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Background:
Review

Factors Considered for the Assessment of Risk in Administrative Review Boards of Canada: A Scoping Review

by
Jane-Caroline Pellerin
1,
Marie Désilets
2,
Stéphanie Borduas Pagé
2 and
Alexandre Hudon
2,3,4,*
1
Department of Psychiatry and Addictology, Université de Montréal, Montreal, QC H3T 1J4, Canada
2
Department of Psychiatry, Institut Universitaire en Santé Mentale de Montréal, Montreal, QC H1N 3M5, Canada
3
Centre de Recherche de l’Institut Universitaire en Santé Mentale de Montréal, Montreal, QC H1N 3V2, Canada
4
Institut Nationale de Psychiatrie Légale Philippe-Pinel, Montreal, QC H1C 1H1, Canada
*
Author to whom correspondence should be addressed.
Forensic Sci. 2024, 4(4), 573-587; https://doi.org/10.3390/forensicsci4040039
Submission received: 19 September 2024 / Revised: 13 October 2024 / Accepted: 14 October 2024 / Published: 1 November 2024
Browse Figure
Versions Notes

Abstract

Background: This scoping review examines the risk factors considered in assessing the dangerousness of individuals found Not Criminally Responsible on Account of Mental Disorder (NCRMD) in Canadian administrative courts. This review aims to identify the factors used by mental health review boards during annual case reviews to guide decisions on detention or release. Methods: Using a scoping review approach following PRISMA guidelines, this study analyzed research across multiple databases to identify relevant studies focusing on risk assessment for NCRMD cases. Results: The findings indicate that five primary categories of risk factors—historical, clinical, behavioral, legal, and miscellaneous—are influential in the decision-making process. Historical factors, such as past violence and early psychiatric contacts, are critical in predicting future risk. Clinical factors, including psychiatric diagnosis and treatment adherence, are key to evaluating current and potential future risks. This study reveals variability in the application of standardized risk assessment tools, highlighting a need for more consistent practices across Canadian jurisdictions. Conclusion: This review concludes that, while a multifaceted approach to risk assessment is essential for balancing public safety with individual rehabilitation, further research is needed to refine these processes and establish more uniform standards for managing NCRMD cases in forensic psychiatry.

1. Introduction

1.1. The Notion of Risk and Violence in Forensic Psychiatry and Mental Health

Violence and mental health are intricately linked, with extensive literature highlighting the bidirectional relationship between them [1,2,3]. Individuals with severe mental disorders, such as schizophrenia, bipolar disorder, and major depressive disorder, have a higher risk of experiencing violence, both as victims and as perpetrators, compared to the general population [4]. Research shows that this increased risk is often exacerbated by co-occurring factors such as substance abuse, socioeconomic disadvantage, and lack of social support [3,5]. Victimization and exposure to violence can also significantly worsen mental health outcomes, leading to a vicious cycle of trauma and psychiatric symptoms [6,7]. For instance, intimate partner violence has been strongly associated with a range of mental health issues, including post-traumatic stress disorder, anxiety, and depression [8]. Additionally, individuals with mental health conditions often face stigmatization and discrimination, which can further contribute to social isolation and the exacerbation of symptoms [9,10]. On the other hand, perpetrators of violence are frequently found to have untreated or inadequately managed mental health issues, underscoring the need for early intervention and comprehensive mental health care [11]. Interventions aimed at reducing violence among individuals with mental illness must therefore adopt a holistic approach, addressing the underlying psychiatric conditions, providing substance abuse treatment, and enhancing social support systems [12]. The importance of integrated care models, which combine mental health services with social and community support, is increasingly recognized as essential in mitigating violence and improving overall health outcomes [13,14]. Moreover, public health strategies that focus on violence prevention, mental health promotion, and the reduction of social inequalities, can play a critical role in breaking the cycle of violence and mental health issues [15,16]. Policies and programs designed to provide safe housing, employment opportunities, and access to healthcare are important in supporting individuals with mental health conditions and reducing their risk of both experiencing and perpetrating violence [16].

