Download MENTAL HEALTH AND CRIMINALITY AMONG PSYCHIATRIC OFFENDERS IN SOUTHEASTERN ONTARIO

MENTAL HEALTH AND CRIMINALITY AMONG PSYCHIATRIC
OFFENDERS IN SOUTHEASTERN ONTARIO
by
Vicky Jahye Bae
A thesis submitted to the Centre for Neuroscience Studies
In conformity with the requirements for
the degree of Master of Science
Queen’s University
Kingston, Ontario, Canada
(May, 2011)
Copyright ©Vicky Jahye Bae, 2011
Abstract
Mental Health and Criminality Among Psychiatric Offenders in Southeastern Ontario.
Master of Sciences Thesis, Queen’s University, Kingston, Ontario, Canada, May 2011.
OBJECTIVES: (1) Describe the population of mentally ill offenders over whom Ontario
Review Board (ORB) held jurisdiction. (2) Assess the influences of psychopathology and
criminal factors on criminal career.
METHOD: This study was a retrospective case series design that reviewed all offenders
who were court ordered for psychiatric evaluation at Mental Health Services Site of
Providence Care in Kingston, Ontario from 1993 to 2007 (N=347). Eighty five subjects
were found not criminally responsible on the account of mental disorder and were
included in statistical analysis (n=85). Bivariate associations between five key variables
and two outcome variables, seriousness of crime and recidivism, were examined. Logistic
regressions were conducted to test the role of the predictor variables on the outcome
variables.
RESULTS: Age and change in principal psychiatric diagnosis over time were shown to
be associated with seriousness of crime. Timing of psychiatric onset, early signs of
deviance and change in diagnosis were shown to be associated with recidivism. On the
whole, study population did not markedly vary in their distribution of variables by the
outcome variables. Regression model included timing of psychiatric onset; psychiatric
history; existence of criminal associate; child abuse history; and early signs of deviance.
Recidivism was shown to be predicted by early signs of deviance (OR=8.154, p<0.05).
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Existence of criminal associates was shown to have substantial values of odds ratio at
marginal significance (OR=7.577, p=0.13).
CONCLUSION: Seriousness of crime is a complex factor that could not be sufficiently
predicted by any one or combinations of study variables. Recidivism is better predicted
by criminality factors than psychopathology. In the future, an exploratory analysis that
more broadly examines the psychopathology and criminal factors in Canadian forensic
population is needed. Findings from this study have important clinical and legal
implications.
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Acknowledgements
I wish to express my gratitude to my supervisor, Dr. Julio Arboleda-Florez not
only for his excellent graduate supervision but also for so much more. You have been a
great mentor and an inspiration.
I also would like to thank Dr. Duncan Scott for co-supervising my thesis and
providing invaluable input along the way and Dr. James Reynolds for guiding me
throughout my graduate education. Thank you Dr. Heather Stuart for your feedback on
research design and statistical analysis. Finally, thank you Dr. Michael Chan and Dr.
Steve Southmayd for your insights into the Ontario Review Board and working with
mentally ill offenders.
The help from staff of the Providence Care Mental Health Care Services and the
ORB have been central to this project. I would like to especially thank Kim Carroll at
Providence Care for mining the moldy case files, sometimes 20 of them in a single day,
to allow me to go through over 300 case files.
The completion of this project would not have been possible without the love and
support from all my family and friends, humans and furry ones alike. Thank you.
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Table of Contents
Abstract................................................................................................................................ii
Acknowledgements.............................................................................................................iv
Table of Contents.................................................................................................................v
List of Tables....................................................................................................................viii
List of Figures ......................................................................................................................x
List of Abbreviations..........................................................................................................xi
List of Definitions..............................................................................................................xii
Chapter 1. Introduction........................................................................................................1
1.1. Background..............................................................................................................1
1.2. Rationale..................................................................................................................4
1.3. Hypotheses and Objectives......................................................................................5
Chapter 2. Literature Review...............................................................................................7
2.1 Mental Health.....................,.....................................................................................7
2.1.1
Diagnosis Of Psychiatric Disorders.............................................................7
2.1.2
Prevalence..................................................................................................14
2.1.3
Impact of Mental Illness on Canadian Society..........................................17
2.2 Mental Illness and Crime.......................................................................................21
2.2.1
Prevalence of Mental Illness in Legal Systems.........................................21
2.2.2
Explanation of Trends in Crime Rate using Psychiatric Factors...............23
2.2.3
Other Explanations of Trends in Crime Rate.............................................30
v
2.2.4
Criminalization of Mentally Ill..................................................................31
2.3 Forensic Psychiatric System in Canada.................................................................35
2.3.1
Forensic Path of Mentally Ill in Canada....................................................35
2.3.2
Provincial Review Boards..........................................................................37
2.4 Challenges in Working with a Vulnerable Population..........................................39
Chapter 3. Methods............................................................................................................41
3.1 Ethical considerations............................................................................................41
3.2 Subjects..................................................................................................................41
3.3 Materials and Procedure........................................................................................41
3.4 Study Variables......................................................................................................43
3.5 Statistical Analyses................................................................................................43
Chapter 4. Results..............................................................................................................45
4.1 Description of Study Population (Objective 1)......................................................45
4.2 Statistical Analysis (Objectives 2 & 3)..................................................................45
4.2.1 Bivariate associations................................................................................ 45
4.2.2 Distribution of variables.............................................................................46
4.2.3 Multivariate associations............................................................................46
4.2.4 Additional analyses....................................................................................48
4.2.5 Assessment of Regression Model.............................................................50
Chapter 5. Discussion........................................................................................................64
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5.1 Population Characteristics......................................................................................64
5.1.1
Criminal responsibility...............................................................................65
5.1.2
Nature of crimes........................................................................................ 66
5.2 Findings and Interpretations from Bivariate Analysis...........................................68
5.2.1
Distribution of Sociodemographic factors.................................................68
5.2.2
Changes in Principal Psychiatric Diagnosis...............................................68
5.2.3
Timing of psychiatric onset with reference to the first crime....................70
5.2.4
Signs of early deviance..............................................................................71
5.3 Findings and Interpretations from Multivariate Analysis......................................71
5.3.1
Seriousness of index offence......................................................................71
5.3.2
Recidivism and early deviance...................................................................73
5.4 Other Contributing Factors....................................................................................73
5.5 Relevance of Findings ............................................................................................75
5.6 Limitations of Study...............................................................................................78
5.7 Future Directions....................................................................................................80
5.8 Conclusion.............................................................................................................81
References..........................................................................................................................82
Appendices.......................................................................................................................105
One.
Detailed DSM Classification Tables........................................................105
Two.
Forensic Path of Mentally Ill...................................................................107
Three.
Data Collection Sheet..............................................................................111
vii
List of Tables
Table 2.1
Brief descriptions and an example of DSM IV-TR Diagnostic method....11
Table 2.2
An illustration of a personality disorder is diagnosed...............................12
Table 4.1
Demographic information of the study population....................................51
Table 4.2
Distribution of variables by seriousness of index offence. P-values less
than 0.05, 0.01 and 0.005 were denoted with *, ** and ***,
respectively................................................................................................53
Table 4.3
Distribution of variables by recidivism. P-values less than 0.05, 0.01 and
0.005 were denoted with *, ** and ***, respectively................................54
Table 4.4
Multivariate logistic regression model. P-values less than 0.05, 0.01 and
0.005 were denoted with *, ** and ***, respectively................................56
Table 4.5
Bivariate logistic regression model for change in principal psychiatric
diagnosis. P-values less than 0.05, 0.01 and 0.005 were denoted with *, **
and ***, respectively.................................................................................57
Table 4.6a
Multivariate logistic regression model with age as the only adjuster. Pvalues less than 0.05, 0.01 and 0.005 were denoted with *, ** and ***,
respectively................................................................................................58
Table 4.6b
Multivariate logistic regression model with gender as the only adjuster. Pvalues less than 0.05, 0.01 and 0.005 were denoted with *, ** and ***,
respectively................................................................................................59
Table 4.7a
Multivariate logistic regression model including changes in principal
diagnosis as a predictor. P-values less than 0.05, 0.01 and 0.005 were
denoted with *, ** and ***, respectively...................................................60
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Table 4.7b
Multivariate logistic regression model including changes in principal
diagnosis as a predictor and with age as the only adjuster. P-values less
than 0.05, 0.01 and 0.005 were denoted with *, ** and ***,
respectively................................................................................................61
Table 4.7c
Multivariate logistic regression model including changes in principal
diagnosis as a predictor and with gender as the only adjuster. P-values less
than 0.05, 0.01 and 0.005 were denoted with *, ** and ***,
respectively................................................................................................62
Table 4.8
Multivariate logistic regression model using psychopathological and
criminal predictors with direct association only. Models were adjusted for
only age or gender. P-values less than 0.05, 0.01 and 0.005 were denoted
with *, ** and ***, respectively..........................................................,,....63
Appendix One Detailed description of DSM IV-TR Classification...................................85
ix
List of Figures
Figure 2.1
Crime rate and violent crime rate trends in Canada from 1962 to
2007............................................................................................................24
Figure A.1
Navigating the forensic system..................................................................90
x
List of Abbreviations
DSM
Diagnostic and Statistic Manual of Mental Disorders
DSM IV-TR Diagnostic and Statistic Manual of Mental Disorder Fourth Edition TextRevision
UST
Unfit to Stand Trial
NGRI
Not Guilty by Reason of Insanity
NCRMD
Not Criminally Responsible on the account of Mental Disorder (formerly
NGRI)
ORB
Ontario Review Board
PCL-R
Hare’s Psychopathy Checklist Revised
VRAG
Violent Risk Appraisal Guide
SORAG
Sexual Offender Risk Appraisal Guide
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List of Definitions
Criminal career: a longitudinal series of criminal acts committed by an individual as the
individual ages across the lifespan from childhood through adolescence and adulthood
Principal psychiatric diagnosis: psychiatric disorder from which the accused primarily
suffered at the time of crime and is therefore said to have the greatest influence on the
criminal offending.
Victimology: a scientific study of victimization, including the relationships between
victims and offenders and the connections between victims and other social groups and
institutions
Unfit to stand trial: an accused is unfit to stand trial when they are unable to participate in
the defense of charges because of a mental disorder or illness prevents the accused from
understanding the nature of the trial, comprehending the possible consequences and
communicating effectively with legal counsel.
Diminished criminal responsibility: an accused who violated the law is not held fully
responsible for the said crime as their mental functions were diminished.
Mens rea: in English, translates to “guilty mind” and refers to the mental element of the
offence that accompanies the actus reus, the “guilty act”
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Chapter 1
Introduction
1.1. Background
Mental illness is one of the fastest growing global health concerns. Over 450
million people develop one or more clinical conditions at some point in life and a greater
number suffers milder mental health problems1. It is also a major public health problem
in Canada, where 10.4% of all above the age of 15 suffers from a major type of
psychiatric disorder such as depression and substance abuse2. Society also suffers
financially from mental illness. Between 2003 and 2004, 6.6 billion dollars have been
spent per year on average on direct mental health care in Canada with significantly more
spent as indirect cost of mental illness3,4.
Challenges of psychiatric disorders are often compounded by stigmatization.
Internal prejudice about mental illness discourages the patient from seeking help, while
the fear of being perceived negatively by others further lessens the willingness to
acknowledge its existence, which further precludes the patient from receiving necessary
care and support5. This fear is not ungrounded according to past research. Stigmatization
against mental illness has been repeatedly shown to be highly prevalent among the
general public as well as those better educated on the subject of psychiatry, like medical
students6. The issue of stigmatization is further complicated in mentally ill offenders
because stigma encountered by these individuals is two-fold: one layer arising out of their
psychiatric conditions and another out of their criminal behaviours7.
This unique population began to attract academic attention in late 20th century as
increases were observed in the number of mentally ill persons reaching the criminal
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justice system and in crime rate following the deinstitutionalization movement8. Starting
in the 1960’s, many western nations went through deinstitutionalization, an essential part
of mental health care reform, in which formal, inpatient-based psychiatric care system
was reduced significantly in size10-12. This resulted in a large number of psychiatric
patients being discharged from hospitals to the community9-11. It was hoped to be a more
cost-effective alternative and a better means of re-introducing psychiatric patients into
communities than inpatient psychiatric care.
While the rationale appeared to be legitimate, the net outcome was negative9-14.
Many psychiatric patients who were prematurely discharged from hospitals due to
deinstitutionalization entered the criminal justice system, creating what has long been
termed the revolving-door patient syndrome12,13. Some researchers attempted to explain
the underlying mechanism of this phenomenon by treating criminal offending as a
symptom or a byproduct of mental illness16,17. This theory assumes that diminished
capacity to comprehend and conform to societal standards caused by mental disorder,
rather than mens rea, is accountable for the criminal offence of these people.
Psychiatrization of crime theory, on the other hand, directly opposes this theory by
positing that criminal offending attracts psychiatric attention18. Another possibility is that
this is merely a coincidence arising from sharing common contributors, in which similar
sets of genetic and developmental factors give rise to one or both of psychiatric disorders
and criminality depending on individual circumstances15. Still more social factors thought
to contribute to criminalization of mentally ill are: deficiency in long- and short-term
mental health care services; difficulty faced by previously hospitalized or imprisoned
individuals in being reintegrated to the community; difficulty faced by previously
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hospitalized or imprisoned individuals in continuing to receive the necessary care in
community setting; antagonizing attitudes of legal personnel in their handling of deviant
behaviours; and stigma on mental illness or crime or both15.
Mentally ill offenders embody a unique yet vulnerable group. In 1992, the
Criminal Code of Canada was amended to better cope with increasing number of
psychiatric offenders19. At this time, the provincial review board system, which holds
jurisdiction over offenders who have been exempted of criminal responsibility given their
severe mental conditions, was established into its current form19. Historically, working
with the forensic population has been fraught with ethical issues, from in-house abuse at
the hand of hospital staff to misuse as subjects of illegal studies20-22. Abuse by the
forensic population on personnel also adds to the difficulty of issue. Scientific study at a
population level has been comparatively scarce and information on Canadian psychiatric
offenders was produced mainly as byproducts of examination of the general offender
population, drawn from policy and administrative reports or extracted from individual
legal cases23-44. Recently, several researchers have examined the Canadian psychiatric
offender population under the jurisdiction of provincial review boards. Findings in these
studies have been reliable but were limited in applicability because they used narrowly
localized samples47-54. As such, previous research in this area left many factors
unexplored.
The limitation in the sample selection is perhaps inevitable given the widely
varying residential characteristics between Canadian provinces55. It is not feasible to
design a single research plan that would adequately account for all individual differences
between localities while still retaining the ability to gather relevant data and draw reliable
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conclusions. Researchers of the present study opined that the most effective way of
generating knowledge about Canadian mentally ill offenders would be to conduct
multiple regional studies then pool the results together. Thus created database would
eventually allow a systematic review of mentally ill offenders at a national level as well
as in-depth examination of the review board system.
1.2 Rationale
Despite the clinical and social importance, empirical research on mentally ill
offenders as a population has been scarce. The primary goal of the present study is to
conduct a systematic review of the criminal offenders who were transferred to the
Ontario Review Board jurisdiction after being found not criminally responsible on the
account of mental disorder (NCRMD). A few studies provided basic description of
regional review board populations19,48-54. Also, administrative reports are produced on
regular basis by most provincial governments or individual review boards and more
sociodemographic information is available through these channels46. Therefore, this study
will provide a description of the population in terms of the psychiatric and criminal
elements. The aim is to capture the characteristics that have a direct bearing on
psychopathology and criminality of this population.
This will be followed by an investigation of relationships between criminality and
key contributors. It is believed that in the seriously mentally ill forensic population,
mental illness would have a greater influence than criminality over criminal behaviours.
In order to test this theory, interaction between criminality and criminal factors will be
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compared to interaction between criminality and psychopathological or developmental
factors. Predictive power of these factors will also be assessed.
