Introduction: Early psychosis is a critical period for establishing long-term trajectories in mental health and other outcomes. Experiences of coercion, such as involuntary or forensic hospitalization early in the course of illness may initiate people in cycles of coercion, disengagement, and relapse. While there is substantial evidence on involuntary admission in early psychosis, it is unclear what is known regarding forensic mental health system contact in this population. Objective: The objective of this study is to scope the extent and type of evidence available around contact with forensic mental health services early in the course of psychotic illness. In particular, to identify whether there is evidence available on prevalence or incidence of contact with forensic mental health services, and associated risk factors and outcomes, within an early psychosis population. Inclusion criteria: Studies including early psychosis participants (within 5 years of psychosis onset) and forensic mental health service use in any context will be included. Methods: MEDLINE, EMBASE, CINAHL, and PsycINFO will be searched using keyword and subject heading searches (no language or date restrictions will be applied). Searches of dissertation and thesis databases (ProQuest Dissertations & Theses Global), and forward and backward citation searching of included studies will also be conducted. Two independent reviewers will screen each study for inclusion at each stage (title/abstract, full text). Data on participants, concept, and context, as well as key findings relevant to forensic mental health service use in early psychosis, will be charted by two independent reviewers using a piloted data extraction tool. Data will be presented in tabular form and narrative summaries will be drafted. Conclusions: Findings from this scoping review will identify knowledge gaps related to forensic mental health service use in early psychosis to inform future studies involving administrative health data. Introduction Early psychosis, referring to the two- to five-year period following a first psychotic episode, is considered a “critical period” for establishing long-term outcomes (Birchwood et al., 1998). This period represents an important opportunity for secondary prevention of impairments and disabilities associated with psychosis (Birchwood et al., 1998; Fusar-Poli et al., 2017). Early psychosis intervention services have been established worldwide to capitalize on this window of opportunity, with the aim of reducing treatment delays and providing comprehensive wraparound care to facilitate recovery in young people (McGorry et al., 2008). The advent of early intervention has led to an interest in pathways to care, and service use experiences that may impact care early in the course of illness. Psychiatric hospitalization, contact with emergency services, and coercive measures such as involuntary hospitalization, are common in early psychosis (Anderson et al., 2010). Meta-analytic evidence suggests that one in two people with early psychosis are hospitalized at least once (Ajnakina et al., 2020). A systematic review found that 22% to 62% of people with early psychosis experience involuntary hospitalization (Fainman-Adelman, 2020). Furthermore, people who are admitted involuntarily are more likely to experience seclusion or control interventions in hospital (Rodrigues et al., 2019). These coercive experiences can be distressing and traumatic to the point of developing posttraumatic stress disorder symptoms (Shaw et al., 2002). The type and quality of care received in early psychosis may have an impact on long-term trajectories (Harrison et al., 2001). Experiencing coercive interventions early in the course of psychotic illness may initiate people in a cycle of coercion, disengagement, and relapse (Compton, 2005; Morgan et al., 2004). While there is a substantial literature base on psychiatric hospitalization and involuntary admission in early psychosis, contact with the forensic mental health system is often overlooked. The “forensic mental health system” refers to the intersection of the mental health system and the criminal justice system (Bettridge & Barbaree, 2008). People entering the forensic mental health system include those who committed a crime and are found not guilty on the grounds of their mental illness, or are too unwell to stand trial, which often results in detention in a forensic hospital or ward (Bettridge & Barbaree, 2008). Forensic hospital populations may also include people who are transferred from general psychiatric units due to violent behaviour (Jones et al., 2010). Treatment received in the forensic mental health system may have considerable implications for experiences with services and outcomes. The aim of forensic psychiatric services is to balance treatment of people suffering from a mental disorder who have committed a crime, along with mitigating the risk to the public. As a result, people detained in forensic settings have more restrictions and intrusions on freedom than in general psychiatric services (Tomlin et al., 2018). People admitted to a forensic hospital