Vol. 4, Issue 1
In This Issue
CPD and Training
Ask the Experts
Todd Tomita, MD, FRCPC
It has been an unsettling year.
I am grateful for the opportunities to have met virtually with my CAPL board colleagues to keep us all connected to the forensic psychiatry community across the country.
We forensic psychiatrists are a disparate and distributed group and CAPL has been the key organization for us to connect. It is more important than ever to sustain this connection as we move into our personal and professional bubbles. I encourage all of you to attend our virtual conference and Annual General Meeting in April 2021. A degree of virtual fatigue may have taken hold of you, but please attend, as it will help us to stay connected and carry us through to the next time we can meet in person.
The Royal College Subspecialty Committee and the National Forensic Psychiatry program directors completed the new Competence by Design (CBD) Forensic Psychiatry Training Guidelines, which will launch in July 2021. These new Royal College training guidelines unpack the features of forensic psychiatry and are an excellent touchstone to explain our professional discipline to trainees, general psychiatrists, the courts, and other stakeholders. I encourage you to check this out.
In other news, the rollout of the new CBD Forensic Psychiatry Training Guidelines prompted the formation of a CAPL Education Committee. Members include the program directors of the eight Canadian PGY-6 forensic psychiatry training programs. The committee chair is Dr. Lenka Zedkova, program director at the University of Alberta.
CAPL board member Dr. Lisa Ramshaw initiated a project that will develop a set of Canadian Guidelines for Forensic Psychiatry Assessments and Reports. The six initial guidelines will focus on General Principles of Forensic Psychiatry Assessment, Fitness to Stand Trial, Criminal Responsibility, Violence Risk Assessment, Fitness for Work/Duty, and Disability. In the longer term, three further guidelines are planned on Sexual Behaviour Assessment, Dangerous Offender/Long-Term Offender Assessment, and Personal Injury Assessment.
Dr. Ramshaw will chair the working group developing the CAPL Canadian Guidelines for Forensic Psychiatry Assessments and Reports. The Working Group has members from across all jurisdictions, as we want to ensure the guidelines reflect practices across Canada. The goal is to complete and e-publish the guidelines by the end of 2021.
There will be a vote on a proposal to form a CAPL Ontario regional section at the CAPL Annual General Meeting on April 20, 2021. Assuming the resolution passes, this will bring the total number of CAPL regional sections to three: Quebec, Ontario, and British Columbia. The CAPL board had discussions over several meetings about the possible benefits and risks that come with the growing number of regional sections. The discussions seem fitting, given our present COVID-19 situation. In brief, the concerns lie in whether the regional sections will reduce or increase participation of CAPL members at the national level, as members may prefer to participate in forensic activities closer to home.
The CAPL board ultimately concluded we will need to wait and observe trends over time. The CAPL board made changes to the governance policy to ensure that communications from the regional sections would come through the CAPL national office, and regional section educational activities will require CAPL board approval to ensure alignment with and promotion of the academy’s overall interests. The CAPL board thought this struck a sensible balance in encouraging more regional activities, while allowing future CAPL boards to monitor any trend of decreasing CAPL participation at the national level.
Finally, I welcome our new CAPL e-newsletter Editorial Coordinator, Eryn Kirkwood, MA. In recent years, our e-newsletter publication has grown sporadic. Ms. Kirkwood is an experienced scientific editor and with her at the helm assisting the e-newsletter editors, I am confident we will have regular issues coming out.
2021 will be a better year. Stay positive, test negative.
Greetings from Your RCPSC Forensic Psychiatry Specialty Committee!
Brad Booth, MD, FRCPC, DABPN (Forensic Psychiatry)
Chair, Specialty Committee in Forensic Psychiatry
As a reminder, CAPL as the national specialty society, has a vital link to your Royal College specialty committee, in existence since December 2009. At the specialty committee, we work in close collaboration with CAPL and our profession nationally to establish training standards in the specialty, develop examinations, ensure appropriate quality training is occurring, and certify individuals holding themselves out as forensic psychiatrists.
Your core voting members include:
Dr. Brad Booth – Chair
Dr. Joel Watts – Vice-Chair and Chair Elect
Dr. Victoria Roth – Region 1 (B.C., Alta., Yuk., N.W.T.)
Dr. Jeff Waldman – Region 2 (Sask., Man.)
Dr. Lisa Ramshaw – Region 3 (Ont., Nvt.)
Dr. Fabien Gagnon – Region 4 (Que.)
Dr. Aileen Brunet – Region 5 (N.B., N.S., P.E.I., N.L.)
Dr. Graham Glancy continues in his role as examination board chair, along with his hard-working team of exam board members: Dr. Mansfield Mela (Vice-Chair), Dr. Johann Brink, Dr. Gary Chaimowitz, Dr. Shaheen Darani, Dr. Mathieu Dufour, Dr. Roy O’Shaughnessy, plus two anonymous exam quality reviewers, and me, as an ex officio.
In addition to the core members, each of the program directors from the accredited programs serve as non-voting members. Since the formal recognition of the specialty in April 2011, a total of eight schools have come online with accredited programs:
|Dr. Yuri Alatishe
|University of Montreal
|Dr. Jocelyne Brault
|University of Alberta
|Dr. Lenka Zedkova
|University of British Columbia
|Dr. Todd Tomita
|University of Calgary
|Dr. David Tano
|University of Ottawa
|Dr. Michelle Mathias
|University of Saskatchewan
|Dr. Azaad Baziany
|University of Toronto
|Dr. Sumeeta Chatterjee
Since the formalization of the subspecialty in 2011, 204 psychiatrists in Canada have successfully been certified as forensic psychiatrists.
This year has been an enjoyable but busy year at the RCPSC for your representatives, who volunteer 100 per cent of their time to this important cause of education and establishing the standard of the discipline.
We are very excited that Competence by Design will be launched on July 1, 2021, for forensic psychiatry in Canada. Make sure you attend the CAPL virtual conference for the highlights. You can access the CBD information on the RCPSC website. This includes the Competencies, Standard of Accreditation, and Training Experiences. With the new Training Experiences, we have outlined the landmark cases that all trainees will need to be familiar with.
The specialty committee is always interested in hearing from Fellows of the Royal College and CAPL members. We continue to work on making forensic psychiatry training high quality. Also, please be sure to extend thanks to your committee members for their endless hours of work advocating for our subspecialty!
CAPL Education Committee: Annual Report to the Board of Directors
Lenka Zedkova, MD, PhD, FRCPC
Program Director, Forensic Psychiatry Residency Program, University of Alberta
Lenka Zedkova (Chair), Program Director, University of Alberta
Yuri Alatishe, Program Director, McMaster University
Azaad Baziany, Program Director, University of Saskatchewan
Jocelyne Brault, Program Director, University of Montreal
Sumeeta Chatterjee, Program Director, University of Toronto
Michelle Mathias, Program Director, University of Ottawa
David Tano, Program Director, University of Calgary
Todd Tomita, Program Director, University of British Columbia
The establishment of the committee coincides with Competence by Design (CBD) implementation in the forensic psychiatry training. The committee will provide the opportunity for the programs to share information related to all aspects of the launch and application of CBD.
During meetings on September 18, 2020, and February 1, 2021, the committee reviewed and finalized the terms of reference document, with the focus on the composition and process of establishing resident representation. Program directors reported on the stages of preparation for the CBD launch in July 2021. During the 2021/22 academic year, the University of Toronto, McMaster University, and the University of Montreal programs will be active.