Information from this study will provide a better understanding of
psychopathology and criminality of the southeastern Ontarian forensic population. The
role of the Ontario Review Board (ORB) will also be better illustrated throughout the
study. Findings may be used to facilitate the appraisal process of criminal responsibility
and better direct clinical and legal rehabilitation effort to factors that actually affect future
criminal outcomes. For example, different rehabilitation methods could be employed for
an offender with stronger predisposition for recidivism or more serious crime and another
offender with fewer propensities. Finally, there are several global projects geared toward
advancement in the academic and clinical practice of forensic psychiatry56. Together with
the results of other regional studies, findings of this study will provide a Canadian
perspective, thereby contributing to the international knowledge on forensic population as
a whole while providing platforms on which relevant regional programs may be adjusted
to best serve Canadian society.
1.3 Hypotheses and Objectives
This study tested the following hypotheses that, in NCRMD offenders:
1. Criminal career will be better predicted by psychopathology than criminal factors.
2. Criminal career will be best predicted when using both psychopathological and
criminal predictors.
The following objectives were met in order to test the above hypotheses.
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1. Description of the mentally-ill offender population under the jurisdiction of
Ontario Review Board at a forensic psychiatric hospital in southeastern Ontario.
2. Investigation of the associations between criminal career and (1) psychopathology
and (2) criminal factors.
3. Exploration of prediction models for any possible predictors of criminal career.
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Chapter 2
Literature Review
2.1 Mental Health
A sound mind in a sound body. This old proverb represents the importance placed
on mental health by the ancient. Mental health, or the ‘sound mind’ as described by the
ancient, refers to a “capacity of each and all of us to feel, think, and act in ways that
enhance our ability to enjoy life and deal with the challenges we face” and “a positive
sense of emotional and spiritual well being that respects the importance of culture, equity,
social justice, interconnections and personal dignity57.” It is apparent that being mentally
healthy requires more than a simple lack of mental illnesses: mental health is an
interactive component of overall health, which in turn is an integrated outcome of mental,
physical and social well-being58.
2.1.1 Diagnosis of Psychiatric Disorders
An accurate diagnosis of a medical disorder requires a clear description of the
disorder and determination of defining features59. Historically, the subjective nature of
mental illness has made the fulfillment of this prerequisite difficult60, but description of
mental illness by Diagnostic and Statistical Manual of Mental Disorders (DSM) provides
an unambiguous and scientific characterization of psychiatric disorders. According to
DSM, a psychiatric disorder is a “clinically significant behavioural or psychological
syndrome or pattern that occurs in an individual61.” An important element in DSM’s
definition is that the problem “must currently be considered a manifestation of a
behavioural, psychological, or biological dysfunction in the individual61.” In other words,
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not every psychological or behavioural problem constitutes a disorder. It must result from
a dysfunction that the individual is currently suffering from and manifest itself to a
clinically significant degree.
The issue of shared symptoms has been yet another hurdle in psychiatric
diagnosis. There is a substantial overlap of symptoms among different disorders and
characterization based on distinctive sets of symptoms is difficult. Most psychiatric
diagnostic manuals circumvent this problem by using a categorical classification system,
in which mental disorders that share a set of symptoms are grouped together61,62. They
are then broken down into individual disorders by a few distinguishing factors. An
example with a detailed explanation may be found in Table 2.2 in a later section of this
chapter. This classification based on shared and distinguishing features is also a logical
alternative of classification based on etiology because it is not possible to identify a
single, principal cause of a mental disorder60,62.
Finally, in many cases, symptoms are not externalized and therefore objective
clinical manifestations are absent60,63. Psychiatric diagnosis must rely on subjective data
such as self-reports and observations by relevant parties, which makes the diagnostic
process more susceptible to confounding compared to diagnosis of other types of medical
conditions that use objective data such as biological markers63. The patient may not
accurately express their conditions to the attending professional either deliberately or
because they lack the narrative power. The diagnosis may also be affected by the
professional’s biases or by a selective rather than exhaustive use of available data.
Subsequently, the reliability of psychiatric diagnosis has been constantly contested63.
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Over the last few decades, much effort has been given to overcome the problems
of psychiatric diagnosis60-63. Mental health professionals across the globe collaborated in
literature review, empirical data analysis and field trials to produce several rigorous and
comprehensive diagnostic tools. The most widely used tool in psychiatric diagnosis is the
Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American
Psychiatric Association. Rivaling DSM in usage is Chapter V: Mental and Behavioural
Disorders of the International Statistical Classification of Diseases and Related Health
Problems 10th Revision (ICD-10) published by the World Health Organization64 DSM is
used more widely in North America and this was the tool with which subjects of this
study were diagnosed. A brief overview of DSM is presented here.
The most recent edition, the DSM IV-Text Revision (TR), was published in 2000.
There are 16 categories of disorders along with an additional list of conditions that
warrant clinical attention. The multiaxial system devised for DSM IV edition has been
retained in DSM IV-TR. This system explores several axes, or dimensions, of the
patient’s life and allows the collection of additional information relevant for diagnosis
and treatment. DSM IV-TR presents the standard conditions for each disorder and the
patient is diagnosed with the disorder of which prototype his or her symptoms most
closely resemble. Table 2.1 briefly illustrates the DSM IV-TR diagnostic method. Table
2.1 also shows that comorbid disorders are diagnosed and presented. Comorbidity is high
in mental disorders and symptom overlap is substantial in many cases. Therefore DSM
IV-TR emphasizes that its categories of mental disorder are not ‘completely discrete
entities with absolute boundaries.’ When multiple diagnoses have been, the condition that
occasioned the admission is designated as the principal diagnosis. DSM IV-TR also
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recommends usage of severity and course specifiers as well as information on the
recurrence of any previous psychiatric disorders. Global assessment of functioning
(GAF) scores, which shows how the mental illness affects one’s functionality in a scale
of 1 to 100, are typically factored in when deciding which severity specifier to use.
The issue of classification by shared symptoms is further explained in Table 2.2
using the example from Table 2.1. The patient satisfied the general diagnostic criteria for
personality disorder and was then subsequently interviewed for more specific personality
traits. This person had met most of the 301.6 diagnostic criteria and was therefore given a
final diagnosis of dependent personality disorder.
10
Table 2.1 Brief descriptions and an example of DSM IV-TR Diagnostic method.
Axis I
Classification
Clinical Disorders
Other Conditions That May Be A Focus of
Clinical Attention
Axis II
Personality Disorders
Mental Retardation
Axis III
Axis IV
Axis V
General Medical Conditions
Psychosocial and Environmental Problems
Global Assessment of Functioning (on a
scale of 1-100)
11
Example
292.23 Major Depressive Disorder, Single
Episode, Severe Without Psychotic
Features
305.00 Alcohol Abuse
301.6 Dependent Personality Disorder,
Moderate, In Partial Remission
Frequent Use of Denial
None
Threat of Job Loss
GAF = 35
Table 2.2 An illustration of a personality disorder is diagnosed.
General diagnostic criteria for personality disorder
A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations
of the individual's culture. This pattern is manifested in two (or more) of the following areas:
(1) cognition (i.e., ways of perceiving and interpreting self, other people, and events)
(2) affectivity (i.e., the range, intensity, liability, and appropriateness of emotional response)
(3) interpersonal functioning
(4) impulse control
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social
situations.
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or
early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental
disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition (e.g., head trauma).
Diagnostic criteria for 301.6 dependent personality disorder
1.
2.
3.
4.
5.
6.
7.
8.
has difficulty making everyday decisions without an excessive amount of advice and reassurance
from others
needs others to assume responsibility for most major areas of his or her life
has difficulty expressing disagreement with others because of fear of loss of support or approval.
Note: do not include realistic fears of retribution.
has difficulty initiating projects or doing things on his or her own (because of a lack of selfconfidence in judgment or abilities rather than a lack of motivation or energy)
goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering
to do things that are unpleasant
feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for
himself or herself
urgently seeks another relationship as a source of care and support when a close relationship ends
is unrealistically preoccupied with fears of being left to take care of himself or herself
12
There are still limitations in common to psychiatric diagnosis in general that DSM
has yet to overcome. For one, culture is an important component in psychiatric
development and cultural difference presents yet another problem that is unmet by other
medical disorders63. DSM has been continually revised to reflect evolving cultural
elements, but it is a predominantly the North American tool that produces most reliable
and valid results when used on North American population61,63. However, most
professionals accept that certain omissions such as specific information for a minor
cultural group are necessary if a diagnostic tool is to be of practical use. It may be
possible to devise a diagnostic bible that encompasses every single patient group, probes
all severity ranges of psychiatric condition and includes all conceivable clinical scenarios,
but professionals would find a large fraction of the tool inapplicable to their clientele and
therefore unnecessary to their practices. It is more pragmatic to devise a diagnostic
manual that can be used on the majority then modify it to serve the individual groups as
the necessity arises. This is the approach adopted by DSM: there are now 22 languages
into which the DSM has been translated with brief guidelines for clinicians of the
respective cultures61.
DSM is also limited in its purpose. It is a clinical diagnostic tool with the ability
to serve research purposes. It is not sensitive enough to accurately grasp conditions that
are not clinically significant and it is inappropriate to use DSM in non-clinical settings
without any adjustment in its mode of employment61,63. This latter point is directly
relevant to the present study because improper application and subsequent misuse of
DSM in forensic setting have been problematic due to the “imperfect fit between the
questions of ultimate concern to the law and the information contained in a clinical
13
diagnosis.” When DSM is used to diagnose forensic population or used for forensic
research, it must be noted that the clinical diagnosis using DSM-IV is insufficient to
establish the existence of varying degrees of mental illness for legal purposes, and that
additional information beyond what DSM can yield is necessary in order to determine
whether an individual meets a specified legal standard, such as competence63,65,66.
2.1.2. Prevalence
In September 2010, the World Health Organization (WHO) estimated 450 million
people to be afflicted with a psychiatric disorder around the globe1. Psychiatric disorders
are now more prevalent than cancer, diabetes or heart diseases and account for five out of
ten most frequent causes of disability2. In 2001, the Assessment, Classification, and
Epidemiology (ACE) Group at the WHO launched an international mental health
epidemiology project called the World Mental Health Survey Initiative which involved
28 nations58. As a part of this on-going project, prevalence rates of mental disorders
between 2001 and 2003 from 17 countries were reported. The lowest rate was observed
in Nigeria (12%) and the highest rate was observed in the United States (47.4%; 25-75th
interquartile range across nations=18.1-36.1%)67. Of the major disorder groups – anxiety,
mood, substance and impulse-control disorders – anxiety disorders were the most
prevalent (IQR=9.9-16.7%), followed by mood disorders (IQR=9.8-15.8%)67. Personality
disorders and psychotic disorders, which are the disorders most visible to the public,
typically account for a very small proportion of overall prevalence except in offender
population67,2.
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In Canada, 10.4% of, or 2.6 million, Canadians above the age of 15 suffer from a
self-reportable psychiatric disorder2. The most prevalent psychiatric disorders in Canada
are mood (4.9%), anxiety (4.7%) and substance disorders (3.0%). Schizophrenia had a
relatively low prevalence (<1%). Gender difference was insignificant, with females
slightly more likely to suffer from all types of disorders other than substance2. Similarly
little differences were noted between provinces, with mental disorders being the most
prevalent in British Columbia (11.9%) and the least prevalent in Prince Edward Island
(7.7%)2. Mental illness is currently the second leading cause of disability in Canada68 and
it is also the second leading cause of premature death, a large fraction of which is due to
suicide2,68.
Prevalence of mental illness is consistently reported to be lower in developing
countries than developed countries69,70. This may be due to under-reporting and flaws in
data collection. In less industrialized countries, public awareness on mental health is
inadequate and results in greater reluctance to admit existence of psychiatric disorders70,71.
Also, history of independent public opinion research is shorter in developing nations and
candidates may not see the importance of their participation72. This specific survey also
paid interviewers per interview. This may have increased human error as some
interviewers possibly rushed through interviews in order to receive a higher wage67.
Several researchers have argued that cultural differences may be the reason for the
lower prevalence rates and better prognosis of psychiatric disorders in developing
nations73-77. According to these researchers, some clinical disorders as defined by western
diagnostic manuals would simply be viewed as a part of the individual’s personality or an
oddity at most73. For instance, Jenkins and Karno have shown that Mexicans and
15
Mexican- Americans in the United States referred to schizophrenia as nervios (case of
nerves), a less stigmatizing term than a psychiatric disorder, and treated people with
schizophrenia as going through a difficult phase of life that everyone else experiences in
varying degrees73. Diagnostic and assessment tools directly translated from even the
globalized ICD or DSM would be imperfect for highly diversified prevalence studies
because some crucial cultural elements may not be sufficiently and adequately
incorporated. Participants may respond truthfully, but their responses would ultimately be
inaccurate for the interviewing material70,73-76.
On the other hand, it is equally possible for some psychiatric conditions that are
unrecognized in North American or European diagnostic manuals to be present as clinical
disorders in other cultures. An example may be found in what is known as hwa-byung in
Korean culture77,78. It is widely recognized as a mental disorder and there is a scale to
diagnose and measure the severity of the condition as well as a fairly standard process of
treatment in Korea, but it does not exist in western culture77,78. Other examples more
familiar to North American culture include Koro or Genital retraction syndrome (GRS) of
African and Asian cultures, amok of Malay culture, and Piblokto or Arctic hysteria of
Eskimos79. The prevalence of overall mental illness in a non-western culture may be
higher if it included the cases of such culture-specific disorders.
The nature of mental illness makes it difficult to investigate psychiatric
prevalence. However, efforts are being made to ensure careful sample selection, adequate
interviewer training, an appropriate comparison group and consideration of cultural
factors.
16
2.1.3. Impact of Mental Illness on Canadian Society
Mental illness has a substantial health and financial impact on society as a whole.
Suffering of secondarily affected persons, such as family and partners of psychiatric
patients, is immense. This impact is especially severe for caregivers who provide
informal, usually residential, care80. Research traditionally focused on caregivers of the
elderly population and undifferentiated illnesses, with dementia and schizophrenia being
the most frequently studied mental illness80-83. In all reviewed studies, caregivers have
been shown to have a higher risk of psychological problems than non-caregivers81-83. In
1990, for instance, 15% of Ontarians above the age of 15 were providing informal care
for some kind of disability or illness84. Caregivers were 1.5 times more likely to be
diagnosed with a psychiatric disorder and twice as likely to require some type of mental
health service (OR=1.5 [1.1-1.9] and OR=1.9 [1.4-2.5] respectively) than noncaregivers84. Recently, a Minnesota study provided fairly conclusive evidence on the
negative influence of dementia care on the caregiver85. Clinically significant burden
symptoms decreased from 52.9% to 28.3% six months following the patient’s
hospitalization to a nursing home (!2(1)=162.30, p<0.001). Prevalence of depression also
decreased slightly from 35.8% to 31.1% (!2(1)=315.65, p<0.001) in the same time frame.
By the 12 month post-placement mark, burden had been reduced to 16.7% and depression
to 27.2% (!2(1)=92.18, p<0.001 and !2(1)=191.66, p<0.001 respectively)85. This study
would have been more reliable if they were able to provide information on the
psychosocial state of the caregivers before they took on their caregiver role in order to
ensure the negative psychiatric conditions were induced by caregiving activities.
17
Mental illness also weighs heavily on the Canadian economy. In 2004, the total
health care expenditure was 132 billion dollars, of which 6.6 billion dollars have been
used in the mental health care3,86. Of the 6.6 billion dollars, 5.1 billion dollars were spent
on the public health care services that the provincial governments subsidized. This figure
also actually represents a decrease in spending. Total health care expenditure in Canada
increased from 71.5 to 131.4 billion dollars between 1993 and 200486. Spending on
mental health care has decreased from 7.3 in 1993 (10.3%) to 6.6 billion dollars in 2004
(5.5%) resulting in a drop of 4.8%87. The final figure of 5.5% placed Canada lower than
other nations that were rated similarly as Canada in the degree of economic
development87.
