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.

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.

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.

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

Research Priorities in Mental Health, Justice, and Safety: A Multidisciplinary Stakeholder Report.

This paper is based on the report following the National Research Agenda Meeting on Mental Health, Justice, and Safety held in Montreal on November 19, 2014, which convened academics; health, social, and legal professionals; and people with lived experience of mental illness from across Canada. The goal was to identify research priorities addressing relevant knowledge gaps and research strategies that can translate into public policy action and improvements in evidence-based services. Participants identified key challenges: (1) inadequate identification and response to needs by civil mental health services and frontline law enforcement, (2) limited specialized resources in forensic and correctional settings, (3) fragmented care and gaps between systems, (4) limited resources for adequate community reintegration, and (5) poor knowledge transfer strategies as obstacles to evidence-based policies. Knowledge gaps were identified in epidemiology and risk reduction, frontline training and programs, forensic and correctional practices, organizations and institutions, knowledge transfer, and rehabilitation. Finally, participants identified potential sources of support to conduct real time research with regard to data collection and sharing. The findings represent a roadmap for how forensic mental health systems can best proceed to address current challenges through research and practice initiatives, drawing from lived, clinical and research experiences of a multidisciplinary group of experts.