Herbel Study
Herbel Study
Herbel Study
A R T I C L E
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Before the Sell decision, the BOP policies on involuntarily medicating incompetent pretrial inmates
were based on the 1990 Supreme Court case Washington v. Harper,18 which ruled that judicial review of
any decision by prison staff to medicate a dangerous,
sentenced inmate involuntarily was not a necessary
part of due process. Between 1990 and 2003, all
Harper-type hearings at FMC Butner were conducted by the Chief Psychiatrist, using the following
as justification for involuntary medication: risk of
dangerousness to self or others, being gravely disabled, being unable to function in the open population of the facility, and being incompetent to stand
trial. A copy of each Harper-type involuntary medication packet was stored in an archive file system.
The forensic evaluations of all mental health inmates
during this period were also copied and stored in a
different archive at FMC Butner, as the BOP does
not provide indefinite storage of the records of pretrial inmates.
Methods
This study was approved by the Federal Correctional Complex Research Committee overseeing research at the Federal Medical Center in Butner,
North Carolina, and by the Information, Policy and
Public Affairs Division of the Federal Bureau of Prisons in Washington, DC.
During the first step of this study, the primary
author searched through all the archived Harper-type
involuntary medication packets of inmates who had
undergone these proceedings from 1990 through
June 2003. During this 13-year period, 288 inmates
had undergone a total of 322 such hearings, with the
higher number of hearings caused by 27 individuals
having undergone more than one period of involuntary treatment at FMC Butner. Approximately one
third of the 288 cases involved noncompetency
inmates, who were sentenced inmates or indefinitely
civilly committed inmates undergoing involuntary
medication hearings because of their status of being
gravely disabled or posing a risk of danger to self or
others while confined in an unmedicated state.
The diagnostic distribution of the inmates who
underwent the Harper-type hearings is listed in Table
1. All the data in this table refer to the number of
individual inmates, not the number of Harper-type
hearings. Since nine defendants had undergone their
first Harper-type hearing during pretrial detention
and a subsequent one while later serving a sentence of
All
Cases
Competency
Restoration
Noncompetency
Cases
Schizophrenia
Psychotic disorder NOS
Schizoaffective disorder
Bipolar disorder
Schizophreniform disorder
Major depression
Delusional disorder
Dementia/head injury
Total
154
31
36
12
2
6
42
5
288
99
22
17
9
2
1
31
0
181
55
9
19
3
0
5
11
5
107
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Restored?
Ten weeks of treatment with quetiapine with dose gradually increased from 100 mg twice daily to 350 mg twice daily
had no impact on underlying delusional ideation; no concomitant psychotropic medication.
No
Three weeks of oral perphenazine 8mg twice daily resulted in significant improvement in mental status; phenylzine 30
mg twice daily was continued during the entire evaluation, which had been prescribed by his community provider to
treat a single past episode of depression successfully.
Yes
Three months of haloperidol decanoate 100 mg every 28 days resulted in gradual but marked diminution of paranoid
ideation; concomitant medication was benztropine 0.5 mg twice daily prescribed for extrapyramidal side effects, as
well as diphenhydramine 75 mg at bedtime for insominia.
Yes
Three weeks of risperidone 4 mg daily resulted in marked reduction of delusional ideation; no concomitant
psychotropic medication; the risperidone was inadvertently discontinued after he was returned to a local jail for
further legal proceedings; he relapsed and was then returned to FMC Butner, where he agreed to resume taking
risperidone 4 mg daily on a voluntary basis; within four weeks the examiners opined that he was again competent to
stand trial.
Yes
Three months of treatment with haloperidol decanoate 150 mg every 28 days resulted in gradual but significant
reduction in delusional ideation; no concomitant psychotropic medication; he returned to FMC Butner two years later
for a second round of competency assessment and treatment for charges of violation of supervised release; examiners
described his treatment response as similar to the preceding one, finding him competent to stand trial following four
months of involuntary treatment with haloperidol decanoate 150 mg every 28 days.
