Peo in Interest of Keene

Opinion

26CA0591 Peo in Interest of Keene 07-30-2026

COLORADO COURT OF APPEALS

Court of Appeals No. 26CA0591 Pueblo County District Court No. 26MH30035 Honorable Gregory J. Styduhar, Judge

The People of the State of Colorado,

Petitioner-Appellee,

In the Interest of Andrew Michael Keene,

Respondent-Appellant.

ORDER AFFIRMED

Division V Opinion by JUDGE SCHUTZ Lipinsky and Yun, JJ., concur

NOT PUBLISHED PURSUANT TO C.A.R. 35(e) Announced July 30, 2026

Cynthia Mitchell, County Attorney, Kate H. Shafer, Special Assistant County Attorney, Pueblo, Colorado, for Plaintiff-Appellee

Tezak Law, P.C., Mary Tezak, Florence, Colorado, for Respondent-Appellant ¶1 Andrew Michael Keene appeals the district court’s order

authorizing staff at the Colorado Mental Health Hospital in Pueblo

(the hospital) to medicate him without his consent. We affirm.

I. Background

¶2 Keene was admitted to the hospital in December 2025 after he

was found incompetent to proceed in two criminal cases.1 His

symptoms, which he experienced intermittently for decades,

involved fluctuations between, on the one hand, depression, low

mood, and low energy, and on the other hand, mania with psychotic

symptoms, persecutory delusions, and aggressive behavior. He was

diagnosed with type I bipolar disorder. Due to his worsening manic

and psychotic symptoms and aggressive behavior, including an

1 Keene was initially admitted to the hospital to restore his

competency so he could stand trial in the criminal proceedings. A petition to administer involuntary medications to restore a defendant to competency is typically governed by Sell v. United States, 539 U.S. 166, 180-81 (2003). But Keene’s mental condition deteriorated while he was at the hospital. Thus, the petition’s stated purposes, and the district court’s bases for granting the petition, were (1) to prevent a significant and long-term deterioration in Keene’s mental condition and (2) to prevent the likelihood of him causing serious harm to himself or others. A petition to administer involuntary medication to a patient in these circumstances triggers the test set forth in People v. Medina, 705 P.2d 961, 973 (Colo. 1985). We therefore apply the Medina framework to the parties’ contentions.

1 incident in which he was verbally aggressive and physically

postured toward staff members, he was started on emergency

medications.

¶3 The People petitioned the district court for authorization to

involuntarily medicate Keene with the antipsychotic medication

olanzapine (Zyprexa) and the mood-stabilizing medication lithium

(jointly, the requested medications).

¶4 Keene and his psychiatrist, Dr. Zachary Wickline, both

testified at the hearing on the petition. Wickline described Keene’s

type I bipolar disorder as “severe” and a substantial disorder of the

cognitive, volitional, or emotion process that grossly impairs

judgment or capacity to recognize reality or to control behavior.”

Wickline proceeded to opine as follows:

• Keene has “little insight” into his mental illness because,

although he agrees that he has post-traumatic stress

disorder (PTSD), he does not believe he has bipolar

disorder.

• The requested medications are necessary to prevent both

a significant and likely long-term deterioration in his

2 bipolar disorder and the likelihood of him causing serious

harm to others in the hospital.

• There isn’t an alternative method of treating him that

would be both effective and less intrusive than the

requested medications because type I bipolar disorder

can only be effectively treated with medications.

• The failure to medicate Keene would be more harmful

than any risks posed by the requested medications.

¶5 Keene testified that he does not have a mental illness,

including bipolar disorder, but said that he does suffer from PTSD

and depression. He testified that he does not need any

antipsychotic or mood-stabilizing medications, but that Ativan (an

anti-anxiety medication) and melatonin (a sleep aid) have helped

him sleep. He also testified about the side effects he said he

experienced from the requested medications. He further clarified

that, although he doesn’t like psychiatry because “it doesn’t tend to

involve any kind of psychological therapy,” he is “very much in favor

of” psychological treatment, such as trauma-informed care and

dialectical behavior therapy.

3 ¶6 Following Keene’s testimony, the district court credited

Wickline’s testimony; examined each of the four elements of the test

from People v. Medina, 705 P.2d 961, 973 (Colo. 1985); concluded

that the People had met their burden of proving all four elements;

and granted the petition.

