The State of Texas for the Best Interest and Protection of D. B. v. the State of Texas

NO. 12-23-00007-CV

IN THE COURT OF APPEALS

TWELFTH COURT OF APPEALS DISTRICT

TYLER, TEXAS

THE STATE OF TEXAS FOR THE § APPEAL FROM THE COUNTY
BEST INTEREST AND PROTECTION
OF D. B. § COURT AT LAW

§ CHEROKEE COUNTY, TEXAS

MEMORANDUM OPINION

D.B. appeals from an order authorizing the administration of psychoactive medication. In
his sole issue, D.B. challenges the legal and factual sufficiency of the evidence to support the
trial court’s order. We affirm.

BACKGROUND

D.B. was found incompetent to stand trial and committed to Rusk State Hospital for
examination and treatment with the specific objective of attaining competency. D.B. refused to
take medication prescribed for his condition and denied needing medication. On January 2, 2023,
Dr. Robert Lee signed an application to order the administration of psychoactive medication.
After conducting a hearing, the trial court signed an order authorizing the administration of
psychoactive medication. In its order, the trial court stated that the allegations in the application
are supported by clear and convincing evidence. The trial court concluded that D.B. lacks the
capacity to make a decision regarding the administration of psychoactive medication and that
treatment with the proposed medications is in D.B.’s best interest. This appeal followed.
SUFFICIENCY OF THE EVIDENCE

In his sole issue, D.B. argues that the evidence is legally and factually insufficient to
support the trial court’s order authorizing administration of psychoactive medication.
Specifically, D.B. contends that the evidence failed to demonstrate his particular diagnosis and
did not establish that the proposed medications were in his best interest.
Standard of Review

Texas law requires that orders authorizing administration of psychoactive medication be
supported by clear and convincing evidence. TEX. HEALTH & SAFETY CODE ANN. § 574.106(a-1)
(West 2017). “Clear and convincing evidence” means the measure or degree of proof that will
produce in the mind of the trier of fact a firm belief or conviction as to the truth of the allegations
sought to be established. State v. Addington, 588 S.W.2d 569, 570 (Tex. 1979). Although the
proof must weigh more heavily than merely the greater weight of the credible evidence, the
evidence need not be unequivocal or undisputed. Id.
In conducting a legal sufficiency review when the burden of proof is clear and convincing
evidence, we look at all the evidence in the light most favorable to the finding to determine
whether a reasonable trier of fact could have formed a firm belief or conviction that its findings
were true. In re J.F.C., 96 S.W.3d 256, 266 (Tex. 2002). We assume that the factfinder settled
disputed facts in favor of its finding if a reasonable factfinder could do so and disregard all
evidence that a reasonable factfinder could have disbelieved or found incredible. Id. When
reviewing factual sufficiency, we must give due consideration to evidence that the factfinder
could reasonably have found to be clear and convincing and then determine whether, based on
the entire record, a factfinder could reasonably form a firm conviction or belief that the
allegations in the petition were proven. Id. We must consider whether the disputed evidence is
such that a reasonable factfinder could not have reconciled that disputed evidence in favor of its
finding. Id. If the disputed evidence is so significant that a factfinder could not reasonably have
formed a firm belief in the finding, the evidence is factually insufficient. Id. The factfinder is the
sole arbiter of the credibility and demeanor of witnesses. In re H.R.M., 209 S.W.3d 105, 109
(Tex. 2006).