1.2. Not Criminally Responsible Due to Mental Disorder: Canada

In Canada, the legal defense known as Not Criminally Responsible on Account of Mental Disorder (NCRMD) is employed when a person suffers from a severe mental illness that prevents them from appreciating their actions or differentiating between right and wrong at the moment of the offense [17]. Section 16 of the Criminal Code of Canada describes this defense, which enables a person to be declared not criminally responsible by reason of mental disorder if they meet the criteria [18]. When someone is declared NCRMD, it indicates that it was proven on balance of probabilities (greater than 50%) that their mental disorder rendered them incapable of appreciating the nature or the wrongness of their actions while committing the offense [19]. A court uses expert evaluations from mental health specialists, typically psychiatrists, who analyze the accused’s mental condition at the time of the crime in order to establish whether this legal defense can be used or not.
If someone is judged NCRMD, they are placed under the supervision of a mental health review board rather than receiving a conventional criminal punishment [20]. The mental health review board oversees the person’s care and treatment, with the main objectives being the safety of the public and the person’s mental health requirements [20]. Depending on the risk they represent to themselves and others, an individual deemed NCRMD may be placed in detention in a mental health facility, be released unconditionally, or be released under certain conditions [21]. If the person is judged not to be a serious threat to public safety, they are released with no conditions, known as an absolute discharge [21]. A conditional release entails releasing the patient under specific conditions (modalities) they must adhere to, such as receiving ongoing mental health treatment or living in a mental health facility under supervision [21]. If such modalities are not respected, the mental health review board can be summoned to reassess the risk towards the public. When someone is deemed a high risk to public safety, a court order may be issued for their detention in a mental health hospital [22]. This order mandates that they remain in a secure treatment facility for continuous care and observation.

1.3. Administrative Courts and Risk Assessments

Mental health review boards operate with the use of administrative courts at the provincial level. Such courts are composed of administrative judges. Several studies have shown that standardized risk assessment tools are rarely presented in Canadian administrative court hearings. For instance, a study published by Crocker et al. (2014) found that out of 6743 hearings reviewed in three Canadian provinces, only 17% mentioned a risk assessment tool [23]. Another study by the same research team concluded that less than half of the items from the Historical Clinical Risk Management-20 (HCR-20) and Violence Risk Appraisal Guide (VRAG) were included in the reports of treatment teams, and the consideration of these items varied based on the patient’s gender and crime severity index [24].
There seem to be difficulties in integrating these types of tools into decision-making processes, despite their validation and the literature indicating that they would facilitate decision-making [25,26,27]. Therefore, it is pertinent to review the work that has been conducted in Canada regarding the factors influencing psychiatrists in formulating their recommendations to tribunals. This would help create an overall picture and determine if these factors align with empirical data on violence risk management, especially considering the importance of these recommendations for both the patient and the public.

1.4. Objectives and Hypotheses

The main objective of this literature review is to identify the risk factors used in assessing the risk of violence during the annual reviews of cases of patients recognized as NCRMD in Canadian administrative courts. This work will enable a better identification of the different risk factors used in the expert evaluations of the dangerousness of patients under the jurisdiction of an administrative court, as well as to analyze their impact on forensic psychiatric practice. It also seems pertinent to provide an overview of the current knowledge to pave the way for new studies or analyses related to the factors that will be identified. It is hypothesized that the identified studies will suggest a heterogeneity in the risk factors used by the expert and recognized by the mental health review boards.

2. Materials and Methods

2.1. Search Strategy

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards for scoping reviews were followed in this review. To find recent studies from their inception to 2023, a thorough scoping search was conducted across several electronic databases, including Medline, PubMed, Embase, and PsycINFO. The search strategy employed a combination of text words and subject headings, with a focus on mental health (such as forensic psychiatry, mental disorders, and mentally ill individuals), administrative tribunals (such as tribunal, review board, court referral, and mental health court), and danger (such as risk assessment, violence, and aggression). This approach ensured alignment with this study’s objectives. Supplementary Material Table S1 contains comprehensive search strategies. A specialized librarian with expertise in psychiatry (MD) designed the search methodology, and the Peer Review of Electronic Search Strategies (PRESS) was used to cross-validate the searches.

2.2. Inclusion and Exclusion Criteria

Studies were selected based on the following inclusion criteria: (1) the population of interest comprised patients under the aegis of a mental health review board because of a NCRMD verdict; (2) the study focused on risk assessment factors; (3) the study explicated such factors. Excluded from consideration were unpublished literature and studies on risk assessment beyond the scope of a mental health review board. The search was restricted to sources available in English and French. Geographically, the search was limited to publications about the Canadian legislation, considering the focus of the study.

2.3. Data Extraction

Two authors independently confirmed the uniformity and integrity of the data extracted using a standardized form in Microsoft Excel (Version 2409) (JCP, AH). Any differences of opinion about whether the research article should be included or excluded were settled by consensus. The following data were systematically extracted: authors, population (sample), risk factors, primary outcomes, and primary conclusions.

2.4. Data Analysis

A descriptive analysis of the data collected was used as the main intent was to identify the factors used in assessing dangerousness. Categories of risk factors were designed using grounded theory to encompass the risk factors.

