A Retrospective Review of the Use of Clozapine in Restoration of Competency to Stand Trial.

Most defendants found incompetent to stand trial have psychotic illnesses. Clozapine has been shown to be superior to other antipsychotic medications in treatment-resistant schizophrenia. It is vastly underutilized, however, including in forensic settings. To our knowledge, there have been no studies exploring the risks and benefits of clozapine for incompetent to stand trial defendants with severe mental illness. We sought to explore the characteristics of patients who were prescribed clozapine in a retrospective sample of defendants deemed incompetent to stand trial with diagnoses of psychotic and bipolar disorders. We found that 25 of 240 defendants (10%) were prescribed clozapine, with 15 (60%) eventually being discharged on it. Of those 15, 8 defendants were successfully restored to competency to stand trial. The restoration rate in the clozapine group was much lower than in the non-clozapine group (32% versus 87%). Our results emphasize the need for prospective comparative studies assessing the efficacy and tolerability of clozapine and other antipsychotic medications related to restoration of competency to stand trial.

Long-Acting Injectable versus Oral Antipsychotics for Restoration of Competency to Stand Trial.

Treatment with antipsychotics is a mainstay of trial competency restoration, particularly given that most defendants deemed incompetent to stand trial have psychotic illnesses. We explored the association between competency restoration and antipsychotic type in a retrospective sample of defendants diagnosed with psychotic disorders and deemed incompetent to stand trial. Using regression models, we calculated the odds ratio of being competent to stand trial, adjusting for relevant confounders. We found that the use of long-acting injectable antipsychotics was not significantly associated with increased odds of restoration of trial competency. Our results highlight the need for larger, longitudinal studies to further explore the efficacy and tolerability of long-acting injectable drugs compared with oral antipsychotics. Future research will help develop treatment guidelines within the setting of trial competency restoration.