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Changing characteristics of the Review Board population in Ontario: A population-based study from 1987-2012

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Review of long-term trends in Ontario Review Board cases, 1987-2012, funded by the Ontario Ministry of Health and Long Term Care via the Ontario Mental Health Foundation
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Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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Changing Characteristics of the Review Board
Population in Ontario: A Population-Based Study from
1987-2012
August 5, 2014
Principal Investigators:
Alexander I. F. Simpson, Stephanie R. Penney, Michael C. Seto
Co-Investigators:
Anne G. Crocker, Tonia L. Nicholls, Padraig L. Darby
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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Table of Contents
Executive summary ......................................................................................................................... 3
Introduction .................................................................................................................................... 5
Objectives........................................................................................................................................ 8
Method ........................................................................................................................................... 8
Data Analysis ................................................................................................................................. 10
Results ........................................................................................................................................... 11
ORB admission rates across time .............................................................................................. 11
Changes in demographic characteristics of ORB cases across time ......................................... 13
Changes in clinical diagnoses across time ................................................................................ 17
Changes in index offence severity across time ......................................................................... 25
Discharge rates over time ......................................................................................................... 29
Discharge rates as a function of illness and offence profile ..................................................... 29
Summary of Findings..................................................................................................................... 32
Summary and Discussion .............................................................................................................. 33
Acknowledgements ....................................................................................................................... 36
References .................................................................................................................................... 37
Appendix A .................................................................................................................................... 40
Appendix B .................................................................................................................................... 44
Appendix C .................................................................................................................................... 45
Appendix D .................................................................................................................................... 46
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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Executive summary
This report presents the results of an analysis of cases registered with the Ontario Review
Board over a 25-year period between 1987 and 2012. Cases were registered as a result of the
accused being found Unfit to Stand Trial (UST) or Not Guilty by Reason of Insanity (NGRI) up
to 1992, and then Unfit to Stand Trial or Not Criminally Responsible on account of Mental
Disorder (NCRMD) since 1992. There has been an overall increase in the number of cases
registered with the Ontario Review Board, with a significant “surge” from 1992 to 1996,
following the 1992 change in Criminal Code provisions, and then again from 2001 to 2007.
The number of ORB registrations declined from 2008 to 2012. The proportion of UST to
NCRMD cases changed dramatically through the 1990s, with a near reversal in proportions
from a majority being UST cases prior to 1992 and a majority being NCRMD cases since 1999.
The ratio of male to female cases has remained stable over time, with a mean ratio of 4:1.
The average age of ORB cases is unchanged over time, though there has been an increase in
the proportion of cases aged of 18-25. The average education level has increased over the
same time period, as has the proportion of individuals who are of non-Caucasian ethno-racial
background. These two demographic trends are consistent with broader trends in the
Canadian population. However, the largest education and ethnoracial groups have
consistently been those who have not completed high school and those who are Caucasian,
respectively.
The most common psychiatric diagnosis underlying the UST or NGRI/NCRMD finding has
consistently been a psychotic spectrum disorder such as schizophrenia, schizoaffective
disorder, or delusional disorder (typically 70-80% of cases). The proportion of individuals
diagnosed with only a psychotic spectrum disorder has declined over time; more cases are
being registered with other diagnoses, particularly comorbid substance use disorders, which
have increased steadily over time.
In terms of the most serious index offence, that is, the most severe offence resulting in a
finding of UST or NGRI/NCRMD, violent offences continue to be the most frequent,
accounting for approximately 50-60% of ORB cases; further, the proportion of individuals
charged with a violent offence as part of their index offence has increased over time.
Although uncommon, the proportion of individuals who have sexually offended has also risen
over the time period studied. The proportion of individuals committing severe acts of
violence (i.e., homicide, attempted murder, aggravated assault) has remained less frequent
than other types of violence and has also decreased over time. Lastly, the proportion of cases
with nonviolent offences has gone down over time, whereas the proportion of cases with
administrative charges has remained relatively stable.
We further examined individuals’ rate of progress through the Review Board system as a
function of their admission year, as well as illness and offence profile. Results indicated that
individuals who came under the ORB in earlier years (i.e., 1987-1992) had the slowest rate of
absolute discharge, while those coming under the Board in 2000-2005 evinced the most rapid
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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rate. Persons coming under the ORB in 1993-1999 and 2006-2012 showed an intermediate
level of absolute discharge. Having a personality disorder significantly increased the duration
of tenure under the ORB across the time period studied, as did having a comorbid substance
use disorder. In terms of offence categories, having a sexual or severely violent index offence
conferred longer duration under the Board as compared to less seriously violent or non-
violent offences.
These trends have implications for forensic mental health systems and resources. For
example, the trend towards more ORB cases under age 21 suggests there will be greater
demands for educational and vocational upgrading as part of rehabilitation efforts; the trend
towards more racially and ethnically diverse ORB cases suggests there will be greater demand
for cultural- and language-specific services; and the trend towards greater psychiatric
comorbidity, particularly for substance use disorders, suggests there will be increasing
demand for addiction services and programs in particular. As with many populations in
conflict with the law, the risk of violence remains a prominent concern given that sexual and
violent offences have risen and reflect more than half of all index offences. This is not
evidence that there is more crime being committed by people with a mental illness; rather it
shows that the defenses raised and disposition pathways taken vary according to how the
law and systems of care are perceived by mentally ill persons, their counsel and the courts.
Finally, the increasing number of young persons coming into the system may suggest the
potential for continual growth of the ORB population and increasing demand for forensic
beds in coming years.
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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Introduction
The following document is a report outlining results of an Ontario Mental Health Foundation
funded project, entitled Changing Characteristics of the Review Board Population in Ontario: A
Population-Based Study from 1987-2012.
1
This research study grew out of concern regarding
the rising number of persons subject to disposition orders under the Ontario Review Board
(ORB). Under the current law as specified in the Canadian Criminal Code (CCC; Criminal Code,
1985), persons come under the jurisdiction of the Ontario Review Board if they are found Unfit
to Stand Trial (UST, unable on account of mental disorder to conduct a defence at any stage of
the proceedings before a verdict is rendered or to instruct counsel to do so; s. 2 CCC) or if they
are found Not Criminally Responsible on account of Mental Disorder (NCRMD, incapable of
appreciating the nature and quality of a criminal act or omission or not knowing that it was
wrong; s. 16 CCC).
2
There has been increasing public policy concern regarding the rising number of persons subject
to orders under the ORB over the last 15 years (e.g., a previous Ontario Mental Health
Foundation supported review by Seto et al., 2001). The number of ORB patients was relatively
static until the early 1990s, and since that time has continued to rise at an average rate of
approximately 9% per annum (Department of Justice Canada, 2006; Simpson, Penney & Darby,
2012). This has resulted in concerns regarding pressures on forensic inpatient and community
services (Crocker & Côté, 2009; Crocker, Nicholls, Côté, Latimer, & Seto, 2010), the increasing
need for forensic inpatient beds, and rising community case loads. Such problems have resulted
in delays in gaining appropriate community placement, as well as people having to wait for
transfer to available beds. Problems developed of individuals having to wait in circumstances of
higher security than their clinical needs require, or at times, in jail awaiting an available hospital
bed. Judicial findings have been critical of Ontario in failing to increase funding of forensic
services (for example, Centre for Addiction and Mental Health v. Ontario, 2012). This trend does
not appear to be unique to Ontario, as there is evidence from other provinces and countries
showing an increase in demand for forensic mental health services (Jansman-Hart, Seto,
Crocker, Nicholls & Côté, 2011).
