Criminal Justice System Involvement Among People with Schizophrenia

ORIGINAL PAPER

Criminal Justice System Involvement Among Peoplewith Schizophrenia

Greg Greenberg • Robert A. Rosenheck • Steven K. Erickson • Rani A. Desai •

Elina A. Stefanovics • Marvin Swartz • Richard S. E. Keefe • Joe McEvoy •

T. Scott Stroup • Other CATIE Investigators

Received: 6 January 2010 / Accepted: 15 November 2010 / Published online: 28 November 2010

� Springer Science+Business Media, LLC (Outside the USA) 2010

Abstract There is growing concern that people with

schizophrenia and other severe mental illnesses are

increasingly at risk for unnecessary criminal justice system

(CJS) involvement. There has been limited examination,

however, of which individual characteristics predict future

CJS involvement. This study uses data from the Clinical

Antipsychotic Trials of Intervention Effectiveness on socio-

demograhic characteristics, baseline clinical status, and

service use among patients diagnosed with schizophrenia to

prospectively identify predictors of CJS involvement during

the following year. A series of bivariate chi-square and F

tests were conducted to examine whether significant rela-

tionships existed between CJS involvement during the first

12 months of the trial and baseline measures of sociode-

mographic characteristics, psychiatric status, substance

abuse, and other patient characteristics. Multivariate logistic

regression analysis was then used to identify the indepen-

dent strength of the relationship between 12-month CJS

involvement and potential risk factors that were found to be

significant in bivariate analyses. Multivariate logistic

regression analyses indicated that past adolescent conduct

disorder, being younger and male, symptoms of Akathisia

(movement disorder, most often develops as a side effect of

antipsychotic medications), and particularly drug abuse

increase the risk for CJS involvement. Since CJS involve-

ment among people with schizophrenia was most strongly

associated with drug abuse, treatment of co-morbid drug

abuse could reduce the risk of stigma, pain, and other

adverse consequences of CJS involvement as well as save

CJS expenditures.

Keywords Schizophrenia � Mental disorder � Criminal

justice system

Introduction

The overrepresentation of persons with severe mental dis-

orders within the criminal justice system (CJS) has garnered

much attention and concern from clinicians, researchers,

and policy makers. While precise estimates remain elusive,

survey reports suggest the prevalence of serious mental ill-

ness in jails and prisons in the United States ranges between

6 and 16% (Dixon 1999; Teplin 1990). The most recent

study (Steadman et al. 2009), which focused on gender-

related issues, found that 14.5% of jailed men and 31.0% of

jailed women had a serious mental illness. These estimates

are well-above those found in the general population of

G. Greenberg � R. A. Rosenheck � R. A. Desai �E. A. Stefanovics

New England Mental Illness, Research, and Clinical Care

Center, VA Connecticut Healthcare System, West Haven,

CT, USA

G. Greenberg � R. A. Rosenheck � R. A. Desai �E. A. Stefanovics

The Department of Psychiatry, Yale University School

of Medicine, West Haven, CT, USA

S. K. Erickson

University of Pennsylvania Law School, Philadelphia, PA, USA

M. Swartz � R. S. E. Keefe � J. McEvoy

Department of Psychiatry and Behavioral Sciences, Duke

University Medical Center, Durham, NC, USA

T. Scott Stroup

Columbia University Medical Center, New York, NY, USA

G. Greenberg (&)

Northeast Program Evaluation Center,

950 Campbell Ave, West Haven, CT 06516, USA

e-mail: [email protected]

123

Community Ment Health J (2011) 47:727–736

DOI 10.1007/s10597-010-9362-9

2.8% (NAMHC 1993) and suggests factors related to serious

mental illnesses are likely risk factors for involvement with

the CJS (Lamberti 2007).

A substantial body of research suggests that mental

disorders are themselves associated with criminal conduct

(Fazel and Danesh 2002; Hodgins 1992; Hodgins et al.

1996; Wallace et al. 2004), an association that appears to

have increased since the period of deinstitutionalization of

the 1960 s and 1970 s (Eronen et al. 1996; Fazel and

Danesh 2002; Wallace et al. 2004). Schizophrenia, in

particular, appears to elevate this risk, especially when

combined with comorbid substance abuse (Arseneault et al.