3. Results

3.1. Studies Identified

Studies examining the risk factors used in assessing dangerousness during the annual reviews of cases of NCRMD patients in Canadian administrative courts were evaluated via the scoping review. After deleting duplicates (n = 205), 187 eligible articles were found at first. Based on the first analysis of titles and abstracts, a total of 125 papers were removed because they did not fit the inclusion criteria. Following a second round of abstract screening, 49 full-text publications were excluded after a detailed evaluation of 62 of them. Thirteen studies were left for in-depth examination. Figure 1 provides a flowchart that depicts the inclusion procedure, and Table 1 contains specific information about the included studies. The studies that satisfied the inclusion requirements revealed a range of risk factors, with historical factors (n = 13) being the most prevalent category, followed by clinical factors (n = 11), behavioral factors (n = 9), legal factors (n = 7), and miscellaneous factors (n = 3).

3.2. Historical Factors

Historical factors encompassed the following elements: demographic factors (age at index offense, gender, ethnicity, education, employment at time of index offense, marital status, social support), historical factors linked to mental health or dispositions (criminal history, age at first psychiatric hospitalization, previous disposition status, number of past convictions for violent behavior), and index offense factors (severity of the index offense, index offense type, province). All studies reported historical factors, most of which are included in the HCR-20. However, despite controlling for historical factors, not all studies established links between such factors and review boards’ dispositions.
In a study by Côté et al., it was reported that despite the identification by the research team of HCR-20 risk factors in patients’ medical charts and in medical interviews, very few of these factors were present in the hearing process (discussions during the hearing, disposition justifications, or clinical reports) [24]. When looking for agreement between the items identified by the research team and the items mentioned in the hearing process, they found agreement for only two items of the HCR-20 historical subscale: H1 (previous violence) and H6 (major mental illness) [24]. In their work, Crocker and colleagues reported that review boards considered a combination of static and dynamic risk factors, as depicted by the items of the HCR-20 [28]. They also mentioned that historical (static) factors were more influential on a conditional discharge decision and had less importance over time, compared to clinical (dynamic) factors that had more influence on an absolute discharge decision and became more important over time [28]. Contrary to these findings, Wilson and his team found that the scores on the historical and risk subscales of the HCR-20 did not influence the decision process of the mental health review board [34].
Interestingly, in the study by Seto and colleagues, who compared individuals found NCRMD for sexual offenses versus those found NCRMD for nonsexual violent offenses, individuals who committed sex offenses were more likely to be unemployed and younger at their first psychiatric contact, but there were no differences between the groups in their first review board disposition or behaviors between hearings [37]. In the National Trajectory Project, which comprised over 1800 individuals found NCRMD, it was reported that a higher number of past offenses and a psychotic spectrum diagnosis decreased the likelihood of discharge, while the severity of the index offense significantly increased the duration of detention and review board supervision across all provinces. Index offense severity was also found to be linked with detention in other studies, while a more recent paper by Cheng and their team on 109 NCRMD individuals reported that it did not predict dispositional outcomes [28,32].

3.3. Clinical Factors

A total of 11 studies evaluated the use of clinical factors. These factors refer to the following items: psychiatric history (serious mental illness, psychotic spectrum disorder, substance use disorder, personality disorder, axis II disorder, active psychiatric symptoms, diagnosis not specified), medication and treatment compliance (type of medication, non-compliance with medication), and clinical risk assessment (psychopathy with PCL-R score, HCR-20 score, VRAG score, other risk instruments, fitness evaluation).
In a study on men found NCRMD in the province of Quebec, Côté and colleagues reported that there was moderate agreement for substance abuse problems and clinical indicators when looking for agreement between the HCR-20 items identified by the research team and the ones mentioned in the hearing process [24]. The same research team also reported that there was a low agreement on antisocial personality traits and psychopathy despite their importance in forensic psychiatry.
Another study on patients found NCRMD from the three largest Canadian provinces reported that the greater presence of clinical items resulted in a higher likelihood of hospital detention at the next hearing when correlating with review board dispositions [30]. Accordingly, Denomme and colleagues found that detained individuals had a higher number of clinically relevant items mentioned in their expert reports (i.e., lack of insight, negative attitudes, active symptoms, impulsivity, unresponsiveness to treatment) [35]. Another study on the correlates of dispositions reported that men who were detained had higher total HCR-20 scores, driven by differences in clinical subscale scores [31]. Similar observations suggested that clinical recovery indicators were more influential than violence risk assessment tools in determining dispositions, emphasizing mental health improvement [31]. In Cheng and colleagues, significant predictors of review board dispositions included pro-criminal attitudes, antisocial patterns, and associations with criminal companions [32].