Ontario forensic mental health services have grown to cope with the rising demand, but the
total number of ORB cases consistently outpaced new resources. The reasons behind this
increasing trend are unclear, and there has been little systematic research to better assess
changes in the sociodemographic, clinical, and legal profiles of the growing number of
individuals coming under the ORB, as well as trends in the consequences, or outcomes, of this
1
Note that the study was originally entitled Causes and Consequences of Rising Number of Patients under the
Ontario Review Board. We have since modified the title to more accurately reflect the study’s data, methodology
and analysis.
2
Individuals found NCRMD are only transferred to a provincial Review Board if the courts make a disposition order
of Detention (custody) or Conditional Discharge (living in the community under specified conditions), or if a
disposition decision was deferred to the Review Board. Individuals who are found NCRMD and who receive a
disposition of Absolute Discharge are free to return to the community without ORB conditions.
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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increase. In particular, it is unclear if the increase in ORB cases was simply a result of more
people becoming subject to such orders each year, or an increased duration under ORB orders.
A related question is whether there has been a change in the type of people becoming subject
to those orders, either by primary psychiatric diagnosis or by the criminal offences that resulted
in such orders.
What is clear is that key changes in legislation have affected the use of the NCRMD designation
in Canada. Several landmark cases and parliamentary bills (most notably, R. v. Swain, 1991; Bill
C-30, 1992; Winko v. British Columbia, 1999) substantially impacted the way in which mentally
disordered accused travel through the forensic mental health system. Briefly, Bill C-30 came
into effect in February of 1992, arising from the constitutional challenges introduced in Swain
the previous year. Bill C-30 provided a mentally disordered accused with significantly greater
due process protections and introduced substantial procedural changes to the nature of
dispositions made available to those found NCRMD. Provincial Review Boards were established
as independent tribunals and these took over the decision-making role previously ascribed to
the Lieutenant Governor. These Boards were given the task of deciding among three possible
dispositions detention, conditional discharge, and unconditional or absolute discharge thus
replacing the automatic and indeterminate detention of individuals declared NGRI prior to 1992
(Eaves, Ogloff, & Roesch, 2000; Tollefson & Starkman, 1993).
The dispositional standards evaluated by Review Boards were subsequently addressed in Winko
v. British Columbia (1999). Winko shifted the onus of proof for demonstrating an individual’s
level of risk to public safety. Prior to Winko, the accused was required to prove that he or she
was not a significant threat before an absolute discharge would be granted. This “reverse onus”
was changed in Winko, whereby it was stated that “unless it makes a positive finding on the
evidence that the NCRMD accused poses a significant threat to the safety of the public, the
court or Review Board must order an absolute discharge”. Further, the ruling specified that
uncertainty surrounding an individual’s level of risk was insufficient to justify further detention,
even conditionally. These changes essentially ended the automatic and indefinite detention of
individuals found NCRMD and granted them the right to an annual review by an administrative
tribunal that possessed increased flexibility in disposition provisions.
Several studies have since demonstrated sharp increases in both the number of individuals
remanded for an assessment of criminal responsibility and the number of people ultimately
adjudicated as NCRMD (Nussbaum, Malcolmson, & Dosis, 2000; Ohayon & Crocker, 2000;
Roesch et al., 1997). Further, Review Board data documented rising trends in NCRMD referrals
and findings in most provinces (Department of Justice Canada, 2006; Livingston, Wilson, Tien, &
Bond, 2003; Ontario Review Board, 2012; Schneider, Forestell, & MacGarvie, 2002) and declines
in the length of hospitalization of individuals declared NCRMD, as well as increases in the
number of absolute discharges granted (Balachandra, Swaminath, & Litman, 2004; Schneider et
al., 2002). Research findings (e.g., Department of Justice Canada, 2006; Grant, 1997; Livingston
et al., 2003) also began pointing to greater heterogeneity in the sociodemographic, clinical, and
criminal offending profiles of more recent NCRMD accused as compared with older (e.g., pre-
1992) samples (e.g., Crocker et al., in press; Department of Justice Canada, 2006; Grant, 1997;
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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Livingston, Wilson, Tien, & Bond, 2003). Similarly, in Ontario, ORB annual data suggested an
increase in the rate of absolute discharges and changes in the duration of tenure under the ORB
following Winko. Examining this question across a random sample of 592 clients across three
provincial Review Boards (British Columbia, Ontario, and Quebec), however, did not support
the idea of reduced tenure post-Winko (Desmarais, Hucker, Brink, & De Freitas, 2008).
Defining the trends that are characterizing the growth in the ORB population has significant
implications for public policy, as forensic psychiatric services are costly and they involve a major
loss of liberty. Despite prior research, we currently have only a high level understanding of the
changes occurring within the population of ORB clients, and know little about how the above-
described legislative changes may have impacted these individuals’ entry, progress through,
and discharge from the Review Board system in Ontario. In particular, we have little robust
information regarding the sociodemographic, clinical, and legal characteristics of this growing
population, and importantly, how these characteristics may have changed over time. Similarly
unknown is whether people are spending comparatively more or less time under the ORB as
compared to earlier years. Within this context, the current study set out to address these
questions by gathering descriptive data on all persons made subject to ORB orders since 1987.
We chose this date so that there could be a 5 year period to serve as a baseline before the
changes enacted under Bill C-30 in 1992, as well as to cover the Winko period. Descriptive
demographic and diagnostic information was sought, as well as progress through and out of
ORB supervision, to explore these trends and their impacts at the population level.
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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Objectives
The purpose of the study is to document the rate of admission to the ORB and the demand for
forensic psychiatric services in Ontario over the past 25 years. Further, we investigate the
sociodemographic, clinical, and legal profiles of individuals coming under the ORB, and to
examine how these characteristics have changed over time. Lastly, we examine factors affecting
individuals’ duration of tenure under the ORB, to specify opportunities for policy change that
could begin to alleviate the growing demand for forensic mental health services in Ontario.
We addressed the following central questions:
1. Is the rise in ORB accused resulting in more individuals coming under the Board for less
serious offences?
2. Is the rise in ORB accused resulting in more individuals coming under the Board with less
severe or complex mental illnesses (SMI)?
3. Compared to the years following Winko, does it now take more time to receive an
absolute discharge, resulting in longer periods under the ORB for the same offence and
illness profile?