II. Applicable Law and Standard of Review

¶7 The parties agree that the Medina test applies. Under that

test, a district court may authorize the involuntary administration

of medication if the People demonstrate by clear and convincing

evidence that

(1) the patient is incompetent to effectively participate in the treatment decision;

(2) the treatment with medication is necessary to prevent a significant and likely long-term deterioration in the patient’s mental health condition or to prevent the likelihood of the patient causing serious harm to himself or others in the institution;

(3) a less intrusive treatment alternative is not available; and

(4) the patient’s need for treatment with medication is sufficiently compelling to override any bona fide and legitimate interest he has in refusing treatment.

Id.

4 ¶8 Application of the Medina test involves mixed questions of fact

and law. People v. Marquardt, 2016 CO 4, ¶ 8. We defer to the

district court’s factual findings if they have record support, while we

review the court’s legal conclusions de novo. Id. Resolving conflicts

in testimony and determining the credibility of the witnesses are

matters solely within the province of the district court. People in

Interest of Ramsey, 2023 COA 95, ¶ 23.

III. Analysis

¶9 Keene contends that the evidence was insufficient to establish

any of the four Medina elements by clear and convincing evidence.

We disagree.

¶ 10 On a sufficiency challenge, we must determine whether the

evidence, viewed as a whole and in the light most favorable to the

People, is sufficient to support the district court’s order. People in

Interest of R.K.L., 2016 COA 84, ¶ 13. The testimony of the

physician seeking to administer treatment may be sufficient,

without more, to satisfy the Medina test. Id. at ¶ 30.

A. The First Medina Element

¶ 11 To show that the patient is incompetent to effectively

participate in a treatment decision, the People must establish that

5 “the patient’s mental illness has so impaired his judgment as to

render him ‘incapable of participating in decisions affecting his

health.’” Medina, 705 P.2d at 973 (quoting Goedecke v. State, 603

P.2d 123, 125 (Colo. 1979)). But “[i]f the patient is competent to

participate in the treatment decision, then the patient’s refusal to

submit to the proposed treatment must be respected out of the

law’s regard for a person’s right to make decisions on matters

affecting his own bodily integrity.” Id.

¶ 12 In finding that Keene is incompetent to effectively participate

in the treatment decision, the district court credited Dr. Wickline’s

opinion that Keene has type I bipolar disorder, while emphasizing

that Keene does not believe he has a mental illness (other than

PTSD and depression). Based on that disagreement, the court

found that Keene has limited insight into his mental illness because

he does not understand “the significance of his diagnosis and the

need for medications.” Therefore, the court found, Keene “is

incapable of making informed treatment decisions.”

¶ 13 Those findings are supported by Dr. Wickline’s testimony that

Keene has “severe” type I bipolar disorder. Wickline opined that

Keene’s “lack of insight [into his mental illness] is the crucial piece”

6 supporting Wickline’s opinion that Keene is incompetent to

effectively participate in deciding whether psychiatric medications

are needed. As Wickline explained, Keene’s “detachment from

reality” makes him unable to understand his mental illness and his

need for the requested medications. (Id. at pp. 7-8) See R.K.L., ¶¶

6-7, 33 (affirming the finding that the patient was incompetent to

effectively participate in the treatment decision because the

psychiatrist testified that, while the patient had schizophrenia, the

patient did not think he had a mental illness); People in Interest of

Strodtman, 293 P.3d 123, 131-32 (Colo. App. 2011) (same).

¶ 14 Although Keene emphasizes that he has “a degree of insight”

into his mental illness because he recognizes that he has PTSD and

depression and is willing to take Ativan and melatonin, that ignores

the fact that he does not believe he has bipolar disorder, which is

the “severe” mental illness that requires treatment with the

requested medications. Keene also points out that he wants to get

psychological therapy without psychiatric medications. But, as

Wickline testified, “medication treatment would always be a part of

his treatment plan. Certainly therapies could help as well. But I

think he does require medications.”

7 ¶ 15 Given that the court credited Wickline’s testimony, the

evidence, viewed as a whole and in the light most favorable to the

People, is sufficient to support the district court’s finding on the

first Medina element. See Ramsey, ¶ 23; R.K.L., ¶¶ 13, 30.

B. The Second Medina Element

¶ 16 In Keene’s opening brief, he challenges the district court’s

finding that the second Medina element was met, but then, in his

reply brief, he states that he “does not challenge the [district

court’s] findings as to this element on appeal.” We resolve this

inconsistency by assuming that the statement in his reply brief was

an oversight, and that he does indeed seek review of all the

arguments raised in his opening brief. So, we turn to the district

court’s finding that the requested medications are necessary to

prevent a significant and likely long-term deterioration in Keene’s

mental condition.

