Intellectual and developmental disabilities in Ontario's criminal justice and forensic mental health systems: Using data to tell the story.

BACKGROUND: International studies show that adults with intellectual and developmental disabilities (IDD) are disproportionately represented in the criminal justice and forensic mental health systems; however, it is difficult to capture their involvement across systems in any one jurisdiction. AIMS: The current study aimed to estimate the prevalence of IDD across different parts of the criminal justice and forensic mental health systems in Ontario and to describe the demographic and clinical profiles of these individuals relative to their counterparts without IDD. METHODS: This project utilised administrative data to identify and describe the demographic and clinical characteristics of adults with IDD and criminal justice or forensic involvement across four sectors: federal correctional facilities, provincial correctional facilities, forensic inpatient mental health care and community mental health programmes. Questions were driven by and results were contextualised by a project advisory group and people with lived experience from the different sectors studied, resulting in a series of recommendations. RESULTS: Adults with IDD were over-represented in each of the four settings, ranging from 2.1% in federal corrections to 16.7% in forensic inpatient care. Between 20% (forensic inpatient) and 38.4% (provincial corrections) were under the age of 25 and between 34.5% (forensic inpatient) and 41.8% (provincial corrections) resided in the lowest income neighbourhoods. Medical complexity and rates of co-occurring mental health conditions were higher for people with IDD than those without IDD in federal and provincial corrections. CONCLUSIONS: Establishing a population-based understanding of people with IDD within these sectors is an essential first step towards understanding and addressing service and care needs. Building on the perspectives of people who work in and use these systems, this paper concludes with intervention recommendations before, during and after justice involvement.

Experiences of Sexual and Reproductive Health Care Access for Women and Nonbinary People With Early Psychosis: Towards an Integrated Perspective of Service Users and Clinicians.

OBJECTIVE: Individuals with psychosis are at elevated risk of adverse sexual and reproductive health (SRH) outcomes, and not receiving adequate SRH care. SRH is important for youth, yet little is known about SRH care access and experiences among those with early psychosis. This study explored SRH care experiences among women and nonbinary individuals with early psychosis. METHOD: We conducted semistructured qualitative interviews with 19 service users (cisgender and transgender women, nonbinary individuals) receiving care in 2 early psychosis programs in Ontario, Canada. We also conducted semistructured interviews and focus groups with 36 clinicians providing SRH or mental health care to this population. Participants were asked about SRH care access/provision experiences and the interplay with psychosis. Using a social interactionist orientation, a thematic analysis described and explained service user and clinician perspectives regarding SRH care. RESULTS: Amongst both service users and clinician groups, common themes developed: (a) diversity of settings: SRH services are accessed in a large range of spaces across the health care system, (b) barriers in nonpsychiatric SRH care settings: psychosis impacts the ability to engage with existing SRH services, (c) invisibility of SRH in psychiatric settings: SRH is rarely addressed in psychiatric care, (d) variability of informal SRH-related conversations and supports, and cutting across all of the above themes, (e) intersecting social and cultural factors impacted SRH services access. CONCLUSIONS: SRH is important for health and wellbeing; improvements are urgently needed across the healthcare system and within early psychosis programs to meet this population's multifaceted SRH needs.

Sexual health experiences of women and non-binary people with early psychosis: qualitative study.

