cover1NASHVILLE, TN (NASHVILLE SCENE) BY  – On a sunny spring day in April, the kind where you get an easy burn because you haven’t felt the sun in months, Daniel Cantrell laces up his sneakers and starts his daily walk. His route is always the same. He walks 30 steps from the nurse’s station. Then he turns and walks 30 paces back.

There are two more hallways the same distance. He walks each one: 30 paces forth, 30 steps back. When he’s walked the last one, he starts all over again. For 10 straight hours.

By the time he finishes, he has walked 41,814 steps — a distance of more than 21 miles.

He has walked a marathon runner’s 26-mile course before in 30-step increments. This is a frequent routine, and his sneakers have the worn-out toes to prove it. He will need new ones before much longer.

The course never changes. The view never changes, even as every day he paces the distance of a walk from Nashville to Franklin. For those with the freedom to roam, the repetition sounds maddening.

For Daniel Cantrell, it’s helping to keep him sane.

As long as he stays out of the orderlies’ way in locked-down Unit A at Middle Tennessee Mental Health Institute, he is free to pace back and forth hundreds of times a day. It focuses him — one way to stave off the boredom and inertia that come with being committed to a mental institution.

“It’s something that the staff doesn’t really mind that you do,” Daniel tells the Scene. “I don’t wanna break any rules while I’m here. In a lot of ways I’m a model patient: I don’t fight with people, I’m not endangering myself or anybody else.”

So Daniel walks to keep his sanity. His voice is calm and low; his demeanor gracious. He is unfailingly polite. For visitors, it’s easy to mistake him for a social worker or other employee rather than a patient. He’s even been asked to teach classes to other residents. With his medication levels properly monitored, Daniel appears as normal as anyone outside the institution’s walls.

It will be a very long time before he can leave them himself.

In 2007, Daniel was diagnosed with schizophrenia. He sought treatment and says he followed it rigorously. According to his wife Kristin, every spring he would fight a cycle of anxiety that might cause him to miss a day or two of work; at worst, he might see his therapist for extra sessions. Never once, in all those years, had he been violent.

In March 2014, the cycle started again. This time, however, he suffered a severe psychotic episode. Ineffective drugs and a deteriorating psyche fueled his paranoia to the point that he became convinced his father, Oliver Cantrell, was a robot assassin trying to kill him. In a manic outburst, Daniel struck first. He stabbed his father three times in the chest with a kitchen knife.

Until the episode that led to him killing his father — known to family, friends and community as his son’s dearest friend — Daniel had a life that was not just functional but joyous. He held an IT manager job, got married, played sports. He even served as best man for his older brother Ryan when he got married in 2013. All this he had done while managing his condition. So what made this time different? Could it have been avoided?

What follows is the Scene’s examination of the killing, through interviews, public documents, the criminal file and Daniel’s medical records.

Seven years to the day before the killing, on April 2, 2007, Daniel was admitted to Vanderbilt University Medical Center in an altered mental state. His parents had called an ambulance after they found him sweating and immobile on their couch, his arms locked at his side. He had reported feeling stressed in his technical support job at Lifeway Christian Resources, where Oliver, an architect, also worked.

Oliver shared a special bond with Daniel from the time he was a boy. Daniel’s mother Deborah, a corporate counsel for Chevron, was the family breadwinner, and Oliver was home more. In some ways, Kristin says, he resembled a more outgoing version of his son. They met every week for lunch dates and enjoyed playing golf together.

Up to the day his parents found him on the couch, Daniel, then 24, had never displayed anything resembling serious mental illness. In medical records obtained by the Scene, his parents told the Vanderbilt staff that he had exhibited some signs of paranoia when he took his first job after graduating from Baylor with a degree in computer science. But his behavior never alarmed them, until the day he was admitted to the hospital.

