Risk and Recovery

Grants

1) CIHR Operating Grant: National Women’s Health Research Initiative

Stephanie Penney, Tonia Nicholls (PIs), Co-Investigators: Ipsita Ray, Smita Vir Tyagi, Adeyo Alabi, Lucy Barker, Liam Dodge, Juliette Dupre, Cory Gerritsen, Roland Jones, Alexander Simpson, Treena Wilkie, Lisa Monchalin, Martha Kahnapace: What are the unique mental health needs of women in correctional and forensic mental health settings? A virtual community of practice model;
($583,022; 3 yrs)

The Problem:  Justice-involved women present with unique mental health needs and carry a greater burden of illness when compared to men; they suffer higher rates of childhood adversities, intimate partner violence and sexual victimization.

Our Goal: Bring together a hub of experts from academia, clinical practice, community partners, and persons with lived and living expertise to co-produce, disseminate and translate research evidence into improved health policies and best practice guidelines for justice-involved women.

2) American Academy of Psychiatry and Law – Institute for Education and Research

Treena Wilkie (PI); Co-Investigators: Sumeeta Chatterjee, Roland Jones, Sandy Simpson, Lisa Ramshaw, Gary Chaimowitz: Factors impacting Recruitment and Retention of Forensic Psychiatrists in Ontario;
($12,320.52 USD; 1 year)

The Problem: The expertise of forensic psychiatrists is highly specialized, and is based on training, clinical experience, and scholarship. In Ontario, there is an increasing demand for forensic psychiatrists in secure hospitals and correctional settings.

Our Goal: We will gather perspectives through surveys and interviews from Forensic Psychiatrists and psychiatry residents to understand factors important for job selection and satisfaction.  Data from this project will help to model future need for forensic psychiatrists and make recommendations to the provincial forensic system. 

3) American Academy of Psychiatry and Law – Institute for Education and Research

Treena Wilkie, Stephanie Penney (PIs); Co-Investigators: Maryana Kravtsenyuk, Ipsita Ray, Sumeeta Chatterjee: Factors Contributing to Absconding from Forensic Mental Health Care;
($23,059 USD; 1 year)

The Problem: Absconding events or unauthorized leave from the hospital can pose significant risks to patient safety, and often delay recovery efforts.  This is particularly concerning in forensic mental health services where patients are mandated to be in a secure therapeutic setting.  Absconding events that gain media or government attention can significantly erode public confidence in the system and contribute to stigmatizing and restrictive practices.

Our Goal:  We will gather perceptions of both patients, staff and forensic division leadership on an every absconding event over the next two years as well as examine impact of risk and behavioural factors measured within days to weeks of an absconding event. Our findings will inform institution and systems-level policies and interventions to better manage the risk of absconding behaviour, and ultimately, improve patient care and public trust.   

Paper Summaries

Clinical and public safety risks associated with cannabis legalization and frequency of cannabis use among forensic mental health patients.

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.

Contributors to Physician Burnout and Well-Being in Forensic Psychiatrists in Canada

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.

Homicide in the context of psychosis: analysis of prior service utilisation and age at onset of illness and violence

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.

Violence risk prediction in mental health inpatient settings using the Dynamic Appraisal of Situational Aggression (DASA)

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.

Addressing Challenges of Mental Illness and Substance Use: A Contemporary Model of Care for Forensic Mental Health Services in Ontario

What: 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.

So What: 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.

Now What: 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.