Highly varying concepts and capacities of forensic mental health services across the European Union.

Introduction: There is wide variation in the processes, structures and treatment models for dealing with mentally disordered offenders across the European Union. There is a serious lack of data on population levels of need, national service capacities, or treatment outcome. This prevents us from comparing the different management and treatment approaches internationally and from identifying models of good practice and indeed what represents financial efficiency, in a sector that is universally needed. Methods: From March 2019 till January 2020 we surveyed forensic psychiatric experts from each European Union Member State on basic concepts, service capacities and indicators for the prevalence and incidence of various forensic psychiatric system components. Each expert completed a detailed questionnaire for their respective country using the best available data. Results: Finally, 22 EU Member States and Switzerland participated in the survey. Due to the frequent lack of a clear definition of what represented a forensic psychiatric bed, exact numbers on bed availability across specialized forensic hospitals or wards, general psychiatric hospitals or prison medical wards were often unknown or could only be estimated in a number of countries. Population-based rates calculated from the survey data suggested a highly variable pattern of forensic psychiatric provision across Europe, ranging from 0.9 forensic psychiatric beds per 100,000 population in Italy to 23.3 in Belgium. Other key service characteristics were similarly heterogeneous. Discussion: Our results show that systems for detaining and treating mentally disordered offenders are highly diverse across European Union Member States. Systems appear to have been designed and reformed with insufficient evidence. Service designers, managers and health care planners in this field lack the most basic of information to describe their systems and analyse their outcomes. As a basic, minimum standardized national reporting systems must be implemented to inform regular EU wide forensic psychiatry reports as a prerequisite to allow the evaluation and comparison of the various systems to identify models of best practice, effectiveness and efficiency.

[Psychiatry, Crises and Policies]. / Psychiatrie, Krisen und Politik.

From the perspective of global societal crises, this paper discusses the long-term socio-political withdrawal of psychiatry into a self-defined position of therapy- and rehabilitation-oriented medicine with no responsibility for social, economic or political conditions. Global crises suggest mental health and overall resilience of the population as key societal resources. Only mental health and psychosocial resilience of people and societies worldwide will determine whether our answers to the current and future existential threats will be effective. This challenge requires a radical change of attitudes of both society and psychiatry. The rich expertise of psychiatry, e. g. on on how to balance autonomy and compulsion or regarding the interdependencies of cognition and human behaviour must contribute significantly to the socio-political debate and the fight against undesirable social or political developments.

A multinational case-control study comparing forensic and non-forensic patients with schizophrenia spectrum disorders: the EU-VIORMED project.

BACKGROUND: The relationship between schizophrenia and violence is complex. The aim of this multicentre case-control study was to examine and compare the characteristics of a group of forensic psychiatric patients with a schizophrenia spectrum disorders and a history of significant interpersonal violence to a group of patients with the same diagnosis but no lifetime history of interpersonal violence. METHOD: Overall, 398 patients (221 forensic and 177 non-forensic patients) were recruited across five European Countries (Italy, Germany, Poland, Austria and the United Kingdom) and assessed using a multidimensional standardised process. RESULTS: The most common primary diagnosis in both groups was schizophrenia (76.4%), but forensic patients more often met criteria for a comorbid personality disorder, almost always antisocial personality disorder (49.1 v. 0%). The forensic patients reported lower levels of disability and better social functioning. Forensic patients were more likely to have been exposed to severe violence in childhood. Education was a protective factor against future violence as well as higher levels of disability, lower social functioning and poorer performances in cognitive processing speed tasks, perhaps as proxy markers of the negative syndrome of schizophrenia. Forensic patients were typically already known to services and in treatment at the time of their index offence, but often poorly compliant. CONCLUSIONS: This study highlights the need for general services to stratify patients under their care for established violence risk factors, to monitor patients for poor compliance and to intervene promptly in order to prevent severe violent incidents in the most clinically vulnerable.

Effectiveness and cost-effectiveness for the treatment of depressive symptoms in refugees and asylum seekers: A multi-centred randomized controlled trial.

