History of offending behavior in first episode psychosis patients: A marker of specific clinical needs and a call for early detection strategies among young offenders

Abstract

Objectives

Previous literature suggests that early psychosis (EP) patients with a history of offending behavior (HOB) have specific clinical needs. The aims of this study were to assess: (1) the prevalence of HOB in a representative sample of EP; (2) the premorbid and baseline characteristics of patients with HOB, and (3) the potential differences in short-term outcome of such patients when compared to patients without HOB.

Methods

The Early Psychosis Prevention and Intervention Centre (EPPIC) admitted 786 EP patients between 1998 and 2000. Data were collected from patients' files using a standardized questionnaire. Data of 647 patients could be analyzed.

Results

HOB patients (29% of the sample) were more likely to be male with lower level of premorbid functioning and education, have used illicit substances and have attempted suicide. They presented with a more complex clinical picture and had poorer 18-month outcome. Most importantly, they had a significantly longer duration of untreated psychosis.

Conclusions

On the basis of the high prevalence and specific features of EP patients with HOB, our study confirms a need for additional research in this domain and for the development of specific treatment strategies. Most importantly, it suggests a need for the promotion of early detection strategies among the populations of young offenders, considering that some of them may be going through the early phases of a psychotic disorder and that reduction of treatment delay and provision of well adapted interventions may have a significant impact at numerous levels in such patients.

Introduction

While reduction of delay between illness onset and treatment initiation is one of the key objectives of specialized early psychosis (EP) programs, the development of tailor cut interventions needed for certain symptomatic targets (Conus and McGorry, 2002, Conus et al., 2006, Gleeson et al., 2013, Lambert et al., 2003, Power et al., 2003) or patients subgroups (Bonsack et al., 2011, Edwards et al., 2002, Macneil et al., 2012) is also an important part of such strategies. The recent literature, reviewed below, suggest that EP patients with history of offending behavior (HOB) may deserve specific attention.

Prevalence of offending behavior has been reported to be higher among patients with psychosis compared to the general population (Fazel et al., 2009). Further, in clinical samples of patients with schizophrenia, rates of criminal conviction range between 14% and 30% and occur mainly before first episode (Humphreys et al., 1992, Modestin and Ammann, 1996, Munkner et al., 2003, Munkner et al., 2009, Prince et al., 2007). Only three papers (Munkner et al., 2009, Ramsay et al., 2011, Hodgins et al., 2011) have explored HOB in EP patients. In the first, a multicenter EP study with 477 patients, Munkner et al. (2009) found that HOB was present in 30% of them and was correlated with gender (40% in male vs 11% in female), lower social status, lower school performance, and substance abuse. They also reported that certain forms of positive symptoms (persecutory delusions or delusional jealousy with hallucination) or a predominance of positive over negative symptoms, increased the odds to have HOB (OR = 1.9, resp. 2.3). In the second based on a sample of 102 EP patients, Ramsay et al. (2011) reported very high rates of history of arrest and incarceration (71% and 58% respectively) and found that HOB patients had significantly poorer premorbid level of functioning, lower education, higher rate of social problems, started using cannabis at an earlier age, were more likely to abuse cannabis and alcohol and had higher levels of psychotic symptoms. Finally, in the third paper, based on a sample of 301 EP patients, Hodgins et al. (2011) reported a HOB rate of 24%. In this sample, HOB was correlated with gender (34% in male vs 10% in female), lower premorbid and current intelligence quotient score, and poorer academic achievement; in addition, African-Caribbean ethnic back-ground was associated with a threefold increase in the odds of offending. These studies suffer however limitations, ranging from a focus on severe crimes only (Ramsay et al., 2011), to exclusive focus on patients with schizophrenia (Munkner et al., 2009), lower level of education (Ramsay et al., 2011), specific ethnic origin (Hodgins et al., 2011, Ramsay et al., 2011) or higher illness intensity in studies based on hospitalized samples (Ramsay et al., 2011). In addition, all three studies were cross-sectional and did not provide information regarding outcome after treatment.

Considering these limitations, we explore HOB in an epidemiological treated sample of EP patients in order to assess: (1) prevalence of HOB in a representative sample of EP; (2) premorbid and baseline characteristics of HOB patients, and (3) the differences in short-term outcome of such patients when compared to patients who had no HOB. In addition, we wanted (4) to see if patients who committed offenses involving harm to others had specific characteristics compared to those who committed exclusively victimless offenses.