Barriers and facilitators of access and utilization of mental health services among forensic service users along the care pathway

This paper provides an overview of who accesses and receives various types of mental health medical services, in a sample of participants who were selected as a result of being found NCRMD. Traditional models of access to care highlight that needs are the main predictors of service utilization [48]; however, that was not the case here. While facilitators and barriers may differ for every level of care, general trends emerged: the person’s living situation, both in terms of geography and in terms of people with whom the person lived, had major influences on what services were accessed and used or not, even when adjusting for need-related variables such as primary and concurrent diagnoses. There was one major exception in terms of need-related variable: a history of NCRMD was by far the largest size effect in determining who reached psychiatric services, and was a significant predictor of volume of psychiatric care and of emergency mental healthcare. These findings show that a NCRMD verdict changes how service users interact with the mental health system.

Geographical considerations were highly important in determining who reached, and who received, psychiatric care – even when including individual factors related to need in the models. All else – including proximity to services – being equal, those who lived outside of major urban centres were 3 times as likely to reach psychiatric services as those who lived in major urban centres. They were also 2 times more likely to frequently visit the emergency room for mental health reasons. This may reflect the lack of access to primary care physicians in rural regions, with ratios of physicians per capita being between 30 to 50% greater in major urban centres compared to other regions [40], a situation that has barely evolved over the past 20 years [49]. General practitioners in rural areas may be especially overwhelmed and not able/willing to treat severe mental illnesses [50], preferring to refer to psychiatric care [51, 52]. Community psychosocial services are also lacking outside urban areas [53], which may result in a greater involvement of medical professionnals. For example, a study of Québec general practitioners’ practices in mental healthcare found that general practitioners of rural areas were 1.5 times more likely to refer to outpatient psychiatric clinics than general practitioners in urban or semi-urban areas, while they were less susceptible to refer to psychosocial services, psychologists offices, community organisms or crisis centres [53]. Another study in the United States supports the hypothesis that rural populations are less likely to rely on psychosocial services, with data suggesting that they are half as likely to initiate psychotherapy when needed as urban populations – but that they engaged in similar intensity and for similar lengths once initiated [54]. It is also possible that lack of access to first line mental health services outside of major urban centres, including primary care and non-medical resources [54], result in increased use of the emergency departments [55], thus increasing the odds of being evaluated by a psychiatrist. This would explain the findings that living in a rural zone influence the odds of reaching specialist care, but not the volume of specialist care used. Finally, it is also possible that existing resources are better known in smaller communities, and that fewer service points results in a more patient-centred, better coordinated care.

When adjusting for urbanization of the area of residence, closer proximity to hospital centres offering services upon referral also increased the odds of reaching specialized mental health care, but proximity to outreach services decreased the volume of psychiatric visits and improved continuity of psychiatric care. This may reflect a greater connection with community-based organisations that offer non-medical mental health services, or interaction with multidisciplinary teams such as Assertive Community Treatment where service users may see non-medical team members more often than the physician associated with the team. Given that nearly half of people with a NCRMD verdict had a history of criminal justice involvement, there is an opportunity to implement Forensic Assertive Community Treatment teams for people with a severe mental illness and who are believed to be at risk of committing an offense to address both their mental health needs and their criminogenic needs [56, 57]. These Forensic Assertive Community Treatment teams may also be offered to people with severe mental illness who are not justice-involved but who are considered at risk of violence or criminal justice involvement.

