Peo in Interest of Carr

24CA2167 Peo in Interest of Carr 02-20-2025

COLORADO COURT OF APPEALS

Court of Appeals No. 24CA2167
Pueblo County District Court No. 24MH30035
Honorable Timothy O’Shea, Judge

The People of the State of Colorado,

Petitioner-Appellee,

In the Interest of Michael Allen Carr,

Respondent-Appellant.

ORDER AFFIRMED

Division III
Opinion by JUDGE TOW
Dunn and Meirink, JJ., concur

NOT PUBLISHED PURSUANT TO C.A.R. 35(e)
Announced February 20, 2025

Cynthia Mitchell, County Attorney, Kate H. Shafer, Special Assistant County
Attorney, Pueblo, Colorado, for Petitioner-Appellee

Tezak Law, P.C., Mary Tezak, Florence, Colorado, for Respondent-Appellant
¶1 Respondent, Michael Allen Carr, appeals the district court’s

order authorizing the involuntary administration of four

antipsychotic medications — olanzapine (Zyprexa), haloperidol

(Haldol), clozapine (Clozaril), and paliperidone (Invega) — and two

mood-stabilizing medications — divalproex sodium (Depakote) and

lithium. We affirm the order.

I. Background

¶2 Carr was admitted to the Colorado Mental Health Hospital in

Pueblo (CMHHIP) after being found incompetent to proceed to trial

on criminal charges. This was not his first mental health

admission. Carr had been previously admitted to CMHHIP in 2019

and 2020 and to the Colorado Mental Health Hospital in Fort Logan

in 2023. Each time, he required involuntary treatment due to his

physical aggression and refusal to eat or drink, causing serious

weight loss. And each time Carr was released, he discontinued his

medications.

¶3 In June 2024, the district court entered an order permitting

the involuntary administration of Zyprexa, Haldol, Depakote, and

an antianxiety medication for six months. In December 2024, the

People requested a new involuntary treatment order.

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¶4 Carr and Dr. Elisabeth Cheney, Carr’s treating physician, both

testified at the hearing on the December petition. Dr. Cheney

testified about each of the four elements required for involuntary

administration of medication under People v. Medina, 705 P.2d 961,

973 (Colo. 1985). She explained Carr’s need for the requested

medications as follows:

• Carr was diagnosed with “schizoaffective disorder bipolar

type,” a substantial disorder that grossly impairs

judgment or capacity to recognize reality or to control

behavior.

• Zyprexa, Haldol, and Depakote were not treating Carr’s

symptoms successfully — he is “still substantially

delusional and thought disordered.”

• Carr’s symptoms had become increasingly resistant to

treatment due to his frequent discontinuation of

medication.

• To manage Carr’s symptoms and to address his side

effects from Haldol (involuntary mouth movements) and

Depakote (sedation), Dr. Cheney plans to taper down his

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current medications and begin treating him with Clozaril,

Invega, and lithium, as necessary.

¶5 Carr testified that he would not take any of the requested

medications without a court order. He complained of the following

existing side effects: drooling, jaw movements, sedation, weight

gain, erectile dysfunction, and inability to focus. And he alleged

that Invega had also caused poor sleep and headaches when he

took it in the past. He wished to be treated with Strattera (an

Attention Deficit Hyperactivity Disorder (ADHD) treatment) and

perhaps a low dose of Seroquel (an antipsychotic) instead.

¶6 At the conclusion of the testimony, the district court found Dr.

Cheney’s opinions to be credible and persuasive and adopted them.

It found that each of the Medina elements had been established by

clear and convincing evidence, and it issued an order authorizing

CMHHIP staff to involuntarily administer all of the requested

medications for a period of six months.

¶7 On appeal, Carr challenges the sufficiency of the evidence

supporting the court’s order.

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II. Legal Authority and Standard of Review

¶8 A district court may authorize the involuntary administration

of medication to a patient only if the People establish each of the

following Medina elements by clear and convincing evidence: (1) the

patient is incompetent to participate effectively in the treatment

decision; (2) treatment by medication is necessary either to prevent

a significant and likely long-term deterioration in the patient’s

mental condition or to prevent the likelihood of the patient causing

serious harm to himself or others in the institution; (3) a less

intrusive treatment alternative is not available; and (4) the patient’s

need for treatment with medication is sufficiently compelling to

override his bona fide and legitimate interest in refusing

medication. Id.; see People in Interest of Strodtman, 293 P.3d 123,

131 (Colo. App. 2011). A physician’s testimony alone may

constitute clear and convincing evidence. See People v. Pflugbeil,

834 P.2d 843, 846-47 (Colo. App. 1992).

¶9 When, as here, a patient challenges the sufficiency of the

evidence supporting the district court’s findings on any of these

elements, we review the court’s conclusions of law de novo and

defer to its findings of fact if supported by evidence in the record.

