PUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
UNITED STATES OF AMERICA,
Plaintiff-Appellee,
v. No. 07-4131
PHILIP A. HOLMAN,
Defendant-Appellant.
UNITED STATES OF AMERICA,
Plaintiff-Appellee,
v. No. 07-4132
PHILIP A. HOLMAN,
Defendant-Appellant.
Appeals from the United States District Court
for the Eastern District of Virginia, at Norfolk.
Henry Coke Morgan, Jr., Senior District Judge.
(2:93-cr-00036-JCC; 2:95-cr-00198-HCM)
Argued: March 21, 2008
Decided: July 7, 2008
Before MOTZ, TRAXLER, and DUNCAN, Circuit Judges.
Affirmed by published opinion. Judge Traxler wrote the opinion, in
which Judge Motz and Judge Duncan joined.
2 UNITED STATES v. HOLMAN
COUNSEL
ARGUED: Joseph Barry McCracken, Norfolk, Virginia, for Appel-
lant. Laura Marie Everhart, OFFICE OF THE UNITED STATES
ATTORNEY, Norfolk, Virginia, for Appellee. ON BRIEF: Chuck
Rosenberg, United States Attorney, Alexandria, Virginia, for Appel-
lee.
OPINION
TRAXLER, Circuit Judge:
After Philip Holman was released from prison and began serving
his term of supervised release, the district court at the government’s
request imposed as a special condition of supervised release a require-
ment that Holman participate in mental health treatment and take all
prescribed medication, including intramuscular injections of an anti-
psychotic drug. Holman appeals, arguing that requiring him to submit
to the intramuscular injections violates his constitutionally protected
liberty interest in "avoiding the unwanted administration of antipsy-
chotic drugs." Washington v. Harper, 494 U.S. 210, 221 (1990). We
find no error, and we therefore affirm the district court’s imposition
of the special condition of supervised release.
I.
Holman pleaded guilty to various drugs and weapons charges in
1993 and 1996. Shortly after he began serving the sentence on the
1993 charges, Holman began exhibiting symptoms of serious mental
illness, and he was eventually diagnosed as suffering from schizoaf-
fective disorder, bipolar type.
During his time in prison, Holman cycled between cooperating
with his psychiatric treatment plan and voluntarily taking the pre-
scribed oral antipsychotic medication and refusing to cooperate with
treatment or take his medication. These periods of refusal led to a
recurrence of his symptoms and manic or depressive psychotic epi-
UNITED STATES v. HOLMAN 3
sodes. In 1997, after Holman again began refusing to take his medica-
tion, he was involuntarily committed to a psychiatric prison facility.
In July 2003, after several months of Holman refusing then agree-
ing then refusing to take the prescribed oral medication, prison offi-
cials convened an "Involuntary Medication Hearing" and received
permission to administer antipsychotic medication to Holman despite
his objections. By late 2003, Holman’s mental condition was deterio-
rating. He was again refusing to take his medication, and he began
threatening to kill himself and prison staff members. On January 14,
2004, "[a]fter a staff show of force," Holman "reluctantly accepted"
an injection of long-acting risperidone, an antipsychotic medication.
J.A. 179. Holman continued to receive injections of risperidone, along
with other oral medications, until September 2004, when he was
released after serving his prison term.
When he was released, Holman’s prison psychiatrist provided him
with a supply of oral risperidone. In a memo to Holman outlining his
condition and treatment needs, the psychiatrist noted that future treat-
ment decisions would be made by local mental health providers, but
recommended that Holman continue the risperidone injections, "to
prevent [Holman] from succumbing to the temptation to stop taking
the tablets." J.A. 174. Upon release from prison, Holman received
psychiatric care through the Community Services Board in Chesa-
peake, Virginia. His treating psychiatrist continued Holman on the
oral risperidone, but at higher dosage than had been prescribed while
Holman was in prison.