BACKGROUND: Women and gender-diverse people with early psychosis are at risk for suboptimal sexual health outcomes, yet little research has explored their sexual health experiences. AIMS: This study explored sexual health experiences and related priorities among women and gender-diverse people with early psychosis, to identify opportunities for improvements in sexual health and well-being. METHOD: Semi-structured individual qualitative interviews explored how patient participants (n = 19, aged 18-31 years, cisgender and transgender women and non-binary individuals) receiving clinical care from early psychosis programmes in Ontario, Canada, experienced their sexual health, including sexual function and behaviour. Thematic analysis was conducted, with triangulation from interviews/focus groups with clinicians (n = 36) who provide sexual and mental healthcare for this population. RESULTS: Three key themes were identified based on patient interviews: theme 1 was the impact of psychotic illness and its treatments on sexual function and activity, including variable changes in sex drive, attitudes and behaviours during acute psychosis, vulnerability to trauma and medications; theme 2 related to intimacy and sexual relationships in the context of psychosis, with bidirectional effects between relationships and mental health; and theme 3 comprised autonomy, identity and intersectional considerations, including gender, sexuality, culture and religion, which interplay with psychosis and sexual health. Clinicians raised each of these priority areas, but emphasised risk prevention relative to patients' more holistic view of their sexual health and well-being. CONCLUSIONS: Women and non-binary people with early psychosis have wide-ranging sexual health priorities, affecting many facets of their lives. Clinical care should incorporate this knowledge to optimise sexual health and well-being in this population.

Examining the Prevalence and Forms of Leveraged Treatment Pressure and Its Relationship to Personal Recovery: A Canadian Cross-Sectional Study.

Across jurisdictions, the use of 'leverage' to promote adherence to mental health treatment is widespread. However, little research exists on the possible association between the application of leverage and personal recovery. We examined the prevalence of various forms of leverage in a Canadian context and compared these rates with those in other jurisdictions. Additionally, we examined the relationship between two prominent forms of leverage (financial and housing) and the experience of personal recovery. Structured interviews were conducted with people receiving community-based mental health care in Toronto, Canada. Rates of overall leverage in our sample were similar to rates reported in other jurisdictions. Personal recovery was negatively associated with financial leverage but was not associated with housing leverage. Our results highlight the importance of separately examining the relationship of specific forms of leverage and personal recovery and raise questions for future research about the possible effect of financial leverage on recovery.

Preparing social workers to address health inequities emerging during the COVID-19 pandemic by building capacity for health policy: a scoping review protocol.

INTRODUCTION: The COVID-19 pandemic has brought tremendous changes in healthcare delivery and exacerbated a wide range of inequities. Social workers across a broad range of healthcare settings bring an expertise in social, behavioural and mental healthcare needed to help address these health inequities. In addition, social workers integrate policy-directed interventions and solutions in clinical practice, which is a needed perspective for recovery from the COVID-19 pandemic. It remains unclear, however, what the most pressing policy issues are that have emerged during the COVID-19 pandemic. In addition, many social workers in health settings tend to underuse policy in their direct practice. The objectives of this scoping review are to: (1) systematically scope the literature on social work, COVID-19 pandemic and policy; and (2) describe the competencies required by social workers and the social work profession to address the policy issues emerging during the COVID-19 pandemic. METHODS AND ANALYSIS: The scoping review follows Arksey and O'Malley's five-stage framework. Identification of literature published between 1 December 2019 and the search date, 31 March 2021, will take place in two stages: (1) title and abstract review, and (2) full-text review. In partnership with a health science librarian, the research team listed keywords related to social work and policy to search databases including Medline, Embase, PsycINFO, CINAHL, Social Services Abstract and Social Work Abstracts. Two graduate-level research assistants will conduct screening and full-text review. Data will then be extracted, charted, analysed and summarised to report on our results and implications on practice, policy and future research. ETHICS AND DISSEMINATION: Results will help develop a policy practice competence framework to inform how social workers can influence policy. We will share our findings through peer-reviewed publications and conference presentations. This study does not require Research Ethics Board approval as it uses publicly available sources of data.

The relationship between clinician leverage, patient experiences, and and the impact of stigma: a study in academic and community outpatient psychiatry settings.

