In The Matter of the            )

              4    Hospitalization                 )


              5                                    )

                   of                              )

              6                                    )

                   FAITH J. MYERS                  )

              7                                    )

                   Case No. 3AN-03-277 P/S










                             DEPOSITION OF ROBERT HANOWELL, MD







             16                 Thursday, February 27, 2003

                                        11:38 A.M.













             23               Taken by Counsel for Respondent


             24                Alaska Psychiatric Institute

                                   2900 Providence Drive

             25                      Anchorage, Alaska



                           PACIFIC RIM REPORTING  907/272-4383






              1                    A-P-P-E-A-R-A-N-C-E-S



                   For Respondent:


                      James B. Gottstein, Esq.

              4       LAW OFFICES OF JAMES B. GOTTSTEIN

                      406 G Street, Suite 206

              5       Anchorage, Alaska  99501





                   For Petitioner:


                      Jeffrey Killip, Esq.

              9       ATTORNEY GENERAL'S OFFICE

                      1031 West Fourth Avenue, Suite 200

             10       Anchorage, Alaska 99501





                   Also Present:


                      Nicholas Kletti, MD




                   Court Reporter:


                      Jeanette Blalock

             17       PACIFIC RIM REPORTING

                      711 M Street, Suite 4

             18       Anchorage, Alaska 99501

















                           PACIFIC RIM REPORTING  907/272-4383






              1                          I-N-D-E-X



                   EXAMINATION BY                                   PAGE


                   Mr. Gottstein                                      4


                   Mr. Killip                                        45


                   Mr. Gottstein                                     50








                    1     1-page letter dated 2/27/03                 7


                    2     Patient chart                              **


                    3     1-page cover of DSM-IV-TR                   9


                    4     PDR report on Zyprexa (18 pages)           18


                    5     From Placebo to Panacea (58 pages)         31


                    6     Letter dated 2/26/03 (2 pages)             36


                    7     Curriculum vitae (2 pages)                 50


                    8     Patient master chart                       **




                   ** - Original retained by API.  No copy provided to

             19         reporter.















                           PACIFIC RIM REPORTING  907/272-4383






              1       ANCHORAGE, ALASKA; THURSDAY, FEBRUARY 27, 2003


              2                         11:38 A.M.


              3                            -o0o-


              4                    ROBERT HANOWELL, MD,


              5            deponent herein, being sworn on oath,


              6           was examined and testified as follows:


              7                         EXAMINATION


              8    BY MR. GOTTSTEIN:


              9        Q    Thank you, Dr. Hanowell.  I understand this


             10    is a diversion from your normal activities of the


             11    day.


             12             You were served with a subpoena duces tecum


             13    to bring certain documents; is that correct?


             14        A    Yes, sir.  And to the best of my ability, I


             15    did so.


             16        Q    So No. 1 was the -- your curriculum vitae.


             17    Did you bring that?


             18        A    I am having a copy of it made.  I can


             19    certainly ask that that be brought down.  I didn't


             20    have a copy in my office, and I asked Dr. Kletti's


             21    administrative assistant to make a copy of that.


             22        Q    Okay.  And then you were asked to bring the


             23    medical chart.  I assume that's there, right?


             24        A    Yes, sir.  I was informed, however, by our


             25    medical records director that I am not to release this



                           PACIFIC RIM REPORTING  907/272-4383






              1    to you at this juncture.  That was -- I received that


              2    in a paged e-mail approximately an hour ago.  But I do


              3    have it here with me.


              4        Q    But you can -- would you be agreeable to


              5    having a copy made, and given to the court reporter?


              6        A    I just wanted to clarify.  Our medical


              7    records director thought that she -- that perhaps a


              8    copy had already been given to you a few days ago.  Is


              9    that accurate?


             10        Q    Yes.


             11        A    Okay.  So you just wanted the additional


             12    information that's been added since that time?


             13        Q    Well, I mean, I guess -- the thing is, is


             14    that I need to have everything, okay?  I don't know


             15    what's been added since.


             16             MR. KILLIP:  You have got a release, right,


             17    Jim?


             18             MR. GOTTSTEIN:  Yeah.


             19    BY MR. GOTTSTEIN:


             20        Q    So the best thing is just to get what you


             21    have now, and make a copy of it.  And then we will


             22    know that's what it is.


             23        A    I defer to my attorney.


             24             MR. KILLIP:  Yeah.  At this point, I don't --


             25    I mean, if you have got a release, and you're her



                           PACIFIC RIM REPORTING  907/272-4383






              1    attorney representing her in this proceeding, I mean,


              2    initially, I just don't see a problem with that.


              3             But given the expedited nature of


              4    everything -- I guess maybe it'll probably be brought


              5    to my attention after this deposition.  But I am not


              6    aware of anything.


              7             MR. GOTTSTEIN:  I think that I am entitled to


              8    it.  I mean, it would take more time to figure out, I


              9    think, what I don't have, than to just ask the office


             10    to copy the whole thing again and give it to the court


             11    reporter, trying to expedite things.


             12             THE WITNESS:  I defer to my attorneys.


             13             DR. KLETTI:  Jim, at what level would it be


             14    reasonable, to every hour Xerox the chart for your


             15    review?  I mean, that's what --


             16             MR. GOTTSTEIN:  Well, it's been a couple of


             17    days.  If you want to compare, I would be happy if you


             18    would agree to, as new entries are made, have copies


             19    available, that would be great.  Or if you want to


             20    review what you sent last time and give me copies of


             21    what --


             22             DR. KLETTI:  I think we have given you


             23    updated progress notes from the last, and updated


             24    treatment plans from the last, the medications orders,


             25    if you'd like that, also.



                           PACIFIC RIM REPORTING  907/272-4383






              1             MR. GOTTSTEIN:  Yeah.  Any changes, any


              2    additions.


              3             But what I'd really like to do is start with


              4    what we have here, unless you have a record of what


              5    you gave me two days ago.


              6             DR. KLETTI:  We don't have a copy of it, but


              7    we have the original chart there.


              8             MR. GOTTSTEIN:  So you'll make a copy of the


              9    whole thing?


             10             We are taking a lot of time on this.


             11             DR. KLETTI:  It's your time.


             12    BY MR. GOTTSTEIN:


             13        Q    And then No. 3 was your written report


             14    regarding this matter?


             15        A    Yes, sir.  I did draft a report.  I wasn't


             16    sure to whom I should address it.  I addressed it to


             17    Mr. Killip.


             18        Q    Could I see that, please?


             19             MR. KILLIP:  Sure.  This is No. 3.


             20        A    I will acknowledge that it was done very


             21    quickly, and it's perhaps not the best written letter


             22    I have ever made -- ever written, but I did my best.


             23             MR. GOTTSTEIN:  Let's mark this as Exhibit A,


             24    or whatever exhibit you want.


             25             (Exhibit No. 1 marked.)



                           PACIFIC RIM REPORTING  907/272-4383






              1    BY MR. GOTTSTEIN:


              2        Q    So we are going to have a copy of that.


              3             MR. GOTTSTEIN:  And let's make that


              4    Exhibit 2.


              5    BY MR. GOTTSTEIN:


              6        Q    How about No. 4?


              7        A    Yes.  That would be the record -- the


              8    hospital record, the medical record.


