CanJPsychiatry 2015;60(3):93–95
The Canadian Journal of Psychiatry
Volume 60, Number 3
March 2015
Guest Editorial
A Valuable (and Ongoing) Study, the National Trajectory Project
Addresses Many Myths About the Verdict of Not Criminally
Responsible on Account of Mental Disorder
Patrick Baillie, PhD, LLB1
1
Psychologist, Alberta Health Services, Calgary, Alberta; Consulting Psychologist, Calgary Police Service, Calgary, Alberta; Lawyer, Calgary, Alberta;
[email protected].
Key Words: NCRMD, insanity,
mental disorder, Criminal Code,
Bill C-14, Bill C-54, criminal
responsibility
Received and accepted August
2014.
open
access
W
ithout a doubt, politicians of whatever stripe should be permitted to determine
public policy based on personal preferences and party positions. Shift tax
burdens to different income groups? Change the legal age for purchase of alcohol
(or marijuana)? Impose additional conditions on new, young drivers? People elected
to make decisions about legislative interventions should feel free to do so based on
whatever variables matter to them.
What is particularly frustrating to at least some of us from a more scientific and less
political background is when major policy changes occur in the absence of—and
sometimes directly contrary to—what quality research has shown to be the current
truth. For example, in early 2013, the federal government introduced what was then
Bill C-14, amending the mental disorder provisions of the Criminal Code and the
National Defence Act, specifically those provisions relating to people found not
criminally responsible on account of a mental disorder (NCRMD). The changes
included the introduction of a new high-risk accused category, which, when imposed
by a court after a finding of NCRMD, limits that person’s access to community
treatment supports and a review board’s (RB’s) discharge options. One factor, among
several, to be considered by the court is the brutal nature of the act perpetrated by
the accused person in the alleged offence. Passed and proclaimed (as Bill C-54 when
reintroduced later in 2013), the new rules came into effect on July 11, 2014.
In some ways, this legislation played into certain beliefs about NCRMD, among
them the notions that most NCRMD cases involve serious personal violence, that
the verdict is used far too frequently (and conveniently, as when someone wishes
to fake a mental illness to avoid punishment), and that, after a brief period of
hospitalization, those found NCRMD are released back to the community where they
promptly reoffend. What stood out most in the debate about the bills was the nearcomplete lack of discussion of any data addressing the key elements of the legislation.
Certainly, Latimer and Lawrence1 had, in 2006, told us that the verdict of NCRMD is
actually quite rare (occurring, they said, in 1.8 per thousand criminal cases per year in
Canada). Nonetheless, little was known about the types of cases in which the verdict
is found, the characteristics of people found NCRMD (for example, prior mental
health histories, prior criminal histories, primary diagnosis, relationship and housing
status, sex, and Aboriginal status), the lengths of hospitalization and treatment in the
community, and the occurrence of recidivism.
Then, along came the results of the National Trajectory Project (NTP), which provided
the data that underscore 5 of the papers included in this issue of The Canadian
www.TheCJP.ca
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 93
Guest Editorial
Journal of Psychiatry.2–7 Described by the thoroughly
dedicated Dr Anne G Crocker and her brilliant colleagues
(particularly Dr Tonia L Nicholls, Dr Michael C Seto, and
Dr Gilles Côté, ably accompanied by Yanick Charette,
Dr Catherine M Wilson, Leila Salem, and Dr Malijai Caulet)
as the “first longitudinal cohort study comparing provincially
representative samples of NCRMD–accused people”3, p 103 to
have been undertaken since the 1992 changes to the mental
disorder provisions of the Criminal Code, the NTP gave
us (and the government, which, through Justice Canada,
sought early access to the data) a detailed picture of the
verdict, its people, their histories, and their outcomes.
For example, we now know, from this comprehensive
review of 1800 patient files in Quebec, Ontario, and
British Columbia, that marked provincial differences
exist in the overall rates of NCRMD cases (Quebec
having proportionately many more) and in changes to
those rates (with Quebec increasing and British Columbia
decreasing). Additionally, we now know that a person
found NCRMD in Ontario is more likely to be under RB
supervision for a longer period than in Quebec and British
Columbia, and is more likely to remain in hospital while
under supervision. Moreover, we now also know that no
statistically significant differences exist between provinces
regarding the proportion of NCRMD–accused people who
had a history of prior mental health hospitalizations and
regarding sex distributions of NCRMD–accused people.
We now know that 51% of this large sample had no prior
criminal convictions before the incident giving rise to the
finding of NCRMD, but that 72% had at least 1 prior mental
health hospitalization (and an average of 3 hospitalizations
when looking only at people who had a mental health
history). We now know that while most (65%) of the
underlying index offences involved acts against a person,
family members of the accused person (and often the
parents of the accused person) were the most common
target, followed by police and mental health workers.
Strangers were a relatively infrequent target (being the
victims in 22.7% of those offences against a person). We
now know that 3.2% of the index offences resulted in the
death of the victim. Further, we now know that women
accounted for 15.6% of the NCRMD population, and that
Aboriginal heritage was identified in just 2.9% of cases.
(In the parliamentary debates, no politician ever mentioned
the potentially different needs of women and Aboriginal
NCRMD–accused people.) Three-quarters of the sample
group was on government assistance at the time of the
index offence and 1 in 10 was homeless. We now know
that the most common primary diagnosis was a psychotic
spectrum disorder, with one-third of the sample having a
co-occurring substance abuse problem. We now also know
that there are some key sex differences that may inform
treatment choices, with women being more likely (than
men) to be diagnosed with a mood disorder or a personality
disorder, but also being less likely to have a prior criminal
history, less likely to offend against strangers, and more
likely to be older at their first offence against a person.
94 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
Regarding gender differences, then, women show fewer of
the identified risk factors for recidivism, thus they may be
at lower risk of reoffending when back in the community.
However, we know that formal risk assessments occur in
only a small minority (17%) of cases.
And, finally, regarding recidivism, the NTP found a reconviction rate of 16.7% during a 3-year follow-up period,
with the time frame starting at the date of the NCRMD
verdict. Quebec, with the lowest median offence severity,
had a higher recidivism rate than the 9.5% and 9.3% figures
found in British Columbia and Ontario, respectively. During
the entire follow-up period, ranging up to 8 years in some
cases, a total of 13 cases of severe violent reoffence were
identified from the 1800-patient sample (0.7%). People
whose verdict of NCRMD stemmed from a serious, violent
offence actually had the lowest 3-year recidivism rate—for
any type of reoffence—(6.0%) of all groups. The primary
diagnosis was not found to significantly influence risk of
reoffending, but substance abuse, the presence of a cooccurring personality disorder (seen in 10% of the sample),
and a prior conviction or finding of NCRMD were relevant
factors that enhanced risk.
In short, an informed debate about the legislation would
have considered that most people who are NCRMDaccused have not committed offences involving serious
violence, that the brutal nature of the offence tells us
nothing about the risk of recidivism, that most people found
NCRMD are already known to the civil mental system
and are on government financial assistance (which easily
could see other forms of assistance being added on), and
that, measured by recidivism rates that are lower than those
seen for people being released from jails and prisons, RBs
(relying on the evidence put before them by dedicated
mental health professionals working with people who are
NCRMD-accused) seem to be doing a very good job of
determining when conditions should be altered.
Given the observed differences across the 3 study provinces,
we should be cautious about assuming that national
statistics accurately measure local circumstances. Adding
information from the Prairie and Maritime provinces could
enhance our understanding of the Canadian realities around
people found NCRMD. Following up to see the impact
of the new legislation could be another fruitful avenue of
future study. Further research is already under way with
the NCRMD population, looking at positive outcomes (for
example, family reunification) and protective factors, such
as social support.
Since time immemorial, criminal law systems have
considered the simple idea that an accused person should
not be convicted when their illegal behaviour stemmed
from a disease of the mind. A truly safe society does not
change that established principle by incarcerating people
with mental disorders—or by further stigmatizing them—
but, rather, ensures that procedures are in place to protect
both the individual and the public. What these papers2–7 and
the NTP give us is an exceptionally valuable picture of how
www.LaRCP.ca
A Valuable (and Ongoing) Study, the National Trajectory Project Addresses Many Myths About the Verdict of Not Criminally Responsible on Account of Mental Disorder
the processes surrounding NCRMD have been working.
The answers are very much worth reading.
Acknowledgements
A significant portion of the financial support for the
National Trajectory Project came through the Mental
Health Commission of Canada (MHCC), with the Project
having been endorsed by the Mental Health and the Law
Advisory Committee of the MHCC. Dr Baillie served on
that Advisory Committee and continues to serve on the
MHCC’s Advisory Council. He acknowledges the support
of the MHCC in this important research endeavour.
References
1. Latimer J, Lawrence A. The review board systems in Canada:
overview of results from the Mentally Disordered Accused Data
Collection Study. Ottawa (ON): Department of Justice Canada;
2006.
2. Crocker AG, Nicholls TL, Seto MC, et al. The National Trajectory
Project of individuals found not criminally responsible on account of
mental disorder in Canada. Can J Psychiatry. 2015;60(3):96–97.
3. Crocker AG, Nicholls TL, Seto MC, et al. The National Trajectory
Project of individuals found not criminally responsible on account
of mental disorder in Canada. Part 1: context and methods. Can J
Psychiatry. 2015;60(3):98–105.
4. Crocker AG, Nicholls TL, Seto MC, et al. The National Trajectory
Project of individuals found not criminally responsible on account of
mental disorder in Canada. Part 2: the people behind the label. Can J
Psychiatry. 2015;60(3):106–116.
5. Crocker AG, Charette Y, Seto MC, et al. The National Trajectory
Project of individuals found not criminally responsible on account of
mental disorder in Canada. Part 3: trajectories and outcomes through
the forensic system. Can J Psychiatry. 2015;60(3):117–126.
6. Charette Y, Crocker AG, Seto MC, et al. The National Trajectory
Project of individuals found not criminally responsible on account
of mental disorder in Canada. Part 4: criminal recidivism. Can J
Psychiatry. 2015;60(3):127–134.
7. Nicholls TL, Crocker AG, Seto MC, et al. National Trajectory
Project of individuals found not criminally responsible on account
of mental disorder. Part 5: how essential are gender-specific forensic
psychiatric services? Can J Psychiatry. 2015;60(3):135–145.
Erratum
Patten SB, Williams JVA, Lavorato DH, et al. Descriptive epidemiology of major depressive disorder in Canada in
2012. Can J Psychiatry. 2015;60(1):23–30.
It has come to the authors’ attention that their article included an error in the lower bound of the confidence interval on
page 27, line 12, of the January 2015 issue. The text should have read: “Therefore, this variable was initially removed
from the models. In a model simultaneously adjusting for each of the remaining variables, the PR for female sex was
1.7 (95% CI 1.4 to 2.0, P < 0.001).” The Canadian Journal of Psychiatry regrets the error and any inconvenience it
may have caused.
www.TheCJP.ca
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 95
CanJPsychiatry 2015;60(3):96–97
Guest Editorial
The National Trajectory Project of Individuals Found
Not Criminally Responsible on Account of Mental Disorder
in Canada
Anne G Crocker, PhD1; Tonia L Nicholls, PhD2; Michael C Seto, PhD3; Gilles Côté, PhD4
Associate Professor, Department of Psychiatry, McGill University, Montreal, Quebec; Associate Director, Policy and Knowledge Exchange,
Douglas Mental Health University Institute Research Centre, Montreal, Quebec.
Correspondence: Douglas Mental Health University Institute Research Centre, 6875 LaSalle Boulevard, Montreal, QC H4H 1R3; [email protected].
1
2
Associate Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia; Senior Research Fellow,
Forensic Psychiatric Services Commission, BC Mental Health & Substance Use Services, Coquitlam, British Columbia.
3
Director of Forensic Rehabilitation Research, Royal Ottawa Health Care Group, Brockville, Ontario.
4
Professor, Department of Psychology, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec; Director, Philippe-Pinel Institute Research Centre,
Montreal, Quebec.
Key Words: not criminally
responsible, legislation, media,
mental illness, criminality,
mental health services, forensic
mental health, Review Board
Received November 2013 and
accepted December 2013.
open
access
W
hen the topic of mental illness is raised, few issues stir public and media interest,
and generate as much controversy, as the verdict of not criminally responsible
on account of mental disorder (NCRMD). Rare but sensational cases make the news,
such as Vincent Li,1 found NCRMD for killing a fellow Greyhound bus passenger, and
Allan Schoenborn,2 found NCRMD for killing his children. However, there is a firmly
established legal doctrine in criminal justice systems around the world that recognizes
that it is inappropriate to punish people who do not have the capacity to form criminal
intent at the time of an offence. In Canada, section 16 of the Criminal Code defines the
verdict of NCRMD as
No person is criminally responsible for an act committed or an omission made
while suffering from a mental disorder that rendered the person incapable of
appreciating the nature and quality of the act or omission or of knowing that it
was wrong.3
The increase in the number of people found NCRMD during the past 20 years,4 some
recent high-profile cases, and the increasing voice of victim advocacy groups has
brought to the forefront issues around processing and dispositions of people found
NCRMD. The prominence of these types of cases has supported the current tough on
crime approach to legislative reforms in Canada, including the trend toward longer
detentions.5–7 The foundation of this approach is its appeal to the public desire for
safer communities and decreased violence and crime. However, recent crime statistics
have continued to show trends of decreasing criminality, and in particular violent
criminality, in Canada.8 As our colleagues very eloquently demonstrated, current tough
on crime policies are not supported by the current scientific evidence.6,7 In fact, theory
(Risk-Need-Responsivity)9 and research firmly demonstrate that excessive intervention
disproportionate to risk can actually increase the rate of adverse events, such as criminal
recidivism, suggesting that the platform on which tough on crime laws are stationed are
unstable and lacking an evidence base. Recently, the federal government introduced Bill
C-54, which then became Bill C-14,5 now known as the Not Criminally Responsible
Reform Act, which took effect on July 11, 2014. This legislative amendment to Part
XX.1 of the Criminal Code on Mental Disorders consists of 3 main components,
namely the explicit recognition that public safety is the paramount consideration in
the decision-making process related to accused people found NCRMD, the creation
of a new category of high-risk NCRMD accused, and the involvement of victims in
the decision-making process related to people found NCRMD. Some elements of the
act, particularly the high-risk designation and dispositions, run counter to the most
recent scientific evidence on the trajectories of Canadian individuals found NCRMD.
This legislative controversy in addition to the recent tough on crime policy trends6 are
96 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
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The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada
likely to have significant effects on vulnerable populations,
such as people living with a mental illness,7 and highlight
the disconnect between evidence, public discontent, and
current legislative policies in Canada.10
In this special section of The Canadian Journal of
Psychiatry, we present the initial results of the National
Trajectory Project.11 The National Trajectory Project
investigated the trajectories of people found NCRMD in the
3 most-populated Canadian provinces (British Columbia,
Ontario, and Quebec), each of which has a distinct
organizational structure of forensic mental health services
and varying general crime statistics. The goal of the study
was to examine the operation of current criminal justice
provisions for people declared NCRMD by the courts, and
made subject to the jurisdiction of a provincial or territorial
review board.
This special feature addresses some of the current beliefs
and perceptions about the NCRMD population and
contextualizes some of the observed profiles and trends
through 4 empirical papers following a detailed description
of the methodology used to conduct the study across
provinces (see Part 112). Part 213 provides a cross-provincial
overview of the sociopsycho-criminological characteristics
of people found NCRMD between 2000 and 2005. Part 314
addresses the processing of people found NCRMD
through the review board system and the criminological
outcomes among this cohort, followed until 2008. Part 415
examines the criminal recidivism rates and associated
factors among NCRMD–accused people. Finally, Part 516
focuses on examining gender differences and similarities
in the characteristics and processing of NCRMD–accused
people.
Acknowledgements
This research was consecutively supported by grant
#6356-2004 from Fonds de recherche Québec—Santé
(FRQ-S) and by the Mental Health Commission of Canada.
Dr Crocker received consecutive salary awards from the
Canadian Institutes of Health Research (CIHR), FRQ-S, and
a William Dawson Scholar award from McGill University
while conducting this research. Dr Nicholls acknowledges
the support of the Michael Smith Foundation for Health
Research and the CIHR for consecutive salary awards.
www.TheCJP.ca
References
1. The Vince Li homicide case. Winnipeg Free Press. 2012 May 17.
Available from: http://www.winnipegfreepress.com/local/
Timeline-The-Vince-Li-homicide-case-151941555.html.
2. Canadian Press. Schoenborn ‘not criminally responsible’ for
murders. Father was insane when he killed 3 children, judge
finds. Canadian Broadcasting Corporation. 2010 Feb 22.
Available from: http://www.cbc.ca/news/canada/british-columbia/
schoenborn-not-criminally-responsible-for-murders-1.899491.
3. Criminal Code, R.S.C., 1985, c. C-46.
4. Latimer J, Lawrence A. The review board systems in Canada:
overview of results from the Mentally Disordered Accused Data
Collection Study. Ottawa (ON): Department of Justice Canada;
2006.
5. Bill C-54: an Act to amend the Criminal Code and the National
Defence Act (mental disorder). 1st session ed. Ottawa (ON): House
of Commons of Canada; 2013. Now known as the Not Criminally
Responsible Reform Act.
6. Cook AN, Roesch R. “Tough on crime” reforms: what psychology
has to say about the recent and proposed justice policy in Canada.
Can Psychol. 2012;53(3):217–225.
7. Barbaree HE, Cook AN, Douglas KS, et al. Canadian Psychological
Association Submission to the Senate Standing Committee on Legal
and Constitutional Affairs. Ottawa (ON): Canadian Psychological
Association; 2012.
8. Brennan S. Police reported crime statistics in Canada, 2011. Juristat
(Catalogue no 85-002-X). Ottawa (ON): Statistics Canada; 2012
9. Andrews DA. The Risk-Need-Responsivity (RNR) model of
correctional assessment and treatment. In: Dvoskin JA, Skeem JL,
Novaco RW, et al, editors. Using social science to reduce violent
offending. New York (NY): Oxford University Press; 2012.
10. Bousfield N, Cook A, Roesch R. Evidence-based criminal justice
policy for Canada: an exploratory study of public opinion and the
perspective of mental health and legal professionals. Can Psychol.
2014;55(3):204–215.
11. Crocker AG, Nicholls TL, Seto MC, et al. The National Trajectory
Project (NTP) [Internet]. Montreal (QC): NTP; [year of publication
unknown; cited 2015 Jan 1]. Available from: https://ntp-ptn.org.
12. Crocker AG, Nicholls TL, Seto MC, et al. The National Trajectory
Project of individuals found not criminally responsible on account
of mental disorder in Canada. Part 1: context and methods. Can J
Psychiatry. 2015;60(3):98–105.
13. Crocker AG, Nicholls TL, Seto MC, et al. The National Trajectory
Project of individuals found not criminally responsible on account of
mental disorder in Canada. Part 2: the people behind the label. Can J
Psychiatry. 2015;60(3):106–116.
14. Crocker AG, Charette Y, Seto MC, et al. The National Trajectory
Project of individuals found not criminally responsible on account of
mental disorder in Canada. Part 3: trajectories and outcomes through
the forensic system. Can J Psychiatry. 2015;60(3):117–126.
15. Charette Y, Crocker AG, Seto MC, et al. The National Trajectory
Project of individuals found not criminally responsible on account
of mental disorder in Canada. Part 4: criminal recidivism. Can J
Psychiatry. 2015;60(3):127–134.
16. Nicholls TL, Crocker AG, Seto MC, et al. National Trajectory
Project of individuals found not criminally responsible on account
of mental disorder. Part 5: how essential are gender-specific forensic
psychiatric services? Can J Psychiatry. 2015;60(3):135–145.
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 97
CanJPsychiatry 2015;60(3):98–105
National Trajectory Project
The National Trajectory Project of Individuals Found Not
Criminally Responsible on Account of Mental Disorder in
Canada. Part 1: Context and Methods
Anne G Crocker, PhD1; Tonia L Nicholls, PhD2; Michael C Seto, PhD3; Gilles Côté, PhD4;
Yanick Charette, MSc (PhD Candidate)5; Malijai Caulet, PhD6
1
Associate Professor, Department of Psychiatry, McGill University, Montreal, Quebec; Associate Director, Policy and Knowledge Exchange, Douglas Mental
Health University Institute Research Centre, Montreal, Quebec.
Correspondence: Douglas Mental Health University Institute Research Centre, 6875 LaSalle Boulevard, Montreal, QC H4H 1R3; [email protected].
2
Associate Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia; Senior Research Fellow, Forensic Psychiatric
Services Commission, BC Mental Health & Substance Use Services, Coquitlam, British Columbia.
3
Director of Forensic Rehabilitation Research, Royal Ottawa Health Care Group, Brockville, Ontario.
4
Professor, Department of Psychology, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec; Director, Philippe-Pinel Institute Research Centre,
Montreal, Quebec.
5
Post-doctoral Fellow, Department of Sociology, Yale University, New Haven, Connecticut; Student, Department of Criminology, Université de Montréal,
Montreal, Quebec.
6
National Coordinator, National Trajectory Project, Douglas Mental Health University Institute Research Centre, Montreal, Quebec.
Key Words: forensic, mental
health, National Trajectory
Project, not criminally
responsible on account of
mental disorder, mental
disorder, criminality, violence,
review board
Received November 2013,
revised, and accepted February
2014.
The National Trajectory Project examined longitudinal data from a large sample of
people found not criminally responsible on account of mental disorder (NCRMD) to
assess the presence of provincial differences in the application of the law, to examine the
characteristics of people with serious mental illness who come into conflict with the law
and receive this verdict, and to investigate the trajectories of NCRMD–accused people
as they traverse the mental health and criminal justice systems. Our paper describes
the rationale for the National Trajectory Project and the methods used to collect data in
Quebec, Ontario, and British Columbia, the 3 most populous provinces in Canada and the
3 provinces with the most people found NCRMD.
WWW
Le Projet national des trajectoires des personnes déclarées non
criminellement responsables pour cause de troubles mentaux au
Canada. Partie 1 : Contexte et méthodes
open
access
Les membres du Projet national des trajectoires ont examiné les données longitudinales
d’un vaste échantillon de personnes déclarées non criminellement responsables
pour cause de troubles mentaux (NCRTM) afin d’évaluer la présence de différences
provinciales en matière d’application de la loi, d’étudier les caractéristiques de personnes
ayant une maladie mentale grave qui, ayant des démêlés avec la justice, sont déclarées
non criminellement responsables, et d’examiner les trajectoires des accusés NCRTM à
travers les systèmes de santé mentale et de justice pénale. Le présent document décrit
la raison d’être du Projet national des trajectoires et les méthodes utilisées pour recueillir
des données au Québec, en Ontario et en Colombie-Britannique, les 3 provinces les
plus populeuses du Canada et celles où se trouve la majorité des personnes déclarées
NCRTM.
98 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
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The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 1: Context and Methods
T
here has been a dramatic growth in the rates of admissions
to forensic mental health services in Europe and North
America.1 In Europe, there has been a significant increase in
the number of hospital beds and other resources dedicated to
the forensic population.2 Seto et al3 reported similar findings
in Ontario, and described data from the United States
showing that an increasing number of psychiatric hospital
beds were being occupied by forensic clients, a trend they
called forensication of people with SMI. In short, research
demonstrates it is increasingly easier to hospitalize someone
with SMI, and access other mental health resources, after
a criminal charge has been laid than it is to access mental
health services through the civil psychiatric system.
The Canadian Context
In Canada, people find themselves in forensic institutions
as a result of having been found unfit to stand trial (unable
to participate in a criminal proceeding as a result of SMI or
other mental disability) or following a verdict of NCRMD.4,5
In line with the common-law principle that it is inappropriate
to punish people who did not have criminal intent at the
time of the offence, section 16 of the Criminal Code defines
the verdict of NCRMD as:
No person is criminally responsible for an act
committed or an omission made while suffering from
a mental disorder that rendered the person incapable
of appreciating the nature and quality of the act or
omission or of knowing that it was wrong.6
Review Boards
RBs are independent tribunals established to determine
dispositions of accused found unfit to stand trial or
NCRMD. At the time the study was conducted, the criteria
that governed the RBs’ dispositions in section 672.54 of the
Criminal Code required the following:
Where a court or Review board makes a disposition . . .
it shall, taking into consideration the need to protect the
public from dangerous persons, the mental condition
of the accused, the reintegration of the accused into
society and the other needs of the accused, make one of
the following dispositions that is the least onerous and
least restrictive to the accused.6
Abbreviations
CPIC
Canadian Police Information Centre
FPSC
Forensic Psychiatric Services Commission
HCR-20 Historical-Clinical-Risk Management-20
NCRMD not criminally responsible on account of
mental disorder
NTP
National Trajectory Project
RB
review board
SMI
serious mental illness
UCR2
Uniform Crime Reporting Survey (1988)
VRAG
Violence Risk Appraisal Guide
www.TheCJP.ca
Highlights
•
Significant interprovincial differences are observed in
the number of people found NCRMD per criminal court
verdict annually.
•
Different trends over time are observed across each
province in the number of NCRMD–accused people
entering the provincial RB systems.
These dispositions are as follows: 1) absolute discharge;
2) conditional discharge (typically living in the community
under conditions set by the RB); or 3) detention in hospital.
Although there has been an overall national increase in the
number of people found NCRMD in Canada,4 there are some
interprovincial differences. In Quebec, there were more than
twice as many NCRMD findings in 2005 (n = 407) as in
1992 (n = 177).7 In fiscal year 2011/12, there were 540 new
verdicts of NCRMD in Quebec (Carmelle Beaulieu, May 9,
2013, personal communication). There also has been a steady
increase in Ontario, with 170 new NCRMD–accused cases
diverted to the RB in 2010–2011.5,8 However, some provinces,
such as British Columbia, have seen smaller increases.5 After
an initial increase in the early 1990s,9 the annual number of
new NCRMD findings has been on a steady gradual decline
in British Columbia since 1999. This suggests there are
potentially important differences in the way that the law is
being applied across provinces.
