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Objectives The objective of the present study is to describe the patterns of health service use and of prescription claims in the year preceding an offense leading to a verdict of not criminally responsible on account of a mental disorder (NCRMD). Methods Provincial health administrative databases were used to identify medical services, hospitalizations, and ambulatory prescription claims among 1,014 individuals found NCRMD in Québec. Contacts in the year preceding the offense were analyzed using descriptive analyses and latent class analysis. Results Overall, 71.4% of subjects were in contact with services for mental health reasons within a year of their NCRMD offense. Among those that received services and not hospitalized for psychiatric reasons at the time of the offense, 20.7% committed the NCRMD offense within a week of the most recent mental health contact. Among those that had at least one prescription claim for an antipsychotic, 45.8% were not taking any antipsychotic at the time of the offense. Latent class analysis provided a multidimensional representation of mental health service use and showed that 58.4% of subjects had no or very rare contact with services. Conclusions Many forensic patients are likely to have experienced service disruption or discontinuity while in the community, for reasons that may relate to perceived need for care, to service organization, or to the acceptability, availability, and accessibility of services. Given the serious impact of the “forensic” label on the lives of service users, not to mention the increased pressure on resources, the considerable economic costs, and the impact on victims, there is reason to advocate for a greater involvement of mental and physical health service providers in early prevention of violence, which requires reorganizing resources to share the forensic knowledge upstream, before an offense is committed.

Given the increasing literature on forensic assertive community treatment (FACT), we conducted a systematic review and meta-analysis to explore the effectiveness of FACT among justice-involved individuals with severe mental illness. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Sixteen studies were included in the systematic review, six of which were included in the meta-analyses for a total of 1,246 participants. Mixed results regarding health-related outcomes were found. The pre-post FACT analysis and comparison with control groups did not yield significant results other than increased outpatient service use. Results on forensic outcomes were more compelling. Both the narrative review and the meta-analysis highlighted that FACT programs may improve justice outcomes such as the number of days spent in jail. More high quality and multisite randomized controlled trials are needed to consolidate findings. Further research is needed to examine other psychosocial factors related to FACT program success.

Objectives Exposure to repeated traumatic events during childhood and adolescence is associated with high prevalences of mental illness, addictions, physical health conditions, and psychosocial difficulties (Felitti et al., 2019). The most common consequence of exposure to trauma is violence towards self and others (Hughes et al., 2017). The very high prevalence of complex trauma among forensic mental health service users challenges these settings to modify their practices, training approaches, policies, and service delivery approaches. The objective of this article is to contribute to such a transformation of forensic mental health services by clarifying the impacts of complex trauma on the trajectories and experiences of forensic mental health services users, as well as practices responding to complex trauma. Methods We reviewed the published and grey literature on complex trauma among forensic mental health service users. After synthesizing the findings, they were contrasted with our experiences as clinicians and researchers in the field of forensic mental health care through the development of a case vignette. Results We first identify the role of complex trauma and victimization in the development and maintenance of violent behaviours. We describe the negative experiences of services and care settings reported by individuals with complex trauma in the absence of recognition and understanding of traumatic experiences and their impacts. We highlight the fundamental principles of trauma-informed care (trust and transparency; safety; peer support; collaboration and reciprocity; empowerment and choice; sensitivity to gender, cultural and historical differences), as well as the clinical and organizational approaches emerging from those principles. Next, we describe the approaches developed internationally to apply and implement trauma-informed care in forensic mental health setting, and the opportunities and challenges associated with their implementation in the Québec context. Conclusion To date, few studies have documented and evaluated the implementation of trauma-informed care in forensic mental health settings. The literature reviewed in this paper indicates that an in-depth understanding of complex trauma among forensic mental health service users should be at the core of contemporary forensic research, policies and practices.

Objectives This article provides an overview of the approaches and instruments used to assess the risk of other-directed violence, with particular focus on risk formulation. Issues pertaining to the development and implementation of these instruments are briefly reviewed. Method A critical analysis of the literature pertaining to the methods and current issues related to risk assessment of other-directed violence is proposed. Results Violence risk assessment instruments are used to manage offenders struggling with mental health issues. They help inform decisions regarding monitoring, supervision, treatment and sentencing in correctional and forensic mental health settings. There are different approaches to violence risk assessment and numerous instruments offered to professionals working in these settings. Considering the structured professional judgement (SPJ) tools, they have considerably evolved in the last years with regard to the types of violence and the methods used to assess and manage risk. Examples of these innovations include taking into consideration victim safety planning and strategies to facilitate risk communication such as scenario planning based on an explanatory framework informed by risk formulation. Risk formulation is a relatively new step in the administration SPJ tools, and invites users to go beyond documenting the presence and relevance of specific risk factors by allowing them to consider the nature and the etiology of violence in an individualized manner. Risk formulation integrates both relevant risk and protective factors that facilitate the process of scenario planning and the identification of successful risk management strategies. Conclusion Although structured approaches to violence risk assessment of offenders struggling with mental health issues have become more and more frequent in many settings, some methodological and implementation issues still have to be tackled. In spite that these issues warrant further discussion based on new empirical data, their contribution to risk reduction and to the success of social rehabilitation of the individuals at the centre of these assessments is undeniable.

