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Year : 2016  |  Volume : 21  |  Issue : 1  |  Page : 58-61

Does clozapine improve competency restoration? a case report of schizophrenia patient opined incompetent to stand trial unlikely to be restored

Department of Psychiatry and Behavior Sciences, University of Texas Medical School, Houston, TX, USA

Date of Web Publication10-May-2016

Correspondence Address:
Ajay Kumar Parsaik
Department of Psychiatry and Behavior Sciences, Harris County Psychiatric Center, University of Texas Health Science Center, 2800 South MacGregor Way, Houston, TX 77021
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-8990.182092

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A number of defendants with chronic psychotic disorders are opined incompetent to stand trial and are subsequently committed for competency restoration. To the best of our knowledge, the role of clozapine in restoring competency among defendants suffering from treatment-resistant schizophrenia has not been previously reported. This article reports a defendant with a diagnosis of treatment-resistant schizophrenia, who was treated with clozapine and restored to competency within a short duration. During a subsequent hospitalization, the same patient was treated with different antipsychotic medications and was found “incompetent to stand trial and unlikely to be restored.” Therefore, clozapine may play an important role in restoring competency in patients with chronic psychotic illness. The authors discuss the potential benefits and underutilization of clozapine therapy in competency restoration.

Keywords: Clozapine, competency restoration, treatment-resistant schizophrenia

How to cite this article:
Hashmi A, Parsaik AK. Does clozapine improve competency restoration? a case report of schizophrenia patient opined incompetent to stand trial unlikely to be restored. J Mental Health Hum Behav 2016;21:58-61

How to cite this URL:
Hashmi A, Parsaik AK. Does clozapine improve competency restoration? a case report of schizophrenia patient opined incompetent to stand trial unlikely to be restored. J Mental Health Hum Behav [serial online] 2016 [cited 2022 Nov 27];21:58-61. Available from: https://www.jmhhb.org/text.asp?2016/21/1/58/182092

  Introduction Top

The prevalence of psychotic disorders is 10 times higher among criminals compared to the normal population.[1] Patients with schizophrenia suffering from severe psychotic symptoms are more likely to be convicted of a criminal offense.[2] Determination of competency to stand trial (CST) is a common procedure involving both the mental health and criminal justice systems. In the landmark case of Dusky v. United States, the Supreme Court established the legal standards to define a defendant's CST, as “sufficient present ability to consult with a lawyer with a reasonable degree of rational understanding” and “a rational as well as factual understanding of the proceedings against him.”[3] Those with psychotic disorders are approximately 8 times more likely to be found incompetent to stand trial for their alleged offense compared to those without a psychotic illness.[4] Incompetent defendants are more likely to have treatment-resistant schizophrenia, which is defined as persistent psychotic symptoms despite treatment with ≥2 traditional or novel antipsychotics.[5] A combination of pharmacological, psychological, and educational interventions is commonly used to restore competency; however, some researchers believe that psychotropic medication is the only reliable treatment for defendants with psychosis.[6]

The current evidence suggests that successful restoration is related to the response to psychotropic medications.[7] Clozapine is considered as a primary pharmacological therapy for treatment-resistant schizophrenia. Therefore, clozapine may play an important role in treating patients in forensic units, especially for persistent delusions and hallucinations, which affect cognitive function.[8],[9] Thus, clozapine treatment may increase the competency restoration rate and reduce the duration required to restore competency. To the best of our knowledge, there is limited literature about the use of clozapine in the context of competency restoration.

  Case Report Top

A 49-year-old male with a psychiatric diagnosis of schizophrenia and cocaine dependence was committed to our inpatient competency restoration unit on two separate occasions after having been opined as incompetent to stand trial. A brief description of the two incarcerations has been described in [Table 1].
Table 1: Description of patient's hospitalizations for competency restoration

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First incarceration for state jail felony charge

Initial competency evaluation

According to the initial competency assessment performed at the county jail, the defendant's mental status was marked as unintelligible speech, and verbal responses containing substantial bizarre somatic and grandiose delusions. The examiner opined that the defendant was incompetent to stand trial due to a mental illness that impaired his ability to engage with counsel in a reasonable and rational manner, and to express a rational and factual understanding of the charges against him. The examiner opined that there was a “substantial probability that his competency to stand trial” would be restored in the foreseeable future. The defendant was subsequently transferred to our inpatient competency restoration unit.