CAPL News: CAPL Resource Document for Prescribing in Corrections
Graham Glancy, MB, ChB, FRCPC; and Kiran Patel, MBBS, FRCPC
It is estimated that about 15%–20% of individuals in correctional centres suffer from a severe mental illness.1 In addition, up to 80% of individuals in correctional institutions have at least one DSM-5 diagnosis.2,3 The proportion of these individuals with substance use disorders, personality disorders, and who evidence malingering is astonishingly high. It is also important to consider that these are congregate living arrangements, which are often very crowded, providing a ready-made setting for the potential misuse and diversion of medications.
Prescribing in corrections is challenging and daunting for the above-mentioned reasons and others, which we will discuss below. With these considerations in mind, CAPL President Todd Tomita revived and reappointed a corrections committee to develop a resource document, to give guidance and assistance to correctional psychiatrists and GPs, regarding rational and safe prescribing in these settings. All members of the committee had experience, expertise, and a special interest in correctional work. There was also an effort to provide as much regional representation as possible, under the circumstances. In addition, experience in both federal and provincial corrections, which are quite different, was given consideration. The committee met at the annual meeting and worked out a plan of action. The first part of the plan was to approach AAPL and seek permission to use their resource document as a starting point. One of us appeared before council and requested permission to modify their document, which was graciously given. We then approached each author of the AAPL document individually and sought their permission, which again was marked with unanimous approval. Each member of the committee reviewed and adapted the material in order to place it in the Canadian context, resulting in the final document. This was affected with astonishing speed, a tribute to each member of the committee, all of whom set aside time to apply their expertise to this endeavour.
The goal of the document is to assist those prescribing in correctional settings. We attempted to use the best available evidence and to place this within the context of the correctional setting or correctional institution.
As we have noted, prescribing in corrections presents different challenges from prescribing in the community.4 In particular, the patient characteristics, including the high proportion of substance use disorders, personality disorders, malingering, and comorbidity, add to the challenge. In addition to this, institutional and environmental factors, such as formulary restrictions, security concerns, schedules for administration of medications, and lockdowns, also require consideration.
In the guide,5 we give practical consideration to such issues as health care operations, continuity of care, and coordination and communication with custody staff and other professionals in the environment. In addition, we discuss the nature of assessments in corrections and issues of informed consent and other ethical considerations.6 A specific section discusses preventative measures and signs of misuse and diversion of medications, which is a major issue in these settings. Finally, we discuss evidence-based practices and community guidelines, and how they can be applied to best effect in correctional settings. These measures are considered within the context of the correctional centre, which presents singular challenges to prescribing.
The members of the committee should be commended for the speed and application they brought to bear on this endeavour. President Todd Tomita and the CAPL executive in particular should be commended for their contribution and support in producing this document. All members of the committee sincerely hope this guideline will be a helpful resource to those hardy souls who toil in difficult conditions in correctional institutions.
1. Beaudette JN, Stewart LA. National prevalence of mental disorders among incoming Canadian male offenders. Can J Psychiatry 2016;61(10):624–632.
2. Beaudette JN, Power J, Stewart LA. National prevalence of mental disorders among incoming federally-sentenced men offenders (Research Report, R-357). Ottawa (ON): Correctional Service Canada; 2015.
3. Brink JH, Doherty D, Boer A. Mental disorder in federal offenders: a Canadian prevalence study. Int J Law Psychiatry 2001;24(4–5):339–356.
4. Scott C, Falls B. Mental illness management in corrections. In: Trestman RL, Appelbaum KL, Metzner JL, eds. Oxford Textbook of Correctional Psychiatry. New York (NY): Oxford University Press; 2015. pp. 8–12.
5. Glancy G, Tomita T, Waldman J, et al. Practice resource for prescribing in corrections [Internet]. Canadian Academy of Psychiatry and the Law; 2020. Available from: https://www.capl-acpd.org/wp-content/uploads/2020/03/CAPL-Rx-Guide-Corrections-FIN-EN-Web.pdf; 2020.
6. Glancy G, Simpson A. Ethics dilemmas in correctional institutions. In: Griffiths EE, ed. Ethics Challenges in Forensic Psychiatry and Psychology Practice. New York (NY): Columbia University Press; 2018.
CAPL Corrections Committee:
Graham Glancy, MB, ChB
Todd Tomita, MD
Jeff Waldman, MD
Kiran Patel, MBBS
Brad Booth, MD
Colin Cameron, MDCM
Samuel Iskander, MD
Rakesh Lamba, MBBS
Hygiea Casiano, MD
Brian Chaze, MD
CPD and Training
Due to the ongoing uncertainty surrounding COVID-19, the 25th CAPL Annual Conference will be held as a one-day virtual conference on Apr. 19, 2021. More details, including registration information, can be found here.
Ask the Experts
Between a Rock and a Hard Place: Ethics Problems and Difficult Problems in Forensic Psychiatry
Graham Glancy, MB, ChB, FRCPC
Substances Abused in Corrections
One of our members has asked whether it is legitimate to limit or control certain medications, for example, Wellbutrin and gabapentin, in a correctional environment, since these medications are not necessarily controlled in the community.
There are a number of issues that need to be raised when considering the practice of psychiatry in a correctional setting. Many people in the field do not realize that correctional psychiatry is its own area of interest and has its own conventions. Community general practitioners, community psychiatrists, as well as some licensing bodies, are not aware of the issues in correctional psychiatry. It is incumbent upon CAPL members to educate them about this. Many of the issues are addressed in the CAPL resource document on prescribing,1 as well as the AAPL resource document,2 which discusses some facility issues in more detail. In particular, many community and hospital psychiatrists think that, because correctional settings are called institutions, they are health or mental health institutions. In fact, as we know only too well, they are security institutions, which grudgingly (historically) supply some health care needs. They are definitely not hospitals, except for a handful of accredited treatment centres that are especially designated. Although there is a concept of providing the same level of health care as provided in the community, this does not mean they should receive exactly the same medication or treatment.
Among others, the three main points I would like to make about this issue include the following:
1. First, the prevalence of substance use disorder is 70%–80% of the whole population in corrections. This means that, when your patient returns to their normal daily routine, most of the people with whom they spend their time have substance use disorders. In these settings, especially provincial detention centres or jails, these people are sitting around in congregant living quarters with very little to do. The concept of detention centres was to provide intermediate housing for a mean length of stay of 30 days; therefore, very little meaningful activity or recreational facilities exist. In practice, many people are released within the first week; this skews the statistics, in that many inmates remain in custody for months or even years. The situation is, like many others, exaggerated by the COVID-19 pandemic, which has delayed trials considerably. The criminal justice system is a cumbersome system that moves at a slow pace, resulting in lengthy waits for trials. There is also the concept of “dead time,” whereby a person can wait patiently for a trial, knowing that the time they have been waiting will count against any future sentence. Sometimes it even counts for one-half or two times the credit, meaning that, if they wait six months and are given a one-year sentence, they will be released at court. As a result, people spend considerable time in provincial detention centres or jails.