Background Housing First does not, on average, reduce criminal justice involvement. This analysis aims to test whether the overall absence of an impact is due to intervention effect heterogeneity as a function of the pattern of lifetime criminal justice involvement, identified through latent class analysis conducted through earlier work. Methods This analysis relied on data from the Montréal, Toronto and Vancouver sites of the Canadian At Home/Chez Soi randomized controlled trial, merged with administrative records of lifetime criminal charges (N = 1,321). Negative binomial models with interaction terms were used to estimate the impact of Housing First, in comparison to treatment as usual, on violent charges, acquisitive charges (e.g., theft, sex work), and administration of justice charges (e.g., breach of probation), for each pre-identified profile. Results Participants with past criminal justice involvement associated with a chronic history of homelessness or with criminalized substance use experienced a decrease in violent charges as a result of Housing First, whereas those with no or little past criminal justice involvement experienced a marginal increase. Housing First did not affect acquisitive or administration of justice charges, regardless of profile. Conclusions Findings suggest that integrating criminological or forensic mental health tools, knowledge and approaches into the multidisciplinary teams that support Housing First service users may be an effective solution, so that all aspects of their recovery, including potential criminogenic needs, are addressed. Future research should focus on the feasibility and effectiveness of such adjunct interventions.

Objective The objective of this paper is to provide an overview of the provision and organization of forensic mental health services around the world. In particular, we attempt to address the following question: What system-level characteristics are important to consider in relation to the organization and structure of forensic mental health services? Methods To do so, we synthesize publicly accessible information, identified through Academic Search Complete (EBSCO), ProQuest Central, Scopus, PsycInfo, Google Scholar and Google, to describe how forensic systems are organized throughout the world. We examine the fundamental principles in the organization of services and examine potential quality indicators. Results This review is a steppingstone for the identification of best practices. Based on these fundamental principles, an efficient forensic mental health system would include the following elements: providing a comprehensive and balanced continuum of services; integrating services within and between systems; matching services to individual need; adhering to human rights; responding to population diversity; and using the best available evidence to make system-wide improvements. Conclusion Though all of these system-level principles are important, we focus on how the first three (service continuum, system integration, and service matching) may be applied to the organization of forensic mental health services.

The knowledge–practice gap remains a challenge in many fields. Health research has shown that professional networks influence various aspects of patient care, including diffusion of innovative practices. In the current study, we examined the potential utility of professional networks to spread the use of violence-risk-assessment tools in forensic psychiatric settings. A total of 6,664 reports, written by 708 clinicians, were used to examine the effect of clinicians’ use of risk-assessment tools on subsequent reports by other clinicians with whom they share patients. Results show that professional networks serve as an important channel for the spread of assessment practices. Simulation of a continuing education program showed that targeting more influential clinicians in the network could be 3 times more efficient at disseminating best practices than randomly training clinicians. Decision-makers may consider using professional networks to identify and train influential clinicians to maximize diffusion of the use of risk-assessment instruments.