              9        Q    So you didn't rely on any medical,


             10    psychiatric or other type of treatises, texts,


             11    manuals, studies, or other materials or authorities


             12    that you used at arriving at your opinion?


             13             DR. KLETTI:  He relied on his training.


             14             MR. GOTTSTEIN:  You are not -- you are not


             15    being deposed here, so you really shouldn't be saying


             16    anything.


             17        A    I didn't refer to any specific text.


             18    However, I based it on the training that I have had


             19    and the texts that I have read.


             20        Q    Do you have a list of those?


             21        A    I could certainly provide one verbally.  I


             22    don't have a written list.  It would be difficult to


             23    provide such a list.


             24        Q    Well, you were ordered to do that by the


             25    court.



                           PACIFIC RIM REPORTING  907/272-4383






              1             I am showing you a copy of the cover page of


              2    the Diagnostic and Statistics Manual of Mental


              3    Disorders, Fourth Edition, Text Revision, DSM-IV-TR.


              4    Are you familiar with that?


              5        A    Yes, sir.


              6        Q    Would you consider that authoritative?


              7        A    Yes, sir.


              8             I should also add something.  I did refer to


              9    the previous chart, as well, sir, the master file, so


             10    to speak, which has a record of Ms. Myers' previous


             11    hospitalizations.


             12        Q    That should have been brought.


             13        A    Indeed.


             14        Q    Could you provide a copy of that, and we'll


             15    mark that as an exhibit.


             16             (Exhibit No. 3 marked.)


             17        A    With my attorney's permission, and the


             18    medical director's permission, I could certainly look


             19    into that, and do my best to provide a copy of that,


             20    if it's agreed upon by my medical director and by my


             21    attorney.


             22             MR. KILLIP:  Yeah, Jim.  My position is I


             23    don't see a problem with that being -- I mean, it's


             24    part of the record for treatment, so I would group


             25    that in.



                           PACIFIC RIM REPORTING  907/272-4383






              1             MR. GOTTSTEIN:  I am entitled to know what


              2    he's basing his opinions on.


              3    BY MR. GOTTSTEIN:


              4        Q    So one of the things that's required is that


              5    you give information to the respondent regarding


              6    medications that you proposed.  Did you bring a copy


              7    of what you provided her with regard to that?


              8             DR. KLETTI:  Where is this?


              9        A    I'm sorry, sir?


             10        Q    It's part of the substance of all


             11    communications to and from the respondent.  But


             12    basically, I can get to it later, and I am about to


             13    get there.  Well, actually, it's a little bit later.


             14             Under AS 47.30.837(d)1-2, before you can seek


             15    court-ordered medication, you have to have given the


             16    patient all information that is material to the


             17    patient's decision to give or withhold consent.  Did


             18    you do that?


             19             DR. KLETTI:  It can be verbally.  It doesn't


             20    have to be in writing.


             21        A    Yes, sir.  It was done verbally.  We did


             22    discuss a number of different medications.


             23             Ms. Myers has in the past taken Navane; she


             24    has taken Zyprexa; she has taken Risperdal.  I


             25    attempted to find out which of these was most



                           PACIFIC RIM REPORTING  907/272-4383






              1    agreeable, that she found most agreeable to her.  And


              2    basically, she indicated she didn't wish to take any


              3    of those medications, that she wished to treat her --


              4    Well, basically she doesn't believe that she has an


              5    illness, but she feels that one can maintain good


              6    mental health by good nutrition.


              7        Q    You should just answer the question.


              8        A    Sorry.


              9        Q    I am showing you a copy of a printout on


             10    Zyprexa.  You are seeking to medicate her with


             11    Zyprexa; is that correct?


             12        A    I have offered her other medications, as


             13    well.


             14        Q    What medication are you seeking the court to


             15    order her to take?


             16        A    My preference would be Zyprexa, yes, sir,


             17    because it has worked for her in the past, yes, sir.


             18        Q    Are you planning on requesting the court to


             19    order any other medication?


             20        A    Generally, my understanding -- perhaps


             21    mistaken, but my understanding is the court generally


             22    provides an order that we can provide medications.  It


             23    doesn't usually specify which one.


             24        Q    Are you refusing to tell me what medications


             25    you might ask the court to order?



                           PACIFIC RIM REPORTING  907/272-4383






              1             MR. KILLIP:  Jim, he's just trying to answer


              2    your question.


              3    BY MR. GOTTSTEIN:


              4        Q    So you don't know at this point?  You are


              5    expecting the court to order you to give her whatever


              6    medications you might choose later?


              7        A    Sir, I did have some discussion with her this


              8    morning in regards to some newer medications that she


              9    hasn't tried.  And perhaps those would be more


             10    agreeable.  She would be perhaps more agreeable to


             11    take those.


             12             She didn't wish to try any of those.  But she


             13    states that she didn't like the effects of Zyprexa.


             14    And I attempted to determine specifically what side


             15    effects she did have, and it wasn't at all clear,


             16    based on our conversation.  However --


             17        Q    I am trying to find out what -- I mean, I am


             18    trying to find out what medications that you might be


             19    requesting the court to order her to take.


             20        A    Well, Zyprexa would be one.


             21             DR. KLETTI:  Counsel --


             22             MR. GOTTSTEIN:  Could you -- Mr. Killip,


             23    could you instruct Dr. Kletti to either not say


             24    anything or to leave the room?


             25             DR. KLETTI:  Well, I think we have the



                           PACIFIC RIM REPORTING  907/272-4383






              1    opportunity to stop and counsel around these questions


              2    if -- you know, if I want to confer.


              3             MR. GOTTSTEIN:  I don't think so.


              4             DR. KLETTI:  We are on opposing sides here.


              5             MR. GOTTSTEIN:  Yeah, but this is my


              6    deposition.  You are not supposed to talk.


              7             Could you please instruct your client to


              8    either not say anything or to leave the room?


              9             DR. KLETTI:  He has the opportunity to confer


             10    with counsel.


             11             MR. GOTTSTEIN:  You don't have the right to


             12    speak now.


             13             MR. KILLIP:  Well, Jim, I mean --


             14             MR. GOTTSTEIN:  You are trying to testify in


             15    his deposition.


             16             DR. KLETTI:  I am trying to object to stop,


             17    so that we can --


             18             MR. GOTTSTEIN:  You don't have the right to


             19    do that.


             20             MR. KILLIP:  Maybe what we should do is, if


             21    it's okay with you, if Dr. Kletti could remain in the


             22    room, and if the question comes up where Dr. Kletti


             23    and Dr. Hanowell want to confer about a certain


             24    question, then --


             25             MR. GOTTSTEIN:  No.



                           PACIFIC RIM REPORTING  907/272-4383






              1             MR. KILLIP:  -- that would be a fast way to


              2    do it.


              3             MR. GOTTSTEIN:  We've got a limit set by the


              4    court.  We should just go through this.  It has


              5    already taken longer than it should.


              6             I am perfectly happy to have him here, but


              7    not participating.  He is not permitted to do that.