Yes
Two months of treatment with fluphenazine decanoate 12.5 mg every 14 day had minimal or no benefit; his delusions
responded within three weeks of increasing the dose of fluphenazine decanoate to 25 mg every two weeks;
concomitant psychotropic medication included benztropine 1 mg twice daily for extrapyramidal side effects and
fluoxetine 20 mg daily for new-onset depressive symptoms.
During his lengthy period of pretrial detention, he relapsed due to medication noncompliance in a local jail facility; two
years later he was returned to FMC Butner for a second round of involuntary treatment; his delusional ideation
responded to two weeks of oral haloperidol 5 mg followed by two weeks of treatment with haloperidol decanoate
100 mg every 28 days; he was also prescribed benztropine 1 mg in the morning and 2 mg at bedtime and
diphenhydramine 50 mg four times daily, as needed, for extrapyramidal side effects.
Three years later he relapsed into psychosis with delusions and more prominent hallucinations while serving his lengthy
sentence of incarceration at FMC Butner, which was attributed to medication noncompliance; his psychosis persisted
at low levels following involuntary treatment with haloperidol decanoate 100 mg every 28 days but resolved within
three weeks of dose increase to 150 mg every 28 days; at this time, he was prescribed doxepin 100 mg daily for
new-onset depressive symptoms; three weeks later he sustained anoxic encephalopathy following a near-lethal
suicide attempt by hanging.
Yes
Three months of fluphenazine decanoate 25 mg every 14 days resulted in partial reduction in delusional ideation, with
initial opinion of restoration of competency; concomitant medication was benztropine 1 mg three times daily as
needed for extrapyramidal side effects; he was returned to FMC Butner for additional involuntary treatment several
months later after he refused fluphenazine at local jail; he remained delusional despite treatment with olanzapine 7.5
mg to 10 mg daily for two months; examiners opined he was nonrestorable to competency, in part due to prediction
he would again stop taking psychotropic medication after leaving FMC Butner.
No
Six weeks of haloperidol decanoate 25 mg every 28 days resulted in significant diminution of paranoid ideation; no
concomitant psychotropic medication.
Yes
One month of treatment with haloperidol decanoate 100 mg every 28 days was discontinued due to side effects of
urinary retention, muscle stiffness, and drooling; most of his delusional ideation gradually resolved following three
months of treatment with risperidone 2 mg twice daily; concomitant medication was trihexyphenidyl 5 mg three
times daily for extrapyramidal side effects and diphenhydramine 75 mg at bedtime for insomnia.
Yes
10
Three months of haloperidol decanoate 75 mg every 28 days resulted in gradual but significant diminution of delusional
ideation; no concomitant psychotropic medication.
Yes
11
Initial trial of haloperidol decanoate 150 mg was discontinued after a single injection due to severe akathisia; severalmonth trial of quetiapine at doses between 500 and 700 mg daily was ineffective, although the exact length of
medication trial was not specified; three-week trial of olanzapine 10 mg daily followed by a few days of risperidone
2 mg daily were ineffective, which he refused to continue due to sedation and muscle aches or weakness; no
concomitant psychotropic medication.
No
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Restored?
12
Four weeks of haloperidol decanoate 100 mg every 28 days resulted in significant reduction of delusional ideation; no
concomitant psychotropic medication.
Yes
13
One month of perphenazine 40 mg daily was ineffective, as was an additional two month trial of perphenazine 56 mg
daily; the delusional ideation responded to an additional two month trial of perphenazine 64 mg daily; no
concomitant psychotropic medication; two years later, he voluntarily accepted treatment with haloperidol decanoate
50 mg every 28 days when he returned for presentence evaluation; with poor insight but no delusional ideation; he
was also treated with benztropine 2 mg twice daily as needed.
Yes
14
Two months of haloperidol decanoate 150 mg every 28 days was ineffective and caused moderate akathisia; the dose
of haloperidol decanoate was then lowered to 100 mg every 28 days; his delusional beliefs gradually resolved during
the next three months of treatment; concomitant psychotropic medication was atenolol 50 mg daily for akathisia;
doxepin 100 mg at bedtime for insomnia; and benztropine 1 mg twice daily as needed for extrapyramidal side
effects.
