IN RE: the Civil Commitment of: X.R. (2024)

MEMORANDUM DECISION

Case Summary

[1] X.R. appeals her temporary involuntary civil commitment, claiming it is not supported by sufficient evidence. Community Health Network, Inc., asks us to dismiss the appeal, arguing it is moot because the commitment has expired. Because of the possibility of collateral consequences, we opt to decide this case on the merits and affirm.

Facts and Procedural History

[2] In January 2024, X.R. was thirty-seven years old and the mother of a fourteen-year-old daughter. X.R. owned a home where she and her daughter had lived for the past seven years. X.R. was employed as a pharmacy technician until late December. According to X.R., she had a job “coming up” at Anthem. Tr. p. 25. In addition, X.R. was receiving outpatient treatment at Jane Pauley Community Health Center for depression and anxiety and was taking Lithium and Buspar.

[3] On January 10, X.R.’s daughter called the police. The police arrived and took X.R., who was in a “full-fledged manic state,” to Community Fairbanks Behavioral Health on an emergency detention. Id. at 17.

[4] While X.R. was initially seen by Dr. Shilpa Guggali, she was later seen by Dr. Kanwaldeep Sidhu on January 11. At that time, X.R. had an “altered mental status,” was “disorganized,” “confused,” “sleepy,” and “not able to think clearly,” and “was making paranoid statements about people being out to harm her.” Id. at 7. X.R. acknowledged there was “some change in her mood that led to her being admitted,” but she couldn't give Dr. Sidhu a “full coherent history” about what was going on. Id. When Dr. Sidhu asked X.R. about the police at her house, X.R. responded that she had been in a domestic dispute with her ex-husband, who was trying to hurt her. X.R. said she had a protective order against him. X.R. admitted punching walls but denied trying to harm herself or anyone else.

[5] On January 19, Community Health sought a temporary commitment for X.R. and requested a hearing. The hearing was set for January 29. That morning, Dr. Sidhu met with X.R. again. At the hearing, Dr. Sidhu testified that he had diagnosed X.R. with “[b]ipolar [I] disorder, manic with psychosis.” Id. at 9. He described X.R.’s symptoms as agitation, decreased sleep, racing thoughts, easy distractibility, paranoid thinking, and pressured speech. Dr. Sidhu noted that X.R. had had that diagnosis “for several years” and had been to the hospital “many times.” Id. Dr. Sidhu acknowledged that X.R. had “some” insight into her mental illness, as she agreed that she has “bipolar depression” and anxiety and was taking medicines for those conditions. Id. at 10. X.R., however, didn't believe that she needed an anti-psychotic medicine or to be hospitalized. Dr. Sidhu emphasized, however, that X.R. needed an anti-psychotic medicine because “all the research shows” that the recommended treatment for bipolar I disorder, manic with psychosis, is “a combination of an anti-psychotic and a mood stabilizer.” Id. at 10, 21. Dr. Sidhu explained that there had been recommendations from different doctors as well as her provider at Jane Pauley that X.R. should be taking an anti-psychotic medicine. Although X.R. was taking a mood stabilizer (Lithium), she refused to take an anti-psychotic medicine (she had tried Abilify, Latuda, and Risperdal) because of the side effects.

[6] Dr. Sidhu testified that X.R. was better on January 29 than when he first saw her on January 11. Dr. Sidhu, however, still observed symptoms including pressured speech, irritability, delusional thoughts, and paranoid thoughts. Dr. Sidhu explained X.R.’s delusional and paranoid thoughts as follows:

She continues to have some paranoid thinking about the police not doing their job because ․ she reported different things including her daughter[’]s sexual assault and she also believes that the staff here is not really trying to help her but harm her and she believes that a doctor that saw her previously Dr. Guggali ․ is trying to experiment with medications on her and she has this ․ it appears to be a delusion of belief that Dr. Guggali's father prescribed her a medication when I know that Dr. Guggali's father has never worked here, doesn't work here.