There he was introduced to his psychiatrist, Michael Murphy, a respected Harvard-trained physician. Murphy diagnosed him as schizophrenic and started him on a regimen of antipsychotic drugs, beginning with Abilify. Daniel saw Murphy every few months after that and began counseling sessions with Terry Huff, a licensed clinical social worker.

Another major development changed his life. In 2008 he met his future wife Kristin while she was spending the summer in Nashville between her second and third years of law school at Alabama.

“It’s a super cheesy story,” remembers Kristin, now a Nashville attorney. “I was sub-leasing a condo in the same building where he lived, and the way that it was set up, there was an open-air courtyard. He was walking his dog and I was sitting out on the porch reading, and his dog came over and we struck up a conversation. … It was his mom’s dog, but he let me think it was his for, like, three months. He asked me out the next night.”

Daniel and Kristin were engaged shortly after she graduated in 2009. They married a year later. A few months after the ceremony that July, though, Daniel had what Kristin believed to be three back-to-back seizures in their home. Dr. Murphy called it “recurrent catatonia” — something brought on by stress and lack of sleep, a seemingly once-a-year event.

Over the next few months, Murphy noted in records that Daniel’s condition improved, but the Abilify had caused him to “gain weight and feel lethargic.” Daniel asked about alternatives. Murphy began a tapering process to move him onto Geodon (also called by its generic name, Ziprasidone) over several weeks, slowly taking the Abilify out of his system and putting the new antipsychotic drug in.

Concurrently, Daniel followed Murphy from Vanderbilt to his new practice at Parthenon Pavilion, where he became the medical director. It was a step up and into management for Murphy, who had also picked up a master’s degree in health care administration while at Harvard. Murphy and Dr. Robert Jack, the clinical director of geriatric services at the hospital, formed a new partnership to see patients, Centennial Psychiatric Associates.

Kristin says she and Daniel had a good relationship with Murphy. He was accessible to both of them by email and by phone when issues arose concerning Daniel’s mental well-being over the next few years, she tells the Scene.

It wasn’t until March of last year that everything began to go very wrong.

Effective March 1, 2014, Dr. Murphy got a promotion. Nashville-based hospital giant HCA, which owns Parthenon Pavilion, named him its national medical director of psychiatric services. This effectively put him in charge of all behavioral health at the company, nationwide. It also ended his days of seeing patients such as Daniel. Centennial Psychiatric Associates sent a letter on March 17 notifying them that Murphy was terminating his practice. The form letter went out two weeks after he had already left for the new job.

“We are committed to the continuity of your care,” the form letter read. “If you do not have a new provider, please call the office to discuss the possibility of continuing your care with our Nurse Practitioner, Michele Dahl. We will try to make the transition as easy as possible for you.”

Daniel learned of this before the letter went out, when he called to schedule an appointment. On March 11, he came in to meet with Dahl. Tennessee law requires that a nurse practitioner operate under the supervision of a doctor, and certain procedures must be followed.

One is that written protocols outlining a patient’s care must be developed by the nurse practitioner and the doctor — in this case Dahl and Dr. Jack, now the consulting physician in the practice. There is also supposed to be a transition memo from the previous doctor. Neither of these things exists, according to an examination of his medical file by the Scene.

“Alert and oriented. Mood is stable, but anxious. Palm is sweaty when I shake his hand,” Dahl’s case notes read. “Some paranoia. No hallucinations or delusions.”

At that appointment, they discussed whether to keep his Geodon levels at 20 or 40 milligram, with Daniel noting that the higher dosage made him sedated in the mornings. What neither Dahl nor Daniel realized was that the anxiety and paranoia he was feeling were indicators — the start of what a state psychiatrist would later term an acute psychotic episode.

In general, Seroquel, Geodon and Abilify are a class of drug known as atypical antipsychotics (AAP), which were developed beginning in the 1990s. The drugs have a record of displaying fewer extrapyramidal side effects than older antipsychotics — chiefly, a reduction in drug-induced motor disorders. AAPs can still have side effects, though, from changes in metabolism to increased risk of cardiovascular disease to tardive dyskinesia, a disorder of repetitive, involuntary movements like excessive blinking or grimacing.