Hospital course

On initial evaluation at hospital, the defendant exhibited rapid and slurred speech with disorganized, illogical, and tangential thought process. He also appeared to be responding to auditory hallucinations. He reported being charged for the distribution of cocaine. He was a poor historian and appeared to have cognitive deficits. He had multiple scars on his face, which he reported being caused by “dancing and singing on New Year's Eve and being cut on the face with a knife.” He verbalized multiple grandiose delusions, i.e. he stated that he worked for the police department and FBI to fight crime; he was a brick mason and a core engineer; and that he was extremely wealthy (but was homeless because he had no identification documents and did not know his real name). He also reported that he was a famous police rapper, married to a famous woman on “that movie with Eddie Murphy;” and was the owner of various banks “the one with the 'C' on it and Bank of America.” In addition, he verbalized somatic delusions of electricity going up his legs. Brief Psychiatric Rating Scale (BPRS) score on hospital admission was 56.

During hospitalization, bizarre behavior was noted on an almost daily basis, i.e. he tried to look like an Arab by donning a cloth over his head, pacing around the ward while shadow boxing. He was unable to engage in court education groups. Previous psychiatric history revealed that the defendant had 14 past involuntary hospitalizations to our hospital and multiple psychiatric hospitalizations at other facilities. There had been multiple failed trials of antipsychotic medications and mood stabilizers including haloperidol, perphenazine, risperidone, quetiapine, olanzapine, and divalproex sodium. He had a well-documented history of nonadherence to treatment. Therefore, we considered his diagnosis as a treatment-resistant psychotic illness. He was prescribed clozapine with eventual titration to 75 mg in the morning and 175 mg at night. He showed remarkable improvement and significant reduction of psychotic symptoms within 3 weeks. He subsequently showed evidence of logical thought process, was less preoccupied with auditory hallucinations and delusional thoughts, and was able to make rational conversation with others. He actively participated in court education groups and demonstrated good factual and rational understanding of court proceedings. He tolerated clozapine well except for initial sedation which resolved with shifting the morning dose to night time. His white blood count showed a drop from 7.8 × 10E3/µl to 5.2 × 10E3/µl; however, it remained stable thereafter with normal absolute neutrophil count. BPRS score at the time of discharge was 24. The total duration of hospitalization was 28 days.

Final competency evaluation

During his subsequent competency evaluation, the defendant was polite and responded questions in a nonevasive manner. He was calm, well groomed, and oriented to person, place, and time. He expressed adequate understanding of abstract concepts such as punishment, guilty plea, court authority, legal defense, and incarceration. The content of his verbal expressions was goal-directed and logical with adequate vocabulary. He denied hallucinations and his responses were primarily logical without bizarre and grandiose delusions. He exhibited partial insight into his mental illness and the need for treatment. The defendant expressed understanding that he was placed in hospital involuntarily and acknowledged that legal proceedings had occurred to order the current commitment. He was able to identify his defense attorney and the court presiding over his case. It was believed that he had capacity to engage with counsel in a reasonable and rational manner. He did not exhibit any bizarre or disruptive behaviors and was therefore considered to be able to exhibit appropriate courtroom behavior. The defendant's verbal reasoning capacity was judged to be sufficient to engage in legal proceedings with the guidance of legal counsel. He was given a clinical diagnosis of schizoaffective disorder, with cocaine dependence and was opined as competent to stand trial.

Second incarceration for misdemeanor charge

Approximately 15 months later, the defendant presented to our competency restoration unit again after being found incompetent to stand trial for a misdemeanor charge.

