychotic medication.
Dr. Sarrazin also discussed studies showing the effectiveness of antipsychotic drugs outside the criminal justice context. The American Psychiatric Association ("APA") reports that:
83% of "first episode" patients experience "stable remission, " by the end of one year of treatment, meaning their symptoms (such as hallucinations and confusion) decrease to the point that the individual can return to his or her normal activities. The end point of the APA data... was that individuals get to this type of remission, rather than "competency." The APA data showed, however, that between 10% and 30% of schizophrenic patients have little to no response to anti-psychotic medication, and that up to another 30% have only a "partial" response to medication, "meaning they exhibit improvement in psychopathology but continue to have mild to severe residual hallucinations or delusions." The APA data did not address success rates in situations where competency, rather than remission, was the end point.
In a recent study, Dr. Sarrazin testified, approximately 79% of defendants in the federal court system who were involuntarily medicated due to a psychotic illness over a six-year period successfully regained competency. Dr. Sarrazin opined that antipsychotic medications are "the gold standard for treatment of individuals with schizophrenia."
Dr. Sarrazin noted that, when Ruark arrived at Springfield, his medical records included a prescription for 80 milligrams of Geodon once per day. According to Dr. Sarrazin, this was about half the normal therapeutic dose, and he would not consider Geodon a failure if this dose did not restore a patient to competency. Ruark was persuaded to resume Geodon and was given 80 milligrams twice per day. After two months, ...