2. Second, abuse and diversion of medication is so common as to be an expectable norm in correctional facilities. Medications are generally given out in what is known as a “med line.” In this procedure, a nurse stands either outside or inside the unit, depending on the facility, and a line of inmates take the medication in turn. In the noisy, boisterous environment, it is often difficult for the nurse to see the inmate actually swallow the medication, allowing for possible abuse and diversion of this medication. Certain medications may be saved and used intranasally, resulting in a temporary high. Particularly at risk are bupropion and gabapentin. Others, such as benzodiazepines and stimulants, may be sold or exchanged. Some may be saved up to be used for extra sleep, or on weekends, such as quetiapine and hypnotics. Inmates higher in the pecking order might only subservient inmates to save their medications and give them to the tougher inmate for their own purposes. Although this may sound like the content of a Netflix series, it happens multiple times every day in a variety of Canadian corrections facilities. Thus, it is important to attempt to limit the prescribing of psychotropic medications, as is recommended by the CAPL resource document.
3. Third, admission to a correctional facility gives a physician the opportunity to rationalize medication. There is tremendous comorbidity in the correctional population. It is rare to be dealing with a pure disorder, for instance, a depressive disorder, without comorbidity with substance use disorder, personality disorder, and possibly symptoms of other syndromes. This population, who have not had regular and steady providers in the community, often receive a number of prescriptions that have been added onto each other over time. On admission to a correctional facility, there is an opportunity to wean the patient off some of these drugs and observe them without the medications. Medications can then be added as indicated in an evidence-based manner, with the benefit of reports and observations. Removing the medications often causes an initial psychological reaction, and it is important to communicate to the patient the reasons why this is done. Evidence-based guidelines, such as the NICE guidelines and Cochrane review, alongside the CAPL resource document, are helpful in guiding the physician through this process.
Prescribing in corrections is not for the faint of heart. Correctional prescribing is considered different from prescribing in the community and in hospitals,3 mainly because correctional facilities have a high proportion of individuals with substance use disorders, who are living in congregant settings, often with little to occupy them. Prescribing in these settings sometimes demands a certain amount of rigidity and resolve. Due to the pressure of work and the isolation of these facilities, often it is not possible to consult colleagues, as can more easily be done in a hospital setting. Sharing the workload among a group of practitioners does provide an opportunity for communication with colleagues and is recommended, if possible.
1. Glancy G. The Canadian Academy of Psychiatry and the Law practice resource for prescribing in corrections; 2020 [cited 2021 Jan 12.] Available from: https://www.capl-acpd.org/wp-content/uploads/2020/03/CAPL-Rx-Guide-Corrections-FIN-EN-Web.pdf.
2. Tamburello A, Metzner J, Fergusen E, et al. The American Academy of Psychiatry and the Law practice resource for prescribing in corrections. J Am Acad Psychiatry Law 2018;46:242–243.
3. Burns KA. The top ten reasons to limit prescription of controlled substances in prisons. J Am Acad Psychiatry Law 2009;37:50–52.
Why the Current Approach to COVID-19 in Jails, and Most Settings, Has Not Worked
Jeffrey Waldman, MD, FRCPC
I am writing this out of concern for my patients in federal custody and Stoney Mountain Institution (SMI), in particular, where they have been without programming, visitors, and education programs and have experienced restricted access to both medical and mental health services. I am not critical of any of the pandemic control measures that have been put in place, as I believe that these were implemented with the best of intentions. It is also important to remember that I am writing this letter as a physician and a psychiatrist. I am confident in my ability to read medical literature and I believe it is incumbent on any physician to educate themselves on issues relevant to patient care. Although I am not treating viral infections, public health recommendations and government policy has had a significant effect on all of my patients. I am not an expert in infectious diseases or epidemiology, and I welcome any corrections to how I am interpreting the literature. I also want to ensure the reader is aware that I understand that COVID-19 has had a significant impact on the lives of many Canadians and that various levels of government, medical advisors, and public institutions have acted out of the interest of Canadians.
This article will attempt to argue that, based on available medical evidence, current pandemic control measures make no sense in a jail setting. Based on my reading of the literature on the characteristics of the COVID-19 virus and its risks, the lack of evidence for the effectiveness of current measures at limiting the spread within a jail setting, and the evidence for alternative measures to improve the safety of inmates and staff, I will present medical evidence for alternative strategies that would improve quality of life, make more sense for jails, and possibly help rethink wider public policy.
In my role as a forensic psychiatrist, I am asked to provide information to decision makers about mental health diagnoses, pathology, and treatment that is based on the best medical evidence. In court, case law such as Daubert1 guides me when I am providing medical expert opinion, as I know that the admissibility of such information requires that it be tested, peer reviewed, and published and is generally accepted. There are two options for addressing COVID-19 in a jail setting: 1) try to limit spread, or 2) ensure that inmates (or citizens) are given education about what is known about the virus and every opportunity to be safe if they are exposed to it. As far as I can tell, all medical experts have provided recommendations to government and other decision makers over the past year that are based on Option 1, although my reading of the medical literature is that there is no medical evidence showing that strategies to limit the spread of COVID-19 could be expected to be effective. There is, however, an abundance of evidence for Option 2. There are known strategies to improve immune function that decrease the risk of becoming sick if exposed to a viral pathogen and that decrease symptom severity, resulting in a decreased risk of hospitalization if someone does develop a viral illness.
What is the stated goal of pandemic control measures? Based on everything I have read, the goal is to “flatten the curve.” The goal of flattening the curve is to not overwhelm the medical system and related infrastructures.2 It is well established and there is good evidence that social distancing and limiting travel, unnecessary activities, and closing places where people interact is effective in flattening the curve and slowing the spread of the virus. Does it have any effect on the area under the curve? That is, if the virus were allowed to run its course, it would infect a certain number of people and kill a certain number of people in a short time. Does flattening the curve change the number of people that will eventually be infected or die? What do we know about the risks of pandemic control measures aimed at limiting the spread of COVID-19? I will discuss the impact of pandemic control measures in a jail setting below. But, in a more general sense, we know that in personal care homes, pandemic control measures have led to severe reduction in quality of life and increased rates of delirium (which is known to be a marker for approaching death) and mental illness.3,4 Locally, it leads to rising unemployment, social isolation, poorer quality of life, increased stress (a factor that decreases immune system response5), and avoidance of routine medical care. Internationally, it has led to similar mental health and social effects6,7; widening of the class divide8; and increased risk of countries declaring bankruptcy, creating political instability. According to Oxfam, pandemic control measures have directly impacted increased starvation rates9 and the United Nations humanitarian chief reported that, by May of 2020, pandemic control measures had already reversed a 20-year effort at reducing global severe poverty, leading to a rapid increase in severe poverty that will likely never be reversed.10 Are those risks worth the benefit of not overwhelming the medical system and related infrastructure?