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People v. Marquardt, 2016 CO 4, ¶ 8. We view the record as a whole

and in the light most favorable to the People, and we defer to the

fact finder to resolve any conflicts in the testimony and determine

the credibility of witnesses. See People in Interest of Ramsey, 2023

COA 95, ¶ 23; see also Strodtman, 293 P.3d at 130.

III. Analysis

¶ 10 Carr challenges the sufficiency of the evidence only for the first

and fourth Medina elements. He argues that the People failed to

demonstrate (1) that he was incompetent to effectively participate in

treatment decisions or (2) a sufficiently compelling need to override

his interest in avoiding side effects from the requested medications.

See Medina, 705 P.2d at 973-74. We conclude that Dr. Cheney’s

testimony provides ample support for the court’s ultimate findings

on these elements.

A. First Medina Element

¶ 11 A patient is incompetent to participate effectively in treatment

decisions when his “mental illness has so impaired his judgment as

to render him ‘incapable of participating in decisions affecting his

health.’” Id. at 973 (citation omitted).

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¶ 12 The district court found that Carr has limited insight into his

mental illness because he wrongly attributes his symptoms to

ADHD and is thus incapable of making informed treatment

decisions. Dr. Cheney testified to that fact, and she also testified

that Carr does not believe he has a psychotic illness and will not

choose to take antipsychotic or mood-stabilizing medications if they

are not court ordered. She opined that ADHD could not cause

Carr’s symptoms, which include paranoia, delusions, auditory

hallucinations, disorganized thinking, irritability, and intermittent

threatening and aggressive behavior. Thus, Carr’s desired

medications — Strattera and even a high dose of Seroquel — would

not treat his illness and could worsen it. Carr’s testimony

corroborated Dr. Cheney’s. Although he acknowledged that he has

schizophrenia, he described the symptoms of this illness only as

“scattered thoughts.” And he confirmed that Strattera is the only

medication he thinks he needs, demonstrating that he lacks insight

into his schizoaffective bipolar type illness.

¶ 13 Accepting Dr. Cheney’s testimony as credible, as we must, and

viewing the record in the light most favorable to the People, we

conclude that the record amply supports the court’s finding that

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Carr’s limited insight into his illness renders him incompetent to

participate effectively in his treatment decisions. See Ramsey, ¶ 23.

B. Fourth Medina Element

¶ 14 In assessing the fourth Medina element — whether the

patient’s need for treatment is sufficiently compelling to override

any legitimate interest in refusing treatment — a court must

determine (1) “whether the patient’s refusal is bona fide and

legitimate” and, if so, (2) “whether the prognosis without treatment

is so unfavorable that the patient’s personal preference must yield

to the legitimate interests of the state in preserving the life and

health of the patient placed in its charge and in protecting the

safety of those in the institution.” Medina, 705 P.2d at 974.

¶ 15 The district court answered both questions, finding that Carr’s

(1) preference for ineffective medications was not a bona fide and

legitimate reason to refuse the requested medications and

(2) prognosis without medications was so unfavorable that his

personal preference must yield. Carr challenges only the court’s

first finding. We agree that the record does not support the court’s

first finding, but we nonetheless conclude that sufficient evidence

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supports this Medina element because the record establishes that

Carr’s prognosis without treatment is very unfavorable.

¶ 16 As to the first finding, Carr told the district court that he

wished to refuse treatment because he did not like numerous side

effects caused by the requested medications. There was no

evidence that the side effects complained of were falsely alleged,

insignificant, improperly attributed to the medications, or effectively

managed. To the contrary, Dr. Cheney testified that because Haldol

and Depakote cause actual and significant side effects, she planned

to taper down those medications and begin treating Carr with

medications posing a lower risk of those adverse effects. Bona fide

and significant adverse effects can constitute a legitimate reason to

refuse medication. See People in Interest of Uwayezuk, 2023 COA

69, ¶ 62. The record establishes a bona fide and legitimate reason

for Carr’s refusal.

¶ 17 However, we discern ample record support for the court’s

second finding that Carr’s prognosis without medication is so

unfavorable that his personal preference must yield to the state’s

legitimate interests in preserving his health and protecting the

safety of those in CMHHIP. Dr. Cheney’s affidavit and testimony

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demonstrated that without treatment, Carr’s mental illness

presents a significant risk to his health. He has refused food and

water, believing it to be poisoned. Dr. Cheney also testified that

without medication, Carr “becomes quite out of control, agitated,

and violent due to his psychosis and disorganized thinking,

delusions, and auditory hallucinations.” And even on medication,

he recently threw objects at staff members.

¶ 18 Viewing this record in the light most favorable to the People,

we perceive clear and convincing evidence of a compelling need for

the involuntary administration of medications. See Ramsey, ¶ 23;

Pflugbeil, 834 P.2d at 846-47. We conclude that the record amply

supports the district court’s findings regarding the fourth Medina

element.

IV. Disposition

¶ 19 The order is affirmed.

JUDGE DUNN and JUDGE MEIRINK concur.

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