The conditions of supervised release imposed when Holman was
sentenced did not require him to seek mental health treatment. In
November 2004, Holman’s probation officer filed a petition with the
district court requesting a hearing to determine whether the conditions
of supervised release should be modified to include a requirement that
Holman receive mental health care and take all prescribed medication.
The district court held the hearing in February 2005 and, in March
2005, issued an order imposing as a special condition of supervised
release a requirement that Holman comply with his mental health
treatment plan and take all prescribed medication. The order specifi-
cally required the use of intramuscular injections of risperidone, as
recommended by Holman’s prison psychiatrist.
4 UNITED STATES v. HOLMAN
In late February 2005, after the hearing but before the issuance of
the district court’s order, Holman disappeared. He left his home with-
out his medication, had no contact with his family, and missed several
appointments with his probation officer. Holman was arrested several
weeks later, after he was found wandering aimlessly and in a partially
catatonic state. Several months later, after treatment and medication
had stabilized his condition and he was deemed competent, Holman
was brought before the district court to answer for the violation of the
terms of his supervised release. The district court sentenced Holman
to eleven months imprisonment, to be followed by a forty-nine-month
term of supervised release. The district court re-imposed all prior spe-
cial conditions of supervised release, including the requirement that
Holman receive intramuscular injections of risperidone.
By June 2006, just a few months after he was released from prison,
Holman had again violated the terms of his supervised release by
refusing to take his prescribed medication. His probation officer filed
another petition alleging a violation of the conditions of supervised
release, and Holman was arrested. The court found Holman to be
incompetent and he was committed for evaluation and treatment. In
January 2007, after treatment and medication restored him to compe-
tency, Holman appeared before the district court. The district court
sentenced him to twelve months imprisonment to be followed by
thirty-seven months of supervised release with the same conditions
previously imposed.
Holman now appeals the sentence, challenging the special condi-
tion of supervised release imposed by the district court.1 While Hol-
man does not object to the requirement that he receive mental health
1
In United States v. Johnson, 138 F.3d 115 (4th Cir. 1998), we held
that when a condition of supervised release was imposed as part of the
defendant’s original sentence, the condition could not be challenged in
an appeal from an order revoking the defendant’s supervised release, but
must instead be challenged on direct appeal from the original conviction
and sentence. See id. at 117-18. In the present case, the challenged spe-
cial condition was not a part of Holman’s original sentence, and the spe-
cial condition was imposed anew in 2005 and 2006 after Holman
violated the conditions of supervised release. Holman’s appeal is there-
fore timely.
UNITED STATES v. HOLMAN 5
treatment, nor to the general requirement that he take antipsychotic
medication, he does object to the requirement that he take antipsycho-
tic drugs by way of intramuscular injections. Antipsychotic
medications generally have the potential for severe or even fatal side
effects2; for Holman, the side effects of the injectable medications are
more significant and unpleasant than those of oral medications. Hol-
man argues that the government failed to establish that the injections
were medically necessary and that no less intrusive alternative would
suffice, and Holman therefore argues that the special condition of
supervised release imposed by the district court violates his constitu-
tionally protected liberty interest in refusing the unwanted injections.
II.
District courts are required to impose certain conditions with every
term of supervised release and are permitted to impose other appropri-
ate conditions. See 18 U.S.C.A. § 3583(d) (West 2000 & Supp. 2008).
A district court may impose any appropriate non-mandatory condition
of supervised release if the condition
(1) is reasonably related to the factors set forth in [18
U.S.C.A. §] 3553(a)(1), (a)(2)(B), (a)(2)(C), and (a)(2)(D);
2
The Supreme Court has explained the side effects of antipsychotic
medications:
The purpose of the drugs is to alter the chemical balance in a
patient’s brain, leading to changes, intended to be beneficial, in
his or her cognitive processes. . . . While the therapeutic benefits
of antipsychotic drugs are well documented, it is also true that
the drugs can have serious, even fatal, side effects. One such side
effect . . . is acute dystonia, a severe involuntary spasm of the
upper body, tongue, throat, or eyes. . . . Other side effects
include akathesia (motor restlessness, often characterized by an
inability to sit still); neuroleptic malignant syndrome (a relatively
rare condition which can lead to death from cardiac dysfunc-
tion); and tardive dyskinesia, perhaps the most discussed side
effect of antipsychotic drugs. . . . Tardive dyskinesia is a neuro-
logical disorder, irreversible in some cases, that is characterized
by involuntary, uncontrollable movements of various muscles,
especially around the face.