Organization of Forensic Mental
Health Services
In Quebec, in addition to the provincial forensic psychiatric
hospital, there are over 50 mental health settings designated
to receive NCRMD–accused people. Thus many NCRMD–
accused people are in custody of civil psychiatric hospitals that
are not specialized for risk assessment and risk management.
There is one interregional forensic services group and one
Montreal intersectoral services group who meet regularly to
ensure interagency communication and training.
British Columbia has a highly integrated network of
forensic services. The BC FPSC is a multi-site organization
that provides and coordinates specialized clinical services at
the BC Forensic Psychiatric Hospital and 6 regional clinics
across the province. All people sent for NCRMD or fitness
assessments, as well as all people found unfit or NCRMD
by the courts, are treated and managed by the FPSC.
The forensic mental health system in Ontario is different
from British Columbia and Quebec. People found NCRMD
are treated and managed by 1 of 10 designated forensic
facilities for adults. These facilities operate independently,
but the staff and services are specialized and their directors
meet regularly through a forensic directors group, thereby
informally coordinating services. Ontario represents a
middle ground between forensic systems in Quebec (highly
distributed, with many nonforensic professionals involved)
and British Columbia (specialized and centrally coordinated
by a single organization).
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 99
Figure 1 Number of annual not criminally responsible on account of mental disorder
National Trajectory Project
verdicts diverted to review boards
Figure 1 Number of annual not criminally responsible on account of mental
disorderPlease
verdicts
diverted
to “to”;
review
boards
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450
400
350
300
250
QC
BC
200
ON
150
100
50
0
May 2000April 2001
May 2001April 2002
May 2002April 2003
The National Trajectory Project
The main goals of the NTP10 were to provide a representative
portrait of people found NCRMD during an extended period
of time, and to examine their trajectories through the RB
system. This study was conducted in the 3 most populated
Canadian provinces: Ontario (39%), Quebec (23%), and
British Columbia (13%),11 which also encompass most
NCRMD cases4 and operate under different provincial
forensic mental health service models.12,13
The primary objectives of the NTP were as follows:
1) Describe the demographic, psychosocial, and
criminological profiles of NCRMD accused in Canada.
2) Evaluate the reporting of violence risk factors and
assessments presented to the RBs.
3) Distinguish the rationales for RB dispositions.
4) Examine rehospitalization and recidivism outcomes.
5) Track the migration patterns of people found
NCRMD.
6) Identify the individual and organizational factors
associated with these geographic and processing
trajectories.
7) Examine the use of mental health services by the
accused people prior to the NCRMD verdict, under the
RB, and following discharge.
100 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
May 2003April 2004
May 2004April 2005
8) Examine each of these findings with respect to culture
and gender.
9) Learn how the Criminal Code and the RB process
are perceived and experienced by people adjudicated
NCRMD, their families, and professionals across
Canada.
Methods
Design and Study Period
The NTP used a longitudinal design to study a cohort
of people found NCRMD in British Columbia, Ontario,
and Quebec, retrospectively. The sample selection start
date considered the Winko decision,14 which could have
influenced the characteristics of NCRMD–accused people
and RB decisions about absolute discharges.15 The study end
date allowed for a minimum of a 3-year follow-up for all
cases, up to a maximum of 8 years. Note, the Winko decision
clarified that the verdict of NCRMD is neither one of guilt nor
acquittal and further elaborated on the notion of significant
threat to public safety and underlined the importance of the
least restrictive and least onerous disposition.16,17
Sample Selection
The sample selection period spanned May 1, 2000, to April
30, 2005. Quebec had a significantly higher number of
www.LaRCP.ca
The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 1: Context and Methods
NCRMD verdicts per year than both Ontario and British
Columbia (Figure 1). Averaged across 5 years, NCRMD
verdicts accounted for 6.08 per 1000 decisions in Quebec
criminal courts, compared with 0.95 in Ontario and 1.34
in British Columbia. No significant changes in the number
of general criminal court cases were observed during this
5-year period.18 The number of NCRMD–accused people
by province was also stable.
For every person found NCRMD and under an RB, the
first NCRMD verdict within the province’s time frame was
identified as the index verdict. Owing to time and budgetary
constraints, time frames varied across provinces.
In Quebec, there were a total of 2389 NCRMD verdicts
between May 1, 2000, and April 30, 2005, corresponding
to 1964 people. To obtain a geographically representative
sample of all 17 justice administrative regions of Quebec,
a random sampling procedure was applied for each region
using a finite population correction factor. Therefore, the
descriptive analyses are weighted.
The Ontario sample was comprised of all adults with an
NCRMD verdict between January 1, 2002, and April 30,
2005 (n = 484). Data collection started with the same end
date as Quebec and then files were coded backwards in
time. Coding was completed to January 1, 2002. The British
Columbia sample was comprised of 222 NCRMD–accused
people registered with the BC RB between May 1, 2001,
and April 30, 2005.
For the Quebec sample, preliminary analyses were conducted
to ensure that potential differences between provinces would
not be attributable to different data collection time frames. No
statistically significant differences in the psychosocio-criminal
characteristics of people found NCRMD in Quebec for the
2000 to 2002 and the 2002 to 2005 time frames were observed.
Thus the full Quebec sample was used for all analyses.
In summary, the full population of people found NCRMD is
represented for British Columbia and Ontario, whereas for
Quebec, a random sample of people was selected, stratified
by region. Normalized weights are attributed to the
Quebec sample and the total sample when presenting total
population rates. This normalized weighting may result in a
slightly different number (±2) of valid cases in the various
descriptive analyses because cell counts are rounded. The
final national sample size was 1800.
Procedures
For each case, RB files 5 years prior to the index verdict
were reviewed and then coded forward until December 31,
2008. In British Columbia, RB files dated before November
2001 had been destroyed; thus the 7 cases from May 2000
until October 31, 2001, were accessed from files kept
at the British Columbia Forensic Psychiatric Hospital.
The hospital files generally contain the same reports and
documents found in RB files. Research assistants were
instructed to code only from the file content that would have
been generally found in RB files, to maintain comparability
with other cases and the other provinces.
www.TheCJP.ca
Trained research assistants coded and entered RB data into
a bilingual computerized database to ensure standardization
of data collection across study sites. Throughout the study,
quality checks included meetings to discuss data collection
issues. A password-protected blog was maintained on
the NTP website to allow discussions between research
assistants, project coordinators, and investigators about
challenging or unusual cases.
Measures and Sources of Information
Five categories of information were coded: sociodemographic information (for example, age at verdict, gender,
and marital status); clinical information (for example, age
at first psychiatric hospitalization, diagnosis at NCRMD
verdict); criminal history (for example, offences leading to
the index NCRMD verdict, past convictions, or NCRMD
verdicts); details of the risk assessments presented at each
RB hearing; contextual factors and processing through the
RB system (for example, RB dispositions and associated
reasons).
Psychopathology
Diagnoses were coded from court-ordered psychiatric
evaluations for the index verdict and annual reports
submitted to the RBs. Diagnoses were rarely identified using
standard codes from the Diagnostic and Statistical Manual19
or the International Classification of Diseases20 and often
included nonstandard descriptors. Eight broad diagnostic
categories were coded: psychosis; mood; organic (for
example, dementia); anxiety; substance use; personality;
other (for example, intellectual disabilities and autism); and
none (the reports specify there is no diagnosis). Percentages
add up to more than 100% because people could have more
than 1 diagnosis.
In 8.1% (n = 153) of NCRMD assessments presented to the
courts, no psychiatric diagnosis was mentioned. Therefore,
we used psychiatric diagnoses from the 3 hearings
following the verdict on the assumption that there would
be less missing information at subsequent hearings; further
clinical evaluation could clarify the primary diagnosis(es);
and diagnosis would be stable over time. In 13 cases, no
diagnostic information was available because no psychiatric
evaluations were found in the RB files. Therefore, the
distribution of diagnoses for this report was calculated on
1787 instead of 1800 people.
Police reports and other documents were also coded
for psychiatric symptoms during the commission of the
offence: unspecified psychotic symptoms, hallucinations,
delusions, suicidal ideation, attempted suicide, self-harming
behaviour, homicidal ideation, and substance use.
Risk Assessments
Research assistants coded the presence or absence of items
from 2 widely used violence risk assessment tools (VRAG21
and HCR-2022) to ascertain the extent to which risk
assessment measures were used and reported by clinicians
to inform the RB dispositions and conditions.
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 101
National Trajectory Project
Table 1 Categories of offences
Causing death or attempting to cause death
Sex offences
Assaults
Deprivation of freedom (for example, forcible confinement)
Threats, and other offences against the person
Property offences (for example, theft)
Prostitution and (or) gambling
Offensive weapons
Administration of justice (for example, failure to attend court and
breach of probation)
Disturbing the peace
Drug possession and (or) trafficking
Dangerous driving and (or) operation of a motor vehicle
Other federal and (or) provincial statutes
Table 2 Categories of victims
Stranger
Professionals (that is, police or security officer, mental health
professional, and landlord)
Family (that is, offspring, parents, current and ex-partner or
spouse, and other family members)
Roommate or co-resident
Friend and acquaintance
Other
Historical-Clinical-Risk Management-20. The HCR-2022
was used to structure coding of risk factors presented by
clinicians to RBs. It has strong psychometric properties
and has been studied and used internationally.23–27 It has
also been validated in French.28 The 20 items on the HCR20 are divided into 3 sections: H for 10 historical or static
variables that do not or seldom change with time; C for 5
clinical variables that are amenable to intervention; and R
for 5 risk management variables that should be the focus
of attention to reduce violence. For our study, coding was
modified to the following: present, absent, mentioned but
uncodable, or not mentioned.
Violence Risk Appraisal Guide. The VRAG29–30 is a 12-item
actuarial measure that uses historical information, such as
offence history and victim characteristics, to estimate longterm risk of violence.21 The measure has very good interrater
reliability, been validated in both forensic and correctional
populations, and very good predictive accuracy.29–31 Though
the VRAG items are usually weighted, they were coded as
present, absent, mentioned but uncodable, or not mentioned
for this study.
Research assistants coded whether HCR-20 or VRAG
items were mentioned in clinical reports submitted to the
RB. The intention of this approach was to examine what
information clinicians brought as explicit evidence to the
RBs. A limitation to this coding approach is that items
102 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
could be considered by clinicians without being specifically
mentioned. Moreover, there is an asymmetry of information
because it is easier to code the presence of a factor than
its absence, because the natural tendency is to mention
presence (for example, “He has a history of substance use
problems.”) rather than to specifically mention absences
(for example, “There is no evidence he ever had substance
use problems.”).
Interrater Reliability
A total of 1835 RB reports associated with 573 NCRMD–
accused people were submitted to interrater reliability
testing for the HCR-20 and the VRAG regarding the expert
reports to the RBs and RB justifications for their decisions.
For the expert reports to the RBs, the average kappa for
the HCR-20 was 0.78 (0.84 for the H factor, 0.75 for the
C factor, and 0.69 for the R factor) and 0.68 for the VRAG.
For the RB justification for their decisions, the total
HCR-20 yielded an average kappa coefficient of 0.76 (0.83
for the H factor, 0.73 for the C factor, and 0.67 for the R
factor) and 0.72 for the VRAG.
Criminal Behaviour
Criminal History. Information on lifetime criminal
convictions was obtained from the CPIC. Given that
NCRMD verdicts are not recorded in CPIC records in a
systematic fashion, we also coded NCRMD verdicts from
RB files.
Index Offence. In many instances, an accused person
had been charged with more than one offence leading to
the index NCRMD verdict. All charges were coded, but
only the most serious charge was selected as the index
offence for the purpose of this study, ensuring consistency
across provinces. Index offences were aggregated into 13
categories (Table 1) corresponding to the UCR2.32
Categories 1 to 5 are offences against the person, category
6 are crimes against property, and the remaining categories
fall under other Criminal Code violations.
Victims. For offences against the person, the relation
between the accused and the victim was assigned to 1 of 6
categories (Table 2).
Severity of Offences. Descriptions of the offences were
coded using the UCR2.32 A severity score was also assigned
to each index offence using the Crime Severity Index,
which is based on average sentence lengths.33
Recidivism. New charges and convictions were also coded
from the CPIC records and the RB files. There is generally
a significant time lapse owing to administrative delays
between the date an offence is committed and the final
verdict. This has important implications for our analysis of
prior criminal offences and future criminality. For example,
a verdict for offence X might occur after a verdict for
offence Y, despite offence X actually being perpetrated
before offence Y. Therefore, what may be identified as
recidivism may be an artefact of delayed processing. Given
that criminal records provide Court dispositions and do
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The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 1: Context and Methods
not provide offence dates, the following algorithm was
applied to paint an accurate portrait of criminal history
and recidivism: for each Court decision, we subtracted the
median justice processing delay by province and matched
for most severe offence; this is measured using the median
time between the first and last hearing of a Court case.18
Ethics
Ethics approval was obtained from the investigators’
primary institutions and renewed annually according to TriCouncil Guidelines.34,35
Discussion
To our knowledge, this is the first longitudinal cohort
study comparing provincially representative samples of
NCRMD–accused people since the 1992 changes to the
Criminal Code. It is clear there are differences across
provinces in the likelihood of an NCRMD verdict; using
data from Statistics Canada and the number of people
found NCRMD, Quebec had 6.4 times the number of cases
diverted to the RB system than Ontario, and 5 times that
of British Columbia. British Columbia had 1.5 times the
number of cases of Ontario when considering all criminal
court decisions. Historically, Quebec courts have always
yielded higher rates of NCRMD verdicts (or previously,
Not Guilty by Reason of Insanity)36,37 and the gap appears
to be increasing. As of 2012, the annual rate of NCRMD
cases had increased in Quebec and stands at 9.27 per 1000
cases, it has stabilized in Ontario at 1.07 cases per 1000, and
has decreased in British Columbia to 0.8 per 1000 criminal
court cases.18 These differences may be due to differences
in prosecutorial discretion, legal aid, and civil mental health
resources and legislation, and Quebec may be using the
NCRMD defence as a criminal justice diversion option.
Strengths and Limitations
Our study has the advantage of a large sample, allowing
us to examine interesting subgroups (for example, gender
and diagnosis), low base rate characteristics, and recidivism
rates. To our knowledge, the NTP is the first study to analyze
detailed RB file content and the information on which RBs
make their decisions. It also comprises one of the largest
samples of people found NCRMD studied to date. The NTP
entails a lengthy follow-up period and integrates official
criminal records in addition to RB files to assess recidivism
rates and predictors. Finally, this is also the only study to
systematically examine provincial differences in the extent
to which clinicians in forensic psychiatric practice have
embedded evidence-based risk assessment measures into
their clinical decision making.38
In terms of limitations, some information was not available
in RB files in this archival study. This limited our ability
to obtain details about symptoms at the time of the index
offence, recovery while under the RBs, detailed diagnostic
information, and violence risk assessments. In some cases,
missing information could be interpreted as the absence
of a factor. For example, one would not expect mention
www.TheCJP.ca
of someone’s non-Aboriginal status, thus no mention of
Aboriginal status was coded as non-Aboriginal status. This
results in a conservative estimate of missing data, as it is
possible information was truly missing in some cases that
were coded as factor absence. Variables with more than 10%
missing data were dropped from multivariate analyses.39
Further, file data quality and quantity differed within and
across provinces, over time and between RB hearings.
Conclusion
Given there are no current indications of increased
criminality and court cases in Canada that could help
explain the increased number of NCRMD cases over
time,4 the profile of the NCRMD population is increasingly
diversified. This increasing heterogeneity is evident
regarding both criminal behaviour and clinical profile. The
next 4 NTP papers, published in this special issue, examine
the psychosocio-criminological profiles of NCRMD people,
their processing across provinces, outcomes, as well as
gender differences, in NCRMD profiles.40–43
Acknowledgements
This research was consecutively supported by grant
#6356-2004 from Fonds de recherche Québec—Santé
(FRQ-S) and by the Mental Health Commission of Canada
(MHCC). Dr Crocker received consecutive salary awards
from the Canadian Institutes of Health Research (CIHR),
FRQ-S, and a William Dawson Scholar award from McGill
University while conducting this research. Dr Nicholls
acknowledges the support of the Michael Smith Foundation
for Health Research and the CIHR for consecutive salary
awards. Yanick Charette acknowledges the support of
the Social Sciences and Humanities Research Council of
Canada in the form of a doctoral fellowship.
This study could not have been possible without the full
collaboration of the Quebec, British Columbia, and Ontario
Review Boards (RBs), and their respective registrars and
chairs. We are especially grateful to attorney Mathieu
Proulx, Bernd Walter, and Justice Douglas H Carruthers and
Justice Richard Schneider, the Quebec, British Columbia,
and consecutive Ontario RB chairs, respectively. We thank
Carmelle Beaulieu from the Quebec RB for providing
recent annual statistics. Ms Beaulieu has provided written
permission to publish the information she sent to us at our
request.
The authors sincerely thank Erika Jansman-Hart and
Dr Cathy Wilson, Ontario and British Columbia
coordinators, respectively, as well as our dedicated research
assistants who coded RB files and Royal Canadian Mounted
Police criminal records: Erika Braithwaite, Dominique
Laferrière, Catherine Patenaude, Jean-François Morin,
Florence Bonneau, Marlène David, Amanda Stevens,
Stephanie Thai, Christian Richter, Duncan Greig, Nancy
Monteiro, and Fiona Dyshniku.
Finally, the authors extend their appreciation to the members
of the Mental Health and the Law Advisory Committee
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 103
National Trajectory Project
of the MHCC, in particular Justice Edward Ormston and
Dr Patrick Baillie, consecutive chairs of the committee as
well as the NTP advisory committee for their continued
support, advice, and guidance throughout this study and the
interpretation of results.
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1956 to 2015
of Medical Publishing Excellence
For 60 years, Canadian psychiatrists have turned
to The Canadian Journal of Psychiatry for reliable
research they can use in their clinical practices to
improve patient care.
d’excellence en publication médicale
Depuis 60 ans, les psychiatres canadiens
consultent La Revue canadienne de psychiatrie
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The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 105
CanJPsychiatry 2015;60(3)106–116
National Trajectory Project
The National Trajectory Project of Individuals Found Not
Criminally Responsible on Account of Mental Disorder in
Canada. Part 2: The People Behind the Label
Anne G Crocker, PhD1; Tonia L Nicholls, PhD2; Michael C Seto, PhD3;
Yanick Charette, MSc (PhD Candidate)4; Gilles Côté, PhD5; Malijai Caulet, PhD6
1
Associate Professor, Department of Psychiatry, McGill University, Montreal, Quebec; Associate Director, Policy and Knowledge Exchange,
Douglas Mental Health University Institute Research Centre, Montreal, Quebec.
Correspondence: Douglas Mental Health University Institute Research Centre, 6875 LaSalle Boulevard, Montreal, QC H4H 1R3; [email protected].
2
Associate Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia; Senior Research Fellow,
Forensic Psychiatric Services Commission, BC Mental Health & Substance Use Services, Coquitlam, British Columbia.
3
Director of Forensic Rehabilitation Research, Royal Ottawa Health Care Group, Brockville, Ontario.
4
Post-doctoral Fellow, Department of Sociology, Yale University, New Haven, Connecticut; Student, Department of Criminology, Université de Montréal,
Montreal, Quebec.
5
Professor, Department of Psychology, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec; Director, Philippe-Pinel Institute Research Centre,
Montreal, Quebec.
6
National Coordinator, National Trajectory Project, Douglas Mental Health University Institute Research Centre, Montreal, Quebec.
Key Words: forensic mental
health, National Trajectory
Project, not criminally
responsible on account of
mental disorder, mental
disorder, criminality, violence,
review board
Received November 2013,
revised, and accepted February
2014.
open
access
Objective: To examine the psychosocio-criminological characteristics of not criminally
responsible on account of mental disorder (NCRMD)–accused people and compare them
across the 3 most populous provinces. In Canada, the number of people found NCRMD
has risen during the past 20 years. The Criminal Code is federally legislated but provincially
administered, and mental health services are provincially governed. Our study offers a rare
opportunity to observe the characteristics and trajectories of NCRMD–accused people.
Method: The National Trajectory Project examined 1800 men and women found NCRMD in
British Columbia (n = 222), Quebec (n = 1094), and Ontario (n = 484) between May 2000 to
April 2005, followed until December 2008.
Results: The most common primary diagnosis was a psychotic spectrum disorder.
One-third of NCRMD–accused people had a severe mental illness and a concomitant
substance use disorder, with British Columbia having the highest rate of dually diagnosed
NCRMD–accused people. Most accused people (72.4%) had at least 1 prior psychiatric
hospitalization. Two-thirds of index NCRMD offences were against the person, with a wide
range of severity. Family members, followed by professionals, such as police and mental
health care workers, were the most frequent victims. Quebec had the highest proportion
of people with a mood disorder and the lowest median offence severity. There were both
interprovincial differences and similarities in the characteristics of NCRMD–accused people.
Conclusions: Contrary to public perception, severe violent offenses such as murder,
attempted murder or sexual offences represent a small proportion of all NCRMD verdict
offences. The results reveal a heterogeneous population regarding mental health and
criminological characteristics in need of hierarchically organized forensic mental health
services and levels of security. NCRMD–accused people were well known to civil psychiatric
services prior to being found NCRMD. Risk assessment training and interventions to reduce
violence and criminality should be a priority in civil mental health services.
WWW
Projet national des trajectoires des personnes déclarées non
criminellement responsables pour cause de troubles mentaux au
Canada. Partie 2 : Les personnes derrière l’étiquette
Objectif : Examiner les caractéristiques psychologiques, sociales et criminologiques
des accusés déclarés non criminellement responsables pour cause de troubles mentaux
(NCRTM) et les comparer dans les 3 provinces les plus peuplées. Au Canada, le
nombre de personnes déclarées NCRTM a augmenté ces 20 dernières années. Le
Code criminel relève de la compétence du gouvernement fédéral mais son application
relève des provinces, et les services de santé mentale sont régis par les provinces.
Cette étude offre l’occasion unique d’observer les caractéristiques et la trajectoire des
accusés NCRTM.
106 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
www.LaRCP.ca
The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 2: The People Behind the Label
Méthode : Le Projet national des trajectoires a permis d’examiner 1800 hommes et femmes déclarés NCRTM
en Colombie-Britannique (n = 222), au Québec (n = 1094) et en Ontario (n = 484) de mai 2000 à avril 2005, et
de les suivre jusqu’en décembre 2008.
Résultats : Le diagnostic principal le plus courant était un trouble du spectre de la psychose. Un tiers des
accusés NCRTM souffraient d’une maladie mentale grave et d’un trouble concomitant lié à l’utilisation de
substances, la Colombie-Britannique ayant le taux le plus élevé d’accusés NCRTM ayant ces troubles
concommitants. La plupart des accusés (72,4 %) avaient déjà été hospitalisés au moins une fois dans
un établissement psychiatrique. Les deux tiers des infractions répertoriées des accusés NCRTM étaient
des infractions contre la personne, de niveaux de gravité variables. Les membres de la famille, puis des
intervenants comme les agents de police et les travailleurs de la santé mentale, étaient les victimes les plus
fréquentes. C’est au Québec que la proportion de personnes souffrant d’un trouble de l’humeur était la plus
élevée et que la gravité médiane des infractions était la plus basse. Les caractéristiques des accusés NCRTM
entre les provinces présentent à la fois des différences et des similarités.
Conclusions : Contrairement à la perception publique, les infractions graves avec violence comme le
meurtre, les tentatives de meurtre ou les agressions sexuelles représentent une faible proportion de tous
les verdicts NCRTM. Les résultats révèlent une population hétérogène en termes de santé mentale et de
caractéristiques criminologiques ayant besoin de services hiérarchisés et des niveaux de sécurités variables.
Les personnes déclarées NCRTM étaient bien connues des services de psychiatrie générale avant d’être
trouvées NCRTM. La formation et les interventions en évaluation du risque, afin de réduire la violence et la
criminalité, devraient être une priorité dans les services de santé mentale civils.
I
nstitutional mental health services are more difficult to
access following the deinstitutionalization movement and
a subsequent shortfall in community-based services,1 often
compelling families to report criminal acts to police to access
services for their relatives with SMI, even for relatively minor
offences, such as uttering threats or causing a disturbance.
The criminal justice system has become a major gateway to
mental health services for people with SMI.2,3
International research suggests that people with SMI find
themselves in forensic facilities at increasing rates.4 In
Canada, the number of forensic clients entering the system
has been growing.5–7 This so-called forensication transforms
mental health systems into de facto forensic systems.8
Criminal Responsibility Legislation
A fundamental principle of Canadian law is that an accused
person must possess the capacity to understand their behaviour
was wrong to be found guilty of an offence. According to the
Criminal Code, section 6, people can be found NCRMD
for an act committed or an omission made while
suffering from a mental disorder that rendered the
person incapable of appreciating the nature and quality
of the act or omission or of knowing that it was wrong.9
People found NCRMD are then under the jurisdiction of
provincial or territorial RBs that must review NCRMD
dispositions (that is, detention in hospital, conditional discharge,
Abbreviations
K-WKruskal–Wallis
or absolute discharge) on a minimum yearly basis. In Part 1 of
this special issue,7 we described the main components of the
NCRMD legislation and the role of review boards.
The forensic population seems more heterogeneous today in
terms of criminological and psychosocial characteristics5,10 as
a reflection of the 1992 legislative changes making the defence
of NCRMD more attractive for some (for example, to people
charged with minor offences).11 Forensic mental health systems
must thus adjust their services to address diverse patient needs
regarding mental health problems, substance use, independent
living, and risk for future violence and criminality.12
Clinical Implications
•
The mental health and criminal heterogeneity of the
NCRMD population reinforces the importance of targeted
evidence-based risk and need assessments to inform
treatment planning.