Questions 1 and 2 allow us to address whether there has been a widening in the scope of the
use of the UST or NCRMD dispositions, or an inclusion of new populations of mentally
disordered persons that were not previously likely to receive such a disposition. Question 3
allows us to address the thresholds for release that the ORB employs.
Method
A coding scheme and manual were developed, containing all relevant sociodemographic,
clinical, and legal variables (see Appendix A for the coding form). The development of these
materials was guided by a previous interprovincial study examining the antecedents and
trajectories of NCRMD accused, including mental health and criminal justice involvement,
Review Board decision-making, and mental health and criminal outcomes (The National
Trajectory Project; Crocker et al., in press). Three research analysts (RAs) were trained on how
to use the coding form and manual, and inter-rater reliability was assessed using the gold
standard method. This method examines agreement on variables between the RAs and two
experienced researchers who developed the tools and were familiar with the variables being
recorded. Good inter-rater reliability was achieved for all variables (intraclass correlation
coefficient [ICC
1
] greater than .75 [Kappa coefficient for categorical variables]). RAs began
coding ORB cases independently using a variety of sources available in files, namely hospital
reports, disposition reports and other important documents included in the files. RAs began
with cases that were still active (i.e., not closed as a result of absolute discharge or other
reasons) and thus available on site at the ORB. Once coding was completed on these active
cases, RAs proceeded to code closed cases that were retrieved systematically through an
archival warehouse where closed case data is stored. Cases were coded chronologically
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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backwards based on the year that the case was closed. Only cases registered under the ORB
between 1987 and onwards were included in the current sample.
Data were collected on 3,957 cases registered by the ORB between 1987 and 2012. Following
an NCRMD or UST finding, these cases were admitted to 1 of 12 forensic hospitals across
Ontario (i.e., the Centre for Addiction and Mental Health, Ontario Shores, Waypoint Center for
Mental Health Care, Brockville Mental Health Centre, St. Joseph’s Healthcare Hamilton, St.
Joseph’s Healthcare London, Royal Ottawa Mental Health Centre, Regional Mental Health Care
St. Thomas, Providence Care Mental Health Services, Lakehead Psychiatric Hospital, North Bay
Regional Health Centre and Thunder Bay Regional Health Sciences Centre). The year of
admission was based on the NCRMD or UST finding date.
There were discrepancies in the number of cases coded per year, particularly between 1997
and 2002 and possibly during the early 1990s (see Figure 1 for annual admission numbers; see
Appendix D for a comparison of the numbers of cases in this study and the numbers of new
cases as presented within the ORB annual reports available online). We were able to identify
these discrepancies based on a comparison with the admission numbers posted within the ORB
annual reports. The reasons for this discrepancy or missing data are unclear; for example, in
this study, older closed cases were retrieved from archives and there may have been some
errors in requests for archives or in retrieval. There may also be some errors in the ORB annual
reports or in the cataloguing of archival cases. Because of these discrepancies, we analyzed
data in terms of proportions rather than absolute values. We have no reason to believe there is
any systematic bias accounting for these discrepancies. Further, by comparing our sample with
the numbers contained in the ORB annual reports, consistent trends could still be adduced.
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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Data Analysis
Time trend analysis. Annual proportions of clients with specific demographic, clinical and legal
characteristics were graphed on time plots and time trend analysis was performed to
determine the statistical effect of time on these proportions. We calculated proportions (%) of
cases per year instead of raw numbers and examined time trends using these proportions.
3
For
the various graphs presented in this report, dotted lines indicate statistically significant trends,
including increasing, decreasing, or fluctuating proportions over time.
Survival analysis. Survival analysis was used to model the time to absolute discharge, and
specifically, whether an individual’s likelihood of receiving an absolute discharge is a function of
their admission year to the ORB, as well as their primary psychiatric diagnosis or index offense.
4
For the purposes of the current analysis, SA was performed while controlling for exposure time,
that is, the fact that individuals admitted to the ORB in later years will have had comparatively
less opportunity to receive an absolute discharge as compared to individuals from earlier
cohorts.
3
Two time regression procedures, curve estimation and the AREG procedure, were utilized depending on the
presence of auto regression. Auto regression, determined using the Durbin-Watson statistic, refers to when the
proportions of a specific variable at one year are linearly dependent on the proportions at previous years. When
autocorrelation occurred, the AREG regression procedure was applied as it removes any autocorrelation and
estimates regression models accordingly. When no autocorrelation was present, the curve estimation regression
procedure was used. To determine the trendline (i.e., curve) used in curve estimation, proportions were graphed
and the trendline of best fit was generated.
4
Survival analysis offers several regression models for estimating the relation between predictor variables and
‘survival’ (i.e., the probability of nonoccurrence of an event), and so can elucidate why certain individuals have a
higher likelihood of experiencing an event of interest (e.g., absolute discharge) than others. The central advantage
of using SA is that it allows for the inclusion of a key group of individuals: those who have not yet experienced the
event of interest by the time of data collection (i.e., censored cases).
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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Results
ORB admission rates across time
Figure 1 presents the raw numbers of annual ORB admissions. There was a substantial increase
in cases following the Criminal Code changes in 1992, and another significant linear increase
from 2000 to 2007. Following the peak of 2007, we found a decline in new ORB cases of 30% by
2012.
0
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1987
1988
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1994
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2008
2009
2010
2011
2012
Figure 1. Raw ORB admission numbers on annual basis
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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Figure 2 depicts the annual proportion of cases that were found either NGRI/NCRMD or UST.
NGRI/NCRMD proportions were lowest in the late 1980s and early 1990s, and began to increase
at a moderate rate until 1998, when proportions started to stabilize. Proportions of NCRMD
findings since 1999 consistently represent 65-80% of new ORB cases per year, as compared to
earlier years when NCRMD cases made up approximately 15-35% of cases. Time trends in
proportions of UST cases showed the opposite pattern. In more recent years, UST cases
represent a smaller proportion (20-35%) of total ORB cases. This has significant implications for
resources and bed availability, given the much longer lengths of stay for NCRMD versus UST
accused.
These changes are likely to be due to the progressive movement away from making UST
accused persons subject to ORB warrants of committal, and instead using new Treatment
Orders or Keep Fit Orders for UST accused established in Bill C-30 (but outside of the ORB
system). Further, it appears that NCRMD was becoming a more attractive dispositional option
so NCRMD numbers rose. Notably this increase in NCRMD cases occurred before the Winko
decision and the benefits to the accused that this decision brought. This suggests that Bill C-30
of itself appeared a superior legislative framework to accused persons and their counsel.
0
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2008
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2010
2011
2012
Figure 2. NCR and Unfit cases (proportions)
NCR
Unfit
Bill C-30
Winko
Swain
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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Changes in demographic characteristics of ORB cases across time
Age. Among all ORB cases over the last 25 years, the mean age at the time of the index offence
was 36.77 years (SD = 13.01). When age was divided into subgroups, the majority of cases fell
within the 26-40 (on average, 43% across 25 years) and 41-64 (on average, 30%) age groups.