Washington v. Harper, 494 U.S. 210, 229-30 (1990).
6 UNITED STATES v. HOLMAN
(2) involves no greater deprivation of liberty than is rea-
sonably necessary for the purposes set forth in section
3553(a)(2)(B), (a)(2)(C), and (a)(2)(D); and
(3) is consistent with any pertinent policy statements
issued by the Sentencing Commission pursuant to 28 U.S.C.
994(a).
Id. The § 3553(a) factors referred to in subsection (d)(1) are: the
defendant’s history and characteristics, and the nature and circum-
stances of the offense for which the defendant was convicted; see 18
U.S.C.A. § 3553(a)(1) (West 2000 & Supp. 2008); the need for ade-
quate deterrence, see id. § (a)(2)(B); the need to protect the public
from further crimes, id. § (a)(2)(C); and the need to provide the defen-
dant in the most effective manner with necessary medical care, voca-
tional or educational training, or other correctional treatment, see id.
§ (a)(2)(D); see also United States v. Dotson, 324 F.3d 256, 260 (4th
Cir. 2003).
District courts "have broad latitude" with regard to special condi-
tions of supervised release, and we review the court’s decision to
impose a condition of supervised release for an abuse of discretion.
See Dotson, 324 F.3d at 259, 260.
The government argues that the special condition imposed by the
district court satisfies the statutory requirements set forth in
§ 3583(d). The government notes that Holman’s history establishes
that he suffers from a mental illness that is well controlled with medi-
cation. When Holman is off his medication, however, he may exhibit
violent behavior towards others and put his own health and safety at
risk. The government therefore contends that the medication require-
ment is reasonably related to the need to protect the public and the
need to effectively provide Holman with the proper medical care. And
because Holman has consistently demonstrated his inability to comply
with a treatment plan centered on oral medication, the requirement
that he take the medication by way of injection is the least intrusive
way of furthering these important governmental purposes. The gov-
ernment therefore contends that the district court properly required as
a special condition of supervised release that Holman receive injec-
tions of prescribed antipsychotic medication.
UNITED STATES v. HOLMAN 7
Holman, however, suggests that our inquiry should not be limited
to an application of § 3583(d)’s requirements that the special condi-
tion be reasonably related to a sentencing purpose and be no greater
a deprivation of liberty than is reasonably necessary to further that
purpose. The special condition at issue in this case implicates Hol-
man’s fundamental liberty interest in refusing to take medications that
substantially change his personality and carry a significant risk of
dangerous side-effects. Holman thus contends that the nature of the
interest affected by the special condition requires us to scrutinize with
more care the district court’s decision to impose the condition.
A.
The Supreme Court has made it clear that under the Due Process
Clauses of the Fifth and Fourteenth Amendments, individuals (includ-
ing pre-trial detainees and convicted criminals) have "a constitution-
ally protected liberty interest in avoiding involuntary administration
of antipsychotic drugs—an interest that only an essential or overrid-
ing [governmental] interest might overcome." Sell v. United States,
539 U.S. 166, 178-79 (2003) (internal quotation marks omitted); see
also Washington v. Harper, 494 U.S. 210, 221-22 (1990) ("We have
no doubt that . . . respondent possesses a significant liberty interest
in avoiding the unwanted administration of antipsychotic drugs under
the Due Process Clause of the Fourteenth Amendment."). Among the
governmental interests that in a given case may be sufficiently impor-
tant to support an order for involuntary medication are the need to
protect the individual and others from the individual’s potentially
dangerous behavior, see Riggins v. Nevada, 504 U.S. 127, 134-35
(1992); Harper, 494 U.S. at 225-26; and the government’s interest in
rendering a criminal defendant competent to stand trial, see Sell, 539
U.S. at 179-80.