¶ 17 Because we conclude that the evidence was sufficient on that

issue, we need not address whether the requested medications were

also necessary to prevent the likelihood of him causing serious

harm to himself or others in the hospital.

8 ¶ 18 In determining whether medication is necessary to prevent a

significant and likely long-term deterioration in a patient’s mental

condition, a court “should focus on the nature and gravity of the

patient’s illness, the extent to which the medication is essential to

effective treatment, the prognosis without the medication, and

whether the failure to medicate will be more harmful to the patient

than any risks posed by the medication.” Medina, 705 P.2d at 973.

¶ 19 The district court explicitly stated that it was relying on Dr.

Wickline’s testimony in finding that the requested medications are

necessary to prevent a significant and likely long-term deterioration

in Keene’s mental condition. Wickline explained his reasoning for

that opinion by addressing the considerations identified in Medina:

• He characterized Keene’s type I bipolar disorder as

“severe.”

• He testified that “when bipolar disorder has psychotic

features [as in Keene’s case], the medical consensus is

that you use . . . a mood stabilizer and an antipsychotic

together.” He further explained that (1) lithium “is the

gold standard mood stabilizer in people with bipolar

disorder” because it “can effectively reduce the symptoms

9 of mania and in doing so, hopefully reduce the symptoms

of psychosis,” and (2) olanzapine “more directly treats the

psychotic symptoms, so we would hope that the

symptoms of hearing voices[,] of disorganized speech and

thought[,] and delusional beliefs would be lessened.”

• He testified that, without the requested medications,

“there would be certainly the continuation of psychotic

symptoms” and “the longer and more persistent these

symptoms, . . . the more likely there is a long term

deterioration and worse[] long term outcomes.”

• He explained why the failure to medicate Keene would be

more harmful than any risks posed by the requested

medications.

¶ 20 In challenging the district court’s finding on this element,

Keene highlights Wickline’s testimony on cross-examination that

delusional beliefs are “often the most treatment resistant” and may

not fully resolve with pharmacological intervention, and that when

Keene has taken medication in the past, “[s]ome of [his] delusional

beliefs were maintained.” However, Wickline proceeded to testify

that “it is possible that his delusional beliefs could resolve,” but

10 given that he has experienced bipolar disorder for decades, “that

aspect of the illness” may not “fully resolve.” He also testified that,

even if Keene’s delusional beliefs do not fully resolve, Keene’s

“emotional reactions around those delusional beliefs can be

lessened” and “he will perhaps be less perseverative and fixated on

those beliefs.”

¶ 21 Regardless of whether Keene’s delusional beliefs could fully

resolve from treatment with the requested medications, the

important point is that Dr. Wickline’s testimony supported a

conclusion that the requested medications would help Keene

improve rather than deteriorate.

C. The Third Medina Element

¶ 22 Similar to his contention regarding the second Medina

element, Keene’s opening brief presents arguments challenging the

district court’s finding that the third Medina element was met, but

then in his reply brief, he states that he “does not challenge the

[district court’s] findings as to this element on appeal.” Here too,

we will assume that Keene seeks review of the arguments he raises

in his opening brief.

11 ¶ 23 For purposes of this Medina element, “a ‘less intrusive

alternative’ constitutes an available treatment that has less harmful

side effects and is at least as effective at alleviating a patient’s

condition as the proposed treatment.” Strodtman, 293 P.3d at 133

(quoting Medina, 705 P.2d at 974). In evaluating this element, “the

focus encompasses not only the gravity of any harmful effects from

the proposed treatment but also the existence, feasibility, and

efficacy of alternative methods of treating the patient’s condition.”

Medina, 705 P.2d at 974.

¶ 24 The district court found that there was no less intrusive

alternative to administration of the requested medications,

explaining how lithium and olanzapine work to treat type I bipolar

disorder. That finding is supported by Wickline’s testimony that (1)

“when bipolar disorder has psychotic features [as in Keene’s case],

the medical consensus is that you use . . . a mood stabilizer and an

antipsychotic together”; and (2) although “therapies could help as

well,” Keene “does require medications.”