•
Given NCRMD legislation is federal and there are
differences in availability of information in the review
board systems, we encourage review boards and forensic
mental health services to align their data and assessment
protocols.
•
Families are among the most common victims of
crimes committed by NCRMD–accused people; further
education, support, and research is needed to better
understand the needs of families and how best to support
them.
Limitations
•
This was an archival study and thus is more likely to have
missing information than a prospective design.
•
We were limited to the 3 most populous provinces
(Quebec, Ontario, and British Columbia), which might
reduce and (or) restrict generalizability to other provinces
(and internationally).
•
The data reflect the population entering the review board
system from the year 2000 to 2005. It is possible that the
characteristics of the population may have changed.
NCRMD not criminally responsible on account of mental disorder
NTP
National Trajectory Project
RB
review board
SMI
serious mental illness
SUD
substance use disorder
www.TheCJP.ca
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 107
National Trajectory Project
Interprovincial Differences
In Canada, all provinces and territories operate under the
same Criminal Code. In previous papers, we13 and others14
reviewed some of the important interprovincial differences
regarding the organization of mental health civil and
forensic services in Canada. Our results indicated significant
interprovincial differences in the use of the NCRMD
verdict, with Quebec having a higher rate of NCRMD
findings per criminal court decision than Ontario or British
Columbia, and that this gap continues to grow.7 Evidence of
continued criminalization of people with mental illness and
interprovincial differences in the application of federal law
suggests the need to explore the characteristics and needs of
the NCRMD population across the country. In turn, this can
help program planning and organization of services.
Current Study
The objective of the NTP was to provide an accurate
portrait of people found NCRMD and to examine the
operation of current criminal justice provisions for people
under the authority of an RB (pursuant to section 672.38,
Criminal Code).9 In this study, we examined psychosociocriminological characteristics of the NCRMD population
and compared them across 3 provinces.
Methods
The full NTP design and procedures are described in more
detail in Crocker et al.7 The sample was comprised of
1800 men and women found NCRMD in British Columbia
(n = 222), Quebec (n = 1094), and Ontario (n = 484) between
May 2000 and April 2005 and followed until December
2008. This archival retrospective cohort study included
information on sociodemographic, clinical, contextual,
and criminological characteristics of the sample. Sources
of information were RB files and national criminal records.
Analytic Strategy
Descriptive information is provided for the total sample
and for each province. Group comparisons were carried out
using chi-square for categorical variables and K-W tests for
continuous variables that were not normally distributed. Post
hoc pairwise comparisons were conducted for significant
omnibus results. A multinomial logistic regression with 3
pairwise comparisons was then used to define NCRMD–
accused profiles by province. Only variables with less than
10% missing data were included in the overall model.15
Results
Sociodemographic Characteristics
Women represented 15.6% of the sample. NCRMD–accused
people were, on average, 36.56 years of age, one-half had
a high school diploma, and more than three-quarters were
single at the time of the index offence (Tables 1A and 1B).
Two-thirds of NCRMD–accused people were Canadian born,
with a slightly higher proportion of immigrants in Quebec
than in British Columbia. At the time of the offence, slightly
108 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
more than one-third of the sample were living alone, less than
one-half resided with family, friends, or a spouse, and 1 in 10
were homeless. Ontario had a higher proportion of people
living with family and a lower proportion of homeless people
than Quebec and British Columbia. Quebec had a higher
proportion of accused people living independently than
British Columbia and Ontario; British Columbia had fewer
accused people living in supervised settings. Nearly threequarters of the NCRMD–accused people were under some
form of governmental income support, whether it be welfare,
pension, or disability; Quebec had the highest proportion.
Aboriginal status (any or First Nations, Inuit, or Metis,
specifically) was mentioned for 53 people (2.9%), with
significant differences across provinces in the expected
direction according to population base rates: 7.7% in
British Columbia, 4.5% in Ontario, and 1.3% in Quebec
[χ2 (n = 1800) = 32.21, df = 2, P < 0.001].
Mental Health Characteristics
Diagnosis at Verdict
Ninety-four per cent of accused people had an SMI at their
index verdict. The most common diagnosis was a psychotic
spectrum disorder (Table 2), with Quebec having the lowest
rate. Quebec had the highest proportion of people with a
mood disorder. One-third of NCRMD–accused people had
an SUD, with British Columbia having the largest proportion.
About 1 in 10 people had a diagnosis of personality disorder
recorded at verdict, with no provincial differences. Slightly
more than one-third (32.7%; n = 588) of NCRMD–accused
people had an SMI and a concomitant personality or SUD
at the time of the verdict, with British Columbia having the
highest proportion of dually diagnosed accused people.
Mental State at the Time of the Offence
The mental state of the accused person at the time of the
offence was clearly mentioned in 70.3% of cases (n = 1265;
Table 2). Delusions were mentioned in less than one-half
of cases and hallucinations in one-fifth of cases. Suicidal or
homicidal ideation was rare, mentioned in less than 10% of
cases. Alcohol or drug abuse at the time of the offence was
mentioned in one-quarter of cases. There were significant
interprovincial differences on all symptoms, with the
exception of substance use.
Psychiatric History
Seventy-two per cent of NCRMD–accused people (n = 1051)
were noted to have had at least 1 psychiatric hospitalization
prior to the index offence, with no interprovincial
differences: 72.5% in Quebec, 71.8% in Ontario, and
72.4% in British Columbia [χ2 (n = 1453) = 0.968, df = 2,
P = 0.97]. The median age at first psychiatric consultation
[median 24.0; K-W, χ2 (n =1102) = 2.35, df = 2, P = 0.31]
and the median age at first psychiatric hospitalization were
in the mid-20s [median 26.0; K-W, χ2 (n = 1608) = 0.59,
df = 2, P = 0.74], with no provincial differences. The median
number of psychiatric hospitalizations prior to the index
verdict of NCRMD was 2.0 [K-W, χ2 (n =1585) = 1.466,
www.LaRCP.ca
The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 2: The People Behind the Label
Table 1A Sociodemographic characteristics
Sociodemographic
characteristic
British Columbia
Ontario
Quebec
33 (14.9)
81 (16.7)
166 (15.2)
Female
Male
Total
0.71, 2, 1799, 0.70
Sex, n (%)
Age, years, mean (SD)
χ2, df, n, P
189 (85.1)
403 (83.3)
927 (84.8)
36.12 (12.45)
37.19 (12.01)
36.37 (12.59)
280 (15.6)
1519 (84.4)
2.41,a 2, 1989, 0.30
36.56 (12.42)
1.71, 2, 1266, 0.42
High school completed, n (%)
Yes
112 (53.3)
215 (48.3)
296 (48.4)
623 (49.2)
No
98 (46.7)
230 (51.7)
315 (51.6)
644 (50.8)
In a relationship
37 (16.7)
85 (19.9)
149 (14.8)
Single
185 (83.3)
343 (80.1)
857 (85.2)
5.61, 2, 1656, 0.06
Civil or marital status, n (%)
271 (16.4)
1385 (83.6)
—
Language, n (%)
English
175 (83.3)
412 (86.2)
199 (33.7)
786 (61.4)
French
2 (1.0)
20 (4.2)
323 (54.6)
345 (27.0)
33 (15.7)
46 (9.6)
69 (11.7)
Other
148 (11.6)
6.30, 2, 1130, 0.04b
Country of birth, n (%)
Canada
157 (73.0)
267 (65.6)
322 (63.4)
Other
58 (27.0)
140 (34.4)
186 (36.6)
746 (66.0)
384 (34.0)
95.80, 8, 1562, 0.001c
Residential status, n (%)
Living alone
62 (29.4)
83 (20.7)
348 (36.6)
493 (31.5)
Living with spouse, family or
friends
93 (44.0)
200 (49.9)
392 (41.3)
686 (43.9)
Supervised setting
12 (5.7)
41 (10.2)
78 (8.2)
131 (8.4)
144 (9.2)
Homeless
20 (9.5)
21 (5.2)
103 (10.8)
Other
24 (11.4)
56 (14.0)
29 (3.1)
109 (7.0)
13.81, 4, 1374, 0.008
Income, n (%)
d
Own paid work (or partner)
35 (17.1)
47 (15.3)
135 (15.7)
217 (15.8)
Pension and (or) welfare
137 (67.2)
207 (67.2)
639 (74.1)
983 (71.5)
Other
32 (15.7)
54 (17.5)
88 (10.2)
174 (12.7)
Totals do not always add up to 1800 owing to weighting of data.
a
Kruskal-Wallis
b
Country of birth: Quebec and British Columbia χ2 (n = 723) = 6.28, df = 2, P = 0.01
Residential status: Ontario and Quebec χ2 (n = 1351) = 91.53, df = 4, P < 0.001; Quebec and British Columbia χ2 (n = 1161) = 30.81,
df = 4, P < 0.001; Ontario and British Columbia χ2 (n = 612) = 13.08, df = 4, P = 0.01
c
d
Income: Ontario and Quebec χ2 (n = 1170) = 11.55, df = 2, P = 0.003
— = Statistical analyses could not be conucted because n is too small
df = 2, P = 0.48]. Among those people with a psychiatric
history, the median number of psychiatric admissions was
3.0 [K-W, χ2 (n =1143) = 4.318, df = 2, P = 0.12].
Criminological Characteristics
Index Offence
There were statistically significant differences in the index
offences across provinces [χ2 (n = 1802) = 87.03, df = 22,
P < 0.001] (Table 1B). Quebec had a lower median offence
severity (median 77.38; mean 263.25; SD 886.29) than
Ontario (median 88.41; mean 533.65; SD 1433.63) or British
Columbia (median 88.41; mean 525.21; SD 1515.90) [K-W
www.TheCJP.ca
χ2 (n = 1989) = 31.71, df = 2, P < 0.001]. Please refer to
Part 1 for a detailed explanation of the severity of offence
calculation.7
Offences against the person accounted for 64.9% of index
offences, property offences for 16.9%, and other Criminal
Code violations for 18.2%. Assaults represented onequarter to one-third of all index offences in the 3 provinces.
Among all assaults, aggravated assaults accounted for
18.3%, assaults with a weapon or causing bodily harm for
51.0%. Quebec had a higher proportion of minor assaults
(22.7%) than Ontario (12.6%) or British Columbia (12.3%)
[χ2 (n = 478) = 17.45, df = 4, P = 0.002].
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 109
National Trajectory Project
Table 1B Index offence
British Columbia
n (%)
Ontario
n (%)
Quebec
n (%)
χ2, df, n, P
Total
n (%)
Causing death and (or)
attempting
18 (8.1)
56 (11.6)
50 (4.6)
26.22, 2, 1800, <0.001e
124 (6.9)
Sex offences
4 (1.8)
18 (3.7)
19 (1.7)
6.18, 2, 1800, 0.045f
41 (2.3)
Most severe index offence
73 (32.9)
127 (26.2)
278 (25.4)
5.32, 2, 1800, 0.07
478 (26.5)
Deprivation of freedom
5 (2.2)
12 (2.5)
16 (1.5)
2.18, 2, 1800, 0.34
33 (1.8)
Threats and (or) other
offences against person
51 (23.0)
124 (25.6)
318 (29.0)
4.57, 2, 1800, 0.10
493 (27.4)
Property offences
30 (13.5)
52 (10.7)
222 (20.2)
23.85, 2, 1800, <0.001h
304 (16.9)
Offensive weapons
22 (9.9)
38 (7.9)
50 (4.6)
12.66, 2, 1800, 0.002i
110 (6.1)
Administration of justice
Assaults
g
2 (0.9)
26 (5.4)
55 (5.0)
8.02, 2, 1800, 0.02
83 (4.6)
Disturbing the peace
0 (0)
2 (0.4)
6 (0.5)
—
8 (0.4)
Drug possession and (or)
trafficking
0 (0)
1 (0.2)
1 (0.1)
—
2 (0.1)
Dangerous driving and (or)
motor vehicle
12 (5.4)
11 (2.3)
38 (3.5)
4.62, 2, 1800, 0.10k
61 (3.4)
Other federal and (or)
provincial statutes
5 (2.3)
17 (3.5)
43 (3.9)
1.51, 2, 1800, 0.47
65 (3.6)
j
Totals do not always add up to 1800 owing to weighting of data. There were no cases of prostitution or gambling as the index offence,
explaining the absence of category 7 offences.
e
Causing death or attempting: Quebec < Ontario χ2 (n = 1578) = 26.24, df = 1, P < 0.001; Quebec < British Columbia
χ2 (n = 1316) = 4.71, df = 1, P = 0.03
Sex offences: Quebec < Ontario χ2 (n = 1578) = 5.76, df = 1, P = 0.02
f
g
Assaults: Quebec < British Columbia χ2 (n = 1316) = 5.27, df = 1, P = 0.02
h
Property: Ontario < Quebec χ2 (n = 1578) = 21.32, df = 1, P < 0.001; British Columbia < Quebec χ2 (n = 1316) = 5.48, df = 1,
P = 0.02
i
Offensive weapons: Quebec < Ontario χ2 (n =1578) = 6.86, df = 1, P = 0.009; Quebec < British Columbia
χ2 (n = 1316) = 10.17, df = 1, P = 0.001
j
Administration of justice: British Columbia < Quebec χ2 (n = 1316) = 7.58, df = 1, P = 0.006; British Columbia < Ontario
χ2 (n = 706) = 7.99, df = 1, P = 0.005
k
Dangerous driving: Ontario < British Columbia χ2 (n = 706) = 4.74, df = 1, P = 0.03
— = Statistical analyses could not be conducted because n is too small
Homicide and attempted murder accounted for less than 7%
of all index NCRMD verdicts. These crimes represented a
lower proportion of index offences in Quebec. Offences
leading to death were rare, accounting for 3.2% (n = 58)
of all index offences (5.4% in British Columbia, 5.4%
in Ontario, and 1.8% in Quebec [χ² (n = 1800) = 17.38;
df = 2/1800, P < 0.001]. Sex offences represented a higher
proportion of NCRMD index offences in Ontario than in
Quebec and British Columbia. Quebec had a higher proportion
of property offences than both Ontario and British Columbia.
British Columbia had a lower rate of administration of justice
offences than both Ontario and Quebec.
Victims
Males were victims in slightly more than one-half of the
cases involving crimes against a person (n = 559; 53.3%),
equally so across the 3 provinces [χ2 (n = 1048) = 0.80, df =
2, P = 0.67] (Table 3). Family members (including partners)
were the most likely victims of index NCRMD offences
against the person, followed by professionals, strangers,
110 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
and other people known to the accused. Among family
members, parents were the most frequent victims, followed
closely by partners or spouses. The children of NCRMD–
accused people were the victims of offences against people
in less than 3% of cases. There were important differences
in the distribution of accused people’s relationships to the
victims by type of index offence [χ2 (n = 1083) = 98.27,
df = 12, P < 0.001]. In particular, family members or
partners and ex-partners were more likely to be victims
when the index offence caused or attempted to cause death
(n = 73; 60.8%) or with offences related to deprivation of
freedom (n = 14; 43.8%). Strangers tended to be the most
likely victims for sexual offences (n = 22; 55.0%). For cases
of assault, professionals (n = 30.7%) were victims one-third
of the time, as were family members (n = 143; 31%).
Criminal History
Among the total sample, one-half had previously been
convicted or found NCRMD; one-third for an offence
against the person and less than one-half for other offences
www.LaRCP.ca
The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 2: The People Behind the Label
Table 2 Mental health characteristics
British Columbia
n (%)
Ontario
n (%)
Quebec
n (%)
χ2, df, n, P
Psychotic spectrum disorder
170 (76.5)
380 (79.7)
718 (65.9)
34.27, 2, 1788, 0.001a
1268 (70.9)
Mood spectrum disorder
41 (18.5)
67 (14.0)
306 (28.1)
40.07, 2, 1787, 0.001
414 (23.2)
11 (5.0)
30 (6.3)
65 (6.0)
0.49, 2, 1788, 0.78
106 (5.9)
87 (39.2)
151 (31.7)
312 (28.7)
9.80, 2, 1787, 0.007c
550 (30.8)
Mental health characteristics
Total
n (%)
Primary diagnosis
Others
SUD
b
PD
21 (9.5)
58 (12.2)
111 (10.2)
1.70, 2, 1787, 0.43
190 (10.6)
SMI + SUD
83 (37.4)
139 (29.1)
294 (27.0)
9.67, 2, 1787, 0.008d
516 (28.9)
SMI + PD
20 (9.0)
52 (10.9)
97 (8.9)
1.59, 2, 1787, 0.45
169 (9.5)
205 (92.3)
348 (71.9)
483 (44.2)
230.71, 2, 1800, <0.001e
1036 (57.6)
Hallucinations—specified
83 (37.4)
115 (23.8)
159 (14.5)
67.04, 2, 1800, <0.001f
357 (19.8)
Delusions—specified
Mental state at time of offence
Any psychotic symptom
174 (78.4)
257 (53.1)
399 (36.5)
143.44, 2, 1800, <0.001
Suicidal ideation
22 (9.9)
24 (5.0)
68 (6.2)
6.35, 2, 1800, 0.04h
g
830 (46.1)
114 (6.3)
Suicide attempt
14 (6.3)
11 (2.3)
6 (0.5)
37.33, 2, 1800, <0.001
Self-harm
6 (2.7)
20 (4.1)
4 (0.4)
30.67, 2, 1799, <0.001j
Homicidal ideation
16 (7.2)
75 (15.5)
18 (1.6)
113.74, 2, 1800, <0.001
Substance use and (or)
under the influence
53 (23.9)
105 (21.7)
259 (23.6)
0.71, 2, 1800, 0.70
31 (1.7)
i
30 (1.7)
k
109 (6.1)
415 (23.1)
Weights were used to ensure the regional representativeness of the Quebec sample, thus totals will not always add to 1800 or 100%.
a
Psychotic spectrum disorder: Ontario > Quebec χ2 (n = 1566) = 29.85, df = 1, P < 0.001; British Columbia > Quebec
χ2 (n = 1311) = 9.56, df = 1, P = 0.002
b
Mood spectrum disorder: Quebec > Ontario χ2 (n = 1565) = 36.21, df = 1, P < 0.001; Quebec > British Columbia
χ2 (n = 1310) = 8.83, df = 1, P = 0.003
SUD: British Columbia > Quebec χ2 (n = 1310) = 9.62, df = 1, P = 0.002; British Columbia > Ontario χ2 (n = 699) = 3.83, df = 1,
P = 0.05
c
d
SMI and SUD: British Columbia > Quebec χ2 (n = 1310) = 9.67, df = 1, P = 0.002; British Columbia > Ontario χ2 (n = 699) = 4.75,
df = 1, P = 0.03
e
Any psychotic symptom: British Columbia > Ontario χ2 (n = 706) = 37.46, df = 1, P < 0.001; British Columbia > Quebec
χ2 (n = 1315) = 171.50, df = 1, P < 0.001; Ontario > Quebec χ2 (n = 1577) = 103.34, df = 1, P < 0.001
f
Hallucinations: British Columbia > Ontario χ2 (n = 706) = 14.01, df = 1, P < 0.001; British Columbia > Quebec χ2 (n = 1316) = 64.23,
df = 1, P < 0.001; Ontario > Quebec χ2 (n = 1578) = 19.91, df = 1, P < 0.001
g
Delusions: British Columbia > Ontario χ2 (n = 706) = 40.90, df = 1, P < 0.001; British Columbia > Quebec χ2 (n = 1318) = 131.84,
df = 1, P < 0.001; Ontario > Quebec χ2 (n = 1578) = 38.19, df = 1, P < 0.001
h
Suicidal ideation: British Columbia > Ontario χ2 (n = 706) = 6.13, df = 1, P = 0.01; British Columbia > Quebec χ2 (n = 1316) = 3.95,
df = 1, P = 0.047
i
Suicide attempt: British Columbia > Quebec χ2 (n = 1316) = 40.88, df = 1, P < 0.001; Ontario > Quebec χ2 (n = 1578) = 9.36, df = 1,
P = 0.002
j
Self-harm: British Columbia > Ontario χ2 (n = 706) = 0.88, df = 1, P = 0.35; British Columbia > Quebec χ2 (n = 1318) = 13.35, df = 1,
P < 0.001; Ontario > Quebec χ2 (n = 1577) = 31.75, df = 1, P < 0.001
Homicidal ideation: Ontario > British Columbia χ2 (n = 706) = 9.31, df = 1, P = 0.002; British Columbia > Quebec
χ2 (n = 1316) = 22.68, df = 1, P < 0.001
PD = personality disorder; SMI = serious mental illness; SUD = substance use disorder
k
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The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 111
National Trajectory Project
Table 3 Relationship of victim to NCRMD–accused people for offences against a person
British Columbia
n (%)
Ontario
n (%)
Quebec
n (%)
Total
n (%)
Stranger
35 (23.8)
86 (26.6)
125 (20.4)
246 (22.7)
Professional
31 (21.1)
60 (18.5)
157 (25.6)
248 (22.9)
Victim
20 (13.6)
32 (9.9)
78 (12.7)
130 (12.0)
Mental health worker
9 (6.1)
27 (8.3)
56 (9.1)
92 (8.5)
Other authority figure
2 (1.4)
1 (0.3)
23 (3.8)
26 (2.4)
49 (33.3)
104 (32.1)
212 (34.6)
365 (33.7)
6 (4.1)
7 (2.2)
15 (2.5)
28 (2.6)
Police officer
Family
Offspring
Partner or spouse
13 (8.8)
41 (12.7)
75 (12.2)
129 (11.9)
Parent
18 (12.2)
40 (12.3)
86 (14.0)
144 (13.3)
Other family member
Other known person
Friend or acquaintance
Roommate, coresident, or copatient
Other
Total
12 (8.2)
16 (4.9)
36 (5.9)
64 (5.9)
32 (21.8)
74 (22.8)
119 (19.4)
225 (20.7)
19 (12.9)
41 (12.7)
83 (13.5)
143 (13.2)
4 (2.7)
15 (4.6)
25 (4.1)
44 (4.1)
9 (6.1)
18 (5.6)
11 (1.8)
38 (3.5)
147 (100)
324 (100)
613 (100)
1084 (100)
Statistical test conducted on the 4 main categories, χ2 (n = 1084) = 10.21, df = 6, P = 0.12
(Table 4). More specifically, 46.6% had at least 1 past
conviction. Less than 1 in 10 of our sample had a previous
NCRMD finding (8.2%), with significant differences across
provinces. Among the 148 people with a prior NCRMD
verdict, a higher proportion were male (90.4%, compared
with 83.9%) [χ2 (n = 1800) = 4.41, df = 1, P = 0.04] and
had a diagnosis of SMI with comorbid SUD or personality
disorder (9.2%, compared with 5.1%) [χ2 (n = 1787] =
4.42, df = 1, P = 0.04], a lower proportion were homeless
(9.2%, compared with 17.3%) [χ2 (n = 1561) = 26.42,
df = 1, P < 0.001], and had a paid job (6%, compared with
16.6%) [χ2 (n = 1254) = 9.76, df = 1, P = 0.008] at index
verdict. No differences between groups were observed as
to index offence. British Columbia had the lowest rate of
people with a criminal record, compared with Ontario and
Quebec; Ontario had the highest rate of past convictions,
significantly higher than British Columbia. Ontario also
had a higher rate of prior of offences against the person,
compared with British Columbia and Quebec (Table 4).
Past offenders had a median of 3 (mean 4.99, SD 5.69)
previous convictions and 1 (mean 1.15, SD 0.36) prior
NCRMD finding. NCRMD–accused people in Ontario had
a higher overall number of previous convictions than those
in Quebec [χ2 (n = 926) = 6.75, df = 2, P = 0.03].
The median age at first criminal conviction or NCRMD
finding (including at index offence for people who had no
prior criminal history) in adulthood was 27.0 years (mean
31.03, SD 12.39), with no differences across provinces
[K-W χ2 (n = 1989) = 16.0, df = 2, P = 0.92].
Comprehensiveness of Files
There were significant differences across provinces in the
availability of information in RB files. Missing data on
112 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
education were quite low in British Columbia (5.4%) and
Ontario (8.1%), but quite common in Quebec (44.1%).
Residential status was unavailable in less than 1 in 5 Ontario
files, about 1 in 10 Quebec files and 1 in 20 British Columbia
files. Similarly, source of income was unavailable in more
than one-third of Ontario files, followed by one-fifth of
Quebec files and only less than one-tenth of British Columbia
files. British Columbia files also tended to contain more
background information about NCRMD–accused people’s
mental health histories than those in Ontario and Quebec.
Among the 12 items surveyed in the current analyses, there
was a median of 2 missing values (mean 2.35, SD 1.91),
with a significant difference across provinces [K-W χ²
(n = 1989) = 493.878, df = 2, P < 0.001]. Quebec files had a
higher level of unavailable information (median 3, mean 2.98,
SD 1.91) than Ontario (median 2, mean 1.78, SD 1.48) [K-W
χ² (n = 1767) = 174.10, df = 1, P < 0.001] and British Columbia
(median 0.0, mean 0.46, SD 0.88) [K-W χ² (n = 1505) = 372.75,
df = 1, P < 0.001]. Files from Ontario had a higher occurrence
of unavailable information than British Columbia [K-W χ²
(n = 706) = 178.58, df = 1, P < 0.001].