Time trend analysis of age subgroups demonstrated increasing proportions of younger clients
aged 18-25 years old since the mid-1990s, and declining proportions of clients aged 26-40. The
26-40 year age group appears to have been declining up until the mid-2000s. Proportions
among the very youngest (i.e., under 18) and the oldest age groups (i.e., anyone older than 41
years old) did not change significantly across time. These results indicate that a greater
proportion of younger individuals (i.e., 18 to 25) are coming under the jurisdiction of the ORB in
more recent years.
0
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1987
1988
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1997
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2002
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2004
2005
2006
2007
2008
2009
2010
2011
2012
Figure 3. Age subgroups (proportions)
Under 18
18-25
26-40
41-64
65 plus
Swain
Bill C-30
Winko
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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Gender
0
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1987
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2008
2009
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2011
2012
Figure 4. Gender (proportions)
Males
Females
Swain
Bill C-30
Winko
Male and female proportions have remained stable across time, with a
mean ratio of 4:1 for men to women
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
15
Ethnicity. While proportions of European-Canadian cases have not shown a significant change
across time, there is a steady increase in individuals coming under the ORB who are of African-
or Caribbean-Canadian, Middle Eastern or Asian backgrounds. These patterns likely reflect
general demographic changes in Canada’s population, rather than changes in ORB practices and
procedures per se. In fact, Statistics Canada (2006) reported an influx of immigrants in the
1980s and 1990s, particularly from Middle Eastern and Asian countries.
Of note, the present sample contained a small percentage (4.9%) of individuals of Aboriginal
descent. This contrasts sharply with the Canadian criminal justice population, where Aboriginal
offenders continue to be disproportionately over represented at all levels. In 2012-2013,
Aboriginal offenders represented 20.5% of the total federal population. Across Canada,
Aboriginal adults make up approximately 3% of the overall adult population (Public Safety
Canada, 2014).
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2007
2008
2009
2010
2011
2012
Figure 5. Ethnicity (proportions)
European (White)
African or Caribbean-Canadian
Middle Eastern
Asian
Swain
Bill C-30
Winko
Note: On average across the years, 37% of cases were missing ethnicity information. This ranged from 23-65%.
Therefore, annual proportions may not add up to 100%. Proportions of missing information decreased significantly
across the years.
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
16
Education. Figure 6 shows time trends for various education levels. Results indicate increasing
proportions of ORB cases with high school diplomas and some or completed post-secondary
education such as college, trade or university. This suggests that there are increasing
proportions of more educated individuals coming under the ORB; however, much like our
ethnoracial findings, these trends may reflect general societal trends in education over the past
three decades. For example, since the 1990s, there has been a steady growth in rates of post
secondary certification such as college, trade school or university (Employment and Social
Development Canada, 2012).
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2011
2012
Figure 6. Education (proportions)
No high school
High school
Post-secondary
Swain
Bill C-30
Winko
Note. On average across the years, 22% of cases were missing education information. This ranged from 7-53%.
Therefore, annual proportions may not add up to 100%. Proportions of missing information decreased significantly
across the years.
Overall, results indicate that there are increasing proportions of individuals from Asian,
African and Middle Eastern backgrounds coming under the jurisdiction of the ORB. In
addition, more persons are being found NCRMD or UST who have educational attainment
beyond secondary school. These particular trends are consistent with Canadian trends, and so
our interpretation of the results is based on these larger societal patterns. It does appear that
there is an increasing proportion of younger individuals (under age 21) coming under the ORB.
Finally, there were no major differences in the gender make-up of ORB cases over the 25
years.
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
17
Changes in clinical diagnoses across time
Figures 7-12 show proportions of clinical diagnostic
5
categories on an annual basis. The majority
of cases under the auspices of the ORB received a psychotic spectrum diagnosis, which includes
schizophrenia, delusional disorder, schizoaffective disorder, schizophreniform disorder or other
psychosis-related disorders. Figure 7 shows psychotic spectrum diagnosis categories. In terms
of trends over time, the proportion of individuals with a psychotic spectrum disorder did not
change significantly over time; however, when psychotic spectrum disorders were examined in
isolation (i.e., with no comorbid disorder), proportions declined since the early 1990’s. This
decline appears to continue until the early to mid-2000’s, when proportions started to stabilize.
An opposite pattern was found when we analyzed time trends for the proportion of individuals
with a psychotic spectrum disorder comorbid with substance abuse. Here, proportions have
been increasing since 1987, and stabilizing around the late 2000’s. This could be the result of a
true increase in comorbid disorders in the general mentally ill population; alternatively, there
may be an increased capacity and sensitivity among mental health care professionals to
diagnosing substance use problems, particularly among the increasing number of younger
clients now receiving forensic mental health services.
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2012
Figure 7. Psychosis-based disorders (proportions)
Psychosis-based
Psychosis-based only
Psychosis + substance
Psychosis + personality
Bill C-30
Swain
Winko
5
Appendix C contains a comprehensive list of clinical diagnoses within diagnostic categories. Of note, diagnostic
categories are not necessarily mutually exclusive. There is comorbidity across categories except in the psychotic
spectrum only category where psychosis-based illness was examined in isolation (i.e., not comorbid with other
disorders).
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
18
Figure 8 presents proportions across time for the second most prevalent diagnosis mentioned
in ORB files: substance abuse disorder. Similar to when it is comorbid with a psychotic illness,
this graph describes a steady rise in the proportion of persons with substance use disorders
over time. Almost all of these are comorbid with other disorders, including psychotic spectrum
illnesses. Less than 1% of individuals in our sample (n = 23) had only a substance use disorder
(i.e., not comorbid with any other disorder). Fifty-four people (1.4%; including the 23
mentioned above) had a comorbid substance use and personality disorder. In 15 of these cases,
a psychotic spectrum or organic disorder was queried but not diagnosed.
0
10
20
30
40
50
60
70
80
90
100
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Figure 8. Substance abuse disorder (proportions)
Swain
Bill C-30
Winko
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
19
Time trend patterns for mood-based disorders are depicted in Figure 9. This category includes
major depression, anxiety disorders, bipolar disorder, cyclothymia and dysthymia. Results
indicate that the proportion of individuals with a mood disorder, in addition to individuals with
comorbid mood and substance abuse disorders, has increased since 1987 and stabilized in the
early to mid-2000 period.
0
10
20
30
40
50
60
70
80
90
100
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Figure 9. Mood-based disorders (proportions)
Mood-based
Mood + substance
Mood + personality
Swain
Bill C-30
Winko
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
20
Organic disorders are relatively rarely resulting in NCRMD or UST findings, resulting in large
year by year variations. However, results demonstrate increasing proportions of individuals
with organic disorders (shown in Figure 10) coming under the ORB with some stabilization
evident beginning around the mid-2000’s. Organic disorders include neurological conditions
and medical disorders causing psychological problems. Examples include epilepsy, dementia,
Alzheimer’s, acquired brain injury and Parkinson’s disease.