In general terms, an involuntary-medication order is constitution-
ally impermissible "absent a finding of overriding justification and a
determination of medical appropriateness." Riggins, 504 U.S. at 135.
The showing necessary to satisfy these requirements, however differs
depending on the context and reasons underlying the order. See
United States v. Baldovinos, 434 F.3d 233, 240-41 (4th Cir. 2006);
United States v. Evans, 404 F.3d 227, 235 n.3 (4th Cir. 2005). If the
involuntary-medication order is premised on the individual’s danger-
8 UNITED STATES v. HOLMAN
ousness (to himself or the public), the government can satisfy the due-
process inquiry by demonstrating that "treatment with antipsychotic
medication [is] medically appropriate and, considering less intrusive
alternatives, essential for the sake of [the individual’s] own safety or
the safety of others." Riggins, 504 U.S. at 135; see Harper, 494 U.S.
at 225-26. In cases where the order is not premised on the individual’s
dangerousness, however, the inquiry is governed by the analysis set
forth in Sell. See Baldovinos, 434 F.3d at 240-41. In such a case, the
government must demonstrate that, in light of the individual facts of
the case, its interest in bringing the individual to trial is sufficiently
important. See Sell, 539 U.S. at 180 ("Special circumstances may
lessen the importance of [the interest in trying a defendant accused of
a serious crime]. The defendant’s failure to take drugs voluntarily, for
example, may mean lengthy confinement in an institution for the
mentally ill—and that would diminish the risks that ordinarily attach
to freeing without punishment one who has committed a serious
crime. . . . And it may be difficult or impossible to try a defendant
who regains competence after years of commitment during which
memories may fade and evidence may be lost. The potential for future
confinement affects, but does not totally undermine, the strength of
the need for prosecution."). The government must also establish that
the involuntary-medication order will "significantly further" its inter-
est, by demonstrating that "administration of the drugs is substantially
likely to render the defendant competent to stand trial" but yet "sub-
stantially unlikely to have side effects that will interfere significantly
with the defendant’s ability to assist counsel in conducting a trial
defense." Id. at 181.
The standards set forth by the Supreme Court for determining
whether an involuntary medication order is constitutionally
permissible—particularly as those standards were applied in Sell—
arguably are more demanding (at least in formulation, if not applica-
tion) than the statutory provisions generally governing conditions of
supervised release. Sell requires such an order to significantly further
a compelling governmental interest, while § 3583(d) requires only a
reasonable relationship to one of several specified sentencing goals.
Moreover, the statute seems to demand a looser fit between the spe-
cial condition and the sentencing goal — § 3583(d)(2) requires only
that the condition of supervised release be no more restrictive than
reasonably necessary to further the sentencing goal, while Sell
UNITED STATES v. HOLMAN 9
requires that there be no less intrusive means of treatment that likely
will achieve substantially the same results.
There is some question as to whether the Harper-Riggins-Sell con-
stitutional analysis supplants or supplements the statutory require-
ments set forth in § 3583(d). See United States v. Williams, 356 F.3d
1045, 1056-57 (9th Cir. 2004) (applying § 3583(d) factors to review
of involuntary medication order imposed as condition of supervised
release, but requiring district court to make "explicit, specific find-
ing[s]" based on evidence reflected in "a medically-informed
record"); United States v. Schave, 186 F.3d 839, 843 (7th Cir. 1999)
("[A] court will not strike down conditions of [supervised] release,
even if they implicate fundamental rights, if such conditions are rea-
sonably related to the ends of rehabilitation and protection of the pub-
lic from recidivism."); United States v. Wilson, 154 F.3d 658, 667
(7th Cir. 1998) (applying § 3853(d) factors and concluding that the
district court did not abuse its discretion by requiring as a condition
of supervised release that the defendant participate in a mental health
treatment program and take all required medications). But see United
States v. Myers, 426 F.3d 117, 125-26 (2d Cir. 2005) (explaining that
in cases where the challenged condition of supervised release impli-
cates "a fundamental liberty interest protected by due process," the
reviewing court’s application of the § 3583(d) factors "must reflect
the heightened constitutional concerns. If the liberty interest at stake
is fundamental, a deprivation of that liberty is ‘reasonably necessary’
only if the deprivation is narrowly tailored to serve a compelling gov-
ernment interest."). In this case, however, there is no need for us to
answer that question, because the special condition of supervised
release was properly imposed in this case even when analyzed under
the framework set out in Harper and Sell.