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Applicable Law

A trial court may issue an order authorizing the administration of one or more classes of
psychoactive medications to a patient who is under a court order to receive inpatient mental
health services. TEX. HEALTH & SAFETY CODE ANN. § 574.106(a) (1) (West 2017). The court
may issue an order if it finds by clear and convincing evidence after the hearing that (1) the
patient lacks the capacity to make a decision regarding the administration of the proposed
medication, and (2) treatment with the proposed medication is in the patient’s best interest. Id. §
574.106(a-1). “Capacity” means a patient’s ability to (1) understand the nature and consequences
of a proposed treatment, including the benefits, risks, and alternatives to the proposed treatment,
and (2) make a decision whether to undergo the proposed treatment. Id. § 574.101(1) (West
2017). In making a finding that treatment with the proposed medication is in the patient’s best
interest, the trial court shall consider (1) the patient’s expressed preferences regarding treatment
with psychoactive medication, (2) the patient’s religious beliefs, (3) the risks and benefits, from
the patient’s perspective, of taking psychoactive medication, (4) the consequences to the patient
if the psychoactive medication is not administered, (5) the patient’s prognosis if he is treated
with psychoactive medication, (6) alternative, less intrusive treatments that are likely to produce
the same results as treatment with psychoactive medication, and (7) less intrusive treatments
likely to secure the patient’s agreement to take the psychoactive medication. Id. § 574.106(b).
Analysis

Dr. Lee’s application, which was admitted into evidence at the hearing, states that D.B. is
subject to an order for court-ordered inpatient mental health services due to his incompetency to
stand trial. According to the application, Dr. Lee diagnosed D.B. with “Bipolar 1 disorder with
psychotic features[.]” Additionally, the application states that (1) D.B. verbally refused to take
medication voluntarily, and (2) D.B. lacks capacity to make a decision regarding administration
of psychoactive medication because he is delusional about certain medications and his insight
and judgment are poor. Dr. Lee indicated that if treated with medication, D.B.’s prognosis is fair,
and if the medication is not administered, D.B. will suffer from “mental deterioration[.]”
Additionally, Dr. Lee stated that he considered medical alternatives to psychoactive medication,
determined that the alternatives will not be as effective as administration of psychoactive
medication, and believes the benefits of psychoactive medication outweigh the risks. He also
indicated that treatment with psychoactive medication is in D.B.’s best interest. Dr. Lee stated

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that unless D.B. is medicated, he presents a danger to himself or others in the facility where he is
being treated. Lastly, Dr. Lee indicated that he “considered less intrusive treatments likely to
secure [D.B.]’s agreement to take the psychoactive medication.” Exhibit A, which was attached
to the application, indicated that Dr. Lee desired to administer antidepressants, antipsychotics,
anxiolytics/sedatives/hypnotics, mood stabilizers, and miscellaneous drugs to D.B.
At the hearing, Dr. Satajeet Lahiri, who is currently treating D.B., testified that he did not
complete the application for administration of psychoactive medication, but he reviewed Dr.
Lee’s application and agrees with it.1 Dr. Lahiri explained that D.B. suffers from a mental illness
and is under a court order for inpatient mental health treatment because he was found
incompetent to stand trial for murder. According to Dr. Lahiri, D.B. verbally refused to take
medication voluntarily, lacks the capacity to make informed decisions about medications,
believes he does not need medication, has been “grandiose,” and believes “he has extra skills and
powers which make[] him feel that it’s not necessary to take medications.” Dr. Lahiri testified
that D.B.’s insight is poor because he does not believe he suffers from mental illness, and D.B.’s
judgment is impaired because he is “not able to act in his best interest.”
Dr. Lahiri explained that Exhibit A sets forth the classifications of medication that Dr.
Lee wishes to administer to D.B., and he opined that the medications are the proper course of
treatment for D.B. and are in his best interest. According to Dr. Lahiri, the benefits of the
medications outweigh their risks, and D.B. is “likely to regain competency faster if these
medications are used.” In addition, Dr. Lahiri stated that the medications would not interfere
with D.B.’s ability to communicate with his attorney, and “in fact, they will facilitate
communications with his attorney.” Dr. Lahiri testified that when he interviewed D.B., D.B. told
him he is reading the Koran, and the Koran “does not allow him to take medications.”
During cross-examination, Dr. Lahiri explained that D.B. refused to take an antipsychotic
medication, as well as his antihypertensive medication, and he would not allow doctors to “adjust
or add other medicines.” According to Dr. Lahiri, these refusals are “where [D.B.]’s lack of
insight comes into play.” Dr. Lahiri explained that D.B. told him the Koran restricts him from
taking medications. Dr. Lahiri indicated that D.B. did not experience harmful side effects from
any medications. He explained that D.B. has a history of previous hospitalizations in the state
hospital, and there is “[n]o record of bad reactions” to medications in the past. Dr. Lahiri opined