Plusieurs programmes et services ont été développés en vue d’adapter les interventions policières et les processus judiciaires aux besoins des personnes ayant des troubles mentaux, de surcroît lorsque celles-ci sont en situation d’itinérance. La présente étude adopte un devis qualitatif descriptif afin d’explorer l’expérience qu’ont les personnes vivant à la fois une situation d’itinérance et un trouble mental de ces services. L’analyse de six entretiens révèle les représentations complexes que se font les participants de leur implication judiciaire, entre sentiment de responsabilité et d’injustice ; le manque de légitimité vécu dans la plupart de leurs interactions, auquel l’accompagnement offre parfois un contrepoids ; et enfin des perceptions distinctes des services selon leur nature « régulière » ou « alternative ». Les participants mettent à l’avant-plan dans leurs récits les principes de la justice procédurale, en particulier ce que des processus dits « alternatifs » permettent à cet égard, mais également le caractère exceptionnel d’interactions respectant ces principes. Les résultats nous amènent à interroger la capacité des diverses institutions sociales à offrir des services vécus comme justes par les personnes situées au confluent d’identités sociales marginalisées, à différents moments de leurs parcours., Several programs and agencies have been developed and implemented in attempts to adapt police and legal processes to the needs of people living with mental illness, especially those who experience homelessness. The present qualitative descriptive study examines how homeless people with mental illness experience police and justice-related services. Analysis of six interviews reveals complex attitudes toward involvement with these services, including feelings of responsibility and injustice ; the perception that most programs and agencies are not fulfilling their mandates, although this failure is sometimes counterbalanced by positive experiences with community-based support programs ; and different views of those services considered to be either “regular” or “alternative” processes. Participants emphasized the principles of procedural justice – in particular what procedures labelled “alternative” offered in this regard, although they noted that even these interactions were unlikely to fully respect these principles. Our results raise questions about the ability of different social institutions to offer services that will be considered fair by individuals who experience convergent marginalized identities and are at different stages along their personal trajectories., Varios programas y servicios han sido desarrollados con el fin de adaptar las intervenciones policiales y los procesos judiciales a las necesidades de las personas con problemas de salud mental, quienes además están en situación de calle. Este estudio adopta una aproximación cualitativa descriptiva con el fin de explorar la experiencia de estos servicios de las personas que viven a la vez una situación de calle, y un problema de salud mental. El análisis de seis entrevistas revela las representaciones complejas, entre sentimiento de responsabilidad e injusticia, de los participantes acerca de su implicación judicial ; la falta de legitimidad vivida en la mayor parte de sus interacciones, a la cual el acompañamiento le ofrece a veces un contra peso ; y, finalmente, las percepciones diferenciales de los servicios según su naturaleza “regular” o “alternativa”. Los participantes ponen en el primer plano de sus narrativas los principios de la justicia procedural, en particular lo que permiten a este respecto los llamados procesos “alternativos”, pero, igualmente, el carácter excepcional de las interacciones que respetan estos principios. Los resultados nos llevan a cuestionar la capacidad por parte de diversas instituciones sociales de ofrecer servicios vividos como justos por las personas situadas en la confluencia de identidades sociales marginalizadas, en diferentes momentos de sus trayectorias.

This study identified factors that predicted which of 713 clinically documented incidents of aggression—threats to kill, assault, or sexual assault—committed by 404 forensic psychiatric patients we...

Individuals experiencing both homelessness and mental illness have high rates of interaction with public safety and criminal justice institutions. Several cross-sector diversion programs have been developed over the past decades as alternatives to incarceration. Most of these initiatives rely on the commitment and expertise of frontline practitioners from different sectors and backgrounds. This research examines the perspectives of frontline practitioners regarding practices and policies that target justice involvement of individuals experiencing both homelessness and mental health issues in a Canadian urban context. Findings from focus groups with 55 participants drawn from the police, the community and public health and social services sectors indicate that frontline practitioners value and support close proximity in cross-sector action, while raising ethical and legal issues related to this type of practice. Participants also describe how exclusion from services for this population, lack of involvement from corrections, housing, and forensic mental health services, and ineffective use of involuntary treatment mechanisms shape and constrain frontline practice. The findings of this article give voice to the specific concerns of frontline service providers. Given these findings, we suggest potential strategies to better serve individuals who are identified as “harder to serve” but who might also benefit from diversion from the criminal justice system.

This study aimed to characterize lifetime criminal involvement among homeless people with mental illness in Canada ( N = 1,682). A latent profile analysis yielded five classes. Most participants fell within the Fewer Needs (75.5%) group, characterized by less complex psychosocial histories and few criminal charges. Participants with Extensive Criminogenic Needs (5.0%) and Acute and Extensive Criminogenic Needs (5.0%) had more charges for justice administration, violent, and mischief/public order offenses and were more likely to have been charged before their first homelessness episode. Participants with Needs Associated with Homelessness (10.6%) and Needs Associated with Drugs (3.8%) were similar, although the former had the longest history of homelessness and the latter had more drug-related charges and were most likely to have drug use disorder. This typology, which sheds light on the cumulative needs associated with different patterns of lifetime criminal involvement among homeless people with mental illness, could guide prevention initiatives and intervention strategies.

Objectives: Exposure to adverse childhood experiences (ACEs) is associated with increased risk of criminal justice involvement and repeated victimization among homeless individuals. This study aimed to (1) examine whether the relationship between cumulative ACE score and odds of experiencing criminal justice involvement and victimization remains significant over time after receiving the Housing First (HF) intervention and (2) investigate the moderating effect of cumulative ACE score on the effectiveness of the HF intervention on the likelihood of experiencing these outcomes among homeless individuals with mental illnesses. Methods: We used longitudinal data over the 2-year follow-up period from the At Home/ Chez Soi demonstration project that provided HF versus treatment as usual (TAU) to homeless adults with mental illness in five Canadian cities (N = 1,888). Results: In all 4 follow-up time points, the relationship between cumulative ACE score and both outcomes remained significant, regardless of study arm (HF vs. TAU) and other confounding factors. However, cumulative ACE score did not moderate intervention effects on odds of experiencing either outcome, suggesting that the effectiveness of HF versus TAU, with regard to the odds of being victimized or criminal justice involvement, did not differ by cumulative ACE scores over the course of study. Conclusions: Findings suggest that providing services for homeless individuals with mental illness should be trauma informed and include specialized treatment strategies targeting the experience of ACEs and trauma to improve their treatment outcomes. An intensive approach is required to directly address the problem of criminal justice involvement and victimization in these individuals.