2000; Fazel et al. 2009; Lafayette et al. 2003; Link et al.

1992; Mullen et al. 2000; Munetz et al. 2001). Numerous

studies have shown that schizophrenia is associated with

increased risk for violent behavior among some patients

(Arseneault et al. 2000; Brennan et al. 2000; Eronen et al.

1996; Fazel and Grann 2006; Lindqvist and Allebeck 1990;

Swanson et al. 1990; Swanson et al. 2006; Walsh et al.

2002), but fewer studies suggest a link between schizo-

phrenia and general criminality (Cuellar et al. 2007; Fazel

and Danesh 2002; Modestin and Wuermle 2005; Wallace

et al. 2004; Wessely 1998).

Understanding the risk for involvement in the CJS

among persons with schizophrenia requires an appreciation

for co-occurring factors which potentially increase this

risk, including substance abuse, lack of insight, treatment

nonadherence, and history of childhood conduct disorder

(Arseneault et al. 2000; Buckley et al. 2004; Elbogen et al.

2003, 2005, 2007; Hodgins et al. 2005; Lafayette et al.

2003; Link et al. 1992; Mueser et al. 2006; Mullen et al.

2000; Munetz et al. 2001; Swanson et al. 2007; Tiihonen

et al. 1997). Drug abuse is itself a crime, and several

studies have found an association between alcohol abuse,

schizophrenia, and violence (Swanson 1993; Rasanen et al.

1998). The high co-morbidity of alcohol abuse and

schizophrenia (Drake and Mueser 2002), and the high

prevalence of alcohol abuse among the prison inmates

(Fazel et al. 2006), suggest that alcohol abuse may also be

an important independent risk factor for CJS involvement

among persons with schizophrenia.

Many of the respected outpatient treatment models

developed in recent years to reduce the risk of incarceration

among people with severe mental illness are premised, at

least in part, on the notion of fostering treatment adherence

among patients who lack insight into their illness (Lamberti

et al. 2004; Monahan et al. 2001). These programs presume

that improvements in insight and/or compliance will lead to

reductions in arrest and incarceration and some such pro-

grams have indeed shown potential to reduce arrests and

incarceration (Erickson 2005; McNiel and Binder 2007;

Steadman and Naples 2005). However, the almost uni-

versal implementation of legal leverage within these

programs leaves it unclear whether improvements in

treatment adherence and insight lead to reduced risk of

arrest or if legal leverage itself is responsible for the

observed changes.

This study used data from the Clinical Antipsychotic

Trials of Intervention Effectiveness (CATIE), a large

medication trial conducted at 57 usual-care as well as

academic settings that compared first and second gener-

ation antipsychotic medications in the treatment of indi-

viduals with schizophrenia (Lieberman et al. 2005). Each

of the 1,460 CATIE participants were assessed periodi-

cally over an 18 month period with a wide assortment of

measures. This study uses information on sociodemogra-

hic characteristics as well as baseline clinical status and

service use to prospectively examine a broad array of

predictors of CJS involvement over the first 12 months of

the trial. We particularly examined the independent

effects and relative importance of symptoms of schizo-

phrenia, insight, medication compliance and substance

abuse.

Methods

Study Setting and Design

The CATIE trial was designed to compare the effectiveness

and cost-effectiveness of currently available atypical and

conventional antipsychotic medications through a ran-

domized clinical trial involving a large sample of patients

treated for schizophrenia at multiple sites, including both

academic and more representative community providers.

Details of the study design and entry criteria have been

presented elsewhere (Stroup et al. 2003a, b; Lieberman

et al. 2005). CATIE was conducted between January 2001

and December 2004 at 57 U.S. sites. The diagnosis of

schizophrenia was confirmed by the SCID (First et al.

