In the present study, approximately 4% of individuals under the ORB had engaged in self-harming behaviors over the reported period. This prevalence is lower than those reported in previous studies, and may be attributed to their small sample size (below 100 individuals) and exclusion of outpatients (i.e., patients in high secure facility in Sweden and minimum secure unit in UK) in the previous studies cited [7, 8, 11, 12]. In addition to the small sample sizes, the operational definitions of self-harming behaviors in previous studies cited varied from the current study which might have led to the differences in the prevalence rate. For example, while the present study examined the prevalence of self-harming over 12-month, some of the cited studies reported only suicide attempts in the past six months [7], another reported both self-harming behaviors and suicide attempts in the past six months [11], and others captured both self-harming behaviors since the age of 18 [12] or lifetime [8]. Capturing self-harming behaviors beyond one year can lead to a higher reported prevalence compared to the current study. Considering that risk management (e.g., risk of violence and self-harming behaviour) is one of the major role of the forensic psychiatric system [24], it is rational to assume that the burden or prevalence would change over time due to treatment and other management modalities. Consequently, capturing recent incidents of self-harming behaviors over six months or one year is clinically more relevant in judging g patients’ current safety or risk profile and any improvement. These indicators (e.g., mitigation of recent risk incidents or current safety profile) can be used in determining patients’ readiness for safe transition into the community. To facilitate decision making in forensic psychiatry system, future studies about self-harming behaviors should endeavor to address the prevalence of recent incidents of self-harming behavior and explore the relationship of self-harming behaviour with dynamic and modifiable factors.

The recent study by Jentz et al. [8] may have reported a higher prevalence compared to the current study because it included only females, who have previously been reported to have higher rates of self-harming behaviors [12, 23]. Closely linked is that the forensic system in Canada may be considered among the most developed or better resourced systems globally and more infrastructural safeguards are in place to ensure patients’ safety, thus, the lower prevalence of self-harming behaviors compared to other systems globally. In addition, the forensic system in Canada conducts routine risk assessment with tools such as the electronic-Hamilton Anatomy of Risk Management (eHARM) that may indirectly monitor, and mitigate, self-harming behaviors among patients [24]. The safeguards in use can be implemented in various forensic psychiatric systems globally to ensure safety of forensic patients and detailed descriptions should be provided. In addition, training regarding the implementations of such methods should be initiated for proper and easy adaptation. Despite the known high standards, little descriptions about the safety or risk mitigation protocols, methods, and algorithms used in Canada for patients in the forensic system have been published. Preventive strategies have been proven to be effective in reducing self harming behaviors among individuals in the criminal justice system [25]. We recommend further research to describe such important methods for other areas to learn from. However, in implementation of these methods, it should be noted that the economic and other contextual need of the approaches may be different, and many low-income settings may need context applicable methods. In addition, important lessons and recommendations to prevent self-harming behaviors can be borrowed form other correctional justice system populations [26].

Forensic inpatients in the present study had a higher likelihood of engaging in self-harming behaviors, with inpatients in secure units having higher odds than those in outpatients’ forensic settings. The present findings indirectly underscore the role played by the severity of mental health unwellness and risk of violence. For this reason, individuals who were UST were also at a higher likelihood of self-harming behaviors. Individuals with severe mental health symptoms, especially psychosis, are at a high likelihood of being found UST [27, 28] and may display self-harming behaviors. The trend worsens among individuals with severe forms of neurodevelopmental disorders such as autism, learning disorders, among others; who are involved in self-harming behaviors as a mode of coping with stress or as part of the presentation of their symptomatology [29, 30]. It is also important to note that the forensic psychiatry system has an overrepresentation of individuals with severe psychotic illness, especially schizophrenia as seen in the present study, who may engage in self-harming behaviors due to commands from hallucination or influence of delusions. The presentation of the individuals within the forensic system indicates a high representation of individuals who do not wish to die but are motivated by active symptoms of their illness - a reflection of symptom involvement in some of their index offences.

