Risk factors for homelessness and housing instability in the first episode of mental illness: Initial findings from the AMONT study.

AIM: People living with mental illness are more likely than the general population to experience adverse housing outcomes, including homelessness. The aim of the current study is to examine residential status when participants have their first contact with mental health services, and the correlates of residential status at that moment. METHODS: First-time mental health service users were recruited from seven clinical sites across Québec. Data on residential status at entry in the project, as well as demographic, clinical and social variables, were collected using self-report and interviewer-rated questionnaires. Participants were classified as 'Homeless', 'At risk of homelessness' and 'Stably Housed', and correlates of residential status were identified through multivariate logistic regression and unbiased recursive partitioning. RESULTS: Among the 478 participants, 206 (43.1%) were in stable housing, 171 (35.8%) were at risk of homelessness and 101 (21.1%) were classified as homeless. Placement in a youth protection facility was strongly associated with adverse housing outcomes, while having a high school diploma and more social support were associated with more stable housing situations. CONCLUSIONS: First-time mental health service users are likely to experience a range of adverse housing situations, indicating the potential for clinical sites to implement homelessness primary prevention strategies. Factors related to family, foster care and schooling seem to be particularly salient in understanding risk of homelessness in first-time mental health service users, calling for intersectoral action to prevent adverse psychosocial outcomes in this population.

Community treatment orders: A qualitative study of stakeholder perspectives.

INTRODUCTION: For people with a serious mental disorder, a community treatment order (CTO) is a legal response that requires them to undergo psychiatric treatment unwillingly under certain conditions. Qualitative studies have explored the perspectives of individuals involved in CTOs, including persons with lived experiences of a CTO, family members and mental health care providers, who are directly involved in these procedures. However, few studies have integrated their different perspectives. METHOD: This descriptive and qualitative study aimed to explore the experience associated with a CTO in hospital and community settings among individuals with a history of CTO, relatives, and mental health care providers. Using a participatory research approach, individual semi-structured interviews were conducted with 35 participants. The data were reviewed using content analysis. RESULTS: Three themes and seven sub-themes were identified: 1) differential positions as a function of meaning conferred to CTOs; 2) a risk management tool; and 3) coping strategies used to deal with CTOs. Overall, relatives' and mental health care providers' perspectives tended to be in opposition to those who went under a CTO. CONCLUSIONS: In a context of recovery-oriented care, more research is needed to reconcile the seemingly contradictory positions of individual with experiential knowledge and the legal leverage that deprives them of their fundamental right to autonomy.

Women experiencing homelessness and mental illness in a Housing First multi-site trial: Looking beyond housing to social outcomes and well-being.

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<0.001. With few exceptions, social and mental health outcomes were similar for both groups at 6-, 12-, 18- and 24-months post-enrollment. Suicidality was a consistent predictor of increased mental health symptoms (beta = 2.85, 95% CI 1.59-4.11, p<0.001), decreased quality of life (beta = -3.99, 95% CI -6.49 to -1.49, p<0.001), decreased community functioning (beta = -1.16, 95% CI -2.10 to -0.22, p = 0.015) and more emergency department visits (rate ratio = 1.44, 95% CI 1.10-1.87, p<0.001) over the study period. Lower education was a predictor of lower community functioning (beta = -1.32, 95% CI -2.27 to -0.37, p = 0.006) and higher substance use problems (rate ratio = 1.27, 95% CI 1.06-1.52, p = 0.009) during the study. 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.

Barriers and facilitators of access and utilization of mental health services among forensic service users along the care pathway.

BACKGROUND: The verdict of Not Criminally Responsible on account of a Mental Disorder (NCRMD) is increasingly used to access specialized mental health services in Canada and elsewhere. This situation highlights the importance of ensuring timely access to services in the community to prevent violence and justice involvement. The objective of the present study is to identify individual and contextual barriers and facilitators of access to mental health services during the period preceding an offense leading to a verdict of NCRMD. METHODS: The sample includes 753 people found NCRMD in Québec, Canada. All episodes of mental health hospitalizations and service use before the index offense were identified using provincial administrative health data, for an average period of 4.5 years. Access was conceptualized as a function of the possibility of seeking, reaching and receiving appropriate health care services, based on Lévesque and colleagues patient-centred model of access to care. Generalized linear models were computed to identify the individual and contextual predictors of: (1) seeking mental healthcare (at least one contact with any type of services for mental health reasons); (2) reaching psychiatric care (at least one contact with a psychiatrist); (3) receiving psychiatric care, operationalized as (3a) continuity and (3b) intensity. Factors associated with volume of emergency mental health services were examined as exploratory analysis. RESULTS: Geographical considerations were highly important in determining who reached, and who received specialized mental health care - above and beyond individual factors related to need. Those who lived outside of major urban centres were 2.6 times as likely to reach psychiatric services as those who lived in major urban centres, and made greater use of emergency mental health services by 2.1 times. Living with family decreased the odds of seeking mental healthcare by half and the intensity of psychiatric care received, even when adjusting for level of need. CONCLUSIONS: Findings support efforts to engage with the family of service users and highlights the importance of providing resources to make family-centred services sustainable for health practitioners. Health policies should also focus on the implementation of outreach programs, such as Forensic Assertive Community Treatment teams as part of prevention initiatives.