Yes
15
Three to four weeks of treatment with risperidone 2 mg daily resulted in resolution of delusional ideation; concomitant
psychotropic medication was lorazepam 1 mg as needed for severe agitation.
Yes
16
Six-week trial of olanzapine 20 mg at bedtime resulted in significant diminution of delusional ideation; concomitant
psychotropic medication was doxepin 100 mg daily, which was prescribed for dysthymia before the olanzapine trial.
Yes
17
One month of olanzapine 10 mg daily was ineffective; his delusional beliefs gradually resolved during the next three
months of treatment with same dose of olanzapine; concomitant medication was paroxetine 20 mg daily for newonset depressive symptoms that emerged only after his delusional ideation waned; his anxiety symptoms were treated
with clonazepam 0.5 mg in the morning and 1 mg at night for two to three weeks.
Yes
18
Two weeks of treatment with risperidone 4 mg daily and lithium 1200 mg daily resulted in significant reduction in
paranoia, although low-level delusions persisted; no other psychotropic medication prescribed.
Yes
19
Three months of haloperidol decanoate 75 mg every 28 days resulted in slow improvement; concomitant psychotropic
medication of benztropine 1 mg twice daily as needed for extrapyramidal side effects was never used by defendant;
two years later he was returned to FMC Butner after relapsing following noncompliance with medication while on
probation; involuntary treatment with haloperidol decanoate 100 mg every two weeks was initiated, but the
evaluation period ended two weeks later with an inadequate medication trial and judge did not authorize additional
period of treatment for competency restoration.
Yes
20
Three months of haloperidol decanoate 50 mg every 21 days resulted in partial reduction in delusional ideation;
concomitant medication was benztropine 1 mg twice daily as needed for extrapyramidal side effects; a few months
later, he was returned to FMC Butner for additional involuntary treatment after relapsing in jail due to
noncompliance; a trial of risperidone 2 mg twice daily for three weeks resulted in partial remission of delusional
ideation; his complaints of constipation from risperidone were treated with oral stool softener twice daily.
Yes
21
Two months of treatment with haloperidol decanoate 100 mg every 28 days was ineffective; the dose was increased to
150 mg every 28 days for the next three months, then increased again to 200 mg every 28 days for 1 month; serum
haloperidol level collected at the end of the six-month period was lower than expected at 2.9 ng/mL; no concomitant
psychotropic medication.
No
22
Two weeks of treatment with unspecified dose of oral fluphenazine followed by two weeks of treatment with
fluphenazine decanoate 25 mg every two weeks resulted in moderate improvement in psychotic symptoms; no
concomitant psychotropic medication; evaluators opined that his competency would be restored with an additional
period of treatment, but the judge did not authorize any additional involuntary treatment.
No
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Regarding the distribution of subtype of delusional disorder during the treatment at FMC Butner,
16 were persecutory type, 5 were mixed persecutory
and grandiose type, and 1 was grandiose type.
Eleven of the 22 patients reported a recent or remote history of one or more brief psychiatric hospitalizations in the community, although the treatment records were often not available for review.
Another five had undergone prior forensic mental
evaluations, one of whom was restored to competency at a state facility following treatment with risperidone 3 mg daily. Of these 16 individuals, only 5
had definitely been treated with antipsychotic medication, with treatment duration lasting a few days to
a few weeks, but all discontinued medication after a
brief period of treatment. Five individuals had previously accepted antidepressant medication treatment
from a community provider for depressive symptoms, which had been brief in duration compared
with their delusional symptoms. A few patients had a
complicated past psychiatric history marked by multiple diagnoses, but the majority seemed to have a
more straightforward development and maintenance
of one or more consistent delusional themes.
Age of Onset of Symptoms
Since the entire group of patients appeared relatively naive to treatment with antipsychotic medication, an estimated duration of untreated psychosis
(DUP) was calculated by subtracting the age of onset
of psychotic symptoms from the age of admission to
FMC Butner. This calculation was based on the assumption that the delusional symptoms were continuously present at some level following the identified
onset of psychosis. Unfortunately, this assumption
could not be verified by the historical information in
many of the forensic evaluations, which poses a chal54
lenge similar to descriptions in the schizophrenia literature of studies using retrospective accounts to define the DUP.21 This uncertainty is a limiting factor
in the following analysis, especially for those defendants with a very long estimated DUP, since the
intensity of delusional symptoms may wax and wane
over time.
