Commitment of A P

FILED Jun 26 2024, 10:08 am

CLERK Indiana Supreme Court Court of Appeals and Tax Court

IN THE

Court of Appeals of Indiana In the Matter of the Civil Commitment of A.P., Appellant-Respondent

v.

Community Health Network, Inc., Appellee-Petitioner

June 26, 2024 Court of Appeals Case No. 24A-MH-218 Appeal from the Hamilton Superior Court The Honorable William Hughes, Judge Trial Court Cause No. 29D03-2401-MH-2

Opinion by Judge Riley Judges Kenworthy and Felix concur.

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Riley, Judge.

STATEMENT OF THE CASE [1] Appellant-Respondent, A.P., appeals the trial court’s Order of involuntary

regular commitment. [2] We affirm.

ISSUE [3] A.P. presents this court with one issue on appeal, which we restate as: Whether

there was sufficient evidence to support the trial court’s Order of involuntary

regular commitment, which concluded that A.P. was gravely disabled and

dangerous because of his mental illness.

FACTS AND PROCEDURAL HISTORY [4] This is A.P.’s second appeal of a mental health commitment order. Previously,

this court dismissed his appeal of a second temporary commitment order as

being moot. See A.P. v. Cmty. Health Network, Inc., 2023 WL 5693625 (Ind. Ct.

App. Sept. 5, 2023). The court’s findings and orders in these previous

proceedings reflected that A.P. is convinced he suffers from Amyotrophic

lateral sclerosis (ALS), a progressive neurological disorder, and has sought the

opinion of Indiana physicians, as well as the opinions of doctors from Chicago,

the Mayo Clinic, and the Cleveland Clinic. A.P. has gone to almost every

relevant program and has submitted to hundreds of plasma tests, eight EMGs,

two barium swallow tests, and a spinal tap muscle biopsy. Despite all those

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tests and appointments, A.P. has never been diagnosed with ALS or any other

terminal disease. [5] On January 9, 2024, A.P. was committed to Community Fairbanks Behavioral

Health on an emergency detention. Shortly after A.P.’s admission, Community

Health Network, Inc.’s (Community) physician, Dr. Jason Ehret (Dr. Ehret),

filed a petition for a commitment hearing and a physician’s statement, asserting

that A.P. was suffering from Delusional Disorder, Somatic Type, was

dangerous to himself as he was seeking assisted suicide, was gravely disabled as

he was not leaving his house, and was in need of a regular commitment. [6] On January 23, 2024, the trial court conducted a hearing on Community’s

petition, at which the trial court took judicial notice of the findings and orders

in A.P.’s two prior temporary commitment proceedings, as well as this court’s

opinion in A.P. During the proceedings, A.P.’s father (Father) testified that

during A.P.’s most recent temporary commitment:

[w]e were really surprised because it seemed like his mood was more stable and we could have more thoughtful interactions and exchanges. It wasn’t all focused on ALS and dying. It was more, I mean there w[ere] actually times that we would have laughter which is almost non-existent and [] there was actually a couple times that he was open to ideas even like [] maybe this is something other, this is a neurological condition, probably terminal, but maybe it’s not ALS.

(Transcript Vol. II, p. 11). However, after A.P.’s temporary commitment

expired, Father noticed that it “was a challenge” to get A.P. to follow up with

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treatment for his mental illness. (Tr. Vol. II, p. 9). A.P.’s personal hygiene

deteriorated, he no longer bathed regularly, and his condominium—which was

owned by his parents who paid all associated expenses—needed to be cleaned

“to get the smell [of body odor] out of it.” (Tr. Vol. II, p. 8). A.P. had not been

employed since 2021, had run out of money several months prior to the

commitment hearing, and had amassed some debts. Father testified that his

conversations with A.P. often drifted “into discussions about how he doesn’t

want to be alive, that ALS is horrible; it’s hell on earth.” (Tr. Vol. II, p. 10).