3.4. Behavioral Factors

Of the identified studies, nine reported the analysis of behavioral factors when assessing review board dispositions. These encompassed behaviors since previous hearing (violent acts, suicidal attempts or thoughts, non-compliance with review board conditions, substance use) and in-hospital conduct (in-hospital physical assaults, problematic behaviors, number of notable events). Most studies did not report significant correlates between review board dispositions and behavioral factors. However, a study by Wilson and colleagues indicated that individuals who committed a violent act during conditional discharge were more likely to be detained [30]. Another study by Hilton reported that almost half of initial review board dispositions were for men to remain in high-security custody, mainly due to in-hospital factors such as physical assaults rather than index severity, VRAG scores, or medication compliance [31]. Crocker and colleagues also found that the presence of a violent act since the hearing reduced the likelihood of receiving a conditional or absolute discharge disposition [23].

3.5. Legal Factors

Seven studies reported using legal factors when assessing the dispositions of the review board. These factors encompass the following: review board and hearing factors (status at hearing, sequence of hearing in time, number of past hearings, duration under review board, reasons for hearing), disposition factors (initial disposition, previous disposition), and protective factors (protective factors mentioned in the review board’s reasons for disposition). In the study by Collins and colleagues on the use of protective factors to influence the decisions of review boards, it was found that dispositions specifying a transfer to a higher security setting had significantly fewer references to Structured Assessment of Protective Factors for violence risk (SAPROF) items compared to those specifying no change or less security [36]. However, they found that the use of protective factors remains limited in review board hearings [36]. Furthermore, Crocker and colleagues suggested that previous disposition and setting were significantly associated with detention decisions, which is consistent with Cheng’s findings that previous disposition status surpassed all predictors of interest in the third hearing sampled, but not for earlier hearings [21,32].

3.6. Control and Miscellaneous Factors

Only two studies reported control and miscellaneous factors. Amongst these factors, attractiveness (physical attractiveness) and insight/participation in treatment (insight into mental illness, participation in therapeutic activities, refusal to participate in therapy, level of participation in recreational, vocational, and therapeutic programming) were found. In their work, Denomme and colleagues identified that both attractiveness and the number of Psychopathy Checklist—revised (PCL-R) items mentioned significantly influenced dispositional outcomes [35]. Higher attractiveness scores increased the likelihood of discharge, while a greater number of PCL-R items mentioned increased the likelihood of detainment [35].
Other miscellaneous factors were reported in Martin’s study on 291 inpatients who were under the jurisdiction of the mental health review board in a public provincial psychiatric hospital. They found that treatment teams in minimum security units emphasized factors such as fewer negative incidents over empirically validated risk factors when considering the addition of a community living provision to the review board disposition [33]. The authors suggest that one reason for this result may be the way the review board dispositions work in terms of imminence of transfer. They also mention that treatment teams may use the community living provision as a potential motivational tool for patients rather than focusing exclusively on risk assessment [33].

4. Discussion

This study aimed at identifying the risk factors used in assessing dangerousness during the annual reviews of cases of patients found NCRMD in Canadian administrative courts. The search strategy identified five main categories of risk factors: historical factors, clinical factors, behavioral factors, legal factors, and miscellaneous factors. The small number of studies and the heterogeneity in the links between risk factors and dispositions highlight the need for future work in this field.
Historical factors play an important role in violence assessment for mental health review boards when deciding dispositions. Understanding an individual’s past behaviors, psychiatric history and socio-demographic background provides a specific context that can inform risk assessments and guide decisions about treatment and supervision [38]. Historical factors such as previous episodes of violence, early psychiatric contacts, substance abuse, and social support networks are important in predicting future risk and tailoring interventions to mitigate this risk [39,40]. Accurate violence assessment ensures that the review board can balance the need for public safety with the rights and rehabilitation of the individual [41,42]. It also helps identify potential triggers and protective factors that can be addressed through targeted therapeutic interventions. By integrating a comprehensive review of historical factors, mental health review boards can make more informed and nuanced decisions, promoting both community safety and the well-being of individuals with mental disorders.
Similarly, clinical and behavioral factors are used by treating teams in violence assessment when suggesting dispositions to mental health review boards, which then consider these factors in their decisions. These factors include the individual’s psychiatric diagnosis, symptom severity, treatment history, medication adherence, and response to previous interventions [43]. Understanding the clinical profile of an individual allows review boards to gauge the current and potential future risk of violence accurately. For instance, certain psychiatric conditions, such as schizophrenia or bipolar disorder, especially when accompanied by substance abuse, are associated with a higher risk of violent behavior [44,45]. Clinical assessments also consider the effectiveness of ongoing treatment and the individual’s engagement in therapeutic programs, which are crucial for managing symptoms and reducing the risk of future incidents [46]. By incorporating clinical and behavioral factors, review boards can make evidence-based decisions that prioritize both the safety of the community and the health needs of the individual. This approach ensures that individuals receive appropriate care, tailored to their specific clinical needs, which can include medication management, psychotherapy, and support for co-occurring conditions. Furthermore, the continuous monitoring of clinical progress allows for adjustments in treatment plans to address any emerging risks or challenges.