1996). Patients were assigned to olanzapine, perphenazine,

quetiapine, risperidone, or ziprasidone under double-blind

conditions. Patients who discontinued their first treatment

were invited to receive other second generation antipsy-

chotics. While patients stayed on Olanzapine longer than

two other second-generation antipsychotics (Lieberman

et al. 2005), none of four second-generation antipsychotics

(Olanzapine, Risperidone, Quetiapine or Ziprasidone)

showed any statistically significant advantage over the

first-generation antipsychotic perphenazine on measures of

symptoms, neurologic side effects, quality of life,

employment, violent behavior, or neuropsychological

functioning (Rosenheck and Sernyak 2009). Assessments

were conducted by trained research assistants. Informed

consent was obtained using Institutional Review Board

approved procedures at each site.

728 Community Ment Health J (2011) 47:727–736

123

Participants

Patients 18–65 years of age with a SCID diagnosis of

schizophrenia who were able to take oral antipsychotic

medication were eligible. Patients were excluded if they

had a diagnosis of schizoaffective disorder, mental retar-

dation or other cognitive disorders; an unstable serious

medical condition; past adverse reactions to a proposed

treatment; treatment-resistant schizophrenia; or if they

were in their first episode of schizophrenia, pregnant, or

breast-feeding. Only data for study participants who had at

least one follow-up interview of between 3 to 12 months

following baseline were used in this study (i.e., 1,140 out

of the 1,460 study participants).

Measures

With the exception of the measure of CJS involvement,

which was assessed over the first 12 months of the trial, all

independent measures were assessed at baseline and details

on these measures are presented below. Further details are

available elsewhere (Swartz et al. 2003).

Criminal Justice System Involvement

A dichotomous measure was used to assess whether each

study participant reported involvement in the CJS at any of

the 3, 6, 9, or 12 month assessments. Indicators of

involvement in the CJS included being arrested, spending

one night or more in jail, visiting with a probation or parole

officer, or going to court in the previous month.

Sociodemographic Characteristics

A series of dichotomous measures represented gender,

marital status, veteran status, and whether the study par-

ticipant was employed. Race and ethnicity were repre-

sented by two dichotomous measures (Black and

Hispanic). Continuous measures of age, years of education,

and total monthly income were also included.

Psychiatric Status

Schizophrenia symptoms were measured with the Positive

and Negative Syndrome Scale (PANSS) (Kay et al. 1987)

with higher scores indicating more severe symptoms.

Depression was measured with the Calgary Depression

Scale (Addington et al. 1996). Neurocognitive function was

assessed with a composite battery of tests that were highly

correlated and combined by z-scores into a single measure

(Keefe et al. 2007).

Substance Abuse

Alcohol and drug use was assessed by two self-report

measures reflecting Alcohol Use and Drug Use items

(possible range of one to five) (Drake et al. 1990). Addi-

tionally, hair and urine tests were performed at admission

to the study to assess whether study participants had used

illegal substances in recent months (Swartz et al. 2006).

Side Effects

Three scales were used to measure the neurological side

effects of antipsychotic medication: the Simpson-Angus

Extrapyramidal Side Effects Scale (six of the teb items)

(Simpson and Angus 1970), the Barnes Akathisia Scale

(four items) (Barnes 1989), and the Abnormal Involuntary

Movement Index of Tardive Dyskinesia (the first seven

items) (Guy 1976). Body mass index, a measure of obesity

that is based on height and weight, was also assessed at

baseline.

Quality of Life, Service Use, Attitudes Toward

Medications, and Insight

Quality of life was assessed with the Heinrichs-Carpenter

Quality of Life Scale (QOLS) (Heinrichs et al. 1984), a

rater-administered scale that assesses overall quality of life

and functioning on 21 items and with the global item from

the Lehman Quality of Life Interview which assesses

overall quality of life with a seven-point item that ranges

from one (terrible) to seven (delighted) (Lehman 1988).

General health related functioning was assessed with

the mental and physical component scales of the SF-12

(Salyers et al. 2000).

Two measures of service use were examined, a self-

reported dichotomous indicator of hospitalization in the

month prior to study participation and the log of total

health care costs during that month, a global measure of

service use. The logarithmic transformation of total health

costs was estimated using baseline self report data on

inpatient, outpatient and residential psychiatric and medi-

cal services, and published unit cost data. Cost estimates

were based on methods described in detail elsewhere

(Rosenheck et al. 2006).