COVID-19 is a virus that can become an effective pandemic, as it is highly contagious, and for many of those infected, it results in mild or even no symptoms. So, in contrast to a virus like Ebola, which results in severe symptoms for all who come into contact with it and, as such, can be identified and contained fairly easily, COVID-19 cannot be. For COVID-19, if there are hosts around who have not mounted an immune response, there is opportunity for ongoing covert spread. Also, people have been infected twice, and like most cold viruses, infection does not provide long-term protection against further infection, so the longer the curve is flattened, the more likely that all those who were infected early in the pandemic will be susceptible to reinfection, making it possible that herd immunity will never be achieved if we continue with efforts at “flattening the curve.” One study showed that an immune response for those who have mild infection could last as little as nine days, and for those who have had the most robust immune response, that response begins to wane in three to four weeks after infection.11 This raises concerns about the effectiveness of vaccination. The proposed strategy for the COVID-19 vaccine does little to impact the spread. Vaccines for seasonal viral respiratory infections work by enhancing herd immunity by inoculating as many people as possible in a brief period of time. Inoculating tiny fractions of a population over long periods of time would make a vaccine much less effective.12
My understanding of the potential benefits of flattening the curve as a way to decrease death rates is that it allows for time to develop treatment and ensures that the medical systems are not overwhelmed. In theory, this allows for ongoing access to medical care for all those who require it for other illnesses. These assertions are theoretical, and there is no evidence that this is the case. In Canada there is unmistakable evidence that pandemic control measures have severely limited access to medical care and this effect is amplified in SMI, with health care staff overwhelmed with testing to the point that there is little time for everything else. One study early in the pandemic found between a 6%–15% increase in avoidable cancer death for 4 distinct types of cancer: “Substantial increases in the number of avoidable cancer deaths in England are to be expected as a result of diagnostic delays due to the COVID-19 pandemic.”13 During my corrections clinic at Stoney Mountain Institution, I am seeing less than one-half the number of patients that I have historically been able to provide psychiatric care to because of restrictions on movement. In the long term, the costs associated with this pandemic will invariably lead to less government income through taxes, along with increased costs attempting to offset the economic crisis resulting from pandemic control measures. In Manitoba, that has already led to slashing of funding to post-secondary education by 30%, and I can see no other solution in the future than cuts to health care and research, resulting in further barriers to adequate health care in the future.
At this time, similar to the elderly residents of personal care homes, the movements of inmates and their access to activities, is severely limited. There is an abundance of evidence of the emotional toil that this level of isolation has on people in general (enough that the Supreme Court directed CSC to eliminate their use of long-term segregation); the effects on those with mental illness, who comprise anywhere between 20%–80% of inmates (the higher number include PTSD, personality disorders, and substance use disorders), is far more severe. For any inmate who comes into the facility, segregation lasts for at least 14 days. Regarding the 14-day isolation period: An early study out of China that looked at patterns of viral shedding found that infection likely occurs in the seven days prior to symptom onset, leading them to conclude that, “Contact tracing and isolation alone are less likely to be successful if more than 30% of transmission occurred before symptom onset, unless > 90% of the contacts can be traced.”14 Another early study out of China found that, “The median duration of viral shedding was 31.0 (IQR, 24.0–40.0) days from illness onset. The shortest observed duration of viral shedding was 18 days, whereas the longest was 48 days.”15 As such, the 14-day isolation period would seem to be arbitrary and likely ineffective.
Regarding masks: At the beginning of the pandemic, a meta-analysis of studies that examined the effectiveness of medical masks used to limit the spread of viral infection in health care staff and family members and of those who are immunocompromised found no statistically significant benefit.16 A more recent Cochrane review (Cochrane reviews are independent, high-quality reviews completed by medical experts in their field) published in November of this year was critical of the bias present in articles written about mask use for COVID-19. The authors concluded that,
The pooled results of randomised trials did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks during seasonal influenza. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness. Harms associated with physical interventions were under‐investigated.17
I am unaware of any benefit attributed to the use of non-medical masks; in one study, they were found to be a source of infection,18 and there are countless studies on items frequently handled by humans (phones, keyboards, etc.) that invariably find those items have high levels of pathogens. Researchers have found similarly high levels of bacterial and viral pathogens on items thought to be protective, such as nurses’ uniforms and medical masks.19,20
Is limiting the spread of COVID-19 the only option? As far as I can tell, no. What do we (the medical community) know (based on medical evidence) about immune system resiliency and the importance of a healthy immune system for fighting off viral infections? Well, lots. And what do we (the medical community) know (based on medical evidence) about how to boost immune function? Well, lots. There are hundreds of articles that consistently show that stress and active mental illness decrease immune function and make people susceptible to getting sick when exposed to a viral pathogen.21,22 One study found that people who have a positive outlook were protected by as much ¬as 50% when exposed to a cold virus and similar findings were found when this was repeated with an influenza virus:
For both viruses, increased PES (Positive Emotional Style) was associated with lower risk of developing an upper respiratory illness as defined by objective criteria (adjusted odds ratio comparing lowest with highest tertile = 2.9) and with reporting fewer symptoms than expected from concurrent objective markers of illness. These associations were independent of prechallenge virus-specific antibody, virus type, age, sex, education, race, body mass, season, and NES (Negative Emotional Style).23
We know that physical activity boosts the immune system24 and we know that social isolation negatively effects the immune system, leading to susceptibility to a variety of physical and mental illnesses.25 What are the current practices? Isolation to increase stress, limited benefits of social contact, and limited access to opportunities for physical activity.
There are multiple reports of obesity being significantly associated with hospitalization with COVID-19.26 A large study looking at risk factors for hospitalization from viral pneumonia found that the third highest risk factor is obesity, behind sedentary lifestyle and low fruit and vegetable consumption:
Using data from 274 US counties, from 2002 to 2008, we regressed county influenza-related hospitalization rates on county prevalence of obesity (BMI ≥ 30), low fruit/vegetable consumption (<5 servings/day), and physical inactivity (<30 minutes/month recreational exercise), while adjusting for community-level confounders . . . Communities with a greater prevalence of obesity were more likely to have high influenza-related hospitalization rates. Similarly, less physically active populations, with lower fruit/vegetable consumption, tended to have higher influenza-related hospitalization rates, even after accounting for obesity.”27
There are other studies showing that supplementing diets with tomato or carrot boosts immune response28 and increased fruit and vegetable intake improves immune response to a vaccine in the elderly by up to 80%.29 As such, there is medical evidence that providing fresh fruits and vegetables, promoting increased physical activity, minimizing stress by allowing for ongoing social interactions, improving recreational activities, and providing groups aimed at improving stress tolerance would all be interventions that require very little financial commitment and would address the three known modifiable risk factors for decreasing hospitalizations and improving outcomes. Improving access to exercise and improving diets for inmates could be achieved for a fraction of the cost of the interventions that are based on current strategies aimed only at limiting the spread of COVID-19.
Another option raised by politicians in the spring was the potential to release inmates who are at high risk of bad outcomes with COVID-19, such as the elderly and those with cancer or severe cardiac or respiratory illnesses. Each of those factors does significantly increase the risk of death or serious complication for an inmate exposed to COVID-19. All of those factors (old age, severe medical illness, and frailty) significantly decrease the risk to the public associated with their release. This could also be revisited if the goals of COVID-19 response measures are truly based on concern for the safety of the inmates.