Limitations

The variety of the studies and the small number of available research articles are the main limitations of this scoping review. Consistent and broadly applicable results are difficult to derive, since studies differ in their definitions, measurements, and reporting of risk factors. Data inconsistencies resulted from the use of non-standardized risk assessment instruments in some of the identified studies. The exclusion of unpublished studies or those inaccessible through the selected databases may have resulted in the omission of pertinent findings due to the dependence on existing literature. Furthermore, even if the scoping review methodology is thorough, it prevents a thorough meta-analysis of the data, which would yield stronger statistical conclusions.

5. Conclusions

To conclude, this scoping review highlights the current nature of risk assessment in Canadian administrative courts for individuals found NCRMD. Five primary categories of risk factors were identified: historical, clinical, behavioral, legal, and miscellaneous. Historical factors, including previous violence and early psychiatric contacts, are used for predicting future risk and guiding intervention strategies. Clinical factors, such as psychiatric diagnosis and treatment adherence, are essential for assessing current and future risk accurately. This literature review underscores the importance of a comprehensive approach that considers multiple risk factors to balance public safety with individual rehabilitation. However, the limited number of studies and variability in findings highlight the need for further research to refine risk assessment processes. Future studies should aim to establish standardized practices that integrate empirical data and enhance the effectiveness of mental health review boards in managing NCRMD cases. This comprehensive understanding of risk factors is vital for improving the fairness and accuracy of dispositions when attempting to predict violence, ultimately contributing to better outcomes for both individuals and the community.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/forensicsci4040039/s1. Table S1: Concept plan.

Author Contributions

Conceptualization, J.-C.P., A.H., and S.B.P.; methodology, J.-C.P., A.H., and M.D.; validation, A.H. and J.-C.P.; formal analysis, J.-C.P. and A.H.; data curation, J.-C.P.; writing—original draft preparation, J.-C.P. and A.H.; writing—review and editing, J.-C.P., S.B.P., M.D., and A.H.; supervision, A.H.; project administration, A.H. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