Employing the definition of DUP just described,
we found sufficient data to estimate the DUP in 19
patients: 10 months to 24 years. Nine individuals
had a DUP of five years or less, seven (78%) of whom
were restored to competency. Six defendants had a
DUP between 7 and 10 years, all of whom were
restored to competency. The treatment response appears more robust than expected from the literature
on DUP of first-episode schizophrenic patients,
which would predict a modest increase in treatment
resistance with a longer DUP.22,23
In contrast, only one of the four defendants with a
much longer DUP (between 13 and 24 years) was
viewed as restored to competency, which is similar to
the dismal treatment response of 11 percent attaining
a good clinical outcome in a group of 18 treatment-naive schizophrenic patients who had a DUP
greater than 15 years.24 The possible confounding
effect of a medication trial of inadequate duration in
two of the four patients, coupled with the very small
sample size and uncertainty about the actual length
of the DUP, reduces confidence that the poorer outcomes in the last group were solely attributable to the
lengthy DUP. At the very least, the data provide
evidence that DUP is not a useful predictor of nonresponse to antipsychotic medication in delusional
patients who have been symptomatic for 10 years or
less.
Ethnicity
another antipsychotic drug. As expected during a relatively short period of antipsychotic exposure of a
few weeks to a few months, there were no reports of
any patients manifesting disfiguring side effects such
as tardive dyskinesia. Consistent with the very low
base rate of dangerous side effects of properly administered antipsychotic medication, no patient was described as manifesting symptoms of a potentially lethal condition, such as neuroleptic malignant
syndrome. Most defendants responded to antipsychotic medication at the same low to moderate dose
range used to treat symptoms of schizophrenia. Two
defendants who had exhibited minimal or no response to low doses of medication manifested significant improvement in delusional ideation after the
medication doses were increased to the moderate or
high end of the recommended therapeutic dose
range.
Time to Response
Of the 17 defendants who were restored to competency, five individuals had a fairly rapid response
within four weeks of beginning treatment. Two were
described as responding within the first six weeks of
treatment. The other 10 individuals did not show
significant improvement until they had received at
least three months of continuous treatment with antipsychotic medication, with some requiring a total
of five months medication before being restored to
competency. This finding suggests that a single adequate medication trial may have to be extended to
four or even five months duration in patients with
delusional disorder, which provides a plausible explanation for the conventional wisdom that these patients are refractory to treatment with antipsychotic
medication. A recent article by Gunduz-Bruce and
colleagues28 describing the treatment report on a cohort of 118 individuals with first-episode schizophrenia supports this premise, since the treatment response of delusions occurred at a group mean of 150
days (median 76 days), which was much later than
the treatment response of hallucinations, with a
group mean of 59 days (median, 27 days). This article included a description of a theoretical framework
that describes delusions as progressing through
stages, which implies that delusional ideation may
also recede through a series of stages. As mentioned
previously, Morimoto et al.14 described delusional
symptoms in one sample of 11 patients as diminishing completely in 65 days, and 5 of 8 patients in a
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search methods to reduce bias, such as random assortment to assigned treatment groups, the use of a
placebo control group, and blinded outcome measures, were not possible in this study. Without these
safeguards, the opinions of the forensic examiners
may have been biased in favor of finding a positive
response to treatment. Another limitation is the
small sample size, which was the result of the low
prevalence of delusional disorder, even in a forensic
mental health population. The methods did not permit comparison between the study cohort and a parallel group of incompetent, delusional defendants
who voluntarily accepted treatment with antipsychotic medication. The available records did not include the judicial ruling on competency for these
cases, although past research results predict a high
rate of agreement between the judge and the forensic
examiner. Future research on this topic should be
designed to avoid some of these methodological
weaknesses.
