First-episode psychosis in the criminal justice system: identifying a critical intercept for early intervention

Systematic Review and Meta-analysis: Rates of Violence During First-Episode Psychosis (FEP)

BACKGROUND

Most people with psychotic disorders will never commit an act of violence. However, the risk of violence committed by people with schizophrenia is higher than the general population. Violence risk is also known to be highest during the first episode of psychosis compared to later stages of illness. Despite this, there have been no comprehensive reviews conducted in the past 10 years examining rates of violence during FEP. We aimed to provide an updated review of the rate of violence in people with FEP.

STUDY DESIGN

Meta-analytical techniques were used to identify pooled proportions of violence according to severity (less serious, serious, severe) and timing of violence (before presentation, at first presentation, after presentation to services).

STUDY RESULTS

Twenty-two studies were included. The pooled prevalence was 13.4% (95% CI [9.0%-19.5%]) for any violence, 16.3% (95% CI [9.1%-27.4%]) for less serious violence, 9.7% (95% CI [5.4%-17.0%]) for serious violence and 2.7% for severe violence, regardless of time point. The pooled prevalence of any violence was 11.6% (95% CI [6.8%-18.9%]) before presentation, 20.8% (95% CI [9.8%-38.7%]) at first presentation and 13.3% (95% CI [7.3%-23.0%]) after presentation to services.

CONCLUSION

Overall, rates of violence appear to be lower in more recent years. However, due to the high between-study heterogeneity related to study design, the findings must be interpreted with consideration of sample characteristics and other contextual factors. The prevalence of violence remained high at all-time points, suggesting that more targeted, holistic, and early interventions are needed for clinical FEP groups.

A County-Level Case Study of Early Psychosis in the Context of a Hybrid Juvenile Competency Restoration and Mental Health Problem-Solving Court and Linkage to Coordinated Specialty Care Services

An important and unresolved question in the context of the implementation of coordinated specialty care (CSC) for early psychosis in the United States is the extent to which youth and young adults from marginalized backgrounds are able to equitably access CSC services. In this brief report, we describe pathways between a county hybrid juvenile competency restoration and mental health problem-solving court ('Court'), serving youth with high rates of psychosis and multiple risk factors for poor long-term outcomes, and local CSC services. We found that the Court was overall successful in linking youth with psychosis to care, but in the majority of cases this was not CSC programming more specifically. Drawing on Court and CSC records as well as family interviews, we report on factors contributing to low linkage to CSC, including family-side barriers (lack of transportation, preference for lower intensity / lower demand services) and provider-side barriers, including eligibility criteria such as duration of psychosis, that ultimately exclude otherwise eligible Court-involved youth.

Identifying Individuals With Early Psychosis in Jail: Lessons Learned for Coordinated Specialty Care Services

OBJECTIVE

This study sought to establish the feasibility of a two-component intervention embedded within a jail setting that would detect detainees with early psychosis and connect them to coordinated specialty care (CSC) in the community upon release.

METHODS

The two components of the intervention were a targeted educational campaign for correction officers and a specialized early engagement support service to facilitate jail discharge planning. Jail detainees with early psychosis were referred to the project and assessed for positive and negative symptoms, substance use, and duration of untreated psychosis (DUP). During a 24-month period, 25 individuals were referred, of whom eight were eligible and interviewed.

RESULTS

The sociodemographic and clinical characteristics of the jail detainees were similar to those of individuals in hospital settings. The median DUP was 36 weeks. One of the eight detainees with early psychosis was successfully referred to CSC; for the other detainees, social or criminal legal factors precluded referral.

CONCLUSIONS

A targeted educational campaign for correction officers and a specialized early engagement support service can be implemented in a jail setting, and referrals can be facilitated. Success of the campaign may depend on having dedicated liaisons within the jail setting (e.g., among correctional health staff) as well as liaisons in local CSC programs and leadership. Changes in the law and policy environments (e.g., criminal legal system reform) and changes in organizational practices and processes for corrections, correctional health, and local CSC programs (such as those made during the COVID-19 pandemic) require ongoing collaborations.

Mental health interventions for individuals with serious mental illness in the criminal legal system: a systematic review

BACKGROUND

Globally, individuals with mental illness get in contact with the law at a greater rate than the general population. The goal of this review was to identify and describe: (1) effectiveness of mental health interventions for individuals with serious mental illness (SMI) who have criminal legal involvement; (2) additional outcomes targeted by these interventions; (3) settings/contexts where interventions were delivered; and (4) barriers and facilitating factors for implementing these interventions.