OBJECTIVE: Various methods are used to induce or pressure patients into being more adherent with treatment; collectively, we can describe them as leverage. Leverage strategies are common in psychiatric services, and may carry unintended, potentially negative effects. We examine their relationships to experiences and impact of stigma. METHODS: Data from 137 researcher-administered surveys with adult general psychiatry patients from hospital and community psychiatric services in Toronto, Canada were analyzed, including socio-demographics, service use history, current level of symptoms, insight into mental illness, and stigma scores. Descriptive and bivariate analyses were performed to guide generalized linear models to examine the relationships between multiple domains of leverage and experiences and impact of stigma. RESULTS: Use of leverage strategies is prevalent, ranging from outpatient commitment (10.2%) to financial (21.2%) to access to children or family (31.2%). Regression analyses show being female, having high psychiatric symptomology, financial leverage, and family and/or child access leverage were significantly correlated with stigma experience; similarly, these same factors, except for being female, were also associated with stigma impact. CONCLUSION: This cross-sectional study shows a significant association between use of some types of leverage and experience and impact of stigma in general psychiatry patients. Care and balance between good intentioned but potentially stigmatizing leveraging practices should be actively considered in clinical decisions to avoid the unintended negative effects.

Examining the need profile of supportive housing applicants with and without current justice involvement: A cross-sectional study.

OBJECTIVE: Permanent supportive housing has been identified as a possible intervention which could reduce the risk of criminal justice involvement (CJI) among people with serious mental illness who are experiencing residential instability and homelessness. However, the evidence evaluating the impact of supportive housing on CJI is mixed. Increasing understanding of the specific needs of people with justice involvement entering supportive housing may inform interventions which improve their criminal justice outcomes. Toward this end, this study compared the characteristics and need profiles of applicants to supportive housing with and without current CJI. METHODS: Secondary analyses were conducted of archival databases of 12,277 individuals applying for supportive housing in Toronto, Canada between 2009 and 2015. The characteristics and support needs of applicants with current CJI were compared to applicants with no current justice involvement. RESULTS: Of the applicants, 2,894 (23.6%) reported having justice involvement at the time of referral to supportive housing services. The strongest predictors of having justice involvement were a history of physical assaults, homelessness, problematic substance use, male gender, and younger age. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Criminological factors rather than functional or mental health needs were most predictive of having current justice involvement at referral. Development of justice-focused supportive housing models may be considered which supplement traditional supportive housing approaches with empirically based interventions targeting the criminogenic needs of people with mental illness and justice involvement. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Service Users' Knowledge and Views on Outpatients' Compulsory Community Treatment Orders: A Cross-Sectional Matched Comparison Study.

OBJECTIVE: Community treatment orders (CTOs) have been used in the treatment of some individuals with serious mental illness who fail to adhere to their psychiatric treatment, leading to frequent hospitalization. This article examines perceptions and knowledge of CTOs amongst outpatient service users in Toronto, Canada. METHOD: Service users under a CTO were matched to a comparison control group of voluntary outpatients (n = 69 in each group). Participants were interviewed using a series of questionnaires aimed at assessing instead of evaluating their knowledge and perceptions of CTOs, as well as understanding their views about the utility and impact of CTOs in the treatment of individuals with mental health issues. RESULTS: Participants in the CTO group knew significantly more about CTO processes, restrictions, and procedural protections than the control group. Both groups thought that a CTO could improve certain individuals' mental health. The control group felt more strongly that a CTO could improve a service user's physical health by providing better access to care and closer monitoring (P = 0.019) while a significant proportion of the CTO group thought that being on a CTO was better than being in the hospital (P = 0.001) and that service users should be able to contest their CTO (P = 0.001). In addition, CTO group participants were significantly more optimistic about the potential positive impact of CTOs on other service users' quality of life (P = 0.008) and mental health (P = 0.023) compared to themselves. CONCLUSIONS: In general, both groups viewed CTOs as potentially capable of positively affecting treatment and lives of some individuals with mental illness.

Mental health and addictions policy priorities and performance measurement frameworks.

To inform the future development of a pan-Canadian Mental Health and Addictions (MHA) performance measurement framework, we undertook a review and comparison of current provincial/territorial MHA policies and performance measurement frameworks. Most did not have performance measurement approaches that were explicitly linked to policy actions but eleven acknowledged the importance of performance measurement. Among the provinces with a framework, there were few performance domains in common. The common policy priorities and areas of convergence in current performance measurement practices may provide a useful starting point for the development of a pan-Canadian MHA performance measurement framework.