This seemingly discouraging comparison result, however, should not be taken as a
direct indication that Canada is lagging behind other countries in providing the necessary
mental health care service. Canadian Community Health Survey (CCHS) found that 9.5%
of Canadians above 15 years of age had a contact with services and support for problems
concerning emotions, mental health or use of alcohol and drugs, which closely matches
the overall mental illness prevalence rate of 10.4%3. A closer examination revealed that
79% of interviewees that identified themselves as suffering from a mental disorder was
able to access mental health care resources within a year immediately preceding the
interview2. Of the remaining 21%, the most frequent reasons for not seeking professional
help had been that they preferred self-care (31%) and the second most frequent response
was that they did not consider it their priority (19%). This suggests that at least half of the
remaining 21% did not contact mental health services voluntarily. Finally, it was
encouraging to note that 82% of those who received the mental health service found it
18
satisfactory, with the majority of this majority group rating it very highly satisfactory
(60%)2.
Attention must be paid, however, to the finding that mental health care was most
frequently given through general medical care services rather than mental health specific
channels. A similar pattern had been seen in other countries such as the United States88,
as well as Belgium, France, Germany, Italy, the Netherlands and Spain89. This pattern is
concerning because it has negative policy and financial implications. It obscures the
distinction between expenditures made on mental health care and general, nonpsychiatric care, thereby confounding the mental health care needs assessment. Also, it
may be indicative of the public’s stigmatizing and avoidant attitude toward mental illness,
in which the affected persons chose to seek help through primary care rather than mental
health services5. This hints that the actual mental health care expenditure including that
spent through non-psychiatric channels may be much higher.
Meanwhile, indirect cost of mental illness is more alarming. It is estimated that
500,000 people per day miss their day of work due to a mental health issue resulting in
30% of disability claims and 70% of the total disability compensations68. A recent study
estimated mental illness to cost the Canadian society a total of 46 billion dollars per year
in addition to the direct cost of health care services4. The same researchers estimated that
8.4 billion dollars were disbursed in long-term work loss such as disability pension and
unemployment compensation. 9.3 billion dollars were given out as short-term work loss
compensations such as short-term disability leave and absenteeism, and 28.2 billion
dollars were spent in care of losses in health-related quality of life from mental illness4.
Mental illness cases account for only a small fraction of total disability claims, but the
19
above figures far surpass cost of physical illness. Short-term and long-term care and
compensation for mental illness is almost twice the amount of physical disability68. While
these figures are sufficiently striking, the overall financial impact of mental illness which
encompasses the loss of productivity in non-psychiatric individuals resulting from mental
illness caregiving is estimated to be much greater.
20
2.2 Mental Illness and Crime
2.2.1 Prevalence of Mental Illness in Forensic System
Strong associations have been repeatedly observed between mental health and
crime. One of the earliest demonstrations was through the high prevalence of mental
illness among the incarcerated population. Prevalence of mental illness in the forensic
system is difficult to measure on a broad scale because of multiple reasons. Firstly, most
levels of judicial system have insufficient human resources to perform their main tasks
and hence, research is seldom the priority. Also, variation in available data89 as well as
definitions of shared terms between different sectors89 disallows any universal data
collection project and impedes accurate comparison of findings from multiple studies.
Finally, diagnosis is a time-consuming process which impinges heavily on the
professionals, who are already struggling with providing care for the identified
patients89,90.
Several researchers have been able to collect prevalence data from highly
localized studies, focusing on a single sector at a single location. Occasionally, results
from various regional studies have been pooled to compile a national profile on basic
descriptive factors. A regional study in London, Ontario, showed that severely mentally
ill persons were involved in 3% of police interactions even though they represented less
than 1% of all persons who came in contact with the police between 2000 and 200591.
This study also revealed that they were more likely than non-psychiatric individuals to be
suspected as criminal perpetrators by the police or the reporting public; to be charged for
an offence; to have criminal history; and to recidivate more quickly91.
21
One of the largest prevalence studies on remandees in Canada was conducted by
Arboleda-Flórez et al. in 1995 in Alberta92. Roughly 1200 arrestees who were being
detained at a remand centre were interviewed over four months and 60.7% of the sample
was diagnosed with a DSM Axis I or II disorder. Diagnosis came most frequently from
Axis I disorders and least frequently from Axis II personality disorders with the
prevalence of substance disorders falling in between. A higher proportion of men than
women suffered from a disorder from all three types92.
In 2002, Fazel and Danesh published their results from reviewing 62 surveys,
from 12 countries, on the prevalence of mental illness in correctional system. The most
prevalent disorders included personality disorders (65% [61-68]), major depressive
disorders (10% [9-11]) and psychotic disorders (3.7% [3.3-4.1]) such as schizophrenia in
men93. Women had same order of prevalence, with slightly different specific percent
values (42% [38-45], 12% [11-14] and 4% [3.2-5.1], respectively). Altogether mentally
ill individuals accounted for 26% of violent offenders. Odds ratios for psychosis and
major depressive disorder were multifold of the general population, although the specific
values varied widely across surveys. Antisocial personality disorder was ten times more
prevalent among prisoners than the general population. They concluded that several
million prisoners worldwide were afflicted with a clinical disorder. This study displayed
substantial heterogeneity, only a small fraction of which was explained by difference
between detainees and sentenced offenders, but it is nevertheless a powerful study with
wide coverage93.
22
2.2.2 Explanations of Trends in Crime Rate Using Psychiatric Factors
Association between mental illness and crime has also been demonstrated in
recent attempts at explaining a puzzling social phenomenon. It was forecasted
unanimously that the crime rate would increase94, but it has decreased noticeably from
the early 1990’s to the late 2000’s8,95-97. Figure 2.1 illustrates the overall crime rates of
Canada from 1962 to 20078. Nationally, crime rate in Canada has been steadily
increasing from 1962 until it peaked in 1992 then it steadily decreased until 2007 and
Figure 2.2 shows a similarly steady decrease in the violent crime incidence rate after
19928. A drop in crime rate was observed in the United States as well as England and
Germany during the 1990’s95-97.
23
Figure 2.1 Crime rate and violent crime trends in Canada from 1962 to 20078.
24
There have been two landmark events in Canadian forensic psychiatry, namely
deinstitutionalization and the Criminal Code reform, which coincided neatly with key
changes in crime rate. Deinstitutionalization was immediately followed by the increase in
crime rate in the 1960’s and Criminal Code reform had shortly preceded the drop in
crime rate in 1992.
Deinstitutionalization refers to the large scaled bed cuts in mental health care that
started in the 1960’s and continued well into the 1990’s90. In Canada, this reduction was
done mainly through closing long stay psychiatric hospitals and discharging patients into
alternative care homes and communities98. Humanitarian and financial challenges of
institutionalized care for psychiatric patients, such as the public outrage against
conditions of asylums and budget cuts, brought in this model with an aim to involve the
broader community in a holistic treatment of mental illness99. However, due to financial
constraints and the lack of preparedness on the part of the receiving communities, the
model has been generally perceived as having produced negative outcomes.
Deinstitutionalization in Canada has not been followed by re-creation of matching
available specialized psychiatric care. Psychiatric departments were created in general
hospitals as an alternative, but this did not increase in the overall number of beds
available for mental health care. Many researchers believe that deinstitutionalization
merely unloaded the burden of care onto various parties such as the families of patients,
other community services like nursing homes and community housing, and the criminal
justice system100.
Some research demonstrated positive outcome of deinstitutionalization, but their
findings were limited in many ways. A study set in Vermont, USA, tracked patients that
25
were discharged as a result of deinstitutionalization and reported that they still needed
clinical and social support, and were receiving care from alternative sources five and ten
years after discharge101. They also reported that most of these patients had “lost contact”
with mental health care after 25 years, but they did not clarify whether the patients
voluntarily gave up care at the recommendation of a clinical professional as a result of
recovery or they were simply lost in the system101. This ambiguity casts doubt on their
conclusion that deinstitutionalization led to better integration back into the community
since the ‘lost’ patients could have died without recovering, become vagrant or ended up
in prison. Another study from the UK reported that discharged patients were settled down
in alternative care services and did not burden relatives102. However, psychiatric
symptoms did not improve as was expected as a positive outcome of
deinstitutionalization and researchers did not investigate the burden of the illness on other
parties, such as the alternative care services, that were providing the necessary care to
these patients.
Deinstitutionalization appears to have had a particular impact on the criminal
justice system. A rising crime rate immediately followed deinstitutionalization in most
countries and a steep increase in psychiatric behaviours such as suicide and self-harming
rates in prisons was observed in the United States8,103. In 1939, Penrose proposed the idea
of an inverse relationship between mental health care and criminal justice system, in
which a decrease in supply for one increased the use of another104. Penrose’s Law
accurately predicted the outcome of deinstitutionalization in Canada when the increased
crime rate directly followed. Furthermore, prevalence of mental illness in federal inmates
has increased following deinstitutionalization. While numbers in Canada have not been
26
clearly reported, by 2004 in the United States, where crime rate trends have been
observed, mentally ill offenders incarcerated in federal prisons grew as a population by
60%, or 84% including substance abuse as a mental illness, since 1967105.
The overall crime rate, which began to rise immediately after the commencement
of deinstitutionalization, peaked in 1992 and has been declining since. The year 1992 is
the year that the Criminal Code of Canada was amended, resulting in a major reform in
the criminal justice system with respect to mentally ill offenders35. Mounting evidence on
the link between crime and psychiatry, the increasing number of psychiatric patients who
found their ways into prisons and the precedence-setting case of R vs. Swain led the
Parliament to amend the Criminal Code (Mental Disorder) to meet the increasing and
changing needs of psychiatric offenders. In 1992, the Parliament introduced Bill C-30
following the Supreme Court’s ruling which enacted several crucial changes. Changes
and additions that were made to the Mental Disorder section of the Criminal Code as a
result of the amendment and that are relevant to the current study are highlighted below.
The amendments were largely of a humanitarian nature, such as replacing the
stigmatizing “insanity defence” term with a newer and more current “defence of mental
disorder” term, but substantial changes in procedure were also made. A definition of
“unfit to stand trial” was codified, which stated the accused is unable on the account of
mental disorder to understand the legal proceedings, and procedures for determining
fitness were implemented. A new requirement of assessment orders was added, replacing
the warrants of remand. In the past, an accused suspected of being mentally unstable
could be detained indefinitely on the warrant of remand whereas the assessment orders
are now to be made with specified purposes and a strict cap is placed on the duration of
27
remand. Quasi-judicial bodies called review boards were established to manage mentally
ill offenders at a provincial-level, replacing the former Lieutenant Governor advisory
board system that existed in some, but not all, provinces. Review boards were also
empowered to make disposition orders, which determine whether and how the mentally
ill accused should be located. They may be discharged absolutely, discharged with some
requirements or detained in forensic psychiatric hospitals. Another crucial change
concerned treatment orders, which in the past dictated how the accused should be treated.
Mandatory treatment orders without the accused’s consent are now only given to those
found unfit. Finally, the concept of criminal responsibility replaced the system of
deciding between guilty and innocent. For instance, an accused may be found to have
diminished responsibility or not be responsible for the crime they committed on the
account of mental disorder as opposed to being found not guilty which implies that the
person is not the one who committed the said offence. In summary, the process through
which an accused is psychiatrically evaluated and arrives at sentencing has become more
humane, systemic and decentralized35.
Violent crime rate decreased for the first time since deinstitutionalization
following the amendment and enactment of the amended Criminal Code. Researchers
began to investigate the role of the Criminal Code reform on reduction of crime rate and a
substantial body of evidence has been built. It has been suggested that the crime rate has
been reduced because the crime fighting programs have been improved over the last
decade with heavy emphasis focusing on controlling chronic repeat offenders106. In this
view, the criminal code reform could have contributed to the crime rate reduction by
detaining psychiatrically affected persons, who repeatedly committed crimes and added
28
considerably to the toll of overall crime, in forensic psychiatric hospitals for longer than
if they were sentenced to general prisons, thereby taking away the opportunity to commit
more crimes. This view is supported by a recent publication by Justice Canada which
showed that over 50% of NCRMD offenders were detained in forensic care for at least
ten years and a large proportion of these people in turn have been in the review board
system for significantly longer46.
Several researchers also found that, after a brief transition period spent on
adjusting to the new system, significantly and substantially more accused entered the
forensic psychiatric system post-reform across Canada19,25,52,107-111. NCRMD verdict was
more frequently given during the first year following amendments, stabilizing into the
second and third year in Alberta107. Studies also found that NCRMD verdict was more
frequently given in British Columbia, along with an increase in number of diminished
criminal responsibility findings19, 25,52,108. Finally, in Ontario, a greater number of
psychiatric evaluations were conducted post-reform109. Assuming that the forensic
psychiatric system provides adequate care that meets the unique needs of psychiatric
offenders, it may be inferred that psychiatrically affected persons directed appropriately
to the special system geared toward management and maintenance of mental stability of
these people, instead of prisons, prevents them from committing multiple criminal
offences.
It is also intriguing that the crime rate began to decrease in 1992, because it was
around the time that Prozac was first introduced into the Canadian market, followed by
many more psychiatric medications. The introduction of Prozac into the American market
in 1989 and into Canadian market in 1991 closely preceded the decrease in crime rate in
29
both countries112. Some researchers have argued that psychiatric drugs contributed to the
reduction of crime by stabilizing mood problems and prevented their manifestation into
criminal offences therefore having at least a partial role in crime reduction in North
America. An American study showed that the diffusion of psychiatric pharmaceuticals
was associated with reduction in violent crimes across various states, attributing the
enhanced mental care using drug therapy to an estimated 5% reduction in crime rate113.
Another study on alcoholic perpetrators of domestic violence showed a significant druginduced reduction in physical and non-physical Partner Abuse Scale ratings (ANOVA
F(1,11)=10.2, p<0.01 and F(1,11)=24.2, p<0.001) compared to other subjects who
received only the cognitive behavioural and alcohol therapy114. Other studies, however,
have produced outcomes that negated the proponent claim. A placebo-controlled,
randomized Prozac trial did not show drug-induced reduction in OAS-M Aggression
scores in men with history of intimate partner abuse (ANCOVA F(1,25)=0.36, p=0.56,
effect size=0.17 SD)115. At the present, there is a general belief that
psychopharmaceuticals have a slight effect in decreasing violence, but the overall
evidence is inconclusive as of yet116.
2.2.3 Other Explanation of Trends in Crime Rate
Researchers have also attempted to explain trends in crime rate using sociological
and legal factors. For instance, improvement in recording technology and practice in the
1960’s is supposed to have contributed to increased reports of crimes between 1960’s and
1970’s117. The increase in crime rate in 1980’s may also have resulted from the difficult
economy. Crime rate has been shown to be inversely proportional to indicators of
30
economic strength such as unemployment rate118. Increases in crime overall and
especially violent crime between 1970’s and early 1980’s are also attributed to the baby
boomers reaching young adulthood, which has been labeled the most violence-prone age,
at this time119-121. The subsequent decline is then deduced to be the positive outcome of a
large decrease in the number of young adult119,121. The criminal justice system has gone
through a number of significant program developments since 1990’s that could have led
to better crime fighting and reduced crime rate119,106. Finally, it has been suggested that
strengthening of the impaired driving laws and increased access to higher education by
young adults could also have contributed to the drop in crime rate119.
2.2.4. Criminalization of Mentally Ill
In 1972, Abramson coined the term criminalization of the mentally ill to describe
the increase in the number of mentally ill persons reaching the judicial system14. As the
link between mental illness and crime became more pronounced, several mechanisms by
which the two spheres might influence each other were proposed. Some scholars assert
that psychiatric conditions diminish the capacity for one to understand their own actions
and this increases one’s chance of inadvertent violation of the law122,123. These
researchers rely on the tendency of severely ill individuals to commit disorganized rather
than premeditated offences for evidence18,122,123. Highly reported cases of deliberate and
scheming psychiatric offenders comprise only a small fraction of crimes committed by
mentally ill offenders and mentally ill offenders have been repeatedly shown to mainly
commit opportunistic, minor crimes52.
