Reducing Duration of Untreated Psychosis Through Early Detection in a Large Jail System - Surveys of Correction Officers
Phase: NA
Conditions: Work-Related Condition
Sponsor: Columbia University

NYSPI 7771 
Compton, Michael 
1 
 
 
 
 
 
 
Protocol Title: Reducing Duration of Untreated Psychosis Through 
Early Detection in a Large Jail System - Surveys of Correction Officers 
NYSPI 7771 
PI: Michael Compton, MD, MPH 
Version Date: 05/02/2022 
NCT05451225  
 
 
 
 
 
 
 
 
 
 
 
 

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Compton, Michael 
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Lay Summary 
Persons with serious mental illnesses are overrepresented in jails. Criminal justice (CJ) involvement, 
including jail detention, is common among those with first-episode psychosis (FEP) and frequently 
precedes psychiatric treatment engagement. Yet, no documented interventions currently exist 
specifically to identify/engage such individuals while in jail and connect them to Coordinated Specialty 
Care (CSC) in the community upon release. Expansion of CSC programs across the U.S. provides an 
opportunity for partnership with the CJ system—one that has the potential to reduce the duration of 
untreated psychosis (DUP) and thus improve outcomes. To detect FEP and reduce DUP among detainees 
in a large, urban jail, we propose to implement: (1) a “Targeted Educational Campaign” (TEC), and (2) a 
Specialized Early Engagement Support Service (SEESS) in 3 jails on Rikers Island in New York City (NYC): 
Anna M. Kross Center (AMKC), Rose M. Singer Center (RMSC) and Robert N. Davoren Complex (RNDC). 
We expect the multi-media TEC to generate referrals to the Correctional Health Services (CHS), and to 
reduce our DUP-1 (psychosis onset to antipsychotic initiation). Then, the jail-based SEESS (a Social 
Worker and Peer Specialist) will link those identified to community-based CSC (primarily OnTrackNY 
sites in NYC), thus reducing DUP-2 (psychosis onset to CSC enrollment). We will examine a set of 
hypothesized targets/mediators (the “how’s”). These are key ingredients that underpin the 
intervention’s ability to reduce DUP. The multi-media TEC will generate referrals to the CHS. How will it 
do that? By improving the behavioral capabilities, expectations, and self-efficacy (constructs from Social 
Cognitive Theory) of the Correction Officers trained. We will assess feasibility and acceptability to lay the 
groundwork for a multi-site, definitive effectiveness trial. 
 
Background, Significance and Rationale 
 
Treatment delay, or longer DUP, is linked to poorer outcomes (e.g., greater symptom severity, less 
remission, poorer quality of life) in FEP patients [1-4]. Early intervention for psychosis, as exemplified by 
CSC, leads to improved outcomes, especially when DUP is shorter. The NIMH RAISE-ETP study found 
that young people who initiate treatment within 1.5 years of symptom onset remain in treatment longer 
and show improved quality of life and work/school functioning [5]. An international movement is 
underway to determine ways to reduce DUP; however, it has largely neglected those with FEP who have 
become entangled in the CJ system. 
 
Even with mounting evidence about the importance of early intervention, early detection programs 
have been concentrated mainly in mental health (e.g., inpatient psychiatric units), primary care (e.g., 
clinics), and educational settings (e.g., colleges) to date, and thus continue to miss a significant number 
of young people who do not traverse traditional pathways to care. Pathways for FEP patients are often 
delayed or bottlenecked by common sequelae of psychosis such as social withdrawal and loss of social 
support. Additionally, social factors like unemployment, residing in public housing, ethnic minority 
status, being underinsured, and—central to our intervention—a history of being locked up, can 
postpone accessing care and lengthen DUP [6-8]. There is very little literature worldwide on this, but 
there is evidence that CJ involvement is common in many FEP samples prior to treatment engagement 
[9-13]. In the PI’s study of 191 urban, disadvantaged, predominantly African American FEP patients—the 
only study that has examined the link between DUP and jail detention history—59% had a history of 
detention (primarily in jails for misdemeanors) prior to their first treatment and 37% had been detained 
at some point during their DUP [14]. Prior detention predicted a much longer DUP [14]. Further, national 
estimates show that 24% of people in jail have had psychotic symptoms in the past 12 months [15]. 
Large jails have become “public health outposts” in screening and, if appropriate, treating, large 
numbers of individuals who might not otherwise seek or be exposed to care in the community. Jails 

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likely have an enriched population for the detection of FEP, and thus need to collaborate with 
community-based CSC. 
 