At SMI the first lockdown in the spring was associated with four suicides, increased violence among inmates and against staff, decreased access to visits and health care (no dentistry or optometry, limited access to therapy and counselling), and reduced programming (which the inmates rely on to move through the system), creating even more frustration, hopelessness, and stress. These restrictions have continued, and between the time I began writing and completing this paper, there has been another suicide and another suspicious death that is likely a suicide or unintentional overdose in the past week. I am genuinely concerned about my patients and the level of tension in the institution and the increased risk for violence and self-harm associated with that tension. I believe the risks associated with pandemic control measures far outweigh the benefits in a context where there is no medical evidence that efforts at controlling the spread of COVID-19 in the jail are effective. Is simply lowering the number of positive COVID-19 tests really a measure of keeping the staff and inmates safe? Policy makers have a responsibility to look at all available medical evidence, not only in limiting spread, but also in implementing strategies to keep inmates and staff healthy in the face of this pandemic. There is a responsibility to weigh all potential risks and benefits of the interventions implemented. I trust that at some point there will be a more balanced approach. As mentioned at the beginning of this article, I welcome any feedback and correction in my reading of the available literature on this topic.
I encourage readers to read the following open letter written by some of Canada’s leading public health experts: A Balanced Response: An Open Letter to the Prime Minister and the Premiers on COVID-19, available here.
1. Daubert v. Merrell Dow Pharmaceuticals Inc., 509 U.S. 579 (1993).
2. Qualls N, Levitt A, Kanade N, et al. Community mitigation guidelines to prevent pandemic influenza — United States, 2017. MMWR Recomm Rep 2017;66(1):1–34.
3. Plagg B, Engl A, Piccoliori G, et al. Prolonged social isolation of the elderly during COVID-19: between benefit and damage. Arch Gerontol Geriatr 2020;89:104086.
4. Manca R, De Marco M, Venneri A. The impact of COVID-19 infection and enforced prolonged social isolation on neuropsychiatric symptoms in older adults with and without dementia: a review. Front Psychiatry 2020;11:585540.
5. Ockenfels MC, Porter L, Smyth J, et al. Effect of chronic stress associated with unemployment on salivary cortisol: overall cortisol levels, diurnal rhythm, and acute stress reactivity. Psychosom Med 1995;57(5):460–467.
6. Xiong J, Lipsitz O, Nasri F, et al. Impact of COVID-19 pandemic on mental health in the general population: a systematic review. J Affect Disord 2020;277:55–64.
7. Rangel JC, Ranade S, Sutcliffe P, et al. COVID‐19 policy measures—advocating for the inclusion of the social determinants of health in modelling and decision making. J Eval Clin Pract 2020;26:1078–1080.
8. McNeely CL, Schintler LA, Stabile B. Social determinants and COVID‐19 disparities: differential pandemic effects and dynamics. World Medical & Health Policy 2020;12:206–217.
9. ReliefWeb. 12,000 people per day could die from Covid-19 linked hunger by end of year, potentially more than the disease, warns Oxfam. Author; 2020 [cited 2021 Jan 18]. Available from: https://reliefweb.int/report/world/12000-people-day-could-die-covid-19-linked-hunger-end-year-potentially-more-disease.
10. Mai HJ. U.N. warns number of people starving to death could double amid pandemic. NPR; 2020 [cited 2021 Jan 18]. Available from: https://www.npr.org/sections/coronavirus-live-updates/2020/05/05/850470436/u-n-warns-number-of-people-starving-to-death-could-double-amid-pandemic.
11. Seow J, Graham C, Merrick B, et al. Longitudinal observation and decline of neutralizing antibody responses in the three months following SARS-CoV-2 infection in humans. Nat Microbiol 2020;5:1598–1607.
12. Mallory ML, Lindesmith LC , Baric RS. Vaccination-induced herd immunity: successes and challenges. J Allergy Clin Immunol 2018;142(1):64–66.
13. Maringe C, Spicer J, Morris M, et al. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study. Lancet Oncol 2020;21(8):1023–1034.
14. He X, Lau EHY, Wu P, et al. Temporal dynamics in viral shedding and transmissibility of COVID-19. Nat Med 2020;26:672–675.
15. Zhou B, She J, Wang Y, et al. Duration of viral shedding of discharged patients with severe COVID-19. Clin Infect Dis 2020;71(16):2240–2242.
16. Jefferson T, Jones MA, Al-Ansary L, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Part 1 – Face masks, eye protection and person distancing: systematic review and meta-analysis. medRxiv 2020.03.30.20047217. DOI: https://doi.org/10.1101/2020.03.30.20047217
17. Jefferson T, Del Mar CB, Dooley L, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev 2011;2011(7):CD006207.
18. MacIntyre CR, Dung TC, Chughtai AA, et al. Open contamination and washing of cloth masks and risk of infection among hospital health workers in Vietnam: a post hoc analysis of a randomized controlled trial. BMJ Open 2020;10(9):e042045.
19. Chughtai AA, Stelzer-Braid S, Rawlinson W, et al. Contamination by respiratory viruses on outer surface of medical masks used by hospital healthcare workers. BMC Infect Dis 2019;19:491.
20. Wiener-Well Y, Galuty M, Rudensky B, et al. Nursing and physician attire as possible source of nosocomial infections. Am J Infect Control 2011;39(7):555–559.
21. Dhabhar FS. Enhancing versus suppressive effects of stress on immune function: implications for immunoprotection versus immunopathology. Allergy Asthma Clin Immunol 2008;4(1):2–11.
22. Dhabhar FS. Effects of stress on immune function: the good, the bad, and the beautiful. Immunol Res 2014;58:193–210.
23. Cohen S, Alper CM, Doyle WJ, et al. Positive emotional style predicts resistance to illness after experimental exposure to rhinovirus or influenza a virus. Psychosom Med 2006;68(6):809–815.
24. Campbell P, Turner JE. Debunking the myth of exercise-induced immune suppression: redefining the impact of exercise on immunological health across the lifespan. Front Immunol 2018;9:648.
25. Cacioppo JT, Cacioppo S, Capitanio JP, et al. The neuroendocrinology of social isolation.
Annu Rev Psychol 2015;66:733–767.
26. Hamer M, Gale RG, Kivimäki M, et al. Overweight, obesity, and risk of hospitalization for COVID-19: a community-based cohort study of adults in the United Kingdom. Proc Natl Acad Sci U S A 2020;117(35):21011–21013.
27. Charland KM, Buckeridge DL, Hoen AG, et al. Relationship between community prevalence of obesity and associated behavioral factors and community rates of influenza-related hospitalizations in the United States. Influenza Other Respir Viruses 2013;7(5):718–728.
28. Watzl B, Bub A, Briviba K, et al. Supplementation of a low-carotenoid diet with tomato or carrot juice modulates immune functions in healthy men. Ann Nutr Metab 2003;47(6):255–261.
29. Gibson A, Edgar JD, Neville CE, et al. Effect of fruit and vegetable consumption on immune function in older people: a randomized controlled trial. Am J Clin Nutr 2012;96(6):1429–1436.
Perception of Independent Assessor Bias in the Context of Independent Medical Examinations: Is It Warranted?
Jeffrey Waldman, MD, FRCPC; Sarah Brown, PhD
Medical information is often required to assist decision makers, such as employers, insurance companies, tribunals, and the courts (both civil and criminal). Treating physicians are frequently asked to respond to questions to assist in this process; however, the treating physician can be faced with competing interests; lack of a clearly stated process; ethical and legal issues; and concerns regarding conflicts of interest and bias when providing medical information, impacting on a decision maker’s ability to use that information without further input. There are also times when a third-party decision maker may require more detailed information, such as when there is non-medical information that the decision maker may believe is impacting on a claimant’s or accused’s presentation, or if there appears to be a difference in opinion between two parties. Under those circumstances, an opinion from a medical expert, whose duty it is to assist in that decision-making process, is considered valuable by the decision maker. Medical experts can contract out their time to provide opinions. This is a common practice that has been occurring for years by physicians, but which has never been systematically assessed. There is a perception that the medical expert is a “hired gun” and that opinions are purchased through the retainer process. Although this process is common in the lay literature, in case law, and has led to the development of legislation to manage perceived bias, there is limited, if any, systematic research evidence that this perception is accurate.