On March 19, 2014, Daniel called the practice seeking an increase in his medication. Dahl raised his Geodon dosage to 40 milligrams, but he was deteriorating already. Notes from his therapist on March 25 indicate that Daniel was increasingly paranoid. Always introspective, Daniel was finding problems where they didn’t exist. Despite getting a large raise that January, he was afraid that he was about to be fired from his job.

“Mr. C reports persistent paranoid thinking, and as a result of the excessive cognition and hyper-vigilance, he appears to be compounding it,” therapist Huff wrote in Daniel’s file.

By March 31, Daniel had moved out of his house with Kristin in Franklin and into his parents’ home in Brentwood. He took a leave from work. Oliver accompanied Daniel to an emergency appointment at Centennial Psychiatric Associates.

“Apparently the patient has been decompensating over the past 2 weeks, having more anxiety, anxious ruminations leading to insomnia, and some irrational fears about losing his job,” Dahl wrote in his file. “He continues to do therapy and may be starting EMDR [eye movement desensitization and processing] soon. It is not quite clear if he is having some paranoia.”

She makes the following notes for his treatment:

1. Start Quetapine Fumarate [Seroquel] tablet, 50 mg, 1/2-2, orally, qhs, 30 days, 60, Refills 0

2. Stop Ziprasidone [Geodon] HCl capsule, 40 mg, 1 capsule with food, orally, qhs

3. Continue Lorazepam [Ativan] Tablet, 0.5 mg, 1 tablet at bedtime as needed, orally, once a day

***he is having anxiety, insomnia, w/ possible paranoia. will change Geodon to Seroquel. He can continue Ativan for now. I’m hoping he may not need in the future with Seroquel. Gave him Rx at this req. Risks, benefits, s/e’s of medications discussed. Patient verbalizes understanding and consents to treatment.

This would become a major point of contention in Daniel’s care. Dr. Murphy had been careful to taper his transition from Abilify to Geodon three years earlier, but there is no notation in Daniel’s medical records to taper. In an interview with Daniel’s criminal defense attorney later in the summer of 2014, Dahl would say that she gave the instructions orally.

But the notes of Daniel’s therapist from later in the day on March 31 seem to indicate otherwise, after Daniel called at 7:43 p.m.

“He reports a medicine change from Geodon to Seroquel. I asked if his anxiety might be medicine-related and if Geodon was being tapered off gradually,” Huff wrote. “He said he was instructed to discontinue Geodon completely and begin Seroquel in the evening.”

At 3:28 the next afternoon, April 1, Daniel placed a frantic call to Centennial Psychiatric Associates, trying to talk to someone about his worsening state. The message relayed to Dahl was that “[he] isn’t sure if the Seroquel is making him anxious as this is part of his issue.” Forty-five minutes later, Dahl notes in his file: “25mg didn’t help him sleep. He has stopped Geodon,” a statement that indicates that there was no tapering going on. She increased his Seroquel dosage to a full 50 milligrams and gave him leeway to take up to 1 milligram of Ativan.

By this point, three factors were at work. First, there was no Geodon left in Daniel’s body: The drug has a half-life of about seven hours. Second, the recommended effective dosage of Seroquel by the manufacturer is between 400 and 800 mg per day to treat schizophrenia in adults, so there was very little of any antipsychotic drug in his system. Third, he had hardly slept in 48 hours. He would barely sleep that night.

On April 2, Daniel melted down. He paced around his parents’ house without a shirt. He held his hand in a fist with two fingers outstretched, insisting that they were permanently stuck. Oliver, concerned, did not want to leave his son alone. He decided to take Daniel with him to the new home he was building with Deborah.

If the visit was meant to calm Daniel, it had the tragically opposite effect.

