Criminal Justice System Involvement Among People with ...

Community Ment Health J (2011) 47:727–736 DOI 10.1007/s10597-010-9362-9

ORIGINAL PAPER

Criminal Justice System Involvement Among People with 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

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Received: 6 January 2010 / Accepted: 15 November 2010 / Published online: 28 November 2010 Ó 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 sociodemograhic 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 relationships existed between CJS involvement during the first

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]

12 months of the trial and baseline measures of sociodemographic characteristics, psychiatric status, substance abuse, and other patient characteristics. Multivariate logistic regression analysis was then used to identify the independent 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 involvement 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 disorders 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 illness 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 genderrelated 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

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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 schizophrenia 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 programs have indeed shown potential to reduce arrests and incarceration (Erickson 2005; McNiel and Binder 2007; Steadman and Naples 2005). However, the almost universal implementation of legal leverage within these

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

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 generation antipsychotic medications in the treatment of individuals with schizophrenia (Lieberman et al. 2005). Each of the 1,460 CATIE participants were assessed periodically over an 18 month period with a wide assortment of measures. This study uses information on sociodemograhic 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 schizophrenia, 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 randomized 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 antipsychotics. 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.


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Participants

Substance Abuse

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 retardation 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).

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). Additionally, 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).

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 participant was employed. Race and ethnicity were represented 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).

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 selfreported 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 medical 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 questions 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 adherence (representing 75–100% compliance to 0–25% compliance) (Swartz et al. 2003).

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Two other measures assessed study participants’ attitudes 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 SoftwareÒ 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 procedure 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

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involvement in the CJS. Specifically, among all participants 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, employment, Hispanic ethnicity, or past military service, participants 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 significantly 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, service 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 Akathisia scale was associated with a 42% greater likelihood of CJS involvement.


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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 Veteran

12.2 21.4%

11.7 18.7%

.016 .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

Drug use

1.28

1.70

\.0001

Alcohol use

1.42

1.65

.0002

Illegal drug test positive

40.2%

67.6%

\.0001

Simpson-Angus Extrapyramidal Side Effects Scale

.218

.212

.834

Barnes Akathisia Scale

.332

.458

.010

Abnormal Involuntary Movement Index of Tardive Dyskinesia Body Mass Index

.257 30.1

.239 29.0

.66 .010

Substance abuse

Side effects

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

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 associated with CJS involvement. Participants who tested positive 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.

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Table 2 Logistic stepwise regression model predicting any criminal justice involvement (with childhood risk factors) Variablea Age in years Gender

Odds ratio .97

Wald v2

P

12.47

.0004

.59

4.08

.043

Childhood conduct problems

1.27

16.24

\.0001

Drug use

1.70

21.06

\.0001


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

Wald v2

P

.97

15.14

\.0001

Drug use

1.49

8.88

.0029

Illegal drug test positive

1.83

6.37

.012


1.46

5.42

.020

Age in years

a

Odds ratio

N = 1,083

Discussion This prospective study sought to identify independent predictors 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 selfreported 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

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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 raises 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 substance 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., measures 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 engendered 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.


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 cooccurring disorders did not increase the risk of incarceration 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 associated 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 associated 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 symptoms (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 involvement 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 appearances or even incarceration. Other methodological advantages 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.

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This study also had several limitations. Most importantly, it may not be fully representative of individuals with schizophrenia, particularly those at highest risk for substance 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 differences 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 underestimation 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 individuals with schizophrenia could reduce CJS involvement, reducing the stigma and pain associated with such CJS involvement and reduce public expenditures.

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