The development and implementation of a TEC and SEET in 3 jails seeks to reduce DUP for detained 
young people with FEP through “supply side” approaches. The TEC will educate Correction Officers 
about early signs and referring to correctional health services (CHS) staff. The SEET will forge referral 
networks that fast-track the initiation of CSC upon release from jail. The SEET will be comprised of two 
people: one professional social worker and one peer worker. Dr. Genevra Jones, Co-Investigator, will 
serve as an expert in peer support theories. Dr. Jones will advise on all aspects of the training and 
supervision of the peer specialist. Four interrelated bodies of knowledge guide this work. Three guide 
our TEC + SEET intervention: (1) the Scandinavian Early Treatment and Intervention in Psychosis (TIPS) 
model, (2) person-centered treatment and shared decision-making, and (3) Critical Time Intervention; 
and one guides our selection of targets/mediators (and thus intervention development): (4) Social 
Cognitive Theory. 
 
Our intervention is critically informed by the TIPS study in Scandinavia, the largest experimental study of 
early detection to date. TIPS successfully reduced median DUP in FEP patients from 15 weeks to 4.5 
using two core strategies: intensive, multi-media public information campaigns, and easy-access, low-
threshold mobile early detection teams [16]. A wide body of literature attests to the pivotal role 
education campaigns can play in improving professional and public recognition of early warning signs 
and symptoms of many disorders [17]. TIPS developed a mass media campaign to both enhance the 
public’s knowledge of psychiatric disorders in general and early signs of psychosis in particular, and to 
reduce stigma associated with schizophrenia and psychiatry. Information was tailored to 3 target 
groups: the general public, general practitioners and healthcare workers, and teachers. Information was 
distributed systematically and repeatedly over several years. Notably, when a lack of funding 
interrupted the campaign for a period of time, the rate of referrals dropped (particularly from general 
practitioners) and DUP increased again, further showing the importance of information campaigns in 
reducing DUP [18]. The success of the TIPS campaign has led to efforts to replicate the approach in other 
places. In the US, the Specialized Treatment Early in Psychosis (STEP) clinic implemented the STEP-ED 
campaign that includes: public education, outreach to and academic detailing of professionals, and rapid 
access to the STEP clinic [19]. Our proposed intervention will take place in an urban jail setting rather 
than in the community; as such, it will focus on the same two interlocking strategies (TEC and SEET) used 
by TIPS to shorten DUP for people experiencing FEP, but tailored within the confines of the jail. The NYC 
jail system has over 55,000 admissions and roughly the same discharges each year, with high 
correctional staff turnover; a continuous and broad-reaching “Targeted Education Campaign” is 
essential to ensure the messaging works. 
 
Studies show that person-centered communication (e.g., asking open-ended questions, involving 
patients in treatment decisions) has positive effects on satisfaction, treatment adherence, and health 
status [20-22]. Both the content of communication (e.g., creating space for the person’s interpretations 
of illness) and the context of communication (e.g., clinicians’ interpersonal behaviors, expectations 
about communication style, use of simplified language) influence treatment initiation and participation 
[23]. Clinician communication behaviors, such as building rapport, using open-ended questions, and 
answering questions, are a key mechanism for engagement. Communication functions that are key to 
promoting improved health outcomes include: establishing and maintaining the provider-patient 
relationship, exchanging information, validating and responding to emotions, managing uncertainty, 
sharing in making treatment decisions, and enabling patient self-management. Some of the pathways 
through which effective communication may lead to better health outcomes include improved patient 

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knowledge and shared understanding, improved access to care, improved therapeutic alliances, and 
improved patient agency [24]. Even though the health care provided in the jail system is not necessarily 
person-centered or oriented around shared decision-making, the work of the SEET—trained by the 
expert resources available at the Center for Practice Innovations and among the PI, Co-Investigators, 
and Consultants—will be framed by an approach that treats communication strategies as central to the 
future engagement of detainees in community-based CSC. 
 
