Behnam Mahjoubi -A Medical Review

Behnam Mahjoubi was a 33-year-old man, a member of the Gonabadi Sufi order in Iran, who was arrested in February 2018 after taking part in peaceful protests at Golestan Haftom in Tehran. Some 300 Gonabadi Sufis were arrested in association with the protests and Behnam Mahjoubi was sentenced to two years in prison. Behnam Mahjoubi was a bright student and graduated with a bachelor’s degree in business management at Kerman University in 2009, however due to the Golestan Haftom protests he became unemployed. He suffered from panic disorder and was prescribed medication for this condition by his general physician. His panic disorder debuted after the passing of his beloved spiritual leader Dr Noor Ali Tabandeh in 2019.

Prior to serving his prison sentence Behnam Mahjoubi had been examined by his ordinary physicians who had written a medical report stating that he was not medically capable of serving a prison sentence due to his underlying condition and in particular not capable of tolerating solitary confinement. Regardless of this official medical expert opinion, Behnam Mahjoubi was held in solitary confinement for 40 days by the Isfahan and Kerman Intelligence Centre, by which time his panic disorder had worsened, and then ordered by judicial authorities to be sent to Evin prison in Tehran in June 2020.

Imprisonment
During imprisonment Behnam Mahjoubi was deliberately denied his own prescribed medicines. According to his wife, Salehe Hosseini, who wrote several letters to the judiciary authorities as well as publishing open letters, Behnam was not only denied his own prescribed medicines but was instead forced to take 14-17 sedative and tranquilizing pills per day by the prison doctor. He was threatened to be sent to Aminabad Mental Hospital if he refused to take the pills. Unfortunately, this practice of sending prisoners to psychiatric hospitals is a common method of breaking down prisoners’ morale and resistance, by prison organizations in Iran (ref: https://english.shabtabnews.com/2021/02/23/political-prisoners-tortured-in-psychiatric-hospitals/) as was also evident in the case of Hashem Khastar, an imprisoned teachers’ union activist who also endured forced hospitalization at a psychiatric ward.

Panic disorder
Panic disorder is a fairly common condition and is characterized by sudden episodes of intense anxiety. While separate panic attacks are generally common, a panic disorder is defined as recurring episodes for longer periods of time and requires specific medication. Although the exact cause for this condition is unknown, genetics and major life stressors seem to be associated with the development and the condition is known to worsen during major life changes. In Behnam Mahjoubi’s case, the panic disorder debuted following the unexplained and tragic death of Dr Noor Ali Tabandeh, the spiritual leader of the Gonabadi Sufis in Iran.

Treatment for panic disorder include prescribed medications such as selective serotonin reuptake inhibitors (SSRI), selective norepinephrine reuptake inhibitors (SNRI), beta-blockers and benzodiazepines. In combination with prescribed medications patients also receive continuous therapy treatments with a clinical psychologist.

SSRI and SNRI are common in the treatment of depression, PTSD and anxiety disorders, these are substances that medical professionals worldwide are familiar with both in regard to their effect and side effects. When starting this type of medication, it is vital that the treatment continues without interruption, if the treatment is terminated abruptly patients develop withdrawal-like symptoms such as nausea, vomiting, tremors, agitation, vertigo, dizziness and lethargy. By denying Behnam Mahjoubi his ordinary medication the medical staff at the prison are directly responsible for both his physical and mental deterioration. Behnam reported all the symptoms consistent with abrupt medication withdrawal. In addition, these medications can cause problems if interacting with other drugs or if administered at high doses. Serotonin syndrome is a serious condition that occurs at high doses of SSRI or if combination of other medications have raised the concentration of serotonin, symptoms include high fever, increased heart rate, anxiety, confusion, myoclonus, restlessness, lack of coordination, circulatory changes and in severe cases of toxicity the condition leads to unconsciousness and death. Clinicians are well aware of these side effects and therefore when prescribing these medications patients are continuously checked for such symptoms and signs. By forcibly making Behnam take up to 17 pills per day and denying him his ordinary medication, it is evident that the responsible physician at the prison was deliberately neglecting these facts. There is absolutely no type of panic disorder that requires a patient taking 17 pills per day, by all evidence available, this was in fact a planned chemical execution covered up by Behnam Mahjoubi’s underlying medical condition.

Behnam was aware of the risks he was facing, therefore he refused to take the medications provided by the prison and underwent several hunger strikes. The hunger strikes weakened his physical strength resulting in his reported symptoms including dizziness, hypotension and fainting. As a consequence of this he was sent to Aminabad Psychiatric Hospital, a Psychiatric Hospital without resources for somatic care. In fact he was sent to Aminabad Psychiatric Hospital on several occasions as a method of punishment. Behnam Mahjoubi detailed the psychological and physical torture he had been subjected to at Aminabad Psychiatric Hospital, he described being constrained to the hospital bed, forcibly received injections and pills consisting of antipsychotic and sedative substances which resulted in him going in and out of consciousness, and he also reported that staff as well as inpatients deliberately urinated on him.

Behnam returned to Evin prison and at a later stage when he released an audio file speaking about the inhumane conditions in prison, he was heard speaking with shortness of breath and coughing, common COVID-19 symptoms, which is currently widespread in Iranian prisons. As a consequence of this he was again transferred to Aminabad Psychiatric Hospital instead of a hospital with resources to treat suspected COVID-19, not only reflecting the human rights violations towards Behnam Mahjoubi who was denied appropriate care, but also displaying a complete disregard for the spreading of COVID-19 in the Iranian society. He later reported that he was repeatedly sedated and forcibly underwent electric shock treatments at Aminabad Hospital. Electric shock treatments are considered contradictory in many parts of the world and only provided in severe cases of depression or psychosis, the treatment is known to cause side effects such as memory loss, drowsiness, confusion and transient aphasia. Behnam Mahjoubi presented all these symptoms and his health deteriorated rapidly in the last months leading up to his death. As he wanted to avoid being sent to Aminabad Pshychiatric Hospital he had no choice but to accept the orders from the prison medical staff.