Initial competency evaluation

During the evaluation at the county jail, the defendant demonstrated pressured speech, acute agitation, and shouted derogatory comments toward the evaluator, and therefore, the competency evaluation was discontinued. The evaluator opined that the defendant was incompetent to stand trial and estimated that he would likely be restored to competency in approximately 2–4 months if required to adhere to a treatment regimen designed for competency restoration. According to records, while at the county jail the defendant was uncooperative, had rambling speech, was agitated, hostile, and threatening toward others. He required emergency medications on two occasions. He was delusional that he was a doctor, positive for self-talk and had impaired judgment and insight. He was treated with haloperidol decanoate 200 mg intramuscularly, Cogentin 1 mg twice daily, and Depakote 1000 mg daily for psychosis. He initially refused medications but eventually agreed to accept treatment because he wanted to return to the general jail population from the jails' mental health unit.

Hospital course

On admission to our competency restoration unit, the defendant was uncooperative and refused to be interviewed. He appeared disheveled, had rambling speech, irritable mood, labile affect, disorganized thought process, and paranoia. BPRS score on admission was 48.

During the initial course in hospital, the defendant continued to show bizarre behavior (shadow boxing, wearing boxers on his head, wearing a piece of cloth on his head, and speaking in tongues while trying to show that he spoke Arabic, etc.). He had poor insight (focused on the fact that he had been wrongfully arrested) and refused to participate in the competency restoration program. He was continued on oral haloperidol 20 mg daily for psychosis without any improvement in his symptoms but refused to take clozapine and stated that he would not comply with blood tests. Approximately 7 weeks later, olanzapine was started, which was effective in that some of his psychotic symptoms such as bizarre appearance and behavior improved. His level of agitation resolved, and he no longer expressed overt delusions. A 60-day extension of commitment for competency restoration was granted on the basis that the defendant would require further treatment to restore competency. However, he remained paranoid and refused to talk to the treatment team. His insight into his legal situation remained impaired causing difficulty in meaningful participation in court education groups. He continued to state that he was wrongfully arrested and that his ex-wife and his sister had conspired to get him arrested. He reported that he would refuse to be seen by a forensic psychologist for a competency evaluation. The defendant therefore continued to show evidence of delusional thought content which impaired his functioning and ability to develop a rational understanding of his legal situation. BPRS on discharge after 92 days of hospitalization was 34.

Final competency evaluation

During the final competency evaluation, the defendant patient was calm and cooperative and able to provide relevant and coherent background information. Mental status examination revealed a noticeable speech impediment that made it difficult to understand him at times. However, he repeated himself whenever prompted. Several peculiar ideas or bizarre verbalizations were elicited. Mood was dysthymic with congruent affect. He was unable to provide reliable information about his arrest and legal situation and was delusional stating that he was part owner of some banks, several fast food restaurants and that they were trying to take them away from him. He reported that his foster sister used a “special system” to talk to him through which other people could hear the conversation such as an intercom. The general impression obtained from the mental status examination and clinical interview revealed that he continued to be significantly impaired by severe mental illness. Based on the above mental examination and the defendants' inability to provide reliable facts about his legal case, he was considered incompetent to stand trial and unlikely to be restored in the time frame available to the court.

  Discussion Top

Although the efficacy of clozapine therapy in chronic psychosis is well established, this case highlights the importance of clozapine in restoring competency in defendants with treatment-resistant psychotic disorders who have been opined as incompetent to stand trial. In this case, clozapine treatment was associated with significant resolution of psychotic symptoms with subsequent restoration of competency in a short duration of time.

Approximately 30% of schizophrenic patients meet criteria for treatment resistance, with clozapine being the prudent treatment choice.[10] Since clozapine is very effective in treating positive symptoms of schizophrenia and it improves cognition, it has a beneficial role in competency restoration. In addition, patients responding favorably to clozapine tend to remain compliant compared to other antipsychotic medications and they have lower relapse rates. Despite the fact that one-third of patients with schizophrenia are treatment resistant, only a small percentage of these patients receive clozapine in the United States.[11] A limitation with clozapine is that patients need to be agreeable with accepting regular blood tests. However, the typical duration of commitment for competency restoration may allow time to partially stabilize the patients with other medications and subsequently encourage them to consider clozapine as a treatment option.