Father explained that a year earlier, in January 2023, prior to A.P.’s first

temporary commitment, “things were really bad” in terms of A.P.’s suicidal

ideation. Father informed the court that as of the date of A.P.’s current

hospitalization, A.P.’s expressions of suicidal ideations have become similar to

the ones he experienced in January 2023. [7] Dr. Ehret, who also testified in A.P.’s most recent temporary commitment

proceeding, examined A.P. daily since his admission on January 9, 2024, and

testified in support of a regular commitment. He explained that A.P. presented

with Delusional Disorder, Somatic Type, with a DSM-5 diagnosis of “major

depression superimposed on the delusional disorder.” (Tr. Vol. II, p. 19). Dr.

Ehret clarified that these are separate diagnoses, which are combined for

research and study purposes. He noted that A.P. continued to believe that he

had experienced a “massive weight loss” with corresponding continued muscle

wasting, even though A.P.’s weight and appearance have remained consistent.

(Tr. Vol. II., p. 19). In fact, A.P.’s muscular testing returned as being normal.

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In essence, Dr. Ehret concluded that A.P. was presenting with the same

symptoms as during his previous temporary commitments. [8] According to Dr. Ehret, A.P.’s mental illness impacts his ability to function

independently, as A.P. is “convinced that he [] has difficulty walking or he’s not

even able to sit [] appropriately. He’s to the point where he can’t drive [] and he

bases [] this feeling that he’s got this terminal illness that’s causing the

weakness.” (Tr. Vol. II, p. 20). Dr. Ehret maintained that A.P. fails to have

insight into his mental illness, and that A.P. “suffers a substantial impairment

in his judgment or reasoning that leads to an inability to function

independently.” (Tr. Vol. II, p. 20). Specifically, Dr. Ehret clarified that A.P.’s

mental illness impacted his ability to live independently without family support.

Dr. Ehret also concluded that A.P. presented a substantial risk of harming

himself. In support of his conclusion, Dr. Ehret explained that individuals

diagnosed with “delusional disorder with somatic symptoms [are in] a high-risk

group for suicide[, as] [t]he attempts are [] high, up to 20%.” (Tr. Vol. II, p.

21). Dr. Ehret noted that this high percentage is even more exacerbated in A.P.

because he “has the view that he has a terminal illness for which he needs to

end his life.” (Tr. Vol. II, p. 21). [9] Dr. Ehret requested the trial court to grant the petition for a regular

commitment, expected to exceed ninety days, because he believed A.P.’s

condition to be ongoing and not quickly resolved. He testified that his

proposed treatment plan consisted of anti-depressant medication for A.P.’s

“significant depressive symptoms,” as well as long-acting injectable anti-

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psychotic medication to treat the delusional disorder, similar to what A.P.

received during his prior temporary commitment. With respect to a possible

transition to outpatient therapy, Dr. Ehret was considering a number of options

since people with delusional disorders do better when they are more engaged

and active than “where people are isolating and by themselves.” (Tr. Vol. II, p.

22). Dr. Ehret also mentioned the possibility of Electro Convulsive Therapy,

which had been proven successful for delusional disorder, but assured the trial

court that he wanted to try medication and therapy first. He explained that

treatment could significantly improve a patient’s mood, as well as reduce the

intensity or severity of the delusions to the point where the patient can try to

engage in some therapeutic measures. Without treatment, A.P.’s “biggest risk

is, obviously, suicide given his hopelessness and [] concerns for . . . his health.”