31
It has also been proposed that mental illness and crime often concur because they
share many of the same predispositions. Developmental history, such as child abuse, and
sociological factors, such as having criminal associates and coming from a low
socioeconomic background, contribute to both psychiatric development and criminal
offending124-126. Differing combinations of similar genetic and developmental factors
drive which of the two outcomes will be generated. It is not surprising that often it results
in both of these outcomes simultaneously occurring; experience in one sphere increase
the likelihood to enter the other.
Psychiatrization of criminal behaviour is an intriguing approach to explain the
criminalization of the mentally ill. According to this theory, criminalization of the
mentally ill is a combined result of mentally ill persons entering judicial system as well
as criminal offenders being sent to psychiatric inspection18. Proponents of the thesis
argue that a psychiatric label is affixed to individuals who commit illegal and violent
behaviours, and mental illness is viewed as a result of crime in the same way criminal
offending is viewed as a result of mental illness.
There are more sociological factors that collectively point to the lack of adequate
accommodation for psychiatrically affected persons as a reason for the criminalization of
the mentally ill. In addition to the reduction in availability of institutionalized psychiatric
care, resulting from deinstitutionalization, there is also a severe lack of integrative
community care programs through which the general psychiatric patients and mentally ill
offenders are re-introduced and re-integrated into the community127. Studies have shown
that mentally ill persons sometimes commit crime intentionally, in order to be brought
back to incarceration settings where they are accustomed to and where they can continue
32
to receive systematic care, or unintentionally as a result of failure to adapt to society127. It
has also been found that personnel in the crime-fighting sector often assume hostile
attitudes when working with mentally ill offenders. Their general belief that deviant
behaviours are best dealt with by taking a firm stance, rather than treating them with an
accommodating mindset, is detrimental to the prognosis of mental illness in these
people127. Stigmatization on mentally ill offenders also appears to be a crucial factor in
criminalizing the mentally ill. Studies have shown that persons with mental illness or
suspected to have mental illness are more likely to be reported and arrested rather than
diverted91.
Studies that investigated the causal role of mental illness on violence have mostly
produced negative results. These studies have shown associations of moderate strength at
best and the direction of causality is yet to be clearly established128-130. For instance, a
study reported that the majority of mentally ill offenders were also comorbid with longterm substance abuse, which is a known cause of violence, and they could not attribute
the case of violent crimes entirely to the principal diagnosis129. These same researchers
also built a predictive model for violence, which predicted violence using severe mental
illness, but only when other predictors such as substance abuse and environmental factors
were also included in the model129. Link, Stueve and Phelan (1998) reported an
association between violence and psychotic disorders, showing that psychotic symptoms,
such as hallucinations, appeared to cause violence if the affected persons had deluded the
victims to be dangerous to themselves or if the severity of symptoms was great as to
override one’s prohibitions against violence130. This study, while particularly useful
because they narrowly defined exactly which component of the mental illness was linked
33
to violence, is still insufficient by itself to establish that mental illness is a cause of
violence nor is it generalizeable to mental illness as a whole130.
In summary, contrary to the popular belief that mental illness is conducive to
violence, scientific evidence is absent.
34
2.3. Forensic Psychiatric System in Canada
Since the large influx of mentally ill individuals into the criminal sector, the
Canadian criminal justice system has been making adjustments to accommodate this
unique population. One measure included active involvement of forensic psychiatrists in
the management of mentally ill offenders. Forensic psychiatry is a highly specialized
field of medicine dedicated to helping the mentally ill with legal troubles in a continuum
of social systems, namely mental health care, criminal justice and correction130.
Contributions of forensic psychiatry in the management of mentally ill offenders are
multi-folds. Forensic psychiatrists perform three types of forensic assessment: fitness to
stand trial, criminal responsibility, and dangerousness to community. Results from these
assessments are crucial in legal proceedings, as judges and counsels rely heavily on the
expert reports in determining the sentences. As crucial as their duty as legal expert in
determining the legal outcome for mentally ill offenders is a forensic psychiatrist’s
responsibilities as a physician. Forensic psychiatrists are key members of the clinical
teams tasked with the mental health care of thus sentenced mentally ill offenders130.
Other ways through which the judicial system has endeavoured to meet the
demands of a mentally ill offenders include the introduction of various points of
diversion in the forensic path of mentally ill accused and the establishment of provincial
review boards.
2.3.1 Forensic Path of the Mentally Ill in Canada
The legal path of a general offender begins with arrest. The arrestee is booked
with or without interrogation by the police and the police lay the charges. The arrestee
35
awaits the court appearance in the remand centre. At the first appearance at the court, one
may be allowed to be bailed out until trial, or, given the risk in their management, may be
disallowed bail and await trail in the remand centre. A trial occurs with or without
preliminary hearing, depending on the seriousness of crime. If convicted, the accused is
sentenced and is incarcerated in a provincial prison if the sentence is less than a two-year
term and in a federal prison if the sentence is any longer than two years and a day131.
The forensic path of the mentally ill is differentiated from this typical path by
points of diversion. A diversion refers to a medico-legal alternative to criminal sanctions
available to the mentally ill persons and is present at every stage of legal proceedings132.
Detailed information on the regular and psychiatric forensic paths and an illustration of
forensic path for the mentally ill are given in Appendix Two. Diversions are mainly used
in order to more humanely handle the cases of those who committed minor offences and
to prevent overloading of criminal courts. A serious offender, on the other hand, may be
diverted by the court in the presence of severe mental illness132. Of relevance to the
present study is this latter case. The accused is transferred to a quasi-judicial body called
the provincial review board if the court determines the accused to be not criminally
responsible on the account of mental disorder (NCRMD). This means that the accused
was incapable of comprehending their actions and consequences when they committed
the crime because of their mental illness. Here they are given the equivalent of sentencing,
called a disposition, which determines whether the accused will be detained in forensic
psychiatric hospitals or will be released into the community. The issue of fitness may be
raised by any party of the court. If the fitness assessment results confirm that the
individual is unfit to stand trial, the court issues a make fit order, which orders the
36
accused to receive treatment for up to 60 days to return to a fit state. If the treatment fails
to restore them to fitness, the jurisdiction over the accused is transferred to the review
board132,133.
2.3.2. Provincial Review Board
Prior to the 1992 Criminal Code reform, mentally ill offenders were handled
through the main criminal justice system. Accused who were found not guilty by reason
of insanity (NGRI) were strictly detained on what was termed the Lieutenant Governor’s
Warrant. The detained accused could hope to climb down the security ladder over time,
but there was no procedure specified as to how this isolated population should be
managed. Lieutenant Governor’s advisory boards had been in existence in some
provinces before the reform, but their activities were restricted to reporting outcomes to
the Lieutenant Governor23,29,47.
Along with amendments to the Criminal Code of Canada, Bill C-30 required each
province to strike a review board, an adjudicative body that holds exclusive jurisdiction
over persons whom the court have found to be NCRMD or unfit to stand trial and did not
regain fitness after the treatment order35. Unlike the Lieutenant Governor’s advisory
board, a provincial review board is empowered to autonomously make orders or
dispositions for these people. The very first hearing held for an accused by the review
board is called the initial hearing. A disposition made here is reviewed every year and
may be modified, largely depending on the prognosis of the mental disorder. Another
crucial determinant of the disposition, especially in the case of sexual offenders, is the
assessment of dangerousness. Using information such as severity of illness, seriousness
37
of index offence and prior criminal history, the psychologist and forensic psychiatrists
assess the risk the offender poses on the general public if they were to be released to the
community. Counsels on each side are given the opportunity to support or challenge the
expert opinion provided by the assessing psychiatrist and the review board ultimately
reaches a disposition, which may order the offender to be detained in the forensic hospital
if their dangerousness assessment indicates that they pose significant threat to the public35.
Review boards have been steadily growing in size across Canada46. This is largely
due to the permanence of the review board regulations. The mentally ill accused often
take a long time to regain fitness or show sufficient improvements in principal diagnosis
as to impose little or no threat to the community. Also, courts have been sending
increasingly more offenders to review boards, which created a cycle where there is a
constant influx with an incomparably small number of offenders leaving the system46,134.
Review boards have a special arrangement with hospitals that meet the Criminal
Code definition for forensic psychiatric assessment and care and have been designated by
the Ministry of Health. There are 12 hospitals designated for the Ontario Review Boards.
Subjects for the current study came exclusively from one of these hospitals, the
Providence Care, Mental Health Services in Kingston, Ontario134.
38
2.4. Challenges in Working with a Vulnerable Population
Forensic psychiatry, the field of medicine tasked with the care of mentally ill
offenders, is a relatively young specialty with conflicting ethical demands on the part of
the practitioners130. On the one hand, they have their responsibilities as physicians whose
priority is patient care. On the other hand, the nature of the field requires the practitioners
to work as an agent for a third party, thereby prioritizing some goal other than patient
care130. This has led to many complications in the protection and care of mentally ill
offenders. For instance, it is more difficult for forensic psychiatrists to build the
necessary trustworthy relationship with their offender patients because the patient, for a
justifiable reason on their end, may be reluctant to reveal information crucial for their
mental health treatment that may be used against them legally135. For another, it is
unclear whether restoration of fitness is truly benefiting the patient because it results in
sending the patient away from specialized care to legal proceedings, which has a good
chance of sending them to a more psychopathogenic prison environment135.
Working with mentally ill offenders is also difficult because they constitute a very
unpopular patient group. Shortages of funding and human resources often lead to mental
health care services being organized around a few priority patient groups, while largely
neglecting other groups such as Aboriginal people and psychiatric offenders130,136.
Mentally ill offenders constitute one of the most desperate patient groups as evidenced by
psychiatric prevalence unrivalled by any other constituent groups93,136. It should then be
more appropriate to accommodate the mentally ill as those with physical disability are
accommodated, but therapeutic and rehabilitative care of mentally ill offenders receive
far less attention than the correctional and punitive measures130.
39
Moreover, the double stigma of mental illness and crime as well as suppressed
human rights, have often led this population to serve as subjects of unethical and
dangerous researches. Offenders are especially susceptible because participation is often
coerced136. Activists have also addressed the concern that, even in the case of voluntary
participation, they may not be able to make truly free and informed consent decisions137.
From the Nazi doctors to the Tuskegee syphilis experiment, instances of inhumane and
unethical sufferings of prisoners in the name of common good are numberless137. The
issue of research participation is especially relevant to mentally ill offenders who often
have diminished capacity for comprehending the details of the research project and their
risks in participation138.
It is evident that mentally ill offenders comprise a difficult group to work with.
Yet this population cannot be neglected, not only in light of the size of the population or
economic impact, but also from a humanitarian stance. The vulnerability as well as the
challenges in providing care and studying this population places clinicians and
researchers of forensic psychiatry against higher standards of practice.
40
Chapter 3
Methods
3.1 Ethical considerations
This study has been approved by the Research Ethics Board of Queen’s
University and the Research Review Committee of Providence Care Hospital.
3.2 Subjects
Since the inception of the ORB in 1992, Providence Care Forensic Services has
admitted a total of 347 adults for court ordered psychiatric evaluation. All charts were
reviewed and basic information was gathered for a descriptive analysis (N=347). Detailed
information was collected on patients who received the verdict of NCRMD and who were
no longer in-patients of the hospital (n=85). Active in-patients of the hospital were
excluded in the study due to ethical considerations. Providence Care has provisions
regarding active in-patients which require added measures for protection of
confidentiality, such as a consent form. It was difficult to follow this protocol because
psychiatric in-patients admitted under treatment orders often had diminished capacity and
were not able to comprehend the concept of an informed consent. It was further
complicated by the fact that these individuals lacked legal guardians who could give
consent on their behalf. Less than 10 patients were excluded on this criterion.
3.3 Materials and Procedure
Data were collected by a retroactive chart review. There was not a direct
interaction between the student researcher and subjects. Charts included a wealth of
41
information including but not limited to: police records, witness statements, medical
records, psychiatric records, reports for the initial and annual hearings of the ORB and
results of specialized tests, such as Hare’s Psychopathy Checklist Revised(PCL-R)139,
Violent Risk Appraisal Guide (VRAG) and Sexual Offender Risk Appraisal Guide
(SORAG)140,141. Physicians at Providence Care began utilizing the Hare’s PCL-R in 1995
and VRAG and SORAG were first introduced in 1998. The gap between the 1993
inception of ORB and the adoption of these tools resulted in the information missing in a
significant number of subjects. Consequently, the scores of the aforementioned
specialized tests were ultimately excluded from data analysis despite their importance in
psycho-criminal research.
Most of the sociodemographic and criminal information was extracted directly
from the police report. Diagnoses were given by forensic psychiatrists at Providence Care
following the guidelines of Diagnostic and Statistical Manual of Mental Disorders IV and
later IV-TR61. Psycho-criminal information was collected by the ORB staff and clinical
teams at Providence Care. Data collection and electronic data coding were conducted
simultaneously (see Appendix Three for data collection sheet).
Sociodemographic information collected included: gender, age, place of
residency, marital status, living arrangement, level of education, and income source.
Psychopathological information collected included: current and life diagnoses, previous
psychiatric admission history, known psychiatric associates, and timing of first
psychiatric diagnosis. Psycho-social information collected included: child abuse history,
adult relationship history, adult violence history, general medical conditions,
psychosocial environmental factors, and global assessment of functioning. Criminal
42
information collected included: type of index offence, place and location of offence,
victim’s relationship to the offender, childhood criminal history, known criminal
associates, criminal history. Psycho-criminal information collected included: legal
verdict, psychiatric assessment site, initial ORB hearing site, scores of the
aforementioned standardized tests such as PCL-R, VRAG and SORAG, fitness to stand
trial, and ORB’s disposition regarding treatment.
3.4 Study Variables
Study variables were chosen in three steps: review of literature; consultation with
ORB forensic psychiatrists; and consideration of the availability of data. An initial list of
over twenty potential study variables was drawn from perusal of earlier literature on ORB
and the general Canadian forensic population25-54,142-146. Forensic psychiatrists with a
lengthy ORB career were consulted in order to narrow down this initial list. They were
asked to select the variables that they had frequently seen in their practice and suspected
to have effect on criminal outcomes. Finally, following data collection, some of the
variables on the created list were excluded when they had insufficient information.
Variables that had a zero cell frequency in one of the categorical level or were missing
from more than a third of the study population were excluded. Seriousness of index
offence and recidivism were chosen as the outcome measures of criminality.
3.5 Statistical Analyses
Chi square tests were performed to explore the distribution of sociodemographic
and predictor variables by the two outcome variables. Cross tabulations were also
43
performed between predictor variables and outcome variables in order to explore
bivariate associations. Chi square and one-tailed exact p-values were reported, except
when there were more than two categorical levels, in which case 2-tailed p-values were
reported. When there was a small cell size (<5), Fisher’s exact test values were reported
instead of chi square values.
A multiple logistic regression analysis was run in order to assess the role of
individual variables and combinations of them in predicting the outcomes of seriousness
of index offence and recidivism. Because predictors were selected from scarce prior
research on a similar topic, none of which focused on Canadian forensic population, it
was not feasible to determine the predictors’ order of importance in predicting the
outcome. Also, after the initial exploratory analysis using chi square, it was apparent that,
although all predictors met the significance cut-off to be included in the model, three
predictors had significance values well over 0.15. The remaining two predictors were
significantly associated (p<0.05) only to one and not the other outcome variable.
Determining the order of importance among thus statistically insignificant associations
would have yielded little benefit. As such, forced entry method was selected. The models
were adjusted for age and gender to control for confounding.