Physicians are all medical experts1; however, a third-party decision-making entity defines an expert as an individual whose credentials, training, and experience collectively qualify them as an ‘expert,’ thereby allowing them to provide opinion evidence that is necessary information to allow the decision maker to make an informed choice. The essential difference between experts hired by third parties to provide specific medical information versus requesting information from a treating physician is the party to whom a duty is owed by that physician. The treating physician’s duty is always to the patient.1 In contrast, the expert’s duty is to the decision maker. It would be assumed that this established duty would result in a reasonable appreciation by the courts and the public of the potential for bias when treatment providers give opinions, but not when the opinion is provided by an independent assessor.
The role of a medical expert is to offer unbiased information to the decision maker, to assist them in adjudicating a case. Expert opinions in the context of Independent Medical Examinations (IMEs) have been criticized in academic circles as biased because of conflict of interest, including the financial exchange between the consulting expert and the contracting agency, and unethical practices, such as “cherry-picking,” defined as claim managers selectively providing examiners with only medical records that support their claim manager’s position.2 There are opinion and commentary articles that scrutinize the objectivity and independence of IMEs.3,4 For example, Lax (2004)4 argued against the claim of objectivity and superiority of independent medical examinations and concluded that, “The IME approach is more accurately characterized as a tool to standardize a product that can be marketed to corporate clients, rather than a way to precisely assess work-related health conditions.” Lax also opined that, “To maintain their niche, IMEs must both produce results (that is, help keep corporate costs under control) and continuously convince their corporate clients that only they are capable of producing quality services,” highlighting the perception of biased opinion and a view that, in order to maintain clientele, independent experts must cater their opinions to their clients’ needs. These perceptions have been long-standing, with literature examining complaints of expert testimony, including bias, dating back to as early as 1897.5
A perception of expert assessors providing biased opinions is also apparent throughout case law, with many examples of expert testimony being dismissed or deemed inadmissible due to perceived bias.6 (Chin JM, Lutsky M, & Dror IE, 2019.) There has also been recent legislation that attempts to manage a perception of bias in both the BC and Ontario legislation. In Ontario, a medical expert is required to sign a Form 53 under the Courts Justice Act, as an “Acknowledgement of Expert’s Duty.” In BC, the Court Rules Act requires that an expert document in their report that,7 he or she (a) is aware of the duty referred to in subrule (1) (an expert appointed under this part by one or more parties or by the court has a duty to assist the court and is not to be an advocate for any party), (b) has made the report in conformity with that duty, and (c) will, if called on to give oral or written testimony, give that testimony in conformity with that duty.
Public and media perception of bias and subjectivity is also apparent, although it typically focuses on a specific case and fails to consider means to mitigate bias, the purpose of the assessment and questions being asked, and expertise of the independent assessor. Headlines, including “Justice by Witness-for-Hire”8 and “Licensed to Bill: How Doctors Profit from Injury Assessments that Benefit Insurers,”9 are only a couple examples that highlight this commonly held belief. Statements labelling expert assessors as having “chameleon-like ability to adapt their opinions to satisfy the needs of their employers”9 further highlight a public perception that IMEs employ unjust, biased processes that physicians primarily participate in for financial gain.
Law firms have also scrutinized the objectivity of IMEs and have highlighted the importance of retaining legal counsel that is “vigilant against biased experts.”10 For example, one firm stated that many expert physician reports are rejected by the courts for providing “biased, erroneous and incorrect assessments of claimants”11 and concluded by emphasizing that anyone who is injured in a car accident needs to seek guidance from a trusted car accident lawyer, because they have “decades of experience working for insurance companies” and are familiar with IME doctors’ “tactics for attempting to lower . . . payments for claims.”
Despite these concerns regarding conflict of interest and bias of IMEs, there is limited, if any, empirical evidence to suggest that an Independent Medical Examination report caters to the needs of the contractor or that the opinions contained are biased. In fact, some evidence, although scarce, suggests the opposite. For example, Aamland and Maeland (2018) conducted a nine-person qualitative interview study examining sick-listed workers in Norway to assess their expectations about and experiences with participating in an IME and concluded that participants’ overall impression was positive, and they appreciated the IME as an affirmative discussion that confirmed they were on track regarding recovery and return to work, even if they did not feel that it had an impact on their follow up or RTW process.12
There will, of course, be some degree of unavoidable bias in any opinion, as implicit bias and other factors will contribute to the opinion of a physician no matter what their role13; however, the means for mitigating bias and increasing objectivity are more clearly defined and achievable for an independent expert, as compared to a treating physician. The role of the independent expert in Canada is explicitly stated, and rules and frameworks pertaining to expert witnesses in civil proceedings have been delineated.1,7,14,15 Similarly, the admissibility of expert evidence has been outlined through case law,16–18 most notably in R v. Mohan (1994).19 Processes involved in the expert assessment that assist in managing bias as much as possible include using objective testing to supplement the patient interview and other subjective aspects of the assessment; consideration of all available information, with time for a thorough review of that information; a thorough explanation of the rationale for the opinion; and a stated consideration of the impact on bias. Conversely, despite the perception that the opinion of the treating physician is unbiased, the potential bias inherent in the special ‘doctor–patient relationship’ raises the question regarding whether a treating physician can ever give the appearance of being unbiased in providing opinion evidence.
A perception of bias can result in dismissal of evidence that may be important for decision makers to consider. It is apparent that there is a need to increase understanding of the role and expertise of an independent assessor and means in which bias is mitigated throughout the independent medical examination process. Given the lack of empirical evidence supporting a perception of bias in opinions provided by independent assessors, it is essential that, like any other intervention in medicine requires investigation, there is a need to examine the perceived bias from a decision-maker and claimant perspective rather than relying on unsubstantiated opinion.
In 2013, the Royal College of Physicians and Surgeons of Canada developed subspecialty certification in the area of forensic psychiatry. Forensic psychiatrists have extensive training on being experts, as well as a reasonable understanding of pertinent case law. The establishment of this new subspecialty and relevant guidelines provides opportunity for members of the subspecialty to provide training to other psychiatrists, and physicians in general, on the role of the expert in providing opinion to the decision maker, versus the traditional medical expert role physicians are familiar with from their medical training. Furthermore, the establishment of this new subspecialty allows for the systematic examination of the role of the expert, the factors that impact on bias, and processes for minimizing bias. This information will be essential in developing relevant guidelines and establishing national standards of communicating to third parties in a manner that allows for a determination of the potential sources of bias.
1. Frank JR, Snell L, Sherbino J. CanMEDS framework. Ottawa (ON): Royal College of Physicians and Surgeons of Canada; 2015 [accessed 2021 Jan 16]. Available from: https://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e.
2. Schatman ME, Thoman JL. Cherry-picking records in independent medical examinations: strategies for intervention to mitigate a legal and ethical imbroglio. Psychol Inj Law 2014;7:191–196.