Modelling Provincial Differences
A multinomial logistic regression was used as a
multivariate model to explain profiles of NCRMD–
accused people by province (Table 5). All variables with
fewer than 10% missing data were entered: sex, age at
the index offence, diagnosis, Aboriginal status, prior
NCRMD finding, prior criminal history (NCRMD finding
or conviction), past offence against people, age at first
offence, age at first violent offence, and most severe index
offence. The listwise sample had on 1575 cases (missing
12.6%). Because some offences were uncommon, only
www.LaRCP.ca
The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 2: The People Behind the Label
Table 4 Criminal history
British Columbia
n (%)
Ontario
n (%)
Quebec
n (%)
χ2, df, n, P
Total
n (%)
Any prior conviction or NCRMD
finding
92 (41.4)
256 (52.9)
538 (49.2)
7.99, 2, 1800, 0.02a
886 (49.2)
Prior offence against person
52 (23.4)
182 (37.6)
322 (29.4)
17.10, 2, 1800, <0.001b
556 (30.9)
Other prior offence
82 (36.9)
217 (44.8)
454 (41.5)
4.03, 2, 1800, 0.13c
753 (41.8)
Any prior conviction
89 (40.1)
243 (50.2)
506 (46.3)
6.36, 2, 1800, 0.04
838 (46.6)
Any prior NCRMD finding
10 (4.5)
30 (6.2)
108 (9.9)
10.64, 2, 1800, 0.005e
Criminal history
d
148 (8.2)
a
Any prior conviction or NCRMD finding: Ontario > British Columbia χ2 (n = 706) = 7.98, df = 1, P = 0.005; Quebec > British Columbia
χ2 (n = 1316) = 4.43, df = 1, P = 0.04
b
Any prior conviction or NCRMD finding—offence against person: Ontario > Quebec χ2 (n = 1578) = 10.30, df = 1, P < 0.001;
Ontario > British Columbia χ2 (n = 706) = 13.81, df = 1, P < 0.001
Any prior conviction or NCRMD finding—other offence: Ontario > British Columbia χ2 (n = 706) = 3.88, df = 1, P = 0.049
c
d
Any prior conviction: Ontario > British Columbia χ2 (n = 706) = 6.25, df = 1, P = 0.01
e
Any prior NCRMD finding: Quebec > British Columbia χ2 (n = 1316) = 6.51, df = 1, P = 0.01; Quebec > Ontario χ2 (n = 1578) = 5.67,
df = 1, P = 0.02
NCRMD = not criminally responsible on account of mental disorder; PD = personality disorder
Table 5 Multinomial logistic regression for NCRMD provincial characteristics (n = 1575)
Ontario, compared with
Quebeca
British Columbia,
compared with Quebeca
Ontario, compared with
British Columbiaa
Predictor
OR
OR
OR
Female
1.29
(0.92 to 1.80)
1.04
(0.65 to 1.68)
1.23
(0.75 to 2.03)
Aboriginal status
3.15
(1.50 to 6.59)b
5.20
(2.30 to 11.76)c
0.61
(0.29 to 1.25)
Age at the index offence
0.99
(0.96 to 1.01)
0.99
(0.95 to 1.03)
1.00
(0.96 to 1.04)
(95% CI)
(95% CI)
(95% CI)
Diagnosis (nonexclusive)
Psychosis
1.16
(0.71 to 1.92)
1.60
(0.75 to 3.40)
0.73
(0.33 to 1.61)
Mood
0.46
(0.26 to 0.80)b
0.56
(0.24 to 1.31)
0.81
(0.33 to 2.00)
SUD
1.21
(0.93 to 1.58)
1.87
(1.32 to 2.66)c
0.65
(0.44 to 0.94)d
PD
1.14
(0.79 to 1.66)
0.85
(0.49 to 1.47)
1.35
(0.76 to 2.40)
Presence of psychiatric history
1.05
(0.81 to 1.36)
1.18
(0.82 to 1.68)
0.89
(0.61 to 1.31)
Age at first offence against person
1.02
(0.99 to 1.05)
1.02
(0.98 to 1.06)
1.01
(0.96 to 1.05)
NCRMD
0.40
(0.25 to 0.64)c
0.33
(0.15 to 0.73)b
1.19
(0.51 to 2.77)
Criminal
0.91
(0.65 to 1.28)
0.81
(0.52 to 1.27)
1.13
(0.69 to 1.85)
Against person
2.01
(1.34 to 3.03)
b
1.07
(0.59 to 1.93)
1.88
(1.00 to 3.54)
Homicides or attempted
2.08
(1.25 to 3.41)b
1.89
(0.91 to 3.95)
1.10
(0.52 to 2.30)
Assault and sexual assaults
0.88
(0.61 to 1.27)
1.41
(0.82 to 2.42)
0.62
(0.36 to 1.10)
Other crimes against persono
0.74
(0.51 to 1.06)
0.97
(0.56 to 1.70)
0.76
(0.42 to 1.35)
Property crimes
0.41
(0.25 to 0.70)
0.70
(0.35 to 1.41)
0.59
(0.27 to 1.27)
Presence of criminal history
Index—most severe offence (others as
reference)
c
–2 Log Likelihood = 2560.22; χ2 = 169.78; df = 32, P < 0.001; Nagelkerke pseudo-R² = 12.2%; proportional chance criteria = 47.8%;
model accuracy rate = 61.5%
a
Reference category; b P < 0.01;
c
P < 0.001; d P < 0.05
NCRMD = not criminally responosible on account of mental disorder
www.TheCJP.ca
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 113
National Trajectory Project
murder or attempted murder, assaults and sexual assaults,
other offences against a person, and property offences
were included. All other offences were collapsed into an
other category, which was used as the reference for this
variable.
This model resulted in an accuracy rate of 61.5%, that
is 29% higher than expected by chance (47.8%; –2 Log
likelihood = 2602.28) [χ² (n = 1575) = 163.83, df = 32,
P < 0.001]. As was observed in the univariate analyses,
there were no interprovincial differences regarding sex or
age at index offence. People with an Aboriginal status were
3.15 times more likely to come from Ontario than Quebec
and 5.20 times more likely to come from British Columbia
than Quebec. As for diagnosis, NCRMD–accused people
diagnosed with an SUD were 1.87 times more likely to come
from British Columbia than Quebec and 1.54 times less
likely to come from Ontario than British Columbia. People
with a mood disorder were 2.17 times less likely to come
from Ontario than from Quebec. No provincial differences
were observed for age at first offence against a person.
People with a past NCRMD verdict were 2.50 and 3.03 times
more likely to come from Quebec than Ontario and British
Columbia, respectively. People with a past offence against
a person were twice more likely to come from Ontario,
compared with Quebec. NCRMD–accused people who had
committed homicide as the index offence were 2.08 times
more likely to come from Ontario than from Quebec. People
who committed property offences were 2.43 times less likely
to come from Ontario than from Quebec.
Discussion
Characteristics of NCRMD–Accused People:
Debunking a Few Myths
In stark contrast to the manner in which people with
mental illness are often portrayed in the media16 and the
misrepresentation of NCRMD–accused people, homicides and
attempted murder account for less than 1 in 10 NCRMD index
offences across provinces. Our study demonstrates that many
people (about one-half) have had no prior contact with the
criminal justice system. Prior NCRMD findings are particularly
uncommon (8.2%). Further, rates of NCRMD–accused people
from the Aboriginal population are far lower than usually
found in the criminal justice system,17,18 suggesting the
NCRMD defence is dramatically underused for this minority
group. This could reflect the lower access to appropriate legal
representation, a general bias in the attribution of criminal
intent or the possibility that Aboriginal people with an SMI are
less likely to get into the criminal justice system. Less than 1
in 10 people found NCRMD was homeless. Despite extensive
histories of mental health and criminal justice contacts few
were NCRMD accused were in supervised residences at the
time of the offence.
Interprovincial Differences
Overall, few differences were observed between Ontario
and British Columbia, the exception being that British
114 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
Columbia cases had a higher rate of SUDs. With higher
rates of NCRMD verdicts and lower general provincial
crime statistics,19 it is not surprising that the NCRMD
population in Quebec is more heterogeneous in terms
of index offences and diagnoses. In addition to those
previously provided,7 there are at least 2 other plausible
explanations to account for these interprovincial
differences: first, Quebec is less likely than Ontario and
British Columbia to limit the NCRMD defence to the most
serious offences. This is in line with the legislation, which
does not preclude any type of offence being associated
with an NCRMD finding. Second, it is also in Quebec
that the most variability in diagnosis is found. This may
indicate clinicians and the judiciary are using a more
liberal20 operationalization of Section 16 of the Criminal
Code than in other provinces.
The implications of these interprovincial differences are
potentially wide-ranging. It can be argued that people with
mental illness who come into conflict with the law are
best served by the forensic system, where mental health
professionals equipped with expertise in risk assessment
and treatment of often comorbid SMI may have advantages
over services in civil mental health settings or in correctional
settings. Conversely, one may conclude we are seeing
evidence of criminalization of people with mental illness.
Does the variability and increasing rate of NCRMD findings
point to a need for more pre-arrest diversion programs for
people accused of minor offences?
Implications
What is glaringly apparent from these findings is that most
people found NCRMD had been under the purview of civil
psychiatric services, with a median of 2 prior psychiatric
hospitalizations. Their first psychiatric consultation
occurred much earlier than their index NCRMD verdict.
This suggests that violence risk assessment training and
interventions to reduce further mental health deterioration
and criminal offending are a priority in civil psychiatric
services.
As was previously observed,5 2 out of 3 index offences of
NCRMD accused are for offences against the person, but
with a wide range of severity. Assaults represented onequarter of all index offences. As many as one-half of all
NCRMD findings are for minor assaults, property offences
and (or) other nonviolent Criminal Code violations. We
found that among all offences against a person, family
members are the most frequent victims, in line with other
studies of victims of violence perpetrated by people with
a mental illness.21,22 This emphasizes the importance of
supporting family members of people with SMI, as both
potential helpers and potential victims.
Finally, the heterogeneity of the NCRMD population
indicates that forensic services are seeing diverse groups
of individuals who do not necessarily mix well.3,23 For
example, we must be careful to monitor the potential
victimization, bullying, and manipulation of people with
www.LaRCP.ca
The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 2: The People Behind the Label
active symptoms of SMI and low antisocial traits by those
with pervasive antisocial personality traits and low levels of
mental health problems.23
Strengths and Limitations
This is the first multi-provincial, longitudinal, regionally
representative sample of a cohort of people found NCRMD
in the 3 largest provinces in Canada. It is also the first study
to delve into RB file content across jurisdictions and to
obtain criminal records for a large sample of NCRMD–
accused people. The most important limitation of this
research relates to it being archival and thus more likely
to generate more missing information than face-to-face
contacts with systematic assessment tools. For instance,
we were reliant on diagnostic information provided to
the courts at a time when the focus is likely very much
on psychotic symptoms, and thus the prevalence of other
diagnoses, such as personality disorders or posttraumatic
stress disorder, are perhaps underreported.24 However,
missing information can be treated as a result relevant to
RB processing, because it is an indication of the information
available to RBs.7 The data reflect the NCRMD populationo
entering the RB system from the year 2000 to 2005. There
may be cohort differences, despite the lack of significant
legislative changes during the study period. For a more indepth discussion of the strengths and limitations of the NTP,
readers are directed to our previous publication.7
Future Directions
Research is needed in the courts to better understand the
decision to raise an NCRMD defence and the process
affecting these verdicts. Differences in availability of
information across RBs point to the potential value of
a national minimal data protocol. This would provide
greater opportunity not only to monitor changes of the RB
population over time but also to evaluate the effects of legal
and mental health policy changes. Finally, as families are
often the victims when violence occurs, further research is
clearly needed to better understand prevention strategies
and to address the needs of families following offences by
people found NCRMD.
Acknowledgements
This research was consecutively supported by grant
#6356-2004 from Fonds de recherche Québec—Santé
(FRQ-S) and by the Mental Health Commission of Canada
(MHCC). Dr Crocker received consecutive salary awards
from the Canadian Institutes of Health Research (CIHR),
FRQ-S, and a William Dawson Scholar award from McGill
University while conducting this research. Dr Nicholls
acknowledges the support of the Michael Smith Foundation
for Health Research and the CIHR for consecutive salary
awards. Yanick Charette acknowledges the support of
the Social Sciences and Humanities Research Council of
Canada in the form of a doctoral fellowship.
This study could not have been possible without the full
collaboration of the Quebec, British Columbia, and Ontario
www.TheCJP.ca
RBs, and their respective registrars and chairs. We are
especially grateful to attorney Mathieu Proulx, Bernd
Walter, and Justice Douglas H C arruthers and Justice
Richard Schneider, the Quebec, British Columbia, and
consecutive Ontario RB chairs, respectively.
The authors sincerely thank Erika Jansman-Hart and
Dr Cathy Wilson, Ontario and British Columbia
coordinators, respectively, as well as our dedicated research
assistants who coded RB files and Royal Canadian Mounted
Police criminal records: Erika Braithwaite, Dominique
Laferrière, Catherine Patenaude, Jean-François Morin,
Florence Bonneau, Marlène David, Amanda Stevens,
Stephanie Thai, Christian Richter, Duncan Greig, Nancy
Monteiro, and Fiona Dyshniku.
Finally, the authors extend their appreciation to the members
of the Mental Health and the Law Advisory Committee
of the MHCC, in particular Justice Edward Ormston and
Dr Patrick Baillie, consecutive chairs of the committee as
well as the NTP advisory committee for their continued
support, advice, and guidance throughout this study and the
interpretation of results.
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treatment of maximum security psychiatric patients. Behav Sci Law.
1988;6(4):497–514.
24. Cardinal C, Côté G. La clientèle psychiatrie-justice au Centre de
détention Rivières-des-Prairies et à l’Institut Philippe Pinel de Montréal.
Montreal (Quebec): Centre de recherche de l’Institut Philippe Pinel de
Montréal et Centre de recherche Fernand-Séguin; 2003.
th Annual Conference
e Congrès annuel
1 - 3 October / octobre 2015
The Fairmont Hotel Vancouver &
Hyatt Regency Vancouver
Vancouver BC
Canadian Psychiatric Association
Dedicated to quality care
Association des psychiatres du Canada
www.cpa-apc.org
116 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
Dévouée aux soins de qualité
www.LaRCP.ca
CanJPsychiatry 2015;60(3):117–126
National Trajectory Project
The National Trajectory Project of Individuals Found Not
Criminally Responsible on Account of Mental Disorder in
Canada. Part 3: Trajectories and Outcomes Through the
Forensic System
Anne G Crocker, PhD1; Yanick Charette, MSc (PhD Candidate)2; Michael C Seto, PhD3;
Tonia L Nicholls, PhD4; Gilles Côté, PhD5; Malijai Caulet, PhD6
1
Associate Professor, Department of Psychiatry, McGill University, Montreal, Quebec; Associate Director, Policy and Knowledge Exchange,
Douglas Mental Health University Institute Research Centre, Montreal, Quebec.
Correspondence: Douglas Mental Health University Institute Research Centre, 6875 LaSalle Boulevard, Montreal, QC H4H 1R3; [email protected].
2
Post-doctoral Fellow, Department of Sociology, Yale University, New Haven, Connecticut; Student, Department of Criminology, Université de Montréal,
Montreal, Quebec.
3
Director of Forensic Rehabilitation Research, Royal Ottawa Health Care Group, Brockville, Ontario.
4
Associate Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia; Senior Research Fellow,
Forensic Psychiatric Services Commission, BC Mental Health & Substance Use Services, Coquitlam, British Columbia.
5
Professor, Department of Psychology, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec; Director, Philippe-Pinel Institute Research Centre,
Montreal, Quebec.
6
National Coordinator, National Trajectory Project, Douglas Mental Health University Institute Research Centre, Montreal, Quebec.
Key Words: forensic mental
health, National Trajectory
Project, not criminally
responsible on account of
mental disorder, mental
disorder, criminality, violence,
review roard, recidivism,
trajectory
Manuscript received May 2014,
revised, and accepted July
2014.
open
access
Objective: To examine the processing and Review Board (RB) disposition outcomes of
people found not criminally responsible on account of mental disorder (NCRMD) across the
3 most populous provinces in Canada. Although the Criminal Code is federally legislated,
criminal justice is administered by provinces and territories. It follows that a person with
mental illness who comes into conflict with the law and subsequently comes under the
management of a legally mandated RB may experience different trajectories across
jurisdictions.
Method: The National Trajectory Project examined 1800 men and women found NCRMD
in British Columbia (n = 222), Quebec (n = 1094), and Ontario (n = 484) between May 2000
and April 2005, followed until December 2008.
Results: We found significant interprovincial differences in the trajectories of people found
NCRMD, including time detained in hospital and time under the supervision of an RB. The
odds of being conditionally or absolutely discharged by the RB varied across provinces,
even after number of past offences, diagnosis at verdict, and most severe index offence (all
covariates decreased likelihood of discharge) were considered.
Conclusions: Considerable discrepancies in the application of NCRMD legislation and the
processing of NCRMD cases through the forensic system across the provinces suggests
that fair and equitable treatment under the law could be enhanced by increased national
integration and collaboration.
WWW
Projet national des trajectoires des personnes déclarées non
criminellement responsables pour cause de troubles mentaux au
Canada. Partie 3 : Trajectoires et résultats au sein du système
médicolégal
Objectif : Examiner les résultats du processus et des dispositions de la Commission
d’examen (CE) pour les personnes déclarées non criminellement responsables pour cause
de troubles mentaux (NCRTM) dans les 3 provinces les plus populeuses du Canada. Le
Code criminel relève de la compétence du gouvernement fédéral, mais la justice pénale
est administrée par les provinces et territoires. Il s’ensuit qu’une personne ayant un
trouble mental qui a des démêlés avec la justice et qui est subséquemment placée sous la
supervision d’une CE peut connaître différentes trajectoires dans différentes juridictions ou
régions ou provinces.
www.TheCJP.ca
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 117
National Trajectory Project
Méthode : Le Projet national des trajectoires a permis d’examiner 1800 hommes et femmes déclarés
NCRTM en Colombie-Britannique (n = 222), au Québec (n = 1094) et en Ontario (n = 484) de mai
2000 à avril 2005, et de les suivre jusqu’en décembre 2008.
Résultats : Nous avons constaté des différences interprovinciales significatives dans les trajectoires
des personnes déclarées NCRTM, notamment le temps de détention dans un hôpital et le temps
sous la supervision d’une CE. Les probabilités d’une libération conditionnelle ou absolue accordée
par la CE variaient entre les provinces, même après examen du nombre d’infractions passées,
du diagnostic au verdict, et des infractions répertoriées les plus graves (toutes les covariables
réduisaient la probabilité d’une libération).
Conclusions : Les écarts considérables dans l’application de la législation NCRTM et dans le
traitement des cas NCRTM au sein du système psycho-olégal entre les provinces suggèrent qu’un
traitement juste et équitable en vertu de la loi pourrait être amélioré par une plus grande intégration et
collaboration nationale.
T
here have been increasing demands for forensic mental
health services abroad1 and in Canada,2,3 though with
variability across provinces.3 In Canada, provincial and
territorial RBs are charged with the dispositions of people
found NCRMD.
Although the Criminal Code is federally legislated,
criminal justice and mental health services are administered
provincially. Our research revealed provincial differences in
forensic patient characteristics.4 It follows that the trajectories
of people found NCRMD through the forensic mental health
and RB systems may also vary from province to province.5
Clinical Implications
•
The findings suggest some important cross-provincial
differences in the processing of people found NCRMD,
indicating that the implementation of federal law by
provincial services could benefit from increased national
collaboration.
•
Number of previous offences, psychotic disorder at
verdict, more severe index offence, and being under the
purview of the province of Ontario’s RB all decreased
the likelihood of conditional or absolute discharge for
NCRMD–accused people.
•
Duration under the purview of the RB has potentially
important implications in the mental health system
regarding patient bed-flow management, forensic
population volume, and resource intensity.
Review Board Dispositions
Dispositions
The dispositions of people found NCRMD are determined
by the Court making the verdict or by RBs. The 3 options
are as follows: detention in hospital; conditional discharge,
which usually means living in the community under specified
conditions; and absolute discharge. The courts tend to defer
the disposition to the RB (82.2% of cases),6 and the RBs tend
to rely heavily on the recommendations of psychiatrists.7,8 It
is rare for NCRMD–accused people to receive an absolute
discharge as their first disposition.6,7,9 Whittemore7 reported
that none of the psychiatrists in her British Columbia study
of 122 persons found NCRMD recommended an absolute
discharge at the initial hearing. Based on their national
data, Latimer and Lawrence2 reported that the likelihood
of receiving an absolute discharge at the initial hearing was
greater for nonviolent offences (16.4%) than for sexual
(9.6%) or violent offences (7.9%).
Limitations
•
Our study only addressed 3 Canadian provinces and
examined data from 2000 to 2008, thus generalizability
to other provinces and territories and present practices
may be limited.
•
Future analyses will examine the risk factors brought to
the RB for rendering their dispositions.
•
The reliance on archival files may miss information
that was not systematically recorded at the time.
Prospective studies collecting data that directly address
the research questions are needed.
Detention Duration
Whittemore7 found the rate of absolute discharges increased
from 0% at the first hearing to 11% at the second hearing.
This remained fairly consistent across the next several
hearings before dropping to near zero at the eighth and ninth
hearings. Canadian studies have found that seriousness of
the offence leading to the NCRMD verdict is associated with
duration of detention6 and total duration under RB2 (including
conditional discharge). Severity of index offence often has
been associated with maintenance of a detention disposition
in Canada and the United States.8,10–13 However, jurisdictional
factors may be at play,14 and need to be explored across the
country with a representative sample of NCRMD–accused
people. As well, the types of conditions imposed by RBs for
conditional discharge and detention disposition needs to be
considered to better understand the trajectories of NCRMD–
accused people through forensic mental health systems.
Abbreviations
Objectives
NCRMD not criminally responsible on account of mental disorder
RB
review board
118 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
Given differences in the profiles of NCRMD–accused
people across the provinces,4 in addition to provincial
differences in criminal justice processes and organization of
www.LaRCP.ca
The National Trajectory Project of Individuals Found NCRMD in Canada. Part 3: Trajectories and Outcomes Through the Forensic System
forensic services,3,5 our study aims to compare and contrast
the processing of and disposition outcomes for people
found NCRMD across provinces.
Methods
The study methods are described in more detail in our
previous paper in this special issue.3 Briefly, a archival
file-based retrospective longitudinal study design was
used to assess the processing of a cohort of people under
the purview of the provincial RBs in British Columbia,
Ontario, and Quebec. The end of data collection allowed
for a minimum of 3 years of post-NCRMD verdict followup time for all cases.
Sample
The sample was comprised of new NCRMD–accused
people entering the RB system in Quebec, British Columbia
between 2000 and 2005.3 Two units of analyses were
used: the NCRMD people and the RB hearings. A total of
1800 people were followed (Quebec, n = 1094; Ontario,
n = 484; British Columbia, n = 222) to assess the initial
disposition given by the Court and their trajectories. These
people were the subject of 6748 RB hearings during the
observation period (Quebec, n = 3509; British Columbia,
n = 1053; Ontario, n = 2186). These hearings were used
to assess the RB decisions, associated conditions, as well
the agreement between clinical recommendations and the
RB decisions. The observation time from index verdict to
end of observation (December 31, 2008) varied between
individuals (between 0 and 8.67 years; mean 5.72, SD 1.48).
Some cases were censored as a result of the participant’s
death (n = 65, 3.61%) or because the individual went
missing (n = 6, 0.33%); that is, their whereabouts were
unknown to the RB (for example, the accused left and had
not returned).
Procedure
Fitness
Previous fitness evaluations and unfitness findings were
coded from RB files. Fitness to stand trial represents
the ability of a defendant to participate in a criminal
proceeding in a basic way, that is, to understand the
nature of the charges, the roles of the various parties, the
consequences of the different plea and verdict options, and
to communicate with their lawyer.1 Someone who is found
unfit to stand trial comes under the jurisdiction of an RB
until they become fit.
Hearing Participants
For each hearing, we coded the people who were present
at the hearings into 1 or more of 9 categories: NCRMD–
accused person, defence lawyer, prosecutor, hospital
representative, psychiatrist, other member of clinical team,
family of the accused, victim, and (or) other (for example,
students, public observers, and patient representatives).
Dispositions and Conditions
www.TheCJP.ca
Decisions by the Court and RB at the initial and subsequent
annual disposition hearings were coded. The content of the
clinical reports to the RB was analyzed for each hearing.
Court and RB dispositions were used to estimate the time
each person spent in detention or conditional discharge up to
absolute discharge or end of observation, whichever came first.
The expert recommendations and RB disposition decisions
were coded, as were disposition conditions according to the
following categories: permission to live in the community;
live in a known place; hospital delegation—section
672.56(1) of the Criminal Code, which states:
A Review Board that makes a disposition in respect
of an accused under paragraph 672.54(b) or (c)
may delegate to the person in charge of the hospital
authority to direct that the restrictions on the liberty
of the accused be increased or decreased within any
limits and subject to any conditions set out in that
disposition, and any direction so made is deemed for
the purposes of this Act to be a disposition made by
the Review Board.15
permission to leave hospital grounds unaccompanied;
permission to leave hospital grounds accompanied;
abstain from alcohol and drug use; follow therapeutic
recommendations; keep the peace; limited or no contact with
victims; no possession of weapons; and other conditions
(for example, abstain from using a motor vehicle).
Analytic Strategy
Weights were used to ensure the regional representativeness
of the Quebec sample.3 Using survival analysis, courts
and RB dispositions were used to estimate the time each
individual spent in detention or on conditional discharge up
to absolute discharge or end of observation, whichever came
first. Survival curves were examined using the Kaplan–
Meier method and Cox proportional hazard regression
models.16 Survival curves and proportional hazard models
were performed using R, version 3.0.2,17 and the survival
package.18
Results
Criminal Court Practices
Fitness Evaluations
Forty-two per cent (n = 760) of the accused had a fitness
evaluation prior to their NCRMD finding, with a higher
proportion in British Columbia (63.5%, n = 141) than
in Ontario (55.6%, n = 269) or Quebec (32%, n = 350)
[χ2 (n = 1232) = 63.72, df = 1, P < 0.001] and in Ontario than
in Quebec [χ2 (n = 1800) = 123.57, df = 2, P < 0.001]. Eight
per cent (n = 152) of NCRMD–accused people were found
unfit to stand trial prior to their NCRMD verdict, with a
higher proportion in Ontario (15%, n = 72) than in Quebec
(6.3%, n = 69) [χ2 (n = 1568) = 30.28, df = 1, P < 0.001]
or British Columbia (5%, n = 11) [χ2 (n = 701) = 14.37,
df = 1, P < 0.001].