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Forensicsci 04 00039 g001
Figure 1. Flowchart of the identified studies.
Figure 1. Flowchart of the identified studies.
Forensicsci 04 00039 g001
Table 1. Studies identified and their description.
Table 1. Studies identified and their description.
AuthorsPopulationRisk Factors
Assessed		Type of Risk FactorsTopic of the StudyMain Outcomes
Côté, G., et al. (2012) [24]Patients found NCRMD, aged 18–65, recruited from Quebec’s forensic psychiatric hospital and 2 hospitals in the Montreal metropolitan area, had a hearing between Oct 2004 and Aug 2006.
N = 96 men		 HCR-20 itemsHistorical Factors, Clinical Factors, Behavioral FactorsRepresentation of HCR-20 items in mental health review board hearings and level of agreement between the scale items identified by the research team and the items noted by the clinicians in their reports and discussed during the hearing.Very few of the HCR-20 items identified by research team were present in the hearing process, either in clinical reports, discussions during the hearing, or disposition justifications.
There was agreement for only two historical items, H1 (previous violence) and H6 (major mental illness), with moderate agreement for substance abuse problems and clinical indicators, but no higher than moderate agreement for any risk management items.
The low agreement for antisocial personality traits and psychopathy, despite their documented importance in forensic mental health literature, was particularly striking and surprising.
Crocker, A. G., et al. (2011) [28]Patients found NCRMD, aged 18–65, recruited from Quebec’s forensic psychiatric hospital and 2 Montreal metropolitan area hospitals, had a hearing between Oct 2004 and Aug 2006.
N = 96 men		Sociodemographic factors, previous disposition, index offense, criminal history, age at first psychiatric hospitalization, serious mental illness, antisocial personality disorder, substance use disorder, psychopathy with PCL-R score, risk assessment with HCR-20, VRAGHistorical Factors, Clinical Factors, Behavioral Factors,
Legal factors		Mental health review board dispositions (detention, discharge)Review boards rely on dynamic (clinical) factors more than historical factors to make the decision to detain or to release people found NCRMD.
Previous disposition, HCR-20 clinical subscale and the severity of index offense were significantly associated with detention.
Neither the VRAG nor total PCL-R scores distinguished review board dispositions.
Crocker, A. G., et al. (2014) [23]Men and women found NCRMD in British Columbia, Québec and Ontario between May 2000 and April 2005, followed until Dec 2008.
N = 1794		Static predictors: province (Québec, Ontario, British Columbia), age at the index verdict, gender, severity of the index offense, presence of psychiatric history, dynamic predictors: behaviors since previous hearing (violent act, suicidal attempt or thoughts, non-compliance with mental health review board conditions, substance use, non-compliance with medication), diagnosis (psychotic spectrum, mood spectrum, other axis 1 diagnosis, substance use spectrum, personality spectrum, diagnosis not specified), use of structured risk assessment tool, number of HCR-20 items mentioned at hearing as present (historical, clinical, and risk items), sequence of hearing in timeHistorical Factors, Clinical Factors, Behavioral Factors, Legal FactorsMental health review boards dispositions (detention, conditional discharge, absolute discharge) Review boards considered a combination of evidence-based static and dynamic risk factors, as depicted by the items of the HCR-20, but presentation of a complete structured risk assessment was rare (17%). Historical (static) factors were more influential on a conditional discharge decision and had less importance over time, compared to clinical (dynamic) factors, which had more influence on an absolute discharge decision and took more importance over time.
The individuals with more severe index offense were less likely to receive a release decision. The presence of a violent act since the previous hearing decreased the likelihood of being released on conditional or absolute discharge.
Psychiatric history before the index offense reduced the likelihood of being released from detention.
Hilton, N. Z., et al. (2016) [29]Patients found NCRMD and detained in a maximum security psychiatric hospital in Ontario, which were admitted between 2009–2011 and followed until 2012.
N = 63 men		Psychiatrists’ testimony, multidisciplinary team recommendations, VRAG score (coded by research team), VRAG, HCR-20 and PCL-R cited, participation in therapeutic activities (skills therapy, group therapy, individual therapy, counseling), refusal to participate in therapy, insight into mental illnessHistorical Factors, Clinical Factors, Behavioral Factors, Control and Miscellaneous FactorsMental health review board dispositions (detention vs. transfer or discharge (binary)), psychiatrists’ testimonyDispositions were most strongly associated with psychiatrists’ testimony and VRAG scores, indicating that detained patients had a higher risk of violent recidivism than transferred patients. Dispositions also correlated with HCR-20 scores, where detained patients had higher scores. Participation in group therapy and other therapeutic activities influenced psychiatrists’ recommendations for transfer and detention, independent of the patients’ length of stay.
Wilson, C. M., et al. (2016) [30]Men and women from the three largest Canadian provinces (BC, QC, ON) found NCRMD between May 2000 and April 2005, who received at least one conditional discharge decision from the RB before December 2008.
N = 1367		Static factors: province (Québec, Ontario, British Columbia), age at the index verdict, sex, severity of the index offense, presence of psychiatric history, diagnosis (psychotic spectrum, substance abuse, personality disorder, diagnosis not specified), Dynamic factors: number of past hearings, rehospitalization, presence of systematic evaluation, behavior since the last hearing (violence, substance use, suicidal attempt or thoughts, non-compliance with mental health review board conditions, non-compliance with medication), number of HCR-20 itemsHistorical Factors, Clinical Factors, Behavioral Factors,
Legal Factors		Revocation of conditional discharge, rehospitalizationThe greater presence of clinical items resulted in a higher likelihood of hospital detention at the next hearing, especially for the re-hospitalized group. The re-hospitalized group was younger, more likely diagnosed with a schizophrenia-spectrum disorder, engaged in concerning behaviors, and had more H, C, and R items reported. Ontario individuals, those with a psychiatric history, or those who committed a violent act during conditional discharge were more likely to be detained, with the number of clinical items being a strong factor in the detention decision. The number of historical and risk items from the HCR-20 did not influence the decision process of the review board.
Hilton, N. Z., et al. (2022) [31]Men found NCRMD and admitted to a high-security forensic hospital in Ontario from 2009 to 2012 (and decisions made up to 2014).
N = 89		VRAG score, severity of the index offense (Cormier Lang Criminal History Score), In-hospital physical assaults, score on the Problem Identification Checklist (i.e., PIC, measures in-hospital clinical factors: psychotic behaviors subscale, social withdrawal subscale, inappropriate behaviors scale, mood problems scale), medication noncompliance Historical Factors, Clinical Factors, Behavioral FactorsMental health review board disposition at hearings held in the first, second, and third years of each man’s hospitalization (detained or transferred/discharged).Almost half of initial RB dispositions were for men to remain in high-security custody, mainly due to in-hospital clinical factors such as assaults and PIC scores, rather than index severity, VRAG scores, or medication compliance. Over time, the odds of remaining in high-security custody increased significantly, with clinical presentation and PIC scores being more crucial than the number of in-hospital assaults. Clinical recovery indicators were more influential than violence risk in determining dispositions, emphasizing mental health improvement.