METHODS

A systematic review was conducted to summarize the mental health treatment literature for individuals with serious mental illness with criminal legal involvement (i.e., bipolar disorder, schizophrenia, major depressive disorder). Searches were conducted using PsychINFO, Embase, ProQuest, PubMed, and Web of Science. Articles were eligible if they were intervention studies among criminal legal involved populations with a mental health primary outcome and provided description of the intervention.

RESULTS

A total of 13 eligible studies were identified. Tested interventions were categorized as cognitive/behavioral, community-based, interpersonal (IPT), psychoeducational, or court-based. Studies that used IPT-based interventions reported clinically significant improvements in mental health symptoms and were also feasible and acceptable. Other interventions demonstrated positive trends favoring the mental health outcomes but did not show statistically and clinically significant changes. All studies reported treatment outcomes, with only 8 studies reporting both treatment and implementation outcomes.

CONCLUSION

Our findings highlight a need for more mental health research in this population. Studies with randomized design, larger sample size and studies that utilize non-clinicians are needed.

Reorienting the focus from an individual to a community-level lens to improve the pathways through care for early psychosis in the United States

The implementation of coordinated specialty care in the U.S. over the past decade has led to the improvements of clinical and functional outcomes among individuals in the early stages of psychosis. While there have been advancements in the delivery of early intervention services for psychosis, it has almost exclusively focused on short-term change at the individual level. In light of these advancements, research has identified gaps in access to care and delivery of services that are driven by different levels of determinants and have the biggest impact on historically excluded groups (e.g., ethnoracial minoritized communities). Interventions or efforts that place an emphasis on community level (structural or sociocultural) factors and how they may influence pathways to care and through care, specifically for those who have been historically excluded, have largely been missing from the design, dissemination and implementation of early psychosis services. The present paper uses a structural violence framework to review current evidence related to pathways to care for early psychosis and the physical/built environment and conditions (e.g., urbanicity, residential instability) and formal and informal community resources. Suggestions on future directions are also provided, that focus on enriching communities and creating sustainable change that spans from pathways leading to care to 'recovery.' In all, this lays the groundwork for a proposed paradigm shift in research and practice that encompasses the need for an emphasis on structural competency and community-driven approaches.

Early phase psychosis and criminal conviction in United States adults

AIM

Individuals experiencing early phase psychosis (EPP) are at increased risk for legal involvement. In prior studies, between 14% and 75% of individuals with EPP reported a history of criminal offending behaviour, criminal charges, or criminal convictions. To better understand the frequency of criminal conviction in a specialty treatment clinic serving EPP clients, the research team supplemented self-reported data from the clinic intake with information from publicly available databases.

METHODS

In this sample of 309 adults, approximately one quarter of patients (n = 76) self-reported a history of arrest, incarceration, probation, or parole within 6 months of enrolment in a treatment clinic. The research team expanded upon this and collected data from a public database of court proceedings in Indiana for all clinic participants before and after enrolment.

RESULTS

Thirty-nine percent (n = 122) had three or more traffic tickets or a conviction for an ordinance violation, misdemeanour, or felony in the state of Indiana as an adult. This is over two times the national average. Drug and alcohol related convictions were the most common single conviction type, and 29% (n = 89) of subjects experienced at least one incarceration.

CONCLUSIONS

These data highlight the need for specialty clinics to partner with professionals with expertise in the prevention and management of criminal behaviour. Future studies should examine risk factors for individuals experiencing EPP and criminal conviction.

Assessing County-Level Behavioral Health and Justice Systems with the Sequential Intercept Model Practices, Leadership, and Expertise Scorecard

The Sequential Intercept Model has helped conceptualize interventions for people with serious mental illness in the criminal/legal system. This paper operationalizes the Sequential Intercept Model into a 35-item scorecard of behavioral health and legal practices. Using interviews, survey, and observational methods, the scorecard assesses an exploratory sample of 19 counties over 27 independent data collections. A series of ordinary least squares regression models assessed the predictor scores on four jail outcomes: prevalence of serious mental illness, length of stay, connections to treatment, and recidivism. Increases in pre-booking scores showed significant decreases in jail prevalence of serious mental illness at the p < 0.05 level, and post-booking scores and overall scores showed significant positive associations with connections to treatment at the p < 0.05 level, though these were non-significant after correcting for multiple comparisons. Preliminary findings suggest a combination of practices across the Sequential Intercept Model could have synergistic impacts on key jail diversion outcomes.