0
10
20
30
40
50
60
70
80
90
100
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Figure 10. Organic disorder (proportions)
Swain
Bill C-30
Winko
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
21
Proportions of personality disorder (Figure 11) and intellectual disability (Figure 12) diagnoses
have not changed significantly across time. Both groups, with quite small numbers, showed
fluctuating proportions across time with no evident time trend. It is possible that personality
disorder may have been under-diagnosed, though we cannot explain any change through time
in under-diagnosis. Intellectual disability is unlikely to have been under-diagnosed.
It is important to recognize that diagnostic and reporting styles among psychiatrists and mental
health professionals may have changed significantly over the wide time period being studied. In
contrast to more objective sociodemographic indicators such as age and sex, clinical diagnosis
variables are more prone to variability over time due both to true variations in the clinical
profiles of the population, as well as changes on the part of the assessor (e.g., skill, expertise,
practice and reporting conventions at the time). The criteria for psychiatric disorders also
changed over time with the release of the DSM-IV diagnostic manual in 1994 and the release
of the DSM-IV-TR manual in 2000 which could affect diagnostic practices.
0
10
20
30
40
50
60
70
80
90
100
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Figure 11. Personality disorder (proportions)
Swain
Bill C-30
Winko
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
22
0
10
20
30
40
50
60
70
80
90
100
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Figure 12. Intellectual disability (proportions)
Swain
Bill C-30
Winko
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
23
Figure 13 displays diagnostic comorbidity proportions over the last 25 years, which is a measure
of diagnostic complexity. Results indicate significantly declining proportions of individuals
coming under the ORB with one clinical diagnosis, and increasing proportions of individuals
with 2-3, and more than 4 diagnoses. These results support the idea that, in recent years,
individuals with more complex and more heterogeneous clinical profiles are being found
NCRMD or UST. These results are also consistent with the significant increase in substance
abuse comorbidity appearing alongside many other clinical diagnoses. More broadly, these
results also speak to what might be enhanced skill and sensitivity among mental health service
providers in diagnosing comorbid conditions, as well as improved assessment methods.
0
10
20
30
40
50
60
70
80
90
100
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Figure 13. Diagnosis comorbidity (proportions)
1 diagnosis
2-3 diagnoses
4 + diagnoses
Swain
Bill C-30
Winko
Taken together, these results suggest there are fewer individuals with “purely” psychotic
spectrum illnesses coming under the jurisdiction of the ORB over the years. Instead, over time,
there appears to be increasing proportions of clients with higher comorbidity and more “mixed”
diagnostic profiles, especially comorbid substance abuse problems. In addition, there are larger
proportions, across time, of individuals receiving an NCRMD or UST finding with mood disorders
and organic conditions, but not personality disorders or intellectual disability. These results
indicate there is a more heterogeneous clinical group coming under the ORB in recent years.
Their increased diagnostic complexity might contribute to altered course under the ORB.
Although we were not able to test this hypothesis directly, this pattern of results suggests that
the NCRMD defense is possibly applied to a wider range of motivations and behaviours, beyond
psychotic symptom-driven ones.
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
24
Figure 14 presents the annual proportions of clients with prior civil psychiatric hospitalizations.
On average, across the years, 62% of clients had a previous civil psychiatric hospitalization. This
may be compared with a national trend of 72% found by Crocker and colleagues in the National
Trajectory Project (Crocker et al., in press). There was no significant change in prior civil
hospitalization across the years of the study.
0
10
20
30
40
50
60
70
80
90
100
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Figure 14. Previous civil hospitalizations (proportions)
Swain
Bill C-30
Winko
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
25
Changes in index offence severity across time
Figure 15 shows index offence type, broken down into five major offence categories: 1) Severe
Violent (includes murder, manslaughter, attempted murder and aggravated assault), 2) Sexual
(e.g., sexual assault, sexual indecency, child pornography charges, sexual interference), 3)
Violent (e.g., assaults other than aggravated assault, robbery, threats, criminal harassment,
forcible confinement), 4) Non-Violent (e.g., mischief, weapons charges, drug offences) and 5)
Administrative charges (e.g., breach of recognizance, failure to appear). Each client was
classified into one (and only one) of the five index offence type categories depending on their
most severe offence (e.g., for index offences encompassing multiple offences), with the severe
violence offence category being considered most severe, followed by sexual, then violent and
non-violent; the administrative offence category was deemed the least serious (see Appendix C
for a comprehensive listing of offences under each offence type category).
6
0
10
20
30
40
50
60
70
80
90
100
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Figure 15. Index offence severity (proportions)
Sexual
Severe violent
Violent
Non-violent
Administrative
Bill C-30
Winko
Swain
6
We had originally classified the Sexual offence category as the most severe, such that if someone had both a
severe violent and sexual charge, they would be classified into the Sexual category. We since modified this to place
the Severe Violence category as primary. There were only 4 individuals in the sample that had both a severe
violent and sexual offence as part of their index offence profile, such that results would not change significantly if
these individuals were classified as violent or sexual offenders.
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
26
These results suggest that the NCRMD defense may be more frequently used, in recent years,
as a disposition for those who have committed sexual offences and less severe violent offences
such as assaults, threats and harassment. This results in proportionately fewer persons under
the ORB who have committed the severe violent offences of homicide, attempted murder and
aggravated assault. This is consistent with the view that the Bill C-30 reforms of 1992 made the
NCRMD defense more attractive to the accused (e.g. Grant, 1997), and may have been more
likely to be raised for relatively less serious offences. This does not appear to be cause by rising
rates of serious violence be persons with mental illness.
These changes can in part be explained by the post-1992 expansion in the range of charges that
could qualify for an NCRMD defense. Further, there is considerable discretion on the part of the
accused person or the Crown as to whether an NCRMD disposition is raised. The current data
show a positive relationship between time and the number of index offences for which one was
found NCRMD or UST. The greater mean number of offences per case in later years raises the
possibility that these are people who have been offending in a persistent manner and the
buildup of multiple offences results in the consideration of an NCRMD or UST disposition. At
least some of these are likely to be lower level assault related charges or less severe sexual
offences.
In terms of time trends, the proportion of individuals committing a violent index offence
has significantly increased, whereas the proportion of severe violence has decreased.
Sexual offence proportions have increased over time and non-violence offences have
decreased over the last 25 years. Proportions of individuals coming under the ORB for an
administrative offence have remained generally low and unchanged across time.
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
27
The proportions of individuals with prior criminal convictions are presented in Figure 16. On
average, across the years, 52% of clients had a prior criminal conviction. In terms of time
trends, there was no significant change in criminal conviction proportions across the years,
particularly over the last 2 decades. This is comparable to what has been found elsewhere
(Crocker et al., in press).
0
10
20
30
40
50
60
70
80
90
100
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Figure 16. Previous criminal conviction (proportions)
Swain
Bill C-30
Winko
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
28
Figure 17 shows the percentages of clients with a previous tenure under the ORB. Four percent
of all cases had a previous NCRMD or NGRI finding and 8% of clients were previously found UST.
