Pretrial Evaluations for Youth with First-Episode Psychosis

Journal of Forensic Psychology Research and Practice 

Oona Appel PsyD; Department of Psychiatry and Behavioral Sciences, University of California, San Francisco

Natalie Armstrong PhD; Department of Behavioral Health and Developmental Services, Forensic Services Division, Virginia, USA 

Sheresa Christopher PhD, ABPP; Department of Psychiatry and Behavioral Sciences, University of California, San Francisco

“First episode psychosis (FEP) commonly occurs between the ages of 16 and 30. A subset of this population, those aged 16 to 25, are considered transition age youth (TAY). TAY are a particularly vulnerable section of the population who are at the highest risk for mental health disorders and among the least likely to seek treatment. TAY with mental health problems are also at increased risk for involvement in the criminal legal system as compared to their peers… There are several points in the criminal legal process that provide opportunities for identification of FEP. The Sequential Intercept Model (SIM) outlines a series of interception points at which interventions can be made to prevent further criminalization of people with mental illness. Munetz and Griffin (2006) identified five intercept points: Intercept 1 includes initial law enforcement contact; Intercept 2 includes initial court hearings and detention; Intercept 3 occurs after initial court hearings and during jail detention; Intercept 4 involves supported reentry into the community from jail or prison; and Intercept 5 includes specialized community-based supervision with added support and treatment” (p. 844-845).

“The SIM can also be used to highlight various points at which legally involved individuals with early psychosis can be identified and intercepted. Competency to stand trial evaluations are included in Intercept 3 (i.e., after first court hearings and during initial detention). The current study further examines pretrial forensic evaluations as a potential intercept point for those experiencing FEP. Specifically, the study aims to estimate the proportion of FEP cases in a sample of pretrial defendants referred for forensic evaluation and describe their sociodemographic characteristics, comorbidities, and legal charges… Participants in this retrospective study were 197 pretrial defendants, ages 16 to 25, referred to the Medical University of South Carolina (MUSC) Forensic Psychiatry Program for evaluations of competency to stand trial and/or criminal responsibility from 2010 to 2017… 

Archival records of each participant were reviewed” (p. 845-846).

“This retrospective study examined the prevalence, demographics, comorbidities, and legal charges for TAY experiencing early psychosis and referred for pretrial forensic evaluations in a southeastern state. To our knowledge, this is the first study to consider using forensic pretrial evaluations as point in the sequential intercept model to identify FEP. The data indicates that forensic evaluations may be a place where identification of FEP in TAY could be effective. Understanding forensic evaluations as an intercept point may increase positive outcomes for TAY with FEP.  The data highlight several important findings. First, defendants newly diagnosed with a psychotic disorder (Group 3) comprised 15% of the total sample and 41% of those diagnosed with a psychotic disorder (Group 2). The majority of Group 3 had a history of mental health treatment (59%) and/or previous arrests, suggesting a history of system contact. Further, the arrest reports of eight defendants in Group 3 described symptoms of active psychosis, suggesting a potential for even earlier identification and diversion to treatment.  Second, almost half (46%) of Black defendants with a psychotic disorder in our sample were newly diagnosed by the forensic evaluator. In contrast, only 11% of White defendants with a psychotic disorder were newly diagnosed by the forensic evaluator” (p. 848). 

“While forensic evaluators may be the first to diagnose a psychotic disorder, their ability to intervene is currently limited. The historic aim of forensic evaluations has been to answer the psycholegal question at hand rather than make treatment recommendations or referrals. However, as posited by Martinez and Candilis (2020), perhaps it is time for forensic psychologists and psychiatrists to consider that “forensic assessment can no longer be some sterile calculation crafted by a technician blind to context and history.” The intersection of ethics and practice within forensic evaluations should be explored, with specific attention paid to whether forensic evaluators may provide referrals to EIS when identifying a defendant with FEP” (p. 849).

The findings show that a substantial portion of transition-age youth referred for pretrial evaluations are experiencing first-episode psychosis, including many who had prior system contact but were never diagnosed. This indicates that forensic evaluations function as a key intercept point where emerging psychosis is first identified. Clinically, this means evaluators are in a position to recognize untreated psychosis early and help direct youth toward appropriate intervention. The disproportionate number of newly diagnosed Black defendants further underscores the need for careful assessment to address racial disparities in identification. Because arrest reports often included clear psychotic symptoms that had not resulted in prior diagnosis, clinicians should be attentive to these cues and consider earlier referral opportunities. Overall, the findings suggest that pretrial evaluations may serve as a critical opportunity to detect first episode psychosis and facilitate diversion into treatment rather than continued legal involvement.

“There were several limitations of the current study. First, the low sample size may limit generalization of findings. The small number of non-Black minority citizens in South Carolina may also affect the reproducibility of these findings in other states. Further, the way in which attorneys identify defendant’s race is unknown (i.e., asking the defendant how they identify vs. assuming the defendant’s race based on appearance). Additionally, because this was a retrospective study that depended on evaluators’ diagnostic formulations for forensic evaluations, tools that reliably assess the presence of psychosis (e.g., the Positive and Negative Syndrome Scale) were not used. Finally, a small number of factors may have resulted in diagnostic misclassification. The availability of historical medical records varied. While some participants had records dating back many years, others had limited historical records available. Moreover, comorbid disorders (e.g., posttraumatic stress disorder) in legally involved individuals may be underdiagnosed and may thus limit diagnostic accuracy in this study” (p. 849).