Our SEET will use a Critical Time Intervention (CTI) model to mobilize support for people with FEP 
during a period of transition from jail to the community. CTI was developed in the US in the 1990s based 
on the principles of case management and Assertive Community Treatment. CTI has been used with 
persons with mental illnesses, as well as those who are incarcerated. It has been evaluated extensively, 
with good evidence for its efficacy [25-26]. In a study of CTI among men with a serious mental illness 
who were leaving prison, CTI was effective at increasing engagement with services at 6 weeks; 
differences between the intervention and control group persisted through 6 months [27]. CTI will 
organize the activities of our SEET in that it is time-limited, focused, and designed to enhance support 
and engagement in services during critical periods of transition. Assertive outreach and ongoing 
engagement in jail, combined with brokering relationships with CSC leading up to and upon release (and 
telephonic support after release until CSC engagement) will ensure that individuals are adequately 
supported while detained and following their return to the community. 
 
The jail-based TEC (and our targets/mediators) are also heavily influenced by Social Cognitive Theory 
and its concepts of behavioral capabilities (knowledge and skills), self-efficacy, and expectations. Social 
Cognitive Theory, developed by Bandura [28-29], posits that behavior is underpinned by personal 
(cognitive, affective, and biological), behavioral, and environmental factors that interact and influence 
each other bidirectionally. As applied to the field of health promotion, Social Cognitive Theory specifies 
a core set of determinants, the mechanisms through which they work, and the optimal ways of 
translating them into health practices. Five determinants are central: (1) behavioral capabilities—or 
knowledge and skills about health risks and benefits—that create the preconditions for change; (2) 
perceived self-efficacy about one’s ability to successfully perform tasks; (3) expectations about the 
outcomes of certain actions or health habits; (4) personal goals for change; and (5) perceived facilitators 
and barriers to change [30]. As described in more detail below, the TEC is an intervention that will target 
Correction Officers' knowledge about the early symptoms of psychosis, and how to make a referral to 
the CHS, their self-efficacy to detect symptoms of psychosis and make referrals, and their expectations 
about their ability to be successful in making that referral (and for referrals to result in beneficial 
outcomes). All aspects of the TEC will be designed to improve behavioral capabilities, expectations, and 
self-efficacy. That is, regardless of the media (e.g., poster, flyer, brief roll-call training for Correction 
Officers), all TEC materials will target very specific knowledge and skills, increase expectations about the 
benefits of the SEET and CSC/OnTrackNY, and increase self-efficacy about one’s ability to make a 
referral. Messaging will be specific, straight-forward, as simple as possible, and repetitive, so that we 
can effectively improve knowledge/skills, expectations, and self-efficacy in a focused way. These 
changes will ultimately influence rates of identifying detainees with undetected FEP and referral to CHS. 
Social Cognitive Theory, as well as everyday experience, suggests that in order to successfully carry out a 
behavior, one must have the necessary knowledge/skills, the beliefs that what is expected to occur 
actually will occur, and the self-confidence to carry out that specific behavior. In targeting these 
mediators, our TEC will therefore have the greatest chances of generating referrals to the CHS 
(especially referrals of quietly psychotic young people who would have otherwise gone undetected and 
thus not referred to CHS). 
 

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Abundant evidence documents racial and ethnic disparities in access to mental health services [31-33]. 
While the underlying root causes of these disparities are complex—explained by patient-level, provider-
level, and system-level factors—studies show that they persist even when controlling for differences in 
socioeconomics [32]. Racial and ethnic disparities also occur in pathways to care in FEP patients. Stigma 
remains a significant barrier to treatment and African Americans are more likely to experience negative 
routes to psychiatric care such as through the CJ system or involuntary hospitalizations [34-38]. Given 
that the population in the NYC jail system is 87% Black and Hispanic and that no specialized FEP 
treatment services currently exist within the jail system, our intervention has the potential to 
significantly improve treatment access for a population of young minorities with FEP who traditionally 
experience significant barriers to care. 
 
