What's New

January 2025

What’s the issue: The development of an overarching model of care that integrates best practices to transform forensic service delivery is outlined. Aims of the model include ensuring all patients have equal access to care, standardizing assessments, patient inclusion in assessment and care planning and aligning therapeutic expectations with patient progress through the ORB system.

Why it matters: Improving forensic mental health services directly impacts the well-being of forensic service users, promoting recovery and reduces the risk of reoffending. Integrating best practices and continuous evaluation helps to optimize resource use and improve overall treatment outcomes.

What’s next: Continued research into the effectiveness of the model can lead to further innovations in treatment approaches, assessment tools, and the integration of digital technologies, improving patient outcomes and service delivery. The service is able to link with international networks committed to excellence in forensic practice.

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December 2024

What we found: We analysed daily DASA scores in 3819 newly admitted inpatients for up to 60 days of their admission.   While it was initially developed for the forensic population, our study found the DASA to also be a good predictor of violence across acute care and longer-stay units though less accurate on geriatric units. 

Why it matters: While the majority of mental health patients are nonviolent, violence and aggression when they occur can cause problems for patients and staff.   Other existing risk assessments are less suited to short-term violence prediction on inpatient units where our study found most initial violent events occurred within the first two weeks of admission.  The DASA can help identify those at higher risk of violence in order for staff to put in place measures to mitigate the risk.

What’s next: Further research is needed to look at how DASA can guide interventions and whether combining risk factors and clinical data with the DASA score improves clinician’s ability to predict and ultimately prevent violence events.

December 2024

What we found: The prevalence of cannabis use among forensic patients is high and has increased since the time of legalization. Forensic patients who used cannabis were more likely to be readmitted to hospital and many reported worsened mental health status a week following the use of cannabis. We found no difference in rates of violence between those who used cannabis and those who did not, and no change in rates of violence as time elapsed from the point of legalization.

Why it matters:  Most forensic patients have a primary psychotic disorder diagnosis and up to two-thirds have a substance use disorder. The use of cannabis has both clinical and legal ramifications for forensic patients, including worsening illness effects, more difficult trajectories of recovery, and increased rates of re-hospitalization. The legalization of cannabis, alongside increases in the potency and availability of the substance, may pose particular risks for users of forensic services and persons with serious forms of mental illness more generally.

What’s next: We are examining the impact of legalization on perceptions of risk associated with cannabis use among forensic patients, and perceptions of changing clinical and legal practices (e.g., by the Review Board) as time from legalization has elapsed. This information will provide an important context and depth of understanding to the quantitative results surrounding changing patterns of cannabis use in forensic patients.

January 2024

What we found: 46.5% of forensic psychiatrists reported feeling burnout, with early-career psychiatrists at the highest risk for burnout. Factors associated with higher burnout rates included high volume of work, administrative bureaucracy, and a lack of autonomy within the healthcare system.

Why it matters: Burnout can negatively affect the quality of care provided to patients, and can negatively impact physician retention. Addressing physician burnout will enhance patient care and foster a sustainable workforce.

What’s next: Leadership within institutions and national forensic professional bodies should recognize and adopt strategies to address burnout as part of a continuous improvement framework. Strategies should enhance communication, mentorship, and support for early-career psychiatrists, while also promoting autonomy and flexibility in workload management.

December 2023

Over the last 30 years, the ethnic diversity among forensic patients has increased, with Indigenous and other minority populations being overrepresented. This article summarizes the framework used by the forensic service to implement a culturally safe environment for patients and staff. Our team is developing analyses to assess the impact of these initiatives on patient and staff experiences, as well as long-term recovery.

September 2023

What’s the issue: The majority of persons who are admitted to forensic hospital following an offence of homicide have had prior, non-forensic mental health contacts, including psychiatric hospitalizations. However, the frequency and intensity of these contacts is often inadequate. In our sample of 112 forensic patients in Ontario with index offences of homicide, sporadic community mental health contacts and poor medication adherence characterized the year preceding the offence. Victims of the homicides were often family members in care-providing roles.

Why it matters: Many individuals admitted to forensic care for homicide have had inadequate mental healthcare leading up to this point. Understanding how well patients with psychotic illness utilize mental healthcare before offending will help develop more targeted prevention strategies to reduce the risk of serious violence and potentially avert some of these tragic events. Earlier and more intensive community mental health services could significantly reduce harm.

What’s next: Population-based data are required to better link the effects of early and more assertive community interventions to homicide rates among those with serious mental illness. Multi-modal interventions that address both illness-related and criminogenic factors, such as substance use treatment and psychosocial support, are needed.