Childhood adversity increases risk of psychotic experiences in patients with substance use disorder

INTRODUCTION

Adverse childhood experiences (ACEs) increase the risk of psychotic experiences (PE), but little is known about heterogeneities of this association in different developmental stages, dimensions, or whether they are affected by substance use disorder (SUD). This study examines the association between different types of ACEs at various developmental stages and lifetime PE in patients with SUD in Chile.

METHODS

We included 399 consenting adults in outpatient or residential SUD treatment programs. Sociodemographic data and information about PE and ACEs were obtained by trained clinical psychologists.

RESULTS

Patients reporting PE experienced more ACEs compared to patients without PE (4.2 versus 3.4). They also experienced more complex adversities (41.8% versus 25.1%), had more psychiatric comorbidities (85% versus 70.4%), and reported using more substances (mean 4.5 versus 3.9). Adjusted association between ACEs and PE showed the highest OR for arrests (1.88), sexual abuse (1.81), alcohol abuse by parents (1.48), school exclusion (1.39), foster or residential care (18.3).

CONCLUSION

Early exposure to ACEs is a risk factor for later PE among patients with SUD. Type of ACE and the period when they occurred is important, suggesting the existence of critical periods where the individual is more susceptible to adverse environmental stimuli.

Non-Indigenous privilege in health, justice and social services preceding first episode psychosis: A population-based cohort study

BACKGROUND

There is evidence of disparities between non-Indigenous and Indigenous incidence of psychotic disorders. Despite these disparities being a clear signpost of the impact of structural racism, there remains a lack of evidence to target institutional factors. We aimed to investigate non-Indigenous and Indigenous differences in government service use prior to first episode diagnosis as a means of identifying points of intervention to improve institutional responses.

METHODS

We used a previously established national New Zealand cohort of 2385 13 to 25-year-old youth diagnosed with psychosis between 2009 and 2012 and a linked database of individual-level multiple government agency administration data, to investigate the differences in health, education, employment, child protection and criminal-justice service use between non-Indigenous (60%) and Indigenous youth (40%) in the year preceding first episode diagnosis. Further comparisons were made with the general population.

RESULTS

A high rate of health service contact did not differ between non-Indigenous and Indigenous youth (adjusted rate ratio 1.0, 95% confidence interval [0.9, 1.1]). Non-Indigenous youth had higher rates of educational enrolment (adjusted rate ratio 1.2, 95% confidence interval [1.1, 1.3]) and employment (adjusted rate ratio 1.2, 95% confidence interval [1.1, 1.3]) and were 40% less likely to have contact with child protection services (adjusted rate ratio 0.6, 95% confidence interval [0.5, 0.8]) and the criminal-justice system (adjusted rate ratio 0.6, 95% confidence interval [0.5, 0.7]). Both first episode cohorts had a higher risk of criminal justice contact compared to the general population, but the difference was greater for non-Indigenous youth (risk ratio 3.0, 95% confidence interval [2.7, 3.4] vs risk ratio 2.0, 95% confidence interval [1.8, 2.2]), explained by the lower background risk.

INTERPRETATION

The results indicate non-Indigenous privilege in multiple sectors prior to first episode diagnosis. Indigenous-based social disparities prior to first episode psychosis are likely to cause further inequities in recovery and will require a response of health, education, employment, justice and political systems.

Predicting crime during or after psychiatric care: Evaluating machine learning for risk assessment using the Danish patient registries

BACKGROUND

Structural changes in psychiatric systems have altered treatment opportunities for patients in need of mental healthcare. These changes are possibly associated with an increase in post-discharge crime, reported in the increase of forensic psychiatric populations. As current risk-assessment tools are time-consuming to administer and offer limited accuracy, this study aims to develop a predictive model designed to identify psychiatric patients at risk of committing crime leading to a future forensic psychiatric treatment course.

METHOD

We utilized the longitudinal quality of the Danish patient registries, identifying the 45.720 adult patients who had contact with the psychiatric system in 2014, of which 474 committed crime leading to a forensic psychiatric treatment course after discharge. Four machine learning models (Logistic Regression, Random Forest, XGBoost and LightGBM) were applied over a range of sociodemographic, judicial, and psychiatric variables.