1
The record does not indicate why Dr. Lee did not testify.

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that Abilify alone is not sufficient to treat D.B.’s condition, so D.B. was being inadequately
treated at the time of the hearing.
D.B. testified that he does not object to taking Abilify. D.B. stated, “I’m trying to live for
my future, but I’m being treated like a name on a piece of paper[.]” D.B. acknowledged that he
suffers from a mental illness, with which he was diagnosed in 2010. With respect to religious
objections, D.B. stated,
[Dr. Lahiri] stated that just the Koran – [i]t was not the Koran. It was – we have a messenger, the
man who taught the man named – the man known as Malcolm X. His name is Elijah Muhammad.
He taught Malcolm X. He’s in the movie Malcolm X, . . . you know, you could find his character
in that movie, but – if you’re not familiar with Elijah Muhammad, but I told him about – it was
religious. We’re – our – our diet is based on one meal a day, and the chemicals of this world is
[sic] based on three meals a day. Now, I am eating three meals a day. So, I said Abilify was okay,
but I – I didn’t want to change medicines. I just felt somewhat extremely uncomfortable when he
said I wouldn’t do any medicine at all. I am working with the system, sir.

D.B. further testified, “[Dr. Lahiri] also said I was incompetent. You know, . . . I’m an Aggie. I
got a degree from Texas A&M University. . . . I heard him say that I was incompetent to make a
decision about my medicine. I speak pretty good. I’m – I’m decently articulate.” D.B. explained
that he believes Abilify is adequate to treat his condition and did not believe he needed other
medications. When asked if medication is against the teachings of his religion under the Nation
of Islam, D.B. stated, “Yes, sir. . . . You can mention that for sure.” Additionally, D.B. stated that
when he was diagnosed, “we went through a lot of different medications[]” and “I had some bad
reactions. I had joint problems. I could hardly walk.” D.B. indicated that he is improving with
Abilify and exercise, and he stated, “if it’s not broke, don’t fix it[.]”
D.B. does not dispute that he suffers from mental illness, but he contends that the
evidence is insufficient because Dr. Lahiri failed to identify D.B.’s specific diagnosis during his
testimony. D.B. does not point us to anything in the statute requiring presentation of evidence as
to the particular mental illness with which the patient was diagnosed, and we are unaware of any
such requirement. See generally TEX. HEALTH & SAFETY CODE ANN. § 574.106. Even if such
evidence were statutorily required, Dr. Lee specified in the application that D.B. suffers from
“bipolar 1 disorder with psychotic features.” Although Dr. Lahiri did not identify D.B.’s
particular mental illness, he did testify that he reviewed Dr. Lee’s application and agreed with it.
He further stated that D.B. suffers from mental illness and lacks the capacity to make an
informed decision about medication, and D.B. testified that he was diagnosed with a mental
illness in 2010. Dr. Lahiri explained that D.B. exhibits grandiose behavior and believes he