That much was evident as soon as they arrived. The construction workers and their equipment agitated Daniel. He became convinced that they were plotting to kill him. Where Oliver and the workers saw building equipment, Daniel saw threats. Where his father and the workers saw circular saws and other tools, Daniel saw weapons, all to be used on him.

“Every room we went into looked like a torture room,” he would later tell authorities. “I thought Dad hired the workers to kill me. Every room had some kind of torture device in it.”

They went back to his parents’ house: Daniel increasingly distraught, and Oliver unable to reassure him. Oliver and Deborah tried desperately to reach anyone at CPA. Phone logs from the practice’s answering service indicate calls at 5:39 p.m. and 6:24 p.m. “MEDICATION IS NOT WORKING. NEED CALL ASAP,” the second entry reads.

Back home, Oliver put Daniel on the phone with his brother Ryan, who attempted to calm him down.

“There were these Mexican workers there, and they were staring at me the whole time. I thought they were going to kill me,” Daniel told his older brother. As his paranoia grew, he could no longer see his father, his golfing buddy, his best friend. In his place was an assassin — a robot sent to kill him.

By this time, Daniel had begun picking up and putting down a large kitchen knife.

Kristin arrived between 6:45 and 6:50 p.m. She had been texting with Daniel for most of the afternoon, encouraging him to take his medicine. Daniel met her outside, smoking a cigarette. As she entered the darkened house, she realized something was wrong. There were signs of struggle.

“Oliver!” she remembers calling out — until she spotted the body on the floor, and the knife beside it. She ran outside and called Deborah, telling her that she feared Oliver was dead. Deborah told her to call 911 immediately.

The 911 operator told her how to begin CPR. While she began compressions, Daniel came in the house. According to court records, he sat on the floor beside her, cupping his father’s head in his hands. He briefly tried mouth-to-mouth.

“It’s OK,” he said. “Kristin is here, and she will help you.”

As Kristin struggled, the message indicator on Oliver’s phone was on. It was a voicemail from Dr. Robert Jack, responding to his frantic earlier call to the practice’s answering service. He asked Oliver to please call back “if it was an emergency.”

Police arrived at 7:08 p.m. and took Daniel into custody under suspicion of murder.

The next afternoon, Dr. Murphy called Kristin, unsolicited. From electronic signatures, it is now apparent that he had accessed Daniel’s charts, despite no longer being Daniel’s psychiatrist.

“He called me on my cellphone, and he said, ‘What happened?’ ” Kristin says. “That was his first question: ‘What happened?’ Of course, you know, I was distraught. I just — I basically said, ‘I don’t know what happened.’ I told him the facts; I told him that Nurse Dahl had changed his medicine, and Murphy said, ‘It must’ve been the medicine.’ ”

The Scene submitted a number of questions about Daniel’s care to HCA, specifically about the change in antipsychotics and his care by a nurse practitioner. The corporation declined to answer, instead issuing the following statement from Jennifer Shain, vice president of marketing and public relations for TriStar Health:

“We work in healthcare because of a common desire to help people, so when things do not happen the way we all wish they would, we feel terrible, but we disagree with the contentions and we are firm in that belief. This is absolutely heartbreaking, but you cannot summarize Daniel’s case, his course of treatment, the clinicians who cared for him and the complexities of his situation by focusing only on the tragic circumstances of his father’s death. Our thoughts and prayers are with Daniel and his family.”

Daniel is more lucid now about the events of that night. His mind is clear enough to know how much he has lost. He remembers killing his father. He remembers the paranoia that drove him, the overwhelming fear of everything around him.

“It’s like you’re fighting for your life,” he says, calmly addressing a visitor to his current home at Middle Tennessee Mental Health Institute. “I was afraid that somebody was gonna kill me, and so instead of them attacking me, I became the attacker and I started on this front. I picked up a nail at the construction site and I started jabbing at my dad with it.

“Inside I felt like, just, sick to my stomach. My heart was racing, and everything was just out of whack. I couldn’t really process normal interactions; I was just terrified. It was mental and emotional and physical.”

