Dynamic and static factors associated with discharge dispositions : the national trajectory project of individuals found not criminally responsible on account of mental disorder (NCRMD) in Canada

The majority of individuals found not criminally responsible on account of mental disorder (NCRMD) in Canada spend some time in hospital before they are conditionally or absolutely (no conditions) discharged to the community by a legally mandated review board. By law, the decision to conditionally discharge an individual found NCRMD should be guided by the need to protect the public, the mental condition of the accused, and the other needs of the accused, especially regarding his/her community reintegration. At the time of this study, Canadian legislation and case law required that the review board disposition should be the "least onerous and least restrictive" possible for the accused. This means that, if there is no evidence that the person poses a significant risk to public safety, he/she must be released. However, the Canadian Criminal Code does not specify the criteria that must be considered when making this risk assessment. This leads to two questions. (1) What predicts review board dispositions? (2) To what extent do disposition determinations reflect evidence-based practices? The present study examined dynamic and static predictors of detention in custody, conditional discharge (CD), and absolute discharge (AD) dispositions among persons found NCRMD across the three largest provinces in Canada. The National Trajectory Project (NTP) examined men and women found NCRMD in British Columbia (BC), Québec (QC), and Ontario (ON) between May 2000 and April 2005, followed until December 2008. For the purposes of this study, individuals who had at least one hearing with a review board were extracted from the NTP dataset (N = 1794: QC = 1089, ON = 483, BC = 222). Over the course of the study, 6743 review board hearings were examined (QC = 3505, ON = 2185, BC = 1053). Despite advances in the risk assessment field, presentation of a comprehensive structured risk assessment to the review board was not the norm. Yet our findings suggest that review boards were taking into account a combination of empirically validated static and dynamic risk factors, as represented by the items of the HCR-20 risk assessment scheme. Particular attention was being paid to the behavior of the patient between hearings (e.g., violent acts, compliance with conditions). Severity of index offense was associated with review board decisions; though index severity is not related to recidivism, it is an important consideration in terms of public perceptions of the justice system and can be related to better established risk factors (i.e., criminal history and prior violence). Historical factors had more influence on the decision to detain someone, while clinical factors were more influential on an AD decision. Disposition stability was the most common trajectory, meaning that a patient with a prior CD disposition was most likely to receive another CD disposition at the next hearing. Static and dynamic risk factors found in the HCR-20 influenced review board determinations, although presentation of a complete structured risk assessment is the exception, not the norm. Results suggest that clinicians recommending less restrictive dispositions are more likely to include a comprehensive risk assessment with their recommendation. An alternative explanation is that, when there is no comprehensive assessment of risk, the review board tends to be more cautious and apply more restrictive dispositions. The practice seems to be contrary to the legislation at the time of the study, given that there should be a presumption that the patient is not a significant threat

Beating the blues after Cancer: randomised controlled trial of a tele-based psychological intervention for high distress patients and carers

Background: The diagnosis and treatment of cancer is a major life stress such that approximately 35% of patients experience persistent clinically significant distress and carers often experience even higher distress than patients. This paper presents the design of a two arm randomised controlled trial with patients and carers who have elevated psychological distress comparing minimal contact self management vs. an individualised tele-based cognitive behavioural intervention. Methods/design: 140 patients and 140 carers per condition (560 participants in total) will been recruited after being identified as high distress through caller screening at two community-based cancer helplines and randomised to 1) a single 30-minute telephone support and education session with a nurse counsellor with self management materials 2) a tele-based psychologist delivered five session individualised cognitive behavioural intervention. Session components will include stress reduction, problem-solving, cognitive challenging and enhancing relationship support and will be delivered weekly. Participants will be assessed at baseline and 3, 6 and 12 months after recruitment. Outcome measures include: anxiety and depression, cancer specific distress, unmet psychological supportive care needs, positive adjustment, overall Quality of life. Discussion: The study will provide recommendations about the efficacy and potential economic value of minimal contact self management vs. tele-based psychologist delivered cognitive behavioural intervention to facilitate better psychosocial adjustment and mental health for people with cancer and their carers