Background: Current evidence points towards a high prevalence of psychological distress in refugee populations, contrasting with a scarcity of resources and amplified by linguistic, institutional, financial, and cultural barriers. The objective of the study is to investigate the overall effectiveness and cost-effectiveness of a Stepped Care and Collaborative Model (SCCM) at reducing depressive symptoms in refugees, compared with the overall routine care practices within Germany's mental healthcare system (treatment-as-usual, TAU). Methods: A multicentre, clinician-blinded, randomised, controlled trial was conducted across seven university sites in Germany. Asylum seekers and refugees with relevant depressive symptoms with a Patient Health Questionnaires score of ≥ 5 and a Refugee Health Screener score of ≥ 12. Participants were randomly allocated to one of two treatment arms (SCCM or TAU) for an intervention period of three months between April 2018 and March 2020. In the SCCM, participants were allocated to interventions tailored to their symptom severity, including watchful waiting, peer-to-peer- or smartphone intervention, psychological group therapies or mental health expert treatment. The primary endpoint was defined as the change in depressive symptoms (Patient Health Questionnaire-9, PHQ-9) after 12 weeks. The secondary outcome was the change in Montgomery Åsberg Depression Rating Scale (MADRS) from baseline to post-intervention. Findings: The intention-to-treat sample included 584 participants who were randomized to the SCCM (n= 294) or TAU (n=290). Using a mixed-effects general linear model with time, and the interaction of time by randomisation group as fixed effects and study site as random effect, we found significant effects for time (p < .001) and time by group interaction (p < .05) for intention-to-treat and per-protocol analysis. Estimated marginal means of the PHQ-9 scores after 12 weeks were significantly lower in SCCM than in TAU (for intention-to-treat: PHQ-9 mean difference at T1 1.30, 95% CI 1.12 to 1.48, p < .001; Cohen's d=.23; baseline-adjusted PHQ-9 mean difference at T1 0.57, 95% CI 0.40 to 0.74, p < .001). Cost-effectiveness and net monetary benefit analyses provided evidence of cost-effectiveness for the primary outcome and quality-adjusted life years. Robustness of results were confirmed by sensitivity analyses. Interpretation: The SSCM resulted in a more effective and cost-effective reduction of depressive symptoms compared with TAU. Findings suggest a suitable model to provide mental health services in circumstances where resources are limited, particularly in the context of forced migration and pandemics. Funding: This project is funded by the Innovationsfond and German Ministry of Health [grant number 01VSF16061]. The present trial is registered under Clinical-Trials.gov under the registration number: NCT03109028. https://clinicaltrials.gov/ct2/show/NCT03109028.

[Structural Features and Use of Coercive Measures in Forensic Psychiatry Throughout Germany]. / Strukturmerkmale und Anwendungshäufigkeit von Zwangsmaßnahmen im deutschen Maßregelvollzug.

OBJECTIVE: Nationwide assessment of structural data and the frequency of use of coercive measures in forensic psychiatric hospitals in Germany. METHODS: Quantitative survey using a postal questionnaire on structural data and on the use of coercive measures in forensic psychiatric hospitals as part of the "ZIPHER" study. RESULTS: About one fourth of all forensic patients are affected by coercive measures, with seclusion (21.2 %) being way more often than mechanical restraint (3.2 %). This ratio contrasts with general psychiatric hospitals, where restraints are more common than seclusions. CONCLUSION: The results of the study reveal nationwide peculiarities in the use of coercive measures in forensic psychiatric hospitals. At the same time, it demonstrated the lack of general structural and process data of forensic hospitals in Germany.

Neurocognition and social cognition in patients with schizophrenia spectrum disorders with and without a history of violence: results of a multinational European study.

OBJECTIVE: Neurocognitive impairment has been extensively studied in people with schizophrenia spectrum disorders and seems to be one of the major determinants of functional outcome in this clinical population. Data exploring the link between neuropsychological deficits and the risk of violence in schizophrenia has been more inconsistent. In this study, we analyse the differential predictive potential of neurocognition and social cognition to discriminate patients with schizophrenia spectrum disorders with and without a history of severe violence. METHODS: Overall, 398 (221 cases and 177 controls) patients were recruited in forensic and general psychiatric settings across five European countries and assessed using a standardized battery. RESULTS: Education and processing speed were the strongest discriminators between forensic and non-forensic patients, followed by emotion recognition. In particular, increased accuracy for anger recognition was the most distinctive feature of the forensic group. CONCLUSIONS: These results may have important clinical implications, suggesting potential enhancements of the assessment and treatment of patients with schizophrenia spectrum disorders with a history of violence, who may benefit from consideration of socio-cognitive skills commonly neglected in ordinary clinical practice.