Medication adherence was assessed by the treating

psychiatrist who used information from self-report ques-

tions and pill counts following methods modified from

Kelly et al. (1987) to derive a summary rating of overall

medication compliance. This global judgment was rated on

a 1–4 scale with higher scores representing poorer adher-

ence (representing 75–100% compliance to 0–25% com-

pliance) (Swartz et al. 2003).

Community Ment Health J (2011) 47:727–736 729

123

Two other measures assessed study participants’ atti-

tudes toward medication and insight into illness. The Drug

Attitude Inventory (DAI) consists of 10 true or false items

that focus on subjectively perceived benefits and side

effects of antipsychotic medications (Hogan and Awad

1992). Insight or self-awareness of illness and of the need

for treatment was assessed with the Insight and Treatment

Attitudes Scale (McEvoy et al. 1989).

Childhood Risk Factors

Two dichotomous indicators represented physical or sexual

abuse prior to the age of 15. An additional scale assessed

the extent to which each participant had childhood conduct

problems prior to age 15. This scale is a simple count of

how many of the following 6 childhood problems the

participant reported prior to age 15: skipped school a lot,

ran away from home more than once, deliberately

destroyed someone else’s property, often started physical

fights, arrested or sent to juvenile court, and suspended

from school.

Analysis

There were three steps to our analyses. First, we performed

a series of bivariate chi-square and F tests to examine

whether significant relationships existed between CJS

involvement during the first 12 months of the trial and each

of the baseline measures. These analyses were performed

with the procedures PROC FREQ and PROC GLM of the

Statistical Analysis Software� system (SAS Institute,

Cary, NC) version 8.0 (SAS).

Secondly, multivariate logistic regression analysis was

used to identify the independent strength of the relationship

between 12-month CJS involvement and each risk factor

that was significant on bivariate analysis at P \ .05.

Stepwise selection of variables was used. The criterion for

entry into the model was P \ .05, and for removal it was

P [ .05. This statistical modeling was done with the pro-

cedure PROC LOGISTIC of SAS.

Lastly, we re-ran this stepwise multivariate regression

analyses, excluding measures of childhood risk factors, to

focus exclusively on current sociodemographic and clinical

measures.

Results

Sample Characteristics

Approximately 12% (N = 138) of the 1,140 participants

with any follow-up data had at least one of four types of

involvement in the CJS. Specifically, among all partici-

pants 3% (N = 34) had been arrested, 2.5% (N = 28) had

spent one night or more in jail, 8.3% (N = 95) had a visit

with a probation or parole officer, and 4.1% (N = 47) went

to court in the previous month.

While those with CJS involvement did not significantly

differ from other participants in marital status, employ-

ment, Hispanic ethnicity, or past military service, partici-

pants who were involved in the CJS were significantly

more likely to be male, black and averaged 5.1 years or

younger than other participants (Table 1). Participants who

had been involved in the CJS also had one-half of a year

less education on average and a monthly income that was

almost $200 less than other participants.

Although those with CJS involvement were not signifi-

cantly different from other participants with regard to

symptoms of schizophrenia or neurocognitive functioning,

they reported more symptoms of depression. Individuals

with CJS involvement also reported substantially greater

alcohol and drug use at baseline. While 68% of participants

who were subsequently involved in the CJS tested positive

for illegal substance use on the hair test, only 40% of

participants with no CJS involvement tested positive.

Participants with a CJS history also had more severe

Akathisia but a lower Body Mass Index.

No significant differences were found between the two

groups of participants on measures of quality of life, ser-

vice use, attitudes toward medications, and insight or

medication compliance.

The two groups of participants differed on one of the

three childhood risk factors as those with CJS involvement

had more childhood conduct problems.