From a legal standpoint, the defendant's competence to stand trial has an impact not only on the final disposition of the matter but also on the duration of confinement. According to the Supreme Court decision in Pate v. Robinson, it is constitutionally impermissible to proceed to trial or accept a plea agreement from an incompetent defendant.[12] As in the case Jackson v. Indiana, defendants' who are found incompetent, should not be held for treatment longer than deemed reasonable based on their diagnosis.[13] It is therefore important to know the baseline prognosis for recovery of incompetent defendants from their diagnosed disorders. When a defendant is determined to be incompetent, it is important to know how likely treatment will in fact restore adjudicative competency. Such information would presumably increase the efficiency and effectiveness of mental health professionals' role in judicial process.

Jurisdictions therefore require evaluating psychiatrists to give an opinion about the likelihood of restoration of competence within a statutorily designated time frame. It is recommended that during competency evaluations, psychiatrists should consider the defendants' previous response to treatment and whether the defendant's incompetence results from treatable psychiatric symptoms.[14] Since pharmacological treatment is considered the most evidence-based treatment method used to restore competence, the authors suggest consideration of pharmacological treatment guidelines for treatment-resistant schizophrenia, while providing opinions about the likelihood of restorability of competence among these defendants. This report points toward the need for further research in this area.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Brugha T, Singleton N, Meltzer H, Bebbington P, Farrell M, Jenkins R, et al. Psychosis in the community and in prisons: A report from the British National survey of psychiatric morbidity. Am J Psychiatry 2005;162:774-80.  Back to cited text no. 1
Wallace C, Mullen PE, Burgess P. Criminal offending in schizophrenia over a 25-year period marked by deinstitutionalization and increasing prevalence of comorbid substance use disorders. Am J Psychiatry 2004;161:716-27.  Back to cited text no. 2
Dusky v. United States, 362 U.S. 402 (1960).  Back to cited text no. 3
Nicholson RA, Kugler KE. Competent and incompetent criminal defendants: A quantitative review of comparative research. Psychol Bull 1991;109:355-70.  Back to cited text no. 4
Advokat CD, Guidry D, Burnett DM, Manguno-Mire G, Thompson JW Jr. Competency restoration treatment: Differences between defendants declared competent or incompetent to stand trial. J Am Acad Psychiatry Law 2012;40:89-97.  Back to cited text no. 5
Carbonell JL, Heilbrun K, Friedman FL. Predicting who will regain trial competency: Initial promise unfulfilled. Special issue: Psychopathology and crime. Forensic Rep 1992;5:67-76.  Back to cited text no. 6
Zapf P. Standardizing Protocols for Treatment to Restore Competency to Stand Trial: Interventions and Clinically Appropriate Time Periods (Document No. 13-01-1901). Olympia: Washington State Institute for Public Policy; 2013.  Back to cited text no. 7
Buckley PF, Kausch O, Gardner G. Clozapine treatment of schizophrenia: Implications for forensic psychiatry. J Clin Forensic Med 1995;2:9-16.  Back to cited text no. 8
Maier GJ. The impact of clozapine on 25 forensic patients. Bull Am Acad Psychiatry Law 1992;20:297-307.  Back to cited text no. 9
Meltzer HY. Clozapine: Balancing safety with superior antipsychotic efficacy. Clin Schizophr Relat Psychoses 2012;6:134-44.  Back to cited text no. 10
Manuel JI, Essock SM, Wu Y, Pangilinan M, Stroup S. Factors associated with initiation on clozapine and on other antipsychotics among medicaid enrollees. Psychiatr Serv 2012;63:1146-9.  Back to cited text no. 11
Pate v. Robinson – 383 U.S. 375 (1966).  Back to cited text no. 12
Jackson v. Indiana, 406 U.S. 715 (1972).  Back to cited text no. 13
Mossman D, Noffsinger SG, Ash P, Frierson RL, Gerbasi J, Hackett M, et al. AAPL practice guideline for the forensic psychiatric evaluation of competence to stand trial. J Am Acad Psychiatry Law 2007;35 4 Suppl: S3-72.  Back to cited text no. 14


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