Evaluation of coercive measures in different psychiatric hospitals: the impact of institutional characteristics.

BACKGROUND: Epidemiological studies have demonstrated considerable differences in the use of coercive measures among psychiatric hospitals; however, the underlying reasons for these differences are largely unclear. We investigated to what extent these differences could be explained by institutional factors. METHODS: Four psychiatric hospitals with identical responsibilities within the mental health care system, but with different inpatient care organizations, participated in this prospective observational study. We included all patients admitted over a period of 24 months who were affected by mechanical restraint, seclusion, or compulsory medication. In addition to the patterns of coercive measures, we investigated the effect of each hospital on the frequency of compulsory medication and the cumulative duration of mechanical restraint and seclusion, using multivariate binary logistic regression. To compare the two outcomes between hospitals, odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated. RESULTS: Altogether, coercive measures were applied in 1542 cases, corresponding to an overall prevalence of 8%. The frequency and patterns of the modalities of coercive measures were different between hospitals, and the differences could be at least partially related to institutional characteristics. For the two hospitals that had no permanently locked wards, certain findings were particularly noticeable. In one of these hospitals, the probability of receiving compulsory medication was significantly higher compared with the other institutions (OR 1.9, CI 1.1-3.0 for patients < 65 years; OR 8.0, CI 3.1-20.7 for patients ≥65 years); in the other hospital, in patients younger than 65 years, the cumulative duration of restraint and seclusion was significantly longer compared with the other institutions (OR 2.6, CI 1.7-3.9). CONCLUSIONS: The findings are compatible with the hypothesis that more open settings are associated with a more extensive use of coercion. However, due to numerous influencing factors, these results should be interpreted with caution. In view of the relevance of this issue, further research is needed for a deeper understanding of the reasons underlying the differences among hospitals.

[DNVF-Discussion paper - Specificities, Challenges and Aims of Mental Health Service Research in Germany]. / DNVF-Diskussionspapier ­ Besonderheiten, Herausforderungen und Ziele der Versorgungsforschung im Feld der seelischen Gesundheit.

Research in mental health services in Germany is of increasing relevance. To this end, the recently founded "Mental Health Working Group" as part of the German Network of Health Services Research (DNVF) has written a discussion paper presenting key specifics, challenges, and goals of health service research in the field of mental health. Some research-relevant specifics in the area of mental health care, pragmatic challenges of research organization, ethical problems, and particular research topics in this field are presented and discussed critically.

A Systematic Review of Non-pharmacological Strategies to Reduce the Risk of Violence in Patients With Schizophrenia Spectrum Disorders in Forensic Settings.

Background: The purpose of this systematic review is to systematically investigate which non-pharmacological interventions are effective in reducing violence risk among patients with schizophrenia spectrum disorders (SSD) in forensic settings. Methods: Six electronic data bases were searched. Two researchers independently screened 6,003 abstracts resulting in 143 potential papers. These were analyzed in detail by two independent researchers yielding 10 articles that could be used. Results: Of the 10 articles, four were non-randomized controlled trials, three were pre-post studies without controls, and one was observational. Only two studies applied a randomized controlled trial design. Cognitive behavioral treatment programs were investigated in three studies. A broad range of other interventions were studied. Often outcome measures were specific to each study and sample sizes were small. Frequently, important methodological information was missing from the papers. It was not possible to carry out a meta-analysis due to the heterogeneity of the study designs and outcome measures. Conclusion: Because of methodological limitations it is difficult to draw firm conclusions about the effectiveness of non-pharmacological interventions to reduce the risk of violence in patents with SSD in forensic psychiatry settings. Studies applying better methods in terms of study design, sample sizes and outcome measures are urgently needed.

Prevalence of depressive symptoms and symptoms of post-traumatic stress disorder among newly arrived refugees and asylum seekers in Germany: systematic review and meta-analysis.

