Gregory P. Brown, Ph.D. Associate Professor, Criminal Justice Program Director, Institute for Applied Social Research N

1. “Seriously Mentally Ill Inmates in OntarioCorrectional Facilities: Prevalence, Mental Health Care Needs, andImplications for Correctional and Mental Health Care Policy” Gregory P. Brown, Ph.D. Associate Professor, Criminal Justice Program Director, Institute for Applied Social Research Nipissing University North Bay, Ontario Presentation to: Ontario Multifaith Council on Spiritual and Religious Care Educational Conference 2010 September 27, 2010 Jackson’s Point, Ontario

2. Origins of the Project

3. The ‘Diversion of the Mentally Ill from the Criminal Justice System’ initiative was established by the Ontario Ministry of Community Safety and Correctional Services in 2005 to investigate means to divert mentally ill persons from entering the criminal justice system, and to address the needs of mentally ill persons upon discharge from correctional services

4. With funding provided by the Ontario Ministry of Health and Long-Term Care, researchers from Nipissing University, the University of Waterloo and the Program Effectiveness, Statistics and Applied Research Unit (MCSCS) cooperated in designing and carrying out a study to determine the prevalence and psychiatric care needs of adult inmates

5. Phase I: Seven institutions were identified for inclusion in the original study which took place June – August 2005. • Phase II: May – August 2006 study extended to include four other sites, and to collect more data to increase Aboriginal and female representation. • Phase III: October – November 2006 evaluation of the Secure Treatment Unit (STU) at the St. Lawrence Valley Correctional and Treatment Centre. • Phase IV: May – August 2007 ongoing research into the development of an offender mental health screening tool, and to conduct a study of recidivism among inmates with a mental illness. Two additional sites (Toronto West and Niagara Detention) included in this phase.

6. Previous Research

7. Estimates of the prevalence of mental illness among inmates can vary widely due to differences in methodology, assessment instruments used, and the definition of ‘mental illness’ (diagnosis vs. symptoms) employed by the researchers. • For legal, treatment, and policy/planning purposes, the majority of studies focus on estimating the prevalence of severe mental illness (psychoses, mood disorders, anxiety disorders) and substance abuse and, to a lesser extent, personality disorder. • Estimates of the prevalence of serious mental illness among inmates average 27.6% (current) to 34.6% (lifetime).

8. Mental illness is more prevalent among the remand population. • Female inmates demonstrate a higher prevalence of psychoses, mood disorders and anxiety disorders. • Male inmates show greater prevalence of substance abuse and personality disorders. • Inmates with a mental disorder are more likely to be Aboriginal or members of a disadvantage visible minority group.

9. Inmates with a mental disorder are more likely to be homeless, unemployed and have family members who have been incarcerated. • Inmates who have a mental disorder are more likely to have lived in a foster home and to have experienced physical or sexual abuse as children and/or as an adult. • The prevalence of serious mental disorders among inmates is on average 2.5 times greater than in the general public; substance abuse is on average 8 times higher; and personality disorders are 9 times greater.

10. Methodology

11. estimation of point (current) prevalence of mental illness among offenders, identification of mental health care needs • fourteen correctional institutions, N = 522 assessments • both remand and sentenced inmates included in the research • over-sampling of Aboriginal, female inmates • recidivism tracking and data linkage follow-up

12. Research Instruments

13. The “Resident Assessment Instrument – Mental Health”(RAI-MH)is a comprehensive, standardized system for evaluating the needs, strengths and preferences of psychiatric patients in institutional settings • Emphasis placed on dynamic assessment at 3 days, 7 days, one month, one year, prior to last year • The RAI-MH is designed for use by mental health professionals (e.g. nurses, social workers, psychiatrists, psychologists, family physicians, recreational and occupational therapists) • The RAI-MH assessment tool was mandated for use in all Ontario mental health care facilities in October 2005

14. Use of the RAI-MH tool in the current research is designed to establish a common language between the Ontario Ministries of Health & Long-Term Care (MOHLTC) and Community Safety & Correctional Services (MCSCS) in determining the nature and level of mental health care needs of inmates • Members of the research team received extensive training on how to use the RAI-MH Version 2.0, along with MCSCS nursing staff • The Minimum Data Set for Mental Health (MDS-MH) is the screening form used to collect information from and about the patient…

15. The Offender Tracking Information System (OTIS) is the database system used by the Ontario Ministry of Community Safety and Correctional Services to record information about adult offenders (both inmates and probationers), including: • demographic information • detailed offence history • sentence information • behavioural indicators/alerts • LSI-OR assessments • recidivism tracking

16. Results – Face-to-Face Assessments

17. Demographic Characteristics of Inmate Sample (N = 522) Number and (Percent)

18. Psychiatric History of Inmate Sample (N=522) Number (Percent)

19. Summary Psychiatric Symptom Scales Inmate Sample (N=522) Mean Scores & Standard Deviations

20. Summary Psychiatric Symptom Scales Inmate Sample (N=522) Mean Scores & Standard Deviations

21. Substance Use/Addiction Inmate Sample (N=522) Number and (Percent)

22. Comparison Between Correctional Inmates, Psychiatric Inpatients, Forensic Patients and Community Mental Health Samples

23. Demographic Comparison of Samples

24. Summary Psychiatric Symptom Scales: Comparison of Inmates, Hospital & Forensic Patients and Community Mental Health Clients Mean Scores & Standard Deviations

25. Stress and Trauma Comparison of Inmates, Hospital & Forensic Patients and Community Mental Health Clients Number and (Percent) Statistically significant difference between proportions at * p<.05, **p<.01, ***p<.001

