From the Editor

He explained to me that he has often been in the “system” – in and out of correctional institutions (and hospitals and shelters) – since he was first diagnosed with schizophrenia in his late adolescence, with charges like failure to appear. The story is too familiar. 

How common is recidivism with those who have mental disorders like my patient? What’s a way forward? In the first selection, Michael Lebenbaum (of the University of Toronto) and his co-authors try to answer these questions in a new paper for The Canadian Journal of Psychiatry. Drawing on Ontario administrative databases, they conducted a population-based cohort study with a sample of almost 46 000 people. They find: “Despite a high risk of recidivism and acute MHA [mental health and addiction] utilization post-release, we found low access to MHA outpatient care, highlighting the necessity for greater efforts to facilitate access to care and care integration for individuals with mental health needs in correctional facilities.” We consider the paper and its clinical implications.

In the second selection, the authors detail different aspects of mental health services and the rise of virtual care in recent years. This new CIHI report highlights physician services. They note the general increase of virtual care with the start of the pandemic: “in 2019–2020, virtual services accounted for 4% of mental health services provided by physicians, while in 2020–2021, they accounted for 57%.” They also consider income (by analyzing neighbourhood data) and geography. 

And in the third selection, Dr. Kwame McKenzie (of the University of Toronto) writes about the health care system in a new Toronto Star essay. While many focus on public versus private provision, Dr. McKenzie sees this debate as a diversion from more fundamental issues. He argues: “If we do not focus on right-sizing the health service and building in redundancy, it is only a matter of time before we see the system crashing.”


Selection 1: “The Association Between Prior Mental Health Service Utilization and Risk of Recidivism among Incarcerated Ontario Residents”

Michael Lebenbaum, Fiona Kouyoumdjian, Anjie Huang, et al.

The Canadian Journal of Psychiatry, 14 December 2022  Online First

There were approximately 11 million individuals incarcerated across the world in 2018… Mental health conditions are substantially over-represented, with a prior study from Ontario demonstrating an 11-fold greater rate of schizophrenia, 9-fold greater rate of mood disorders, and 5-fold greater rate of substance-related disorders, with findings similar in other jurisdictions.

Recidivism (i.e., re-arrest, re-conviction, or re-imprisonment) is common post-incarceration with re-conviction within 2 years globally ranging from ∼20% to 60% (∼35% in Canada) and is often used to judge the effectiveness of the criminal justice system. A greater risk of recidivism among individuals with mental health and addiction (MHA) conditions may contribute to their over-representation in prisons. Reviews have found small or null associations for non-substance disorder-related mental illnesses or clinical psychiatric factors on risk of recidivism; however, the included studies were largely conducted in small samples in the USA and UK and often focused on specific psychiatric diagnoses…

Given worsening mental health post-release is associated with greater risks of recidivism and some types of post-release substance disorder treatment have been shown to reduce risk of recividism, a lack of post-release MHA care may be a contributing factor to the increased risks of recidivism.

So begins a paper by Lebenbaum et al.

Here’s what they did:

“We conducted a population-based cohort study linking individuals held in provincial correctional institutions in 2010 to health administrative databases. Prior MHA service use was assigned hierarchically in order of hospitalization, emergency department visit and outpatient visit. We followed up individuals post-release for up to 5 years for the first occurrence of recidivism and MHA hospitalization, emergency department visit and outpatient visit. We use Cox-proportional hazards models to examine the association between prior MHA service use and each outcome adjusting for prior correctional involvement and demographic characteristics.”

Here’s what they found:

  • “After exclusion criteria were applied, a total of 45,890 individuals were included in the analysis.”
  • Service use. 66.4% had past 5 years (pre-incarceration) MHA service use. 
  • Types of visits. Outpatient visit for 33.9% of individuals; ED visit, 19.1%; and a hospitalization, 13.3%.”
  • Recidivism. “We found that prior MHA service use was moderately associated with recidivism…” Types of visits were important. “There was a significantly greater rate of recidivism for individuals with a prior MHA outpatient visit (hazards ratio (HR): 1.20…), ED visit (HR: 1.47…), or hospitalization (HR: 1.50…), compared with those with no prior MHA health care use.” Secondary analyses. They found “larger associations for addiction service use (HR range: 1.34–1.54…) than for mental health service use (HR range: 1.09–1.18…).”
  • Post-release care. “We found high levels of post-release MHA hospitalization and low levels of outpatient MHA care relative to need even among individuals with prior MHA hospitalization.”

A few thoughts:

1. This is a good paper with relevant data.

2. The big finding: “Recidivism was high and most likely to occur amongst those with a prior MHA ED visit or hospitalization, followed by a prior outpatient visit; these associations remained statistically significant even after controlling for duration of prior incarceration and socio-demographic characteristics.” 

