Abstract

Forensic mental health systems have evolved over time as a function of legal frameworks, health care environments, and broader social and cultural processes. The past 20 years has seen a general increase in demand for forensic services in many countries around the world (Jansman-Hart, Seto, Crocker, Nicholls, & Côté, 2011), a phenomenon that has sometimes been referred to as forensication (Seto et al., 2001). This increase has been attributed to a variety of factors such as significant changes of Mental Health Acts or civil commitment legislation, the successive downsizing of psychiatric institutions, a lack of community-based resources and supports, the criminalization of people with mental health and substance use problems, the increasingly complex clinical profiles of certain persons with severe mental illness, increased media reporting of violence, and public intolerance of nonconforming behavior (Jansman-Hart et al., 2011; Lamb, 2009; Priebe et al., 2008; Rock, 2001; Whitley & Berry, 2013; Whitley & Prince, 2005). It is also influenced by broader social phenomena linked to society’s handling of risk, such as how modern societies are organized to respond proactively to risk and neoliberal tendencies to frame risk as a problem within individuals rather than a social problem. Authors have even suggested that, in some countries, forensic services may become the de facto mental health services (Seto, Harris, & Rice, 2004). In addition to posing a number of humanitarian questions as well as questions regarding the capacity of the regular mental health services to deal with sometimes more disruptive patients, this trend may also come at significant economic cost. In Alberta, Canada, the cost of forensic cases has been estimated about CAD$275,000 per year, which is almost five times the costs for any other psychiatric inpatient (Jacobs et al., 2014). This number compares to the cost of care in forensic psychiatric hospitals in the Netherlands (R388 per day, or R142,000/CAD$207,000 per year: Avramenko, Evers, Philipse, Chakhssi, & Ament, 2009) and in the United Kingdom (£131,000 per year, or CAD$243,000: Barrett et al., 2005). In England and Wales, treating forensic patients in secure hospitals costs 15 percent of the total adult mental health investment (Wilson, James, & Forrester, 2011). To date, however, there remains relatively little research into the economic cost of forensic mental health services over time. The immense cost of forensic services should give rise to questions about the degree to which this is a wise investment; that is, are the potential benefits of the forensic mental health system being optimized?