Objective There is scant research on the effectiveness of permanent supportive housing for homeless women with mental illness. This study examines the effectiveness of Housing First with an unprecedentedly large sample of homeless women from five Canadian cities, and explore baseline risk factors that predict social, health and well-being outcomes over a 24 month-period. Methods The At Home/Chez Soi multi-site randomized controlled Housing First trial recruited over 600 women between October 2009 and July 2011. This is a post-hoc subgroup exploratory analysis of self-identified women with at least one follow-up interview who were randomized to Housing First (HF) (n = 374) or treatment-as-usual (TAU) (n = 279) and had at least one follow-up interview. Linear mixed models and generalized estimating equations were used after multiple imputation was applied to address missing data. Results At the end of follow-up, the mean percentage of days spent stably housed was higher for women in the intervention 74.8% (95%CI = 71.7%–77.8%) compared with women in the treatment-as-usual group, 37.9% (95%CI = 34.4%–41.3%), p Conclusions Housing First interventions ensured that women experiencing homelessness are quickly and consistently stably housed. However, they did not differentially impact health and social measures compared to treatment as usual. Ensuring positive health and social outcomes may require greater supports at enrolment for subgroups such as those with low educational attainment, and additional attention to severity of baseline mental health challenges, such as suicidality. Trial registration International Standard Randomized Control Trial Number Register Identifier: ISRCTN42520374.

BackgroundThe public often perceives the insanity defense as a “get out of jail free card”. Conversely, several studies demonstrate the substantial control imposed upon these defendants. This study compares Review Boards decisions regarding people found not criminally responsible on account of mental disorder (NCRMD) to criminal courts decisions regarding convicted offenders for similar offenses in Canada.MethodDetention, using logistic regression, and duration under detention and supervision, using Cox regression, were compared between a cohort of 1794 individuals found NCRMD in three Canadian provinces (Quebec, Ontario, and British Columbia) between 2000 and 2005 followed until 2008 from the National Trajectory Project and a national sample of 3,20,919 Canadians convicted of criminal offense from Statistics Canada's Criminal Court Survey.ResultsIndividuals found NCRMD are 3.8 times (95% CI 3.4–4.3) more likely to be detained than convicted offenders as well as 4.8 times (95% CI 4.5–5.3) and 2.9 times (95% CI 2.6–3.1) less likely to be released from detention and supervision, respectively. One year after the verdict, 73% of the NCRMD accused were still under legal supervision and 42% were still in detention, whereas these proportions were, respectively, 41 and 1% for their convicted counterparts. Interaction effects show that sex, age, jurisdiction, number of offenses, and severity of crimes committed have a differential impact on decisions applied to NCRMD accused compared to convicted persons.ConclusionContrary to popular perceptions, the insanity defense is not a loophole. Differences as to factors influencing the trajectories of the two samples confirm that Review Boards are able to distance their practices from the criminal courts and can set aside, at least in part, the principles of proportionality and punitiveness governing the traditional sentencing practices.

This paper adopts a conventionalist approach to shed light on the measurement and reification problems that underlie the quantification of desistance from crime in the scientific literature. Analysis of 100 papers spanning three decades indicates that approaches based on theoretical classification have recently lost ground in favor of more sophisticated techniques aimed at empirically identifying subgroups. These techniques convey the impression of objectiveness among statistics users and consumers and, as a result, the classification “desisters” and “persisters” are increasingly reified. Findings suggest that the quantification of desistance is intimately linked to the maintenance of a classification system that constitutes delinquency as a stable category and contributes to “making” up new kinds of people over which institutions can legitimately intervene.

