Retrospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Psychiatr. Jun 22, 2015; 5(2): 228-233
Published online Jun 22, 2015. doi: 10.5498/wjp.v5.i2.228
Outpatient competence restoration: A model and outcomes
Nicole R Johnson, Philip J Candilis
Nicole R Johnson, Department of Behavioral Health, Washington, DC 20002, United States
Philip J Candilis, Department of Behavioral Health, Saint Elizabeths Hospital, Washington, DC 20032, United States
Author contributions: Both authors contributed to this manuscript.
Ethics approval: This project was exempted from review by the Saint Elizabeths Hospital/Department of Behavioral Health (Washington DC) Institutional Review Board.
Informed consent: Only retrospective aggregate data is used in this review so that individual informed consent was not obtained (see IRB waiver).
Conflict-of-interest: The authors declare no conflicts of interest in the conduct or publication of this work.
Data sharing: All the data used in this study is presented in the text of the paper.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Nicole R Johnson, MD, FAPA, Forensic Services Director, Department of Behavioral Health, 35 K Street, NE, Washington, DC 20002, United States. nicole.johnson3@dc.gov
Telephone: +1-202-4072121 Fax: +1-202-7249697
Received: December 5, 2014
Peer-review started: December 6, 2014
First decision: January 20, 2015
Revised: February 18, 2015
Accepted: March 16, 2015
Article in press: March 18, 2015
Published online: June 22, 2015
Abstract

AIM: To describe a model outpatient competence restoration program (OCRP) and provide data on time to restoration of adjudicative competence.

METHODS: The authors tracked the process by which individuals are referred for outpatient competence restoration (OCR) by courts in the United States capital, describing the unique requirements of American law, and the avenues available for compelling adherence. Competence to stand trial is a critical gate-keeping function of the judicial and forensic communities and assures that defendants understand courtroom procedures. OCR is therefore an effort to assure fairness and protection of important legal rights. Multi-media efforts are described that educate patients and restore competence to stand trial. These include resources such as group training, use of licensed clinicians, visual aids, structured instruments, and cinema. Aggregate data from the OCRP’s previous 4 years of OCR efforts were reviewed for demographic characteristics, restoration rate, and time to restoration. Poisson regression modeling identified the differences in restoration between sequential 45-d periods after entrance into the program.

RESULTS: In the past 4 years, the DC OCRP has been successful in restoring 55 of 170 participants (32%), with an average referral rate of 35 persons per year. 76% are restored after the initial 45 d in the program. Demographics of the group indicate a predominance of African-American men with a mean age of 42. Thought disorders predominate and individuals in care face misdemeanor charges 78% of the time. Poisson regression modeling of the number attaining competence during four successive 45-d periods showed a substantial difference among the time periods for the rate of attaining competence (P = 0.0011). The three time periods after 45 d each showed a significant decrease in the restoration rate when compared to the initial 0 to 45 d period - their relative rates were only 22% to 33% as high as the rate for 0-45 d (all P-values, compared to the 0-45 d rate, were 0.013 or smaller). However, the three periods from day 45 to day 135 showed no difference among themselves (P = 0.87).

CONCLUSION: The majority of restored participants were restored after 45 d, suggesting a model that may identify an optimal length of time to restoration.

Keywords: Forensic psychiatry, Mental competence/legislation and jurisprudence, Adjudicative competence, Competence restoration, United States

Core tip: Restoring a defendant’s competence to stand trial is a cardinal element of public sector forensic services in the United States. The Washington DC outpatient competence restoration program (OCRP) is one of a number of state programs that offers a model of education and support for incompetent defendants. Using a combination of specialized assessment, multi-modal education, support, and court leverage, the DC OCRP is the first to identify the length of time most useful for restoring its referral population. Implications of these findings can affect the court calendar, further research, and inter-agency collaboration.