To the best our knowledge, the present analysis represents the largest study assessing self-harming behaviors among individuals in the forensic systems. Additionally, the dataset was derived from multiple sites and included a wide range of patients and their status (i.e., secure in-patients and outpatients) along the continuum of the forensic system. Despite the size of the database, some study limitations are identified. For example, the present study is retrospective in design and did not specify the type of self-harming behaviors, the methods used, number of incidents, and the severity of the self-harming behaviors and medical outcomes. We recommend future studies to explore such factors or variables to enable the development of a robust strategies to protect the patients better. Second, not all factors related to self-harming behaviors were explored in the present study. Third, this is a retrospective study, and causality can not be inferred. We recommend prospective studies to understand these phenomena. Fourth, the data included was derived from reports covering 2014-15, which may not accurately reflect the current state of self-harming behaviors in the forensic psychiatry system. We recommend the use of recent data in determining the accurate burden of self-harming behaviors. Moreover, future studies using adequately powered models as well as big data analysis to explore the composite relationship of forensic system-related factors with self-harming behaviors are indicated. Lastly, it is also important to note that the prevalence in the current study may be low because it was based on reported incidents by staff or patients that may be biased to including mainly severe incidents and less severe incidents might be ignored.

Implications of the study findings

The present study has the following implications as per the various stakeholders.

1)

Forensic psychiatry patients.

The study findings imply that patients that are unfit to stand trial or inpatients in the forensic system may have a higher risk of self-harming behaviors. Hence, they may benefit from more support and care from the forensic system to mitigate the risk of self-harming behaviour. In addition, those with these identifiable patient-status factors associated with self-harming behaviors may benefit from a closer observation, more screening, monitoring, and individual tailored management strategies, albeit this can sometimes be perceived as stressful and an infringement of their privacy [31].

2)

Forensic psychiatry clinicians.

The study findings imply that clinicians need to be more aware of the forensic system-related factors that may influence the risk of self-harming behaviors among their patients. They may need to complete stratified clinical evaluation and analysis to identify individuals with forensic related factors associated with self-harming behaviors in their practice based on evidence-based research and promotion of protective measures to mitigate self-harming behaviors or actions. Such interventions may include monitoring of the patients and completing nuanced evaluation to better understand and develop interventions to relieve all underlying risk factors for self-harm [32]. Clinicians may also need to collaborate with other stakeholders in the forensic system, such as the review board, the legal system, and the correctional system, to ensure the safety and well-being of their patients.

3)

Forensic psychiatry researchers.

Based on the study findings, mechanisms and pathways that link the forensic system-related factors and self-harming behaviors among forensic patients need to be explored further. Importantly, there is a need to conduct more studies with larger and more diverse samples using advanced and more rigorous methodology (e.g., use of longitudinal and experimental study designs, to establish causal relationships and test interventions). Large language models may also be used to assist in identifying unit links between the plausible risk factors and self-harm. As research in this area evolves, a detailed exploration of the various forms of self-harm (especially emotional self-harm with behavioural manifestations that could easily be missed) should be explored [33, 34]. This may provide key insight into understanding the warning signs and developing of preventative measures against physical self-harming behaviors. Furthermore, the linkage between the different types or nature of self-harm can be explored to better understand the phenomenon and develop potential interventions. Lastly, dissemination of research findings and recommendations to policy makers, practitioners, and the public is indicated for easy translation.

4)

Forensic psychiatry policy makers.

Active engagement of policy makers is needed to promote allocation of adequate resources to provide care for individuals that need indicated intervention or support based on their risk profile for self harm. This is particularly important for patients found unfit to stand trial and inpatients given the present study finding. The resources can support clinical monitoring, staffing, system-related changes and promotion of research targeted mitigating the risk of self-harming behaviors.

5)

The general public.

Public health education and support for families or caregivers to understand the need of patients, especially those transitioning into the community might be beneficial. Appropriate access to community based resources, including support lines, counseling teams and emergency care for at-risk individuals are encouraged.

6)

The review boards.

In addition to ensuring public safety, the boards should emphasis strategies and promote support for mitigation measures for self-harm for forensic patients, especially those with identifiable risk. This can be done by canvassing for support and mandating provision of services for the rehabilitation and management of patients at risk of self-harm.