BACKGROUND: In total numbers, Germany has faced the largest number of refugees and asylum seekers (RAS) in Europe in the past decade. Although a considerable proportion have experienced traumatic and stressful life events, there is no systematic review to date examining the prevalence of depressive symptoms and post-traumatic stress disorder (PTSD) symptoms in RAS in Germany. AIMS: To calculate the prevalence of depressive symptoms and PTSD symptoms in the general population of RAS living in Germany after the year 2000 and explore the impact of study- and participant-related characteristics on prevalence estimates. METHOD: We systematically searched PubMed, CINAHL, PsycINFO, PSYNDEX, Academic Search Complete, Science Direct and Web of Science from January 2000 to May 2020 to identify articles reporting prevalence of depressive symptoms and PTSD in RAS in Germany (PROSPERO registration number: CRD42020182796). RESULTS: In total, 31 different surveys met inclusion criteria with 20 surveys reporting prevalence estimates of depressive symptoms and 25 surveys symptoms of PTSD. Based on screening tools, the pooled prevalence estimate of PTSD symptoms was 29.9% (95% CI 20.8-38.7%) and of depressive symptoms 39.8% (95% CI 29.8-50.1%). Heterogeneity was large within and between subgroups. In multivariate meta-regressions on depressive symptoms, heterogeneity was largely explained by survey period, length of field period and study quality. CONCLUSIONS: Prevalence rates of depressive symptoms and PTSD symptoms in RAS are notably large. They exceed the prevalence in the general German population. As a result of high heterogeneity, however, pooled prevalence rates should be interpreted with caution.

Pharmacological interventions to reduce violence in patients with schizophrenia in forensic psychiatry.

BACKGROUND: The purpose was to systematically investigate which pharmacological strategies are effective to reduce the risk of violence among patients with Schizophrenia Spectrum Disorders (SSD) in forensic settings. METHODS: For this systematic review six electronic data bases were searched. Two researchers independently screened the 6,003 abstracts resulting in 143 potential papers. These were then analyzed in detail by two independent researchers. Of these, 133 were excluded for various reasons leaving 10 articles in the present review. RESULTS: Of the 10 articles included, five were merely observational, and three were pre-post studies without controls. One study applied a matched case-control design and one was a non-randomized controlled trial. Clozapine was investigated most frequently, followed by olanzapine and risperidone. Often, outcome measures were specific to the study and sample sizes were small. Frequently, relevant methodological information was missing. Due to heterogeneous study designs and outcomes meta-analytic methods could not be applied. CONCLUSION: Due to substantial methodological limitations it is difficult to draw any firm conclusions about the most effective pharmacological strategies to reduce the risk of violence in patents with SSD in forensic psychiatry settings. Studies applying more rigorous methods regarding case-definition, outcome measures, sample sizes, and study designs are urgently needed.

[Sexual Abuse of Minors in the Area of Responsibility of the Catholic Church: Institutional Specifics]. / Sexueller Missbrauch von Minderjährigen im Verantwortungsbereich der katholischen Kirche: Institutionelle Spezifika.

INTRODUCTION: From 2014 to 2018, an interdisciplinary consortium of scientists investigated the extent and possible causes of the sexual abuse of children in the area of responsibility of the Catholic Church in Germany. The study bears the acronym MHG (Mannheim / Heidelberg/Gießen) after the locations of the participating universities. The personnel file analysis identified 1670 Catholic clerics accused of sexual abuse of minors for the period from 1946 to 2014. For the Catholic Church specific conditions that favour the sexual abuse of minors could be identified. METHOD: A comparison of criminal records of accused clerics and perpetrators from other institutional contexts has been carried out. RESULT: Sexual offenses of priests are severe and the number of persons affected per convicted person is not less than that of perpetrators in other institutions; the duration of abuse by Catholic clerics is even significantly longer. Persons affected by sexual abuse in the context of the Catholic Church are significantly more often male. The Catholic Church has tried more extensively than other institutions to cover up accusations of sexual abuse of children or young people by clerics. CONCLUSION: Prevention concepts must take greater account of the specific conditions of sexual abuse in the Catholic Church.

Child Sexual Abuse by Catholic Priests, Deacons, and Male Members of Religious Orders in the Authority of the German Bishops' Conference 1946-2014.