[Complex Trauma and Forensic Mental Health Services: Towards Trauma-informed Care]. / Traumatismes complexes et services psycholégaux : vers des pratiques sensibles au trauma.

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.

[Beyond Housing: The Heterogenous Effect of Housing First on Criminal Justice Outcomes Among Homeless People With Mental Illness]. / Au-delà du logement : l'effet hétérogène de Logement d'abord sur l'implication criminelle de personnes vivant avec un trouble mental.

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.

[Methods and Current Issues Related to Risk Assessment of Other-Directed Violence]. / Les méthodes et enjeux relatifs à l'évaluation du risque de la violence hétérodirigée.

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.

[Overview of the Organisation of Forensic Mental Health Services Internationally: Towards a Balanced Care Model]. / Survol de l'organisation des services de santé mentale forensique à travers le monde : vers un modèle hiérarchisé-équilibré.

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.

COVID-19 et pratiques professionnelles dans les milieux institutionnels fermés.

INTRODUCTION: While governments have focused efforts on implementing health measures such as physical distancing and confinement to protect communities from the spread of COVID-19, some researchers focused on the significant impact of these measures on mental health and well-being. Persons with mental disorders who are both institutionalized and justice-involved in psychiatric and forensic hospitals find themselves more vulnerable to these measures and more limited in their movements and activities. AIMS: The purpose of this paper is to examine the changes in practice in response to the pandemic and their potential impact on individuals in institutional settings. RESULTS: A rapid review including 69 publications identified nine major themes in the literature, which will serve as a framework to analyze the experience of one forensic psychiatry institution in Canada. These themes are: 1) population-specific vulnerability factors; 2) staff management and training; 3) early discharge, parole, and community integration; 4) management of contagion in closed spaces; 5) sanitary measures and personal protective equipment; 6) care and service continuity; 7) use of technology to maintain social ties and services; 8) legal mechanisms and individual rights; and 9) post-pandemic realities. CONCLUSION: Although this is the first pandemic of such international magnitude, experts point to an increase in epidemics over the past decade and continued growth in the coming decades. It is thus essential to learn from this health crisis in order to be prepared and minimize their potential impact on vulnerable populations in the future. The reflections presented here could be contrasted with the lived-experiences of people in institutions in order to nuance the data and propose new strategies.

Care Pathways, Health Service Use Patterns and Opportunities for Justice Involvement Prevention Among Forensic Mental Health Clients.

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.

Not a "Get Out of Jail Free Card": Comparing the Legal Supervision of Persons Found Not Criminally Responsible on Account of Mental Disorder and Convicted Offenders.

BACKGROUND: The 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. METHOD: Detention, 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. RESULTS: Individuals 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. CONCLUSION: Contrary 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.

Examining the Relationships between Cumulative Childhood Adversity and the Risk of Criminal Justice Involvement and Victimization among Homeless Adults with Mental Illnesses after Receiving Housing First Intervention.

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.

Pathways to Recovery among Homeless People with Mental Illness: Is Impulsiveness Getting in the Way?

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.

The Impact of Housing First on Criminal Justice Outcomes among Homeless People with Mental Illness: A Systematic Review.

OBJECTIVE: Housing First is increasingly put forward as an important component of a pragmatic plan to end homelessness. The literature evaluating the impact of Housing First on criminal justice involvement has not yet been systematically examined. The objective of this systematic review is to examine the impact of Housing First on criminal justice outcomes among homeless people with mental illness. METHOD: Five electronic databases (PsycINFO, MEDLINE, Embase, CINAHL, Web of Science) were searched up until July 2018 for randomised and nonrandomised studies of Housing First among homeless people with a serious mental disorder. RESULTS: Five studies were included for a total of 7128 participants. Two studies from a randomised controlled trial found no effect of Housing First on arrests compared to treatment as usual. Other studies compared Housing First to other programs or compared configurations of HF and found reductions in criminal justice involvement among Housing First participants. CONCLUSIONS: This systematic review suggests that Housing First, on average, has little impact on criminal justice involvement. Community services such as Housing First are potentially an important setting to put in place strategies to reduce criminal justice involvement. However, forensic mental health approaches such as risk assessment and management strategies and interventions may need to be integrated into existing services to better address potential underlying individual criminogenic risk factors. Further outcome assessment studies would be necessary.