RESULTS

This study achieves a F1-macro score of 76%, with precision = 57% and recall = 47% reported by the LightGBM algorithm. Our model was therefore able to identify 47% of future forensic psychiatric patients, while making correct predictions in 57% of cases.

CONCLUSION

The study demonstrates how a clinically useful initial risk-assessment can be achieved using machine learning on data from patient registries. The proposed approach offers the opportunity to flag potential future forensic psychiatric patients, while in contact with the general psychiatric system, hereby allowing early-intervention initiatives to be activated.

Structural Racism and Inequities in Incidence, Course of Illness, and Treatment of Psychotic Disorders Among Black Americans

Psychotic disorders (e.g., schizophrenia, schizoaffective disorder) are a leading cause of morbidity and premature mortality and an overlooked health inequity in the United States. European data indicate inequities in incidence, severity, and treatment of psychotic disorders, particularly for Black communities, that appear to be primarily attributable to social adversities. The dominant US narrative is that any observed differences are primarily a result of clinician bias and misdiagnosis. We propose that employing the framework of structural racism will prompt European and US research to converge and consider the multifaceted drivers of inequities in psychotic disorders among Black Americans. In particular, we describe how historical and contemporary practices of (1) racialized policing and incarceration, and (2) economic exploitation and disinvestment, which are already linked to other psychiatric disorders, likely contribute to risks and experiences of psychotic disorders among Black Americans. This framework can inform new strategies to (1) document the role of racism in the incidence, severity, and treatment of psychotic disorders; and (2) dismantle how racism operates in the United States, including defunding the police, abolishing carceral systems, and redirecting funds to invest in neighborhoods, housing, and community-based crisis response and mental health care. (Am J Public Health. 2022;112(4):624-632. https://doi.org/10.2105/AJPH.2021.306631).

Mental Health Units in Correctional Facilities in the United States

BACKGROUND

The prevalence of severe mental illness (SMI) in correctional settings is alarmingly high. Some correctional facilities have developed mental health units (MHUs) to treat incarcerated individuals with SMI.

OBJECTIVE

To identify existing MHUs in the United States and collate information on these units.

DATA SOURCES

A systematic review using Criminal Justice Abstracts, ERIC, PsycINFO, PubMed, and SocINDEX, plus an exploratory review using the Google search engine were conducted. MHUs were included if they were located within an adult correctional facility in the United States, specifically catered to SMI populations, and were in active operation as of June 2019.

RESULTS

Eleven articles were identified through the peer-reviewed literature, but there were still major gaps in the information on MHUs. The Google search identified 317 MHUs. The majority of units were located within prisons (79.5%) and served only men (76%). The Google search found information indicating that 169 (53.3%) offered groups or programming to inmates; 104 (32.8%) offered individual therapy; and 89 (23%) offered both. One hundred sixty-six units (52.4%) had dedicated mental health staff, and 75 (23.7%) provided mental health training to correctional officers. Information on funding and outcomes of the MHUs is presented.

LIMITATIONS

Use of the Google search engine and sources that have not been peer reviewed limits the robustness of conclusions about the MHUs.

CONCLUSIONS

Standards for developing and implementing MHUs are not widespread. The shortcomings of current MHUs are discussed in the context of desired criteria for size, staffing, and programming.

Analysis of Early Intervention Services on Adult Judicial Outcomes

This secondary analysis of a randomized clinical trial assesses the association of specialty team-based services for first-episode psychosis with criminal justice outcomes compared with usual treatment.

Transforming the Treatment of Schizophrenia in the United States: The RAISE Initiative

The schizophrenia spectrum disorders are neurodevelopmental illnesses with a lifetime prevalence near 1%, producing extensive functional impairment and low expectations for recovery. Until recently, treatment in the United States has largely attempted to stabilize individuals with chronic schizophrenia. The identification and promotion of evidence-based practices for schizophrenia via the Patient Outcomes Research Team, combined with international studies supporting the value of early intervention, provided the foundation for the Recovery After an Initial Schizophrenia Episode (RAISE) project. The RAISE studies further supported the value of reducing the duration of untreated psychosis and providing a multi-element treatment called coordinated specialty care (CSC) to improve outcomes for patients in usual treatment settings. Although CSC programs have proliferated rapidly in the United States, many challenges remain in the treatment and recovery of individuals with schizophrenia in the aftermath of RAISE.