44
Chapter 4
Results
4.1 Description of Study Population (Objective 1)
Out of 347 psychiatrically evaluated offenders, 85 received the verdict of
NCRMD and were included in data analysis. This represents a success rate of 25.5% for
NCRMD among those who raised the NCRMD defense. The study population was
predominantly male (88.2%), had a mean age of 33 years and was most frequently
diagnosed with schizophrenia (70.6%). Nearly all subjects came from low socioeconomic status: the majority received no post-secondary education (70.7%) and had no
income or received some kind of assistance or pension (94.1%). The most common index
offence was assault (48.2%) and the disposition most frequently given by the ORB was
full-time detention at the hospital (92.9%). Subjects more often began their psychiatric
life before criminal career as shown by first official psychiatric diagnosis predating the
first criminal charge (78.8%); more often had psychiatric history than criminal history
(84.7% vs. 67.1%); and were more likely to have psychiatric associates than criminal
associates (45.9% vs. 17.6%). In some of the subjects, a different primary psychiatric
diagnosis was given during the ORB assessment than their first official diagnosis (27%).
Detailed demographic information of the study population is presented in Table 4.1.
4.2 Statistical Analysis
4.2.1 Bivariate associations
Bivariate associations were explored using chi-square tests between the
seriousness of index offence or recidivism. This also allowed for detection of
!
45!
dissimilarities in distribution of variables by the outcome variables. Summary of cross
tabulations and one-tailed chi-square or Fisher’s exact test p-values are reported in Table
4.2 and 4.3. For some variables that were initially divided into groups of narrow ranges,
category levels were collapsed into larger ranges and therefore a fewer number of groups.
This practice increased cell sizes for individual groups and allowed chi-square
significance testing.
4.2.2 Distribution of variables
Variables that did differ by the outcome variable were more closely examined to
learn where the differences came from. Both sociodemographic factors and predictor
variables were similarly distributed between the subjects who committed petty crimes
and the subjects who committed serious crimes with the exception of age. Subjects
tended to have committed serious crimes when they were younger (!2(5)=13.624,
p<0.05).
First-time offenders and repeat offenders showed more marked differences.
Psychiatric onset had predated the first crime in all first-time offenders while one third of
repeat offenders reported to have developed a psychiatric disorder after they committed
their first crime (!2(1)=15.468, p<0.001). Repeat offenders also far surpassed first timers
in early deviance history (73.1% and 37.5%, respectively; !2(1)=15.468, p<0.005).
4.2.3 Multivariate associations (Objective 2&3)
A cut-off significance value of p=0.2 was applied when selecting variables to be
used as predictors in the regression analysis. Predictors that met this cut-off value for
!
46!
either of the two outcome variables were included in the model for both.
Sociodemographic variables were not included in the main regression model even if they
met the cut-off value in order to avoid overloading of the model and also because the
primary goal of this study was investigation of association between criminality and
psychiatric and criminal factors, not basic sociodemography. Also, the variable that
represented changes in principal diagnosis was not included in the model even though it
met the significance cut-off for both of the outcome variables. The concern here was that
this variable was not applicable to subjects who did not previously have a psychiatric
diagnosis (n=14). Also, this variable was suspected to be prone to human error because it
was not always indicated in the charts when and where the diagnoses were given.
Furthermore, it was not clear how the change was patterned because it did not always
change from an initial diagnosis of a type of disorder to another, like going from
dysthymic disorder to major depressive disorder. The risk for confounding would have
been severe and therefore it was excluded from the regression model and was examined
individually.
Psychiatric history and timing of psychiatric onset were chosen as
psychopathological predictors. Known criminal associates and early signs of deviance
were chosen as criminal predictors. The term ‘associate’ was limited to family members
and romantic partners and excluded more ambiguous relationships like friends or
colleagues. Also, child abuse history was chosen as a developmental predictor that was
attributed to both psychopathology and criminality.
Both crude and adjusted results from the multiple logistic regression analysis are
reported in Table 4.4 to compare confounding. Seriousness of index offence was not
!
47!
significantly predicted by any of the examined predictor variables and any substantial
values of odds ratio were accompanied by high p-values (p=0.581, OR=1.812 for
existence of criminal associate and p=0.396, OR=2.292 for child abuse history) and were
consequently not considered further.
Subject’s risk of recidivism increased by eight times with a history of early
deviance (OR=8.154 [1.401-47.461], p<0.05). Other predictor variables did not
significantly affect the likelihood to recidivate, but existence of criminal associates was
shown to increase the likelihood to recidivate by seven times at a marginal significance
(OR=7.758 [0.541-106.2], p=0.133).
Results from individual examination of change in principal diagnosis variable are
presented Table 4.5. A meaningful odds ratio for committing more serious crime was
observed initially (crude OR=2.914 [0.754-11.271], p=0.121), but the effect disappeared
with adjustment (OR=1.986 [0.473-8.332], p=0.348). The variable did not significantly
predict recidivism (crude OR=0.488 [0.164-1.452], p=0.197 and adjusted OR=0.637
[0.194-2.093], p=0.458).
4.2.4 Additional analyses
Comparison of regression models showed that values adjusted using age and
gender were substantially different from the crude values. To test the role of age and
gender as possible confounders, models were run again with age or gender as the sole
adjusters and results are shown in Table 4.6. Odds ratio of recidivism predicted by early
deviance was improved when age was controlled, but remained the same when gender
was controlled. Significance values did not change substantially. It may be indicative that
!
48!
age is a greater confounder than gender in predicting the criminality of the subjects.
Gender should still be monitored as a possible confounder since adjusting for gender as
well as age produced a greater change in the odds ratio than when age alone was used.
Also, existence of criminal associate substantially predicted recidivism at a marginal
significance when adjusted for age and child abuse history substantially predicted
recidivism at a marginal significance when adjusted for gender (OR=6.628 [0.56078.501], p=0.134, and OR=5.041 [0.509-49.955], p=0.167, respectively).
Changes in principal diagnosis had not been included as a predictor in the main
regression analysis given the high chance of human error in information collection
process. An additional analysis was done with this variable as one of the predictors to
examine its role in predicting criminality. Findings are presented in Table 4.7a.
Regression models were also run including changes in principal diagnosis as a predictor
and adjusted for age or gender only. Findings may be found in Tables 4.7b and 4.7c.
Significant results were not produced in this analysis. Early deviance, however,
substantially predicted recidivism at a marginal significance when adjusted for both age
and gender as well as when adjusted for age alone. Child abuse history substantially
predicted recidivism at a marginal significance when adjusted for gender (OR=4.274
[0.638-28.623], p=0.134, OR=2.886 [0.634-13.137], p=0.171 and OR=3.645 [0.60821.864], p=0.157, respectively).
Each of the outcome variables was then tested using the predictor variables that
were shown to be associated with only that outcome variable, as opposed to either of the
two outcome variables, as was done in the main analysis. They were also adjusted using
only the sociodemographic factor that was shown to be associated with only that outcome
!
49!
variable. Regression analysis on the outcome of recidivism was ultimately not run
because the list of predictor variables was exactly the same as results produced for this
outcome variable in Table 4.6b. Therefore, only the seriousness of index offence variable
was tested using age as the sole adjuster. Findings are presented in Tables 4.8.
4.2.5 Assessment of Regression Model
Goodness of fit statistics (R2L, R2CS, R2N and -2 Log Likelihood), residuals and
collinearity diagnostics were generated for the final logistic regression model. Only main
effects were tested without assessment of interactions. R2 values in logistic regression
should be interpreted with caution since they only provide hypothetical trends in model
fitness here. Maximum R2 values indicate that 35.7% and 56.8% of the variation in the
final models were explained by the predictors. Both of these figures were significant and
substantial improvement from the basic model which only included the intercepts.
Residuals appeared mostly normal. There were two cases in the seriousness of crime
model whose Cook’s Distance values were slightly above five and two cases in the
recidivism model with values over one. There were 12 cases and 18 cases respectively in
each of the models that exceeded the predicted leverage value, which again may indicate
a problem. Doubtful leverage values, however, do not indicate undue influence on
regression coefficient but rather on the outcome variable189. Also, given that quite a few
predictors were used in the model, influence may have been overly presented.
Collinearity diagnostics did not indicate any multicollinearity. No tolerance value
was less than 0.1, no VIF higher than 10 was observed and eigenvalues were not
correlated.
!
50!
Table 4.1. Demographic information of the study population.
Variable (n=85)
Gender
Male
Female
Age (years)
Mean (SEM)
18-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
Highest level of education reached
Grade 8 or less
High School - some
High School - complete
Community College - some
Community College - complete
University - some
University - complete
Income source
Unemployed
Paid employment
Employment Insurance
Social Assistance
Disability Pension
Retirement/Old Age Pension
Other (specify when possible)
Primary psychiatric diagnosis
Schizophrenia (excluding schizoaffective & schizophreniform)
Delusional or other psychotic disorder
Schizoaffective disorder
Bipolar disorder - manic
Personality disorder - Antisocial
Other
Index offence
Homicide
Assault
Sexual assault
Offence against property
Others (e.g. prostitution)
Treatment disposition by the ORB
Detain - inpatient care
Conditional discharge - halfway housing
Conditional discharge - with supervision only
Timing of psychiatric onset
Predates first crime
Follows first crime
Other Psychiatric Characteristics
Has psychiatric history
Has psychiatric associates
!
51!
n(%)
75(88.2)
10(11.8)
33.59(1.254)
22(25.6)
22(25.6)
11(12.7)
11(12.8)
7(8.2)
3(3.5)
3(3.6)
3(3.6)
3(3.5)
10(11.8)
31(36.5)
19(22.4)
7(8.2)
5(5.9)
4(4.7)
7(8.2)
19(22.4)
5(5.9)
2(2.4)
7(8.2)
35(41.2)
1(1.2)
7(8.2)
60(70.6)
5(5.9)
4(4.7)
4(4.7)
3(3.5)
9(10.6)
14(16.5)
41(48.2)
6(7.1)
9(10.6)
14(16.5)
79(92.9)
1(1.2)
1(1.2)
67(78.8)
18(21.2)
72(84.7)
39(45.9)
Primary psychiatric diagnosis changed between first official diagnosis and
the ORB assessment
Other Criminal Characteristics
Has criminal history
Has criminal associates
!
52!
20 (27.0)
57(67.1)
15(17.6)
Table 4.2. Distribution of variables by seriousness of index offence. P-values less than
0.05, 0.01 and 0.005 were denoted with *, ** and ***, respectively.
Variable (n=84)
Seriousness of Index Offence
Petty
Grave
n=23(27.4%)
n=61(72.6%)
Gender (84)
Male (75)
Female (9)
Age (84)
18-25 (22)
26-30 (22)
31-35 (11)
36-40 (11)
41-45 (7)
46 or above (11)
Highest level of education reached (83)
Grade 8 or less (10)
High School - some (31)
High School - complete (19)
Community College - some (7)
Community College - complete (5)
University or above (11)
Income source (76)
Unemployed (19)
Paid employment & income resulting from
previous paid employment (retirement plan,
employment insurance) (8)
Social Assistance (e.g. Disability Pension,
Ont. Works, Family Benefits Act) (41)
Other (specify when possible) (8)
Primary psychiatric diagnosis (84)
Schizophrenia (59)
Other psychotic disorder (8)
Mood Disorder (6)
Personality disorder (5)
Other (6)
Treatment disposition by the ORB (80)
Detain - inpatient care (78)
Conditional discharge (2)
Timing of psychiatric onset (84)
Predates first crime (66)
Follows first crime (18)
Other Psychiatric Characteristics
Has psychiatric history (71)
Has psychiatric associates (38)
Primary psychiatric diagnosis changed
between first official diagnosis and the
ORB assessment (20)
Other Criminal Characteristics
Has criminal history (56)
Has criminal associates (15)
Signs of deviance in childhood (48)
Developmental Characteristics
Has child abuse history (18)
!
53!
!2 p-value
21(91.3%)
2(8.7%)
54(88.5%)
7(11.5%)
0.531
4(17.4%)
5(21.7%)
3(13%)
2(8.7%)
6(26.1%)
3(13%)
18(29.5%)
17(27.9%)
8(13.1%)
9(14.8%)
1(1.6%)
8(13.1%)
0.032*
(Fisher’s
exact; 2tailed)
3(13%)
8(34.8%)
7(30.4%)
1(4.3%)
2(8.7%)
2(8.7%)
7(11.9%)
22(37.3%)
12(20.3%)
6(10.2%)
3(5.1%)
9(15.3%)
0.825
(Fisher’s
exact; 2
tailed)
3(15.8%)
0(0%)
16(28.1%)
8(14%)
0.153
(Fisher’s
exact; 2
tailed)
14(73.7%)
27(47.4%)
2(10.5%)
6(10.5%)
15(65.2%)
2(8.7%)
2(8.7%)
2(8.7%)
2(8.7%)
44(72.1%)
6(9.8%)
4(6.6%)
3(4.9%)
4(6.6%)
0.88
(Fisher’s
exact; 2
tailed)
22(100%)
0
56(96.6%)
2(3.4%)
0.523
(Fisher’s
exact)
16(69.6%)
7(30.4%)
50(82%)
11(18%)
0.173
21(91.3%)
12(54.5%)
3(14.3)
50(82%)
26(44.8%)
17(32.7%)
0.244
0.299
0.093
16(69.6%)
4(19%)
13(68.4%)
40(66.7%)
11(19.3%)
35(60.3%)
0.509
0.628
0.364
6(33.3%)
12(32.1%)
0.570
Table 4.3. Distribution of variables by recidivism. P-values less than 0.05, 0.01 and 0.005
were denoted with *, ** and ***, respectively.
Variable (n=84)
Recidivism
First timer
Repeat offender
n=27(32.1%)
n=57(67.9%)
Gender (84)
Male (74)
Female (10)
Age (84)
18-25 (22)
26-30 (21)
31-35 (11)
36-40 (11)
41-45 (7)
46 or above (12)
Highest level of education reached (82)
Grade 8 or less (10)
High School - some (30)
High School - complete (19)
Community College - some (7)
Community College - complete (5)
University or above (11)
Income source (76)
Unemployed (19)
Paid employment & income resulting from
previous paid employment (retirement plan,
employment insurance) (8)
Social Assistance (e.g. Disability Pension,
Ont. Works, Family Benefits Act) (42)
Other (specify when possible) (7)
Primary psychiatric diagnosis (84)
Schizophrenia (59)
Other psychotic disorder (8)
Mood Disorder (6)
Personality disorder (5)
Other (6)
Index offence (83)
Homicide (14)
Assault (40)
Sexual assault (6)
Property and other Criminal Code offences
(23)
Treatment disposition by the ORB (80)
Detain - inpatient care (78)
Conditional discharge (2)
Timing of psychiatric onset (84)
Predates first crime (67)
Follows first crime (18)
Other Psychiatric Characteristics
Has psychiatric history (71)
Has psychiatric associates (38)
Primary psychiatric diagnosis changed
between first official diagnosis and the
!
54!
!2 p-value
22(81.5%)
5(18.5%)
52(91.2)
5(8.7)
0.176
8(29.6%)
9(33.3%)
3(11.1%)
2(7.4%)
1(3.7%)
4(14.8%)
14(24.6%)
12(21.1%)
8(14%)
9(15.8%)
6(10.5%)
8(14%)
0.693
(Fisher’s
exact; 2
tailed)
2(7.4%)
7(25.9%)
8(29.6%)
3(11.1%)
1(3.17%)
6(22.1%)
8(14.5%)
23(41.8%)
11(20%)
4(7.3%)
4(7.3%)
5(9.1%)
0.339
(Fisher’s
exact; 2
tailed)
6(23.1%)
5(19.2%)
13(26%)
3(6%)
0.389
(Fisher’s
exact; 2
tailed)
13(50%)
29(58%)
2(7.7%)
5(10%)
17(63%)
3(11.1%)
4(14.8%)
1(3.7%)
2(7.4%)
42(73.7%)
5(8.8%)
2(3.5%)
4(7%)
4(7%)
5(18.5%)
14(51.9%)
1(3.7%)
7(25.9%)
9(16.1%)
26(46.4%)
5(8.9%)
16(28.6%)
24(96%)
1(54%)
54(98.2%)
1(1.8%)
0.530
(Fisher’s
exact)
27(100%)
0
39(68.4%)
18(31.6%)
0.000***
21(77.8%)
12(46.2%)
8(38.1%)
50(87.7%)
26(48.1%)
12(23.1%)
0.195
0.529
0.156
0.435
(Fisher’s
exact; 2
tailed)
0.906
(Fisher’s
exact; 2
tailed)
ORB assessment (20)
Other Criminal Characteristics
Has criminal associates (15)
Signs of deviance in childhood (47)
Developmental Characteristics
Has child abuse history (23)
!