B.
The district court imposed the involuntary-medication condition in
order to protect Holman himself and to protect the general public, and
the record clearly supports the district court’s determination that Hol-
man is a danger to himself and others when off his medication. Hol-
man had several episodes of violent behavior while he was in prison,
episodes that happened only during periods when he refused to take
his medication. Holman made threats against his prison psychiatrist
10 UNITED STATES v. HOLMAN
and other prison staffers and threatened to commit suicide, actions
that again happened only during periods when he was refusing to take
the prescribed oral medication. The first time after his release from
prison that Holman quit taking his medication and vanished, he was
found several weeks later, "disoriented, disheveled, and partially cata-
tonic," J.A. 197, which further demonstrates the danger Holman poses
to himself when off his medication. The government’s interest in pro-
tecting Holman from himself and protecting the general public from
Holman are essential or overriding interests sufficient to support an
order requiring the involuntary administration of antipsychotic drugs.
See Sell, 539 U.S. at 179; Harper, 494 U.S. at 225-26.
The evidence establishing Holman’s dangerousness also establishes
that the district court’s order was narrowly tailored to the circum-
stances of this case. As the district court noted, Holman became a
danger to himself and others when he was off his medication, and
injections of long-lasting antipsychotic drugs provide the only means
of insuring that Holman takes his medication. The special condition
of supervised release thus significantly furthers and is clearly neces-
sary to further the government’s interests in protecting Holman and
the public. See Sell, 539 U.S. at 181 (explaining that an order to invol-
untarily medicate an individual must "significantly further" overriding
governmental interests and must be "necessary to further those inter-
ests" and that involuntary medication may be necessary if "any alter-
native, less intrusive treatments are unlikely to achieve substantially
the same results").
Finally, the record establishes that the involuntary-medication
requirement is medically appropriate. Prison officials generally were
required to use injections to stabilize Holman’s condition once he quit
taking his oral medications, and Holman’s prison psychiatrist
believed that the long-lasting injections were his best treatment
option, in part because the injections helped prevent Holman from
"succumbing to the temptation" to stop taking medication. J.A. 174.
Given Holman’s "absolute dependence on medication to maintain his
mental health," J.A. 80, and his inability to comply with his treatment
plan when on oral medication, we have no difficulty concluding that
the special condition requiring Holman to take the required antipsy-
chotic drugs by way of intramuscular injections was medically neces-
sary.
UNITED STATES v. HOLMAN 11
We therefore conclude the district court’s decision to require intra-
muscular injections of antipsychotic medications as a special condi-
tion of supervised release was consistent with the due-process
requirements set out by the Supreme Court in Harper and Sell. And
because the due-process standards are, if anything, more demanding
than the statutory requirements, it follows that the special condition
likewise complies with § 3583(d). The special condition is reasonably
related to the need to protect the public and the need to provide the
defendant with appropriate medical care, see 18 U.S.C.A. § 3583(d);
Dotson, 324 F.3d at 260, and the involuntary medication order
involves no greater deprivation of liberty than is reasonably necessary
to further these governmental interests.
III.
Accordingly, for the foregoing reasons, we hereby affirm the dis-
trict court’s decision to require intramuscular injections of antipsy-
chotic medications as a special condition of Holman’s term of
supervised release.
AFFIRMED