Key steps for a mental health and addictions performance measurement framework for Canada.

To inform the development of a pan-Canadian Mental Health and Addictions (MHA) performance measurement framework, we undertook a rapid review of the recent Performance Measurement (PM) literature and solicited input from 20 MHA policy and measurement experts. Six key steps for framework development were identified: recognizing and acknowledging key issues, developing shared language and understanding of key concepts, defining overall scope, defining framework dimension/domains, selecting indicators and using systematic engagement and consultation processes with stakeholders. Subject matter experts underscored the need for a comprehensive engagement process which would honour multiple stakeholder viewpoints and attend to key issues in the codesign of features of the PM framework. Findings from this analysis may be used to inform a comprehensive stakeholder consultation process for the development of a pan-Canadian PM framework for MHA.

Coercion in Outpatients under Community Treatment Orders: A Matched Comparison Study.

OBJECTIVE: Since the deinstitutionalization of psychiatric services around the world, the scope of outpatient psychiatric care has also increased to better support treatment access and adherence. For those with serious mental illness who may lack insight into their own illness, available interventions include coercive community practices such as mandated community treatment orders (CTOs). This paper examines the perceptions of coercion among service users treated with a CTO. METHOD: We used a cross-sectional comparative design where service users treated under a CTO were matched to a comparison group of voluntary psychiatric outpatients. Both groups were receiving intensive community mental health services (n = 69 in each group). Participants were interviewed using a series of questionnaires aimed at evaluating their perceptions of coercion and other aspects of the psychiatric treatment. RESULTS: The level of coercion reported by service users treated under a CTO was significantly higher than that in the comparison group. However, in adjusted analyses, service users' perception of coercion, irrespective of their CTO status, was directly correlated with their previous experience with probation and inversely correlated with the sense of procedural justice in their treatment. CONCLUSIONS: Evaluation of psychiatric service users' experiences of coercion should consider their past and current involvement with other types of coercive measures, particularly history of probation. Clinicians may be able to minimize these experiences of coercion by incorporating procedural justice principles into their practice.

Mental Health Disorders and Publicly Funded Service Use by HIV Positive Individuals: A Population-Based Cross-Sectional Study in Ontario, Canada.

We compared use of community and hospital-based mental health and addiction (MH&A) services by adults with and without HIV. This population-based study examined the probability and intensity of MH&A service use by individuals with (n = 5095) and without HIV (n = 2,753,091) in Ontario, Canada between 2013 and 2014. Adults with HIV were more likely than HIV-negative adults to use MH&A primary and psychiatric care, and to have MH&A emergency department visits and hospital admissions; they also used more of each service. Use of MH&A hospital services was particularly high for persons in the HIV group compared to the no HIV group.

Unmet Needs of Adults in Community Mental Health Care With and Without Intellectual and Developmental Disabilities: A Cross-Sectional Study.

The cross-sectional study compared the clinical and need profiles for clients with and without intellectual and developmental disabilities (IDD) in seven mental health case management programs in Toronto, Canada on March 31, 2013. Unmet needs in domains within four broad clusters were measured by staff using an internationally utilized tool, the Camberwell Assessment of Need. Among the 2560 clients, 8.3 % had a co-occurring IDD. For most assessed domains rates of unmet need were not different for persons with and without IDD. However, the IDD group had greater unmet needs for adaptive functioning/skills and cognitive needs [self-care (p = 0.023), education (p < 0.001), transportation (p < 0.001), and information on condition (p = 0.038)]. While clients with IDD and psychiatric diagnoses often receive poor quality care, in the case management programs examined their rates of unmet need were similar to individuals without IDD across most assessed domains, including in the areas of addictions and physical health care.

Unmet needs among men with human immunodeficiency virus in community mental health care: a cross-sectional study.