Multivariate Logistic Regressions

Fewer measures were independently associated with CJS

involvement in the two multivariate regression models we

examined. In the first model, in which all measures that

were significant in bivariate analyses, including reports of

childhood experiences, were included, only five measures

were significantly associated with CJS involvement (see

Table 2). As would be expected, being younger and male

increased the likelihood of CJS involvement. In addition,

each additional childhood conduct problem increased the

likelihood of CJS involvement by 27% and self-reported

drug use was found to be strongly associated with

increased likelihood of CJS involvement in that for every

unit increase in the drug use scale an individual had a 70%

greater chance of having been involved in the CJS. There

was no significant relationship of CJS involvement with

alcohol use. Lastly, each unit increase in the Barnes Aka-

thisia scale was associated with a 42% greater likelihood of

CJS involvement.

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123

The second multivariate regression model excluded the

historic measure of childhood conduct problems. In contrast

to the first model, four rather than five measures were found

to be independently and significantly associated with CJS

involvement and gender was no longer one of these measures

(see Table 3). More importantly, CJS involvement was

found to be significantly and independently associated with

both the toxicological measure and the self-report measure of

drug use. Thus, when the measure of childhood conduct

disorder is excluded from the model, two rather than one of

the three substance abuse measures are significantly asso-

ciated with CJS involvement. Participants who tested posi-

tive for illegal drug use were almost twice as likely as others

to have been involved in the CJS. As in the previous model

individuals who self-reported drug use were still found to be

much more likely to have been involved in the CJS system

(OR = 1.49 for each unit increase), even with adjustment for

the toxicological testing. Being younger and having more

severe Akathisia remained independently and significantly

associated with CJS involvement.

Table 1 Baseline sample characteristics

No criminal justice system

involvement (N = 1,002)

Criminal justice system

involvement (N = 138)

P value

Sociodemographic

Age in years 41.6 36.5 \.0001

Male 72.1% 84.8% .0015

Married 12.0% 8.0% .17

Black 32.5% 41.3% .039

Hispanic 11.9% 8.7% .27

Years of education 12.2 11.7 .016

Veteran 21.4% 18.7% .47

Employed 18.3% 15.9% .51

Total monthly income $745 $552 .0024

Psychiatric clinical characteristics

Positive and negative syndrome scale: total score 75.1 75.6 .34

Neurocongitive functioning (Z-score units) -.0311 .0226 .34

Calgary depression scale 1.55 1.66 .027

Substance abuse

Drug use 1.28 1.70 \.0001

Alcohol use 1.42 1.65 .0002

Illegal drug test positive 40.2% 67.6% \.0001

Side effects

Simpson-Angus Extrapyramidal Side Effects Scale .218 .212 .834

Barnes Akathisia Scale .332 .458 .010

Abnormal Involuntary Movement Index of Tardive Dyskinesia .257 .239 .66

Body Mass Index 30.1 29.0 .010

Quality of life, service use, attitudes toward medications, and insight

Heinrichs–carpenter quality of life index 2.78 2.68 .30

Lehman quality of life global item 4.36 4.24 .34

SF-12 Physical Component Score 48.2 48.2 .95

SF-12 Mental Component Score 41.1 39.7 .18

Log of total monthly health care costs 6.61 6.76 .37

Hospitalized in Month prior to study 16.0% 20.1% .22

Medication adherence 1.21 1.31 .077

Drug attitude inventory .0477 .00987 .40

Insight and Treatment Attitudes Scale -.0191 .0441 .38

Childhood risk factors

Childhood physical abuse 18.8% 23.7% .16

Childhood sexual abuse 19.4% 23.0% .32

Childhood conduct problems 1.05 1.81 \.0001

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Discussion

This prospective study sought to identify independent pre-

dictors of CJS involvement in a large sample of people

diagnosed with schizophrenia who participated in an

effectiveness study of antipsychotic medication. Significant

independent predictors of CJS involvement were self-

reported conduct disorder behavior before the age of 15,

being younger and male, symptoms of Akathisia, and both

self-report and toxicological measures of drugs use. Several

hypothesized risk factors were not associated with greater

CJS involvement, including more severe schizophrenia

symptoms, poorer neurocognitive functioning, lack of

insight, medication non-compliance, and reluctance to take

medication. This study is thus consistent with prior research

which found co-morbid drug abuse to be one of the strongest

risk factors for violence and/or criminal activity among

persons with schizophrenia (Cuffel et al. 1994; Fowler et al.