A strength of the study is the patient cohort was
selected in a real-world manner by criminal prosecution, after which they were assessed and involuntarily
treated in a real-world manner at a forensic mental
health facility. The main contribution of this study
was the observation of treatment response in patients
with delusional disorder who, in contrast to the usual
protocols in community research studies, were not
permitted to drop out of treatment. That 10 of the
17 patients who responded to treatment required
continuous antipsychotic treatment for at least three
months, and some up to five months, was unexpected. This result provides a plausible explanation
for the presumed refractory nature of delusional disorder symptoms. The real obstacle to a positive treatment response in delusional disorder may not be the
intrinsic biological features of the illness, but may
instead be the difficulties in convincing these patients to adhere to an adequate trial of medication.
Conclusions
In summary, most of the 22 incompetent criminal
defendants with delusional disorder in this study
manifested a positive response to involuntary treatment with antipsychotic medication, as the forensic
examiners opined that over three-fourths of defendants in this group were restored to competency status. The treatment response of this cohort would
meet the standard for substantially likely for restoration of competency with involuntary treatment as
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7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17. Ladds B, Convit A, Zito J, et al: Involuntary medication of patients who are incompetent to stand trial: a descriptive study of the
New York experience with judicial review. Bull Am Acad Psychiatry Law 21:529 45, 1993
18. Washington v. Harper, 494 U.S. 210 (1990)
19. Reich J, Tookey L: Disagreements between court and psychiatrist
on competency to stand trial. J Clin Psychiatry 47:29 30, 1986
20. Hart S, Hare R: Predicting fitness to stand trial: the relative power
of demographic, criminal, and clinical variables. Forensic Rep
5:53 65, 1992
21. Norman R, Malla A: Duration of untreated psychosis: a critical
examination of the concept and its importance. Psychol Med
31:381 400, 2001
22. Perkins D, Hongbin G, Boteva K, et al: Relationship between
duration of untreated psychosis and outcome in first-episode
schizophrenia; a critical review and meta-analysis. Am J Psychiatry
162:1785 804, 2005
23. Marshall M, Lewis S, Lockwood A, et al: Association between
duration of untreated psychosis and outcome in cohorts of firstepisode patients. Arch Gen Psychiatry 62:975 83, 2005
24. Tirupati N, Rangaswamy T, Raman P: Duration of untreated
psychosis and treatment outcome in schizophrenia patients untreated for many years. Aust NZ J Psychiatry 38:339 43, 2004
25. Kapur S, Seeman P: Antipsychotic agents differ in how fast they
come off the dopamine D2 receptors: implications for atypical
antipsychotic action. J Psychiatry Neurosci 25:1619, 2000
26. Kapur S: Psychosis as a state of aberrant salience: a framework
linking biology, phenomenology, and pharmacology in schizophrenia. Am J Psychiatry 160:1323, 2003
27. van der Gaag M: A neuropsychiatric model of biological and
psychological processes in the remission of delusions and auditory
hallucinations. Schizophr Bull (Suppl 1) 32:S11322, 2006
28. Gunduz-Bruce H, McMeniman M, Robinson D, et al: Duration
of untreated psychosis and time to treatment response for delusions and hallucinations. Am J Psychiatry 162:1966 9, 2005
29. Preskorn S: Have you phenotyped your patient lately? J Prac
Psych Behav Health 2:11517, 1996
30. Correll C: Real-life dosing with second-generation antipsychotics.
J Clin Psychiatry 66:1610 11, 2005
31. Bourgeois M, Swendsen J, Young F, et al: Aware of disorder and
suicide risk in the treatment of schizophrenia: results of the International Suicide Prevention Trial. Am J Psychiatry 161:1494 6,
2004
32. Lieberman J, Stroup T, McEvoy J, et al: Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med
353:1209 23, 2005
33. Stroup T, Lieberman J, McEvoy, et al: Effectiveness of olanzapine,
quetiapine, risperidone and ziprasidone in patients with chronic
schizophrenia following discontinuation of a previous atypical
antipsychotic. Am J Psychiatry 163:61122, 2006
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