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 119
National Trajectory Project
Table 1 People present at the Review Board hearing by province
British Columbia
n = 995
n (%)
Ontario
n = 2185
n (%)
Quebec
n = 3501
n (%)
χ2, df, n, P
Accused
937 (94.2)
2129 (97.4)
3454 (98.7)
66.64, 2, 6681, <0.001a
6520 (97.6)
Accused’s lawyer
948 (95.3)
2100 (96.1)
2279 (65.1)
975.61, 2, 6681, <0.001
5327 (79.7)
Hospital representative
955 (96.0)
2054 (94.0)
1827 (52.2)
1502.67, 2, 6681, <0.001c
Prosecutor
826 (83.0)
2185 (100)
254 (7.3)
5176.76, 2, 6681, <0.001
Psychiatrist
922 (92.7)
1982 (90.7)
3223 (92.1)
4.63, 2, 6681, <0.10
Other professionals
881 (88.5)
122 (5.6)
1556 (44.5)
2108.55, 2, 6681, <0.001e
2559 (38.3)
Family of the accused
1015 (15.2)
Present at the hearing
Total
n = 6681
n (%)
b
d
4836 (72.4)
3265 (48.9)
6127 (91.7)
111 (11.2)
283 (13.0)
621 (17.7)
38.70, 2, 6681, 0.001
Victim
14 (1.4)
50 (2.3)
68 (1.9)
2.78, 2, 6681, 0.25
132 (2.0)
Others
72 (7.2)
139 (6.4)
296 (8.5)
8.61, 2, 6681, 0.01
507 (7.6)
g
f
a
Quebec > Ontario χ2 (n = 5686) = 11.27, df = 1, P = 0.001; Quebec > British Columbia χ2 (n = 4496) = 68.38, df = 1, P < 0.001;
Ontario > British Columbia χ2 (n = 3180) = 21.10, df = 1, P < 0.001
b
Quebec < Ontario χ2 (n = 5686) = 731.00, df = 1, P < 0.001; Quebec < British Columbia χ2 (n = 4496) = 348.37, df = 1, P < 0.001
Quebec < Ontario χ2 (n = 5686) = 1085.89, df = 1, P < 0.001; Quebec < British Columbia χ2 (n = 4496) = 629.97, df = 1, P < 0.001;
Ontario > British Columbia χ2 (n = 3180) = 5.24, df = 1, P = 0.02
c
d
Quebec < Ontario χ2 (n = 5686) = 4824.29, df = 1, P < 0.001; Quebec < British Columbia χ2 (n = 4496) = 2436.58, df = 1, P < 0.001;
Ontario > British Columbia χ2 (n = 3180) = 391.95, df = 1, P < 0.001
e
Quebec > Ontario χ2 (n = 5686) = 977.12, df = 1, P < 0.001; Quebec < British Columbia χ2 (n = 4496) = 606.62, df = 1, P < 0.001;
Ontario < British Columbia χ2 (n = 3180) = 2179.07, df = 1, P < 0.001
f
Quebec > Ontario χ2 (n = 5686) = 23.05, df = 1, P < 0.001; Quebec > British Columbia χ2 (n = 4496) = 24.63, df = 1, P < 0.001
g
Quebec > Ontario χ2 (n = 5686) = 8.34, df = 1, P = 0.004
Initial Disposition
The courts deferred the initial post-NCRMD verdict
disposition to the RB in 39.3% (n = 705) of cases. Quebec
had a distinctive practice, with only 6.8% (n = 74) of initial
Court disposition decisions deferred to RBs, compared with
90.5% (n = 436) in Ontario and 87.8% in British Columbia
(n = 195) [χ2 (n = 1795) = 1235.39, df = 4, P < 0.001]. Given
this difference, we imputed custody status at the time of
the first hearing, when disposition had been deferred to the
RB. Using this method, 62.9% (n = 1133) of all NCRMD
accused were detained in custody at their first hearing, 37.1%
(n = 667) were conditionally discharged and interprovincial
differences remained significant [χ2 (n = 1800) = 35.25, df =
2, P < 0.001]. NCRMD–accused people from Ontario were
more likely to receive an initial disposition of detention
(73.6%) than those in Quebec (58%) [χ2 (n = 1597) = 34.94,
df = 2, P < 0.001] or British Columbia (64.4%) [χ2 (n =
706) = 6.13, df = 2, P = 0.01).
Review Board Hearing Practices
Reasons for Hearing
Hearings occurred for the following reasons: following
an NCRMD verdict (28.1%), as an annual review of
disposition (57.3%), when requested by the accused (1.1%),
when requested by the hospital (5.7%), when requested by
the RB (3.6%), following a dual designation for people
found NCRMD on at least 1 offence but convicted of
another offence (0.1%), and following a hospitalization
of the accused for more than 7 days (4.1%). Reasons for
120 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
the hearings were not equally distributed across provinces
[χ2 (n = 6700) = 767.22, df = 12, P < 0.001]. Overall,
given the higher number of cases in Quebec, it also had
the highest number of hearings following a verdict
(33.7%), greater than Ontario (22.4%), which was higher
than British Columbia (21.1%) [χ2 (n = 6699) = 115.13,
df = 2, P < 0.001]. Ontario had the higher proportion of its
hearings occurring as an annual review (67.7%), compared
with British Columbia (50.7%) and Quebec, which
were equivalent (52.8%) [χ2 (n = 6698) = 142.23, df = 2,
P < 0.001]. Very few hearings were held at the request of
the accused, and there was no variation across provinces:
Quebec (1.0%), Ontario (1.1%), or (1.3%) [χ2 (n =
6698) = 0.832, df = 2, P = 0.66]. The hospital requested more
hearings in Quebec (7.9%), followed by Ontario (4.0%) and
then by British Columbia (1.8%) [χ2 (n = 6699) = 72.89,
df = 2, P < 0.001]. However, more hearings were requested
in British Columbia following a hospitalization of at least
7 days (9.8%), compared with Ontario (2.8%) and Quebec
(3.2%) [χ2 (n = 6699) = 102.78, df = 2, P < 0.001]. The
British Columbia RB requested more hearings (15.2%)
than the Quebec (1.3%) and Ontario boards (1.7%) [χ2 (n =
6698) = 470.97, df = 2, P < 0.001]. Duration of the hearing
was available for 98.9% of the hearings in Quebec and for
20.4% of the hearings in British Columbia, but it was never
mentioned in the Ontario RB files. In Quebec, hearings
lasted 51.07 minutes on average (SD 26.03), and, when the
information was available, hearings lasted 120.23 minutes
(SD 4.74) in British Columbia.
www.LaRCP.ca
The National Trajectory Project of Individuals Found NCRMD in Canada. Part 3: Trajectories and Outcomes Through the Forensic System
Hearing Participants
In British Columbia, some hearings (n = 57, 5.4%) are
waived if all parties agree to the preferred outcome.
This does not occur in Quebec or Ontario, thus these
British Columbia cases were eliminated from subsequent
comparisons. There were significant differences across
provinces in the distribution of participants at hearings.
Quebec had a higher presence of accused than the
other 2 provinces (Table 1). Ontario had the highest
presence of defence lawyers, prosecutors, and hospital
representatives, and was significantly higher than Quebec
but not British Columbia. Other clinical team members
were more often present in British Columbia than Quebec;
other professionals were rarely present in Ontario. Family
members were more often present at hearings in Quebec
than both British Columbia and Ontario. This could
be partially explained because in Quebec, with more
designated hospitals and assignment to hospital influenced
by distance to family, it may simply be easier for family
members to attend hearings.
Dispositions
Decisions were usually unanimous across RB members;
however, this happened more often in Quebec (99.8%)
than in Ontario (96.3%) or British Columbia (88.2%)
[χ2 (n = 6096) = 266.37, df = 2, P < 0.001]. In Ontario,
there was almost always (98.3%) a period of deliberation
between the hearing and disposition decision; this practice
was less likely in Quebec (11.8%), and almost never took
place in British Columbia (0.3%) [χ2 (n = 6096) = 266.37,
df = 2, P < 0.001]. When deliberation was required by
the RB, the decision was almost always provided to the
accused the very same day (94.1%) in Quebec, compared
with British Columbia (33.7%) or Ontario (0.3%) [χ2 (n = 2536) = 2304.53, df = 2, P < 0.001]. When the decision
was not provided on the same day as the hearing, a median
period of 8 days was required by the Ontario RB to transmit
the decision to the accused, while this period was 43 days
for Quebec and 15 days for British Columbia [Kruskal–
Wallis test: χ2 (n = 2164) = 34.02, df = 2, P < 0.001].
Detention without specific conditions, was ordered in 4%
of all hearings, conditional detention in 40%, conditional
release in 37%, and unconditional discharge in 19% of
hearings (Table 2). Detention with no conditions was more
likely to occur in Quebec than Ontario, and in Ontario
more than British Columbia. Detention with conditions
were much more likely to be rendered in Ontario than in
British Columbia or Quebec. Conditional discharge was
more frequent in Quebec than in British Columbia or
Ontario. Absolute discharge is more likely in Quebec than
in British Columbia, and in British Columbia more than
Ontario.
Conditions
Significant variations in the conditions associated with
detention or conditional discharge dispositions were
observed (Table 2). For example, permission to live in
the community was mentioned in nearly 60% of detention
www.TheCJP.ca
with condition dispositions in Ontario, but never in
British Columbia and Quebec. In 98.2% of detention with
condition dispositions in British Columbia, a condition
of following therapeutic recommendations is specified,
compared with never being mentioned in Ontario and very
rarely being mentioned in Quebec (1.4%). Conversely,
hospital delegation was used in 57.7% of conditional
discharge dispositions in Quebec, compared with none in
Ontario and practically none (0.9%) in British Columbia.
Forbidding possession of a weapon is a condition
often mentioned in British Columbia, whether it be
for conditional discharge or detention with conditions,
compared with both Ontario and Quebec. Restrained
contact with the victim or family member of the victim
is rarely mentioned in Quebec, compared with British
Columbia and Ontario.
Clinician–Review Board Agreement
Most reports (86.9%, n = 5557) included a recommended
disposition; however, this was unevenly distributed across
provinces [χ2 (n = 6396) = 267.99, df = 2, P < 0.001].
In Ontario, a recommendation was included in 97.1%
(n = 1949) of expert reports, higher than in Quebec (82.6%,
n = 2770) [χ2 (n = 5361) = 248.74, df = 1, P < 0.001] or
British Columbia (81.0%, n = 838) χ2 (n = 3043) = 229.64,
df = 1, P < 0.001]; Quebec and British Columbia did not
differ [χ2 (n = 4388) = 1.47, df = 1, P = 0.23].
There was high (86.9%) agreement between clinician
recommendations and RB decisions (κ [kappa] = 0.79),
with differences across provinces in agreement [χ2 (n =
5554) = 72.36, df = 2, P < 0.001]. Ontario had the highest
agreement rate (92.0%), followed by British Columbia
(86.4%) and Quebec (83.5%). Six per cent of RB decisions
were more restrictive than the clinical recommendations,
and 6.9% of clinical recommendations were more restrictive
than the RB decisions. The Quebec RB rendered decisions
more restrictive than the clinical recommendations in 9.2%
of cases, compared with 2.9% for Ontario [χ2 (n = 4716) =
73.76, df = 1, P < 0.001] and 3.6% in British Columbia
[χ2 (n = 3606) = 28.31, df = 1, P < 0.001].
Review Board Supervision
The survival curves presented in Figure 1 (A–D) show
the proportion of people who were under the supervision
of provincial RBs over time. Figure 1A shows that the
Quebec RB had the fastest release rate over time, followed
by British Columbia and Ontario. After 1 year, 74% of
the people were still under the RB in Quebec, 82% in
British Columbia, and 92% in Ontario. After 5 years,
19% of NCRMD–accused people were still under the
supervision of the RB in Quebec, 31% in British Columbia
and 58% in Ontario. This difference was also observed
for people who were detained in custody (Figure 1B–
D). After 1 year, 42% of the people still under the RB were
detained in hospital in Quebec, while 57% and 90% were
detained in British Columbia and Ontario, respectively;
after 2 years, it was 28%, 51%, and 88%, and after 5 years
it was 23%, 47%, and 79%, respectively.
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 121
National Trajectory Project
Table 2 Review Board dispositions and conditions
British Columbia
n = 1053
n (%)
Ontario
n = 2185
n (%)
Quebec
n = 3505
n (%)
χ2, df, n, P
4 (0.4)
63 (2.9)
233 (6.6)
93.47, 2, 6743, <0.001a
300 (4.4)
459 (43.6)
1621 (74.2)
592 (16.9)
1855.20, 2, 6743, <0.001b
2672 (39.6)
Permission to leave hospital
grounds accompanied
3 (0.7)
1370 (84.5)
1 (0.2)
1806.85, 2, 2672, <0.001
1374 (51.4)
Permission to leave hospital
grounds unaccompanied
403 (87.8)
1439 (88.8)
573 (97.0)
37.83, 2, 2672, <0.001
2415 (90.4)
Disposition and (or) conditions
Detention
Detention with conditions
Total
n = 6743
n (%)
0 (0)
955 (58.9)
0 (0)
1806.85, 2, 2672, <0.001
1374 (51.4)
450 (98)
1590 (98.1)
19 (3.2)
2346.06, 2, 2672, <0.001
2059 (77.1)
Abstain from using alcohol or drugs
264 (57.7)
1178 (72.7)
17 (2.9)
854.18, 2, 2672, <0.001
1459 (54.6)
Follow therapeutic
recommendations
439 (95.6)
0 (0)
8 (1.4)
2477.09, 2, 2672, <0.001
447 (16.7)
Keep the peace
116 (25.3)
10 (0.6)
10 (1.7)
468.13, 2, 2672, <0.001
136 (5.1)
25 (5.4)
227 (14.0)
4 (0.7)
99.85, 2, 2672, <0.001
256 (9.6)
303 (66.0)
577 (35.6)
3 (0.5)
513.52, 2, 2672, <0.001
883 (33.0)
Permission to live in the community
Live in a known place
Limited or no contact with victim
(or close relative of victim)
No possession of weapons
Other conditions
Conditional discharge
5 (1.1)
228 (14.1)
4 (0.7)
137.64, 2, 2672, <0.001
237 (8.9)
432 (41.0)
292 (13.4)
1785 (50.9)
820.63, 2, 6743, <0.001c
2509 (37.2)
Delegation (hospital)
4 (0.9)
0 (0)
1030 (57.7)
695.05, 2, 2508, <0.001
1034 (41.2)
Live in a known place
410 (94.9)
207 (70.9)
1726 (96.7)
272.41, 2, 2508, <0.001
2343 (93.4)
Abstain from using alcohol or drugs
307 (71.1)
203 (69.5)
1064 (59.6)
26.04, 2, 2508, <0.001
1574 (62.7)
Follow therapeutic
recommendations
167 (38.7)
9 (3.1)
1762 (98.8)
1751.29, 2, 2508, <0.001
1938 (77.3)
Keep the peace
420 (97.2)
276 (94.5)
1749 (98.0)
12.83, 2, 2508, <0.001
2445 (97.5)
Limited or no contact with victim
(or close relative of victim)
126 (29.2)
106 (36.3)
60 (3.4)
420.70, 2, 2508, <0.001
292 (11.6)
No possession of weapons
402 (93.1)
207 (70.9)
18 (1.0)
1943.56, 2, 2508, <0.001
627 (25.0)
Other conditions
427 (98.8)
291 (99.7)
181 (10.1)
1775.78, 2, 2508, <0.001
899 (35.8)
Absolute discharge
158 (15.0)
209 (9.6)
895 (25.5)
237.10, 2, 6743, <0.001d
1262 (18.7)
a
Quebec > Ontario χ2 (n = 5686) = 38.68, df = 1, P < 0.001; Quebec > British Columbia χ2 (n = 4558) = 64.53, df = 1, P < 0.001;
Ontario > British Columbia χ2 (n = 3238) = 21.98, df = 1, P < 0.001
b
Quebec < Ontario χ2 (n = 5690) = 1859.25, df = 1, P < 0.001; Quebec < British Columbia χ2 (n = 4558) = 325.36, df = 1, P < 0.001;
Ontario > British Columbia χ2 (n = 3238) = 289.58, df = 1, P < 0.001
Quebec > Ontario χ2 (n = 5690) = 819.36, df = 1, P < 0.001; Quebec > British Columbia χ2 (n = 4558) = 31.78, df = 1, P < 0.001;
Ontario < British Columbia χ2 (n = 3238) = 313.19, df = 1, P < 0.001
c
d
Quebec > Ontario χ2 (n = 5689) = 219.65, df = 1, P < 0.001; Quebec > British Columbia χ2 (n = 4557) = 50.60, df = 1, P < 0.001;
Ontario < British Columbia χ2 (n = 3238) = 20.92, df = 1, P < 0.001
Factors Related to Dispositions
The results of the Cox regression model (Tables 3 and
4) reveal the odds of being conditionally or absolutely
discharged varied across provinces, even after number
of past offences, diagnosis at verdict, and most severe
index offence (which all differed across provinces) were
statistically controlled. People from Ontario and British
Columbia have, respectively, 2.70 and 1.35 times lower
chances of being absolutely discharged over time than
people with an NCRMD finding from Quebec. People
from Ontario are 1.99 times less likely of being absolutely
discharged over time than those from British Columbia
(Exp[b] = 0.50, 95% CI 0.41 to 0.62, P < 0.001). These
122 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
differences are even more prominent when we examine the
probability of being conditionally discharged. People from
Ontario and British Columbia have, respectively, 4.17 and
1.49 times lower odds of being conditionally discharged
than those from Quebec. For people from Ontario, the odds
of being released from detention are 2.78 lower than for
those from British Columbia (Exp[b] = 0.36, 95% CI 0.30
to 0.44, P < 0.001).
A higher number of past offences reduced the odds of being
conditionally or absolutely discharged in all provinces.
Having a psychotic spectrum diagnosis decreased the
probability of being conditionally or absolutely discharged
www.LaRCP.ca
The National Trajectory Project of Individuals Found NCRMD in Canada. Part 3: Trajectories and Outcomes Through the Forensic System
Figure 1 Proportion of people detained and under Review Board (RB) purview following not criminally responsible
onFigure 1 Proportion of people detained and under Review Board (RB) purview following not criminally responsible account of mental disorder (NCRMD) verdict by province, with shaded areas representing 95% confidence
Figure 1 Proportion of people detained and under Review Board (RB) purview following not criminally responsible intervals
on account of mental disorder (NCRMD) verdict by province on account of mental disorder (NCRMD) verdict by province Proportion of people still under the purview of the
1a Proportion of people still under the purview of the RB 1b Proportion of people still under the purview of the 1a Proportion of people still under the purview of the RB 1B
1b Proportion of people still under the purview of the 1d Proportion of people still under the purview of the RB and detained over time following NCRMD verdict
RB and detained over time following NCRMD verdict RB and detained over time following NCRMD verdict (Quebec)
RB and detained over time following NCRMD verdict (Quebec) (Quebec) (British Columbia) 1c Proportion of people still under the purview of the RB 1A
Proportion of people still under the purview of the
over time following NCRMD verdict RB
over time following NCRMD verdict
and detained over time following NCRMD (Ontario) 100%
100%
90%
90%
100%
100%
100%
80%
80%
80%
80%
80%
People
not released,
%
%
%of
ofindividuals
individualsnot
notreleased
released
%
of
individuals
not
released
% ofPeople
individuals
not released
not released,
%
%
not released
% of
of individuals
individuals
90%
90%
90%
70%
70%
70%
70%
70%
60%
60%
60%
60%
60%
50%
50%
50%
50%
50%
40%
40%
40%
40%
40%
30%
30%
30%
30%
30%
QC
20%
20%
10%
10%
0%
0% 0
0
20%
20%
20%
ON
Mandate
BC
Detention
1
1
2
33
2
3
Years
after
verdict
Years
after verdict
verdict
Years
after
Years after verdict
Mandate
RB
purview
Mandate
Mandate
Detention
Detention
Detention
Detention
10%
10%
10%
0%
0%
0%
44
4
55
5
000
111
333
222
Years
Years
after
verdict
Years
after
verdict
Yearsafter
afterverdict
verdict
444
555
ote: Grey area indicates confidence intervals. 1D Proportion of people still under the purview of the
1c Proportion of people still under the purview of the RB 1d Proportion of people still under the purview of the 1c Proportion of people still under the purview of the RB 1d Proportion of people still under the purview of the RB and detained over time following NCRMD verdict
1C
Proportion of people still under the purview of the
ayout: Please remove bold from x axis. Please change y axis to the following: People not released, %] and detained over time following NCRMD (Ontario) RB and detained over time following NCRMD verdict and detained over time following NCRMD (Ontario) RB and detained over time following NCRMD verdict (British Columbia)
RB
and detained over time following NCRMD (Ontario)
(British Columbia) (British Columbia) 100%
100%
100%
90%
90%
90%
90%
80%
80%
80%
80%
not released,
%
%
of
not
%People
ofindividuals
individuals
notreleased
released
%
individuals
not
%of
of
individuals
notreleased
released
People
not released,
%
100%
70%
70%
70%
70%
60%
60%
60%
60%
50%
50%
50%
50%
40%
40%
40%
40%
30%
30%
30%
30%
20%
20%
20%
20%
10%
10%
0%
0%
0
0
RB
purview
Mandate
Mandate
10%
10%
Detention
Detention
Detention
0%
0%
1
1
2
3
2
3
Years
verdict
Years after
Years
after verdict
4
4
5
5
Mandate
Mandate
RB purview
Detention
Detention
Detention
0
0
1
1
2
2
3
3
Years after
after verdict
verdict
Years
Years
verdict
4
4
5
5
ote: Grey area indicates confidence intervals. ote: Grey area indicates confidence intervals. ayout: Please remove bold from x axis. Please change y axis to the following: People not released, %] ayout: Please remove bold from x axis. Please change y axis to the following: People not released, %] www.TheCJP.ca
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 123
National Trajectory Project
Table 3 Cox regression predicting time before absolute discharge from the Review Board
Likelihood of being absolutely discharged
Total
British Columbia
Ontario
Quebec
1.12 (0.87 to 1.43)
0.74 (0.60 to 0.92)b
0.68 (0.56 to 0.81)a
0.78 (0.72 to 0.85)a
Psychosis spectrum
disorder
0.68 (0.54 to 0.87)b
0.34 (0.17 to 0.66)b
1.08 (0.57 to 2.06)
0.67 (0.51 to 0.88)b
Mood disorder
1.12 (0.87 to 1.43)
0.57 (0.28 to 1.17)
2.37 (1.18 to 4.75)c
1.02 (0.76 to 1.37)
Substance use disorder
0.90 (0.79 to 1.02)
0.84 (0.59 to 1.19)
0.74 (0.53 to 1.04)
0.96 (0.83 to 1.12)
Personality disorder
0.91 (0.75 to 1.11)
0.66 (0.34 to 1.27)
0.49 (0.27 to 0.89)c
1.07 (0.86 to 1.34)
Other against person
1.89 (1.48 to 2.40)a
2.83 (1.42 to 5.67)b
2.07 (1.30 to 3.27)b
1.72 (1.26 to 2.35)a
Not against person
2.27 (1.77 to 2.91)a
3.56 (1.74 to 7.26)a
2.39 (1.46 to 3.93)a
2.09 (1.52 to 2.87)a
0.22
0.19
0.14
0.08
434.2, df = 9, P < 0.001
46.1, df = 7, P < 0.001
70.9, df = 7, P < 0.001
94.8, df = 7, P < 0.001
Covariates
Province (Quebec as
reference), OR (95% CI)
Ontario
0.37 (0.32 to 0.43)a
British Columbia
0.74 (0.62 to 0.88)a
Number of past criminal
convictions, ln, OR (95% CI)
Diagnosis at NCRMD
verdict, OR (95% CI)
Index NCRMD offence
(Severe violent as
reference), OR (95% CI)
R
2
Likelihood ratio test
P < 0.001; P < 0.01; P < 0.05
ln = natural logarithm; NCRMD = not criminally responsible on account of mental disorder
a
b
c
by 2.6 to 2.9 times in British Columbia, and by about 1.5
times in Quebec. Having a mood disorder increased the
odds of being conditionally or absolutely discharged by 2.4
in Ontario. The severity of the index offence significantly
affected the duration of detention and RB supervision across
all 3 provinces. Having committed a serious index offence
(that is, offences causing death, attempt to cause death, and
sexual offences) decreased the probability of discharge from
1.6 to 2.8 times, compared with other offences against a
person, and between 2.1 and 3.6 times for other offences not
against a person. Having committed other crimes against a
person decreased the odds of being conditionally released
by 1.2 (Exp[b] = 0.83, 95% CI 0.74 to 0.94, P = 0.002) and
absolutely discharged by 1.25 (Exp[b] = 0.80, 95% CI 0.72
to 0.89, P < 0.001), compared with other offences.
Discussion
Our results reveal similarities as well as some discrepancies
in the court decision following an NCRMD finding, the
characteristics of the provincial RB hearings, as well as the
duration of time an NCRMD accused remains under the
purview of the RB. These findings have important policy,
clinical, and research implications.
Quebec courts have a distinct practice in which they rarely
defer the initial disposition decision to the RB. People
in Quebec are more likely to remain detained or under
124 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
RB purview longer (90 days instead of 45 days) before
the RB initially determines the appropriate dispositions
and conditions. However, this is offset by shorter overall
stays under RB supervision. This clearly has important
implications for initiating patient-centred treatment, as well
as economic and bed-flow implications.
