Loughner's mental health treatment extended 4 months

Accused mass shooter Jared Lee Loughner must spend another four months in a federal prison hospital as doctors work to make him fit to stand trial, a judge ruled Wednesday evening.

"He understands that he's murdered people," a prison doctor testified, and no longer believes that U.S. Rep. Gabrielle Giffords was killed in the shooting rampage.

Loughner, charged with killing six and wounding 13 others, including Giffords, on Jan. 8, will continue to be involuntarily medicated at the Springfield, Mo., facility, ruled U.S. District Judge Larry Burns.

Loughner has refused to voluntarily take prescribed psychtropic drugs, but acquiesces and takes oral medication when informed that prison officials will otherwise forcibly inject the drugs. He was been taking the drugs for nine weeks, after prison officials were ordered by the court to stop for nearly three weeks in July.

Prison officials have determined in non-judicial hearings that Loughner is a danger to himself, and he remains on a suicide watch that was imposed July 8.

The drugs, including the anti-psychotic Risperidone, antidepressant Wellbutrin and sedative Lorazepam, have increased Loughner's functioning, testified prison psychologist Dr. Christina Pietz.

There is a "substantial probability" that Loughner will be restored to competence and be able to stand trial with more treatment, Burns ruled, after hearing testimony from a prison psychologist and an expert witness.

Burns determined in May that Loughner was not capable of cooperating with his lawyers or understanding the trial.

"Measurable progress toward restoration (of competence) has been made," Burns said in announcing his decision.

The judge noted that Loughner's demeanor was changed from his previous appearances in court.

"The smirk is gone," Burns said, saying the the defendant "appears to be paying attention" to court proceedings.

The last time Burns and Loughner were in a Tucson courtroom, an outburst by Loughner caused U.S. marshals to remove him from the room.

Loughner sat quietly during Wednesday's nearly eight-hour hearing, sometimes slowly swiveling side-to-side in his chair at the defense table. He was mostly expressionless, only blinking occasionally.

Both his prison psychologist and Burns remarked on his changed appearance. He requested a haircut and that his fingernails be trimmed for the hearing, Pietz testified.

His hair is now closely cropped, and he was clean-shaven. Loughner wore a baggy white t-shirt above khaki pants. He wore handcuffs attached to a waist chain, and his steps were slowed to a shuffle by ankle chains.

The hearing started slightly earlier than scheduled, at 10:55 a.m., and lasted until after sunset, with just two 15-minute breaks.

Remorseful

Loughner is aware that he killed six people, Pietz testified, and he has shown remorse for his actions.

"He understands that he's murdered people," she told the court. "He talks about it. He talks about how remorseful he is."

Loughner no longer believes that Giffords died in the shooting.

"He now believes that she's alive," Pietz said.

Loughner has been shown a surveillance video that captured the shooting spree, though he has said it was edited by either law enforcement or his attorneys, or is a re-enactment, Pietz told the court.

Loughner remains on suicide watch, separated from other inmates. Antidepressants may never resolve his depression, Pietz said. "He feels guilty, and I'm not sure medication is going to help him with that."

He likely suffered from undiagnosed schizophrenia for several years before the Jan. 8 shooting incident, Pietz said.

Dr. Samuel Ballenger, an expert witness called by prosecutors, testified that Loughner was diagnosed with depression at some point in the past.

Ballenger, a psychiatrist who specializes in schizophrenia, said Loughner would "inevitably relapse" if the anti-psychotic drugs were stopped.

"He was devastated," when told of his diagnosis, Pietz said. "He didn't want to be mentally ill."

Loughner later told Pietz "he thought ... he had been mentally ill for some time," she testified.

Defense argued against meds

Trying to halt the forced medication, defense attorneys maintain the government hasn't proven that Loughner can be restored to competency and go to trial.

While prosecutors asked for an eight-month extension, attorneys for Loughner have repeatedly argued against the involuntary medication.

They have repeatedly asked Burns to hold a hearing to determine if Loughner should be forcibly drugged to restore him to competency, holding that the extra-judicial hearings on the question by prison officials have violated his due process rights.

Wednesday, Loughner's lawyers argued that the drugs may in fact have made him worse.

"Rather than just being psychotic — Mr. Loughner's mental state at the end of May 2011 — he is now also severely depressed, tearful, restless, agitated and psychotic," lead attorney Judy Clarke wrote in a court filing.

"All I can tell you today is he's been better since he's been medicated," Pietz said on the stand.

Loughner, who recently turned 23, was recently provided with photos of his pet dogs and turtles, and discussed them with Pietz.

He visited with his parents on Tuesday, after being transported from Missouri.

Medication has quelled his visual and auditory hallucinations, she said. He now makes eye contact more frequently and no longer has an "inappropriate smile," she said.

"If we take him off medications, it is our belief that he will deteriorate and potentially die" because he's suicidal, Pietz said.

But Loughner is not now competent to stand trail, she said.

"In my opinion he's still delusional," she said.