1998; Rasanen et al. 1998; Swanson et al. 2006; Wallace

et al. 2004) as well as among individuals with any severe

mental illnesses (Fulwiler et al. 1997; Munetz et al. 2001;

Swartz et al. 1998; White et al. 2006). Being younger, male,

and having childhood conduct problems were independently

associated with greater risk of CJS involvement, consistent

with the findings of studies that relied on surveys of the

general population (Hamby 2005; Babinski et al. 1999;

Taylor and Bragado-Jimenez 2009; FBI 2001; Freeman

1996; Satterfield et al. 2007). In contrast to prior studies that

have found a link between schizophrenia symptoms and

violence (Swanson et al. 2006, 2008), we did not find that

more severe schizophrenia symptoms were an independent

risk factor for CJS involvement. Akathisia, a neurological

side effect of medication was also found to be significantly

and independently associated with greater CJS involvement,

although the reason for this association is not apparent.

That drug abuse increases the risk for CJS involvement

among individuals with schizophrenia is likely to be

explained by the fact that drug use itself is a crime and that

drug abuse may also lead to participation in illicit drug

distribution networks and to property crimes to fund the

purchase of illicit drugs. Additionally, substance abuse rai-

ses the risk of violent behavior and criminal activities in

general through such biological processes as the reduction

of inhibitions, impairment of cognitive abilities, increases in

excitability, irritability, or paranoia, and the irritability and

temporary cognitive impairment associated with withdrawal

(Anglin and Speckart 1988; Boles and Miotto 2003; Cuffel

et al. 1994; Fischer et al. 2001; French et al. 2004; Goldstein

1985; Johns 1997). We did not find alcohol abuse to be

independently associated with increased risk of CJS

involvement suggesting that criminal activities committed

in the acquisition and consumption of illegal drugs may be

more relevant than other factors, such as these biological

processes. Alcohol abuse is a less antisocial type of sub-

stance abuse and does not appear to pose as high a risk for

CJS involvement as criminal activities committed in the

acquisition and consumption of illegal drugs.

It is not clear from the data presented here (i.e., mea-

sures derived from a sample of individuals that were all

diagnosed with schizophrenia) whether drug abuse alone

resulted in criminal justice involvement or whether its

effects are exacerbated by the presence of co-morbid

schizophrenia. Some studies have suggested that the

combination of mental illness with substance abuse and

non-compliance with medication increases the risk of

violent behavior and CJS involvement beyond the risk that

is directly due to either mental illness or substance abuse

alone (Steadman et al. 1998; Elbogen and Johnson 2009;

Rasanen et al. 1998). However, Sacks et al. (2009) found

that co-occurring disorders generally did not increase the

risk of violence beyond the main effects of specific mental

disorders. Other studies that have addressed this issue

appear not to have investigated the degree to which the risk

of violence increased above and beyond the risk engen-

dered by the main effects of mental health and substance

abuse diagnoses by themselves (Swanson et al. 1996) or

only examined how substance abuse increased the risk of

violence among individuals with a mental illness (Cuffel

et al. 1994; Fulwiler et al. 1997; Swanson et al. 2006;

Swartz et al. 1998). More importantly, most individuals,

whether diagnosed with a mental illness or not, are not

involved in the CJS because of violent crimes and the focus

of this study was on the risk of any CJS involvement rather

than on the more specific risk of violent behavior.

Table 2 Logistic stepwise regression model predicting any criminal

justice involvement (with childhood risk factors)

Variablea Odds ratio Wald v2 P

Age in years .97 12.47 .0004

Gender .59 4.08 .043

Childhood conduct problems 1.27 16.24 \.0001

Drug use 1.70 21.06 \.0001

Barnes Akathisia Scale 1.42 4.73 .030

a N = 1,083

Table 3 Logistic stepwise regression model predicting any criminal

justice involvement (without childhood risk factors)

Variablea Odds ratio Wald v2 P

Age in years .97 15.14 \.0001

Drug use 1.49 8.88 .0029

Illegal drug test positive 1.83 6.37 .012

Barnes Akathisia Scale 1.46 5.42 .020

a N = 1,083

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123

While several studies have examined the degree to

which substance abuse increases the risk of criminal

charges or incarceration among individuals with mental

illnesses (White et al. 2006; Munetz et al. 2001; Fowler

et al. 1998) or have investigated the rates of comorbidity

and different types of offenses among already incarcerated

individuals (Abram and Teplin 1990, 1991; Ellaj et al.

