THE COURT: This is cause number 300536-P-CC, a matter in the interest of Katherine Garrett. Before the Court is a petition for a twenty-one day involuntary detention and treatment, and further a petition for court ordered electroconvulsive therapy.
The Petitioner is South Pointe Hospital here represented by Mr. Timothy Finnegan, Assistant Circuit Attorney. Let the record reflect that the respondent, Ms. Katherine Garrett, is present in person and at this point is represented by Mr. Blair K. Drazik, Attorney at Law. Previously she was -- Ms. Garrett was represented by Ms. Pricilla Price by court appointed attorney by this Court, who has since the entry of Mr. Drazik, she will withdraw as attorney for Ms. Garrett.
Is the Petitioner ready to proceed on these petitions?
MR. FINNEGAN: Petitioner is ready to proceed, Your Honor.
THE COURT: Mr. Drazik, are you ready to proceed on behalf of Ms. Garrett?
MR. DRAZIK: Yes, Your Honor, but previous to the hearing of the evidence, we would like to move to dismiss the petition on the grounds that if the facts therein are proven to be true, it would constitute a violation of the due process clause of the 14th Amendment
of the United States Constitution in that it would allow the State to determine the best medical treatment for this lady, thereby depriving her of the right to bodily self determination. And so for that reason, we believe even if the ground as proven in the petition are proved to be true, that even in that event, it would be an unconstitutional deprivation of her right to liberty and unconstitutional intrusion of the due process clause to do the electroconvulsive therapy.
THE COURT: Your motion goes to the petition for a court ordered electroconvulsive therapy?
MR. DRAZIK: Correct. We -- our constitutional argument does not go to the commitment portion of the petition. Only to the electroshock therapy, in that deprives her of her right to bodily self determination as secured by the 14th Amendment of the United States Constitution, since it's the State who is attempting to take that from her.
THE COURT: Okay. Thank you, Mr. Drazik. Before we begin with the hearing - -
MR. DRAZIK: Your Honor, for the record further, even if the petition does state a claim, we would ask that the Court construe the language of the statute and the law if it could be done so that's consistent with the due process as possible by making the least intrusion as possible into the right to - -
THE COURT- Your motion to dismiss is overruled. Your second request or motion will be considered by the Court. Anything further before we begin?
MR. DRAZIK: No, Your Honor.
THE COURT: Mr. Finnegan, you may call your first witness.
MR. FINNEGAN: Thank you, Your Honor. Petitioner would call Dr. Mofsen.
DOCTOR RICK MOFSEN
being duly sworn, testified as follows:
DIRECT EXAMINATION BY MR. FINNEGAN:
THE COURT: You may inquire, Mr. Finnegan.
MR. FINNEGAN: Thank you, Your Honor.
Q Doctor, tell the Court your name.
A Doctor Rick Mofsen.
Q What's your occupation?
A Physician.
Q Do you have a specialty?
A Yes.
Q What is that?
A Psychiatry.
Q Are you licensed to practice medicine in the State of Missouri?
A Yes, I am.
Q How long have you been practicing in the field of psychiatry?
A Over eleven years.
Q Have you previously appeared in this Court as an expert witness?
A Yes, I have.
Q Can you estimate for the Court on how many occasions?
A Twenty-five or thirty.
Q And when you say in court, in the Probate Division of this St. Louis City Court?
A Yes.
Q Where are you employed?
A I'm self-employed.
Q Do you have admitting privileges at South Pointe Hospital?
A Yes.
Q And this case arises out of an admission at South Pointe Hospital?
A Yes.
MR. FINNEGAN: Your Honor, I'd like to offer the Doctor as an expert witness in the field of psychiatry.
THE COURT: Any objection, Mr. Drazik?
MR. DRAZIK: No, Your Honor. I think he qualifies. I'm not admitting any weight of his testimony, but I think his qualifications that the Court can weigh as it sees fit.
THE COURT: Thank you. You may proceed, Mr. Finnegan.
Q (by Mr. Finnegan) Do you know the respondent, Kathleen Garrett?
A Yes, I do.
Q How do you know her?
A I've treated her for several years now.
Q As part of her treatment, do you have a diagnosis of any condition she might have?
A Yes.
Q Specifically does she suffer from any psychiatric illness?
A Yes.
Q What is that?
A Major depressive episodes with psychotic features.
Q What about her history and her presentation on this admission is consistent, in your judgment, with the disease you just mentioned?
A Well, she presented in a very depressed state, very psycho-motor retarded, speaking very slowly. She had suicidal ideation and also she was very delusional.
Q Talking about a couple of aspects of that, you said she had suicidal ideation. What specifically about her, what she said to you or what you observed, brings you to that conclusion?
A Well, she said many times to me that she wanted to end her life.