While community-based mental health services play an important role in caring for persons with HIV (human immunodeficiency virus) and co-existing mental health disorders, the extent to which their support needs are addressed in this setting is unknown. Accordingly, we examined if HIV infection was associated with unmet support needs among men living with and without HIV receiving community mental health care. This cross-sectional study examined 215 men (135 living with HIV and 80 without HIV) receiving case management services in urban Ontario. Using the Camberwell Assessment of Need, we ascertained the prevalence of support needs in 13 domains grouped into three clusters: Basic needs (accommodation, food, benefits, and money management); self-care/functional needs (daytime activities, self-care, and looking after the home); and health/safety needs (physical, psychological distress, psychotic symptoms, safety to self, and safety to others). We used generalized estimating equations with a logit link to examine the association between HIV and unmet need in each domain. Compared to HIV-negative men, men with HIV were more likely to have mood and concurrent disorders, and intellectual and developmental disabilities. Following multivariable analyses, men with HIV had greater unmet needs related to food (odds ratio + 95% confidence interval: 9.36 (4.03, 21.75), p < 0.001); money (OR: 1.90 (1.04, 3.47), p = 0.036) [basic need domains]; psychological distress (OR: 2.39 (1.68, 3.41), p < 0.001); drug use (OR: 5.10 (2.16, 12.08) p < 0.001); and safety to self (OR: 3.35 (1.51, 7.52), p < 0.003) [health and safety domains]. Despite living in a setting with universal health insurance, men with HIV receiving community mental health support had greater unmet need in basic and health domains than HIV-negative men receiving such support. Further research is required to develop and evaluate interventions to best support community-dwelling persons with HIV and mental health disorders.

Examining the need profiles of patients with multiple emergency department visits for mental health reasons: a cross-sectional study.

OBJECTIVES: Study objectives were to: (1) provide an estimate of the prevalence of repeat emergency department (ED) use for mental health reasons among individuals enrolled in intensive case management programs; and (2) to identify socio-demographic, diagnostic, and service need characteristics associated with repeat ED visits among this service population. METHODS: The study utilized administrative health data from community mental health organizations in Toronto, Canada on a sample of 2274 individuals enrolled in intensive case management programs. Patients with 2+ ED visits for mental health reasons within the prior 6 months were compared with individuals who had no ED visits or one visit on the basis of demographic, diagnostic and service need characteristics. RESULTS: Approximately 6 % of intensive case management clients had two or more ED visits over a 6-month period. Membership in the repeat ED user group was associated with younger age (OR 0.98), a mood disorder (OR 1.58), being in service less than 1 year (OR 1.94) and unmet needs related to psychotic symptoms (OR 2.19), substance use (OR 2.27), and safety to self/others (OR 3.42). CONCLUSIONS: The repeat ED user group within case management may have distinct need profiles that require different treatment responses. Moreover, clinical needs rather than psychosocial needs have the greatest relationship with repeat psychiatric ED utilization. These unmet needs suggest areas for future interventions aimed at reducing the use of ED services for mental health reasons and improving care for patients who repeatedly present at the ED.

Predictors of unmet need for medical care among justice-involved persons with mental illness.

OBJECTIVE: This cross-sectional study examined factors associated with unmet need for care from primary care physicians or from psychiatrists among clients enrolled in mental health court support programs in Toronto, Ontario. METHODS: The sample included adults admitted to these programs during 2009 (N=994). Both measures of unmet need were determined by mental health court workers at program intake. Predictors included client predisposing, clinical, and enabling variables. RESULTS: Twelve percent had unmet need for care from primary care physicians and 34% from psychiatrists. Both measures of unmet need were associated with having an unknown diagnosis, having no income source or receiving welfare, homelessness, and not having a case manager. Unmet need for care from psychiatrists was associated with symptoms of serious mental illness and current hospitalization. CONCLUSIONS: Obtaining care from psychiatrists appears to be a particular challenge for justice-involved persons with mental illness. Policies and practices that improve access warrant more attention.