Soon after receiving an injection of a substance at the prison, Behnam Mahjoubi fell into a deep comatose state and on February 15^th, he was transferred to an intensive care unit at Loghman Hospital. The substance that was injected was a sedative drug of the class barbiturates, which act as a depressant to the central nervous system and the respiratory system in high doses. Low doses of barbiturates can reduce anxiety and tension while higher doses can cause coma and pulmonary arrest. Because of the risk of fatal overdose is high with barbiturates and there is no effective antidote to reverse the effect, these medications have largely been replaced with benzodiazepines in the treatment of anxiety disorders today. Although benzodiazepines also carry risks of overdose, fatal overdose is uncommon compared to barbiturates. In fact, some states in the US administer barbiturates for capital punishment by lethal injection, the onset of action with intravenous administration is almost immediate to 5 minutes. Barbiturate intoxication leads to severe hypotension, coma, respiratory and cardiovascular depression, multiorgan failure including renal failure, hypoxic brain injury and death.

When Behnam Mahjoubi reached the ICU his consciousness level was at score of 5 on the Glasgow Coma Scale (GCS) where 8 or less indicates coma. Soon he dropped to a GCS score of 3 which indicates the lowest possible score associated with an extremely high mortality rate. He had lost function in one lung due to aspiration pneumonia which further confirms barbiturate intoxication, since studies show that barbiturate overdose carries higher risk of aspiration pneumonia compared to other sedative overdose, caused by its depressant effect on the respiratory system. Soon he was diagnosed brain dead, defined as irreversible loss of all brain functions, including brainstem functions. A patient determined brain dead is legally and clinically dead. Even though the medical staff at Loghman Hospital announced his death on February 16^th, the torture was still not over for Behnam Mahjoubi and his family. Security forces had ordered the medical staff at the ICU to keep his body attached to a respirator and his death announcement was withdrawn, only to keep his family and loved ones in total despair and confusion over another seven days. A week later, on 21^st of February, Behnam Mahjoubi was announced dead again and this time the official explanation was that Behnam had suffered 3 heart attacks during a surgical intervention of unknown purpose.

Regardless of his family and relatives’ wishes to let Behnam Mahjoubi undergo a legal post-mortem examination; security forces denied these wishes and Behnam Mahjoubi was buried in all haste the next day.

Summary
By reviewing this case, we find evident signs of torture and induced death at the hands of the prison organization under the direction of the Iranian regime. Behnam Mahjoubi, a healthy young man, with no prior serious somatic diseases, indeed suffered from panic disorder, but was well managed and monitored for this condition before serving his prison sentence. During a 9-month period he endured both psychological and physical torture and his death was caused by poisoning at the Evin prison Medical Centre. His reported symptom of nausea, tremors, vertigo, dizziness and agitation are consistent with abruptly terminated treatment due to prison staff refusing him his ordinary medication for panic disorder. Furthermore, since he refused taking the medication provided by the prison, (17 pills of sedatives per day) he underwent several hunger strikes which further deteriorated his physical health. In an audio file recorded at the prison, he speaks with shortness of breath and repeatedly coughs through the conversation, signs indicative of COVID-19, but he received no medical attention. He underwent severe torture in his forced visits to Aminabad Psychiatric Hospital and after receiving a mixture of medications both orally and intravenously as well as undergoing electric shock treatments, he returned to Evin prison in an even weaker state than when he left for Aminabad. An evening in February, he received a lethal injection of sedatives (barbiturates) which put him in a coma and resulted in respiratory depression with following multiorgan failure leading to his death on February 16^th. From this tragic case we demand answers from the Iranian prison authorities responsible for the physical and psychological health care of all prisoners.

1. Explain why Behnam Mahjoubi was denied his own prescribed medication when serving his sentence at Evin prison.
2. Describe in detail what substances/medications was given to Behnam Mahjoubi by the Medical Centre at Evin prison, including a full list of the 17 pills he was ordered to take every day.
3. Why was Behnam Mahjoubi transferred to Aminabad Psychiatric Hospital when he presented symptoms consistent with COVID-19?
4. To the medical staff of Aminabad Psychiatric Hospital; what type of medication did Behnam Mahjoubi receive during your care? Please provide a full report of his medical examinations and his complete medical records during his visits to your psychiatric ward.
5. Why was Behnam Mahjoubi subjected to electric shock treatment, what were the indications for this treatment? Did Behnam Mahjoubi consent to such a treatment? If so, please provide his written consent form.
6. Explain why Behnam Mahjoubi fell into a deep comatose state after receiving an injection at the Medical Centre of Evin prison in February, prior to his death. Provide the medical record and medication administration record of this day.
7. At Loghman Hospital did you perform a toxic screening at admission, if not, explain why. If yes, provide the results.
8. To the medical staff at Loghman hospital, please provide all medical and medication records on Behnam Mahjoubi.
9. What was the cause of his aspiration pneumonia?
10. Why did the medical staff announce his death on February 16^th and then withdrew the announcement soon after?
11. What was the purpose of performing surgery on a patient who had already been determined brain dead?
12. Why was there no post-mortem examination at the time of death?
13. What was the reason for rushing Behnam Mahjoubi to the burial site?