Q Okay. You also talked about some delusional aspects of the illness. What led you to that conclusion?
A The delusions that she has are primarily of a symptomatic nature. She's very focused on bodily problems, issues with her mouth. If there's a little problem, for example, she ruminates about that excessively. Constipation for many, many days. She would continue to ask the same questions over and over again, ten, twenty, thirty times an hour, concerning specific treatments concerning that. And concerns that she had very classic symptomatic types of delusions.
Q Now, in terms of her general health other than or in addition to the psychiatric illness you've diagnosed, what is her health like otherwise?
A Well, she is basically in fairly good health right now. However, she does have some significant medical problems. She does have hypertension. She also has mild chronic obstructive pulmonary disease. She had breast cancer and has had surgery for that. And I think that's the major issues.
Q Is she recently currently being treated or recently treated for the breast cancer?
A Yes.
Q And if you know, how recently?
A I think she had chemotherapy treatment within the past month. I'm not exactly sure when the last time was.
Q Do you know either from discussions with her or information from other doctors that the nature and seriousness of the cancer is currently?
A Well, she has breast cancer so it's serious and she's undergoing treatment. So it's always an issue.
Q Has medicine been prescribed for her psychiatric condition?
A Yes.
Q What medication?
A Well, she's currently on several different medications. She's on an anti-depressant called Paxil, anti-anxiety medication Adavan. She's on Remaran (sic), another anti-depressent. And she's on Respidal, an anti-psychotic.
Q Okay. Addressing first, just to keep things from becoming too complex, the issues on the twenty-one day detention, do you believe to a reasonable degree of medical certainty that in-patient hospitalization, and specifically at your facility, is the appropriate, least restrictive environment for the care of Ms.-Garrett at the present time?
A Yes.
Q Why is that? Why wouldn't she be appropriate as an out- patient?
A She's still, even this morning, she expressed concern about her ability to live at home alone. She told me she was still quite nervous about going home. And she was not quite sure whether she would be able to do well there.
Q What specific concerns do those statements raise in your mind?
A Well, I still believe that she was a suicidal risk. And even though over the past few days she has in fact had fewer suicidal thoughts, I still judge her as a significant risk.
Q So is some part of your concern related to your interpretation of the concerns she has related to this possibility of suicide?
A Yes.
Q Do you believe that her condition and these thoughts outside of your facility, as her condition is now, would represent a likelihood of serious harm to her?
A Yes.
Q If she were to be retained by the Court, would your facility accept responsibility for caring for her during the twenty-one days?
A Yes.
Q And moving into the second aspect, what would your treatment plan be in her case?
A The treatment plan would be electroconvulsive therapy.
Q Let's talk about that. Do you believe that the medication that she's currently taking have significantly improved her condition?
A No.
Q Why? What do you think they need to do that they haven't done?
A Well, number one, she's still quite depressed and anxious. And secondly, she still does have the delusional component of the illness.
Q Do you believe that there is a strong likelihood that electroconvulsive therapy would significantly improve her condition for a substantial period of time?
A Yes.
Q Why is that?
A Well, with her particular diagnosis of delusional depression, the literature over the years has been quite clear. This is not only the most effective treatment for her particular diagnosis, but also is considered in the field of psychiatry as the treatment of first use for this particular diagnosis.
As you know, ECT in some quarters does not have the best representation. But despite that, psychiatrists in general agree that for depression with psychotic features this is the treatment, the first line treatment of choice.
Q If, hypothetically, we weren't in the State of Missouri, for example, somewhere else, is it your medical opinion that ECT would have been the first thing you would have tried rather than the last?
A Correct.
Q Since we are here in Missouri though, you're basing it on the idea that these other medical treatments are not likely to significantly improve her condition?
A I think they're likely to improve her condition. I think that the medications have improved her condition to a certain extent. I do not believe that her medications will in fact put her in remission, which I think is necessary before she would be safe to go home.
Q And specifically, is it the aspect of suicidality that concerns you?
A Well, certainly that's a concern as far as the safety issue. But the quality of life issue of course is of great concern too. I think she continues to be very, very anxious and nervous, very depressed and not functioning well. And I have had the opportunity to treat her over the years and I have seen her in much better condition. And I think she should be able to obtain previous levels of efficacy.
Q And in your medical opinion, is there a substantial strong likelihood that the medications would achieve this, even if given a much longer course?
A I don't believe they would.
Q Okay. What course of ECT are you asking the Court for, over what period of time?
A I'm asking for a maximum of twelve treatments over a four week period.
Q Okay. Do you believe that the respondent will suffer any serious loss of function as a result of these treatments?
A No, I don't. In fact, I think compared to how she is right now, I would expect improvement in function.
Q Do you know whether she has received ECT in the past?
A Yes, she has.
Q And do you know when the most recent course of treatment was?