Cheng, J., et al. (2023) [32]Alberta NCRMD cohort that entered the review board system between 2005 and 2010 and their respective review board hearings until 2015. N = 109Level of Service/Case Management Inventory (LS/CMI), HCR-20V3, VRAG-R, Static and dynamic factors not captured by the study instruments: Static factors included sociodemographic variables (i.e., gender, ancestry) and index offense severity, dynamic factors included Institutional conduct divided into: (a) violence, (b) suicide attempts or ideation, (c) breach of RB conditions, (d) substance use, and (e) treatment noncompliance, diagnoses, number of hearings since the NCR verdict, previous disposition status, use of other risk instrument type (PCL-R, SAVRY, Static-99, SARA, SVR-20, SAM)Historical Factors, Clinical Factors, Behavioral Factors, Legal FactorsMental health review board dispositions (detention, conditional discharge, absolute discharge)Risk instruments were routinely included in clinical reports, with usage increasing from 54% at the first hearing to 92% at the third, predominantly by psychiatrists using HCR-20, followed by Psychopathy Checklist—revised, and VRAG-R. Despite this, the LS/CMI items were often unscorable due to incomplete profiles, indicating that central criminogenic risk/need factors were not fully captured in reports. Dispositions were significantly predicted by independently coded LS/CMI total scores, with pro-criminal attitudes, antisocial patterns, and companions consistently emerging as significant predictors, while previous disposition status was the strongest predictor in later hearings.
Martin, K. and E.
Martin (2016) [33]		Inpatients from a public provincial psychiatric hospital who were under the jurisdiction of the review board between January 1, 2009, and September 1, 2013. N = 291Demographic variables (age at time of recommendation to the review board, ethnicity, education, employment at time of index offence (part time, full time, or unemployed), marital status at time of index offence (single/never married, married/common-law, separated/divorced, or widowed), and social support (yes or no), psychopathy (PCL-R score), violence risk (using the HCR-20 version 23), index offence (murder, sexual violence, serious physical violence, less serious physical violence, verbal violence (e.g., threats), or non-violent behavior), and number of past convictions for violent behavior, axis II disorder (yes or no), presence of active psychiatric symptoms (active or not active), age at first hospitalization, medication (oral, depot, or no medication), level of insight into illness (none, limited, moderate, or full), level of participation in recreational, vocational, therapeutic programming in the past year (number of activities engaged in), time in hospital since NCR finding, and number of notable negative events in the last year (e.g., elopements, drug use, etc.)Historical Factors, Clinical Factors, Behavioral Factors, Control and Miscellaneous FactorsTreatment team recommendations for review board (move to a lesser secure environment or stay at their current level of security) for 2 different comparison groups: medium secure unit and minimum secure unit.Psychotic symptoms and overall violence risk level (measured by HCR-20) were the main factors influencing treatment teams’ recommendations for transferring patients from medium to minimum secure units. Factors such as violent behavior, insight, and participation were correlated but not predictive of these recommendations; patients transferred to minimum security showed more engagement in treatment and fewer violent incidents. Treatment teams on minimum security units focused less on empirically validated risk factors and more on factors such as fewer negative incidents when considering the addition of a community living provision to the disposition, possibly using it as motivational tools rather than focusing solely on risk assessment.
Wilson, C. M., et al. (2015) [34]Individuals found NCRMD in British Columbia, Ontario, and Québec between May 2000 and April 2005, who had at least one hearing with a review board.
N = 1794
The sample represents the full population of NCRMD adults for BC and ON within their respective time frames and a regionally stratified random sample for QC. Files were reviewed from 2000 to 2008.		Index offense severity, gender. Control variables: province, age at index offense, time since index verdict, index offense severityHistorical Factors,
Legal Factors		Mention of risk factors in expert reports and in review board decisions (items of the HCR-20 or the VRAG), regardless of whether the item is present or absent for the individual.A complete risk assessment measure was infrequently completed, with the HCR-20 and VRAG used in only 8% and 9% of hearings, respectively. The mean number of HCR-20 items in expert reports was 8.59, and VRAG items were 5.10, with significant agreement between expert reports and review board decisions focusing on mental health, treatment, and criminal history. Factors such as relationship instability and stress were more likely to be mentioned for women, while substance use and psychopathy were more likely for men, indicating some gender differences in risk factor consideration.
Crocker, A.G., et al. (2015) [21]Men and women found NCRMD in British Columbia, Quebec, and Ontario between May 2000 and April 2005, followed until December 2008.
N = 1800 		Fitness evaluation, hearing participants, initial disposition, reasons for hearing, duration under mental health review board, province, number of past criminal convictions, diagnosis at NCRMD verdict (psychosis spectrum disorder, mood disorder, substance use disorder, personality disorder), index NCRMD offenseHistorical Factors, Clinical factors, Legal FactorsMental health review board decisions, associated conditions, as well the agreement between clinical recommendations and the review board decisions.Most reports (86.9%) included a recommended disposition, with a high agreement (86.9%) between clinician recommendations and review board decisions, though this varied across provinces. The odds of being conditionally or absolutely discharged varied significantly across provinces, with Quebec having higher discharge rates compared to Ontario and British Columbia, even after controlling for factors such as past offenses and diagnosis at verdict. A higher number of past offenses and a psychotic spectrum diagnosis decreased the likelihood of discharge, while the severity of the index offense significantly affected the duration of detention and RB supervision across all provinces.
Denomme, W. J., et al. (2020) [35]Male NCRMD patients from a mental health facility in Canada, who had a hearing held between 2007 and 2014.
N = 62		Risk factors, protective factors and psychopathic traits (items from the HCR-20, SAPROF, and PCL-R scales), physical attractiveness, severity of index offense, criminal history (Cormier-Lang criminal history scale), diagnosis and demographicsHistorical Factors, Clinical Factors, Behavioral Factors, Control and Miscellaneous FactorsMental health review board disposition (discharge or detainment)The sample had a mean number of 11.50 HCR-20 item mentions, 4.36 PCL-R item mentions, and 8.86 SAPROF item mentions in clinician reports. Attractiveness and PCL-R item mentions significantly influenced dispositional outcomes, with higher attractiveness increasing the odds of discharge and more PCL-R mentions increasing the odds of detainment. Analyses showed a significant emphasis on psychopathic traits and risk factors in decisions to detain NCRMD patients, indicating a potential overemphasis on risk, while underemphasizing protective factors.
Detained individuals had a higher number of clinically relevant items mentioned in their expert reports (i.e., lack of insight, negative attitudes, active symptoms, impulsivity, unresponsiveness to treatment).
Collins, C., et al. (2019) [36]Patients randomly selected from a public psychiatric hospital in Ontario, who had a hearing held between July 2016 and June 2017.
N = 116		Items from the SAPROF (protective factors) Historical Factors, Clinical factors, Legal FactorsDisposition outcome (no change, decreased security, increased security).On average, less than half of the SAPROF items are mentioned in hospital reports and only about a third in reasons documents, with external items being mentioned most frequently. Dispositions specifying a transfer to a higher security setting had significantly fewer references to SAPROF items compared to those specifying no change or less security. The discussion of protective factors is limited and mainly includes external factors, suggesting an overreliance on traditional risk assessment and potentially leading to unjust detentions and misappropriation of treatment resources.
Seto, M. et al. (2018) [37]Population extracted from the National Trajectory project (NCRMD patients who entered the mental health review board system (Quebec, Ontario and British Colombia) between 1 May 2000 and 30 April 2005):