Id. at 8-9 (cleaned up). Dr. Sidhu believed that X.R.’s mental illness affected her ability to take the needed medicine and that if she didn't take an anti-psychotic medicine, it would affect her ability to function independently during an acute episode. He believed that an anti-psychotic medicine “would help greatly in [X.R.’s] symptoms.” Id. at 18. He noted there were other anti-psychotic medicines they could try, like Paliperidone, Invega, Rexulti, and Cariprazine. Dr. Sidhu thought that X.R. needed “just a few days more” before she could be discharged. Id. at 14. Dr. Sidhu said that with an anti-psychotic medicine, X.R.’s prognosis was “good”; however, without one her prognosis was “[l]ikely to be poor.” Id.

[7] X.R. testified, acknowledging that she has “bipolar depression” but disagreeing with the diagnosis of bipolar I disorder, manic with psychosis. Id. at 24, 29-30. She said she refused to take an anti-psychotic medicine because of the “bad side effects.” Id. at 30.

[8] The trial court found that X.R. was suffering from bipolar I disorder, was gravely disabled, and was in need of custody, care, and treatment not to exceed ninety days. The court thoughtfully and thoroughly explained its decision to the parties:

I'm especially grateful that [X.R.] has chosen to testify, she didn't have to, but also for Dr. Sidhu's expert medical opinion and I'm not just incapable but unwilling to substitute my judgement for his. Today I'm grateful that [X.R.] has given us an outstanding account of her view of the world, however it does not coincide with the rest of the world[’]s view of her. Under the circumstances she's described her high functioning abilities and her depression, which as it turns out, is the definition for bipolar disorder. In fact, [when] one feels great but knows there's a disabling episode coming that is bipolar condition and it turns out everybody feels great if he or she is perfectly capable **INDECIPHERABLE** and under the circumstances I heard how the police were out to get [X.R.], how the doctors were also not listening to her and confining her against her will, maybe even experimenting on her with medication, these are in fact paranoid delusions and I'm grateful that they are abating. But today, [X.R.] has no insight into how she ended up at the hospital except being persecuted and especially if she's going to care for a fourteen year old and be concerned for her safety with someone else potentially living at her house to push her out of the hospital at this moment while she's still disabled by those delusions would be irresponsible and in fact contradict the expert medical opinion of Dr. Sidhu and the treatment team.

Under these circumstances, I'll order a temporary commitment not to exceed ninety days, because it is by clear and convincing evidence the court finds [X.R.] is suffering from a mental illness as diagnosed by Dr. Sidhu, bipolar one disorder and we've seen evidence in this hearing both of mania and psychosis as described by Dr. Sidhu in his exam this morning. I'm very grateful though [X.R.] is doing much better than she was when she was admitted to the hospital, but the gross impairment of her judgement and reasoning almost assures that she'll end up back in the hospital if she fails to take medication as prescribed and if she insists on doing her own thing with care and treatment rather than listening to and adhering to strictly the treatment plan. It may be that she can choose her own care and treatment except in as much as she ends up in an emergency room gravely disabled and unable to care for herself and others in her charge. Under these circumstances I also have to conclude that she's not currently working which is the description she's given to us, that she's currently between jobs and I hope that she'll be able to return to work especially in a high functioning job with Anthem, but that all depends on her willingness to adhere to treatment that helps her to manage in a healthy way a serious mental disorder. Lots of people can, [X.R.], and I encourage you, but you must ma'am be selfish in adhering to medication and to talking with your treatment team.

I understand nobody wants to suffer from mental illness or even to take medication, at this moment though, I beg you, I plead with you, for your daughter's behalf and for your safety, to adhere to the medication regimen[ ] that is prescribed for you under these circumstances. I know it's not what you want to do that's why this is an involuntary commitment hearing, but the court will be a partner for you ma'am in your treatment at least until this temporary commitment order should expire. I'm also grateful that Dr. Sidhu has opined another four or five days might be required and ma'am you'd be ready to discharge to good outpatient care.