September 2023

This study investigates whether two stalking-specific risk instruments— the Guidelines for Stalking Assessment and Management (SAM) and the Stalking Risk Profile (SRP) — can more accurately predict stalking in forensic patients compared to a well-validated violence risk assessment measure (Historical, Clinical, Risk Management-20, Version 3 (HCR-20V3)). Dynamic risk factors were rated once a year over three years and revealed significant change over time. Results supported the value of stalking-specific risk factors on the SAM and SRP in terms of risk prediction, as well as tailoring risk-management and treatment plans for patients with a history of stalking-related behaviors. The paper also highlights the value of monitoring changing patterns in dynamic risk factors over time. 

March 2023

In this paper we describe a novel, integrated conceptual model that assesses risk for future violence, protective factors and progress in treatment and recovery in forensic mental health settings. We propose that the value of such a model lies in its ability to improve clinical efficiencies and streamline assessment protocols, facilitate meaningful participation of patients in assessment and treatment, and increase the accessibility of clinical assessments to principal users of this information.

January 2025

What’s the issue: There are high rates of reincarceration among people with mental illness released from correctional facilities. A community mental health service was designed to provide continuity of care and immediate access to community mental health support and psychiatric care.  

Why it matters: Community reintegration mental health services following incarceration can prevent return to custody, by helping to address continuity of clinical care including prescribing of medication, and support in obtaining housing and other social support.

What’s next: Evaluation of patient outcomes and service effectiveness at 6 and 12 months is being carried out to report on effectiveness and lessons learned from the first year of the service. 

June 2023

This study looks at the course of mental health symptoms during an individual’s care in the Forensic Early Intervention Service (FEIS) in two Toronto jails. We were able to identify three separate trajectories of change using group-based modelling separated by their level of illness at admission. Although all groups showed some improvement, a significant number of individuals continue to have moderately severe symptoms. There is a need for adequate detection of mental disorders and appropriate treatment within jails, but also the need for timely transfer to hospital for those with severe symptoms. Our group is further researching the effectiveness of hospital care for these severely ill individuals. 

January 2022

The STAIR (Screening, Triage, Assessment, Intervention, and Re-integration) model is an evidence-based framework that defines and measures correctional mental health services as a clinical pathway. Our team reviewed the data on all measures and programs that align with the STAIR pathway. We found that there is a large body of studies on correctional mental health services. However, more research is needed on care pathways as a whole and in particular on interventions for severe mental illness and community reintegration programs.

May 2024

What’s the issue: The complexities of allowing prisoners and people in mental health facilities to choose Medical Assistance in Dying (MAiD) are discussed in this paper. Four recent cases are described which illustrate the challenges and ethical dilemmas involved.

Why it matters: Deciding whether prisoners should access MAiD based on mental illness as the sole criterion raises questions about balancing the right to self-determination against the state's duty to protect vulnerable individuals. Allowing those who have committed serious crimes to choose death also potentially impacts on victims' rights and societal perceptions of justice and care.

What’s next: While individuals should have the right to equivalence of health care, jurisdictions that are considering laws permitting MAiD for non-terminal disorders should consider where the balance between personal autonomy and paternalism should lie.

October 2023

Due to the involuntary nature of their treatment, patients in the forensic system often have decisions made for them. Procedural justice relates to the fairness of processes used by those in positions of authority in the forensic system. This article advocates for forensic mental health services to be provided under a procedural justice framework. This would include shared decision-making where patients are involved in developing their own treatment plans. Such autonomy and “ownership” of treatment has been shown to improve trust in the system and increase compliance — and thus promote recovery. 

April 2023

This study is the first in Canada to examine the relationship between forms of leveraged treatment pressures and personal recovery in outpatient community mental systems. Leverage involves suggesting access to desired resources (e.g. social welfare entitlements and money) or avoidance of some undesired outcome (e.g. criminal sanctions) to encourage adherence to recommended treatment. Leverage is widespread in mental health settings. The authors found that financial leverage was associated with feelings of coercion and negatively related to personal recovery. This suggests the need for further studies to better understand the relationship between different types of leverage and recovery. 

December 2022

Published in 2022, this paper examined the ethical implications of the then-proposed expansion of Medical Assistance in Dying (MAiD) to include mental disorder as the sole underlying condition, with a particular focus on incarcerated populations. In the prison environment, where hopelessness, stigmatization of mental disorders and lack of treatment opportunities are pervasive, there may be similarities between MAiD and suicide. Furthermore, there was a concern that MAiD may be used to avoid justice, impacting victims and society more broadly. Given these considerations, there is a need for careful appraisal when incarcerated individuals request MAiD to alleviate suffering solely for mental disorders.