              8             DR. KLETTI:  If you truly want answers to,


              9    you know, these questions that you are asking, you


             10    want to move to more germane areas.


             11             MR. GOTTSTEIN:  It is not your decision to


             12    make.


             13             DR. KLETTI:  That's why I am asking for --


             14             MR. GOTTSTEIN:  I am requesting that you


             15    instruct Dr. Kletti to leave the room, please.


             16             MR. KILLIP:  Well, I guess it's your -- If


             17    that's what you want, I mean, then --


             18             MR. GOTTSTEIN:  I have asked repeatedly that


             19    he just remain silent, and he is refusing to do it, so


             20    I don't have any other alternative.


             21             MR. KILLIP:  I guess we would object.  And


             22    then if -- in an effort to try and reach a greater


             23    area of common ground, I guess it's up to Dr. Kletti


             24    about whether he wants to leave.  And then if we have


             25    a question for him, if Dr. Hanowell has a question, we



                           PACIFIC RIM REPORTING  907/272-4383






              1    will try to track him down.  And hopefully, that won't


              2    delay the deposition too long.


              3             MR. GOTTSTEIN:  Fine.


              4             MR. KILLIP:  How do you feel about that?


              5             DR. KLETTI:  If I leave the room, I am going


              6    to ask Mr. Killip to object to every question, and


              7    come out and confer.  I think that your line of


              8    questioning is narrow-minded, biased, and you are


              9    trying to get some kind of answer that suits the "when


             10    did you stop beating your wife" kinds of questions.


             11             MR. GOTTSTEIN:  So earlier, we -- you know,


             12    you mentioned -- when I talked about following the


             13    law, you said that there's a spirit in the letter.


             14    You know, can you explain a little bit more what you


             15    mean by that?


             16             MR. KILLIP:  Jim, I am going to object to


             17    that, because I mean, as you said, Dr. Kletti is not


             18    being deposed.


             19             MR. GOTTSTEIN:  So he gets to talk when he


             20    wants to, but not when I ask him a question?


             21             MR. KILLIP:  Well, the -- we've got four


             22    educated professionals here, and we are acting -- we


             23    are going down a road --


             24             MR. GOTTSTEIN:  I am just trying to find out


             25    what medications he is going to ask the court to order



                           PACIFIC RIM REPORTING  907/272-4383






              1    my client to take.  That's a very basic question.


              2             MR. KILLIP:  I think he's already answered


              3    it.


              4             DR. KLETTI:  Right.


              5    BY MR. GOTTSTEIN:


              6        Q    Is it only Zyprexa?


              7             DR. KLETTI:  If you let me --


              8             MR. GOTTSTEIN:  That's all I was trying to


              9    get.


             10    BY MR. GOTTSTEIN:


             11        Q    Is it only Zyprexa?


             12             DR. KLETTI:  No.  The treatment of


             13    antipsychotic conditions is with antipsychotics.


             14             MR. GOTTSTEIN:  Please leave the room.


             15             MR. KILLIP:  Can we just move on.


             16             Dr. Hanowell can you answer the question,


             17    please?


             18        A    Sir, just to explain, basically, what I would


             19    do, if Ms. Myers were court ordered to take


             20    medications, I would meet with her again and say:


             21    Look, these are the options that are available to you.


             22    I have discussed them with her previously.  Would you


             23    prefer to go back on Zyprexa, or something different


             24    that maybe you might find less objectionable?


             25             So if I seem to --



                           PACIFIC RIM REPORTING  907/272-4383






              1        Q    What was the substance of the information


              2    that you gave Ms.  -- the respondent, regarding


              3    information that is material to the patient's decision


              4    to give her consent?  You said you gave it verbally.


              5    What was it?


              6        A    Yes, sir.  I mentioned to her that she had


              7    benefited -- this is my first discussion with her.


              8    Excuse me, my second discussion with her.


              9             My first discussion with her, she didn't wish


             10    to continue the discussion beyond a very brief time.


             11             My second discussion with her was on Monday.


             12    And I mentioned to her that Zyprexa had helped her in


             13    the past, and that it appeared to -- Going by memory


             14    now.  But it appeared to have been helpful to her, and


             15    that when she left the hospital, she was doing well,


             16    and would she be willing to resume that medication.


             17             She indicated that she would not, that she


             18    was opposed to medication, and that she felt the best


             19    approach to deal with her issues -- although she


             20    doesn't believe she has a mental illness, that the


             21    best way for her to deal with her issues is maintain


             22    good nutrition.


             23        Q    Okay.  So I am going to give you a copy of


             24    the printout.  First off, you would agree, wouldn't


             25    you, that the PDR is authoritative -- the Physician's



                           PACIFIC RIM REPORTING  907/272-4383






              1    Desk Reference is authoritative with respect to


              2    medications; is that correct?


              3        A    Yes, sir.


              4        Q    Could you look at that?  It's a printout from


              5    a CD version of the PDR.  Does that look correct?


              6        A    Yes, sir.


              7             MR. GOTTSTEIN:  Could we mark that as


              8    exhibit --


              9             (Exhibit No. 4 marked.)


             10    BY MR. GOTTSTEIN:


             11        Q    So specifically, then, did you warn her about


             12    neuroleptic malignant syndrome?


             13        A    I did not.


             14        Q    Did you warn her about tardive dyskinesia?


             15        A    I did not, because the discussion didn't get


             16    that far.  She declined to take the medication before


             17    I got to that point.


             18        Q    Did you advise her about somnolence?


             19        A    I believe she brought up the issue that she


             20    had noticed some drowsiness on the medication.


             21        Q    And that wouldn't affect your desire to


             22    forcibly medicate her with that?


             23        A    No.  Because we -- as I mentioned, we have


             24    discussed other medications, as well.  And she has


             25    indicated she is opposed to taking any psychiatric



                           PACIFIC RIM REPORTING  907/272-4383






              1    medication.


              2        Q    Did you warn her that Zyprexa has a potential


              3    to impair judgment, thinking or motor skills?


              4        A    Again, sir, we didn't discuss the side


              5    effects in detail, because she declined to take any


              6    medication.


              7        Q    So basically, you didn't give her any of


              8    these indications -- any of the warnings, and didn't


              9    give her any material about adverse effects; is that


             10    correct?


             11        A    I certainly would have.  Would she have


             12    expressed an openness to taking medication, yes, sir,


             13    I would have done that.


             14        Q    Did you discuss alternative treatments and


             15    their risks, side effects and benefits?


             16        A    Actually, yes.  I mean, we did talk about


             17    alternative medications.  Again, I didn't get to the


             18    point where I could discuss -- have a reasonable


             19    discussion of side effects with her, because she


             20    declined to consider that possibility.  She declined


             21    to consider taking medication.


             22             In terms of further alternative


             23    interventions --


             24        Q    I'm sorry; could you repeat that again?


             25        A    Which part, sir?



                           PACIFIC RIM REPORTING  907/272-4383






              1        Q    The first part that you just said.


              2        A    Well, she -- I didn't get to the point of


              3    discussing side effects with her, because she --


              4        Q    For alternative treatments, we are talking


              5    about.  You talked about alternative treatments.