3. Baer MA. Opinion piece: is an independent medical evaluation independent? Forensic Examiner 2005;14:33.
4. Lax M. Independent of what? The independent medical examination business. New Solut 2004;14:3:219–251.
5. Foster WL. Expert testimony-prevalent complaints and proposed remedies. Harvard Law Review 1897;11:169–186.
6. Chin JM, Lutsky M, Dror IE. The biases of experts: an empirical analysis of expert witness challenges. Manitoba Law Journal 2019;42(4):22–67. Appendix B.
7. Court Rules Act, British Columbia Supreme Court Civil Rules. BC Reg 168/2009. Victoria (BC): Queen’s Printer; 2009.
8. Simmons LRS. Justice by witnesses-for-hire. Christian Science Monitor 1992. Available from: https://www.csmonitor.com/1992/0114/14181.html. Accessed on January 19, 2021.
9. Tomlinson K. Licensed to bill: how doctors profit from injury assessments that benefit insurers. The Globe and Mail; 2017 [accessed 2021 Jan 19]. Available from:
10. Goodman Law. Court finds ICBC doctor’s evidence biased and unreliable [website]. Vancouver (BC): Author; 2019 [accessed 2021 Jan 18]. Available from:
11. Greg Monforton & Partners Injury Lawyers. Investigation reveals bias in independent medical evaluations [blog post]. Windsor (ON): Author; 2017 [accessed 2021 Jan 19]. Available from: https://www.gregmonforton.com/blog/independent-medical-examination-investigation.html
12. Aamland A, Maeland S. Sick-listed workers’ expectations about and experiences with independent medical evaluation: a qualitative interview study from Norway. Scand J Prim Health Care 2018;36(2):134–141.
13. Kang J, Bennett JM, Carbado D, et al. Implicit bias in the courtroom. UCLA Review 2012;59:1124–1186.
14. The Ontario Rules of Civil Procedure. Available from: https://www.canlii.org/en/on/laws/regu/rro-1990-reg-194/latest/rro-1990-reg-194.html
15. National Justice Compania Naviera SA v. Prudential Assurance Co Ltd. (the “Ikarian Reefer”)  2 Lloyd’s Rep 68. Queen’s Bench Division (commercial court).
16. R v. Lavallee  1 SCR 852 (Supreme Court of Canada 1990).
17. R v. Abbey  ONCA 624 (Court of Appeal for Ontario 2009).
18. R v. Fringe Product Inc. . CanLII 10990 (ON SC).
19. R v. Mohan  2 SCR 9 (Supreme Court of Canada 1994).
Barker v. Barker: Ruling on the Past Through a Modern Ethical Lens
Marissa Heintzman, MLitt; Graham Glancy, MB, ChB, FRCPC; John McD.W. Bradford, MB, ChB, DPM, FFPsych, MRCPsych, DABPN, FRCPC
Barker v. Barker: The Ethical Question of Treatment or Experimentation
In June 2020, the Ontario Supreme Court issued a decision on Barker v. Barker. The case had been brought against two doctors, Drs. Maier and Barker, and the Crown, by 28 plaintiffs who had been patients at a maximum-security health centre between 1966 and 1983. The central question of judgement was whether three programs implemented by the doctors as part of the institution’s Social Therapy Unit (STU)—which involved nu de solitary confinement, the administration of hallucinogenic and mind-altering drugs, patient-on-patient physical enforcement, and other dehumanizing treatment—should be considered acceptable treatments or callous, non-therapeutic experimentation.
Evaluating cases like that of Barker v. Barker today requires prudent deliberation on the concept of informed consent and what constitutes experimental research versus innovative treatment. It also requires careful consideration of the standards of the time in the context of today’s ethical research processes. Although such experiments can easily be deemed unethical by today’s standards, they were not entirely unique at the time they were performed. In the 1950s and 1960s, “Procedures such as lobotomy, insulin coma, convulsive seizures produced by electricity or chemicals—all intrusive and invasive methods—had been introduced from Europe and had provided a feeling that at last a cure for mental illness might be at hand.”1
Another infamous Canadian case is that of Dr. Cameron, who conducted a series of ethically questionable experiments at a renowned psychiatric hospital in Montreal in the 1950s and 1960s.2 Dr. Cameron sought to “depattern” patients (ridding them of psychotic thoughts and feelings) through controversial techniques that, much like the STU programs, involved solitary confinement, sensory deprivation, and the administration of LSD, among other methods. Patients were not informed of the exact nature of the experiments or the dangers involved.3 Adding to the controversy, Cameron’s experiments were partially funded by the CIA and the Canadian government as part of the Cold War–era push to understand mental functioning (particularly, how brainwashing might be resisted, reversed, and weaponized).4,5
These same issues formed the crux of Barker v. Barker, and we may take a number of lessons from them. First is the notion of informed consent, which must be voluntary and free from coercion. This applies to treatment and, more particularly, to innovative treatment and experimental research. The principles also include an ability to withdraw from the program at any time, ensuring that this withdrawal does not come with any detriment or punishment. At trial, it was acknowledged that patients had given written consent and were involved in continuous group discussions regarding the nature of the STU programs; however, as one’s chances of being released from the program depended upon participation, the “necessary level of informed consent was absent”6 (at para. 103). The Court ruled that the plaintiffs could not have given informed consent to the impugned treatments, due to the coercive nature of the STU programs and the presence of severe mental illness in the plaintiffs.
Another contentious issue at trial was whether the programs in question qualified as research experiments, as claimed by the plaintiffs, or innovative treatments, as claimed by the Crown. One expert called at trial stated that “the ethical tenets of medical research would apply not just to self-declared research projects, but to the novel and experimental forms of therapy that departed from the orthodox therapies of the day”6 (at para. 142). The judge concluded that the programs, regardless of the label applied to them, “were conducted in a way that violated applicable ethical principles”6( at para. 147).
The court ultimately found Drs. Maier and Barker to be in breach of fiduciary duty as treating physicians, as well as researchers and experimenters; however, they were not found liable for two intentional torts, namely, battery and assault and intentional infliction of emotional distress. The Crown, that is, the province of Ontario, was found liable on the basis of accessory liability and vicariously liable for the breach of duty due to the fact that the doctors were employees and agents of the Crown. This finding further highlights the need for ethics review boards and oversight of experimentation.
Perhaps another lesson to be learned is to approach new and innovative treatments with caution and forethought. The history of medicine, and perhaps psychiatry in particular, is replete with a variety of treatments thought to be novel and innovative at the time, which history has revealed to be at best ridiculous and at worst horrifically detrimental.
1. Griffin J. Cameron’s search for a cure. Can Bull Med Hist 1991;8:121–126. p. 125.
2. Lemov R. Brainwashing’s avatar: the curious career of Dr. Ewen Cameron. Grey Room 2011;45:61–87.
3. Gillmor D. I Swear by Apollo: Dr. Ewen Cameron and the CIA-Brainwashing Experiments. Fountain Valley (CA): Eden Press; 1987.
4. Raz M. Alone again: John Zubek and the troubled history of sensory deprivation research. J Hist Behav Sci 2013;49:379–395.
5. Cooper G. Opinion of George Cooper, QC, regarding Canadian government funding of the Allan Memorial Institute in the 1950’s and 1960’s. Ottawa (ON): Communications and Public Affairs, Department of Justice; 1986.