2004), there appears to be little research on whether being

dually diagnosed significantly increases an individuals risk

for CJS involvement beyond the main effects of mental

illness or substance abuse alone. Only two studies seem to

have directly examined this issue. Both found that co-

occurring disorders did not increase the risk of incarcera-

tion beyond the main effects of having a substance abuse or

a mental health disorder (Erickson et al. 2008; Greenberg

and Rosenheck, Under Review). This literature would

suggest that the increased risk for CJS involvement asso-

ciated with drug use is not likely to be due to the specific

interaction of drug abuse and schizophrenia but rather is

due to the independent effect of drug abuse itself.

While many studies have examined whether a diagnosis

of schizophrenia is associated with criminal activity and/or

violence there has been relatively little examination of the

degree to which schizophrenia symptom severity is asso-

ciated with violence or criminal activity. Two previous

studies that also used CATIE data found that specific

subscales of the PANSS were differently associated with

violence (Swanson et al. 2006, 2008). One of these studies

found that while positive psychotic symptoms (PANSS

positive), such as persecutory ideation, were associated

with increased risk of violence, negative psychotic symp-

toms (PANSS negative), such as social withdrawal, were

associated with lower risk of violence. In further analyses

of our data we found no significant relationship between

either positive, negative, or general psychiatric subscales of

the PANSS and CJS involvement. Thus, while symptom

severity and particular schizophrenia symptoms may be

associated with violent behavior they are not associated

with greater CJS involvement in general.

This study had several advantages that allowed for a

better understanding of the risk factors for CJS involve-

ment among individuals with schizophrenia. Of special

value is that it was a prospective longitudinal examination,

although some of the component items of the measure of

CJS involvement could have reflected past criminal activity

e.g., visits with a probation or parole office, court appear-

ances or even incarceration. Other methodological advan-

tages of CATIE include well-validated diagnostic and

clinical measures, a wide variety of salient covariates for

use in multivariate analyses, a large and representative

comparison group of individuals with schizophrenia who

were not involved in the CJS, and a sample of individuals

with schizophrenia with broad geographic coverage.

This study also had several limitations. Most impor-

tantly, it may not be fully representative of individuals with

schizophrenia, particularly those at highest risk for sub-

stance abuse. While the inclusion of 56 sites from across

the United States suggests a geographically representative

sample, the CATIE sample consists of patients involved in

treatment who were willing to enroll in a randomized

clinical trial, a group that is potentially better off than the

overall population of individuals with schizophrenia. One

other limitation of this study is that the results presented

here may not be applicable to other countries due to dif-

ferences in incarceration rates, criminal justice codes, and

access to mental health services. A third limitation is that

study depended on self-report for the measure on CJS

involvement, which may have resulted in an underestima-

tion of this socially undesirable event. Lastly, although this

study used a longitudinal data set there was a relatively

short period between baseline measurement of risk factors

and the indicators of CJS involvement.

In spite of these limitations, the CATIE study is one of

the largest nation-wide prospective studies of people with

schizophrenia and included well validated measures of

psychiatric symptoms as well as comprehensive measures

of substance abuse and of CJS involvement. Drug abuse

was found to be the most prominent independent clinical

risk factor for CJS involvement. Although alcohol abuse is

more prevalent than drug abuse among individuals with

schizophrenia it was not a significant independent risk

factor for CJS involvement. Thus, our results suggest that

the effective treatment of drug abuse problems of indi-

viduals with schizophrenia could reduce CJS involvement,

reducing the stigma and pain associated with such CJS

involvement and reduce public expenditures.

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