              6        A    Are you referring to alternative medicine


              7    treatments or --


              8        Q    Alternatives to medication.


              9        A    Alternatives to medication.  We provide that.


             10    We provide alternatives to medication to supplement --


             11    not really alternatives, but we provide interventions


             12    here at this hospital that supplement pharmacotherapy.


             13        Q    So you didn't really provide her with --


             14    discuss alternative treatments to medication?


             15        A    I did -- I didn't discuss those interventions


             16    with her at this hospital in detail.  However, those


             17    have been discussed with her by her nursing staff.  I


             18    have no question of that.  We do provide unit --


             19    provide groups and various activities and so on.


             20        Q    Is that an alternative to medication?


             21        A    In her situation, that would not be an


             22    acceptable -- it would not be adequate treatment for


             23    her illness.


             24             I did talk with her about potentially trying


             25    a low dose of an antipsychotic medication, in



                           PACIFIC RIM REPORTING  907/272-4383






              1    conjunction with fish oil, since she's -- She was


              2    unwilling to consider that.


              3        Q    Now, what was the basis for your deciding


              4    that she was incapable of giving informed consent?


              5        A    Because she does not have insight into her


              6    illness.  She doesn't believe she has an illness.  And


              7    that is generally considered to be a fundamental tenet


              8    of one's ability to give informed consent.


              9        Q    Is that the sole basis?


             10        A    No, sir.


             11        Q    What's the other?


             12        A    There are other considerations, as well,


             13    including a person's recognition of the side effects


             14    of the medication, a person's recognition of -- Well,


             15    the benefits and risks, basically.  Those are two of


             16    the other tenets.  And --


             17        Q    So what -- it seems to me that she recognizes


             18    the benefits and side effects; isn't that true?  She


             19    has taken it before, hasn't she?


             20        A    Well, again, those are two of the tenets of


             21    informed consent.


             22             The third one being -- additional --


             23    additional and crucial one being recognizing that she


             24    has a condition that needs treatment.


             25        Q    So that -- so what I understand -- I am not



                           PACIFIC RIM REPORTING  907/272-4383






              1    trying to put words in your mouth.  I am just trying


              2    to understand what the basis of your decision that she


              3    lacked informed consent was.


              4             So what I understand, from what you are


              5    saying, is that the sole basis was that she lacked


              6    insight into the need for it, or her mental illness?


              7        A    Yes, sir.  You know, often, we have --


              8        Q    You didn't need to say more than yes, sir.


              9        A    Great.


             10        Q    Okay.


             11             MR. KILLIP:  Did you need to explain that?


             12    If you do, then you can go ahead and explain.


             13             THE WITNESS:  That's okay.


             14    BY MR. GOTTSTEIN:


             15        Q    Okay.  You -- is this a copy of the petition


             16    that you signed?


             17        A    Yes, sir, it is.


             18        Q    Let's just let the record reflect -- I don't


             19    want to do it as an exhibit, because I didn't bring


             20    one.  But it's the petition.


             21             And you added No. 3 after it was originally


             22    filed, right?


             23        A    Yes, sir.


             24        Q    I'm sorry for interrupting you.  I am just


             25    kind of pressed for time.  Go ahead.



                           PACIFIC RIM REPORTING  907/272-4383






              1        A    Thank you, sir.


              2             Atypically -- actually, I don't recall ever


              3    having done this before.  But when I made out the


              4    petition, I forgot to add the statement from the -- I


              5    forgot to make reference -- I had checked both boxes:


              6    Danger to self/others, and gravely disabled.  But I


              7    forgot to explain the reason I had checked the box of


              8    danger to self or others, pertaining to danger to self


              9    or others.


             10             In this case, there was a concern about


             11    danger to others, due to reports from the family that


             12    Ms. Myers allegedly made threatening remarks to the


             13    fellow -- excuse me, to her neighbors and to her


             14    landlord.


             15        Q    Do you know the nature of those threats?


             16        A    In talking with the family -- in talking with


             17    the family, there was mention made of a note that was


             18    left on someone's car.  They couldn't tell me the


             19    exact content of the note, but that it was somewhat


             20    threatening in its wording.


             21        Q    Did it threaten bodily harm?


             22        A    I think that was what they had indicated,


             23    yes.


             24             And in addition, one of the petitioners,


             25    Ms. Meyers' daughter, indicated that when she had



                           PACIFIC RIM REPORTING  907/272-4383






              1    interacted with Ms. Myers late last week, Ms. Myers


              2    had been very belligerent, and she was frightened of


              3    her.  She also indicated the other tenants in the


              4    building were frightened of her.


              5        Q    So based on that, are you predicting that if


              6    she wasn't in here, that she would cause harm to these


              7    people?


              8        A    Potentially, yes, sir.


              9        Q    What does potentially mean?  What likelihood?


             10        A    It's difficult for me to put a percentage of


             11    likelihood on it.


             12             However, when I hear about people making


             13    threatening remarks in the community, and when I hear


             14    about patients' own children being frightened -- adult


             15    children being frightened of them, that gives me cause


             16    for concern.


             17        Q    Do you think that someone being frightened is


             18    grounds for confinement here, under the relevant


             19    commitment laws?


             20        A    It depends on the circumstances.  In this


             21    case, the fear was based on the daughter's belief that


             22    she might be assaulted by the patient.


             23        Q    Does Ms. Myers have a -- Strike that.


             24             Have you been trained in predicting future


             25    violence?



                           PACIFIC RIM REPORTING  907/272-4383






              1        A    That's a difficult question to answer.  We


              2    are trained to act when we are aware of potential


              3    violent situations, in terms of going through


              4    proceedings like this one or medicating patients or


              5    referring them to anger management programs.


              6        Q    No, no.  But in terms of are you trained in


              7    predicting who is going to be violent in the future?


              8    Do you have training in that?


              9        A    Only to the extent that my psychiatric


             10    residency addressed that issue.  However --


             11        Q    How did it address that issue, specifically


             12    predicting someone is going to be violent in the


             13    future?


             14        A    We are not able to specifically predict.


             15        Q    Okay.  Now, you marked "gravely disabled."


             16    What does that mean?  What standard do you use to


             17    determine what gravely disabled means?


             18        A    Well, basically, that she is unable to


             19    provide for her basic needs of food, clothing and


             20    shelter.


             21        Q    Is that different than causing harm to


             22    herself?


             23        A    Yes, sir.


             24        Q    How is that different?


             25        A    Danger to self usually implies suicidality or



                           PACIFIC RIM REPORTING  907/272-4383






              1    other willful self-injurious behavior.


              2        Q    Does that mean serious harm?


              3        A    I'm sorry, sir; I don't understand the


              4    question.


              5        Q    I will strike that.


              6             So in other words, some -- you might mark


              7    gravely disabled when you don't think a person is


              8    likely to cause harm to himself or herself or others?


              9        A    Yes, sir.


             10        Q    Okay.  Now, you say that you considered, but


             11    had not found any, less-restrictive alternatives.


             12        A    Yes.


             13        Q    What less-restrictive alternatives did you


             14    consider?


             15        A    Well, that's a difficult question to answer.


             16    Because in this instance --


             17        Q    You signed an affidavit that says you did it,


             18    so you ought to know the answer.


