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.
730 Community Ment Health J (2011) 47:727–736
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
Community Ment Health J (2011) 47:727–736 731
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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
732 Community Ment Health J (2011) 47:727–736
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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