The data also suggest that the British Columbia system
has a more interdisciplinary approach to RB hearings than
Ontario or Quebec, with attendance by psychology staff
and case managers, in addition to the psychiatrist, being
the norm. This may have the benefit of providing the RB
with additional insights into treatment progress and the risk
presented by patients, though we could not ascertain from
the files if those who attend are systematically asked for
input and the psychiatrist may actually be speaking on behalf
of the team. The added expense and clinical advantages or
disadvantages of having the treatment team present at RB
hearings needs to be evaluated. Other provinces may still
have multidisciplinary input via psychological assessments,
treatment updates, social work involvement with family, and
community services integrated in their reports to the RBs.
NCRMD–accused people in Ontario are under a detention
order for a much longer period than those in the 2 other
provinces, even after controlling for criminal history, severity
of index offence, and diagnosis. Speaking to stakeholders,
it became quite clear that the Ontario RB sometimes uses
www.LaRCP.ca
The National Trajectory Project of Individuals Found NCRMD in Canada. Part 3: Trajectories and Outcomes Through the Forensic System
Table 4 Cox regression predicting time before conditional discharge from the Review Board
Likelihood of being conditionally discharged
Total
British Columbia
Ontario
Quebec
0.76 (0.72 to 0.81)a
0.70 (0.58 to 0.85)a
0.71 (0.61 to 0.83)a
0.81 (0.75 to 0.87)a
Psychosis spectrum
disorder
0.67 (0.54 to 0.84)a
0.39 (0.21 to 0.73)b
1.09 (0.62 to 1.92)
0.64 (0.49 to 0.83)a
Mood disorder
1.16 (0.92 to 1.46)
0.72 (0.37 to 1.42)
2.35 (1.26 to 4.36)b
1.03 (0.79 to 1.36)
Substance use
disorder
0.87 (0.77 to 0.98)
c
0.79 (0.57 to 1.08)
0.83 (0.62 to 1.11)
0.93 (0.80 to 1.07)
Personality disorder
0.82 (0.69 to 0.98)c
0.69 (0.40 to 1.19)
0.61 (0.38 to 0.97)c
0.92 (0.74 to 1.14)
Other against person
1.84 (1.50 to 2.27)a
2.63 (1.53 to 4.53)a
2.40 (1.59 to 3.61)a
1.56 (1.20 to 2.05)b
Not against person
2.30 (1.86 to 2.85)
2.94 (1.67 to 5.15)
2.36 (1.51 to 3.68)
2.08 (1.58 to 2.74)a
Covariate
Province (Quebec as
reference), OR (95% CI)
Ontario
0.24 (0.21 to 0.28)a
British Columbia
0.67 (0.57 to 0.78)a
Number of past criminal
convictions, ln, OR (95% CI)
Diagnosis at NCRMD
verdict, OR (95% CI)
Index NCRMD offence
(Severe violent as
reference), OR (95% CI)
a
a
a
0.22
0.15
0.10
0.35
754.3, df = 9, P < 0.001
54.7, df = 7, P < 0.001
75.01, df = 7, P < 0.001
117.8, df = 7, P < 0.001
R2
Likelihood ratio test
a
P < 0.001; b P < 0.01; c P < 0.05
ln = natural logarithm; NCRMD = not criminally responsible on account of mental disorder
the detention disposition in the same manner as the 2 other
provinces use conditional discharges. For example, Ontario
uses many conditions within detention that are meant to
be applied in a sequential manner at the discretion of the
treatment teams, consistent with the hospital delegation
option of the legislation. Therefore, RBs use a set of
conditions that are likely to be adequate during a 12-month
period allowing some level of hospital discretion. Under a
detention disposition, NCRMD–accused people in Ontario
may be first allowed to leave hospital grounds accompanied,
then move to unaccompanied community outings, to then
live in the community. These critical junctures are overseen
by the NCRMD–accused person’s treatment team, without
bringing the RB back for another hearing at each decision
point.
There were also significant provincial variations in the kinds
of conditions that are applied, indicating distinct provincial
management patterns. Above and beyond this, when
controlling for province, higher number of past offences,
psychotic spectrum disorder, severity of the index offence
all decreased the odds of a conditional or absolute discharge.
Interestingly, severity of index offence has been the factor
that has been the most consistently found to be associated
with dispositions in Canada and the United States,8,10–13 even
though it has been found to have little predictive power for
future offending.19 This indicates that, despite the fact that
people found NCRMD are not considered to be criminally
www.TheCJP.ca
responsible, they continue to be detained as a function of
the severity of the index offence, as if sentenced. This and
other studies show that other factors may be at play, such as
diagnosis and criminal history,8,10,12 but future research needs
to examine the role of dynamic changes of people over time.
Strengths and Limitations
Our study reports on one of the largest samples of
NCRMD–accused people followed longitudinally, and it
also contributes unique insights by comparing 3 provinces.
Despite these strengths, there were limitations. First, all data
were gathered through files, thus some hearing information
that could have been observed was not captured. For
example, the duration of hearings was only systematically
available in Quebec files. Second, we only sampled hearings
between 2000 and 2008, and some changes in processing
may have occurred during the past few years. As such, we
are presently undertaking a prospective study funded by the
Canadian Institutes of Health Research that will address
several of these methodological issues.
Conclusions
Our results demonstrate the trajectories of an NCRMD–
accused person depends on the province. For example, an
individual remains under RB supervision longer in Ontario
than the other 2 provinces; does this translate to differences
in recidivism? The next paper will address this question.20
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 125
National Trajectory Project
Given that our study is examining federal legislation, the
findings point to a need for greater national collaboration.
Two large-scale initiatives are already under way. First,
our colleagues have initiated a Canadian Forensic Mental
Health Network of clinicians and administrators. Second,
we recently brought together forensic decision makers,
clinicians, researchers, and other stakeholders to work
toward a national agenda for forensic systems research. A
report will soon be made available.
Acknowledgements
This research was consecutively supported by grant
#6356-2004 from Fonds de recherche Québec—Santé
(FRQ-S) and by the Mental Health Commission of Canada
(MHCC). Dr Crocker received consecutive salary awards
from, the Canadian Institutes of Health Research (CIHR)
and FRQ-S, as well as a William Dawson Scholar award
from McGill University while conducting this research.
Dr Nicholls acknowledges the support of the Michael
Smith Foundation for Health Research and the CIHR for
consecutive salary awards. Yanick Charette acknowledges
the support of the Social Sciences and Humanities Research
Council of Canada in the form of a doctoral fellowship.
This study would not have been possible without the full
collaboration of the Quebec, British Columbia, and Ontario
Review Boards, and their respective registrars and chairs.
We are especially grateful to Me [attorney] Mathieu Proulx,
Bernd Walter, and Justice Douglas H Carruthers and Justice
Richard Schneider, the Quebec, British Columbia, and
consecutive Ontario RB chairs, respectively.
The authors sincerely thank Erika Jansman-Hart and
Dr Cathy Wilson, Ontario and British Columbia coordinators,
respectively, as well as our dedicated research assistants who
spent an innumerable number of hours coding RB files and
Royal Canadian Mounted Police criminal records: Erika
Braithwaite, Dominique Laferrière, Catherine Patenaude,
Jean-François Morin, Florence Bonneau, Marlène David,
Amanda Stevens, Stephanie Thai, Christian Richter, Duncan
Greig, Nancy Monteiro and Fiona Dyshniku.
Finally, the authors extend their appreciation to the members
of the Mental Health and the Law Advisory Committee
of the MHCC, in particular Justice Edward Ormston and
Dr Patrick Baillie, consecutive chairs of the committee as
well as the National Trajectory Project advisory committee
for their continued support, advice, and guidance throughout
this study and the interpretation of results.
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CanJPsychiatry 2015;60(3):127–134
National Trajectory Project
The National Trajectory Project of Individuals Found Not
Criminally Responsible on Account of Mental Disorder in
Canada. Part 4: Criminal Recidivism
Yanick Charette, MSc (PhD Candidate)1; Anne G Crocker, PhD2; Michael C Seto, PhD3;
Leila Salem, BA (PhD Candidate)4; Tonia L Nicholls, PhD5; Malijai Caulet, PhD6
1
Post-doctoral Fellow, Department of Sociology, Yale University, New Haven, Connecticut. Student, Department of Criminology, Université de Montréal,
Montreal, Quebec.
2
Associate Professor, Department of Psychiatry, McGill University, Montreal, Quebec; Associate Director, Policy and Knowledge Exchange,
Douglas Mental Health University Institute Research Centre, Montreal, Quebec.
Correspondence: Douglas Mental Health University Institute Research Centre, 6875 LaSalle Boulevard, Montreal, QC H4H 1R3; [email protected].
3
Director of Forensic Rehabilitation Research, Royal Ottawa Health Care Group, Brockville, Ontario.
4
Student, Department of Psychology, Université de Montréal, Montreal, Quebec.
5
Associate Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia; Senior Research Fellow,
Forensic Psychiatric Services Commission, BC Mental Health & Substance Use Services, Coquitlam, British Columbia.
6
National Coordinator, National Trajectory Project, Douglas Mental Health University Institute Research Centre, Montreal, Quebec.
Key Words: forensic mental
health, National Trajectory
Project, not criminally
responsible on account of
mental disorder, mental
disorder, recidivism, review
board
Received May 2014, revised,
and accepted June 2014.
open
access
Objective: To examine criminal recidivism rates of a large sample of people found not
criminally responsible on account of mental disorder (NCRMD) in Canada’s 3 most
populous provinces, British Columbia, Ontario, and Quebec. Public concern about the
dangerousness of people found NCRMD has been fed by media attention on high-profile
cases. However, little research is available on the rate of reoffending among people found
NCRMD across Canadian provinces.
Method: Using data from the National Trajectory Project, this study examined 1800 men
and women in British Columbia (n = 222), Ontario (n = 484), and Quebec (n = 1094) who
were found NCRMD between May 2000 and April 2005 and followed until December 2008.
Results: Recidivism was relatively low after 3 years (17%). There were interprovincial
differences after controlling for number of prior criminal offences, diagnosis, seriousness
of the index offence, and supervision by the review boards. British Columbia (10%) and
Ontario (9%) were similar, whereas Quebec had almost twice the recidivism (22%). People
who had committed severe violent index offences were less likely to reoffend than those
who had committed less severe offences. People from the sample were less likely to
reoffend when under the purview of review boards, across all 3 provinces.
Conclusion: The results of this study, along with other research on processing differences,
suggest systemic differences in the trajectories and outcomes of persons found NCRMD
need to be better understood to guide national policies and practices.
WWW
Projet national des trajectoires des personnes déclarées non
criminellement responsables pour cause de troubles mentaux au
Canada. Partie 4 : La récidive criminelle
Objectif : Examiner les taux de récidive criminelle dans un large échantillon de personnes
déclarées non criminellement responsables pour cause de troubles mentaux (NCRTM)
dans les 3 provinces les plus populeuses du Canada, la Colombie-Britannique, l’Ontario,
et le Québec. Les craintes du public à l’égard de la dangerosité des personnes déclarées
NCRTM ont été nourries par l’attention portée par les médias à des affaires spectaculaires.
Toutefois, il y a peu de recherche sur le taux de récidive chez les personnes déclarées
NCRTM à travers le Canada.
Méthode : À l’aide des données du Projet national des trajectoires, la présente étude a
examiné 1800 hommes et femmes du Colombie-Britannique (n = 222), de l’Ontario
(n = 484) et de le Québec (n = 1094) qui ont été déclarés NCRTM entre mai 2000 et avril
2005, et suivis jusqu’en décembre 2008.
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The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 127
National Trajectory Project
Résultats : La récidive était relativement faible après 3 ans (17 %). On observe des
différences interprovinciales après contrôle pour le nombre d’infractions criminelles
antérieures, le diagnostic, la gravité de l’infraction répertoriée, et la supervision des
Commisions d’examen (CE). Les provinces du Colombie-Britannique (10 %) et de
l’Ontario (9 %) étaient semblables tandis que le Québec avait près du double de
récidives (22 %). Les personnes qui avaient commis une infraction répertoriée grave
étaient moins susceptibles de récidive que celles dont les infractions étaient moins
graves. Les personnes de l’échantillon étaient moins susceptibles de récidive quand
elles étaient sous la supervision de la CE, dans les 3 provinces.
Conclusion : Les résultats de cette étude, de même que ceux d’autres recherches
sur les différences de traitement, suggèrent que les différences systémiques dans
les trajectoires et les résultats des personnes déclarées NCRTM doivent être mieux
comprises pour guider les politiques et pratiques nationales.
T
here is substantial variation in risk for violence among
people with SMI.1–4 Nonetheless, the general public
often perceives people with SMI as being dangerous.5,6
Although multiple factors may influence this perception,
media portrayal of people with a mental illness may
be an important contributor.7,8 Studies show there is an
overemphasis on violence in the depiction of mental illness
in the media, particularly sensational cases involving
brutal or multiple homicides.9–11 The perception of the
dangerousness of people with mental illness may foster
support for the use of stricter measures in the management
of people with mental illness, such as longer periods of
detention or involuntary commitment.12
Recent attention to high-profile cases involving offenders
with mental disorders and a tough-on-crime agenda has
led the current Canadian government to amend Part XX.1
of the Criminal Code on mental disorder (section 672.1).13
This amendment establishes stricter guidelines in the
management of people found NCRMD, through the
identification of a new legal category of high-risk accused.
People are found NCRMD if they committed a criminal
offence while suffering from a mental disorder that caused
them to be incapable of knowing that the offence was wrong
(mens rea) or that prevented them from controlling their
behaviour (actus reus). People subject to the new status of
high-risk accused include those who committed a serious
personal injury offence, such as homicide, attempted
homicide, and sexual offences.13 Categorizing people as
high-risk accused suggests they have a higher probability
of reoffending than people found NCRMD who did not
commit a serious personal injury offence, and (or) commit
more serious violence if they do reoffend.
Abbreviations
NCRMD not criminally responsible on account of mental disorder
NTP
National Trajectory Project
PD
personality disorder
RB
review board
SMI
serious mental illness
SUD
substance use disorder
128 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
Clinical Implications
•
There is a relatively low rate of recidivism among
NCRMD–accused people, compared with general
offenders or offenders with mental disorders in
correctional custody.
•
Findings contradict the notion that changes to the
legislation are required to protect public safety.
•
Forensic mental health experts and RBs across
provinces may learn from their respective practices
in relation to the prediction of recidivism and release
decisions.
Limitations
•
Our study relied on archival files from 2000 to 2008,
accessed in 3 Canadian provinces, and therefore
may not generalize to other jurisdictions and present
practices.
•
Recidivism was recorded from a national criminal
records database, and thus was limited by the
information that was available (for example, new
offences may result in rehospitalization or other
diversion practices rather than new criminal
charges).
According to a seminal meta-analysis by Bonta et al,14
multiple factors are associated with the likelihood of
general and specifically violent recidivism of offenders with
mental disorders. These factors include criminal history,
psychiatric diagnosis, and nature of the index offence. Their
results also showed that people found not guilty by reason
of insanity (equivalent to the NCRMD verdict) were less
likely to reoffend than those who did not have this finding.
Moreover, people with mental illness who committed
a serious offence, such as homicide or sexual offences,
were less likely to reoffend than those who committed less
serious offences.
Provincial and territorial RBs are mandated by Canadian
law to determine a suitable disposition for people declared
NCRMD, based on “the need to protect the public from
dangerous persons, the mental condition of the accused,
the reintegration of the accused into society and the other
needs of the accused.”15 These dispositions of people found
NCRMD, reviewed on at least an annual basis, are expected
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The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 4: Criminal Recidivism
to have an effect on subsequent offending. Dispositions
include whether the person is detained in hospital or
allowed to reside in the community, and conditions that can
include travel restrictions, contact restrictions, treatment
participation, and forbidding substance use.16 The RB has
oversight until a person is absolutely discharged.
The number of people found NCRMD has increased
steadily during the past 2 decades in Canada, paralleling
increasing demands for forensic mental health services
in other countries.17 This indicates that an examination of
the trajectories and outcomes of NCRMD–accused people
is essential to inform policies and practices in this area.
Though some studies outside Canada have examined the
risk of recidivism related to people found NCRMD or its
equivalent,18–20 few Canadian studies have done so.
In this study, we addressed the following 3 research
questions: How likely are NCRMD individuals to reoffend?
Do individuals with serious index offences have a higher
rate of recidivism than other persons found NCRMD?
And, are there provincial differences in recidivism rates
when taking into account criminal history, mental illness,
seriousness of the index offence, and the RB disposition?
Method
Sample
Data for the current analyses were drawn from the NTP.21
The objective of the NTP was to provide an accurate
portrait of 1800 people found NCRMD and to examine the
trajectories and outcomes of people under the authority of
an RB. The full NTP design and procedures are described
in more detail in Crocker et al.21 The sample was comprised
of new NCRMD–accused people entering the RB system
in Quebec (n = 1094), British Columbia (n = 222), and
Ontario (n = 484). The cases spanned between 2000 and
2005.21 People were followed until December 31, 2008,
which allowed for 3 to 8 years of follow-up after the index
NCRMD verdict. On average, people were followed for 5.7
years (SD 1.48) following their verdict. Table 1 presents the
descriptive analyses of the sample. For more analyses of
variation across provinces, see Crocker et al.16,22
Recidivism
Based on official criminal records, all offences leading
to a conviction or NCRMD finding following the index
NCRMD verdict were classified as recidivism. A total of
421 people (23.5%) reoffended during the entire followup period (17% reoffended after 3 years of follow-up).
The most serious offence associated with each recidivism
event was categorized as follows: severe offences (that is,
offences causing death or attempting to cause death and
sex offences), other offences against a person (including
assaults, threats, harassment, kidnapping, extortion, and
robbery), and offences not against the person.21 Recidivism
was determined as the first new offence following the
NCRMD index verdict. Time to each type of new offence
(against the person or not against the person) was calculated
www.TheCJP.ca
Table 1 Descriptive analyses of the sample
(n = 1800)
Characteristic
n (%) or
mean (SD)
Province, n (%)
Quebec
1094 (60.8)
Ontario
484 (26.9)
British Columbia
Observation period, years, mean (SD)
222 (12.3)
5.73 (1.48)
Type of reoffences for the whole observation
period, n (%)
Against person
257 (14.3)
Severe
13 (0.7)
Causing death or attempting
4 (0.2)
Sex offences
9 (0.5)
Other against person
244 (13.6)
Assaults
130 (7.2)
Threats
76 (4.2)
Other offences against person
Not against person
Total
39 (2.2)
164 (9.1)
421 (23.4)
Period under RB purview, years, mean (SD)
2.83 (2.17)
Past criminal convictions or NCRMD findings,
mean (SD)
2.43 (4.67)
Diagnosis at the index NCRMD verdict, n (%)
Primary diagnosis
Psychotic spectrum disorder
1268 (70.9)
Mood spectrum disorder
414 (23.2)
Others
106 (5.9)
SUD
550 (30.8)
PD
190 (10.6)
Missing
16 (0.9)
Index verdict offence, n (%)
Severe
164 (9.1)
Other against the person
1004 (55.8)
Not against the person
631 (35.1)
NCRMD = not criminally responsible on account of mental
disorder; PD = personality disorder; RB = review board;
SUD = substance use disorder
as the time from the index NCRMD verdict to the first
incident of that type of new offence. Severe offences were
combined with other offences against a person for our
multivariate modelling (Model II, see below) because there
were only 13 cases of new severe offences during the entire
follow-up period (9 cases after 3 years of follow-up).
Time Under the Purview of the Review Board
The date of absolute discharge from the RB system was
obtained from RB files. People are considered to be under
the purview of the RB until an absolute discharge. Given
that this status changes over time, it was included as a
time-dependent covariate in proportional hazard models to
evaluate its impact on recidivism. People were under the
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 129
National Trajectory Project
purview of an RB for an average of 2.84 years (SD 2.2
years). For a more detailed analysis of the supervision by
the RB, see Crocker et al.16
Control Variables
Many factors are associated with the likelihood of
recidivism of people with mental illness, including criminal
history, psychiatric diagnosis, and nature of the index
offence.14 Given these individual characteristics vary
across the provinces,22 we statistically controlled for these
characteristics to conduct a fair comparison of recidivism.
Criminal history was represented by the number of prior
criminal convictions and NCRMD findings. As presented
in Crocker et al,22 about one-half (51%) of the participants
had no prior criminal history. For NCRMD–accused people
with an official criminal history, there was a median of
3 (mean 4.99, SD 5.69) previous convictions and 1 prior
NCRMD finding.
Diagnosis was coded into the following major categories22:
psychotic spectrum disorder, such as schizophrenia or
schizoaffective disorder (71%); mood disorder, such as
bipolar disorder or depression (23%); SUD (31%); and PD
(11%). The percentages add up to more than 100% because
people could have multiple diagnoses.
Seriousness of the index offence followed our categorization
for recidivism: severe offences, other offences against the
person, and offences not against a person. Other offences
against a person accounted for 55.8% of index offences,
with assaults representing one-quarter to one-third of all
index offences across the 3 provinces. Severe offences
accounted for 9% of all index NCRMD verdicts.22
Analyses
Weighting was used to ensure that the Quebec sample was
regionally representative.21 Time at risk for recidivism
varied, with fewer cases under observation as the followup period increased; survival analysis controls for censored
observations and for varying time at risk. Multivariate
comparisons of survival curves were performed using
Cox proportional hazard regression models.23 Sixteen
cases presented missing information about diagnosis
and were removed listwise in this multivariate model,
resulting in a final sample of 1784 people. Survival curves
and proportional hazard models were performed using R,
version 3.0.2,24 and the survival package.25
Results
To control for differential time at risk and censoring
of observations, we first examined recidivism after a
fixed follow-up period. Among the 1768 people under
observation 3 years after the index verdict, 16.7% (n = 295)
had committed a new offence, regardless of whether they
were still under the purview of the RB. This rate went up to
20.3% (267/1319) 3 years following conditional discharge,
and to 21.8% (207/949) 3 years following absolute discharge.
In the 3 years following the index verdict, Ontario and British
130 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
Columbia had similar recidivism rates, but in Quebec the rate
was more than twice as high: 21.5% (229/1063) of people
from Quebec, 9.5% (21/221) of those from British Columbia,
and 9.3% (45/484) of those from Ontario had perpetrated
a new offence, regardless of their disposition status
(Figure 1A). People who had committed a severe offence
for their index NCRMD verdict had the lowest recidivism
rates (Figure 1B) of all groups: 3 years following the index
offence, only 6.0% (10/159) committed a new offence of
any kind. The recidivism rate was higher among people
who committed a less severe index offence against a person
(15.3%; /151/988) or people who committed index offences
that were not against a person (21.6%; 134/621).
The recidivism rate when only reoffences against a person
not classified as severe were considered (8.8% after 3 years;
154/1755) was similar to the recidivism rate when only
reoffences that were not against a person were considered
(10.5% after 3 years; 186/1765; Figure 1C). Almost
one-third (29%) of these offences against a person involved
threats. The recidivism rate for a severe violent offence
within 3 years was extremely low: 0.6% (9/1611).
Table 
2 presents Cox regression models predicting
recidivism, for all types of reoffences and for reoffences
against the person specifically, controlling for the number
of past criminal convictions or NCRMD findings, diagnosis
at the index verdict, most severe offence related to the
index verdict, and RB disposition. Results show that,
when these characteristics are held constant, people from
Quebec had nearly twice the probability of a reconviction
or a new finding of NCRMD than people from Ontario and
British Columbia for all types of reoffences. No significant
differences in recidivism rates were found between British
Columbia and Ontario (b = –0.17, SE = 0.22, P = 0.43).
For reoffence against a person only, people from British
Columbia were 3 times less likely, and from Ontario were
2 times less likely, to reoffend than people from Quebec.
Again, no differences were observed between British
Columbia and Ontario (b = 0.40, SE = 0.33, P = 0.23).
Being under the purview of the RB significantly reduced
the risk of recidivism by 0.77 for all types of reoffences,
compared with being absolutely discharged. A model with
an interaction effect between provinces and the supervision
of the RB showed no significant results (likelihood
ratio = –1597.2, χ² = 1.30, df = 2, P = 0.52), suggesting
that the supervision of the RB is equally efficient to prevent
recidivism for all provinces. However, the supervision of
the RB had no effect on likelihood of recidivism when only
new offences against a person were considered.
People who had committed more criminal offences prior to
the index verdict were more likely to reoffend regardless of
type of reoffence. While the primary diagnosis (psychotic
or mood spectrum disorders) had no influence on the risk of
recidivism, a comorbid diagnosis of SUD increased the risk
of recidivism by 1.41 for all type of reoffences and by 1.48
for crimes against a person only. A comorbid diagnosis of
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The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 4: Criminal Recidivism
PD also increased the risk of recidivism, by 1.38 for all type
of reoffences and by 1.48 for offences against a person only.
Figure 1 Proportion of people who did not reoffend
over
time,1with
95% CI as
function
of did
province,
type over time, w
Figure
Proportion
of apeople
who
not reoffend
of index
offence,
and type
of recidivism
offenceand type of recidivis
function
of province,
type
of index offence,
For all types of reoffences, people who committed a severe
index offence were 1.76 times less likely to reoffend than
people whose index offences were categorized as other
offences against a person, and 2.14 times less likely to
reoffend than people whose index offences were not against
a person. Severity of index offence had no significant effect
on the likelihood of recidivism against the person.
1a
who
diddid
notnot
reoffend
over
timetime1b Proportion o
1A Proportion
Proportionofofpeople
people
who
reoffend
over
after index verdict by provinces (all type of reoffences)
after index verdi
after index verdict by provinces (all type of reoffences)
100%
Discussion
95%
% of individuals who did not recidivate
% of individuals who did not recidivate
People who did not reoffend, %
100%
90%
95%
90%
85%
80%
70%
3
Severe offences
75%
% of individuals who did not recidivate
In line with previous studies, the number of past criminal
85%
convictions and NCRMD
findings was a good predictor of
future offences. A comorbid diagnosis of PD or SUD also
80%of reoffending. Even if people found
increased the risk
NCRMD were less likely to
QC reoffend under the purview
75%
of the RB, to a similar
degree
ON across provinces, the abovementioned predictors shouldBCbe attended to more closely by
treatment teams and
70% RBs to enhance their decision making.