55!
2(8%)
9(37.5%)
12(22.6%)
38(73.1)
0.101
0.003***
5(20.8%)
18(36.7%)
0.134
Table 4.4. Multivariate logistic regression model. P-values less than 0.05, 0.01 and 0.005
were denoted with *, ** and ***, respectively.
Predictors
Constant
Psychiatric
onset
Seriousness of Index Offence
Crude
Adjusted
B (SE)
OR
B (SE)
OR
[95%
[95%
CI]
CI]
1.849
6.351*
1.691
5.426
(0.873)*
(1.007)
-0.873
0.418
-0.299
0.742
(0.635)
[0.120(0.770)!
[0.1641.450]
3.352]
Psychiatric
history
-0.556
(0.858)
0.573
[0.1073.080]
-0.050
(0.925)!
0.951
[0.1555.831]!
0.279
(0.806)!
0.321
[0.2726.410]!
0.352
(0.948)!
1.422
[0.2229.125]!
Existence of
criminal
associate(s)
Child abuse
history
0.111
(0.681)
0.595
(1.077)!
5.239
[0.52752.121]
2.197
[0.5199.304]
3.642
[1.02212.972]*
67.2%
2.025
(1.347)!
-0.271
(0.646)
1.812
[0.21914.972]
2.292
[0.33715.600]
0.827
[0.1773.862]
82.4%
1.656
(1.172)!
Signs of
early
deviance
Accuracy of
prediction
-2LL
R 2N
1.713
[0.3079.576]
1.117
[0.2944.247]
0.762
[0.2152.705]
75%
7.577
[0.541106.2]
1.958
[0.31712.103]
8.154
[1.40147.461]*
83.6%
0.538
(0.878)
76.5***
0.067
0.830
(0.978)!
-0.190
(0.786)
!
57.705
0.357
!
!
Recidivism
Crude
Adjusted
B (SE)
OR
B (SE)
OR
[95%
[95%
CI]
CI]
-1.051
0.350
-1.652
0.192
(0.801)
(1.079)
21.100
1.457E9
21.389
1.946E9
(9676.72
[0-]
(9417.67
[0-]
1)!
0)!
0.787
(0.736)!
1.292
(0.648)*
!
!
56!
84.8***
0.438
0.672
(0.929)!
2.099
(0.899)*
!
!
49.7***
0.568
Table 4.5. Bivariate logistic regression model for change in principal psychiatric
diagnosis. P-values less than 0.05, 0.01 and 0.005 were denoted with *, ** and ***,
respectively.
Predictors
Constant
Change in
principal
diagnosis
Accuracy of
prediction
-2LL
R 2N
!
Seriousness of Index Offence
Crude
Adjusted
B (SE)
OR
B (SE)
OR
[95%
[95%
CI]
CI]
0.665
1.944*
0.948
2.580
(0.290)*
(0.602)
1.070
2.914
0.686
1.986
(0.690)
[0.754(0.732)
[0.47311.271]
8.332]
71.2%
78.1%
87.6***
0.053
74.207
0.240
57!
Recidivism
Crude
Adjusted
B (SE)
OR
B (SE)
OR
[95%
[95%
CI]
CI]
1.124
3.077*
-0.450
2.307
(0.319)*
(0.607)
-0.718
0.488
0.836
0.637
(0.557)
[0.164(0.553)
[0.1941.452]
2.093]
71.2%
72.6%
87.6***
0.032
78.993
0.159
Table 4.6a. Multivariate logistic regression model with age as the only adjuster. P-values
less than 0.05, 0.01 and 0.005 were denoted with *, ** and ***, respectively.
Seriousness of Index Offence
Crude
Predictors
B (SE)
Adjusted
OR
B (SE)
[95%
CI]
OR
Crude
B (SE)
[95%
CI]
Adjusted
OR
B (SE)
[95%
CI]
OR
[95%
CI]
Constant
1.849
(0.873)*
6.351*
2.585
(1.025)*
13.267*
-1.051
(0.801)
0.350
-1.324
(1.023)
0.266
Psychiatric
onset
-0.873
(0.635)
0.418
[0.1201.450]
-0.861
(0.641)
0.423
[0.1201.487]
21.100
(9676.7
21)
1.457E9
[0-]
21.493
(9634.0
86)
2.160E9
[0-]
Psychiatric
history
-0.556
(0.858)
0.573
-0.186
(.909)
0.831
[0.1404.932]
0.279
(0.806)
0.321
[0.2726.410]
0.169
(0.921)
1.185
[0.1957.209]
Existence of
criminal
associate(s)
0.111
(0.681)
0.586
(0.896)
1.797
[0.31010.412]
1.656
(1.172)
5.239
[0.52752.121]
1.891
(1.261)
6.628
[0.56078.501]
Child abuse
history
0.538
(0.878)
1.117
0.439
[0.2944.247]
(-0.726)
1.551
[0.3746.435]
0.787
(0.736)
2.197
[0.5199.304]
0.380
(0.843)
1.462
[0.2807.636]
Signs of
early
deviance
-0.271
(0.646)
0.762
0.698
(0.735)
0.497
[0.1182.101]
1.292
(0.648)*
3.642
[1.02212.972]
*
1.913
(0.852)*
6.770
[1.27335.991]
*
Accuracy of
prediction
-2LL
R 2N
!
Recidivism
[0.1073.080]
1.713
[0.3079.576]
[0.2152.705]
75.0%
75.0%
67.2%
80.6%
76.5***
0.067
71.016
0.114
84.82**
0.438
53.0***
0.527
58!
Table 4.6b. Multivariate logistic regression model with gender as the only adjuster. Pvalues less than 0.05, 0.01 and 0.005 were denoted with *, ** and ***, respectively.
Seriousness of Index Offence
Crude
Predictors
B (SE)
Adjusted
OR
B (SE)
[95%
CI]
OR
Crude
B (SE)
[95%
CI]
Adjusted
OR
B (SE)
[95%
CI]
OR
[95%
CI]
Constant
1.849
(0.873)*
6.351*
1.874
(0.884)*
6.517*
-1.051
(0.801)
0.350
-1.145
(0.822)
0.318
Psychiatric
onset
-0.873
(0.635)
0.418
[0.1201.450]
-0.891
(0.637)
0.410
[0.1181.430]
21.100
(9676.7
21)
1.457E9
[0-]
21.076
(9634.2
00)
1.423E9
[0-]
Psychiatric
history
-0.556
(0.858)
0.573
-0.554
(0.863)
0.575
[0.1063.120]
0.279
(0.806)
0.321
[0.2726.410]
0.457
(0.837)
1.579
[0.3068.145]
Existence of
criminal
associate(s)
0.111
(0.681)
0.512
(0.881)
1.669
[0.2979.388]
1.656
(1.172)
5.239
[0.52752.121]
1.618
(1.170)
5.041
[0.50949.955]
Child abuse
history
0.538
(0.878)
0.194
(0.724)
1.214
[0.2945.015]
0.787
(0.736)
2.197
[0.5199.304]
1.050
(0.801)
2.857
[0.59513.725]
Signs of
early
deviance
-0.271
(0.646)
1.292
(0.648)*
3.642
[1.02212.972]
*
1.297
(0.659)*
3.660
[1.00713.304]
Accuracy of
prediction
-2LL
R 2N
!
Recidivism
[0.1073.080]
1.713
[0.3079.576]
1.117
[0.2944.247]
0.762
[0.2152.705]
-0.280
(0.650)
0.756
[0.2122.700]
75.0%
75.0%
67.2%
76.1%
76.5***
0.067
74.207
0.070
84.82**
0.438
58.4***
0.454
59!
Table 4.7a. Multivariate logistic regression model including changes in principal
diagnosis as a predictor. P-values less than 0.05, 0.01 and 0.005 were denoted with *, **
and ***, respectively.
Seriousness of Index Offence
Crude
Predictors
B (SE)
Adjusted
OR
B (SE)
[95%
CI]
OR
Crude
B (SE)
[95%
CI]
Adjusted
OR
B (SE)
[95%
CI]
OR
[95%
CI]
Constant
1.728
(1.270)
5.631
1.498
(1.420)
4.475
-0.627
(1.205)
0.534
-1.753
(1.492)
0.173
Psychiatric
onset
-0.671
(0.669)
0.511
[0.1381.899]
-0.366
(0.786)
0.694
[0.1493.234]
20.939
(9939.3
04)
1.240E9
[0-]
21.256
(9407.5
93)
1.703E9
[0-]
Psychiatric
history
-0.779
(1.195)
0.459
[0.0444.772]
-0.291
(1.251)
0.747
[0.0648.668]
0.223
(1.126)
1.250
0.503
(1.233)
1.653
[0.14818.515]
Existence of
criminal
associate(s)
0.500
(0.900)
1.648
[0.2829.626]
0.356
(1.110)
1.428
[0.16212.582]
1.410
(1.173)
4.096
[0.41140.847]
1.770
(1.392)
5.869
[0.38389.905]
Child abuse
history
-0.005
(0.698)
0.995
[0.2533.909]
0.667
(1.001)
1.948
[0.27413.858]
0.896
(0.797)
2.450
[0.51411.679]
1.453
(1.056)
3.262
[0.41225.827]
Signs of
early
deviance
-0.133
(0.702)
0.875
[0.2213.462]
-0.107
(0.865)
0.899
[0.1654.895]
0.725
(0.712)
2.064
[0.5128.327]
1.182
(0.970)
4.274
Change in
principal
diagnosis
0.951
(0.869)
2.589
[0.47114.229]
0.327
(0.974)
1.386
[0.2059.360]
0.103
(0.736)
1.109
[0.2624.695]
0.604
(0.951)
Accuracy of
prediction
-2LL
R 2N
!
Recidivism
73.3%
69.6***
0.098
73.3%
65.171
0.103
60!
[0.13811.355]
[0.63828.623]
1.830
[0.28411.796]
71.2%
83.1%
n/a
0.376
42.59**
0.544
Table 4.7b. Multivariate logistic regression model including changes in principal
diagnosis as a predictor and with age as the only adjuster. P-values less than 0.05, 0.01
and 0.005 were denoted with *, ** and ***, respectively.
Seriousness of Index Offence
Crude
Predictors
B (SE)
Adjusted
OR
B (SE)
[95%
CI]
OR
Crude
B (SE)
[95%
CI]
Adjusted
OR
B (SE)
[95%
CI]
OR
[95%
CI]
Constant
1.728
(1.270)
5.631
2.367
(1.418)
10.670
-0.627
(1.205)
0.534
-1.334
(1.309)
0.263
Psychiatric
onset
-0.671
(0.669)
0.511
-0.689
(0.678)
0.502
[0.1331.897]
20.939
(9939.3
04)
1.240E9
[0-]
20.902
(9935.8
76)
1.196E9
[0-]
Psychiatric
history
-0.779
(1.195)
-0.531
(1.222)
0.588
0.223
(1.126)
1.250
-0.074
(1.136)
0.929
Existence of
criminal
associate(s)
0.500
(0.900)
Child abuse
history
-0.005
(0.698)
Signs of
early
deviance
-0.133
(-0.702)
Change in
principal
diagnosis
0.951
(0.869)
Accuracy of
prediction
-2LL
R 2N
!
Recidivism
[0.1381.899]
0.459
[0.0444.772]
1.648
[0.2829.626]
0.995
[0.2533.909]
0.875
[0.2213.462]
2.589
[0.47114.229]
73.3%
69.6***
0.098
[0.0546.445]
[0.13811.355]
[0.1008.605]
0.543
(0.912)
1.721
[0.28810.274]
1.410
(1.173)
4.096
[0.41140.847]
1.491
(1.201)
4.443
[0.42246.741]
0.240
(0.746)
1.271
[0.2955.489]
0.896
(0.797)
2.450
[0.51411.679]
0.607
(0.836)
1.835
[0.3569.449]
-0.485
(0.800)
0.616
0.725
(0.712)
2.064
[0.5128.327]
1.060
(0.773)
2.886
0.103
(0.736)
1.109
[0.2624.695]
0.152
(0.743)
0.862
(0.885)
[0.1282.952]
2.369
[0.41813.418]
[0.63413.137]
1.165
[-.2724.993]
70.0%
71.2%
72.9%
64.284
0.123
70.86**
0.376
51.351*
0.403
61!
Table 4.7c. Multivariate logistic regression model including changes in principal
diagnosis as a predictor and with gender as the only adjuster. P-values less than 0.05,
0.01 and 0.005 were denoted with *, ** and ***, respectively.
Seriousness of Index Offence
Crude
Predictors
B (SE)
Adjusted
OR
B (SE)
[95%
CI]
OR
Crude
B (SE)
[95%
CI]
Adjusted
OR
B (SE)
[95%
CI]
OR
[95%
CI]
Constant
1.728
(1.270)
5.631
1.811
(1.309)
6.116
-0.627
(1.205)
0.534
-0.846
(1.256)
0.429
Psychiatric
onset
-0.671
(0.669)
0.511
-0.695
(0.674)
0.499
[0.1331.869]
20.939
(9939.3
04)
1.240E9
[0-]
20.965
(9861.5
83)
1.274E9
[0-]
Psychiatric
history
-0.779
(1.195)
-0.859
(1.229)
0.424
[0.0384.708]
0.223
(1.126)
1.250
0.467
(1.170)
1.594
Existence of
criminal
associate(s)
0.500
(0.900)
0.475
(0.904)
1.608
[0.2739.461]
1.410
(1.173)
4.096
[0.41140.847]
1.353
(1.173)
3.870
[0.38838.561]
Child abuse
history
-0.005
(0.698)
0.124
(0.752)
1.132
[0.2594.948]
0.896
(0.797)
2.450
[0.51411.679]
1.293
(0.914)
3.645
[0.60821.864]
Signs of
early
deviance
-0.133
(-0.702)
0.875
[0.2213.462]
-0.119
(0.708)
0.888
[0.2223.556]
0.725
(0.712)
2.064
[0.5128.327]
0.736
(0.731)
2.087
Change in
principal
diagnosis
0.951
(0.869)
2.589
1.034
(0.897)
2.811
[0.48516.301]
0.103
(0.736)
1.109
[0.2624.695]
0.342
(0.788)
Accuracy of
prediction
-2LL
R 2N
!
Recidivism
[0.1381.899]
0.459
[0.0444.772]
1.648
[0.2829.626]
0.995
[0.2533.909]
[0.47114.229]
[0.13811.355]
[0.16115.792]
[0.4988.752]
1.408
[0.3016.597]
73.3%
78.1%
71.2%
72.9%
69.6***
0.098
52.88**
0.225
70.86**
0.376
51.35**
0.403
62!
Table 4.8. Multivariate logistic regression model using psychopathological and criminal
predictors with direct association only. Models were adjusted for only age or gender. Pvalues less than 0.05, 0.01 and 0.005 were denoted with *, ** and ***, respectively.
Seriousness of Index Offence
Crude
Predictors
B (SE)
Age adjusted
OR
B (SE)
[95%
CI]
[95%
CI]
Constant
0.745
(0.336)*
2.107*
1.014
(0.616)
2.755
Psychiatric onset
-0.294
(0.602)
0.745
[0.2292.423]
-0.129
(0.712)
0.879
[0.2173.550]
Change in
principal
diagnosis
1.037
(0.694)
2.822
[0.72510.990]
0.759
(0.725)
2.135
[0.5158.846]
Accuracy of
prediction
-2LL
R 2N
!