It may take up to eight more months for him to be able to face trial, she said.

"Today, in my lay view, he does appear to be more connected to the proceedings," Burns said as he ordered another hearing in January to assess Loughner's progress.

The judge said he wants to see "measurable progress, more than I've seen here today," at that hearing.

In a lengthy cross-examination, Clarke questioned whether Loughner has truly improved because of the medication.

In court, Loughner was "expressionless" and "sedated," Clarke said.

"He doesn't appear to be there," she said.

Clarke pointed to notes make by Pietz and other prison staffers that pointed toward Loughner's continued mental illness.

In a Sept. 17 incident, Loughner, on wakening, complained to a prison doctor that he couldn't see. The doctor pointed out to Loughner that his eyes were still closed.

In one sharp exchange, Pietz told Clarke, "You're putting words in my mouth."

"You don't think he would get it, do you?" Clarke asked, questioning Loughner's ability to understand the hearing.

Clarke and Pietz sparred over the psychologist's practice of not documenting the details of every conversation she has with Loughner.

"So we're left to your memory" regarding some discussions Pietz testified about, Clarke said.

"I think I have integrity," Pietz said.

"I don't know that his thinking is organized enough that he's reached competence," Pietz testified at one point.

Loughner suicidal

Implicitly backing the decision to forcibly medicate Loughner, Pietz described him as still possibly suicidal.

An undated note in which Loughner threatened to "hang himself" was recently found in his cell, she testified.

During the period in July when Loughner went unmedicated, his condition deteriorated, she said.

Pietz described a Loughner who was awake for up to 50 hours at a stretch, pacing so much that a blister on his foot became infected — an infection that spread up his leg.

Loughner refused an antibiotic to fight the infection which Pietz said was moving "towards his knee." Prison doctors eventually forcibly injected him, she said.

Loughner's expression remained flat throughout the hearing as Pietz and Ballenger testified about his condition.

Pietz described his behavior when not on the medications as "hypersexual," including penetrating himself with his fingers and a plastic spork, and smearing feces on his bedding and clothes.

Loughner told Pietz that he has "imaginary friends," she said.

At one point, his weight shifted as much as five pounds in one day, Pietz said.

Loughner was frequently "sobbing uncontrollably" during the July period he went without medication, she said.

"He told staff he wanted to die, that he intended to commit suicide," she said.

"He clearly told his father that he wanted to commit suicide" during a phone call, she said.

Loughner is "passively cooperative" when told he has to take the medication, Pietz said.

Prison staff have "never had to in any way force him to take his medication," she said.

Loughner has been on medication for 60 days, and it has "already made an impact," Pietz said.

Prison records show that Loughner spends much of his time in bed - up to 20 hours a day, Clarke said.

"There's no reason to believe he's not going to continue to make progress" toward being competent to stand trial, she told the court.

"He feels guilty. He may always be depressed because of that, but that doesn't mean he can't be competent" to stand trial, she said.

"I think he needs to be on medication for the rest of his life" so that Loughner is not a danger to himself, Pietz said.

Loughner is being medicated daily with 6 mg. of Risperidone, 300 mg. of Wellbutrin, 1 mg. of Klonopin, 1 mg. of anti-tremor drug Cogentin (also as needed), and sedative Lorazepam (Ativan) as needed.

Lengthy hearing

Pietz was on the stand for nearly four hours. 2 1/2 hours into her cross-examination of Pietz, Burns told Clarke she had 15 minutes to wind things up. She asked questions just a few more moments.

Later, while defense attorney Ruben Cahn was questioning Ballenger, the judge again asked both prosecution and defense to keep their questions on point.

"I want to focus on the issue of the day," he said.

"Both sides are asking questions for the appellate record," Burns said.

Victims, witnesses to the shooting and reporters crowded the courtroom, forcing some to watch the proceedings via closed-circuit video in an overflow room.

Loughner's parents were present, along with shooting victims Mavanell Stoddard and George Morris — both lost a spouse in the attack — and witnesses Mark Kimble and Daniel Hernandez.

Throughout the hearing, the defendant was flanked by three U.S. marshals, and several more stood at the back of the courtroom.

As the hearing wore on, many of those watching left. After both of the short recesses the number in the gallery lessened, until just a handful remained as the judge ended the proceedings around 6:30 p.m.

Another hearing possible

The question of whether Loughner should continue to be forcibly medicated may not rest until January.

Burns said he is uncomfortable ordering Loughner to return to a facility where he will be drugged without his consent without holding a hearing specifically on whether he should be involuntarily medicated for the purpose of restoring his competency.

While the law allows prison officials to drug Loughner if he's a danger to himself or others, doing so for the purpose of restoring him to competency requires a judicial finding, Burns said.

The judge gave defense lawyers one week to file a brief on the question, and said the prosecution must respond within two days following that with a brief of their own.

In January, the judge entered a not guilty for Loughner on 49 charges stemming from the rampage, of which 14 could potentially result in a death sentence.