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possesses skills and powers that render medications unnecessary. Moreover, the trial court heard
D.B.’s testimony and observed his demeanor.
With respect to the sufficiency of the evidence as to best interest, D.B. argues that his
case is analogous to State ex rel. E.G., 249 S.W.3d 728 (Tex. App.—Tyler 2008, no pet.), in
which we held that the evidence was insufficient to support a finding that the proposed
medications were in the patient’s best interest. In E.G., the only evidence regarding the patient’s
best interest was in the application, and we determined that a conclusory statement in the
application, without testimony from a physician at the hearing, could not support the order for
administration of psychoactive medication. Id. at 731-32. In addition, D.B. relies upon State ex
rel. B.D., No. 12-17-00174-CV, 2017 WL 4161297 (Tex. App.—Tyler Sept. 20, 2017) (mem.
op.), in which we held that the evidence was insufficient to support a finding that administration
of psychoactive medication was in the patient’s best interest. In B.D., we concluded that the
testifying physician’s testimony regarding best interest “was merely a perfunctory recitation of
the conclusory statements made in [the] application.” Id. at *3. Moreover, in B.D., the testifying
physician offered no testimony regarding the consequences to the patient of not administering
the medications, his prognosis if the medication is administered, or alternatives to treatment with
psychoactive medication. Id.
We conclude that both E.G. and B.D. are distinguishable from the instant case. In this
case, Dr. Lahiri testified that he reviewed Dr. Lee’s application and agrees with it. Dr. Lahiri
explained that D.B. will regain competency more quickly if psychoactive medications are
administered, and the medications would facilitate D.B.’s communications with his attorney.
Moreover, Dr. Lahiri testified that the proposed medications constitute the proper course of
treatment for D.B, the benefits of the proposed medications outweigh their risks, and taking the
medications is in D.B.’s best interest. Dr. Lahiri further testified that he considered alternatives,
but no alternatives would work as effectively as psychoactive medications. Although Dr. Lahiri
reiterated much of what was in Lee’s application, his testimony addressed the majority of the
required items listed in Section 574.106(b). See TEX. HEALTH & SAFETY CODE ANN. §
574.106(b). “While mindful that unsupported conclusions are legally insufficient to support the
existence of the fact asserted, there may be a fine line between conclusory and succinct.
However, the trial court may well be able to connect the dots, based on its knowledge of the law

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and brief testimony.” State of Tex. for Best Interest and Prot. of S.P., 592 S.W.3d 508, 513
(Tex. App.—Tyler 2019, no pet.).
As discussed above, in evaluating legal sufficiency, we must assume that the factfinder
settled disputed facts in favor of its finding if a reasonable factfinder could do so and disregard
all evidence that a reasonable factfinder could have disbelieved or found incredible. In re J.F.C.,
96 S.W.3d at 266. The trial court could have disregarded D.B.’s testimony that he does not need
psychoactive medication. Considering all the evidence in the light most favorable to the finding,
we conclude that a reasonable trier of fact could have formed a firm belief or conviction that its
findings were true. See id. Therefore, the evidence is legally sufficient. See id.
In evaluating factual sufficiency, we consider whether a reasonable factfinder could not
have resolved disputed evidence in favor of its finding and, if there is such evidence, whether
that evidence is so significant that a factfinder could not have reasonably formed a firm belief or
conviction that administering the medication is in the patient’s best interest. Id. The trial court
was entitled to disbelieve D.B.’s testimony that he did not need psychoactive medication. The
trial court could have reasonably determined that the medication’s value in restoring competency
outweighed the concerns D.B. expressed regarding his religious preferences and the possibility
of adverse reactions. See id.; S.P., 592 S.W.3d at 514. There was no disputed evidence that the
trial court could not reasonably have resolved in favor of its ruling. See In re J.F.C., 96 S.W.3d
at 266; S.P., 592 S.W.3d at 514. Accordingly, the evidence is factually sufficient to support the
trial court’s finding. See In re J.F.C., 96 S.W.3d at 266; S.P., 592 S.W.3d at 514. We overrule
D.B.’s sole issue.

DISPOSITION

Having overruled D.B.’s sole issue, we affirm the trial court’s judgment.

BRIAN HOYLE
Justice

Opinion delivered May 10, 2023.
Panel consisted of Worthen, C.J., Hoyle, J., and Neeley, J.

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COURT OF APPEALS

TWELFTH COURT OF APPEALS DISTRICT OF TEXAS

JUDGMENT

MAY 10, 2023

NO. 12-23-00007-CV

THE STATE OF TEXAS FOR THE BEST INTEREST AND PROTECTION OF D. B.

Appeal from the County Court at Law
of Cherokee County, Texas (Tr.Ct.No. 43451)

THIS CAUSE came to be heard on the appellate record and briefs filed
herein, and the same being considered, it is the opinion of this court that there was no error in the
judgment.
It is therefore ORDERED, ADJUDGED and DECREED that the judgment of
the court below be in all things affirmed, and that the decision be certified to the court below
for observance.
Brian Hoyle, Justice.
Panel consisted of Worthen, C.J., Hoyle, J., and Neeley, J.