Clinical Summary: Correlates and Predictors of Criminal Legal Involvement in People With First-Episode Psychosis
Criminal legal involvement is common early in first-episode psychosis and can derail treatment at the point when rapid engagement matters most. This study identifies who is most likely to have criminal legal involvement before and after entering care, highlighting practical targets for prevention such as substance use, untreated psychosis, and persistent excitement symptoms.
Key Findings
- Of the 378 participants with data on CLI over the 2-year follow-up period, 52 (14%) had CLI, and baseline CLI strongly predicted later CLI: 13 of 39 participants (33%) with CLI at baseline had subsequent CLI over follow-up versus 39 of 335 participants (12%) with no CLI at baseline (χ21 = 13.73, p < .001).
- CLI at baseline was tied to major treatment disruption: participants with CLI at baseline were more likely to drop out due to incarceration (7 of 39, 18%) than participants without CLI at baseline (9 of 374, 2%; χ21 = 13.63, p < .001), and 14 of 16 (88%) incarceration-related dropouts occurred within the first 6 months of treatment.
- Before treatment entry, 41 (11%) reported CLI in the month prior to baseline; participants with a longer DUP were significantly more likely to have CLI (16%) than those with a shorter DUP (6%).
- In post hoc univariate analyses adjusted for baseline CLI, higher average PANSS positive symptoms (B = .11, SE = .05, p = .02, OR = 1.12, 95% CI = 1.02–1.24), excitement symptoms (B = .24, SE = .07, p = .001, OR = 1.27, 95% CI = 1.10–1.47), alcohol use (B = .11, SE = .05, p = .02, OR = 1.12, 95% CI = 1.02–1.23), and cannabis use (B = .05, SE = .02, p = .02, OR = 1.06, 95% CI = 1.00–1.11) were significantly associated with new CLI over follow-up.
- NAVIGATE did not reduce CLI relative to Community Care: follow-up CLI rates were 13.88% and 13.61%, respectively, and after adjustment for treatment site and baseline CLI, treatment group was not significantly associated with CLI over follow-up (B = .02, SE = .38, p = .96, OR = 1.02, 95% CI = 0.55–1.87).
Criminal legal involvement affects more than 1 in 10 patients with first-episode psychosis before and during treatment, and recent CLI marks a high-risk group for recurrent CLI and early incarceration-related dropout. Standard coordinated specialty care alone did not lower this risk, so clinicians should actively target current substance use, prolonged untreated psychosis, and persistent excitement symptoms.
Practice Implications
- Screen for recent arrest, incarceration, and probation/parole at intake, because 33% of participants with CLI at baseline had later CLI versus 12% without baseline CLI.
- Intensify early follow-up and care coordination for patients with recent CLI, since dropout due to incarceration was 18% versus 2% and 88% of incarceration-related dropouts occurred within the first 6 months of treatment.
- Prioritize assessment and treatment of current substance use, especially cannabis and alcohol use, because these variables were associated with later CLI and cannabis use in the month before baseline remained the only baseline predictor in the multivariable follow-up model.
- Address persistent excitement and positive psychotic symptoms aggressively during follow-up, as average excitement symptoms remained significantly associated with CLI over follow-up in the multivariable longitudinal model (B = .20, SE = .09, p = .02, OR = 1.22, 95% CI = 1.03–1.44).