This study explores the extent of sexual abuse of minors by members of the Catholic Church in Germany. It is the first comprehensive study to examine this extent in a European country. The goals of this study are as follows: (a) to analyze whether the extent and characteristics of sexual abuse in a European country are comparable to those in the United States and Australia and (b) how discrepancies can be explained. The personnel files of 38,156 Catholic Priests, deacons, and male members of religious orders in the authority of the German Bishops' Conference were analyzed. The study period lasted from 1946 to 2014. All 27 German dioceses took part in this study. A total of 4.4% of all clerics (N = 1,670) from 1946 to 2014 were alleged to have committed sexual abuse, and 3,677 children or adolescents were identified as victims. These results are similar to those from comparable studies in the United States. Sexual abuse of minors within the authority of the Catholic Church seems to be a worldwide phenomenon.

Mental health and the criminal justice system in France: A narrative review.

The treatment of people diagnosed with mental disorders who committed crimes differ greatly in countries around the world because of the long histories of criminal justice and psychiatry specific to each country. As a result, it is often difficult to grasp the specificities of each system. The main objective of this paper is to provide a narrative review of the interactions between the French mental health and judicial systems. Subsequently, we will discuss how the concept of forensic psychiatry does not yet exist in France and how it can be applied.

Mental health in refugees and asylum seekers (MEHIRA): study design and methodology of a prospective multicentre randomized controlled trail investigating the effects of a stepped and collaborative care model.

The sudden arrival of culturally diverse asylum seekers and refugees into Germany has created a strong demand for recognizing and appropriately treating those suffering from mental health issues. Due to many systemic, organizational, cultural and socio-linguistic barriers, psychiatric treatment of refugees is posing a major challenge to Germany's mental health care system. Thus, there is a need for alternative models that allow for increased access to adequate, effective and efficient culturally sensitive mental health care services. Here, we describe the Mental Health in Refugees and Asylum Seekers (MEHIRA) project, a multicentre randomized controlled trial investigating a stepped collaborative care model (SCCM) for providing mental health treatment in this vulnerable population. The proposed SCCM aims to decrease the aforementioned barriers. Adult and adolescent participants will be screened for depressive symptoms and matched to appropriate psychological interventions, including group-level interventions (START intervention, Empowerment/Gender-sensitive/Peer to peer), and other innovative, digital treatment approaches (Smartphone application). The therapeutic effect of the SCCM will be compared to TAU (treatment-as-usual). All interventions have been designed to be culturally sensitive, and offered in two different languages: Arabic and Farsi. The outcome of this study may contribute significantly to future clinical and legal guidelines in developing parallel and efficient new structures of treatment. Collected data will inform primary and secondary mental health care providers with recommendations concerning the design and implementation of effective treatment models and programmes. Guidelines and recommendations may also potentially be adopted by other host countries, developing countries and also in humanitarian aid programmes.

Stress, mental and physical health and the costs of health care in German high school students.

Stress is a mind-body phenomenon, which affects both mental and physical health and is highly relevant to the health care system. Yet, knowledge on the costs of stress and related health problems in adolescence is missing. The present study addresses this gap by investigating direct health care costs in relation to stress, mental health problems and physical health in high school students. The sample comprised 284 pupils from four schools in Heidelberg (mean age 16.75 ± 0.64 years, 59.64% female). Self-reported health care utilization and medication intake within 1 month were translated into costs. We established correlative associations of the dichotomized overall costs (no vs. any) with stress, mental health problems and physical health within generalized structural equation models. In particular, mental health problems and physical health were examined as mediators of the association between stress and costs. An increase of stress by 1 SD corresponded increased chances for costs by OR 1.39 (Odds Ratio; 95% CI 0.13-0.53, p = 0.001). When mediators were analysed separately, both mental and physical health (problems) fully mediated the association. Yet, when examined together, only mental health problems acted as a mediator. Our results indicate the health economic relevance of stress-related mental health problems in high school students. The finding is meant to set the stage for further cost-of-illness studies of stress and related health problems, as well as economic evaluations. Longitudinal research is needed to allow conclusions on directionality.

Sexual Abuse at the Hands of Catholic Clergy.