             19        A    Pharmacotherapy --


             20             DR. KLETTI:  Objection.


             21        A    -- is crucial --


             22             MR. KILLIP:  Jim, really, the sarcasm is not


             23    helpful.  This is an intelligent, seasoned


             24    psychiatrist.


             25             MR. GOTTSTEIN:  I apologize, Dr. Hanowell.



                           PACIFIC RIM REPORTING  907/272-4383






              1             MR. KILLIP:  He is trying to be very helpful


              2    and direct.


              3             MR. GOTTSTEIN:  I'm sorry.  You're right.


              4    You are absolutely right.


              5        A    I feel that pharmacotherapy is so crucial to


              6    this patient -- to Ms. Myers' care, that there really


              7    are no currently acceptable alternative --


              8    alternatives to inpatient -- less restrictive


              9    alternatives to inpatient hospitalization.


             10             For example, if she were to go to the Crisis


             11    Treatment Center, and not receive medication, her


             12    illness would not be treated.


             13             If she were to go to Providence on a


             14    voluntary basis, her illness would not be treated.


             15             If she were to be discharged home, without


             16    patient follow-up, her illness would not be treated.


             17             If she were to remain here on a voluntary


             18    basis, and not take medications, her illness would not


             19    be treated adequately.


             20        Q    Are you aware that there is controversy over


             21    the efficacy of the drug treatment regime?


             22        A    I realize that some people have raised that


             23    question, yes, sir.


             24        Q    Including prominent psychiatrists?


             25        A    Some -- well, I think "prominent" would need



                           PACIFIC RIM REPORTING  907/272-4383






              1    to be defined.  But certainly, yes.  And certainly,


              2    the medications we prescribe are not 100 percent


              3    effective by any means; I will acknowledge that.  And


              4    I wish they were more efficacious than they are.


              5        Q    Now, is it your -- would it be your opinion


              6    that the respondent should be on medication for the


              7    rest of her life?


              8        A    That's a difficult question to answer.  I --


              9    I think it may be that she may need to be on


             10    medication for the rest of her life, but I can't see


             11    that far into the future.


             12             There are some cases -- one very famous one


             13    right now is John Nash.  He -- his illness appeared to


             14    go into remission after many, many, many years of


             15    suffering.


             16             So I certainly don't claim to have that kind


             17    of foresight.


             18             I do feel that currently, however, she is in


             19    need of medication.  And it, in my opinion, would be


             20    of great benefit to her over the course of the next


             21    several months to the next year or two.


             22        Q    Are you aware of studies that suggest that an


             23    extremely small percentage of people should be


             24    maintained on neuroleptics indefinitely?


             25        A    I know of clinicians who would recommend that



                           PACIFIC RIM REPORTING  907/272-4383






              1    for some people -- for a number of patients.  I am not


              2    aware of specific articles I could quote regarding


              3    that.


              4        Q    Would that be something that you would be


              5    interested in finding out, in forming your opinion


              6    about medications, what -- you know, what other


              7    studies have shown about what other people should be


              8    maintained on medication?


              9        A    I am always interested and always open to


             10    hearing alternative views, absolutely.


             11        Q    Have you read any studies in that -- in that


             12    line?


             13             MR. KILLIP:  I am going to object.  You are


             14    asking him questions about evidence that is not before


             15    the court.


             16             I mean, if you have got those studies, you


             17    want to show them to Dr. Hanowell for him to look at,


             18    I'm sure he'd be happy to do that.


             19             I think he's answered your question.


             20             MR. GOTTSTEIN:  Actually, I have a bunch of


             21    them, but I didn't bring them all here, because I


             22    didn't figure we'd have time to go through them.


             23    BY MR. GOTTSTEIN:


             24        Q    But the question is:  Have you read any such


             25    studies?



                           PACIFIC RIM REPORTING  907/272-4383






              1        A    Studies regarding the need for --


              2        Q    That suggest a very small percentage, if any,


              3    patient should be maintained long term on


              4    neuroleptics?


              5        A    Sir, I want to apologize.  I misunderstood


              6    your question.  I'm sorry.  I thought the question was


              7    are you aware of studies that suggest that some


              8    patients need to be on medications for the rest of


              9    their life.  I misunderstood your question.  I am


             10    sorry.


             11             So what you actually asked was, was I aware


             12    of studies that suggest that very few patients should


             13    be maintained on medications for the rest of their


             14    lives?


             15        Q    Yes.


             16        A    My apologies.  I am not aware of any specific


             17    studies that I have read that indicate that.


             18             My apologies for misunderstanding your


             19    question.


             20             I haven't read any of those studies, but I


             21    would be interested in reading them.  I certainly have


             22    heard a speaker recently that you are familiar with


             23    who spoke at this hospital who addressed that issue.


             24    I haven't read his book, though.  I have to confess


             25    that I haven't read that.



                           PACIFIC RIM REPORTING  907/272-4383






              1        Q    And that hasn't caused you to read any


              2    studies that might support what he -- his research


              3    shows; is that correct?


              4        A    Not at this point, sir, no.  I haven't had a


              5    chance to -- But if you wish to show me, I would be


              6    very interested in reading them.


              7        Q    You know, actually, maybe I think I will.  I


              8    am going to show you --


              9        A    Thank you.


             10        Q    I assume you haven't read that.


             11        A    No, sir.


             12        Q    Let's mark this as Exhibit 5.


             13             (Exhibit No. 5 marked.)


             14    BY MR. GOTTSTEIN:


             15        Q    Now, do you -- you indicate on the petition


             16    that -- as facts and specific behavior, that Ms. Myers


             17    exhibits clear evidence of a psychotic process?


             18        A    Yes, sir.


             19        Q    Do you believe that justifies confinement?


             20        A    No, sir.  No.  There are many psychotic


             21    patients who do fine in the community, despite the


             22    fact that they're still exhibiting symptoms of their


             23    illness.


             24        Q    Okay.  So that alone is not sufficient to


             25    support confinement, in your view?



                           PACIFIC RIM REPORTING  907/272-4383






              1        A    No, sir.  No, sir.


              2        Q    Okay.  So does that in itself -- is that


              3    enough for -- in your opinion, that Ms. Myers is


              4    mentally ill?


              5        A    That she exhibits evidence of a psychotic


              6    process?


              7        Q    Yeah.  Does that make her mentally ill?


              8        A    In Ms. Myers' case, I believe it does, based


              9    on my review of her records and history, and having


             10    worked with her in the past, a couple of years ago.


             11             But in general, one has to be very careful


             12    about making that determination.  Where we are


             13    actually very compulsive here about doing medical


             14    workups on people who have just presented for the


             15    first time with psychosis.  So one has to be certain


             16    that there's not a medical issue that one is missing.


             17        Q    Okay.  So what causes mental illness?


             18        A    Regrettably, no one knows for sure.


             19        Q    Is it a chemical imbalance in the brain?


             20        A    There appears -- it certainly appears that


             21    there are neurophysiologic changes in the brain of


             22    many, if not most -- if not all individuals who suffer


             23    from mental illnesses such as schizophrenia,


             24    schizoaffective disorder, bipolar disorder.