3. Is anyone surprised?

4. The implications? “Despite a high risk of poor outcomes including recidivism and acute MHA utilization post-release, we found low access to outpatient care in prison and post-release. Therefore, access to care appears to be poorly aligned with need.” Ouch.

5. Again, is anyone surprised?

6. Like all studies, there are limitations. The authors note several, including: “since only provincial corrections data were available, the sample only includes individuals awaiting trial or sentencing and those with sentences of less than 2 years (∼64% of adults in prison nationally). Therefore, our study would exclude many violent offenders (, sexual assault, aggravated assault, homicide), which requires further study given mental health and addiction may be an important factor predicting recidivism and post-release care in these populations.”

7. For those who see things through the prism of economics: wouldn’t it be cheaper to provide mental health care than prison?

The full CJP paper can be found here:

Selection 2: “Virtual care: Use of physician mental health services in Canada”

Canadian Institute for Health Information, 15 December 2022

As the COVID-19 pandemic emerged and public health measures reduced social contacts and interrupted normal life, the mental health of individuals who experience anxiety, depression and psychological distress was negatively impacted. Simultaneously, many health services moved to virtual modalities, including those for mental health, replacing in-person services. While physician mental health services increased overall, access to virtual services was not equal across the country and the population.

So begins a new CIHI report.

They describe several aspects of physician mental health services. Here, we focus on two.

Physician services for anxiety or depression

“Despite lockdowns and restricted access to in-person care, the number of services provided for a diagnosis of anxiety or depression increased steadily over the first year of the pandemic. From January to March 2021, the total (in-person and virtual) number of physician services for mental health increased by 15% (502,007 services) compared with the same time period 1 year earlier.”

Virtual care and neighbourhoods

“In the first year of the pandemic (April 2020 to March 2021), patients across all income levels and neighbourhoods accessed virtual care; however, the proportion of services delivered virtually varied. More virtual care was delivered in higher-income and urban neighbourhoods. Though slight gradients were seen among income quintiles for all types of virtual physician services, the gap between the lowest and highest income quintiles was larger for virtual mental health services. The difference in use ranged from 3% to 5% for all services, and from 7% to 14% for mental health services.”

A few thoughts:

1. This report provides good data on the shift to virtual care over the early days of the pandemic.

2. The results aren’t surprising. And, as earlier data showed, technology solutions can create inequity problems.

3. Of course, virtual care has been considered in past Readings. In a recent Canadian Journal of Psychiatry paper, Stephenson et al. analyzed care for those with schizophrenia in the primary care setting. They found: “There were substantial decreases in preventive care after the onset of the pandemic, although primary care access was largely maintained through virtual care.” That Reading can be found here:

The full CIHI report can be found here:

Selection 3: “Time to focus on right sizing our health service”

Kwame McKenzie

Toronto Star, 20 January 2023

Current arguments about for-profit health care can divert our attention from more fundamental issues that we should be considering if we want a safe health system. One issue was brought into focus by a recent experience on a plane.

My flight from Toronto to Montreal last week was taking longer than usual. I thought it must be the snowstorm, but the captain soon disabused me of that theory. In the understated way that captains do, he announced that we were circling because there was a hydraulic fluid leak and he was testing systems to work out how much runway was needed to land. He did not think there would be a problem but the announcement was to stop us being concerned when we saw emergency vehicles waiting for us when we landed.

So begins an essay by Dr. McKenzie.

He explains that he was sitting by a pilot who explained the emergency: “Hydraulic systems are the heart and arteries of planes. They are used to move landing gear, flaps, brakes and the reverse thrusters on the engines. A leak could be catastrophic. But he said he was not concerned because modern planes had built-in redundancy. There was more than one system and if one broke down, another would help ensure the plane was operable.”

Dr. McKenzie contrasts the redundancy of the plane’s hydraulic system with the reality of Canadian health care. “Predictable issues, like annual respiratory viruses or flu, lead to hallway medicine and delays in treatment which can impact disease prognosis and increase death rates. Our lack of spare capacity means that less predictable problems such as the pandemic cause treatment backlogs and puts so much stress on staff that there are high rates of burnout and resignations. And it may have impacted the economy.”

He focuses on Ontario. “The Ontario health system is small and lacks redundancy.” While some are keen to focus on decisions made in the 1990s, he feels that successive governments have created and perpetuated the problems we see today.

And he draws on an international example. “When I worked in Belgium in the 1990s, they had a similar model of non-profit hospitals paid on a fee for service basis. But they considered the system to be poorly run if it was full. In fact, hospitals were penalized financially for being at capacity. They believed that the health system needed to run with the same redundancy as planes.”

A couple of thoughts:

1. This is a well-argued essay.

2. The comparison to the redundancy and safety of planes is particularly compelling.

The full Toronto Star essay can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.