In the days after his arrest, Daniel tried to kill himself. He took stock of the limited options in his jail cell, climbed onto the top bunk, and made a swan dive head-first onto the concrete floor below. Ironically, that act may have saved his life, not ended it — or at least accelerated his recovery. After he was treated for a shattered face and other injuries, he was moved to the institution, where they finally regulated his meds, ultimately placing Daniel on Haldol.

Since then, he’s gained a measure of perspective about how he deteriorated and what he would do over again. Would he question a change in his care?

“I don’t know,” Daniel says. “I think I was in the state that I knew I needed an extra set of ears, and that’s why I got my dad in there. To have him hear what they were hearing and ask those questions, I knew that, that I deteriorated a good bit. You know, there’s so many factors that went into changing that medication; I’ve always looked at doctors like they know more than me, they went to a higher level of schooling than me, they’re the people that you can put your trust in, and I held a lot of faith in that, especially with Dr. Murphy. Anything he said I did, even if I didn’t wanna do it. If he said, ‘You need to go up on your medicine,’ I would do it. I never missed a dose; I just didn’t.

“What he said, there were times that I would leave his office, I would get in my car, drive a block, and just start crying because it was so hard for me, what he told me to do, but I knew I was gonna do it anyway. So it’s really hard, I struggle with how much trust I should put in the doctor, and after this incident, maybe I need a healthier realization of, ‘A doctor’s a person, too, they can make mistakes.’ But when they make mistakes it could be very dangerous — it could have a very big impact.”

By all accounts the system seemed to work in the case of State of Tennessee v. Daniel Cantrell. Law enforcement in Brentwood recognized early that this was not a typical homicide, and that Daniel needed some kind of care. David Raybin, Daniel’s criminal defense attorney, moved quickly to get forensic psychiatrists from the state to evaluate his client’s state of mind; District Attorney Kim Helper’s office stipulated that Daniel was mentally ill and went along with a report that stated, “Daniel was unable to appreciate the nature or wrongfulness of his acts,” and Judge Timothy Easter issued the verdict that he was not guilty by reason of insanity, after a two-hour trial where the only witness was the state psychiatrist.

That doesn’t always happen, and certainly not in Tennessee. Raybin, one of the leading authorities on insanity defenses, called it “rare.” The brisk, sensitive handling kept coverage of the case from ballooning into a media circus.

Even so, the path forward for Daniel is murky. Unlike a prison sentence, there is no defined set of time for him to remain at the institution. He has earned privileges at what feels to him like a glacial pace — he gets to go outside for 30 minutes a day now — but in reality is exceptionally fast for people assigned there. Some patients who have committed a homicide, for example, spend years in the maximum-security Forensic Service Program unit.

Daniel’s mother Deborah moved away to Houston, nearer to his brother Ryan. She has not been to see Daniel. Kristin’s visits are restricted to visiting hours.

He may eventually graduate into a group home and then potentially to an apartment of his own. Any such move, however, will require a judge’s approval. And even if he gets it, a career is likely out of the question if, as he notes, an employer “Googles ‘Dan Cantrell’ and it’s like, ‘Well, this is a criminally insane person.’ ” Right now, he’s just hoping to get into a work-skills program that would allow him to fix radios.

So at age 31, Daniel Cantrell will spend every day for the foreseeable future the same way: He will lace up his sneakers. He will walk 30 steps from the nurse’s station to the end of a hallway, then 30 paces back. And he will continue down the next hallway, and the next. He will repeat that over and over, until his shoes wear out and he has exhausted every calorie in his body.

“They say if you’re not crazy when you get here,” Daniel says, “you are when you leave.”

Tom Lohrmann contributed to this story.

 

Email editor@nashvillescene.com

Source: Nashville Scene, http://www.nashvillescene.com/nashville/did-a-shift-in-medication-help-cause-daniel-cantrell-to-kill-his-father/Content?oid=5026432