Restoring to Competence a Case-by-Case Matter

SEATTLE – Defendants who are incompetent to stand trial are less likely to be restored to competence with treatment if they are older or have dementia, according to study results reported at the annual meeting of the American Academy of Psychiatry and the Law. Still, roughly half of them achieve this goal.

The U.S. Supreme Court has ruled that defendants thought to be permanently incompetent to stand trial or unlikely to be restored in the foreseeable future must either be released or evaluated for civil commitment, Dr. Douglas R. Morris noted in an interview. But it remains difficult for treating psychiatrists to predict which incompetent defendants have little probability of restoration.

Dr. Morris and his colleagues searched the Indiana forensic database for 1988–2004 to identify defendants hospitalized for treatment to restore competency to stand trial. They ascertained whether the defendants were restored to competence after 6 months (the state's statutory standard) and 1 year (the standard used in other states and published reports) and the clinical factors associated with restoration.

They identified 1,380 incompetent defendants. Some 3% had dementia, 2% were older (at least 65 years) and did not have dementia, and 95% had other diagnoses or reasons for admission.

About one-third of patients in the dementia group had Alzheimer's disease, one-third had dementia not otherwise specified, and the remaining third had dementia because of vascular causes or substance use, said Dr. Morris, a psychiatrist at the University of South Carolina, Columbia. Overall, about one-quarter had comorbid psychotic disorders.

Mean age differed significantly across groups: It was 50 years in the dementia group, 72 years in the older group without dementia, and 35 years in the group with other diagnoses. More than 85% of the defendants were male, with no difference across groups. Those with dementia were significantly more likely to be white than were their counterparts with other diagnoses (72% vs. 57%).

After 6 months of treatment, the percentage of defendants who remained incompetent to stand trial was significantly higher in the dementia group (49%) and the older group (55%) than in the other-diagnoses group (26%), Dr. Morris said. The finding was similar after 1 year of treatment (36% and 32% vs. 15%).

In a multivariate analysis adjusted for potential confounders (sex, race, treating hospital, psychotic disorder, mood disorder, and mental retardation), defendants with dementia were significantly less likely than were those with other diagnoses to be restored at 6 months (odds ratio 0.63) and at 1 year (OR 0.58).

The older defendants were on admission, the less likely they were to be restored to competence after adjustment for the above factors and dementia. The odds of restoration at 6 months were reduced by about 10% with a 5-year increment in age (OR 0.88) and by more than 50% with a 30-year increment (OR 0.46). Again, the findings were similar for restoration by 1 year (OR 0.85 and 0.36).

Dr. Morris said the link between older age and a decreased chance of restoration could be attributable to the impact of chronic mental illnesses, medical comorbidities, or both on cognitive function.

The link between dementia and reduced odds of restoration was not unexpected, he said, but it was noteworthy that almost half of demented defendants were restored to competence. Planned research might show which treatments and factors led to restoration in this group. In the end, “[prediction] will have to be done on a case-by-case basis–it will depend on the individual s specific deficits,” he said.

Dr. Morris reported no conflicts of interest in association with the study.

SEATTLE – Defendants who are incompetent to stand trial are less likely to be restored to competence with treatment if they are older or have dementia, according to study results reported at the annual meeting of the American Academy of Psychiatry and the Law. Still, roughly half of them achieve this goal.

The U.S. Supreme Court has ruled that defendants thought to be permanently incompetent to stand trial or unlikely to be restored in the foreseeable future must either be released or evaluated for civil commitment, Dr. Douglas R. Morris noted in an interview. But it remains difficult for treating psychiatrists to predict which incompetent defendants have little probability of restoration.

Dr. Morris and his colleagues searched the Indiana forensic database for 1988–2004 to identify defendants hospitalized for treatment to restore competency to stand trial. They ascertained whether the defendants were restored to competence after 6 months (the state's statutory standard) and 1 year (the standard used in other states and published reports) and the clinical factors associated with restoration.

They identified 1,380 incompetent defendants. Some 3% had dementia, 2% were older (at least 65 years) and did not have dementia, and 95% had other diagnoses or reasons for admission.

About one-third of patients in the dementia group had Alzheimer's disease, one-third had dementia not otherwise specified, and the remaining third had dementia because of vascular causes or substance use, said Dr. Morris, a psychiatrist at the University of South Carolina, Columbia. Overall, about one-quarter had comorbid psychotic disorders.

Mean age differed significantly across groups: It was 50 years in the dementia group, 72 years in the older group without dementia, and 35 years in the group with other diagnoses. More than 85% of the defendants were male, with no difference across groups. Those with dementia were significantly more likely to be white than were their counterparts with other diagnoses (72% vs. 57%).