Thus, 12% of clients had a previous registration under the ORB. This is again consistent with
previous studies (Crocker et al., in press; Department of Justice Canada, 2006).
0
2
4
6
8
10
12
14
16
18
20
NCR Unfit
Figure 17. Proportion of indviduals with previous ORB tenure
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
29
Discharge rates over time
Table 1 shows the proportion of individuals receiving an absolute discharge at specific time
points following their admission to the ORB (i.e., at 1, 5, 10, 15 and 20 years post-admission).
The data are presented as a function of admission year for all NCRMD cases. Here, the sample is
divided into 4 cohorts based on the year of admission: 1987-1992, 1993-1999, 2000-2005, and
2006-2012, corresponding to relevant legislative changes (e.g., Bill C-30, Winko). Table 1
shows that the earliest cohort had the slowest rate of absolute discharge, the 2000-2005 the
most rapid and the 1993-1999 and 2006-2012 an intermediate level of absolute discharge. This
suggests that prior to the 1992 changes, there was indeed a slower progression through the
forensic system and that the time cohort immediately following the Winko decision had a more
rapid rate of progress.
Table 1: Duration to Absolute Discharge by Time Cohort
1 year
5 years
10 years
15 years
20 years
Cohort 1:
1987-1992
2.8
19.3
33.0
45.9
56.0
Cohort 2:
1993-1999
4.7
24.1
49.8
64.0
---
Cohort 3:
2000-2005
8.2
43.8
61.4
---
---
Cohort 4:
2006-2012
4.3
26.5
---
---
---
Note. These figures are cumulative (e.g., an individual receiving an absolute discharge at 5 years post admission is
also considered to have received it at 10 years post admission). The denominator includes all individuals who had
not received absolute discharges at the specified time points, in addition to those individuals who had not yet
received an absolute discharge by the time of the study’s end.
Discharge rates as a function of illness and offence profile
The figures below show the survival function for time to absolute discharge as a function of
illness type (Figure 18) and offence category (Figure 19). As might be expected, results
examining illness types show that the presence of a personality disorder, as well as comorbid
substance use problems, tend to lengthen the amount of time spent under the Board. Results
further indicate that having committed a severely violent or sexual offence confers
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
30
comparatively longer tenure under the ORB as compared to less seriously violent offences, non-
violent and administrative-type offences.
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
31
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
32
Summary of Findings
New ORB cases show a sudden rise in 1992-3, and then a progressive steady increase in new
ORB numbers following that, peaking in 2007. Since then, new cases have declined by 30%
by 2012.
Over time, increasing numbers of NCRMD cases have become the predominant cases
coming under the ORB.
Less serious violence such as simple assault and threats has become a more common index
offence and serious violence relatively less so.
Demographically, gender and mean age of ORB cases changed little, and minority
ethnoracial background rose, as did educational level (the latter two in line with Canadian
population changes). There was a rise in the younger age group (18-25) coming under the
ORB system.
Psychotic related disorders remain overwhelmingly the most common, but with a steady
rise in substance abuse disorder comorbidity over time. Organic disorders rose slightly,
intellectual disability cases little, as a proportion of all cases.
There were distinct differences in the duration of ORB orders across four time cohorts. The
pre-1992 cohort had the slowest rate of absolute discharges at 5 years after imposition of
the order, followed by the 1993-9 and 2006-2012 cohorts that had very similar rates of 5
year absolute discharges. The cohort with the highest rate of 5 year absolute discharges was
the one that followed most closely on the Winko decision, from 2000-2005 with a 43.8%
rate.
Having a personality disorder significantly increased the duration of tenure under the ORB
across the time period studied, as did having a comorbid substance use disorder.
Having a sexual or severely violent index offence conferred longer duration under the
Board.
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
33
Summary and Discussion
This study presents an analysis of changing populations of forensic patients, the rate at which
such categories of cases are created, the index offences they commit, the psychiatric problems
they have and the way the ORB makes decisions about them. Data were extracted reliably for
available ORB files over a 25 year time period. Some of the variables we coded (e.g., clinical
diagnosis) may have been vulnerable to assessment or reporting inconsistencies over the time
period studied, such that their variation over time may reflect both true variations in the clinical
profiles of this population, as well as changes on the part of the assessor (e.g., skill, expertise,
practice and reporting conventions at the time). However, the major methodological concern of
this study is the observation that the total number of cases collected by our team was
discrepant from the admission numbers posted in the ORB annual reports, particularly for the
years 1995-2003. For the reasons argued above, we believe that despite this gap reasonable
analyses regarding time trends and the main study questions can still be addressed as we have
no reason to believe there is any systematic bias in the missing cases. We believe the following
points can be reasonably concluded from the results.
First, increasing ORB numbers show a clear and immediate response to the introduction of
legislative changes in 1992. There was a sudden rise in 1992-3, and then a progressive steady
increase in new ORB numbers from 2000 to 2007. Since 2007, new cases have been declining,
by approximately 30% by the end of the study period.
Second, in legal terms, the composition of the new ORB cases was the same immediately
before and after Bill C-30 [that is, predominantly UST cases] but over time the new treatment
order provisions of Bill C-30 were employed. With increasing numbers of NCRMD cases only 20-
30% of all cases were UST by 1997 and have remained stable since. In other words, the
overwhelming rise in cases was of new NCRMD cases.
Third, less serious violence such as simple assault and threats has become a relatively more
common index offence, and serious violence relatively less so. Thus there is no evidence that
the rise in ORB cases is due to a rise in more serious offending, but rather an expansion of the
use of NCRMD for less serious violence and sex offences. Put another way, the NCRMD regime
established under Bill C-30 was immediately more attractive to mentally ill persons appearing in
court than taking the usual criminal justice pathways and so the disposition became more
commonly employed.
Fourth, demographically, gender and mean age changed little, and minority ethnoracial
background rose, as did educational level [the latter two in line with Canadian population
changes]. There was a rise in cases aged 18-25 coming under the ORB system.
Fifth, diagnostically, psychotic spectrum disorders remain overwhelmingly the most common,
but the major change is of a steady rise in comorbidity, particularly for substance abuse
disorders. Diagnostic complexity has increased over time. Organic disorders rose slightly,
intellectual disability cases little, as a proportion of all cases.
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
34
Finally, there appear to be distinct differences in the duration of ORB orders across four time
cohorts. The pre-1992 cohort had the slowest rate of absolute discharge across each time point
post-imposition of the order, followed by the 1993-9 and 2006-2012 cohorts which had very
similar rates of absolute discharges at 1- and 5-years post ORB admission. The cohort with the
highest rate of absolute discharges was the one that followed most closely on the Winko
decision, from 2000-2005 with a 43.8% rate at 5-years post-admission, and 61.4% at 10-years
post-admission. The reasons behind changes in ORB decisions are not clear. It may represent a
change in ORB practice, changes in the law consequent on the Winko decision or may be a
result of rising problems of a more diverse clinical population with higher rates of difficult-to-
treat substance use disorders. Both of these factors have been noted to contribute to slower
progress through forensic care in other jurisdictions (Skipworth, 2005; Simpson, Evans,
McKenna, & Jones, 2006).