Specific Aims and Hypotheses 
 
Implement a Targeted Educational Campaign (TEC) within 3 jails at NYC's Rikers Island. The TEC 
is designed to lead to referrals of detainees (previously not detected as having potential mental health 
concerns) to Correctional Health Services (CHS) by Correction Officers. We expect that referral will occur 
via changes in scores on behavioral capability (knowledge/skills), expectations, and self-efficacy (among 
Correction Officers). Although this R34 feasibility study is meant to determine likely effect sizes rather 
than demonstrate statistical significance (which would be the goal of a subsequent, larger, multi-site 
study), using the data that we collect, we hypothesize that the number of referrals to CHS will be 
associated with: cumulative changes in Correction Officers' survey scores on behavioral capability, 
expectations, and self-efficacy. 
 
Description of Subject Population 
 
Specify subject population: 
Correction Officers 
Number of completers required to accomplish study aims: 
540 
Projected number of subjects who will be enrolled to obtain required number of completers: 
540 
Age range of subject population: 
over 21 
 
The implementation of the Target Educational Campaign (TEC) will involve Correction Officers working 
at three jails: the Anna M. Kross Center (AMKC), the Rose M. Singer Center (RMSC), and the Robert N. 
Davoren Complex (RNDC), all located on Rikers Island in New York City. Correction Officers in these 
three jails will be approached to complete brief surveys. The study will need 540 completed surveys over 
the course of the three time points (180 surveys at each). Since identifying information is not being 
collected from the Correction Officers, it is possible that some of Correction Officers will participate 
more than once, meaning less than 540 Officers total will participate. 
 
Recruitment Procedures 
 
Recruitment of the study sample will take place in 3 jails on Rikers Island in New York City (NYC): Anna 
M. Kross Center (AMKC), Rose M. Singer Center (RMSC), and the Robert N. Davoren Complex (RNDC). 
 
How and by whom will subjects be approached and/or recruited? 

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Correction Officers in these three jails will be exposed to the Targeted Educational Campaign (TEC). 
Correction Officers will be approached and recruited during roll call and in the staff canteen where they 
take their meal breaks, or at a time/location agreed upon by the Department of Correction, to complete 
brief surveys to assess engagement of Target C at three different times: pre-exposure, after 6 months, 
and after 12 months from the beginning of the TEC. Jason Tan de Bibiana and Adria Zern, coordinated 
and supervised by Dr. Pope and Dr. Compton, will approach Correction Officers briefly presenting the 
study and asking for completion of the survey. 
 
In the event that social distancing guidelines pertaining COVID-19 prevent the research team for going 
to the jails to survey the Officers at the 6 and 12-month follow-up time periods, we will coordinate with 
our study partners to administer the anonymous survey. The Deputy Wardens and/or Captains at the 
jails will introduce the survey during the daily roll-call meetings, and they will distribute the participant 
information document and survey to each Officer for their review. The Deputy Wardens and Captains 
will tell the Officers that the survey is voluntary and anonymous, but if they wish to complete it, they 
can put their completed survey in a container in the Officer's canteen or other communal space. 
 
Inclusion/Exclusion Criteria 
 
Inclusion Criteria 
1. Exposure to the Targeted Educational Campaign 
2. Aged at least 21 years 
 
Exclusion Criteria 
1. Children under the age of 21 
 
Consent Procedures 
 
Correction Officers staff will receive an information sheet at the beginning of the questionnaire 
explaining the study, confidentiality, and possible risks and benefits. Continuing on to the questionnaire 
will imply that the subject consents to take part to the study. The survey takes about 10 minutes. We 
will not be using a signed informed consent form so that this study can be anonymous in addition to 
being confidential. 
 
Waiver of Documentation of Consent 
 
We will not be collecting any identifiable information from survey participants (Correction Officers); the 
surveys will be anonymous. Our plan to use a “Participant Information Document” (rather than signed 
Informed Consent Form) will allow us to not collect name and signature. 
 
Study Procedures 
 
We will collect pre-Targeted Educational Campaign (TEC) and during-TEC (at 6 months and 12 months) 
survey data, which will be used to test engagement of Target C: changes in mean scores for behavioral 
capability, expectations, and self-efficacy, which are three key constructs from Social Cognitive Theory. 
The brief (10-minute) survey will assess knowledge and skills (behavioral capability), expectations, and 

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self-efficacy. It will be offered to any staff in the jail, regardless of whether they have received an in-
person (e.g., in roll call) training, since the various types of TEC materials are hypothesized to influence 
behavior, expectations, and self-efficacy. 
 