¶ 25 Keene asserts that “Dr. Wickline testified that [l]ithium alone

could be sufficient to address [his] symptoms.” We are

unpersuaded because, although Wickline testified it was “possible”

12 that lithium alone could treat Keene’s symptoms, he continued by

testifying that, “given the degree of impairment owed to the

psychotic symptoms specifically, I do think that targeting them

directly with an antipsychotic is indicated.” And although Ativan

and melatonin helped Keene with insomnia, those medications are

not the antipsychotics or mood stabilizers needed to treat his

bipolar disorder. And regarding Keene’s desire to be treated with

psychological treatment, rather than with psychiatric medications,

Wickline conceded that “therapies could help as well.” But he did

not waver from his opinion that Keene “does require medications.”

D. The Fourth Medina Element

¶ 26 In analyzing the fourth Medina element, a court first

determines “whether the patient’s refusal [of treatment] is bona fide

and legitimate.” Medina, 705 P.2d at 974. If it is, the court then

determines “whether the prognosis without treatment is so

unfavorable that the patient’s personal preference must yield to the

legitimate interests of the state in preserving the life and health of

the patient placed in its charge and in protecting the safety of those

in the institution.” Id.

13 ¶ 27 The district court noted Keene’s testimony about the

numerous side effects he said he experienced from the requested

medications but then credited Wickline’s testimony that Keene

tolerated the requested medications well when he took them on an

emergency basis. So, the court found, Keene’s reported side effects

were “not necessarily” bona fide and legitimate. But the court also

found that, even if Keene’s complaints about side effects were bona

fide and legitimate, his prognosis if he did not take the requested

medications would be so unfavorable that his interests in avoiding

side effects must yield to the “legitimate interests of the state in

preserving the life and health of the patient who [was] placed in its

charge and protecting the safety of those in the institution.”

¶ 28 Before discussing the issue of side effects, we first note that

Keene identifies on appeal another interest in refusing the

requested medications, namely, that testing has revealed that he

has decreased blood counts, which could indicate a broad range of

serious underlying conditions. However, Keene did not testify on

this issue, and Wickline noted that (1) Keene refused to see a

hematologist regarding the low blood counts; (2) he hoped that

Keene would be more willing to see a hematologist as his psychotic

14 symptoms and mood improve on the requested medications; and

(3) “a wide range of things” could cause the low blood counts. So,

there is little to no reason to think that the requested medications

played any role in Keene’s low blood counts, particularly given that

he had low blood counts when he was admitted to the hospital.

¶ 29 In addition, Keene asserts that he experienced “debilitating”

side effects from the requested medications, including cognitive

decline, physical pain, physical impairment, dry mouth, tremors,

dizziness, restlessness, sedation, and depression. He also testified

that he experienced negative reactions to similar medications in the

past. Finally, he emphasizes the potential side effects of the

requested medications, as Wickline testified.

¶ 30 In light of Wickline’s testimony that he observed only that

Keene was “a little bit slower,” was “a little bit more tired,” and had

“a little bit depressed mood stage” when he took the requested

medications on an emergency basis, we acknowledge the district

court’s skepticism as to whether Keene’s list of endorsed side effects

was bona fide and legitimate. However, like the district court, we

will assume, without deciding, that his interest in avoiding side

effects is bona fide and legitimate.

15 ¶ 31 The question then turns to whether Keene’s need for treatment

with the requested medications is sufficiently compelling to override

his interest in avoiding their side effects. On appeal, Keene does

not specifically address this issue but, having challenged the

second Medina element regarding whether the requested

medications are necessary to prevent a significant and likely

long-term deterioration in his condition, he implicitly did.

¶ 32 Given our analysis of the second Medina element in Part III.B

above, we discern no error in the district court’s assessment of the

fourth Medina element. When viewed as a whole and in the light

most favorable to the People, Wickline’s unequivocal testimony

regarding the reasons why the court should order the involuntary

administration of the requested medications establishes that

Keene’s compelling need for treatment outweighs his interest in

avoiding side effects. Ramsey, ¶ 23; R.K.L., ¶¶ 13, 30. Recall that

Wickline testified that Keene’s type I bipolar disorder, which he has

had for decades, is severe; an antipsychotic medication and a

mood-stabilizing medication are necessary to effectively treat the

condition; and without the requested medications, he would

experience a significant and likely long-term deterioration in the

16 condition. Further, Wickline specifically opined that not treating

Keene with the requested medications would be more harmful than

their risks.

IV. Disposition

¶ 33 The order is affirmed.

JUDGE LIPINSKY and JUDGE YUN concur.