             25             I'm sorry that --



                           PACIFIC RIM REPORTING  907/272-4383






              1        Q    No, no.  That's a good answer.  What studies


              2    are those?  And the -- I'm sorry.  I shouldn't


              3    interrupt you.


              4        A    I couldn't quote the studies specifically.  I


              5    apologize.  But there are certainly numerous theorists


              6    who believe this to be true.  There is a substantial


              7    amount of research that's been done in this area.


              8             Certainly, dopamine has been implicated as an


              9    important neurotransmitter in the genesis of


             10    psychosis.


             11        Q    But isn't it true there has never been any


             12    proof that dopamine -- that any kind of dopamine


             13    abnormality causes mental illness?  Isn't it true that


             14    that's never been proven?


             15             MR. KILLIP:  Objection, asked and answered.


             16    He already said it hasn't been.  There is no specific


             17    answer for cause of mental illness.  He can elaborate


             18    on that.


             19             MR. GOTTSTEIN:  I am not sure that he did


             20    actually answer that.  And he seemed to change it a


             21    little bit.  That's why I'm asking.


             22        A    There's no proof -- no unequivocal proof that


             23    that's the case.  But it's felt strongly that it may


             24    play a role.  At least -- perhaps not in all


             25    individuals afflicted with schizophrenia, but at least



                           PACIFIC RIM REPORTING  907/272-4383






              1    in some.


              2             Certainly, we do know that the medications


              3    that are efficacious, for the most part, impact the


              4    dopamine system.  So it would be -- it's difficult


              5    to -- I think it would be difficult to ever prove


              6    beyond a shadow of a doubt that dopamine is the answer


              7    to mental illness.


              8             And I don't think anyone would try to prove


              9    that, because it's quite clear to many of the


             10    profession that -- for example, schizophrenia is


             11    probably more a syndrome than an illness.  In other


             12    words, it could be a collection of illnesses rather


             13    than just one illness, myriad causes.


             14        Q    So the neuroleptics don't correct any


             15    chemical imbalance in the brain, do they?


             16        A    It's clear that -- it is clear that they are


             17    efficacious.  They do appear to --


             18        Q    That is not the question.


             19        A    I -- it's a difficult question to answer,


             20    because I am not sure that anyone's -- we do know


             21    that -- we do know what they do.  How should I put


             22    this?


             23             It's -- there are many studies looking at


             24    what they do; however, no one knows for sure exactly


             25    why they work.  No one knows for sure, okay?  So I



                           PACIFIC RIM REPORTING  907/272-4383






              1    guess it's difficult for me to answer that question.


              2             I would probably argue that yes, there is


              3    some.  And obviously, they don't work in everybody.


              4    But I would argue that for many people, there is some


              5    chemical imbalance, if you will, that is brought back


              6    into balance by use of antipsychotic medications, just


              7    based on the fact that they do affect brain chemistry,


              8    and they do for many people work.


              9        Q    Do you have any studies -- can you recite any


             10    studies that support that opinion?


             11             MR. KILLIP:  I would object.  Are you asking


             12    whether he can cite them right now, or can he get you


             13    cites to those studies?


             14             MR. GOTTSTEIN:  Right now.


             15        A    I couldn't recite them.  Sorry.


             16        Q    Are you aware of any studies that support


             17    that?


             18        A    Yes.  Yes.


             19        Q    And -- but you don't know what they are right


             20    now?


             21        A    I couldn't quote the researchers.  I


             22    apologize.


             23        Q    Can you provide that, say, by the end of the


             24    day?


             25        A    I think I could, at least for some of the



                           PACIFIC RIM REPORTING  907/272-4383






              1    medications.  I think I have some files in my


              2    office -- some papers in my office that I could bring.


              3        Q    Great.  Is this the -- well, could you


              4    identify this, please?


              5        A    Sorry, sir.  This is a letter that I wrote to


              6    Mr. Killip yesterday.


              7             MR. GOTTSTEIN:  Let's mark that.


              8             (Exhibit No. 6 marked.)


              9             MR. GOTTSTEIN:  We go to 12:40, I think,


             10    because we started ten minutes late?


             11             MR. KILLIP:  Yes.


             12    BY MR. GOTTSTEIN:


             13        Q    Now, you stated that you've been involved in


             14    more than 100 commitment cases over the years; is that


             15    correct?


             16        A    Yes, sir.


             17        Q    How many are here?


             18        A    Presently, sir?


             19        Q    No.  How many at API?


             20        A    Oh, all at API, sir.


             21        Q    How many forced medication hearings,


             22    approximately?


             23        A    I would -- probably nearly the same number.


             24        Q    How many times have you -- Well, let me put


             25    it this way.  Have you ever sought an informed consent



                           PACIFIC RIM REPORTING  907/272-4383






              1    order when the patient voluntarily accepted


              2    medication?


              3        A    You mean a medication order from the court?


              4        Q    Yes.  In other words, if you suggest


              5    medication, have you ever decided, well, maybe the


              6    person is not really competent to make that decision;


              7    I should ask the court to confirm that?  Have you ever


              8    done that?


              9        A    There have been a few cases, I think, where I


             10    may have done that.  I couldn't quote them for you,


             11    no.


             12        Q    Are you sure that you have?


             13        A    Let me think for a moment.  I am fairly


             14    certain I have done it on a couple of occasions.


             15        Q    Two occasions?


             16        A    I am not certain of the number.  Sorry.


             17        Q    Less than five?


             18        A    Probably less than five, yes, sir.


             19        Q    What were the circumstances that made you do


             20    that?


             21        A    I don't recall.  I'm sorry; I just don't


             22    remember the details.  But I am fairly certain I have


             23    done it on less than five occasions, sir.


             24        Q    So is it fair to say that in 90 -- at least


             25    97 and a half -- I guess that's not a fair way to look



                           PACIFIC RIM REPORTING  907/272-4383






              1    at it.


              2             Is it fair to say that in virtually all


              3    cases, if the person decides to accept the medication,


              4    that that would be considered by you to be informed


              5    consent?


              6        A    I think -- the way I was trained was that in


              7    general -- This is how I was trained in residency, and


              8    it appears to be the way -- the way -- well, anyway.


              9             In residency, I was trained that if a


             10    person -- a person is deemed competent by law until


             11    proven otherwise in a court.


             12             So in general, I kind of -- I rest on that --


             13    that tenet, yes.  I base my prescribing practices on


             14    that tenet.  If someone is psychotic, but is willing


             15    to resume their medication, I see no reason to go


             16    through the -- put the person through the stress of


             17    going through a commitment hearing, when I feel like


             18    I'm doing what they want me to do, anyway.


             19        Q    No, not a commitment hearing.  It's just that


             20    AS 47.30.836 says that you can't administer


             21    psychotropic medication unless the patient has the


             22    capacity to give informed consent.


             23             So I'm just exploring, you know, how that


             24    works in terms of when people consent.  And it sounds


             25    like you automatically -- not automatically, but



                           PACIFIC RIM REPORTING  907/272-4383






              1    virtually automatically assume that if they agree to


              2    it, then they are competent to do so; is that correct?