also experience significantly more coercive events immediately and prior to admission, compared to people admitted to general psychiatry beds, such as being handcuffed and transferred to hospital by police (McKenna et al., 2003). Length of stay in a forensic hospital tends to be long, ranging from 1 year to 10 years on average across European countries (Tomlin et al., 2021), and may be inappropriately extended with some people getting “stuck” in the system (Sampson et al., 2016). In particular, people with psychotic disorders are more likely to experience longer lengths of stay relative to people without psychotic disorders (Crocker et al., 2015; Gosek et al., 2020, p. 202; Huband et al., 2018). Premature mortality, violent offending, and rehospitalization are prevalent outcomes following discharge from forensic hospital settings (Fazel et al., 2016). As well, forensic service users, encompassing people with both severe mental illness and criminal justice involvement, may be exposed to greater levels of social and structural stigma (Livingston et al., 2011). In early psychosis, forensic hospitalization may be a barrier to accessing early psychosis intervention services, as some services exclude people with forensic involvement (Edwards et al., 2019; Standards Implementation Steering Committee, 2015). Young people with early psychosis may be at high risk of contact with the forensic mental health services. People with psychotic disorders account for most forensic admissions, as high as 80% in Canada (Chaimowitz et al., 2022) and New Zealand (Geheran et al., 2022). Contact with the criminal justice system in early psychosis is high, with Canadian data showing half of people with early psychosis having police contact on the pathway to care (Anderson et al., 2015), which may result in a forensic hospitalization. Early psychosis is a high-risk time for violence (Large & Nielssen, 2011) and homicide (Nielssen & Large, 2010), suggesting that this period may also be a high-risk time for contact with the forensic mental health system. Furthermore, evidence from Denmark suggests that as many as one in five people have a history of offending prior to their first psychiatric contact for psychotic disorder (Stevens et al., 2012) – a risk factor for violence (Large & Nielssen, 2011) and forensic mental health system contact (Chaimowitz et al., 2022). While there has been reductions in the availability of psychiatric hospital beds internationally, a number of countries, including Canada, the United States, and countries in Western Europe, have reported an increased demand for forensic mental health services in recent years (Jansman-Hart et al., 2011). In particular, Canadian data note that the growth in forensic mental health service users can be attributed to people who are younger, abuse substances, are of diverse ethno-racial backgrounds, and have committed low-level violent offences (Penney et al., 2019). This growth may suggest that more people with early psychosis are in contact with forensic mental health services. While it is clear that involvement in the forensic mental health system may have a substantial impact on outcomes in early psychosis, and this may also be a high-risk time for forensic hospitalization, there is limited evidence available on this topic. Data on forensic mental health service use in this population may be included in some studies on pathways to care in early psychosis (Fusar-Poli et al., 2020), however, this type of contact is not commonly reported. It is unclear what evidence is available regarding forensic mental health service use in early psychosis, including basic epidemiological data on prevalence and risk factors, as well as the clinical needs and outcomes of forensic patients with early psychosis. Thus, there is a need to identify and synthsize the available evidence on this topic in order to inform future studies. Given the scant literature on this topic, a scoping review is the most appropriate approach to gather information on the available evidence, rather than a systematic review. A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews, PROSPERO and JBI Evidence Synthesis was conducted and no in progress systematic reviews or scoping reviews on the topic were identified. The objective of this study is to scope the extent and type of evidence available around contact with forensic mental health services in an early psychosis population. In particular, this study aims to identify whether there is evidence available on prevalence or incidence of contact with forensic mental health services, and associated risk factors and outcomes, within an early psychosis population. Review Question What evidence is available around forensic mental health service use in people with early psychosis? Sub-questions: - What evidence is available on the prevalence or incidence of contact with forensic mental health services in early psychosis? - What evidence is available on the risk factors for forensic mental health service use in early psychosis? - What evidence is available on outcomes associated with forensic mental health service use in early psychosis?
