Short-term outcomes for forensic patients receiving an absolute discharge under the Canadian Criminal Code

Abstract

There is insufficient knowledge regarding outcomes among persons who are no longer supervised by the forensic mental health system, and consequently little data to inform public perception regarding the risk of harm posed by such persons. We performed a retrospective case audit and one-year follow-up of all patients receiving an absolute discharge from compulsory forensic care in the years 2013 and 2014 (N = 60) and report on the prevalence of outcomes concerning mental health deterioration, treatment non-compliance, hospital readmission, substance use and recidivism. In the year following absolute discharge, rates of medication non-compliance, hospital readmission and violence increased significantly (odds ratios = 3.51–10.41). Discharged patients who engaged in violence or reoffending (n = 10) were characterized by greater substance use problems, and were less likely to be rated as low risk on the HCR-20. A comparison to a matched sample of community-dwelling but not absolutely discharged patients revealed that those not yet discharged experienced more symptoms of mental illness and greater problems with treatment compliance and social support. The low base rate of serious violence among absolutely discharged patients suggests that the decision-making model employed by the review board in our jurisdiction is a reasonably accurate and balanced one.

Keywords:

• Absolute discharge
• forensic mental health
• substance use
• recidivism
• violence risk

Notes

1. Defined as ‘a real risk of physical or psychological harm to members of the public that is serious in the sense of going beyond the merely trivial or annoying. The conduct giving rise to the harm must be criminal in nature.’.

2. The HCR-20 is a 20-item violence risk assessment scheme for use with adults who have a history of violence as well as mental illness and/or personality disorder. It consists of 10 items relating to historical factors (H scale; e.g. previous violence, past problems with substance use or employment, trauma history), 5 items describing current clinical concerns (C scale; e.g. insight, active symptoms of mental illness, current treatment compliance), and 5 items describing areas for future risk management (R scale; e.g. future plans for housing or employment, presence of social supports). Each item may be scored on a 3-point scale as 0 (not present), 1 (possibly or partially present), or 2 (definitely present). A final summary risk rating is then presented as low, moderate, or high.