Assessment Instruments 
 
Correction Officer Surveys: will measure three constructs from Social Cognitive Theory (behavioral 
capabilities (knowledge/skills), expectations, self-efficacy), as well as social distance stigma, while 
keeping the survey to approximately 10 minutes. 
 
Risks/Discomforts/Inconveniences 
 
We do not foresee any risks for Correction Officers. Their participation is completely voluntary and the 
information collected will be confidential and anonymous, and will not be disclosed outside of the 
research team. 
 
Procedures for Minimizing Risks 
 
Any risk of perceived coercion will be addressed by fully informing participants that their decision to 
participate is voluntary and will not be reported to anyone outside of the research team. We (or in the 
event that we cannot distribute the surveys due to social distancing, the Deputy Wardens and Captains) 
will explain that their decision will in no way impact their relationship with their employer or others. 
Risks to confidentiality also will be minimized. Participants’ names and other potential identifiers will not 
be included in the dataset and each participant will be assigned a unique ID number. Surveys will be 
made anonymous by using a unique code created by the participant, as in Dr. Compton’s prior survey-
based research. For example, on the front page of the survey, respondents will be asked: 
• What is the first letter of your middle name? 
• What is the first letter of the street you live on? 
• What is the last digit of the year you were born? 
• What is the last two digits of your Social Security Number? 
Doing so will create a unique identification code for each participant (e.g., JB223, TF189) to ensure 
anonymity, while allowing us to match any participants who complete a later survey (at 6 months or 12 
months). 
 
Method to Protect Confidentiality 
 
We will collect some identifiable information that will be used for the purpose of determining basic 
eligibility criteria, and we will carefully protect such information. All information collected will be 
confidential and will not be disclosed outside of the research team. We will keep all records private and 
confidential to the extent permitted by law. 
 
All initial screenings and interviews will be conducted in the same private interview rooms/spaces used 
by Correctional Health Services staff for meetings and counseling sessions. Consent forms with 
participants' signatures will be securely stored in a locked file cabinet in a locked research office in a 
secure building. 
Subjects' name and other potential identifiers will not be included in the notes or dataset, and each 
participant in the study will be assigned a unique ID number. The only link between identifying 
information and the unique ID number will be the paper consent forms. Information pertaining to 

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individual participants will only be released with their informed and written consent, except in unusual 
cases where withholding such information might pose a serious risk or danger to the participant or 
others. Publications and presentations will not report names, initials, or descriptors that could in any 
way violate confidentiality. These efforts to protect against potential risks are expected to be very 
effective, as they have been for our prior research. 
 
Direct Benefits to Subjects 
 
There may be no definite direct benefits to individual participants of the proposed study. Given the 
minimal risks and potential benefits of the proposed research to participants and the significant 
potential benefit of knowledge gained, there is no evidence that the risk-benefit ratio would suggest 
changes to the research plan at the present time. 
 
Statistical Analysis Plan 
 
The Targeted Educational Campaign (TEC) is designed to lead to referrals of detainees (previously not 
detected as having potential mental health concerns) to Correctional Health Services (CHS) by 
Correction Officers within 3 jails at NYC's Rikers Island. We expect that referral will occur via changes in 
scores on behavioral capability (knowledge/skills), expectations, and self-efficacy (among Correction 
Officers). Although this R34 feasibility study is meant to determine likely effect sizes rather than 
demonstrate statistical significance (which would be the goal of a subsequent, larger, multi-site study), 
using the data that we collect, we hypothesize that the number of referrals to CHS will be associated 
with: cumulative changes in Correction Officers' survey scores on behavioral capability, expectations, 
and self-efficacy.  
 
Although survey participants who complete a short series of questions allow us to generate unique IDs 
that would be consistent across time, we expect that the number of surveys that matched from baseline 
to 6-months, from baseline to 12-months, and from 6-months to 12-months will be low. Therefore, 
rather than calculating changes in measurement scores as the primary outcome, each independent 
cohort (at each time point) will be considered to be a representative sample of the overall correction 
officer population over time, and we will use the measurement scores at 6-months as the primary 
outcome. 
 
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