OR
71.2%
78.1%
87.6***
0.053
74.207
0.240
63!
!
Chapter 5
Discussions
5.1 Population Characteristics
The study population shared many characteristics with the general offender
population as well as the NCRMD population examined in earlier studies25-28,32-46,48-54,141146
. Subjects were primarily young males who came from low socioeconomic background
and were most commonly diagnosed with schizophrenia. In most cases, first official
psychiatric diagnosis predated the first criminal charge, indicating that psychiatric
development preceded criminal career. Also, patients more often had a psychiatric history
than a criminal history. Finally, patients more often had psychiatric associates than
criminal associates.
As expected, almost all subjects were ordered to full-time detention at forensic
psychiatric hospitals for treatment (93%). Only 2.4% of the subjects were treated in a
community setting and none received an absolute discharge. This finding appears
appropriate given that offenders do not successfully reach ORB unless they are severely
ill, and the severity of illness warrants hospitalization. The rate at which full-time
detention versus conditional discharge is given had varied from study to study, with
findings of this study on the conservative side. Two studies in British Columbia found
25% and 37.5% of NCRMD offenders conditionally discharged, respectively146,25.
However, most studies generally agree that a NCRMD verdict most frequently results in
detention at a hospital, followed by a conditional discharge and almost never results in
absolute discharge.
!
64!
!
5.1.1 Criminal Responsibility
Out of 347 offenders who were psychiatrically evaluated, 85 were found NCRMD
and were included as the subjects of this study (24.5%). This rate appears higher than
observations from other countries. In the United States, the national success rate was less
than 20% among those who attempted to plead not guilty by reason of insanity and less
than 1% of all criminal cases within the same time period147. In a recent study on a
Chilean offender population, only 4.3% of all psychiatrically evaluated offenders in two
large forensic psychiatric hospitals were found not criminally responsible148. Currently
there is no data available to estimate the national success rate of NCRMD in Canada.
Justice Canada recently presented that 0.12% of all criminal cases was referred to a
review board jurisdiction across Canada, but this report did not break down the success
rates of NCRMD among the overall offender population, among psychiatrically evaluated
offenders or among those that specifically raised NCRMD defense46. More insight was
provided in regionally reported rates of attempt and success of NCRMD defense. A study
in British Columbia reported 53 successful NCRMD defenses among 185 offenders who
raised the question of criminal responsibility and among all 620 psychiatrically evaluated
offenders over a two-year period (28.6% and 8.5%)19. Based on these numbers, the
success rate of NCRMD seen in this study population appears higher than the reported
average.
This seemingly high success rate, however, must be taken with caution. The
charts used to gather this study’s data did not clarify the purpose of the court ordered
psychiatric evaluations. It was not feasible to track this down because it required
reviewing restricted material such as court transcripts. The student researcher therefore
!
65!
!
collectively treated them as psychiatric evaluations without further differentiating them
by the purpose of evaluation. It is possible that all charts were of those who were
specifically sent for criminal responsibility evaluations, but it is equally possible that
some of them were sent for fitness to stand trial evaluations. In the latter case, the success
rate would be reduced substantially as the denominator would surely have been higher in
actuality. Also, the aforementioned rate of 24.5% would be the success rate of NCRMD
among those who specifically tried this defense, in which case it would be more in line
with findings of other Canadian studies.
5.1.2 Nature of Crimes
Most frequently committed crimes were assault (48.2%) followed by homicide
(16.5%). Sexual assault, offence against property and other minor crimes such as
possession of drugs were less common (7.1%, 10.6% and 16.5%, respectively).
Altogether violent crimes comprised 71.8% of all index offences. This observation is
dissimilar to the trend seen in the general Canadian offender population. Despite the
constant increase in the violent crime rate in Canada from 1960’s until 1992, violent
crimes have been a smaller proportion of crimes than the other two categories, namely
property and other criminal code crimes. For instance, violent crimes accounted for 11%
and 20.5% of total crimes committed in Canada in 1996 and 2009 respectively8, neither
of which was comparable to 71.8% observed in the study population. This outcome,
while unusually high compared to the general offender population, is in keeping with
findings of previous studies of psychiatric offenders where a greater tendency to commit
!
66!
!
violent crimes was observed19,149,150. Nationally, violent crimes accounted for 80.8% of
all crimes committed by NCRMD offenders46.
There are several possible explanations for this irregularity. Firstly, because all
ORB patients were referred from the court, an offender with a less serious charge, who
was less likely to reach the sentencing stage, would have been less likely to be transferred
from court to an ORB jurisdiction. Also, while violent crimes were the most common
index offence among the study population, they were not the most commonly committed
crimes by these people on a broader scale. Typically, severely ill psychiatric offenders
have a long and complex criminal history consisting of mostly petty crimes. It has been
postulated that psychiatric offenders are not any more violent in nature than the general
offender population but are simply less able to act according to social standards due to
the mental illness121,122. Severe psychiatric conditions often render those affected
disoriented and disorganized, predisposing them to a wide array of violations18,121,122. A
large number of such violations, such as breaking and entering, go unreported because
there are many points of diversion throughout the forensic system for the mentally
ill133,151. However, violent crimes such as attacking a stranger during a psychotic episode,
which comprise a smaller fraction of such violations, would bring the offender into the
criminal justice system. In this light, it is owing to the selective nature of diversion and
less to the violent intent of the participants that there is a higher than normal incidence of
violent crime in this population.
!
67!
!
5.2 Findings and Interpretations from Bivariate Analysis
5.2.1 Distribution of sociodemographic factors
Chi square tests showed that most sociodemographic factors and all predictor
variables were similarly distributed between the subgroups by seriousness of index
offence. A difference was found in the age, with the minor crime group being generally
older than the serious crime group. The majority of serious crimes were committed by
subjects between the ages of 18 and 25 years old, and then 26 and 30 years old, while less
than one fourth of the violent crimes was committed by subjects who were 46 years old
or older. This is in agreement with the previous discovery that violent crimes are
committed most frequently by young adults around the age of 18 and this is therefore the
violence-prone age120. First-time offenders and repeat offenders did not significantly
differ in sociodemographic description.
5.2.2 Changes in Principal Psychiatric Diagnosis
In a significant number of subjects, the primary diagnosis was seen to have
changed between the initial psychiatric assessment and the ORB assessment (27%). This
variable met the significance cut-off for the multivariate regression model when tested for
bivariate association with recidivism, but it had been excluded due to high chance of
human error. When individually examined, it did not significantly increase the chance of
committing more serious crime or recidivating.
Possibly, this may simply represent misdiagnosis at an earlier stage when clinical
manifestations were less visible. The charts used for data capture did not always include
detailed information on when, where and by whom the diagnoses were made, which
!
68!
!
made it impossible to follow up on the discrepancies. Also, there was no discernible
pattern in changes, which led to more doubt on the quality of information. For instance, if
it were shown that diagnosis usually changed from a less severe or more general disorder
to a more severe or specific one, like changing from general delusional disorder to
schizophrenia, it would have increased the perceived integrity of the data as this is often
the course of prognosis of psychiatric disorders152. Also, with a visible pattern, it might
have been possible to see if a diagnosis changed between otherwise linked disorders. For
instance, it was shown recently that a personality disorder quite accurately predicts
remission of major depressive disorder, while another study showed that dysthymic
disorder affects the prognosis of personality disorder153,154. However, the changes were
random and the researchers were led to mainly attribute changes to the result of human
error like misdiagnosis or mistake during information transfer.
Another explanation may be found in the change of the diagnostic tools. It is
likely that a vast majority of subjects had already been diagnosed using an earlier edition
of the DSM before they were assessed by the ORB staff. Two new versions of DSM,
DSM IV and DSM IV-TR, had been published since the 1992 inception of ORB,
reflecting substantial changes in diagnostic criteria and disorder classifications. Different
versions may have led psychiatrists to different diagnoses under the same circumstances.
Alternatively, a change in the main diagnostic tool may have induced a substantial
change in diagnostic trends and led psychiatrists to move toward or away from
diagnosing some disorders155,156.
Primary diagnoses may have changed also because more information was factored
in during the diagnostic process. Results from VRAG, SORAG and PCL-R tests add
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valuable information to psychological assessment of violent offenders, but these tools
were unavailable until several years after the ORB was established139-141. Perhaps
introduction of these tools added a new set of information that was previously
unaccounted for.
Finally, it has been suggested that criminal lifestyle influences psychiatric
disorder development157,158. In light of this theory, it is possible that the diagnosis for
some subjects changed accurately reflecting the change in their mental illnesses, which in
turn had been caused by their criminal lifestyle. There has not been substantiating
evidence for this theory, but it may partially account for the changed diagnoses in the
current study population.
5.2.3 Timing of psychiatric onset with reference to the first crime
Psychiatric onset was shown to have followed criminal career in some of the
repeat offenders while it always predated criminal career in first-time offenders. Overall,
it more frequently predated crime as it was observed in other studies of the psychiatric
offender population145,147. This finding may support the abovementioned criminogenicity
of mental illness, in which crime is viewed as a byproduct of psychiatric condition18,121.
Also, some researchers have suggested mentally ill people often commit crime in
order to enter the forensic system, where they could receive systemic psychiatric care that
they cannot access in the community126. While this explanation nicely fits into the above
criminogenicity of mental illness theory, it likely does not apply to this study population.
Multiple studies have shown that crimes committed for these reasons tend to be fairly
minor ones126 whereas the average crime committed by study subjects was serious.
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Instead, these same researchers argue that serious crime offenders could have been driven
to commit such crimes because their psychiatric conditions were not adequately cared
for126. Timely mental health care may prevent advancement of illness and subsequently
prevent advancement in criminal career.
Alternatively, seriousness of initial crime may be attributed to the finding that
psychiatric onset predated crime in most subjects. One may have committed one or more
petty crimes before receiving a diagnosis, but were diverted without criminal charges. In
this case, a later, more serious crime, which resulted in the first official criminal charge
following the first psychiatric diagnosis, would falsely indicate that psychiatric onset
before their criminal career.
5.2.4 Signs of early deviance
Most repeat offenders had displayed deviant traits in childhood (73.1%) while
most first-time offenders had not (37.5%). This finding is easily understandable given the
role played by the early deviance variable in criminalization in adulthood157,159,160 and in
prediction of recidivism, as shown in the results of this study. This issue will be revisited
in a later section.
5.3 Findings and Interpretations from Multivariate Regression Analysis
5.3.1 Seriousness of Index Offence
The regression model showed that the seriousness of the index offence was not
predicted by any one or groups of predictor variables. There are several possibilities that
may account for this lack of association. A probable reason is that this variable was
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defined too loosely. In the current study, the category level ‘grave’ had been used to
include all crimes that directly harmed persons from murder to sexual assault, while the
level ‘petty’ had been used to include all other crimes, such as prostitution and theft.
Perhaps grouping the subjects first by the crime type and then subdividing them
according to seriousness would have yielded better results. When seriousness of crime
was investigated only within the same crime type (violent assault), the predictive power
of study variables was substantial161. A better categorization may also have been
achieved by using more than two category levels or coding it into a continuous instead of
categorical variable. Significant results were produced from a predictive model in an
earlier study that tested seriousness of crime as an ordinal variable with multiple levels162.
A vast number of factors were examined and a considerable number of them were
included in the model. It is nevertheless possible that the selected predictors were
insufficient to fully account for the complexity of crime severity. Seriousness of crime
interacts with virtually all aspects of life, from psychopathology to developmental
history163-164. There have been numerous attempts at building a model for prediction of
seriousness of crime, but such efforts had been limited success at best166. The lack of
predictive power was sometimes due to small sample size167 and due to insufficient
predictor selection at other times168. Both of these explanations may be applied in
explaining the present study’s results. The reduction of sample size after applying all
exclusion criteria likely reduced the power, while statistical strengths were lessened from
exclusion of some key factors like PCL-R scores.
In summary, it is postulated that some associations existed but were not detected
in the study. There is a clear indication that a wider range of information must be
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collected from a greater number of subjects in order to more accurately investigate this
variable.
5.3.2 Recidivism and Early Deviance
Recidivism was significantly predicted by deviant behaviours in childhood.
Strong correlations have been reported between deviant traits displayed early in life and
criminality in adulthood159,160,169-171. Consequently, it was anticipated that it would also
be associated with recidivism and analysis results confirmed this theory. Recidivism is an
important criminological research topic with academic and practical implications. The
detection of early deviance as a significant and substantial predictor of recidivism,
therefore, is an important finding.
While there is an abundance of explanations for how early conduct problems lead
to criminality in adulthood, the exact role it plays in recidivism is less clear because the
specific association between deviance in childhood and recidivism in adulthood has been
less frequently studied172-174. It may be theorized that childhood truancy, which hinders
the opportunity to learn and conform to rules, naturally progresses into psychiatric
disorders as well as criminality in adulthood170,171,174-176, and this long history of deviance
in turn develops into recidivism.
5.4 Other Contributing Factors
Some predictors were analyzed but did not yield statistically significant results.
Given the evidence found within past literature on their importance in the understanding
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of psychiatric offenders, three variables – existence of criminal associates, existence of
psychiatric associates and a history of child abuse – are discussed.
Prior research found that people with criminal family members or romantic
partners are more likely to commit crime. For instance, a child growing up with
exposures to unlawful conducts of a criminal family member may learn to mimic the
observed criminal behaviours177. Alternatively, antisocial behaviours of a female
romantic partner have been shown to increase the likelihood to commit a criminal offence
in young adult males178. Finally, people who are surrounded by criminal individuals may
get accustomed to the dissipated environment, accept an antisocial lifestyle as the norm
and continue down the transgressive path176. The present study partially supported this
last view with a substantial odds ratio with some significance: subjects with criminal
associates were seven times more likely to recidivate (OR=7.577 [0.541-106.2]; p=0.13).
Many psychiatric disorders are hereditary and hence a family history increases the
risk of mental illness179,180. Also, a psychiatric family member or a romantic partner is a
significant stressor that may trigger psychiatric development in a previously undiagnosed
individual6. In a study on burdens of schizophrenia on the caregiving family, half of the
subjects were diagnosed with a minimum of one and a maximum of four clinical mental
disorders181. Close associates of bipolar disorder patients were more likely to suffer from
similarly varying moods and high level of distress180. Mental illness also fosters intrarelationship conflicts and thus, increased relationship stress from psychiatric partner often
deteriorates a patient’s condition, predisposing the patient to an array of violations and
thereby increasing the likelihood to commit criminal violation181,182,121,122,. Thus
increased chance of criminal offending qualifies the legal inclusion criterion while
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increased chance of severe mental illness qualifies the psychiatric inclusion criterion of
ORB.
Child abuse is another crucial developmental factor in the study of mentally ill
offenders. It is often viewed as an outcome of having a criminal or psychiatric family
member123,124. This pattern was replicated in this study population as well, where 75% of
subjects with a history of child abuse had psychiatric associates or criminal associates or
both. In turn, criminal or psychiatric associations as well as child abuse could simply be
the symptoms, rather than the causes, of unconventional family environment. Difficult
family situations were repeatedly shown as contributing factors of criminality and mental
illness123,124. They are also indicative of low socioeconomic status, which again has
negative influence on mental health125. As such, insight into developmental and current
domestic environment through examination of these variables were a vital element of this
study.