Objective: This study investigates the association between impulsiveness and six dimensions of recovery among homeless people with mental illness. Method: The sample was composed of 418 participants of a randomized controlled trial of Housing First, a recovery-oriented program that provides immediate access to permanent housing. The reliable change index method was used to provide an estimate of the statistical and clinical significance of the change from baseline to 24 months (i.e., clinically meaningful improvement), on outcomes that pertain to recovery dimensions: psychiatric symptoms (clinical), physical health and substance use problems (physical), residential stability (functional), arrests (criminological), community integration (social), and hope and personal confidence (existential). We tested for the effect of impulsiveness, assessed with the Barratt Impulsiveness Scale–11, on clinically meaningful improvement on each specific outcome, adjusting for age, gender and intervention assignment, as both intervention arms were included in the analysis. Results: For every increase in total impulsiveness score by one standard deviation, the odds of experiencing clinically meaningful improvement decreased by 29% (OR = 0.71, 95% CI, 0.55 to 0.91) on the clinical dimension and by 53% (OR = 0.47, 95% CI, 0.32 to 0.68) on the existential dimension. However, changes in outcomes pertaining to physical, functional, criminological, and social dimensions were not significantly influenced by impulsiveness. Conclusions: Findings highlight the importance of addressing impulsiveness in the context of recovery-oriented interventions for homeless people with mental illness. Further research may be required to improve interventions that are responsive to unique needs of impulsive individuals to support clinical and existential recovery., Objectif : La présente étude porte sur l’association entre l’impulsivité et six dimensions du rétablissement chez des personnes en situation d’itinérance vivant avec une maladie mentale. Méthode : L’échantillon est composé de 418 participants à un essai randomisé contrôlé de l’approche Logement d’abord, un programme axé sur le rétablissement qui offre un accès immédiat à un logement permanent. La méthode de l’indicateur de changement fiable a été utilisée afin de fournir une estimation de la signification statistique et clinique du changement de l’entrée dans l’étude à 24 mois (c.-à-d., une amélioration cliniquement significative) pour les mesures qui ont trait aux dimensions du rétablissement: symptômes psychiatriques (clinique), santé physique et problèmes liés à l’utilisation de substances (physique), stabilité résidentielle (fonctionnelle), arrestations (criminologique), intégration communautaire (social) et espoir et confiance en soi (existentiel). Nous avons testé l’effet de l’impulsivité, évaluée à l’aide de l’échelle d’impulsivité de Barratt, sur l’amélioration cliniquement significative pour chaque mesure, en ajustant pour l’âge, le genre et l’assignation à une intervention, les deux volets de l’intervention étant inclus dans l’analyse. Résultats : Pour chaque augmentation du score total d’impulsivité d’un écart-type, les probabilités de connaître une amélioration cliniquement significative diminuaient de 29% (RC = 0,71; IC à 95% 0,55 à 0,91) pour la dimension clinique et de 53% (RC = 0,47; IC à 95% 0,32 à 0,68) pour la dimension existentielle. Toutefois, les dimensions physique, fonctionnelle, criminologique et sociale n’étaient pas influencées significativement par l’impulsivité. Conclusions : Les résultats soulignent l’importance de prendre en compte l’impulsivité dans le contexte d’interventions axées sur le rétablissement pour les personnes en situation d’itinérance vivant avec une maladie mentale. Des recherches futures pourraient être nécessaires pour améliorer les interventions afin qu’elles soutiennent mieux le rétablissement clinique et existentiel en répondant aux besoins uniques des personnes impulsives.

Involuntary treatment orders (ITOs) represent coercive leverage for treatment adherence against the will of individuals incapable of providing consent. ITOs have failed to demonstrate benef...

Most countries have implemented guidelines and policies in response to COVID-19 that have had a direct impact on institutionalized or incarcerated persons with mental health problems. Although thes...

To quantify the demand for forensic psychiatric services in Ontario over the past 25 years and investigate whether the sociodemographic, clinical and offense-based characteristics of forensic patients have changed over time. We investigated all forensic admissions from 1987 to 2012 resulting in a disposition of Not Criminally Responsible on account of Mental Disorder (N = 2533). We present annual proportions of patients with specified sociodemographic, clinical and offense characteristics, and investigate whether the duration of forensic system tenure varies as a function of admission year, psychiatric diagnosis, or index offense. There has been a steady increase in forensic admissions over this time period, particularly individuals with comorbid substance use disorders and individuals of non-Caucasian ethno-racial background. The proportion of persons committing severe violence has remained low and has decreased over time. Having a comorbid personality, neurological, or substance use disorder significantly increased forensic system tenure, as did committing a violent offense. Individuals who came into the system in earlier years had slower rates of discharge compared to more recent admissions. Defining the trends characterizing the growth of the forensic population has important policy implications, as forensic services are costly and involve a significant loss of liberty. The current results indicate that young, substance abusing individuals of diverse ethno-racial backgrounds and who commit relatively low-level violence comprise an increasing proportion of Ontario’s forensic population, and suggest that treatment must be optimized to best serve the needs of these individuals.