6. Barker v. Barker. 2020, ONSC 3746 (2020).
CAPL BC Regional Section Update
Todd Tomita, MD, FRCPC
Chair, BC Regional Section
Since the last e-newsletter in March 2019, the CAPL BC Regional Section, in conjunction with the UBC Division of Forensic Psychiatry, continued to hold spring and fall forensic education days at UBC Robson Square in Vancouver, until the COVID-19 disruption. We cancelled our spring 2020 forensic education day and went online for our fall 2020 forensic education day.
In the before times, our in-person forensic education days had between 30 and 40 people, with a mix of forensic psychiatrists, forensic psychologists, psychiatry and psychology trainees, Crown and Defence counsel, correctional and forensic managers, and members of the BC Review Board. At our November 2020 virtual forensic education day, we had about 55 participants.
The pivot to virtual format resulted in mixed feedback. We have tentatively planned to hold the 13th edition of the forensic education day in May 2021, in virtual format again. We look forward to in-person events being possible, as we miss the collegial exchanges that are only possible in a group gathering.
CAPL BC and UBC Forensic Education Day 10th Edition — June 14, 2019
Cognitive Bias on Forensic Work and the Search for Countermeasures:
Cognitive Bias in Professional Practice: What the Research Tells Us
Dr. Carla McLean, Cognitive Consultants International
Learning the Hard Way: Assessors Succumbing to Forensic Bias
Dr. Hugh Herve, Director, The Forensic Practice
Dr. Todd Tomita, UBC Clinical Associate Professor
Taking Measure: Bias and the Admissibility of Expert Evidence
Dr. Roy O’Shaughnessy, UBC Clinical Professor
Dr. Rakesh Lamba, UBC Clinical Associate Professor
Louise Kenworthy, Crown Counsel
Bias and the Law: Legal Views from the Bench, Crown, and Defence
The Honourable Heather Holmes, Associate Chief Justice of BC Supreme Court
Troy D. Anderson, Troy Anderson Law
Marilyn Sanford, Richie Sanford McCowan Barristers
Daniel Mulligan, Crown Counsel
Moderator: Lyle Hillaby, Senior Crown Counsel
CAPL BC and UBC Forensic Education Day 11th Edition—October 31, 2019
Tell Your Children: The Truth About Marijuana, Mental Illness, and Violence, Free Press (2019)
Alex Berenson, book author
Cannabis, Mental Disorder, and Violence: A Review of the Literature
Dr. Nick Mathew, UBC Clinical Associate Professor
Cannabis-Related Violence: Emerging Trends from Recent Cases and Figuring It All Out
A Panel Discussion on the Assessment of Cannabis-Related Violence
Dr. Shabreham Lohrasbe, Forensic Psychiatrist
Dr. Kulwant Riar, UBC Clinical Professor
Dr. David Morgan, UBC Clinical Assistant Professor
Dr. Rakesh Lamba, UBC Clinical Assistant Professor
CAPL BC and UBC Forensic Education Day 12th Edition—May 22, 2020
Cancelled due to COVID-19
CAPL BC Section and UBC Forensic Education Day 12th Edition—November 20, 2020
A Review of Somatoform Disorders for the Forensic Psychiatrist
Dr. Andrew Howard, UBC Clinical Associate Professor
The Use of Actuarial and Structured Forensic Assessment Measures with Indigenous Correctional Populations: Findings, Issues, and Controversies
Dr. Mark Olver, Professor, University of Saskatchewan
Does Sexual Offender Specific Treatment Work? The Importance of Program and Staffing Moderators
Dr. Mark Olver, Professor, University of Saskatchewan
News from CAPL – Quebec Regional Section
Fabien Gagnon, MD, Psy. D., PGDipl., FCFP, FRCPC
President, Quebec Regional Section
As president of the CAPL Quebec Regional Section, I have been asked to prepare a short summary about the activities of our section for this year.
As with most physicians across Canada, COVID-19 has dramatically changed our personal and professional lives. Most of our members were quite busy, facing the pandemic and adapting our practice to this new reality. We postponed our usual section meetings for 2020. In March 2020, most Quebec Courts of Justice significantly reduced their activities, following the government lockdown order. The Palaces of Justice progressively resumed their activities in May/June 2020; however, since then, the trials have been done virtually most of the time, and the experts’ testimonies are still most often done through videoconferencing. In the COVID-19 context, the different evaluations (e.g., competency to stand trial) for the court are, for now, also done virtually, with the objective of avoiding, as much as possible, limiting prison and penitentiary presential encounters.
There is only one forensic psychiatry fellowship program in Quebec. The program is at the Philippe-Pinel National Institute of Legal Psychiatry in Montreal. Dr. Jocelyne Brault is the fellowship program director. For 2020–2021, there was no forensic psychiatry fellow; however, the program will have two fellows for 2021–2022. And, of course, the program is ready for the new RCPSC Competence by Design (CBD) scheme.
Three of our CAPL-QC section members are active members of the Quebec Psychiatric Association Medico-Legal Committee (Comité des affaires médicales et juridiques). The committee is chaired by Dr. France Proulx, who is vice-president of our section. The following were among the topics recently discussed at that committee: treatment order periodic reports; licence to carry a weapon; safety committee for security departments; issues related to the Act Respecting the Protection of Persons Whose Mental State Presents a Danger to Themselves or to Others; and medical assistance in dying and the forensic population. The Quebec Psychiatric Association asked some of our members to organize a short CPD program on “Forensic Psychiatry 101” to help general psychiatry colleagues working in different Quebec regions who have to give their opinion on usual (mostly criminal) forensic psychiatry issues.
We have between 30 and 35 regular members in the section, which gives an opportunity to network with colleagues from different regions. As mentioned, with the pandemic, we postponed our usual meetings; however, we should meet virtually in a month or two, or around the CAPL annual meeting.
Annual Membership Dues
CAPL members will have already received their 2020 membership dues notices (2021 dues will be invoiced in June). We encourage you to pay your dues to remain updated on CAPL news, including the Annual General Meeting, and to maintain your member status. If your active member status lapses, you will not receive CAPL updates nor will you be eligible for discounted member registration rates for the virtual annual conference. Please stay engaged and help support CAPL by paying your dues, if you’ve not done so already.
2021 CAPL Annual General Meeting
The CAPL Annual General Meeting (AGM) will be held on Apr. 20, 2021 from 12:00 – 1:30 p.m. EDT. Further details, including the agenda, were sent to CAPL members on Mar. 25.
Please note that the legislation under which CAPL is incorporated restricts voting at the AGM to members in the Full, Life, and Member-in-Training categories who renewed within three months of their invoice date (i.e., by Nov. 26, 2020).
Landmark Cases in Forensic Psychiatry
The updated list of Landmark Cases in Forensic Psychiatry in Canada has been translated into both official languages and is available on the CAPL website in English and French.
This case list was initially developed by the national group of forensic psychiatry PGY-6 program directors. It was reviewed and updated by the Royal College Specialty Committee in Forensic Psychiatry as part of the revision of forensic psychiatry training standards for Competence by Design that start in July 2021.
The Landmark Cases in Forensic Psychiatry list will be used by program directors as a reference document. While the Landmark Cases list will be used as part of the new forensic psychiatry training standards, please note that it is not recognized officially by the Royal College of Physicians and Surgeons of Canada for examination purposes.