50 individuals with an NCRMD finding for a sexual offence at any time were compared with a group of 50 individuals found NCRMD for a violent offence against a person at any time, but who had never committed a sexual offence.
N = 100		Sexual index NCRMD offense, nonsexual violent index NCRMD offense Historical FactorsSociodemographic characteristics (age at index NCRMD verdict, gender, education, relationship status, residential status, and employment status prior to the index offence), clinical history, criminal history, mental health review board trajectories, and details of the risk assessments (behavior while under the mandate of mental health review board) and time until reoffending.NCRMD individuals who committed sex offenses were more likely to lack paid work and were younger at the time of first psychiatric contact compared to violent offenders, but no significant differences were found in most other sociodemographic or psychiatric history aspects. There were no differences between the groups in their first review board disposition or behaviors between hearings, but sex offenders had a longer mean duration under the review board mandate (6.6 years vs. 4.8 years for violent offenders). Despite these differences, no significant differences were found in recidivism hazards, suggesting that review boards may be overly conservative in managing sex offenders, given their low overall recidivism rates.
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Pellerin, J.-C.; Désilets, M.; Borduas Pagé, S.; Hudon, A. Factors Considered for the Assessment of Risk in Administrative Review Boards of Canada: A Scoping Review. Forensic Sci. 2024, 4, 573-587. https://doi.org/10.3390/forensicsci4040039

AMA Style

Pellerin J-C, Désilets M, Borduas Pagé S, Hudon A. Factors Considered for the Assessment of Risk in Administrative Review Boards of Canada: A Scoping Review. Forensic Sciences. 2024; 4(4):573-587. https://doi.org/10.3390/forensicsci4040039

Chicago/Turabian Style

Pellerin, Jane-Caroline, Marie Désilets, Stéphanie Borduas Pagé, and Alexandre Hudon. 2024. "Factors Considered for the Assessment of Risk in Administrative Review Boards of Canada: A Scoping Review" Forensic Sciences 4, no. 4: 573-587. https://doi.org/10.3390/forensicsci4040039

APA Style

Pellerin, J.-C., Désilets, M., Borduas Pagé, S., & Hudon, A. (2024). Factors Considered for the Assessment of Risk in Administrative Review Boards of Canada: A Scoping Review. Forensic Sciences, 4(4), 573-587. https://doi.org/10.3390/forensicsci4040039

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