              3        A    And they would have had to, you know, engage


              4    in some kind of a meaningful discussion with me about


              5    it.


              6             For example, if a person were catatonic and


              7    said -- I wouldn't say to them:  Do you have any


              8    objections to my giving you medicine, and then when


              9    they don't respond, I just prescribe it.  I would


             10    never do that.  I would have to -- situations like


             11    that would probably represent the five or less times


             12    that I went to court.


             13        Q    Situations tantamount to being catatonic?


             14        A    Yeah.


             15        Q    Could you speak up, so she can hear?


             16        A    Yes.  If I may elaborate further, I guess I'd


             17    just say that suppose Mrs. -- just make up a name --


             18    Mrs. Jones comes into the hospital, and she is hearing


             19    voices, she is responding to internal stimuli, but


             20    says to me:  Dr. Hanowell, I really want to go back on


             21    my medication X.  It's really helpful to me.  Can I


             22    please take that?


             23             And I talk to her about the medication, the


             24    side effects, and we resume the medication.


             25    Whether -- I guess I -- it -- I think that in a



                           PACIFIC RIM REPORTING  907/272-4383






              1    situation like that, I am doing what the patient


              2    wants, and I'm assuming that they appear to be making


              3    an informed decision.


              4             I might not perhaps go through an extremely


              5    meticulous process of determining whether or not they


              6    technically meet the criteria of -- I may ask them,


              7    for example, do you -- in a situation like that, they


              8    might not believe that they have schizophrenia or


              9    whatever.  They might believe they are demon possessed


             10    or what have you.


             11             But they feel the medication helps them; they


             12    want to take it.  And I think it would be unfair to


             13    them to put them through the rigors of a commitment


             14    process, for purposes of getting a medication order.


             15        Q    I am not suggesting that you should.  I am


             16    just wondering what it is -- you know, what the


             17    process is.  And I don't necessarily think that you


             18    have to go through a forced medication proceeding to


             19    follow that part of it, anyway.  And I am all in favor


             20    of that.


             21             But if someone disagrees that -- about --


             22    that has decided that they don't want to take the


             23    medication, then what's the process?


             24        A    Well, then you have to go through a more


             25    rigorous process of determining whether or not the



                           PACIFIC RIM REPORTING  907/272-4383






              1    person meets the criteria, whether or not the person


              2    is able to give informed consent.


              3        Q    What percentage of patients would you say


              4    don't give consent -- voluntary consent?


              5        A    I don't know.  I'm sorry.  I can't quote you


              6    a statistic.  I just don't know what it is.


              7        Q    Okay.  Let's say that you have 100 patients


              8    that don't want to consent to the medication.  How


              9    many of those would you seek court-ordered medication


             10    on?


             11        A    It would be difficult to say, because I would


             12    have to look at each case individually.


             13        Q    I am talking about on average.  I mean, if


             14    there are 100 people that -- I mean, have you had 100


             15    people since you have been here that have refused --


             16    or have not voluntarily agreed to medication?


             17        A    Oh, including those that I have gone to court


             18    on and such?


             19        Q    Yeah.


             20        A    Yes, sir.


             21        Q    What percentage of the people that you


             22    don't -- that don't voluntarily agree to the


             23    medication do you go to court on?


             24        A    Well, that's a difficult question to answer,


             25    because on my -- by the time folks come to my unit,



                           PACIFIC RIM REPORTING  907/272-4383






              1    it's usually felt that they are going to need a longer


              2    period of time for treatment.


              3             And usually -- so in other words, there is a


              4    selection process.  There are folks who come into the


              5    Denali Unit, who may exhibit psychotic symptoms and


              6    may refuse treatment, get discharged.  By the time


              7    they transfer to my unit, it is usually agreed upon by


              8    the doctors or Denali that this person is going to be


              9    disabled or presents a danger to themselves or others,


             10    and therefore need treatment and need pharmacotherapy.


             11             So I guess there is a bit of a selection


             12    process.


             13        Q    So is your decision to seek court order based


             14    on whether or not, in your opinion, the person needs


             15    psycho -- the medications, is that -- that needs it,


             16    that the person needs the medication?


             17        A    Well, sure.  That certainly figures into the


             18    equation, absolutely.


             19        Q    Sure.  But what about the informed consent


             20    part?


             21        A    Well, again, that has to be rigorously


             22    assessed.


             23        Q    So --


             24        A    But actually, by the time they come to my


             25    unit, often that already has been rigorously assessed.



                           PACIFIC RIM REPORTING  907/272-4383






              1    And I reassess it when I meet with the patient.


              2        Q    So then what I am hearing from you -- again,


              3    I don't want to put anything into your mouth.  But


              4    what I am hearing is that virtually all the patients


              5    that come to your unit that don't want medication,


              6    you'll seek court-ordered medication.  But that group


              7    has already been kind of selected into that -- into


              8    that kind of a position; is that a fair


              9    characterization?


             10        A    I wouldn't say all patients, no, sir.  I


             11    wouldn't say all patients, no.


             12        Q    So what percent would not be?


             13        A    It would be a low percentage, but I couldn't


             14    give you the exact percentage.


             15        Q    Under 10 percent?


             16        A    Probably under 10 percent, yes, sir.


             17        Q    Under 5 percent?


             18        A    Probably under 5 percent, yes, sir.


             19        Q    You've agreed to provide the chart, and


             20    you've agreed to provide the studies that suggest a


             21    chemical imbalance, the CV.


             22             The respondent hasn't been assaultive on the


             23    unit, has she?


             24        A    No, sir.


             25        Q    I have known the respondent for some time, so



                           PACIFIC RIM REPORTING  907/272-4383






              1    it wouldn't surprise me to hear that she would get


              2    angry fairly quickly and raise her voice.  Does that


              3    happen?


              4        A    Yes, sir.


              5        Q    Was -- are you aware of any instance where


              6    people on the unit were in fear that they would be


              7    assaulted?


              8        A    No, sir.  But she is in a controlled


              9    environment -- excuse me -- a structured environment.


             10        Q    I mean, looking through the notes, it seems


             11    to me that her -- her behavior on the unit, while not


             12    maybe ideal, has not really been anything that would


             13    be considered problematic; would that be a fair


             14    characterization?


             15        A    She is in a structured environment.  However,


             16    she has not presented on the unit as an imminent


             17    danger to herself or others on the unit.


             18        Q    Now, you put on the petition -- or somewhere


             19    in there, I noticed that there are remarks about that


             20    she hasn't bathed recently and has an odor; is that


             21    correct?


             22        A    Yes, sir.


             23        Q    Is that -- in your view, does that support a


             24    conclusion of someone being gravely disabled?


             25        A    I think it helps support that conclusion.  I



                           PACIFIC RIM REPORTING  907/272-4383






              1    don't think in and of itself, it's satisfactory


              2    evidence.  There needs to be more evidence than that.


              3             MR. GOTTSTEIN:  Well, I didn't want to leave


              4    you any time for cross, but I guess I can.  We're


              5    about up, aren't we?  So I'm through.


              6             MR. KILLIP:  Do you object to some questions?


              7             MR. GOTTSTEIN:  Well, for all the time we


              8    have left.  I have an appointment at 1, so we need


              9    to -- I mean, I think we're at the hour now, but I


             10    think we could go for ten minutes.


