On the heels of Bell Let’s Talk Day, mental health is at the top of mind for many Canadians.
Everyone is affected by mental illness in some way – whether it is through a family member, friend, or colleague, or through their own personal experience – and with public campaigns like Bell Let’s Talk that encourage people to speak up about their experiences, mental illness is becoming increasingly de-stigmatized.
For those who suffer from a mental illness and have also come into contact with the law, however, significant stigma still exists.
There are many myths and misunderstandings that still exist around forensic mental health care (the area where the mental health system and the criminal justice system meet) – and the value of innovative research in the field can sometimes be discounted.
For Dr. Mathieu Dufour, a frontline forensic psychiatrist and associate chief of psychiatry (Ottawa) at The Royal, however, forensics care and research plays a critical role in the mental health landscape.
Further, he sees the Forensics Program at The Royal as an exemplary model for how mental health care can drive research, and mental health research can effectively inform practice; to improve outcomes for patients and society as a whole.
Dr. Dufour took the time out of his busy schedule to chat about why research is integral to his frontline clinical practice; to dispel some of the myths around the forensic mental health system; and to explain how patient outcomes can be improved in real-time at The Royal, through an increasingly integrated research and care model.
IMHR: For those who may not be familiar with The Royal’s Forensic Program – or with what a frontline forensic psychiatrist does – could you tell us a bit about your role?
MD: About half of my time is spent working clinically as a frontline forensic psychiatrist. I have around 10 inpatient beds on the forensic inpatient unit, where I conduct ‘Fitness to Stand Trial’ and ‘Criminal Responsibility’ assessments for the courts. If the court finds any of these individuals Not Criminally Responsible (NCR), then we would provide care to them with an interdisciplinary team under the Ontario Review Board (ORB).
After individuals are discharged from the hospital, I would continue to provide care with an outpatient interdisciplinary team, until their absolute discharge by the ORB. I also do some correctional work, providing psychiatric care for patients in jail; mainly by telemedicine.
IMHR: Your role mainly involves frontline work with patients and the court system –how does research factor in?
MD: In general, frontline forensic psychiatrists are quite engaged in research. Because we also work here at The Royal, which is a mental health care and academic health science centre, we all have university appointments with the University of Ottawa. We constantly are reading the latest journal articles and case law from the courts, which helps us to provide the best, evidence-based care possible.
We are also very fortunate at The Royal to have a strong Forensics Research Unit, led by Dr. Michael Seto. What’s great is that even though we are busy clinicians, we know that we have research support. I sit down regularly with Dr. Seto and bring him all the pressing clinical questions that I have that I think research could help answer. Together, we’ve put together many research proposals, and I’ve had important support from the research side to write grants, conduct literature reviews, and find research assistants.
IMHR: Can you tell us about a specific project you’ve collaborated on recently with the Forensics Research Unit?
MD: I have a special interest in geriatric offenders and looking at the links between geriatric psychiatry and forensic psychiatry. [I recently collaborated on] a few research projects that looked at the risk factors for violence in geriatric offenders versus non-geriatric offenders. Prior to that, there was very little research in this area compared to other domains of forensic mental health. Dr. Seto was instrumental in helping to pilot this project based on some of the clinical questions I had, and we were able to find many important answers that have helped us to improve patient care.
Some of the clinical questions we sought to answer through research started to come up initially for me, as we were beginning to see more and more elderly people going through the judicial system. Having this close relationship with Dr. Seto and his research unit, we were able to put together a timely research study that has helped to inform care in real-time. There exists so much potential for research projects like this one, where we can collaboratively grow knowledge within forensic psychiatry and improve our practice.
IMHR: Why do you think that collaboration between research and care is so valuable within the area of Forensic Mental Health, in particular?
MD: At times, Forensic Psychiatry can be a really undervalued speciality, where both the patients and the speciality overall suffer from a sort of ‘double stigma’. Occasionally, we need to justify and prove why the forensics mental health system works – and that’s one area where research is really critical.
We know because of research that the system is good for the patients – they recover better, faster and can be re-integrated into the community quicker. We also know because of research that Dr. Seto conducted through the National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada, that when a patient enters the forensics system, their risk of recidivism – especially for violent offenders is much lower than if they were to go straight into a correctional setting.
Research is critical in demonstrating that what we’re doing in forensic mental health is benefiting not only the patients, but society and public safety overall.
IMHR: You’ve talked a bit about the value of research from a systems perspective, but what role does research play in your everyday clinical practice?
MD: One example is that The Royal recently participated in research around risk assessment tools for violence – and these are actually tools that we use on a daily basis to assess risk when we make decisions with the interdisciplinary team around patient privileges, medications, etc.
Most of my clinical practice is actually based off of research studies related to risk assessment for violence, so really, research plays a huge role.
IMHR: Do you have any pressing clinical questions right now that you hope research can answer in the future? Any current knowledge gaps that you’ve identified through your clinical work?
MD: Right now, something that we don’t really know is what type of models of care work best within correctional settings. So, we know what kinds of health care teams are most effective in delivering care in hospital inpatient settings, for instance, but there is not a lot of research that has been done from a correctional perspective. How many staff do we need per patient? What kind of staff? Do we need more mental health nurses versus psychologists, versus psychiatrics, etc.?
There are more administrative-type research questions, but very important ones. We are actually working on a proposal right now [with the Research Unit] that will hopefully help to answer some of these questions, and improve the delivery of mental health services in correctional settings.
IMHR: You are clearly a very strong supporter of having research and care come together to improve patient outcomes – and the Forensics Program model certainly demonstrates the value of evidence-based practice in mental health care settings. How do you hope to continue to strengthen research-care relationships here at The Royal, going forward?
MD: I’ve been the acting clinical director for The Royal’s Mood and Anxiety Disorders Program since October 2018, and I’ve been meeting with many scientists from the IMHR to see how we can continue to align research with clinical programs here at The Royal.
The IMHR has a strong focus on translational research – research that can help enhance the care that we provide to patients right now.
I strongly believe that all clinical programs at The Royal can get involved with and promote this type of research, and see if we have patients that we can refer to clinical research studies.
I’m currently in discussion with Dr. Rébecca Robillard [Clinical Research Director, Sleep, The Royal’s IMHR], for instance, to see how her research in sleep and mental health might be able to benefit some of our clinical patients with depression. Most of the patients we see in the Mood and Anxiety Program have sleep problems, and many would make great research participants. Some of Dr. Robillard’s ongoing research projects could actually enhance the current care that we provide to patients, as they would have the opportunity to receive novel, evidence-based treatment.
By fostering relationships between research and care here at The Royal, it’s really a win-win for the patients – they have the opportunity to receive enhanced care, and we can have more participants in research projects. This provides our researchers with even more opportunities to better understand the brain and inform treatment.
*This interview has been edited for length.