0
1
2
Future research should focus on Years
additional
risk factors
after verdict
found in traditional risk assessment measures, as well as
risk management strategies used by treatment teams.
People who did not reoffend, %
% of individuals who did not recidivate
% of individuals who did not recidivate
The 3-year follow-up recidivism rates for our multi-province
85%
85%
sample of people found NCRMD was 17% following index
verdict, 20% following conditional discharge and 22%
80%
80%
following absolute discharge. These rates are lower than rates
QC
of recidivism found among a general offender population
S
75%
75%
ON
O
(34%)26 and much lower than rates found among an inmate
BC
27
O
population treated for mental disorder (70%) during the
70%
70%
0
1
2
3
same observation
period.
The NCRMD
population
to reoffend over time, with 95% confidence interval as a
0
Figure
1 Proportion
of people
whoseems
did not
Yearsafter
after verdict
Years
verdict
be adequately
managed
thetype
RB system.
Asoffence,
shown and type of recidivism offence
function
ofthrough
province,
of index
in other studies,14 and inconsistent with the introduction of a
1B Proportion
Proportionofofpeople
people
who
did
not
reoffend
over
time
1a Proportion of people who did not reoffend over time
1b
who
not
reoffend
over
time
1c did
Proportion
of people
who
did not reoffend ov
high-risk accused
category
inby
Canadian
people
afterindex
indexverdict
verdictby
bytype
typeofofmost
most
severe
index
offence
after index
verdict
provinceslegislation,
(all type of reoffences)
after
severe
offence
index verdict
byindex
type of
most severe reoffence
found NCRMD for severe offences (such as those causing
100%
100%
100%
death, attempting
to cause death, or sex offences) were
actually less likely to reoffend, compared with people who
95%
95%
95% severe offences against the person or
had not committed
offences that were not against a person (for example, theft
90%
90%
and possession of90%
narcotics).
85%
80%
Severe re-offences
75%
Other re-offences against person
Other offences against person
Offences not against person
70%
0
1
Re-Offences not against person
0
2
Yearsafter
after verdict
Years
verdict
1
3
Years after verdict
of people
who did not reoffend over time
1c Proportion of people who did1C
notProportion
reoffend over
time after
after
index
verdict
by
type
of most severe reoffence
index
verdict
by
type
of
most
severe
reoffence
Quebec, and remained
People who did not reoffend, %
80%
100%
% of individuals who did not recidivate
Strengths and Limitations
% of individuals who did not recidivate
Recidivism rates were the highest in
100%
about twice as high as Ontario and British Columbia,
even
after controlling for number of prior offences, diagnostic
95%
category, seriousness of the index offence,
and the
supervision of the RB. This interprovincial difference in
recidivism rates may be related to differences
90% in judicial
processing and (or) risk assessment and management
practices. The reasons for this notable difference
requires
85%
further investigation.
95%
90%
85%
80%
A strength of our study is that it is the first multiSevere re-offences
75%
provincial, longitudinal, and representative75%sample Other
of are-offences against person
cohort of people found NCRMD in the 3 largest Canadian
Re-Offences not against person
70%
provinces, using information from RB files70%and national
02
0
1
criminal records. Limitations include that recidivism was Years after verdict
based on official criminal records only, and thus must be
www.TheCJP.ca
Severe reoffences
Other reoffences against person
Reoffences not against person
13
2
Years after
after verdict
Years
verdict
3
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 131
2
National Trajectory Project
Table 2 Cox regression predicting time before reoffence by all types of offences and by offences against a
person specifically
Hazards of recidivism OR (95% CI)
Model I
All types of reoffences
n = 1784, NR = 421
Model II
Reoffences against person
n = 1784, NR = 224
Ontario
0.43 (0.32 to 0.58)a
0.44 (0.31 to 0.64)a
British Columbia
0.51 (0.36 to 0.74)a
0.30 (0.17 to 0.54)a
Covariate
Province (Quebec as reference)
Under the purview of the RB
0.77 (0.60 to 0.98)
b
0.87 (0.64 to 1.19)
Past criminal convictions or NCRMD findings
1.06 (1.04 to 1.07)a
1.06 (1.04 to 1.08)a
Psychotic spectrum disorder
1.16 (0.73 to 1.83)
1.44 (0.78 to 2.67)
Mood spectrum disorder
1.47 (0.92 to 2.37)
1.20 (0.62 to 2.31)
Substance use disorder
1.41 (1.14 to 1.75)c
1.48 (1.12 to 1.96)c
Personality disorder
1.38 (1.03 to 1.84)b
1.48 (1.03 to 2.13)b
Other against person
1.76 (1.03 to 2.99)b
1.37 (0.73 to 2.60)
Not against person
2.14 (1.25 to 3.67)
Diagnosis at the index NCRMD verdict
Primary diagnosis (Others as reference)
Comorbidity
Index verdict offence (Severe as reference)
Likelihood ratio test
a
c
χ2 = 143.4, df = 10, P < 0.001
1.80 (0.94 to 3.45)
χ2 = 87.4, df = 10, P < 0.001
P < 0.001; b P < 0.05; c P < 0.01
NCRMD = not criminally responsible on account of mental disorder; NR = number of recidivists; RB = Review Board
interpreted with caution.28 In addition, we had a limited
follow-up period and we only considered the first incident
of reoffending following the index offence. Because
criminal justice is administered provincially, differences
in criminal justice processing may influence observed
recidivism rates. For example, in the general population
in 2000, 75% of charges led to a conviction in Quebec,
while in British Columbia and Ontario the rate is 62%.29
This may reflect differences in judicial decision making,
pre-trial diversion, and other decisions. These differences
across jurisdictions need to be considered when comparing
recidivism rates coming from official records and when
drawing conclusions about cross-provincial differences in
our study.
Recidivism rates were relatively low in our sample,
restraining our statistical power to capture the presence
of effects, despite our large initial sample size. This may
underestimate the impact of some factors, for example, the
influence of the supervision of the RB on recidivism against
a person. This limitation would be even more pronounced if
we had focused only on criminal acts that resulted or could
result in physical injury.
A related limitation is that our measure of recidivism
did not capture all new offences. The national criminal
records database does not capture all new criminal charges
or convictions, and does not capture all cases lost to
follow-up as a result of death or deportation. Some new
132 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
offences, particularly those that were perceived as less
serious (for example, theft, drug use, or vandalism) or
that involved family members or professionals, may lead
to rehospitalization instead of criminal charges for people
still under the purview of the RB. Also, though we recorded
new NCRMD findings resulting in a disposition under 1
of the 3 study provinces, some people may have moved to
another province and been found NCRMD. This highlights
the value of a broader assessment of outcomes beyond
official criminal records. More discussion of strengths and
limitations of the NTP is provided in Crocker et al.21
Conclusions and Future Directions
Careful comparisons are needed to understand observed
differences in official recidivism rates, including a better
understanding of judicial processing and other systemic
parameters (for example, availability of community mental
health services, and provision of services through civil,
compared with forensic, facilities) on subsequent offending.
For example, in our companion study of RB processing and
trajectories, we found that the provinces differed in the total
time that NCRMD–accused people spent under the purview
of an RB before absolute discharge.16 Information about
rehospitalizations is needed, as some new offences may
result in these outcomes rather than new criminal charges
and convictions. Also, though new offences are a very
important outcome for policy and practice, given the central
importance of public safety, evaluations of other outcomes,
www.LaRCP.ca
The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 4: Criminal Recidivism
including degree of rehabilitation and recovery, quality of
life, and other aspects of community reintegration are also
needed.
support, advice, and guidance throughout this study and the
interpretation of results.
The risk to public safety that people found NCRMD pose
is an important factor considered by RBs. Most people
suffering from mental illness do not represent a high risk
to society, and an individualized assessment of risk to
reoffend is needed to balance the costs of unnecessarily
restraining individual liberties (as well as health and
processing costs) against the costs of new offences,
particularly new offences against a person and new serious
offences. Results from this study show, as others have,14
that risk to reoffend is inversely rather than positively
related to the seriousness of the index offence. Criminal
history, mental disorder diagnosis (more specifically
comorbid SUD and PD), and level of supervision are
relevant, as are various other risk factors. These findings
should help shape policies rather than relying on the
severity of the offence.
References
Acknowledgements
This research was consecutively supported by grant
#6356-2004 from Fonds de recherche Québec—Santé
(FRQ-S) and by the MHCC. Yanick Charette acknowledges
the support of the Social Sciences and Humanities Research
Council of Canada in the form of a doctoral fellowship.
Dr Crocker received consecutive salary awards from the
Canadian Institutes of Health Research (CIHR) and FRQ-S,
as well as a William Dawson Scholar award from McGill
University while conducting this research. Leila Salem
currently holds a FRQ—Society and Culture doctoral
fellowship. Dr Nicholls would like to acknowledge the
support of the Michael Smith Foundation for Health
Research and the CIHR for consecutive salary awards.
This study could not have been possible without the full
collaboration of the Quebec, British Columbia, and Ontario
Review Boards, and their respective registrars and chairs.
We are especially grateful to attorney Mathieu Proulx,
Bernd Walter, and Justice Douglas H Carruthers and Justice
Richard Schneider, the Quebec, British Columbia, and
consecutive Ontario RB chairs, respectively.
The authors sincerely thank Erika Jansman-Hart and
Dr Cathy Wilson, Ontario and British Columbia
coordinators, respectively, as well as our dedicated research
assistants who coded RB files and Royal Canadian Mounted
Police criminal records: Erika Braithwaite, Dominique
Laferrière, Catherine Patenaude, Jean-François Morin,
Florence Bonneau, Marlène David, Amanda Stevens,
Stephanie Thai, Christian Richter, Duncan Greig, Nancy
Monteiro, and Fiona Dyshniku.
Finally, the authors extend their appreciation to the members
of the Mental Health and the Law Advisory Committee of
the Mental Health Commission of Canada (MHCC), in
particular Justice Edward Ormston and Dr Patrick Baillie,
consecutive chairs of the committee as well as the National
Trajectory Project advisory committee for their continued
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T H E C A NA D I A N J O U R NA L O F
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www.TheCJP.ca
Please include full citation information, including article title, issue date, and page numbers, as well as quantities needed.
134 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
www.LaRCP.ca
CanJPsychiatry 2015;60(3):135–145
National Trajectory Project
The National Trajectory Project of Individuals Found Not
Criminally Responsible on Account of Mental Disorder.
Part 5: How Essential Are Gender-Specific Forensic
Psychiatric Services?
Tonia L Nicholls, PhD1; Anne G Crocker, PhD2; Michael C Seto, PhD3;
Catherine M Wilson, PhD4; Yanick Charette, MSc (PhD Candidate)5; Gilles Côté, PhD6
1
Associate Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia; Senior Research Fellow,
Forensic Psychiatric Services Commission, BC Mental Health & Substance Use Services, Coquitlam, British Columbia.
Correspondence: Forensic Psychiatric Hospital, 70 Colony Farm Road, Coquitlam, BC V3C 5X9; [email protected].
2
Associate Professor, Department of Psychiatry, McGill University, Montreal, Quebec; Associate Director, Policy and Knowledge Exchange,
Douglas Mental Health University Institute Research Centre, Montreal, Quebec.
3
Director of Forensic Rehabilitation Research, Royal Ottawa Health Care Group, Brockville, Ontario.
4
Post-doctoral Research Fellow, University of British Columbia and British Columbia Forensic Psychiatric Services Commission,
BC Mental Health & Substance Use Services, Coquitlam, British Columbia.
5
Post-doctoral Fellow, Department of Sociology, Yale University, New Haven, Connecticut.
6
Professor, Department of Psychology, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec; Director, Philippe-Pinel Institute Research Centre,
Montreal, Quebec.
Key Words: female, gender,
forensic, mental health,
psychiatric, National Trajectory
Project, review board, not
criminally responsible on
account of mental disorder
Received May 2014, revised,
and accepted October 2014.
open
access
Objective: To state the sociodemographic characteristics, mental health histories, index
offence characteristics, and criminal histories of male and female forensic psychiatric
patients. Clinicians and researchers advocate that mental health and criminal justice
organizations implement gender-specific services; however, few studies have sampled
forensic patients to evaluate the extent to which men’s and women’s treatment and
management needs are different.
Method: Data were collected from Review Board files from May 2000 to April 2005 in the
3 largest Canadian provinces. Using official criminal records, participants were followed
for 3 to 8 years, until December 2008. The final sample comprised 1800 individuals:
15.6% were women and 84.4% were men.
Results: There were few demographic differences, but women had higher psychosocial
functioning than men. Both men and women had extensive mental health histories;
women were more likely diagnosed with mood disorders and PDs and men were more
likely diagnosed with schizophrenia spectrum disorders and SUDs. The nature of the
index offence did not differ by gender, except women were more likely to have perpetrated
murders and attempted murders. For offences against a person, women were more
likely to offend against offspring and partners and less likely to offend against strangers,
compared with men. Women had significantly less extensive criminal histories than men.
Conclusions: Not criminally responsible on account of mental disorder–accused
women have a distinct psychosocial, clinical, and criminological profile from their male
counterparts, which may suggest gender-specific assessment, risk management, and
treatment in forensic services could benefit patients. The findings are also consistent with
traditional models (Risk-Need-Responsivity) and ultimately demonstrate the importance of
individual assessment and client-centred services.
WWW
www.TheCJP.ca
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 135
National Trajectory Project
Projet national des trajectoires des personnes déclarées non
criminellement responsables pour cause de troubles mentaux
au Canada. Partie 5 : Les services de psychiatrie légale
sexospécifiques sont-ils essentiels?
Objectif : Établir les caractéristiques sociodémographiques, les antécédents de santé
mentale, les caractéristiques de l’infraction répertoriée, et les antécédents criminels
des patients masculins et féminins de psychiatrie légale. Cliniciens et chercheurs
revendiquent que les organisations de santé mentale et de justice pénale offrent des
services sexospécifiques; toutefois, peu d’études ont évalué à quel point les besoins de
traitement et de prise en charge des hommes et des femmes sont différents dans des
échantillons de patients médicolégaux.
Méthode : Les données ont été recueillies dans les dossiers de la CE, de mai 2000 à
avril 2005, dans les 3 provinces les plus populeuses. Au moyen des casiers judiciaires
officiels, les participants ont été suivis de 3 à 8 ans, jusqu’en décembre 2008.
L’échantillon final comptait 1800 personnes dont 15,6 % étaient des femmes et 84,4 %,
des hommes.
Résultats : Il y avait peu de différences démograhiques, mais les femmes avaient un
fonctionnement psychosocial plus élevé que celui des hommes. Les hommes comme
les femmes avaient de longs antécédents de santé mentale, les femmes étant plus
susceptibles de recevoir un diagnostic de trouble de l’humeur ou de la personnalité et les
hommes, un diagnostic du spectre de la schizophrénie ou d’un trouble lié aux substances.
La nature de l’infraction répertoriée ne différait pas selon le sexe, sauf que les femmes
étaient plus susceptibles d’avoir commis un meurtre ou une tentative de meurtre. Pour
les infractions contre la personne, les femmes étaient plus susceptibles de s’en prendre
à leurs enfants et leurs partenaires et moins à des étrangers, comparées aux hommes.
Elles avaient des antécédents criminels significativement moins lourds que les hommes.
Conclusions : Les femmes NCRTM ont un profil psychosocial, clinique et criminologique
distinct de celui des hommes, suggérant ainsi qu’une évaluation, une gestion de risque et
un traitement sexospécifiques dans les services psycho-légaux pourraient bénéficier aux
patients. Les résultats sont aussi conformes aux modèles traditionnels (risque-besoinréceptivité) et démontrent finalement l’importance de l’évaluation individuelle et des
services axés sur le client.
I
t is well recognized that women in the general population
represent much less risk of violence and crime to
the general public than men.1 Women are substantially
less likely to come into conflict with the law while men
are disproportionately responsible for violent offences
(for example, robbery, sexual offences, assault, and
homicide).2,3 According to feminist criminological theories,
the genesis of female crime is proposed to represent risk
factors and pathways that are unique to girls and women.4,5
In light of this perspective, experts have been increasingly
advocating that the provision of services must reflect
the gender-specific profiles of women offenders.6,7 For
instance, emotional, physical, and sexual abuse among
female offenders has been found to exceed abuse histories
Abbreviations
K-WKruskal-Wallis
Clinical Implications
•
The findings suggest that NCRMD women are a multiproblem population and present with a profile that
overlaps considerably with their male counterparts.
•
Compared with men, despite similarities in the severity
of the index offence, women found NCRMD are
significantly less likely to have a criminal history and
to offend against strangers, suggesting that they may
present less risk to the public.
•
The results reflect the essential nature of individualized
assessment and treatment and offer preliminary
support for testing gender-informed approaches to
risk assessment and gender-responsive treatment in
forensic psychiatric settings.
Limitations
•
Generalizability is limited owing to sampling from only 3
Canadian provinces.
•
The study is based on archival data and official records;
in the absence of interviews we were limited in the
variables we could attend to (for example, insufficient
information pertaining to strengths or protective factors)
and the confidence we have in some data (for example,
diagnoses), as a result of missing information.
•
Further research specific to Aboriginal women and
other subgroups (for example, diagnostic and offence
categories) is needed.
NCRMD not criminally responsible on account of mental disorder
NTP
National Trajectory Project
PD
personality disorder
PTSD
posttraumatic stress disorder
RB
review board
SUD
substance use disorder
136 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
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The National Trajectory Project of Individuals Found NCRMD: Part 5: How Essential Are Gender-Specific Forensic Psychiatric Services?
among male offenders.8,9 Women who come into conflict
with the law typically have substantially higher rates of
mental disorder, social and environmental disadvantage
(for example, education, unemployment, and poverty), and
unique behavioural manifestations of mental disorders (for
example, more frequent self-harm and suicide attempts)
than men.1
The purpose of our study was to compare the profiles of
men and women found NCRMD. Our 4 hypothesies were
as follows:
Research suggests that the gender gap in the risk of
aggression, crime and violence is considerably reduced
among people with mental illness. For example, Nicholls
et al10 found that among all forensic psychiatric inpatients
treated during a 1-year period (n = 527), women perpetrated
all forms of aggression—any aggression, verbal aggression,
property damage, physical aggression, and sexually
inappropriate and (or) aggressive behaviour—at rates
that equalled or exceeded male rates. These findings are
consistent with a larger body of work pointing to the extent
to which psychiatric dysfunction drastically mitigates
the otherwise large sex crime ratio in aggression and
offending.11,12
2) Based on lifetime prevalence rates of mental disorders,
we expected the men and women would have different
patterns of diagnoses.24 However, given the specific
legislation for an NCRMD finding, we hypothesized
men and women would have similar symptoms at the
index offence.25
The discourse and research on gender-informed care has
been heavily concentrated on correctional samples, to
the neglect of women in the forensic system.13 Research
examining the extent to which men and women in conflict
with the law require gender-specific services has also
yielded somewhat equivocal findings.6,14 Moreover, the
sociological and criminological literature suggests that
we may expect to see important differences between
correctional and forensic samples of women, as a reflection
of the medicalization of female offending, compared with
the criminalization of male offending (that is, reconstructing
female offending as a reflection of the need for treatment,
compared with punishment in response to male offending),
the chivalry hypothesis (paternalism reflected in sentencing
disparities),15–17 or, conversely, biased perspectives of
women who perpetrate offences, particularly of a violent
nature, as doubly deviant (that is, resulting in harsher
responses to women who transgress social and [or] legal
norms and gender norms).18
In one of the few studies to speak to gender-specific
interventions in the forensic context, Coid et al19
recommended therapeutic regimes specialized for women
to reflect their unique psychiatric, criminal histories, and
index offences. Identifying the primary drivers relevant to
offending and violence among women with mental illness
who come into conflict with the law is the first step to
ensuring appropriate services and enhancing community
safety for this population.
Present Study
The purpose of the NTP was to document the characteristics
of people found NCRMD in Canada. Our other papers in
this special issue have investigated national trends and
cross-provincial comparisons.20–23 An overarching objective
of the NTP was to examine each of the findings with respect
to gender.
www.TheCJP.ca
1) The women would present with unique
sociodemographic profiles indicative of greater
marginalization, more mental health problems, and
poorer functioning than men.1
3) Despite anticipating no differences in the severity of
the most serious index offence,10–12 differences were
expected to be evident in the relationship with the
victim (that is, women were hypothesized to be more
likely to offend against children and spouses and less
likely to offend against strangers than men).1,26
4) Compared with the men, we anticipated the women
would have less extensive criminal histories (for
example, first offence at older age, fewer previous
convictions, fewer violent offences, and fewer prior
NCRMD findings).1,27
Method
Our paper is part of the NTP, described in greater detail
in this special feature.23 Briefly, we sampled 1800 men
(84.4%) and women (15.6%) found NCRMD and under
the jurisdiction of RBs from the 3 provinces with the
most NCRMD findings in Canada (British Columbia =
222; Ontario = 484; Quebec = 1094). Weights were used
to ensure the regional representativeness of the Quebec
sample, thus totals will not always add to 1800 or 100%.
The sample included people found NCRMD between May
2000 and April 2005. Participants were followed for 3 to
8 years using official criminal records. Reflecting details
gleaned from expert reports to the RB and the dispositions
and rationale provided by the RB, as well as Royal
Canadian Mounted Police finger print services records
(lifetime criminal records), we collected extensive, archival
information pertaining to sociodemographic characteristics,
criminal histories, mental health histories, and index
offences. The institutional RBs at each of the investigator’s
primary affiliated universities approved this research.
Analytic Strategy
To compare and contrast the characteristics of male and
female NCRMD–accused index offences, we completed
bivariate analyses using chi-square tests for categorical
variables and K-W tests for continuous variables that were
not normally distributed. Post hoc pairwise comparisons
were conducted for significant omnibus results. Next, a
logistic regression was used to define NCRMD–accused
profiles by gender, all other things being equal. Only
variables with less than 10% missing data were included
to avoid excessive sample reduction in the overall model.
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 137
National Trajectory Project
Table 1 Sociodemographic characteristics at the time of the index verdict of not criminally responsible
on account of mental disorder–accused men and women
Sociodemographic characteristic
Men
n (%) or mean (SD)
Women
n (%) or mean (SD)
χ2, df, n, P
0.71, 2, 1799, 0.70
Location, n (%)
British Columbia
189 (12.4)
33 (11.8)
Quebec
927 (61.0)
166 (59.3)
403 (26.5)
81 (28.9)
Age, years, mean (SD)
35.8 (12.5)
40.6 (11.2)
53.24,a 1, 1989, <0.001
Aboriginal status, n (%)
45 (3.0)
8 (2.9)
0.009, 1, 1800, <0.92
Yes
507 (47.3)
115 (60.1)
10.81, 1, 1266, <0.001
No
566 (52.7)
77 (39.9)
Ontario
High school completed, n (%)
Civil or marital status, n (%)
In a relationship
200 (14.3)
71 (27.6)
Single
1199 (85.7)
186 (72.4)
English
668 (61.1)
117 (63.6)
French
294 (26.9)
51 (27.7)
Other
132 (12.1)
16 (8.7)
Canada
635 (65.7)
111 (68.1)
Other
332 (34.3)
52 (31.9)
28.19, 1, 1656, <0.001
Language, n (%)
1.75, 2, 1278, 0.42
Country of birth, n (%)
15.81, 4, 1561, 0.003b
Residential status, n (%)
Living alone
399 (30.3)
94 (38.2)
Living with spouse, family,
or friends
572 (43.5)
113 (46.1)
Supervised setting
Homeless
Other
0.37, 1, 1130, 0.54
113 (8.6)
17 (6.9)
133 (10.1)
11 (4.5)
99 (7.5)
10 (4.1)
2.67, 2, 1372, 0.26
Income, n (%)
Own paid work (or partner)
189 (16.2)
28 (13.9)
Pension and (or) welfare
828 (70.8)
154 (76.2)
Other
153 (13.1)
20 (9.9)
Weights were used to ensure the regional representativeness of the Quebec sample, thus totals will not always add to
1800 or 100%.
a
Kruskal–Wallis
b
Living alone, men < women χ2 (n = 1562) = 5.98, df = 1, P = 0.01; homeless, men > women χ2 (n = 1130) = 7.86, df = 1,
P = 0.005
Results
Sociodemographic Characteristics
Women represented a minority of the total sample (15.6%)
and the gender split did not vary significantly across the 3
provinces (British Columbia = 14.9%; Ontario = 16.7%;
Quebec = 15.2%) [χ2 (n = 1799) = 0.71, df = 2, P < 0.70]. With
the exception that women were older at the time of the index
offence, no gender differences were found regarding basic
demographic characteristics, including language, ethnicity,
or country of birth (Table 1). As expected, there were several
significant gender differences in the psychosocial profile of
138 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
the patients, but these tended to be in the opposite direction
hypothesized. Compared with the men, the women were
more likely to be in a relationship and to have completed a
high school diploma prior to the index offence. Men were
significantly more likely than women to be homeless or to
have been living in a supervised setting, whereas women were
more likely to be residing alone or with family (Table 1).
Mental Health Characteristics
We examined psychiatric histories, mental health symptoms
at the time of the index offence, and the experts’ diagnoses
at the time of the NCRMD verdict, by gender (Table 2).
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The National Trajectory Project of Individuals Found NCRMD: Part 5: How Essential Are Gender-Specific Forensic Psychiatric Services?