BACKGROUND Few studies have examined attitudes that may promote the social inclusion of persons with an intellectual disability (ID) among health care providers (HCPs). Yet these attitudes could impact the accessibility and quality of services provided to this population, as well as the general attitudes of HCPs. The objectives of this study were to (1) examine HCPs' pro-inclusion attitudes toward people with ID, (2) compare these to the general population's attitudes and (3) examine how HCPs' attitudes vary as a function of their socio-demographic characteristics. METHOD The Attitudes Toward Intellectual Disability Questionnaire was administered to 367 HCPs and a representative sample of the Quebec population (N = 1605). RESULTS Results indicated that at least half of HCPs displayed positive attitudes, that is, attitudes that are compatible with notions of social inclusion and equal rights, toward individuals with ID. Positive attitudes were less frequently observed for the Interaction and the Sensitivity or tenderness factors measured by the Attitudes Toward Intellectual Disability Questionnaire. In comparison with the general population, HCPs exhibited more positive attitudes on the Knowledge of causes and Sensitivity or tenderness factors and less positive attitudes on the Interaction factor. HCPs who regarded themselves as more knowledgeable about ID and those who reported higher quality contacts or interactions with persons with ID expressed attitudes that were more favourable toward social inclusion. CONCLUSIONS In addition to providing general knowledge about ID and the specific health care needs of individuals with ID, training programmes should also promote interactions with this population. Further studies are needed to document HCPs' pro-inclusion attitudes toward people with ID and to assess the impact of interventions on these attitudes.

Using data from the National Trajectory Project, we compared 50 individuals found Not Criminally Responsible on account of Mental Disorder (NCRMD) for sexual offences with 50 age- and gender-matche...

We examined the predictive validity of individual, service, and neighborhood factors for aggression by 1,491 forensic clients found Not Criminally Responsible on account of Mental Disorder (NCRMD), under the jurisdiction of a Review Board, and thus subject to supervision conditions. Younger patient age and personality disorder diagnosis were associated with both clinically documented aggression and recidivism. Medication adherence was related to clinically documented aggression, but not criminal recidivism. Number of reports from an institution (possibly reflecting assessor or institutional experience with NCRMD assessments) did not predict clinically documented aggression, but more comprehensive risk reports were associated with fewer such clinical incidents. More community mental health resources within a 45-min drive of an individual’s residence were associated with less recidivism, but not less clinically documented aggression. We conclude that extra-individual factors are related to aggression, the neighborhood to which forensic clients return matters, and effects can differ for criminal recidivism versus clinically documented aggression.

There is little study of the impacts of screening on distal outcomes such as recovery or adverse incidents during incarceration. Furthermore, screening practices vary greatly between jurisdictions;...

Objective: Disparities in mental health care exist between regional and demographic groups. While screening is recommended as part of a correctional mental health strategy, little work has been done to explore whether it can narrow regional and demographic disparities in access to care. We compared treatment access rates by sex, race, age, and region in relation to screening results. Methods: We conducted a retrospective cohort study using administrative data. All 7965 admissions to the prison system were followed for a median of 14 months. Results: Males and non-Indigenous minority racial groups had lower rates of treatment regardless of screening results; they were less likely both to self-report needs and to receive treatment if these needs were reported. Regional differences revealed higher treatment rates in Atlantic Canada and Ontario, as well as higher rates of inmates self-reporting needs on screening who did not receive treatment in the Atlantic, Québec, and Pacific regions. There were minimal differences between inmates of different age groups. Conclusions: Findings suggest potential resource gaps and/or differences in the performance of screening to detect mental health needs across demographic and regional groups. Screening did not narrow, and may have widened, differences between groups.

Individuals with mental illnesses who experience homelessness have frequent interactions with the criminal justice system. Correctly measuring this involvement is essential to develop and evaluate the efficacy of intervention programs. Criminal justice involvement is typically assessed through administrative records or self-reported accounts. The aims of this study are to: 1) assess agreement between self-report and administrative data related to court appearances, and 2) identify individual characteristics that affect discrepancies between sources. Participants were 468 homeless persons with mental illness from the Montreal site of the At Home/ Chez Soi randomized controlled trial, in Canada. Self-reported data was collected through an interviewer-administered questionnaire. Administrative data was collected through provincial and municipal court databases. Overall, agreement was good. Discrepancies were more common among those with a diagnosis of mood disorder with psychotic features, and those with a criminal history. Increased age and interviewer’s perception of sincerity and interest increased likelihood of concordance. Generally, high agreement between self-report and administrative data suggests that either source can provide reliable information. Further work to understand predictors of discrepancies could further enhance the quality of data collected through these different sources.

Forensic service use was examined using self-report interview data from a prospective study of homeless persons with mental illness (N = 435) and administrative file review data from a Canadian forensic system. Of the study's participants, 41% had contact with forensic services, 40% had contact with community clinics, and 20% had been admitted to the forensic hospital. Forensic involvement was associated with age, gender, disorder, impulse control and social network. Most participants with forensic contacts received services for minor, mostly poverty-related offenses. Findings highlight the need for early intervention for individuals with severe mental illness as one mechanism for preventing crime.