             11             MR. KILLIP:  I don't think I have too much.


             12                         EXAMINATION


             13    BY MR. KILLIP:


             14        Q    Dr. Hanowell, was there anything that you


             15    want to clarify, any questions?  For example, the


             16    question about the fish oil and alternatives to


             17    treatment.


             18        A    Yeah.  I just -- when I spoke with the


             19    patient this morning, she indicated again her interest


             20    in nutrition.


             21             And I offered to her the possibility that we


             22    could try perhaps a lower dose of Zyprexa, in


             23    conjunction with Omega-3 fish oil.  Omega-3 fatty acid


             24    supplements have been shown to be -- very few, but


             25    have been shown at times, in a small percentage of



                           PACIFIC RIM REPORTING  907/272-4383






              1    patients, to be helpful in terms of addressing


              2    psychosis.


              3             Unfortunately, they're not -- I wish they


              4    were more efficacious than they seem to be.  But I was


              5    willing to give that a try.


              6             I offered the patient to get an opportunity


              7    to work with me on a voluntary basis, and she


              8    declined.  In terms of participating in


              9    pharmacotherapy at a lower dosage of Zyprexa or some


             10    alternative antipsychotic medication, in conjunction


             11    with Omega-3 fish oil.  Again, she declined.


             12             But I was attempting to respond to her


             13    interest in nutritional interventions in addressing


             14    her health.  I don't think that she -- she would not


             15    agree that she has a mental illness, but I think she


             16    feels that she has an interest in nutrition in terms


             17    of her health.


             18        Q    About approximately how many times have you


             19    testified as an expert in psychiatry in connection


             20    with cases like this?


             21        A    More than 100 times.


             22        Q    What is your -- what is your as-recommended


             23    treatment plan for her?


             24        A    I would continue her on an inpatient basis


             25    for the time being, with routine group activities.



                           PACIFIC RIM REPORTING  907/272-4383






              1             She is concerned about nutrition, and


              2    certainly, her nutritional concerns would be addressed


              3    on our unit by our cafeteria.  And part of her


              4    treatment will of course -- would ideally involve


              5    pharmacotherapy.


              6        Q    And what is your -- what is the present


              7    diagnosis for her?


              8        A    Schizophrenia, paranoid type.


              9        Q    Based on the cases that you have handled over


             10    the years and your expertise, where would -- what is


             11    your best evaluation of where she fits, I guess, on


             12    the severity of that diagnosis?  I mean, how bad does


             13    she need to be at API?


             14        A    I'd say she'd be at the far end of the


             15    spectrum, in terms of severity.  She would be


             16    experiencing severe symptoms of her mental illness at


             17    this juncture.


             18        Q    Okay.  And as far as treatment options go,


             19    could you describe the treatment options?  Like, what


             20    are the realistic treatment options for her at this


             21    time?


             22        A    You mean in terms of the different


             23    medications or in terms of --


             24        Q    Yeah.  Placement, medications.


             25        A    I feel that the only -- regrettably, the only



                           PACIFIC RIM REPORTING  907/272-4383






              1    realistic treatment option for her at this juncture,


              2    to ensure that -- I feel that at this time, the only


              3    realistic treatment option for her is treatment on


              4    Susitna Unit, in the patient mental health unit,


              5    with -- regrettably, with a court order for


              6    medications on commitment status.


              7             I would much prefer that she participate in


              8    treatment on a voluntary basis, but that clearly isn't


              9    possible at this juncture, and clearly isn't her


             10    preference at this juncture.


             11        Q    Okay.  And what is your best guess as to how


             12    long she'll have to be at API?


             13        A    It's always a really difficult question to


             14    answer.


             15             Her previous hospitalization lasted somewhere


             16    in the neighborhood of a month, I believe.  I don't


             17    have her old chart, but I think she was here more than


             18    a month.  So it unfortunately did take her a while to


             19    get better.


             20        Q    Where do you see her going after API,


             21    assuming that her condition improves and API feels


             22    that it is appropriate for her to be released, or she


             23    is released?


             24        A    There were -- although there was report from


             25    the family that she was in danger of being evicted, it



                           PACIFIC RIM REPORTING  907/272-4383






              1    doesn't appear that she has in fact been evicted at


              2    this juncture.  She probably could return to her home,


              3    or perhaps have a period of transition through the


              4    Crisis Treatment Center before returning home.


              5        Q    And could you describe API's efforts and


              6    continued commitment to working with the family to try


              7    and help Ms. Myers get out of API and succeed outside


              8    of API?


              9        A    Yes.  Family contact and family involvement


             10    is always our preference.


             11             I attempted to -- to facilitate that, I


             12    attempted to get a release for information from


             13    Ms. Myers, which she didn't wish to sign.


             14             However, it has always been a preference to


             15    have family involved in treatment planning and a


             16    discharge plan.  I find it not only -- well, I find it


             17    useful, very useful.


             18        Q    Then concerning the studies that have been


             19    referenced in your testimony, do you find it unusual


             20    for somebody in your position to appear at a


             21    deposition and not have a list of studies memorized,


             22    to be able to just provide to somebody upon request


             23    verbally on an immediate basis?


             24        A    I -- I'm sorry, sir.  I apologize.  Did you


             25    say do I find it unusual or --



                           PACIFIC RIM REPORTING  907/272-4383






              1        Q    Yeah.


              2        A    Yes, it would be unusual to expect someone to


              3    be able to recite a list of such studies, or at least


              4    to expect me to.  I would have difficulty doing that.


              5             I could certainly find those studies in my


              6    files and refer to them, but I don't have them


              7    memorized.


              8        Q    Okay.


              9             MR. KILLIP:  That's all I've got.


             10                       RE-EXAMINATION


             11    BY MR. GOTTSTEIN:


             12        Q    How many of these depositions have you


             13    attended, a deposition like this?


             14        A    This is the first.


             15             MR. GOTTSTEIN:  That's it.


             16             (Exhibit No. 7 marked.)


             17             (Proceedings concluded at 12:47 P.M.)


             18             (Signature waived.)


             19                           -o0o-















                           PACIFIC RIM REPORTING  907/272-4383






              1                         CERTIFICATE




              3           I, JEANETTE BLALOCK, Certified Shorthand


              4    Reporter and Notary Public in and for the State of


              5    Alaska, do hereby certify that the witness in the


              6    foregoing proceedings was duly sworn; that the


              7    proceedings were then taken before me at the time


              8    and place herein set forth; that the testimony


              9    and proceedings were reported stenographically by


             10    me and later transcribed by computer transcription;


             11    that the foregoing is a true record of the


             12    testimony and proceedings taken at that time;


             13    and that I am not a party to nor have I any


             14    interest in the outcome of the action herein


             15    contained.


             16           IN WITNESS WHEREOF, I have hereunto set


             17    my hand and affixed my seal this ________ day


             18    of _______________________ 2003.






             21                            ______________________________

                                           JEANETTE BLALOCK

             22                            My Commission Expires 6/25/03









                           PACIFIC RIM REPORTING  907/272-4383