It appears, therefore, that the rise in new ORB cases was primarily the result of a dramatic
increase in NCRMD cases during the 1992-2007 timeframe. The diagnostic groupings of who
were becoming subject to such orders changed little, though their comorbid substance use
increased greatly, and they are increasingly of minority ethnoracial groups. The second major
factor is shifting rates of absolute discharge: slow initially, increasing post Winko and now
slowing once again.
We cannot discern from this data why the striking recent fall in new cases since 2007 has
occurred. This is primarily due to a decrease in the NCRMD disposition. This was not an
expected finding given the experience in the sector of ongoing pressure on resources. The
reason this effect has been hidden may be that the rate of absolute discharge has also slowed,
resulting in continuing high numbers of persons under the ORB. Further, we cannot attribute
this change to the Government’s amendments in Bill C-14, enacted in July 2014. The discussion
of these reforms, following publicity related to certain high profile offences, first occurred in
late 2012, too late to have been responsible for any of these effects.
More detailed analyses of this data will provide more subgroup specificities within this large
population.
The recognition of these issues may well have implications for forensic mental health systems
and resources. The emergence of a larger group of younger group of ORB cases under age 25
suggests there will need to be a set of services aimed at the needs of this transitional age
group. This includes educational and vocational upgrading as part of rehabilitation efforts and
family focused services. The trend towards more racially and ethnically diverse ORB cases
mirrors the changing face of our communities and will mean that focus on cultural- and
language-specific services, and consideration of issues of adjustment and trauma these for
refugees and migrants.
The striking rise in substance use disorders, likely both a cause of relapses of mental disorder
and a perpetuating factor in recovery deserves particular attention. Rehabilitative programming
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
35
will need to actively focus on addiction services and programs in particular, integrated with
forensic recovery programs. Sexual offenders are less common in NCRMD populations in
general but they represent an important and growing subset of Ontario MCRMD cases. Specific
programming for this group will be needed.
Our results suggest some factors suggesting forensic demand may be falling in recent years for
reasons we cannot discern. This may be a result of the development of new services for
criminal justice involved mentally ill persons in the community such as diversion programs,
court support and increasing provision of ACT and other high contact community services. This
may contribute to a slow reduction in the total number of persons under the ORB. However,
the increasing diagnostic complexity and substance related disorders may mean that people
remain under the ORB for longer periods of time, maintaining or increasing ORB case load
unless recovery based programming can more effectively address their needs.
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
36
Acknowledgements
Many thanks to Hon. Justice Richard Schneider, Angie Baggetta, Sheila McDermott, Chloe Vice
and other staff at ORB for their generous and ongoing support throughout this project. Teresa
Grimbos PhD contributed a huge amount to study as did Stephanie Fernane and we want to
acknowledge them both. We also thank the Ontario Mental Health Foundation and Ministry of
Health and Long Term Care for their financial support which made this project possible.
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
37
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Ontario: Trends, potential causes and international comparisons. Paper session
presented at the Annual Conference of the International Association of Forensic Mental
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Skipworth, J. (2005). Rehabilitation in forensic psychiatry: Punishment or treatment? The
Journal of Forensic Psychiatry & Psychology, 16, 70-84.
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Tollefson, E. A., & Starkman, B. (1993). Mental disorder in criminal proceedings. Canada:
Carswell.
Winko v British Columbia (Forensic Psychiatric Institute). (1999). 135 C.C.C. (3d) 129 (S.C.C.).
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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Appendix A
Coding form
1. CODING INFORMATION
Coder
(initials)
Coding Date
(dd/mm/yyyy)
Hospital where report
written
Report Date
(dd/mm/yyyy)
Initial Coding
Coding 2
Coding 3
Coding 4
Report type used (check all that apply):
Ontario Review Board annual report Disposition
Reasons for Disposition Other: ____________________________
2. IDENTIFICATION INFORMATION
ORB Client Name (first name last name): ______________________________________
Date of Birth (dd/mm/yyyy): __________________
ORB Study ID: _________________
Medical Record Number: ____________________
Client Registry Study ID: ____________________
NTP Study ID: _______________
FPS Number: ________________
3. DEMOGRAPHICS
Client Gender: Male Female
Country of Birth: ___________________________
Ethnicity:
European-Canadian (white) Aboriginal
African-Canadian Caribbean-Canadian
Latin-American Middle Eastern
East Asian South Asian
Southeast Asian Unknown
Other: __________________________
Education (prior to index):
Some elementary school (less than gr. 8) Completed elementary school (up to gr. 8)
Some high school (less than gr. 12) Completed high school (up to gr. 12)
Some post-secondary (trade, college, uni.) Completed post-secondary (certificate,
diploma, degree)
Some graduate level education Completed graduate level education
Non-traditional education stream (e.g., MR) Unknown
Main source of financial support (prior to index):
Own paid work Social assistance (any kind)
Supported by family, friends No income
Unknown Other:__________________________
Marital status (prior to index):
Singleno relationship Relationshipcommon law/married
Divorced or Separated Widowed
In relationshipdating Unknown
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
41
Residential status (prior to index):
Living on own or with spouse, family or friends Living in supervised setting/Hospital
Homeless/no fixed address/boarding house Unknown
Other: __________________________
4. CURRENT ORB STATUS
Yes
Finding Date
(dd/mm/yyyy)
Finding Date
(dd/mm/yyyy)
Finding Date
(dd/mm/yyyy)
NGRI
NCR
Unfit
If currently NGRI or NCR, were they previously Unfit?
No Yes N/A
If previously Unfit, date of initial Unfit finding (dd/mm/yyyy): _____________________
Comments related to atypical circumstances:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_______________________________________________________________________
5. INDEX OFFENCE INFORMATION
Total number of index offences: _________
Index offence date #1: __________________
Index offence date #2: __________________
Index offence date #3: __________________
Index offence date #4: __________________
Index offence date #5: __________________
Index offence date #6: __________________
If any index offence(s) took place over a range of time, specify here separated by a dash (e.g., May 5-
June 9, 2011) and a comma if there are multiple ranges: __________________________________
Client Age at the time of the index offence (if multiple dates, use the earliest): _________
Index Offence(s):
Offence
Count
Index Offencespecify with count
Index Offencespecify with count
Index Offencespecify with count
Index Offencespecify with count
Index Offencespecify with count
Index Offencespecify with count
Index Offencespecify with count
Index Offencespecify with count
Index Offencespecify with count
Index Offencespecify with count
Index offence(s) category (check all that apply):
Non-violent Violent Sexual
6. IMPORTANT DATES
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
42
Yes
N/Anot yet
granted
N/Astarted
higher
Date first granted
through Disposition
Community Living
privileges
Conditional Discharge
Absolute Discharge
Comments related to atypical circumstances:
______________________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________
7. MENTAL HEALTH, HOSPITALIZATION & ORB HISTORY
Mental illness diagnosis (check all that apply):
Schizophrenia Delusional disorder
Pervasive developmental disorder Schizoaffective disorder
Bipolar disorder Depression
Anxiety disorder Intellectual disability
Paraphilia Conduct disorder
Other psychotic disorder, specify: _________________________________________
Personality disorder, specify: _____________________________________________
Substance use disorder, specify: ___________________________________________
Dementia, Alzheimer’s, acquired brain injury, specify: _________________________
Personality disorder traits, specify: _________________________________________
Query, specify: ________________________________________________________
Other, specify: _________________________________________________________
Unknown
Hospital admitted to:
CAMH (site unknown) CAMH (Queen)
CAMH (college) CAMH (Metfors)
Waypoint (formerly Penetanguishene/Oak Ridge) Ontario Shores/Whitby
Royal Ottawa Mental Health Centre Brockville Mental Health Centre
Thunder Bay Regional Health Sciences Centre Regional Mental Health CareSt. Thomas
Providence Continuing Care Centre Syl Apps Youth Centre
Northeast Mental Health, North Bay Campus St. Joseph’s HealthcareHamilton
St. Joseph’s HealthcareLondon Unknown
Other: __________________________________
Was there prior mental health contact before the index offence(s)?