BACKGROUND: When cases of sexual abuse within the Catholic Church became known, the German Bishops' Conference (Deutsche Bischofskonferenz, DBK) commissioned a study by an interdisciplinary consortium to determine the frequency of sexual abuse by Catholic clergy in Germany (the MHG study). METHODS: Qualitative and quantitative research methods were used and the subject matter of the study was analyzed in seven component projects. To determine the frequency of sexual abuse, 38 156 personnel files of Catholic clergy from the period 1946 to 2014 were studied, and the epidemiologic findings of these evaluations are presented. RESULTS: 1670 persons belonging to the Catholic clergy who were accused of sexual abuse of minors were identified from their personnel files, corresponding to 4.4% of the clergy overall. 3677 victims of sexual abuse could be linked to the accused persons; 62.8% of them were male, and 66.7% were under 14 years old when the abuse took place. The mean duration of the abuse in individual cases was 1.3 years. "Hands-on" abuses (i.e., abuses involving bodily contact) occurred in more than 80% of cases. Many of the affected persons suffered serious consequences for their health and social functioning. The ones most commonly reported were anxiety, depression, mistrust, sexual problems, and difficulties with interpersonal contact. CONCLUSION: The figures reported here should be considered a lower bound to the actual frequency of sexual abuse. Asymmetrical power relationships in a closed system such as the Catholic Church can facilitate sexual abuse. Physicians play an important role in the diagnosis and treatment of the victims of sexual abuse, in the diagnosis and treatment of persons inclined to commit abuses and actual abusers, and in the development and implementation of preventive strategies.

Correction: Care management intervention to strengthen self-care of multimorbid patients with type 2 diabetes in a German primary care network: A randomized controlled trial.

[This corrects the article DOI: 10.1371/journal.pone.0214056.].

[Sexual Abuse of Children by Catholic Priests since 2009: Course and Relative Frequency Compared to the Male General Population]. / Sexueller Missbrauch von Kindern durch katholische Priester seit 2009: Verlauf und relative Häufigkeit im Vergleich zur männlichen Allgemeinbevölkerung.

OBJECTIVE: This paper explores the frequency of sexual abuse allegations against Catholic priests and deacons in the years 2009 to 2015 in relation to the male general population in Germany. METHOD: An annual rate of sexual abuse accusations is calculated from the sexual abuse allegations against Catholic priests identified in the MHG-study for the years 2009 to 2015. This is compared to figures of the male general population from the police crime statistics. RESULTS: The number of suspected men in the general population ranged from 17.6 - 20.0/100.000 between 2009 and 2015. For Catholic priests the rate of accusations ranged from 8.4 to 31.7/100.000. A decrease of the quota was not detectable in either group during the study period. DISCUSSION: The findings suggest that there is a relatively constant rate of people being disposed to child sexual abuse in the group of Catholic priests. These results should be addressed specifically in the prevention work of the Catholic Church.

Care management intervention to strengthen self-care of multimorbid patients with type 2 diabetes in a German primary care network: A randomized controlled trial.

PURPOSE: This study aimed to assess the effectiveness of a care management intervention in improving self-management behavior in multimorbid patients with type 2 diabetes; care was delivered by medical assistants in the context of a primary care network (PCN) in Germany. METHODS: This study is an 18-month, multi-center, two-armed, open-label, patient-randomized parallel-group superiority trial (ISRCTN 83908315). The intervention group received the care management intervention in addition to the usual care. The control group received usual care only. The primary outcome was the change in self-care behavior at month 9 compared to baseline. The self-care behavior was measured with the German version of the Summary of Diabetes Self-Care Activities Measure (SDSCA-G). A multilevel regression analysis was applied. RESULTS: We assigned 495 patients to intervention (n = 252) and control (n = 243). At baseline, the mean age was 68 ±11 years, 47.8% of the patients were female and the mean HbA1c was 7.1±1.2%. The primary analysis showed no statistically significant effect, but a positive trend was observed (p = 0.206; 95%-CI = -0.084; 0.384). The descriptive analysis revealed a significantly increased sum score of the SDSCA-G in the intervention group over time (P = 0.012) but not in the control group (p = 0.1973). CONCLUSION: The sum score for self-care behavior markedly improved in the intervention group over time. However, the results of our primary analysis showed no statistically significant effect. Possible reasons are the high baseline performance in our sample and the low intervention fidelity. The implementation of this care management intervention in PCNs has the potential to improve self-care behavior of multimorbid patients with type 2 diabetes.