Clozapine Use and Forensic Outcomes in Psychiatric Inpatients Deemed Incompetent to Stand Trial

Referrals for competency restoration increased in the past decade, with the majority of incompetent to stand trial (IST) patients having schizophrenia; 25 percent of schizophrenia patients are treatment resistant. Clozapine is superior to other antipsychotics for treatment resistance but remains underutilized, particularly in forensic settings. Despite the impact of treatment resistance on the legal system, the literature on clozapine for IST patients is limited to two papers comprising 26 patients. A retrospective chart review was conducted of all IST admissions to a California hospital for 2014 to -2018, examining clinical and forensic outcomes in those newly started on clozapine and discharged. There were 191 new clozapine starts among IST patients, 92.7 percent of whom were diagnosed with schizophrenia or another psychosis. Over 90 percent were discharged on clozapine, and 36.1 percent were discharged on clozapine as trial competent; moreover, this cohort also had the shortest length of stay. This analysis indicates that most IST patients needing clozapine can be successfully treated, with a substantial proportion restored to trial competency. These data and earlier studies reinforce the concept that forensic programs have a medical duty to offer IST patients with severe mental illness a clozapine trial when indications exist for its use.