5.5 Relevance of Findings
This is one of the earliest attempts to systematically examine the review board
offender population in Canada and the first to describe the southeastern ORB population
in detail studies25-28,32-46,48-54,141-146. Traditionally, psychiatric offenders have been studied
as individuals in legal cases25-28 or with reference to law or policy32-46, rather than as
subjects of a scientific study. Such scarcity in population-based studies has led to a lack
of evidence on mentally ill offenders. Subsequently the standards of evidence-based
medicine, in which development and reform of medical care are based on scientific
evidence183, have not been rigorously adhered to in management of these people. This
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study presented a wealth of psychopathological, criminal and developmental information
on mentally ill offenders, which will add to the growing body of information on Canadian
forensic offenders. It is hoped that this study will stimulate further research into the
forensic offender population. The growth of scientific evidence will also be the platform
on which care for forensic offenders will become a better practice of evidence-based
medicine.
In most review board population studies, data collection only captured the
population characteristics within five years of the new system. This includes the
adjustment period necessary for the courts to adapt to a new legislation and accuracy of
information may be influenced by this adjustment period. The current study captures 15
years of data and findings would be relatively free of confounding influence of
adjustment period. It may also be broken down into time blocks to investigate periodical
trends.
This study also provides a current understanding of the ORB system. There has
not been a systematic data collection conducted on provincial review board systems since
their inception in 1992. There are two published papers that examined the Lieutenant
Governor’s advisory board system in detail, but these were published over 20 years ago,
set in a single province and before the review boards were in their current format29,47.
Furthermore, one of these studies placed main focus on administrative aspects of the
system with little reference to the patient population itself29. As such, information
presented in these papers are outdated and do not accurately reflect the elements of the
current system, such as specific legislations and patient demographics. Because the ORB
was never systematically reviewed since its inception in 1992, understanding of the
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effectiveness and efficiency of the system has been largely lacking. Current
characterization and identification of risk factors of a key participant group as presented
in this study will be helpful not only to service providers of ORB but also in the
evaluative efforts of the review board system. Successful evaluation of the review board
system may be followed by outcome evaluation of the mental health care reform.
Information generated during this review process would also provide the context in which
results of this study are better interpreted.
On a related note, currently there is no single appraisal method used by physicians
across the board to reach clinical decision about criminal responsibility and
dangerousness184. It is possible that this resulted in the psychiatrists and subsequently the
review boards of different regions to adopt different assessment styles. Such differences
range from using different clinical and judicial tools to differential weights given to
components of the assessment184. While it is reasonable for the physicians and board to
account for the changes that they see through time or to reflect local offender
characteristics, it may also lead to different dispositions given by the board based on
jurisdictions rather than objective information, as was pointed out in the American
criminal courts147. The previously illustrated discrepancies between provinces in legal
outcomes, like the rates at which offenders are detained or discharged and NCRMD
success rate, may be indicative of this problem19,25,52,106,107,110,145. Clearly, there is a need
for a uniformly practiced appraisal method. This study has captured much of the
psychiatrist’s decision-making process and proceedings of the mental health courts. It is
hoped that this information will contribute to a greater uniformity in management of the
population.
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Finally, data source was of high reliability since they were collected, examined
and re-verified by multiple staff. Also, a new report is drafted every year for each patient
for the annual ORB hearing, providing an additional opportunity to supply insufficiencies
and correct misinformation. Moreover, the case files included a wealth of information.
Much of this information, such as the relationship of the offender to the victim, was not
included in this study. All available information was still captured and electronically
converted. It is anticipated that these information will be useful in future studies on this
population.
5.6 Limitations of Study
This study focused on a localized population and hence the applicability of the
results is limited. Findings should not be directly applied to the general Canadian
population nor is it appropriate for the general offender population. The highly selective
nature of the study sample had limited the applicability of findings to similarly unique
population, which is a predominantly male mentally ill offender population in North
America whose charges are grave enough to bring them to the court sentencing and are
suffering from severe psychiatric conditions as to render them not criminally responsible
on the account of the condition or unfit to stand trial.
After applying all exclusion criteria, the sample size had been reduced from 347
to 84. This led to reduction in power and statistical significance in analysis. As a result,
the data collected in this study had been insufficient to appropriately test the first
outcome variable. While adjusting for age and primary psychiatric diagnosis contributed
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to the significance and power of the associations seen in the recidivism variable, it did not
aid to the results from the seriousness of index offence variable.
The deficiency in population-based knowledge on the Canadian forensic
population added to novelty of this study, but it also presented the researchers with many
challenges, one of which was encountered during variable selection. Literature was
reviewed and veteran ORB psychiatrists were consulted, but there is a chance that the
selected variables did not sufficiently cover the key study areas. Previous studies were
dissimilar in scope, target population or primary aims from this study25-28,32-46,48-54,141-146,
but they were still referenced for variable selection because no other resources existed.
Several psychological, criminal, developmental or legal factors that were initially
selected as potential predictors were excluded in the main analysis due to confidentiality
issues (e.g. victimology) or missing data (e.g. scores from PCL-R, VRAG and SORAG
tests). Inclusion of this information would have expanded the scope of this study and
strengthen the results. For instance, seriousness of crime, as well as recidivism, have been
shown to be closely related to PCL-R scores in offender population161,185 and to severity
of illness in psychiatric offenders186,187. The regression model may have shown a greater
predictive power for seriousness of index offence if these variables were included. Also,
victim selection as well as the mode of crime, such as time of the day and crime site,
could provide valuable insight into the study of psychology of the offender188.
It was communicated to the student investigator that it might be premature to
posit hypotheses in an area where there exists so little prior research. However,
hypothesis testing was only a part of this project. The thesis was designed to first describe
the study population and explore data before testing specific hypotheses. Additional
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safeguarding against false theory was employed by formulating hypotheses based on
sound and related, if not directly transferable, previous research.
5.7 Future Direction
A crude exploratory analysis that encompasses variables that were excluded in
this study would be useful in detecting unexpected associations. For instance,
victimology was uninvestigated due to confidentiality issues, but this is an important
psycho-legal factor1 that must be examined in detail in the future. Scores of specialized
tests, such as the PCL-R and the VRAG, should also be included for the study of the next
generation of the ORB population. These analyses may be extended beyond the study
population to all psychiatric offenders in order to provide valuable insight on mentally ill
offenders as a whole.
Following an exploratory study, predictive models may be run for the same
outcome variables, seriousness of crime and recidivism, using newly identified
associations as predictor variables. This would be bettered by redefining the seriousness
of crime variable, either by assigning it into specific crime types or dividing it into
multiple categories. Results of these analyses may serve as measures with which the
predictive model of this study is evaluated.
Finally, findings will be useful together with and in comparison to results of
similar studies that cover other regional samples of the ORB offender population. These
data could provide current consensus of Canadian forensic population while highlighting
specific attributes of regional samples.
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5.8 Conclusion
This thesis systematically reviewed Ontario forensic offenders who were
exempted from criminal responsibility on the account of mental disorder. Population
characteristics were described and key variables were studied with regard to their effects
on seriousness of index offence and recidivism. It was found that early signs of deviance
positively influenced the likelihood to recidivate. Findings of this study may have clinical,
legal and policy implications in the management of the forensic population in Canada.
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Appendices
Appendix One. Detailed description of DSM IV-TR Classification.
Axis I
Axis II
Axis III
Clinical Disorders
Other Conditions That May Be A Focus of Clinical Attention
Disorders usually first diagnosed in infancy, childhood, or adolescence
Delirium, dementia, and amnestic and other cognitive disorders
Mental disorders due to a general medical condition not elsewhere classified
Substance-related disorders
Schizophrenia and other psychotic disorders
Mood disorders
Anxiety disorders
Somatoform disorders
Factitious disorders
Dissociative disorders
Sexual and gender identity disorders
Eating disorders
Sleep disorders
Impulse-control disorders not elsewhere classified
Adjustment disorders
Other Conditions That May Be A Focus of Clinical Attention
Personality Disorders
Mental Retardation
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder
Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder
Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorder
Personality Disorder Not Otherwise Specified
Mental Retardation
General Medical Conditions
Infectious and Parasitic Diseases
Neoplasms
Endocrine, Nutritional, and Metabolic Diseases. Immunity Disorders
Diseases of the Blood and Blood-Forming Organs
Diseases of the Nervous System and Sense Organs
Diseases of the Circulatory System
Diseases of the Respiratory System
Diseases of the Digestive System
Diseases of the Genitourinary System
Complications of Pregnancy, Childbirth, and the Puerperium
Diseases of the Skin and Subcutaneous Tissue
Diseases of the Musculoskeletal System and Connective Tissue
Congenital Anomalies
Certain Conditions Originating in the Perinatal Period
Systems, Signs, and Ill-Defined Conditions
Injury and Poisoning
105
Axis IV
Axis V
Psychosocial and Environmental Problems
Problems with primary support group
Problems related to the social environment
Educational problems
Occupational problems
Housing problems
Economic problems
Problems with access to health care services
Problems related to interaction with the legal system/crime
Other psychosocial and environmental problems
Global Assessment of Functioning
91-100: Superior functioning in a wide range of activities; No Symptoms
81-90: Absent or minimal symptoms
71-80: If symptoms are present
61-70: Some mild symptoms
51-60: Moderate symptoms
41-50: Severe symptoms
31-40: Some impairment in reality testing or communication
21-30: Behavior is considerably influenced by delusions or hallucinations OR serious
impairment in communication or judgment
20-11: Some danger of hurting self or others
10-1: Persistent danger of severely hurting self or others
106
Appendix Two. Forensic Path
Forensic path for psychiatric offenders is different from the path taken by general
offenders. In the case of a general offender who committed a minor or a summary crime,
arrest follows booking and interrogation by the police. The police then charge the
individual with a summary conviction offence. A person accused of a crime is not always
arrested. The accused may simply receive a “summons,” or an order to appear in court at
a certain time to answer to the charge, after the police lay a charge. The accused then
appears before a provincial court judge, who determines if the accused should be
remanded until the trial or if the accused may be released on bail and return to the court
for the trial. This step occurs within 24 hours of arrest unless the accused is released by
the police. The trial following remand in a jail or return to the court on a bail determines
if the accused is guilty. An accused found guilty is sentenced to a term of imprisonment,
a fine or a combination of the two. For an imprisonment sentence under two years, the
convict is admitted to a provincial prison. For an imprisonment sentence over two years,
the convict is admitted to a federal prison.
For more serious crimes than summary conviction offense, arrest is followed by
indictment. There may be a preliminary hearing for a judge to examine the case to decide
if there is enough evidence to proceed with the trial. This sometimes results in dismissal
of the case if the court finds there to be insufficient evidence that crime has been
committed or the accused is the perpetrator of the crime. The accused may be tried by a
provincial court judge, by a superior court judge or by a judge of a superior court with a
jury.
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When the police encounter a mentally ill person upon arriving at the crime scene,
they may use discretion to decide between arresting the perpetrator of the crime or calling
in a local crisis team if there is a prior agreement between two services. Arrest diversion
occurs when the police arrested a person but decide not to lay charges because the crime
is minor and the arrested individual’s psychiatric condition is severe. The police may also
take the arrested person to a local hospital if he is suspected of suffering from a mental
illness. The attending physician may issue a Form 1, the Application for Psychiatric
Assessment. This is a legal form that gives the hospital the power to hold custody of the
arrestee in order to conduct a full psychiatric examination. Post-charge diversion, pretrial diversion or court diversion all refer to the diversion before trial by the court. Crown
attorneys may divert the person into mental health treatment instead of persecuting,
usually when the charges are minor. A judge may also divert the accused to mental health
institution instead of trying them at the court depending on the severity of the mental
illness. Both of these diversions may happen with or without an application by the
defense lawyer and ultimately result in the accused entering the provincial review board
system. If an accused is found to be NCRMD, they remain under the review board
jurisdiction. If an accused is found unfit to stand trial but later regains the fitness, they are
returned to the court for the trial. If fitness is not restored after the timeline set out in the
Criminal Code of Canada, they remain under the review board jurisdiction.
The review board determines if the person may be released back to the
community or if they pose a significant threat to the general public and self and must be
detained in the forensic psychiatric facility. This decision, called disposition, is reviewed
annually and the accused with the NCRMD verdict may eventually be released if their
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conditions improve. The clinical team at the facility works with community mental health
service providers to create a discharge plan. Forensic path undertaken by mentally ill
offenders is illustrated in Figure A.1.
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Figure A.1. Navigating the forensic system132.
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Appendix Three. Data Collection Sheet
The following list of information was extracted from each patient chart and was
compiled into a Microsoft Excel sheet.
1. Hospital location admitted to – current facility (Providence Care), other forensic
psychiatric institution, psychiatric hospital, jail/detention centres, or court house
2. Attending physician
3. Record number
4. Date of Birth
5. Gender
6. Clinical status – court referral, recurring patient, outpatient and inpatient
7. Is the subject a current inpatient?
8. Area of residence
9. Marital status
10. Living arrangement
11. Highest education reached
12. Income source
13. Date of Index offence
14. Date of ORB finding
15. Index Offence –homicide, assault, sexual assault, offence against property or other
(e.g. prostitution)
16. Geographical location of index offence
17. Crime site – on the street, in the victim’s house – bedroom, kitchen, living room,
front door, restroom; in the patient’s house – bedroom, kitchen, living room, front
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door, restroom; in the victim and patient’s shared house – bedroom, kitchen, living
room, front door, restroom; business property in a public setting; business property in
a private setting; public property in a public setting; or public property in a private
setting
18. Relationship to victim – parent of the victim, child of the victim, spouse, romantic
partner, friend, colleague, acquaintance, stranger, or crime did not target/involve a
specific person
19. Child Abuse History – No abuse in the family, witness of physical/sexual/physical
and sexual abuse, victim of physical/sexual/physical and sexual abuse, victim of
passive abuse (negligence)
20. Early signs of deviation – no known childhood problems, early behavior problems,
suspension or expulsion from school or incompletion of grade 10 education,
nonviolent criminal history, did not live with biological parents until the age of 16, an
arrest before age 16
21. Adult romantic relationship history – never been engaged in 1-3 serious relationships
ending in a marriage or common law, 1-3 relationships or many unsuccessful
marriages/common law
22. Current status of adult romantic relationship – currently in or not in a mutually agreed
significant relationship
23. Adult violence history – no previous violent conduct, violence against romantic
partner, violence against offspring, violence against family or violence against others
24. Psychiatric history –no previous psychiatric episode, previous psychiatric inpatient
admission/outpatient treatment at the current facility, previous psychiatric inpatient
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admission/outpatient treatment at other facility, previous alcohol and/or substance
abuse, previous serious suicide attempt, previous legal problems, history of serious
physical violence towards others, currently active medical/surgical condition or
previous community mental health agency contact
25. Psychiatric admission history – 1-2, 3-5 or more than 5 previous admissions
26. Criminal history – no previous record; 1-3, 4-5 or more than 5 offences against
human (homicide); 1-3, 4-5 or more than 5 offences against human (assault); 1-3, 4-5
or more than 5 offences against human (sexual assault); 1-3, 4-5 or more than 5
offences against property; or 1-3, 4-5 or more than 5 other offences
27. Presence of criminal associates – no known criminal associates, criminal parent(s),
criminal sibling(s), criminal relative(s), criminal romantic partner
28. Presence of psychiatric associates – no known psychiatric associates, psychiatric
parent(s), psychiatric sibling(s), psychiatric relative(s), psychiatric romantic partner
29. Timing of first official psychiatric – diagnosis before first criminal offence (juvenile
crime), at first criminal offence (juvenile crime), after first criminal offence (juvenile
crime); diagnosis before first criminal offence (adult crime), at first criminal offence
(adult crime), after first criminal offence (adult crime)
30. Has the principal psychiatric diagnosis changed since the first official diagnosis?
31. Current psychopathology
32. Medical history as per DSM IV-TR Axis III A-D
33. Psychosocial history as per DSM IV-TR Axis IV A-H
34. Global assessment of functioning – on a scale of 1-100
35. Life psychopathology
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36. Fitness to stand trial
37. Hare’s Psychopathy Checklist-Revised
38. Recidivism score
39. ORB disposition – fulltime detention, conditional discharge or absolute discharge
40. Has the patient or legal guardian of the patient given consent to the treatment?
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