Id. at 40-41; see also Appellant's App. Vol. II p. 10 (“[X.R.] is gravely disabled by delusions, including that she suffers only from depression, not bi-polar disorder, and is very high functioning when she is not seriously depressed. She exhibits paranoia toward the police for bringing her to the hospital and her treatment team for keeping her there. [X.R.] told Dr. Sidhu today that Dr. Guggali's father treated her when that's not possible.”).

[9] X.R. now appeals.

Discussion and Decision

[10] X.R. argues the evidence is insufficient to support her involuntary commitment. In reviewing the sufficiency of the evidence to support a civil commitment, “an appellate court will affirm if, considering only the probative evidence and the reasonable inferences supporting it, without weighing evidence or assessing witness credibility, a reasonable trier of fact could find [the necessary elements] proven by clear and convincing evidence.” Civ. Commitment of T.K. v. Dep't of Veterans Affs., 27 N.E.3d 271, 273 (Ind. 2015). Clear and convincing evidence is an intermediate standard of proof that is greater than a preponderance of the evidence but less than proof beyond a reasonable doubt. T.D. v. Eskenazi Health Midtown Cmty. Mental Health Ctr., 40 N.E.3d 507, 510 (Ind. Ct. App. 2015).

[11] Indiana law allows an individual to be involuntarily committed if the petitioner proves by clear and convincing evidence that (1) the individual is mentally ill and either dangerous or gravely disabled and (2) detention or commitment of that individual is appropriate. Ind. Code § 12-26-2-5(e). Here, the trial court found that X.R. was mentally ill in that she suffered from bipolar I disorder, was gravely disabled, and was in need of custody, care, and treatment not to exceed ninety days. On appeal, X.R. challenges only one of these requirements. That is, she claims that the trial court's finding that she was gravely disabled is not supported by clear and convincing evidence. As relevant here, “gravely disabled” means:

a condition in which an individual, as a result of mental illness, is in danger of coming to harm because the individual ․ has a substantial impairment or an obvious deterioration of that individual's judgment, reasoning, or behavior that results in the individual's inability to function independently.

I.C. § 12-7-2-96.

[12] X.R. claims that she “was not at risk of coming to harm because of any impairment or deterioration of judgment or behavior and was sufficiently capable of functioning independently.” Appellant's Br. p. 11. Although X.R. admitted that she has bipolar depression, she didn't accept the diagnosis of bipolar I disorder, manic with psychosis, and refused to take an anti-psychotic medicine, which Dr. Sidhu stressed was needed for her diagnosis. As X.R. points out, the denial of a mental illness and refusal to medicate, standing alone, are insufficient to establish grave disability. See T.K., 27 N.E.3d at 276. Here, however, there was other evidence. According to Dr. Sidhu, X.R. had had the diagnosis of bipolar I disorder “for several years” and had been to the hospital “many times.” On this occasion, the police brought X.R. to the hospital in a “full-fledged manic state,” which had involved X.R. punching walls. Although X.R. had improved, she was still having symptoms of pressured speech, irritability, delusional thoughts, and paranoid thoughts. Dr. Sidhu gave examples of X.R.’s delusional and paranoid thoughts, including that the police and medical providers were out to get her, and opined that if X.R. didn't take an anti-psychotic medicine, she would not be able to function independently during an acute episode and would likely have a “poor prognosis.” See Golub v. Giles, 814 N.E.2d 1034, 1039 (Ind. Ct. App. 2004) (patient's refusal to accept diagnosis of “Bipolar Disorder, Psychotic” and refusal to take an anti-psychotic medication, paired with history of mental-health issues and destructive behavior, was sufficient to support a finding of grave disability), trans. denied. The evidence is sufficient to prove by clear and convincing evidence that X.R. was gravely disabled. We therefore affirm the trial court's commitment order.

[13] Affirmed.

Memorandum Decision by Judge Vaidik

Judges Weissmann and Foley concur. Weissmann, J., and Foley, J., concur.