Table 2 Psychiatric diagnoses and co-occurring disorders at not criminally responsible on account
of mental disorder verdict and mental state at the time of the offence by gender
Men, n (%)
Women, n (%)
χ2, df, n, P
Psychotic spectrum disorder
1084 (71.8)
184 (66.2)
3.57, 1, 1788, 0.06
Mood spectrum disorder
335 (22.2)
79 (28.4)
5.10, 1, 1787, 0.02
91 (6.0)
15 (5.4)
0.17, 1, 1788, 0.68
SUD
490 (32.5)
60 (21.6)
13.06, 1, 1787, <0.001
PD
150 (9.9)
40 (14.4)
4.91, 1, 1788, 0.03
SMI + substance use disorder
460 (30.5)
56 (20.1)
12.22, 1, 1787, <0.001
SMI + personality disorder
135 (8.9)
34 (12.2)
2.96, 1, 1787, 0.09
Psychiatric characteristic
Primary diagnosis at time of verdict
Other disordera
Mental state at time of the offence
881 (58.0)
155 (55.4)
0.68, 1, 1799, 0.41
Hallucinations—specified
307 (20.2)
50 (17.8)
0.87, 1, 1800, 0.35
Delusions—specified
Any psychotic symptom
707 (46.5)
123 (43.9)
0.65, 1, 1799, 0.42
Suicidal ideation
88 (5.8)
25 (8.9)
3.95, 1, 1799, 0.047
Suicide attempt
22 (1.4)
9 (3.2)
4.35, 1, 1799, 0.04
Self-harm
23 (1.5)
7 (2.5)
1.40, 1, 1799, 0.24
Homicidal ideation
Substance use and (or) under the influence
85 (5.6)
24 (8.6)
3.69, 1, 1800, 0.05
368 (24.2)
48 (17.2)
6.78, 1, 1801, 0.009
Weights were used to ensure the regional representativeness of the Quebec sample, thus totals will not always add to
1800 or 100%.
a
Includes, for example, organic and anxiety disorders
PD = personality disorder; SMI = serious mental illness; SUD = substance use disorder
Consistent with women being older at the time of the index
offence, we found that the women (mean years 31.33, SD
11.89) were also older than the men (mean years 28.21, SD
11.41) at the time of their first psychiatric hospitalization
[K-W χ2 (n = 1608) = 20.34, df = 1, P < 0.001]. There were
no gender differences regarding participants’ ages at the time
of their first psychiatric consultations (women mean years
28.25, SD 12.59; men mean years 26.48, SD 11.68) [K-W
χ2 (n = 1102) = 2.79, df = 1, P < 0.10]. Men and women had
a comparable number of prior psychiatric hospitalizations
(women mean = 4.34, SD 5.91; men mean = 3.68, SD 5.51)
[K-W χ2 (n = 1585) = 2.56, df = 1, P = 0.11].
Regarding their primary diagnoses at the time of the
NCRMD verdict, according to the expert reports provided
to the courts and RBs, the women had a significantly higher
rate of mood disorders than the men. SUDs were also
significantly more common among the men, but we found
that the rate of PDs diagnosed in the women (n = 40, 14.4%)
exceeded that of the men (n = 150, 9.9%) [χ2 (n = 1788) =
4.91, df = 1, P = 0.03] (Table 2). Among that small minority
of NCRMD–accused people to be diagnosed with a PD
(n = 190), women (n = 15, 36.6%) were more likely than men
(n = 13, 8.7%) to have been diagnosed with borderline PD.
Other PDs were too rarely diagnosed to make meaningful
gender comparisons.
According to both police and expert reports, the symptoms
of the men and women at the time of the index offence were
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highly comparable (Table 2). As hypothesized, we found no
gender differences regarding psychotic symptoms overall, or
when we examined hallucinations and delusions separately.
However, there were a handful of noteworthy gender
differences regarding other mental health characteristics.
The women were significantly more likely than the men to
have been noted to have suicidal ideation and (or) suicide
attempts at the time of the index offence. In contrast, the
men were significantly more likely than the women to have
been using substances at the time of the offence that lead to
the index NCRMD finding.
Criminological Characteristics
Nature of the Index Offence
Overall, there was no significant difference in the nature and
severity of the most severe offences that led to the men’s
and women’s NCRMD findings [χ2 (n = 1801) = 13.75,
df = 8, P = 0.09] (Table 3). As hypothesized, women
(64.5%) were as likely as men (65.1%) to be facing charges
for an offence against a person. In addition, women (9.6%)
had substantially more offences causing death or attempting
to cause death, than men (6.3%) [χ2 (n = 1799) = 4.10,
df = 1, P = 0.04].
Relationship to the Victim
When the index offence involved an offence against a person,
we were able to obtain details about the relationship between
the NCRMD accused and their victim in 92.7% of cases
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 139
National Trajectory Project
Table 3 Characteristics of the index offence and relationship with the victim of not criminally
responsible on account of mental disorder–accused for offences against the person
Characteristic
Men, n (%)
Women, n (%)
χ2, df, n, P
96 (6.3)
27 (9.6)
4.10, 1, 1799, 0.04
Most severe index offence characteristic
Causing death or attempting
Sex offences
Assaults
39 (2.6)
2 (0.7)
3.66, 1, 1801, 0.06
401 (26.4)
78 (27.8)
0.23, 1, 1801, 0.63
27 (1.8)
6 (2.1)
0.17, 1, 1801, 0.68
Threats or other offences against a person
425 (28.0)
68 (24.3)
1.62, 1, 1799, 0.20
Property offences
246 (16.2)
58 (20.6)
3.34, 1, 1800, 0.07
95 (6.2)
15 (5.3)
0.34, 1, 1801, 0.56
Administration of justice
73 (4.8)
10 (3.6)
0.84, 1, 1800, 0.36
Other federal or provincial statutes
118 (7.8)
17 (6.0)
0.32, 1, 1800, 0.32
Stranger
221 (24.1)
25 (15.0)
6.51, 1, 1084, 0.01
Professional
211 (23.0)
37 (22.3)
0.04, 1, 1084, 0.84
112 (12.2)
18 (10.8)
0.25, 1, 1084, 0.62
78 (8.5)
15 (9.0)
0.05, 1, 1084, 0.82
Deprivation of freedom
Offensive weapons
Relationship to the victim
Police officer
Mental health worker
Other authority figure
Family
21 (2.3)
5 (3.0)
0.32, 1, 1084, 0.58
299 (32.6)
66 (39.8)
3.25, 1, 1084, 0.07
Offspring
14 (1.5)
14 (8.4)
26.67, 1, 1084, <0.001
Partner or spouse
99 (10.8)
30 (18.0)
7.12, 1, 1084, 0.008
Parent
129 (14.1)
15 (9.0)
3.07, 1, 1084, 0.08
57 (6.2)
7 (4.2)
0.97, 1, 1084, 0.32
187 (20.4)
38 (22.9)
0.60, 1, 1084, 0.44
119 (13.0)
24 (14.4)
0.28, 1, 1084, <0.60
38 (4.1)
6 (3.6)
0.09, 1, 1084, 0.76
Other family member
Other known person
Friend or acquaintance
Roommate, co-resident, or co-patient
Other
Total
30 (3.3)
8 (4.8)
1.00, 1, 1084, 0.32
918 (100.1)
166 (100)
42.58, 10, 1084, <0.001
Weights were used to ensure the regional representativeness of the Quebec sample, thus totals will not always add
to 1800 or 100%.
Fisher exact test is reported when n < 5
(Table 3). Though offences against strangers were relatively
uncommon overall (22.7%), they were significantly less
likely to be perpetrated by women (15.0%) than by men
(24.1%). In contrast, women were significantly more likely
than men to offend against offspring (8.4% and 1.5%,
respectively) and partners (18.0% and 10.8%, respectively),
but there were no gender differences for offences against a
parent or other family members. The rate of offences against
a person involving professionals (for example, police officers
and mental health workers) was nearly identical for both men
and women, as was the proportion of offences involving other
persons familiar to the perpetrator (for example, friends,
acquaintances, roommates, co-residents, and co-patients).
Criminal History
Analyses comparing the prevalence and incidence of prior
offending revealed several important gender differences
(Table 4). Overall, men had more extensive criminal
histories, and that finding remained consistent regardless
140 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
of the type of offence and verdict examined. Specifically,
the men were significantly more likely to have a prior
NCRMD finding, and were also more likely to have a
criminal conviction that predated the index offence, than
the women. Taken together, men were significantly more
likely to have a criminal history (prior NCRMD finding
or criminal conviction combined) and this pattern held for
both offences against a person and for any offence.
NCRMD Profiles by Gender
A logistic regression analysis was conducted to predict
gender of NCRMD–accused people, using mental health
history, criminal history, and details of the index offence
as predictors, producing a significant model (‒2LL [log
likelihood] = 1207.72; χ2 = 96.85; df = 17, P < 0.001;
Nagelkerke pseudo-R² = 10.6%). Results showed that all
other variables being equal, women were more likely than
men to be diagnosed with a PD (OR 2.23, 95% CI 1.44 to
3.45, P < 0.001), to be older at the time of the first offence
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The National Trajectory Project of Individuals Found NCRMD: Part 5: How Essential Are Gender-Specific Forensic Psychiatric Services?
Table 4 Criminal histories of not criminally responsible on account of mental disorder (NCRMD)–accused by
gender
Criminal history
Men, n (%)
Women, n (%),
χ 2, df, n, P
Total, n (%)
Any previous conviction or NCRMD finding
797 (52.5)
88 (31.4)
47.88, 1, 1799, <0.001
885 (49.2)
Offence against a person
504 (33.2)
52 (18.6)
23.57, 1, 1800, <0.001
556 (30.9)
Other offence
683 (45.0)
70 (24.9)
39.19, 1, 1800, <0.001
753 (41.8)
756 (49.7)
82 (29.2)
40.28, 1, 1801, <0.001
838 (46.5)
Offence against a person
464 (30.5)
46 (16.4)
4.44, 1, 1799, <0.001
510 (28.3)
Other offence
659 (43.4)
68 (24.2)
36.15, 1, 1801, <0.001
727 (40.4)
Any previous NCRMD finding
133 (8.8)
14 (5.0)
4.44, 1, 1799, 0.04
147 (8.2)
Offence against person
85 (5.6)
9 (3.2)
2.71, 1, 1799, 0.10
94 (5.2)
Other offence
60 (3.9)
5 (1.8)
3.18, 1, 1799, 0.08
65 (3.6)
Any previous conviction
against a person (OR 1.05, 95% CI 1.01 to 1.09, P = 0.05),
and less likely to have a prior criminal conviction (OR 0.46,
95% CI 0.29 to 0.71, P = 0.001) (Table 5).
Discussion
Consistent with gender-informed theories of offending and
evidence of female-specific pathways into crime,1,4,5 we
concluded that although men and women found NCRMD
present with many of the same characteristics, there are also
many differences in their profiles relevant to treatment and
management. In particular, our results indicate that women
found NCRMD present with significantly fewer criminogenic
needs than their male counterparts. Similar to prior research
examining women in secure forensic psychiatric services, the
results suggest that women in this population may require
similarly intensive mental health interventions as men but
may be more appropriate for community care once their
psychiatric symptoms abate.19 In particular, compared with
men, female NCRMD acquittees could benefit from less
intensive and (or) different management strategies regarding
criminogenic needs.28 However, further research is needed
to determine the need for internal and perimeter security
measures for women found NCRMD, particularly in the
presence of PDs.19,28 For instance, Nicholls et al10 found
that inpatient incidents of aggression and violence were as
common among female forensic patients as male patients.
Smith et al28 similarly concluded that the management
problems evident in their sample of female patients may
justify a custodial disposition in a secure hospital. That said,
it could also be the case that the secure setting exacerbates
behavioural disturbances and symptoms among these women
(and men, for that matter) who often present with high rates
of victimization and trauma, particularly in childhood.19,29,30
Characteristics of NCRMD–Accused People:
Contrasting the Profiles of Men and Women
Sociodemographic Characteristics
In many ways, the sociodemographic profiles of the men and
women in this large and representative sample of Canadians
found NCRMD overlap; with the exception of age, none
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of the demographic variables distinguished women from
men. However, a consideration of variables relevant to
psychosocial functioning revealed some important gender
differences; for instance, men were significantly more likely
than women to be homeless prior to the index offence. Taken
together, the results suggest that, contrary to our hypotheses
(based largely on correctional research comparing men
and women), the women had achieved somewhat greater
levels of social integration and higher degrees of daily
functioning than the men (for example, higher rates of
marriage and [or] cohabitation, high school completion,
and independent living). Late-onset schizophrenia and
other psychotic disorders in women may account for the
age discrepancy and provide women more time than men
to build up protective factors (for example, obtaining an
education and establishing a romantic relationship) before
becoming ill, thereby reducing their vulnerability to being
criminalized.31,32 That said, these results must be considered
cautiously, given we are relying on gross indicators of social
integration and daily functioning. Many important variables
to draw firm conclusions about illness onset, marginalization,
disadvantage, and psychosocial functioning were unavailable
in our study (for example, social support and activities of
daily living) as a result of our reliance on secondary data;
they will be addressed in our ongoing prospective research.33
Mental Health Characteristics
We measured multiple indicators of the severity of the
sample’s mental illness, including variables relevant to the
men’s and women’s mental health histories, their symptoms
at the time of the index offence, as well as their diagnoses
at the index NCRMD verdict. Although some gender
differences were evident, in many respects the variations
cannot be easily interpreted (for example, to suggest that
women or men suffered from more persistent or more severe
mental disorders). With the exception that women were
older at the time of their first psychiatric hospitalization,
there was no evidence to suggest the men and women in our
sample had highly divergent mental health histories.
A consideration of the NCRMD–accused person’s mental
state at the time of the index offence is particularly relevant,
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 141
National Trajectory Project
Table 5 Logistic regression predicting gender of not
criminally responsible on account of mental disorder
(NCRMD)–accused people (men = 0, women = 1;
n = 1569)
OR
(95% CI)
Ontario
1.29
(0.92 to 1.81)
British Columbia
1.04
(0.65 to 1.67)
Aboriginal status
1.62
(0.72 to 3.63)
Age at the index offence
0.99
(0.95 to 1.03)
Psychosis
1.52
(0.76 to 3.06)
Mood
1.93
(0.93 to 4.00)
Substance
0.71
(0.50 to 1.01)
Personality
2.23
(1.44 to 3.45)a
Covariates
Province (Quebec as reference)
Diagnosis (nonexclusive)
Presence of psychiatric history
1.10
(0.80 to 1.51)
Age at first offence against person
1.05
(1.01 to 1.09)b
Presence of criminal history
NCRMD
0.66
(0.34 to 1.28)
Criminal
0.46
(0.29 to 0.71)c
Against person
1.25
(0.70 to 2.24)
Index most severe offence (Others
as reference)
Clinical Implications
Homicides or attempted
1.37
(0.73 to 2.57)
Assault and sexual assaults
1.10
(0.67 to 1.80)
Other crimes against person
0.98
(0.60 to 1.62)
Property crimes
1.22
(0.66 to 2.26)
–2 LL [log likelihood] = 1207.72; χ = 96.85, df = 17, P < 0.001;
Nagelkerke pseudo-R² = 10.6%
2
a
Criminological Characteristics
We found no evidence that the NCRMD–accused women
in our sample perpetrated less serious index offences than
the men. In fact, the women had a nearly identical rate of
offences against a person when compared with the men,
and perpetrated significantly more offences that did or
could result in death.37,38 Also of note, offences such as
prostitution, drug possession and (or) trafficking, crime
categories that often are highly represented among women
offenders, in general,27 were negligible in our sample. The
marked gender disparities in the participants’ criminal
histories mirrors what we see in the general public and
the general offender populations,1,27 yet the nature of the
index offence is consistent with research on offending12,38
and aggression and (or) violence10 among women with
mental disorders. In sum, the results suggest that despite
female NCRMD acquitees coming into forensic psychiatric
services for offences that parallel their male counterparts
(in terms of severity), they have substantially fewer prior
criminal offences. Consistent with the extant literature,39 this
would suggest that provided their psychiatric symptoms are
resolved, women found NCRMD likely pose significantly
less threat of recidivism than men.
P < 0.001; b P < 0.05; c P < 0.01
given that should be precisely what dictates who will or
will not be found NCRMD (that is, the capacity of the
accused to form mens rea). Despite considerable debate
in the literature regarding the extent to which women are
given leniency or are treated more harshly when in conflict
with the law, and given the letter of the law is very clear on
the matter, we anticipated that similarly severe psychotic
symptoms would be required to receive an NCRMD finding
regardless of the gender of the accused person. The results
largely matched our expectations; there was no gender
difference in the rate of delusions, hallucinations, or a
combined category of psychotic symptoms by gender of the
accused. Moreover, although some prominent differences
were evident, they are not relevant to the legislation and
an NCRMD finding, per se. Specifically, consistent with a
large substance abuse literature,34 the men had significantly
higher rates of substance use at the time of the offence.
The women had higher rates of suicidality (ideation and
attempts) than the men.35,36 Also typical of the extant
literature,24 women were also more likely to be diagnosed
with mood spectrum disorders, and men were more likely
to have SUD diagnoses recorded on file.
142 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
The mandate of the provincial RBs is to protect the public
while safeguarding the needs of people found NCRMD
(Criminal Code, Section 672.54).25 Our pursuit of this
research reflects our perception that, to the extent that
dangerousness, mental condition, and other needs of the
accused vary by gender, these issues should be considered
in treatment planning. As would be expected, our findings
document substantial overlap in the profiles of Canadian
men and women found NCRMD, yet several prominent
features distinguish the 2 groups. These results have direct
implications for treatment planning and rehabilitation
prospects with women, as a reflection of their higher pre–
NCRMD functioning overall and evidence to suggest they
are less likely than the men to be entrenched in a criminal
lifestyle. Clinicians should be aware of the potential for
gender differences in their management and treatment of
forensic patients, but ultimately, individualized assessment
should be the standard of practice, regardless of gender.40
The coexistence of multiple pathologies in this complex
population is apt to hinder optimal treatment and potential
resolution of the individual’s problems.41,42 For instance,
patients with multi-morbidities and treatment-resistant
disorders should be singled out for intensive case
management early on, but particularly on return to the
community.43 However, we remain mindful that simply
because a diagnosis is not recorded on the files does not
necessarily indicate that relevant characteristics are not
being imbedded in a patient’s treatment and (or) discharge
plan, thus making prospective studies a priority. Given the
potential for gender biases in diagnostic determinations,
this will be a particularly interesting avenue of research
for informing discussion about gender needs in this
www.LaRCP.ca
The National Trajectory Project of Individuals Found NCRMD: Part 5: How Essential Are Gender-Specific Forensic Psychiatric Services?
population. Two specific categories of diagnoses appeared
conspicuously absent, PDs and PTSD.
The low base rates of PDs recorded on file may suggest
that insufficient attention is being drawn to the challenges
inherent in treating that important subgroup of people who
frequently have a poor prognosis owing to the challenges in
attracting them to treatment and keeping them engaged (for
example, low insight, poor attendance, high dropout rates).44
Given the primary objective of the initial expert reports in
NCRMD cases is foremost on the extent to which Axis I
disorders and psychotic symptoms were evident at the time
of the offence, this may not be surprising. Nonetheless, the
scope of the diagnostic inquiry does not appear to expand
substantially during the course of the time the patients are
under the purview of the RBs, indicating that potentially
important insights into treatment and management may be
overlooked. The low base rates overall, and the disparity in
rates of PDs among men and women in secure forensic care
specifically, could also reflect the preference to assign men
with PDs to the criminal justice system and women to the
mental health or forensic system.19,28
Our data also point to a lack of attention to trauma and
victimization among forensic patients as just 11 cases
mentioned PTSD (4 women and 7 men). Trauma is a topic
of considerable relevance to any mental health or criminal
justice population, and potentially of particular relevance
to women in forensic settings. Although adverse events are
relatively ubiquitous in the general population,45 severe,
chronic, and repeated victimization and violence resulting
in complex trauma are much more widespread within
populations that come into conflict with the law and live
with mental disorders (for example, foster care placements,
experiences of neglect, and physical and sexual abuse that
are often not single events but rather repeated pervasive
processes).9,46–48 These experiences have intermingled and
prolonged detrimental effects, including exacerbating mental
illness, personality changes, and increased vulnerability to
repeated victimization.49–51 Experts46,48 assert that unlike
single traumatic events, the conditions found among people
who suffer repeated neglect, violence, and abandonment are
reflected in wide-ranging neurobiological and behavioural
deficits. An appreciation of the complexity and the range
of the implications of dysfunctional and traumatic histories
is an essential component of a forensic service. Ensuring
that people are assessed thoroughly when they come under
the purview of the RB could aid substantially in identifying
appropriate treatment and management options.
Strengths and Limitations
The capacity to examine female forensic psychiatric patients
in prior research has been seriously thwarted by small sample
sizes, underscoring the necessity of subsequent research
with this unique population. The NTP provides one of the
largest samples of female forensic psychiatric patients ever
available for study,19 and is the first national examination
of the characteristics and longitudinal processing of people
found NCRMD in Canada since Criminal Code changes
www.TheCJP.ca
in 1992 with a representative sampling design. Having
280 women in this sample allowed us to speak to low
base rate behaviours (for example, suicidality at the time
of the offence, sexual offences) in a population for whom
research to advance evidence-informed practice is lacking.
Despite the study’s strengths there are several limitations
that suggest caution is warranted in the interpretation and
application of the results.
The most important limitation of the study is that we
relied on archival records and official data sources,
thereby limiting our ability to speak to certain issues (for
example, protective factors and [or] a patient’s strengths).
For instance, in the absence of interviews we cannot know
for certain if living independently was actually evidence of
strengths and capacities of the women in the sample, or if it
might have reflected a lack of support and supervision and
ultimately played a role in their deteriorating mental health,
culminating in the index offences. The reliance on secondary
data also has implications to the extent there is consistency
in documentation between provinces, clinicians, and RBs
(for example, suicidality at the time of the offence) and the
amount of inquiry into symptoms and diagnostic categories.
Of specific relevance to studying gender differences and
similarities, research suggests that clinicians attend to
different factors when working with male and female
patients.52 Commentators also note that clinicians feel a
greater need to explain female deviancy than male deviancy.
As such, future research using more rigorous and resource
intensive study designs is urgently required. For instance,
prospective studies examining the extent to which there
are truly higher rates of PDs in NCRMD–accused women,
compared with NCRMD–accused men, and the extent
to which victimization and trauma is uniquely relevant to
this population is needed. The extent to which biases and
heuristics among clinicians affected our results in general,
and regarding gender, specifically, is unknown.
Conclusions
Our study clearly points to the need to continue to explore
NCRMD–accused people’s clinical and criminogenic
needs in more detail, preferably using longitudinal designs.
The results reflect the essential nature of individualized
assessment and treatment. To clarify, although there are
evidently important differences between the average man
and the average woman found NCRMD, there is also
substantial within-gender variability. For instance, although
women are less likely to have a criminal history on average,
there will also be men who are found NCRMD for whom
there is little evidence of any prior involvement in antisocial
activities. Clinicians should conduct individualized
assessments and avoid being biased at the outset to presume
certain characteristics about a client based on gender alone.
As such, although the results offer preliminary support for
testing gender-informed approaches to risk assessment and
gender-responsive treatment in forensic psychiatric settings,
the findings are not necessarily inconsistent with established
approaches; for instance, gender is a well-recognized
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 143
National Trajectory Project
responsivity factor in the Risk–Need–Responsivity model.40
Despite women representing a minority of forensic patients,
they are often high intensity users of services and are more
likely to offend within private relationships (for example,
against children), making their care a priority.
Acknowledgements
This research was consecutively supported by grant
#6356–2004 from Fonds de recherche Québec—Santé
(FRQ-S) and by the Mental Health Commission of Canada
(MHCC). Dr Nicholls acknowledges the support of the
Michael Smith Foundation for Health Research (MSFHR)
and the Canadian Institutes of Health Research (CIHR)
for consecutive salary awards. Dr Crocker received
consecutive salary awards from the CIHR, FRQ-S, and a
William Dawson Scholar award from McGill University
while conducting this research. Dr Wilson acknowledges
the support of the Social Sciences and Humanities Research
Council of Canada (SSHRC; Doctoral Fellowship) and
the MSFHR (Postdoctoral Research Fellowship). Yanick
Charette acknowledges the support of the SSHRC in the
form of a doctoral fellowship.
This study would not have been possible without the full
collaboration of the Quebec, British Columbia, and Ontario
Review Boards, and their respective registrars and chairs.
We are especially grateful to attorney Mathieu Proulx,
Bernd Walter, and Justice Douglas H Carruthers and Justice
Richard Schneider, the Quebec, British Columbia, and
consecutive Ontario RB chairs, respectively.
The authors sincerely thank Dr Malijai Caulet, National
Coordinator, and Erika Jansman-Hart, Ontario Coordinator,
as well as our dedicated research assistants who spent
an innumerable number of hours coding RB files and
Royal Canadian Mounted Police criminal records: Erika
Braithwaite, Dominique Laferrière, Catherine Patenaude,
Jean-François Morin, Florence Bonneau, Marlène David,
Amanda Stevens, Christian Richter, Duncan Greig, Nancy
Monteiro, and Fiona Dyshniku.
Finally, the authors extend their appreciation to the members
of the Mental Health and the Law Advisory Committee
of the MHCC, in particular Justice Edward Ormston and
Dr Patrick Baillie, consecutive chairs of the committee as
well as the National Trajectory Project advisory committee
for their continued support, advice, and guidance throughout
this study and the interpretation of results.
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th Annual Conference
1 - 3 October 2015
The Fairmont Hotel Vancouver &
Hyatt Regency Vancouver
Vancouver BC
Canadian Psychiatric Association
Dedicated to quality care
Association des psychiatres du Canada
www.cpa-apc.org
Dévouée aux soins de qualité
HIGHLIGHTS
CPA-at-the-Movies Presents:
15 Reasons to Live
Post-screening discussion with
Director Alan Zweig
www.TheCJP.ca
Expert Psychiatry Series With CAGP
The End of The Road: Enhancing Autonomy
While Managing Driving Risks in Older Adulthood
Mark Rapoport*, Holly Tuokko, David Carr
The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 145