The goal of this study is to identify patterns of various forms of aggression in the general population and their psychosocial and environmental correlates. Data from the Montreal Epidemiological Catchment Area study (N = 1855) were analyzed using latent class analysis and multinomial logistic regression. Four classes were identified: a ‘Low Aggression’ profile (91.4%) – individuals were older, more likely to be women, and had greater quality of life – and three profiles with individuals displaying aggression. The ‘Acting out’ profile (4.3%) reported property and mild verbal aggression, and profile membership was associated with impulsivity. The ‘Violent’ profile (2.0%) reported severe verbal aggression and physical aggression, and membership was associated with posttraumatic stress disorder and substance use disorders. Finally, the ‘Self-injuring’ profile (2.2%) reported self-harming behaviors along with mild verbal aggression and property destruction and were psychologically distressed. Findings are consistent with the risk factors in violence risk assessment instruments. They also shed light on how different types of aggression are interrelated and may help in the development of a psychological formulation of individuals for whom different types of aggression co-occur so that integrated prevention strategies may be put in place.

The objectives of this study were to describe the disposition and housing trajectories of individuals found Not Criminally Responsible on account of Mental Disorder (NCRMD), and the factors that predict different trajectories. To do so, disposition and housing status were coded for 934 NCRMD patients over a 36-month follow-up period. Sequential data analysis resulted in four distinct trajectories: detention in hospital, conditional discharge in supportive housing, conditional discharge in independent housing, and absolute discharge to unknown housing. The likelihood of a placement in supportive housing compared with detention significantly decreased for individuals with a higher index offense severity. Less restrictive trajectories were significantly predicted by clinical factors. The results revealed little change in the disposition and housing trajectories of NCRMD patients. Furthermore, decisions about disposition and housing placement reflect a knowledge-practice gap between risk factors known to be predictive of community resources use in the forensic population. Copyright © 2016 John Wiley & Sons, Ltd.

In the Canadian forensic mental health system, a person found Not Criminally Responsible on account of Mental Disorder (NCRMD) and given a conditional discharge returns to the community while remaining under the jurisdiction of a provincial/territorial Review Board. However, the individual can be re-hospitalized while on conditional discharge, for reasons such as substance use, violation of conditions, or violence. We investigated whether being re-hospitalized has an impact on the factors associated with the subsequent Review Board disposition. Persons found NCRMD from the three largest Canadian provinces who were conditionally discharged at least once during the observation period were included in the sample (N = 1,367). These individuals were involved in 2,920 disposition hearings; nearly one-third of patients (30%) were re-hospitalized after having been conditionally discharged by the Review Board. The factors examined included the scales of the Historical Clinical Risk Management-20 and salient behavior that occurred since the previous hearing, such as substance use or violence. The greater presence of clinical items resulted in a greater likelihood of a hospital detention decision at the next hearing. The effect was larger for the re-hospitalized group than for the group who successfully remained in the community since the last hearing. The results suggest that dynamic factors, specifically indicators of mental health, are heavily weighted by the Review Boards, consistent with the literature on imminent risk and in line with the NCRMD legislation. Copyright © 2016 John Wiley & Sons, Ltd.

Objectives This study aims to examine the rates of self-reported contacts with the criminal justice system among homeless adults with mental illness, to identify the characteristics of participants who have had contacts with the criminal justice system, to report the dimensional structure of criminal justice system involvement in this sample, and to identify typologies of justice-involved participants. Methods Self-report data on criminal justice system involvement of 2221 adults participating in a Canadian Housing First trial were analyzed using multiple correspondence and cluster analysis. Results Almost half of the participants had at least one contact with the criminal justice system in the 6 months prior to study enrollment. Factors associated with justice involvement included age, gender, ethnic background, diagnosis, substance misuse, impulse control, compliance, victimization, service use, and duration of homelessness. A typology of criminal justice involvement was developed. Seven criminal justice system involvement profiles emerged; substance use and impulse control distinguished the clusters, whereas demographic and contextual variables did not. Conclusions The large number of profiles indicates the need for a diverse and flexible range of interventions that could be integrated within or in addition to current support of housing services, including integrated substance use and mental health interventions, risk management strategies, and trauma-oriented services.

Notre comprehension des liens entre la maladie mentale et les comportements de violence s’est significativement accrue au cours des dernieres annees. Le lien entre les troubles mentaux et le comportement violent n’a vraiment ete montre empiriquement qu’au debut des annees 1990 (Cote et Hodgins, 2003), mais il est encore conteste (Arboleda-Florez, Holley et Crisanti, 1998 ; Elbogen et Johnson, 2009 ; Stuart et Arboleda-Florez, 2001). Certains facteurs associes au comportement violent sont mieu...