Another important trend that emerged from the findings was that living with a partner or family decreased the odds of accessing and receiving mental healthcare. While Andersen’s model of behavioral access to care purports that social support is a facilitator for health services use [48], it was not the case here. Instead, living with relatives decreased the odds of seeking mental healthcare, of reaching psychiatric care, and the volume of psychiatric visits. The empirical literature on social networks and mental health service use among people with severe mental illness tends to show that smaller social networks or lower social/family support are associated with greater inpatient service use [47, 58]. Epidemiological catchement area studies (in Montréal, Québec [59] and Baltimore, USA [60] respectively) have also shown that greater social support reduced the likelihood of reaching psychiatric care [59, 60]. It is possible that living with loved ones increases the self-perceived stigma both from the service user perspective and from the relatives, as the “marked difference that [is] negatively appraised” may become more apparent when cohabiting [61]. This may increase the preference for self-reliance, as stigma related to severe mental illness, especially when combined with that of a history of criminal justice involvement [9, 62, 63], may interfere with the ability and willingness of service users and their loved ones to fully participate in care [64]. Living with relatives may also increase the perceived ability to self-manage [65], as some may take the role of caregiver and provide some aspects of care, thus reducing the reliance on psychiatric visits or or delaying the referral to a psychiatrist by a family physician. This may be especially true in health systems that rely heavily on families and loved ones for daily care and help seeking. Another possible explanation is that families may protect their loved ones with mental illness from services that they do not find acceptable or that are accessed through judicial levers that families are not willing to use (e.g., involuntary treatment orders, involuntary admission) [66, 67]. Issues related to the acceptability of mental health services are important barriers to access and use of healthcare in Québec [68] and elsewhere [27], especially in a context where living with a severe mental illness is still heavily stigmatized. A narrative synthesis of access to services for another highly stigmatized group (people who inject drugs) has highlighted the strong role of non-judgmental health workers, high confidentiality, and flexibility of services in making services more acceptable to service users and increasing access [69]. In the context of mental health services, families may be unwilling to use levers to access care that may jeopardize their relationship with their loved one [66], that may subject them to discrimination or judgement from health workers, or that they may perceive themselves as unsafe or ineffective [27]. A fragmented system of care [70] may have also left many families and service users – especially those with concurrent substance use disorders – frustrated, having experienced considerable discrimination and disregard from some practitioners [71], and having received very little support in return. For some service users, the association may be reverse: people who are unable to access appropriate mental healthcare in a timely manner may be more susceptible to moving in with relatives and loved ones, such as parents, siblings or adult children. Regardless of the direction of the association, this finding is important as people who are found NCRMD are especially likely to victimize family members [72]. Resources should be invested to provide psycho-education and support to relatives [73], who are primary sources of financial, psychological and social support. This requires sufficient resources so that healthcare providers have the time to listen to families and engage with them, and that they are well-trained in the ethical and legal considerations that such a close collaboration with the family entails [74]. Relatives are too often in untenable positions, having to juggle seeking care, understanding the administrative maze and civil court provisions, and their own health and safety.

Finally, findings suggest that general practitioners, to the extent that they have a sustained relationship with their patient, may play an important role in the first line of identification of mental health problems. Nearly all participants who had a significant connection to a general practitioner were identified as having mental health needs and received primary mental health care in response to those needs. Yet, less than one in five participants were considered as significantly attached to a general practitioner, which is slightly lower than what is observed in the general population of the province of Québec during the same period [44], despite considerably higher needs. The decision to seek help for a health problem has been found to be associated to the sense of affinity to a primary care practice and the sense of trust in a primary care provider, especially for those who are socioeconomically disadvantaged [30]. Health policies should continue focusing on providing access to family physicians, supporting greater involvement from primary care clinicians, and access as appropriate to specialists in mental health, substance use and the plight of socially marginalized persons in prevention of criminal justice involvement. Those changes may require more structural transformations, such as to the mode of remuneration of physicians. The traditional fee-for-service adopted throughout Canada has shown to have deleterious effects on access to services by service users who are perceived as difficult or vulnerable, and thus less “cost-effective” [75]. Other models may be more appropriate for this population, especially as mental health care should be interprofessional [75]. For example, a study in Ontario robustly showed that a blended capitation model for primary care physicians was associated with better outcomes in terms of psychiatric health than a blended fee-for-service, as it may promote continuity of care and accessibility to services as well as promote interdisciplinary work [76].

 The findings reveal inequities in opportunities to access mental health services in the trajectories of forensic service users. Geographic factors and the presence of relatives in the lives of service users have a greater influence on the odds of seeking, reaching and receiving mental healthcare than factors related to the intensity of needs. Engagement with family members – both in the clinical setting with family-centred services and in the research setting with participatory action research – is an area that is vastly underprioritized, especially as close relatives are the most likely victims of NCRMD offenses. Family-centred services are potentially an important lever to improve engagement with mental healthcare among people who have a severe mental illness and who have behaviors that make them at risk of criminal justice involvement. Access to mental health services may prevent violence and criminal justice involvement for a subset of mental health service users, as long as services are appropriate in nature and intensity.