A I'm not certain how long ago the last treatment was.
Q She has not received ECT while under your care?
A I treated her at another hospital in the past on several occasions and I don't recall whether we gave her ECT. I don't have those medical records available.
Q Would it be accurate if you did, it was voluntary as opposed to having to go through a hearing of this type?
A I don't recall coming to court before.
Q And just a phrase in the language of the statute, is there any less drastic form of therapy in your medical opinion as likely to result in significant improvement in her condition, assuming ECT is -
A I have to first comment I don't think it's drastic, and next, in many ways, it may be safer than the medication she's taking. But I do not believe there's anything less drastic.
Q Specifically is there any pharmacological therapy likely to produce a significant improvement in her condition?
A I don't believe so.
MR. FINNEGAN: That's all I have, Your Honor.
THE COURT: Mr. Drazik?
MR. DRAZIK: Thank you, Your Honor.
CROSS-EXAMINATION BY MR. DRAZIK:
Q Is you were to release Kathleen Garrett today, what are the probabilities that she would commit suicide?
A I think they're substantial.
Q Would you give me a number?
A No, I cannot.
Q Can you give me a range of numbers?
A Greater than fifty percent, over a period of time.
Q Over what period of time?
A Over a month.
Q And if she remains on the medication, would that probability decrease?
A It's very difficult to say. I would say that it's possible over the next several weeks that there may be some slight additional improvement with the medication. But I would have to say slight.
Q What is the probability that electro -- if you gave her electroshock therapy, would you describe specifically what you would expect to happen?
A I would expect -- are you talking about results or -
Q Results?
A With the results I would expect a drastic reduction in the depressive features, a drastic reduction in the anxiety, and elimination of this symptomatic delusions.
Q What are the side affects of ECT?
A Side affects of ECT are dependent upon how the treatment is administered. But in general, short term memory loss. That's not uncommon. That probably other than some mild headache on the day of treatment are the two most commonly experienced side affects.
Q Have you had people lose memory as a long standing event?
A Long standing?
Q In other words, loss of memory of their childhood or loss of memory of young adulthood?
A No, I never had that happen.
Q Have you known of anyone else that's had that happen?
A I've heard anecdotal stories, but have not spoken to anyone directly who has experienced that.
Q If you were treating a patient who had electroconvulsive therapy in the past and had thereafter experienced memory loss of distant events, would that effect your treatment of her?
A Well, if someone has had substantial memory problems with ECT in the past, especially if it was the distant past, I would do several things. Number one, I would start the treatments off in the unilateral fashion. There's two ways to administer ECT. One bilateral and one unilateral. And over the past few years it's been well demonstrated that unilateral treatment substantially reduces the probability of any type of memory problem from the treatment.
Also I would make sure that the perimeters for administering the treatment were at the lowest possible in order to produce an effective treatment, but at the same time not to over treat where again you might have problems with memory.
Q Do you know whether or not Kathleen has had that experience in the past where she's lost memory?
A I believe her son mentioned that has been the case.
Q When you mention unilateral, what do you mean by that?
A Well, with the way that ECT has been done in the past, there was typically an electrode placed on each temple, right and left. And unilateral is an electrode placed on the nondominent hemisphere, typically the right side, and then on the more of the crown of the head. And when that occurs, the evidence is quite remarkable on the decreased problems with memory loss.
Q In other words, you would see the memory loss if it were going to occur?
A Well, if the memory loss were to occur there it would be substantially less than compared to doing it the other way.
Q Would you test the person after the initial unilateral treatment to see if she was experiencing memory loss?
A Well, we always evaluate the patient on the day of and then throughout really the course of the treatment. That's one of the things that the nursing staff from the hospital does, as well as the treating physician.
Q Have you known any other side affects of electroconvulsive therapy?
A I mentioned headache, which is fairly common. Usually that's treated well with just Tylenol. Other than that, I have not had any other serious types of side affects noted.
Q Are there other -- is there any current literature critical on electroshock therapy?
A From what source?
Q From either the medical or psychological field?
A Well, from the medical source, medical journals, I have not seen anything critical of ECT. As a matter of fact, there's actually a resurgence over the past few years and it's being used much more readily throughout the country. And the popular literature there are groups that are anti-psychiatry in general that have mounted campaigns against ECT as well as psychiatric medication in general.
Q What about from the therapy communities, are there any discussions on that, psychologists?
A Psychologists? It depends on the psychologist you talk to. Psychologists familiar with treating seriously mentally ill patients and familiar with the technique, they see the benefits. If somebody is not, then of course they only know what was in movies and popular literature.
Q Are there some medical treatments that are universally accepted one time in history and later not universally accepted?
A Absolutely.
Q Because medicine isn't an exact science?
A That's correct.
MR. DRAZIK: I have nothing else.
THE COURT: Redirect?