(Tr. Vol. II, p. 24). [10] A.P. testified at the hearing. He insisted that he did not suffer from a mental

illness and that any ailment he suffered from was neuromuscular in nature. He

explained that he was “committed to finding a competent physician, competent

neurologist, neuromuscular specialist who is going to see the process through

until it’s finished[.]” (Tr. Vol. II, p. 36). Even though he was focused on

getting a diagnosis of his underlying problem, he did not rule out attempting to

obtain medically assisted suicide if the ultimate diagnosis was ALS or another

terminal illness. [11] At the close of the evidence, the trial court granted Community’s request for a

regular commitment, concluding that Community established that A.P. was

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suffering from Delusional Disorder Somatic Type and Major Depression, was

dangerous to himself, was gravely disabled, and was in need of custody, care

and treatment expected to exceed ninety days. The trial court noted specifically

at the hearing that it had

evidence in front of [it] in the form of the testimony of a qualified psychiatrist that [A.P.] suffers from a mental illness. I have visible evidence of my own that I can see that in fact [ ] it appears that there is some delusion ongoing [ ] given the fact that he believes he can’t walk, he can’t drive, he can’t do all these things and I’ve watched him do those things throughout the course of this proceeding. I don’t know whether there is an underlying neurological problem or not. All I know is that there is a delusion that the extent . . . of that problem and that [A.P.] has exhibited previously on two occasions and I believe since that in regard to the statement of his [F]ather, a tendency to at least consider doing away with himself and it’s not assisted suicide that I’m worried about. I don’t think that we have to worry about an assisted suicide with this diagnosis, but I’m concerned that [A.P.] might seek to harm himself otherwise because of his depression and other mental illness.

(Tr. Vol. II, p. 55). As a special condition, the trial court ordered, among

others, that A.P. take all medications as prescribed, attend all clinic sessions as

scheduled, and that Electro Shock Therapy may be performed only upon

additional order from the court. [12] A.P. now appeals. Additional facts will be provided if necessary.

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DISCUSSION AND DECISION [13] A.P. contends that there was insufficient evidence to support his involuntary

regular commitment because Community did not prove by clear and

convincing evidence that he is gravely disabled and a danger to himself. [14] “‘[T]he purpose of civil commitment proceedings is dual: to protect the public

and to ensure the rights of the person whose liberty is at stake.’” T.K. v. Dep’t of

Veterans Affs., 27 N.E.3d 271, 273 (Ind. 2015) (quoting In re Commitment of

Roberts, 723 N.E.2d 474, 476 (Ind. Ct. App. 2000)). “The liberty interest at

stake in a civil commitment proceeding goes beyond a loss of one’s physical

freedom, and given the serious stigma and adverse social consequences that

accompany such physical confinement, a proceeding for an involuntary civil

commitment is subject to due process requirements.” Id. [15] To satisfy due process, the facts justifying an involuntary commitment must be

proved by clear and convincing evidence. In re Commitment of G.M., 743 N.E.2d

1148, 1151 (Ind. Ct. App. 2001). Clear and convincing evidence is defined as

an intermediate standard of proof greater than a preponderance of the evidence

and less than proof beyond a reasonable doubt. T.D. v. Eskenazi Midtown Cmty.

Mental Health Ctr., 40 N.E.3d 507, 510 (Ind. Ct. App. 2015). In order to be clear

and convincing, the existence of a fact must be highly probable. Id. When we

review the sufficiency of the evidence supporting an involuntary commitment,

we will affirm if, “considering only the probative evidence and the reasonable

inferences supporting it, without weighing evidence or assessing witness

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credibility, a reasonable trier of fact could find [the necessary elements] proven

by clear and convincing evidence.” T.K., 27 N.E.3d at 273. [16] To obtain an involuntary commitment, the petitioner is “required to prove 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). Because the statute is

written in the disjunctive, the petitioner need only prove that the individual is

either dangerous or gravely disabled to carry the burden of proof. In the Matter

of the Commitment of M.Z. v. Clarian Health Partners, 829 N.E2d 634, 637 (Ind. Ct.