No Yes Unknown
Has this person previously been found NGRI?
No Yes Unknown
Has this person previously been under the jurisdiction of the ORB for a separate set of offences (e.g.,
not part of the current index offence)? (check NCR and Unfit if necessary)
YesNCR UnknownNCR
YesUnfit UnknownUnfit
No
Age at first known serious mental illness (SMI) symptoms: ________ Unknown N/A
Age at first contact with mental health service: __________ Unknown
Age at first hospitalization for psychiatric reasons: __________ Unknown
Number of civil psychiatric hospitalizations prior to the index offence
(estimate if necessary): __________ Unknown
8. CRIMINAL HISTORY
Age at first arrest/charge: ___________ Unknown
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
43
Number of previous criminal convictions: __________ Unknown
Were there any previous VIOLENT charges/convictions (not including index offence):
No Yes Unknown N/Ano criminal history
Were there any previous NON-VIOLENT charges/convictions (not including index offence):
No Yes Unknown N/Ano criminal history
Were there any previous SEXUAL charges/convictions (not including index offence):
No Yes Unknown N/Ano criminal history
Has this person been in a custodial placement with the criminal justice system?
No Yes Unknown N/Ano criminal history
Has this person been involved with the law prior to the onset of SMI symptoms?
Note: If “Age of first psychiatric symptoms” is N/A, check this item as “N/A” too
No Yes Unknown N/A
Has this person had any criminal charges and/or convictions, post-index offence(s)
No Yes Unknown
Record charge, date, legal consequence, if possible:__________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
9. ABSOLUTE DISCHARGE
Hospital absolutely discharged from:
CAMH (site unknown) CAMH (Queen)
CAMH (college) CAMH (Metfors)
Waypoint (formerly Penetanguishene/Oak Ridge) Ontario Shores/Whitby
Royal Ottawa Mental Health Centre Brockville Mental Health Centre
Thunder Bay Regional Health Sciences Centre Regional Mental Health CareSt. Thomas
Providence Continuing Care Centre Syl Apps Youth Centre
Northeast Mental Health, North Bay Campus St. Joseph’s HealthcareHamilton
St. Joseph’s HealthcareLondon Unknown
Not absolutely discharged Other: _______________________________
10. GENERAL COMMENTS
Record anything unique or concerning about this case, as well as miscellaneous questions or
important notes.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_______________________________________________________________________
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
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Appendix B
Clinical Diagnosis Categories
Psychotic spectrum disorders: Schizophrenia, schizoaffective, schizophreniform, delusional
disorder, psychotic disorder, acute psychosis, psychotic features, delirium.
Mood-based disorders: Major depression, bipolar, anxiety disorders, somatization,
somatoform, cyclothymia, dysthymia, affective disorder, mood disorder.
Substance abuse disorders: Alcohol abuse of dependence disorders, substance abuse of
dependence disorders.
Other Axis I disorders: Attention-deficit/hyperactivity disorder, eating disorders, adjustment
disorders, oppositional defiant disorder, conduct disorder, pervasive developmental disorder,
autism spectrum disorders, asperger’s, tourette’s disorder, learning disabilities, gender identity
disorder, fetal alcohol syndrome, sleep disorders, post-traumatic stress disorder, impulse
control disorders, malingering.
Personality disorders: Any cluster A, B or C personality disorders (e.g., antisocial personality
disorder, dependent personality disorder, schizotypal personality disorder).
Intellectual disabilities: Intellectual disability, mental retardation, intellectual developmental
disorders, Down Syndrome.
Organic disorders: Neurological and medical conditions causing psychiatric problems, for
example, epilepsy, personality change due to a medical condition, acquired brain injury,
cerebral palsy, Parkinson’s, dysphasia, cerebral accident, hyperkinetic syndrome, dementia,
Alzheimer’s.
Note. Diagnostic categories are not mutually exclusive and so individuals classified into one
disorder category may have other, comorbid (i.e., co-occurring) diagnoses. Classifications were
based on Diagnostic and Statistical Manual of Mental Disorders fourth edition (DMS-IV).
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
45
Appendix C
Index offence types
Sexual offences: Sexual assaults, indecent acts, invitation to sexual touching,
prostitution/soliciting services for prostitution, sexual interference, child pornography charges.
Severe violent offences: Murder (first and second degree), manslaughter, attempted murder
and aggravated assault.
Violent offences: Assaults (excluding aggravated assault), threats, robbery, extortion,
kidnapping/abduction, forcible confinement, extortion, criminal harassment, administering
noxious substance, firearms charges, cruelty to animals, endangering life specifiers (e.g., arson
with endangering life), criminal negligence or dangerous operation of vehicle (only with causing
death or bodily harm specifiers).
Non-violent offences: Theft, break and enter, drug offences, mischief, vandalism/willful
damage, weapons violations, escaping lawful custody, trespassing/loitering, disturbing the
peace, causing disturbance, possession of stolen property, fraud, driving offences,
counterfeiting, obstructing peace office, resist arrest, arson (without endangering life specifier).
Administrative offences: Breach of bail, breach of probation, breach of recognizance, failure to
appear, failure to attend court, failure to comply (with probation, recognizance).
Note. Individuals are classified as having committed one type of index offences, based on the
most severe offence, if there are multiple index offences. More severe offences include sexual
offences, followed by severe violent offences, violent offences and then non-violent offences;
administrative offences are considered the least severe offence category.
Changing Characteristics of the Review Board Population in Ontario: A Population-Based Study from 1987-2012
46
Appendix D
Discrepancies between our data collection and numbers posted on ORB website
0
20
40
60
80
100
120
140
160
180
200
220
240
260
280
300
320
340
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
ORB/MOH study
ORB website
ResearchGate has not been able to resolve any citations for this publication.
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