26. Stress and Trauma Comparison of Inmates, Hospital & Forensic Patients and Community Mental Health Clients Number and (Percent) Statistically significant difference between proportions at * p<.05, **p<.01, ***p<.001

27. Hospitalization HistoryComparison of Inmates, Hospital & Forensic Patientsand Community Mental Health ClientsNumber and (Percent) ** refers to community mental health contact

28. Prevalence of Severe Symptoms of Mental Illness

29. Definition of Mental Illness • PSS score recoded: 0 through 2 = 0, 3 through highest = 1; • DRS score recoded: 0 through 5 = 0, 6 through highest = 1; • NSS score recoded: 0 through 5 = 0, 6 through highest = 1; • MSS score recoded: 0 through 5 = 0, 6 through highest = 1; and, • CPS score recoded: 0 through 1 = 0, 2 through highest = 1. • Making use of the recoded scores for the five symptom scales, a • Total Severe Symptoms Score was constructed, where; • Total Severe Symptoms Score • (TSS) = PSS + DRS + NSS + MSS + CPS

30. Definition of Mental Illness • Severe Symptoms of Mental Illness Prevalence Score • was derived as follows, where; • TSS = 0 = ‘None’ – no severe symptoms • TSS = 1-2 = ‘Moderate’ – moderate number of severe • symptoms • TSS = 3+ = ‘High’ – high number of severe symptoms • Propensity score weighting was used to estimate population • Prevalence

31. Prevalence of Mental Illness • It is estimated that 5% of inmates (approximately 429 of total population) currently demonstrate a ‘high’ number of severe symptoms of mental illness, in line with estimates derived in other research • 35.1% of inmates (3,014 of total population) currently have a ‘moderate’ number of symptoms of a severe mental illness • 59.9% of inmates (5,145 of total population) currently have no severe symptoms of a mental illness

32. (Estimated) Point Prevalence of Symptoms of Mental Illness Among Inmates Based on Nw = 977 Propensity Weight Applied to 2006/07 Adult Institutional Population Average Daily Count, N = 8,588: Total, Sentenced versus Remand, by Gender Number and (Percent)

33. (Estimated)Point Prevalence of Symptoms of Mental Illness Based on Nw = 977 Propensity Weight Applied to 2006/07 Adult Institutional Admissions, N = 78, 831 Total, Aboriginal and Non-Aboriginal Inmates, by Gender Number and (Percent)

34. Mental Health Care Needs

35. RAI-MH/MDS-MH Clinical Assessment Protocols (CAPs) are statistical algorithms that ‘trigger’ the need for further assessment and care planning around the symptom characteristics included in the CAP. • 28 different CAPs are identified in the MDS-MH data, ranging from violent behaviour to social functioning, through to oral hygiene, bladder and bowel functioning and dehydration. • Triggering rates of 15% to 40% were observed for physical-health related CAPs, including skin and foot disorders, oral health, pain, and bladder and bowel disorders.

36. (Estimated) CAP (Clinical Assessment Protocol) Trigger Rates for Mental Health Care Planning Based on Nw = 977 Propensity Weight Applied to 2006/07 Adult Institutional Population Average Daily Count N=8,588: by Gender Number and (Percent)

37. Recontact & Recidivism

38. Recontact with the correctional system was measured as any readmission subsequent to a release from custody, including readmission on a remand warrant, warrant of committal, probation order, conditional sentence, or intermittent sentence. • Inmates with a ''High' number of severe symptoms of a mental illness are statistically significantly more likely to have recontact with the correctional system within a shorter period of time (mean time to re-contact 525.9 days) compared to inmates with a 'Moderate' number of symptoms (mean time to recontact = 712.2 days) or no severe symptoms of mental illness (752.2 days). • There were no statistically significant differences in the recontact rates of inmates with a 'Moderate' number of severe symptoms compared to inmates with no severe symptoms of mental illness.

39. Recidivism was measured as a readmission subsequent to a release from custody for a conviction resulting in a new sentence, including a sentence to incarceration on a warrant of committal, a probation order, or a conditional sentence. • There was no statistically significant difference in the recidivism (reconviction) rate of inmates with either a 'High' or a 'Moderate' number of severe symptoms of mental illness compared to those with no symptoms.

40. Questions? 

41. To obtain a copy of the final report titled: Final Report – Part 1 The Prevalence of Symptoms of Mental Illness and the Mental Health Care Needs of Adult Inmates in Ontario Correctional Facilities Contact: Ms Krista Papkie Program Effectiveness, Statistics and Applied Research Unit Ministry of Community Safety and Correctional Services 200 First Avenue W., North Bay, ON P1B 9M3

42. Thanks • Ontario Ministry of Community Safety & Correctional Services (MCSCS) • Ontario Ministry of Health & Long-Term Care (MOHLTC) • Kathy Underhill, Supervisor, Statistical Services, PESAR • Chris Higgins, Team Lead, Forensic Mental Health, MOHLTC • Alex Firby, Information Management Data Analyst, Health Data Branch, MOHLTC • Michael Henighan, Statistics Officer, PESAR • The research team: Krista Mathias Duyen Luong, Kindra Houle, Kyla Marcoux, Erin Hogan, Tracey McCarthy, Tara Schuck, Kyle Archambault, Robin Lajeunesse • The institutional staff at North Bay Jail, Sudbury Jail, Hamilton-Wentworth Detention Centre, Maplehurst Correctional Complex, Milton-Vanier Centre for Women, Toronto Jail, Ottawa-Carleton Detention Centre, Thunder Bay Correctional Complex/Jail, Elgin-Middlesex Detention Centre, Central East Correctional Centre and Windsor Jail, Toronto West Detention Centre and Niagara Detention Centre

43. Corbeil, Ontario