App. 2005). Here, the trial court found that A.P. is mentally ill, gravely

disabled, and dangerous to himself. A.P. does not dispute that he is mentally

ill. His sole challenge to the sufficiency of the evidence revolves around the

trial court’s finding that he is gravely disabled and dangerous to himself. [17] We first consider whether Community presented clear and convincing evidence

that A.P. was dangerous to himself. Indiana Code section 12-7-2-53 defines

“dangerous” as “a condition in which an individual as a result of mental illness,

presents a substantial risk that the individual will harm the individual or

others.” “Dangerousness must be shown by clear and convincing evidence

indicating that the behavior used as an index of a person’s dangerousness would

not occur but for the person’s mental illness.” Commitment of M.M. v. Clarian

Health Partners, 826 N.E.2d 90, 97 (Ind. Ct. App. 2005).

Court of Appeals of Indiana | Opinion 24A-MH-218 | June 26, 2024 Page 9 of 12 [18] The record reflects that A.P. was dangerous to himself as a result of his mental

illness. Dr. Ehret testified that individuals with delusional disorder are

categorized to be at a high risk of suicide—up to 20%. This percentage is even

higher in A.P.’s situation because of A.P.’s major depression in which he is

convinced that “he has a terminal illness for which he needs to end his life.”

(Tr. Vol. II, p. 21). A.P.’s Father confirmed that “history shows that [A.P.] is

resistant to anything other than pursuing the ALS diagnosis.” (Tr. Vol. II, p.

12). A.P. expressed suicidal statements to his family members. A.P.’s Father

stated that his conversations with A.P. often “drifted into discussion about how

he doesn’t want to be alive, that ALS is horrible; it’s hell on earth.” (Tr. Vol. II,

p. 10). Father told the trial court that in January 2023, prior to A.P.’s first

temporary commitment, “things were really bad” with respect to A.P.’s suicidal

ideation. Father expressly noted that as of the date of A.P.’s current admission,

the situation was “similar” to January 2023. Again, as previously, A.P. was

making veiled suicide comments and, according to Father’s testimony, “there

had been more specific ideation around a plan, a time or two.” (Tr. Vol. II, p.

10.). Father explained that on the night of A.P.’s current admission, A.P.

stated that he didn’t “want to live like this.” (Tr. Vol. II, p. 11). A.P.’s own

testimony confirms a finding of dangerousness as A.P. stated that he would not

rule out obtaining medically assisted suicide if he was ultimately diagnosed

with ALS or another terminal illness. In this regard, the trial court took judicial

notice that in the most recent prior temporary commitment, an express finding

had been made that A.P. had purchased a plane ticked to Switzerland to get

medically aided suicide. This led the trial court to be “concerned that [A.P.]

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might seek to harm himself otherwise because of his depression and other

mental illness.” (Tr. Vol. II, p. 55). [19] A trial court is not required to wait until harm has nearly or actually occurred

before determining that an individual is dangerous to himself or others. C.J. v.

Health and Hosp. Corp. of Marion Co., 842 N.E.2d 407, 410 (Ind. Ct. App. 2006).

Here, the trial court received clear and convincing evidence that A.P.’s

diagnosis placed him at an extremely high risk for suicide which, coupled with

his belief that he had a terminal illness and the continuous suicidal ideations

expressed to his family, as well as his testimony at the commitment hearing that

he refused to rule out medically assisted suicide if he ever received the terminal

diagnosis that he desperately seeks, supported a finding that A.P. was

dangerous to himself. 1

CONCLUSION [20] Based on the foregoing, we conclude that clear and convincing evidence was

presented to support the trial court’s Order of involuntary regular commitment. [21] Affirmed.

Kenworthy, J. and Felix, J. concur.

1 Because the statute is written in the disjunctive and we affirm the trial court’s finding that A.P. was dangerous to himself, we do not address A.P.’s claim that the trial court erred in finding him to be gravely disabled. See I.C. § 12-26-2-5(e).

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ATTORNEY FOR APPELLANT Michael Frischkorn Brand & Morelock Greenfield, Indiana

ATTORNEYS FOR APPELLEE Jenny R. Buchheit Sean T. Dewey Ice Miller, LLP Indianapolis, Indiana

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