Changing characteristics of forensic psychiatric patients in Ontario: a population-based study from 1987 to 2012.

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Mental Health Screening and Differences in Access to Care among Prisoners.

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.

Decision curve analysis as a framework to estimate the potential value of screening or other decision-making aids.

OBJECTIVES: There is an increasing debate about the impact of mental health screening. We illustrate the use of a decision making framework that can be applied when there is no sufficient data to support a traditional cost-benefit analysis. METHODS: We conducted secondary analyses of data from 459 male prisoners who were screened upon intake. We compared the potential benefit of different approaches (screening, history taking, and universal interventions) to allocating treatment resources using decision curve analysis. RESULTS: Screening prisoners for distress at typical levels of sensitivity (75%) and specificity (71%) were estimated to provide the greatest net benefit if between 2 and 5 false positives per detected illness are tolerable. History taking and self-harm screening provide the largest net benefit when only 1 or 2 false positives per detected illness would be tolerable. The benefits of screening were less among those without a recent psychiatric history, ethnic minorities, and those with fewer psychosocial needs. CONCLUSIONS: Although screening has potential to increase detection of treatment, important subgroup differences exist. Greater consideration of responses to positive screens or alternatives to screening are needed to maximize the impact of efforts to improve detection and treatment of mental illness.

Expanding the early and late starter model of criminal justice involvement for forensic mental health clients.

The early and late starter model provides one of the most enduring frameworks for understanding the developmental course and severity of violence and criminality among individuals with severe mental illness. We expanded the model to account for differences in the age of onset of criminal behavior and added a group with no prior contact with the justice or mental health systems. We sampled 1,800 men and women found Not Criminally Responsible on account of Mental Disorder in 3 Canadian provinces. Using a retrospective file-based study, we explored differences in criminal, health, demographic, and social functioning characteristics, processing through the forensic psychiatric system and recidivism outcomes of 5 groups. We replicated prior research, finding more typical criminogenic needs among those with early onset crime. Those with crime onset after mental illness were more likely to show fewer criminogenic needs and to have better outcomes upon release than those who had crime onset during adulthood, before mental illness. Individuals with no prior contact with mental health or criminal justice had higher functioning prior to their crime and had a lower risk of reoffending. Given little information is needed to identify the groups, computing the distribution of these groups within forensic mental health services or across services can provide estimates of potential intensity or duration of services that might be needed. This study suggests that distinguishing subgroups of forensic clients based on the sequence of onset of mental illness and criminal behavior and on the age of onset of criminal behavior may be useful to identify criminogenic needs and predict outcomes upon release. This updated framework can be useful for planning organization of services, understanding case mix, as well as patient flow in forensic services and flow of mentally disordered offenders in correctional services. (PsycINFO Database Record

Mental health treatment patterns following screening at intake to prison.

OBJECTIVE: While there is general consensus about the need to increase access to mental health treatment, it is debated whether screening is an effective solution. We examined treatment use by inmates in a prison system that offers universal mental health screening. METHOD: We conducted an observational study of 7,965 consecutive admissions to Canadian prisons. We described patterns of mental health treatment from admission until first release, death, or March, 2015 (median 14-month follow-up). We explored the association between screening results and time of first treatment contact duration of first treatment episode, and total number of treatment episodes. RESULTS: Forty-three percent of inmates received at least some treatment, although this was often of short duration; 8% received treatment for at least half of their incarceration. Screening results were predictive of initiation of treatment and recurrent episodes, with stronger associations among those who did not report a history prior to incarceration. Half of all inmates with a known mental health need prior to incarceration had at least 1 interruption in care, and only 46% of inmates with a diagnosable mental illness received treatment for more than 10% of their incarceration. CONCLUSION: Screening results were associated with treatment use during incarceration. However, mental health screening may have diverted resources from the already known highest need cases toward newly identified cases who often received brief treatment suggestive of lower needs. Further work is needed to determine the most cost-effective responses to positive screens, or alternatives to screening that increase uptake of services. (PsycINFO Database Record