This paper is based on the report following the National Research Agenda Meeting on Mental Health, Justice, and Safety held in Montreal on November 19, 2014, which convened academics; health, social, and legal professionals; and people with lived experience of mental illness from across Canada. The goal was to identify research priorities addressing relevant knowledge gaps and research strategies that can translate into public policy action and improvements in evidence-based services. Participants identified key challenges: (1) inadequate identification and response to needs by civil mental health services and frontline law enforcement, (2) limited specialized resources in forensic and correctional settings, (3) fragmented care and gaps between systems, (4) limited resources for adequate community reintegration, and (5) poor knowledge transfer strategies as obstacles to evidence-based policies. Knowledge gaps were identified in epidemiology and risk reduction, frontline training and programs, forensic and correctional practices, organizations and institutions, knowledge transfer, and rehabilitation. Finally, participants identified potential sources of support to conduct real time research with regard to data collection and sharing. The findings represent a roadmap for how forensic mental health systems can best proceed to address current challenges through research and practice initiatives, drawing from lived, clinical and research experiences of a multidisciplinary group of experts.

Impulsivity is associated with aggression and major mental disorders. The Barratt Impulsiveness Scale (BIS) is arguably the most commonly administered self-report measure of impulsiveness. However, some confusion surrounding the versions of the BIS—in particular version 11a—can be seen in the extant literature, especially regarding differences in item content and factor structures. Furthermore, no study has validated the factor structure of the BIS-11a. Thus, our study aimed to support the BIS-11a's internal validity based on Barratt's (1994) original factor model. Data was collected through the southwest Montreal psychiatric epidemiological catchment area study (Caron, Fleury et al., 2012). Randomly selected participants completed the English (n = 703) or French (n = 1,450) BIS-11a. Confirmatory factor analyses showed that Barratt's factor structure fit both language versions almost identically well. However, results suggest that a higher order factor structure might be optimal. This marks the first stud...

Objective: To examine the psychosocio-criminological characteristics of not criminally responsible on account of mental disorder (NCRMD)–accused people and compare them across the 3 most populous provinces. In Canada, the number of people found NCRMD has risen during the past 20 years. The Criminal Code is federally legislated but provincially administered, and mental health services are provincially governed. Our study offers a rare opportunity to observe the characteristics and trajectories of NCRMD–accused people. Method: The National Trajectory Project examined 1800 men and women found NCRMD in British Columbia ( n = 222), Quebec ( n = 1094), and Ontario ( n = 484) between May 2000 to April 2005, followed until December 2008. Results: The most common primary diagnosis was a psychotic spectrum disorder. One-third of NCRMD–accused people had a severe mental illness and a concomitant substance use disorder, with British Columbia having the highest rate of dually diagnosed NCRMD–accused people. Most accused people (72.4%) had at least 1 prior psychiatric hospitalization. Two-thirds of index NCRMD offences were against the person, with a wide range of severity. Family members, followed by professionals, such as police and mental health care workers, were the most frequent victims. Quebec had the highest proportion of people with a mood disorder and the lowest median offence severity. There were both interprovincial differences and similarities in the characteristics of NCRMD-accused people. Conclusions: Contrary to public perception, severe violent offenses such as murder, attempted murder or sexual offences represent a small proportion of all NCRMD verdict offences. The results reveal a heterogeneous population regarding mental health and criminological characteristics in need of hierarchically organized forensic mental health services and levels of security. NCRMD—accused people were well known to civil psychiatric services prior to being found NCRMD. Risk assessment training and interventions to reduce violence and criminality should be a priority in civil mental health services.

Objective: To state the sociodemographic characteristics, mental health histories, index offence characteristics, and criminal histories of male and female forensic psychiatric patients. Clinicians and researchers advocate that mental health and criminal justice organizations implement gender-specific services; however, few studies have sampled forensic patients to evaluate the extent to which men's and women's treatment and management needs are different. Method: Data were collected from Review Board files from May 2000 to April 2005 in the 3 largest Canadian provinces. Using official criminal records, participants were followed for 3 to 8 years, until December 2008. The final sample comprised 1800 individuals: 15.6% were women and 84.4% were men. Results: There were few demographic differences, but women had higher psychosocial functioning than men. Both men and women had extensive mental health histories; women were more likely diagnosed with mood disorders and PDs and men were more likely diagnosed with schizophrenia spectrum disorders and SUDs. The nature of the index offence did not differ by gender, except women were more likely to have perpetrated murders and attempted murders. For offences against a person, women were more likely to offend against offspring and partners and less likely to offend against strangers, compared with men. Women had significantly less extensive criminal histories than men. Conclusions: Not criminally responsible on account of mental disorder-accused women have a distinct psychosocial, clinical, and criminological profile from their male counterparts, which may suggest gender-specific assessment, risk management, and treatment in forensic services could benefit patients. The findings are also consistent with traditional models (Risk-Need-Responsivity) and ultimately demonstrate the importance of individual assessment and client-centred services.