After 6 months of treatment, the percentage of defendants who remained incompetent to stand trial was significantly higher in the dementia group (49%) and the older group (55%) than in the other-diagnoses group (26%), Dr. Morris said. The finding was similar after 1 year of treatment (36% and 32% vs. 15%).

In a multivariate analysis adjusted for potential confounders (sex, race, treating hospital, psychotic disorder, mood disorder, and mental retardation), defendants with dementia were significantly less likely than were those with other diagnoses to be restored at 6 months (odds ratio 0.63) and at 1 year (OR 0.58).

The older defendants were on admission, the less likely they were to be restored to competence after adjustment for the above factors and dementia. The odds of restoration at 6 months were reduced by about 10% with a 5-year increment in age (OR 0.88) and by more than 50% with a 30-year increment (OR 0.46). Again, the findings were similar for restoration by 1 year (OR 0.85 and 0.36).

Dr. Morris said the link between older age and a decreased chance of restoration could be attributable to the impact of chronic mental illnesses, medical comorbidities, or both on cognitive function.

The link between dementia and reduced odds of restoration was not unexpected, he said, but it was noteworthy that almost half of demented defendants were restored to competence. Planned research might show which treatments and factors led to restoration in this group. In the end, “[prediction] will have to be done on a case-by-case basis–it will depend on the individual s specific deficits,” he said.

Dr. Morris reported no conflicts of interest in association with the study.

SEATTLE – Defendants who are incompetent to stand trial are less likely to be restored to competence with treatment if they are older or have dementia, according to study results reported at the annual meeting of the American Academy of Psychiatry and the Law. Still, roughly half of them achieve this goal.

The U.S. Supreme Court has ruled that defendants thought to be permanently incompetent to stand trial or unlikely to be restored in the foreseeable future must either be released or evaluated for civil commitment, Dr. Douglas R. Morris noted in an interview. But it remains difficult for treating psychiatrists to predict which incompetent defendants have little probability of restoration.

Dr. Morris and his colleagues searched the Indiana forensic database for 1988–2004 to identify defendants hospitalized for treatment to restore competency to stand trial. They ascertained whether the defendants were restored to competence after 6 months (the state's statutory standard) and 1 year (the standard used in other states and published reports) and the clinical factors associated with restoration.

They identified 1,380 incompetent defendants. Some 3% had dementia, 2% were older (at least 65 years) and did not have dementia, and 95% had other diagnoses or reasons for admission.

About one-third of patients in the dementia group had Alzheimer's disease, one-third had dementia not otherwise specified, and the remaining third had dementia because of vascular causes or substance use, said Dr. Morris, a psychiatrist at the University of South Carolina, Columbia. Overall, about one-quarter had comorbid psychotic disorders.

Mean age differed significantly across groups: It was 50 years in the dementia group, 72 years in the older group without dementia, and 35 years in the group with other diagnoses. More than 85% of the defendants were male, with no difference across groups. Those with dementia were significantly more likely to be white than were their counterparts with other diagnoses (72% vs. 57%).

After 6 months of treatment, the percentage of defendants who remained incompetent to stand trial was significantly higher in the dementia group (49%) and the older group (55%) than in the other-diagnoses group (26%), Dr. Morris said. The finding was similar after 1 year of treatment (36% and 32% vs. 15%).

In a multivariate analysis adjusted for potential confounders (sex, race, treating hospital, psychotic disorder, mood disorder, and mental retardation), defendants with dementia were significantly less likely than were those with other diagnoses to be restored at 6 months (odds ratio 0.63) and at 1 year (OR 0.58).

The older defendants were on admission, the less likely they were to be restored to competence after adjustment for the above factors and dementia. The odds of restoration at 6 months were reduced by about 10% with a 5-year increment in age (OR 0.88) and by more than 50% with a 30-year increment (OR 0.46). Again, the findings were similar for restoration by 1 year (OR 0.85 and 0.36).

Dr. Morris said the link between older age and a decreased chance of restoration could be attributable to the impact of chronic mental illnesses, medical comorbidities, or both on cognitive function.

The link between dementia and reduced odds of restoration was not unexpected, he said, but it was noteworthy that almost half of demented defendants were restored to competence. Planned research might show which treatments and factors led to restoration in this group. In the end, “[prediction] will have to be done on a case-by-case basis–it will depend on the individual s specific deficits,” he said.

Dr. Morris reported no conflicts of interest in association with the study.