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.
With the increased need to assess and manage risk in inpatient settings, the Short-Term Assessment of Risk and Treatability (START) was implemented on a civil psychiatric unit. The goal of the present study was to examine the tool's predictive validity when completed by clinical teams as part of routine practice. Data were collected for 34 patients hospitalized for a minimum of 30 days prior to and after a START evaluation. Several challenging behaviors, such as aggression towards others, self-harm, and substance abuse were assessed using the START Outcomes Scale . Results from multilevel logistic regression and Receiver Operating Characteristics analyses lend partial support for the predictive validity of the START. A limited set of START items combined was significantly better at predicting the challenging behaviors than the original total Strength and Vulnerability scales. Results are discussed in terms of the clinical use of risk assessment.
The National Trajectory Project examined longitudinal data from a large sample of people found not criminally responsible on account of mental disorder (NCRMD) to assess the presence of provincial differences in the application of the law, to examine the characteristics of people with serious mental illness who come into conflict with the law and receive this verdict, and to investigate the trajectories of NCRMD-accused people as they traverse the mental health and criminal justice systems. Our paper describes the rationale for the National Trajectory Project and the methods used to collect data in Quebec, Ontario, and British Columbia, the 3 most populous provinces in Canada and the 3 provinces with the most people found NCRMD.
The majority of individuals found not criminally responsible on account of mental disorder (NCRMD) in Canada spend some time in hospital before they are conditionally or absolutely (no conditions) discharged to the community by a legally mandated review board. By law, the decision to conditionally discharge an individual found NCRMD should be guided by the need to protect the public, the mental condition of the accused, and the other needs of the accused, especially regarding his/her community reintegration. At the time of this study, Canadian legislation and case law required that the review board disposition should be the "least onerous and least restrictive" possible for the accused. This means that, if there is no evidence that the person poses a significant risk to public safety, he/she must be released. However, the Canadian Criminal Code does not specify the criteria that must be considered when making this risk assessment. This leads to two questions. (1) What predicts review board dispositions? (2) To what extent do disposition determinations reflect evidence-based practices? The present study examined dynamic and static predictors of detention in custody, conditional discharge (CD), and absolute discharge (AD) dispositions among persons found NCRMD across the three largest provinces in Canada. The National Trajectory Project (NTP) examined men and women found NCRMD in British Columbia (BC), Québec (QC), and Ontario (ON) between May 2000 and April 2005, followed until December 2008. For the purposes of this study, individuals who had at least one hearing with a review board were extracted from the NTP dataset (N = 1794: QC = 1089, ON = 483, BC = 222). Over the course of the study, 6743 review board hearings were examined (QC = 3505, ON = 2185, BC = 1053). Despite advances in the risk assessment field, presentation of a comprehensive structured risk assessment to the review board was not the norm. Yet our findings suggest that review boards were taking into account a combination of empirically validated static and dynamic risk factors, as represented by the items of the HCR-20 risk assessment scheme. Particular attention was being paid to the behavior of the patient between hearings (e.g., violent acts, compliance with conditions). Severity of index offense was associated with review board decisions; though index severity is not related to recidivism, it is an important consideration in terms of public perceptions of the justice system and can be related to better established risk factors (i.e., criminal history and prior violence). Historical factors had more influence on the decision to detain someone, while clinical factors were more influential on an AD decision. Disposition stability was the most common trajectory, meaning that a patient with a prior CD disposition was most likely to receive another CD disposition at the next hearing. Static and dynamic risk factors found in the HCR-20 influenced review board determinations, although presentation of a complete structured risk assessment is the except...
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