The role of cognitive functioning in predicting restoration among criminal defendants committed for inpatient restoration of competence to stand trial

In the United States, the due process and equal protection clauses of the 14th Amendment require that criminal defendants found incompetent to stand trial be committed for competency restoration only for such a time considered to be reasonable to achieve this aim. Adherence to these protections requires that forensic clinicians have the capacity to accurately identify defendants unlikely to be restored and to provide evidence-based estimates regarding anticipated restoration timelines. The present study examines restoration rates in a large sample (N = 492) of incompetent male defendants consecutively admitted for inpatient competency restoration between 2013 and 2017. Expanding on prior research suggesting that shared cognitive deficits might underlie impaired competency-related abilities across diverse psychiatric illnesses, the predictive classification accuracy of the Mini Mental State Examination (MMSE) on restoration was examined. Results showed that 90.4% of all defendants were restored in an average of 90.5 days and that restoration rates differed across psychiatric classification, such that patients with mood and psychotic disorders were more likely to be restored whereas those with intellectual disabilities and neurocognitive disorders were less likely. The MMSE was associated with restoration outcomes, such that over 90% of patients with no or mild cognitive impairment were restored compared to 68% of patients with severe cognitive impairment. Multivariable logistic regression showed that each one-point decrease on the MMSE total score was associated with a 19.7% (p <.001) increased odds of restoration failure and the MMSE total score produced an area under the curve (AUC) of 0.767. The MMSE appears to provide a brief, reliable screening instrument to quantify the presence and severity of cognitive impairment underlying a range of serious psychiatric illness that is capable of discriminating defendants based upon their likelihood of being restored in a reasonable amount of time with a moderate degree of accuracy.