Mental Health Consultations in Immigration Detention: What Can We Learn From Clinical Records?

Objectives: Knowledge on mental health consultations in immigration detention and characteristics of people receiving consultations is scarce. Based on a sample of 230 adult men in immigration detention in Switzerland, we aimed to: (1) Quantify the proportion of persons receiving mental health consultations during detention; and (2) Identify socio-demographic and clinical characteristics associated with mental health consultations. Methods: Retrospective observational study with a cross-sectional design. Prevalence estimates, logistic regressions, and contingency tables were used to analyse the data. Results: A total of 30% of the sample received mental health consultations during detention. Time spent in immigration detention, mental health problems during detention, use of psychotropic medication, and self-harm were associated with mental health consultations. Although mental health consultations are provided to people with more severe mental health problems, 41% of persons with assessed mental health needs during the initial screening and 26% of those who self-harmed during detention did not receive mental health consultations. Conclusion: Mental health resources and screening procedures could be improved to ensure that mental health consultations are matched to clinical need in immigration detention settings.

Protocol of a monocentric, double-blind, randomized, superiority, controlled trial evaluating the effect of in-prison OROS-methylphenidate vs. placebo treatment in detained people with attention-deficit hyperactivity disorder (BATIR).

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is characterized by difficulty paying attention, poor impulse control, and hyperactive behavior. It is associated with several adverse health and social outcomes and leads to an increased risk of criminality and recidivism. Worldwide, ADHD is thus highly prevalent in prisons. However, ADHD treatment has been neglected in such environments. Stimulant medications such as osmotic-release oral system methylphenidate (OROS-MPH) are first-line treatments in the general population, but they are under-prescribed in prisons due to concerns about abuse, even though such claims are not empirically supported. This project aims to compare the efficacy of a 3-month in-prison OROS-MPH vs. placebo treatment on the severity of core ADHD symptoms and relevant in- and post-prison outcomes. METHODS: This study is a phase III, double-blinded, randomized, superiority, controlled trial of OROS-MPH vs. placebo. After randomization, the participants will receive 3 months of treatment with OROS-MPH or placebo (1:1 ratio) while incarcerated. Upon release, all participants will be offered the treatment (OROS-MPH) for 1 year but will remain blinded to their initial study group. The study will be conducted at the Division of Prison Health, Geneva, Switzerland, among incarcerated men (n = 150). Measures will include (1) investigator-rated ADHD symptoms, (2) acute events collected by the medical and prison teams, (3) assessment of the risk of recidivism, (4) medication side effects, (5) medication adherence, (6) study retention, (7) health care/prison costs, and (8) 1-year recidivism. Analyses will include bivariable and multivariable modeling (e.g., regression models, mixed-effects models, survival analyses) and an economic evaluation (cost-benefit analysis). DISCUSSION: We expect that early identification and treatment of ADHD in prison will be an important public health opportunity and a cost-effective approach that is likely to reduce the vulnerability of incarcerated individuals and promote pathways out of criminal involvement. The study will also promote standards of care for people with ADHD in prison and provide recommendations for continuity of care after release. TRIAL REGISTRATION: ClinicalTrials.gov NCT05842330 . Registered on June 5, 2023. Kofam.ch SNCTP000005388. Registered on July 17, 2023.

Do Personal Nurse-Initiated Medication Boxes Work in Prison? A Cross-Sectional Study Involving Incarcerated Persons and Prison Officers in a Swiss Prison.

INTRODUCTION: Daily in-hand medication dispensing in prisons and jails is resource intensive, disempowering, and nonconfidential. This research aimed to assess a nurse-initiated, low-frequency medication dispensing system using personal lockable boxes. METHODS: A cross-sectional study was carried out in a Swiss prison involving 47 box users and 19 custodial officers. FINDINGS: Box users agreed or strongly agreed about the perceived advantages of the box system, including user-friendliness, lower theft risk, and increased dignity, confidentiality, compliance, and autonomy to self-manage medication. Officers, who must accompany nurses during dispensing rounds, concurred that medication boxes were more time-efficient and improved role differentiation between custodial and clinical staff. Patients and officers were overall satisfied with the system and would recommend scaling it up in other facilities. DISCUSSION: This study suggests that medication boxes are feasible, acceptable, easy to use, and secure. Boxes could promote patients' autonomy, protect confidentiality, and allow nurses to dedicate more time to individual visits and health promotion and prevention activities.

Refusal to participate in research among hard-to-reach populations: The case of detained persons.

Providing insights on refusal to participate in research is critical to achieve a better understanding of the non-response bias. Little is known on people who refused to participate, especially in hard-to-reach populations such as detained persons. This study investigated the potential non-response bias among detained persons, comparing participants who accepted or refused to sign a one-time general informed consent. We used data collected in a cross-sectional study primary designed to evaluate a one-time general informed consent for research. A total of 190 participants were included in the study (response rate = 84.7%). The main outcome was the acceptance to sign the informed consent, used as a proxy to evaluate non-response. We collected sociodemographic variables, health literacy, and self-reported clinical information. A total of 83.2% of the participants signed the informed consent. In the multivariable model after lasso selection and according to the relative bias, the most important predictors were the level of education (OR = 2.13, bias = 20.7%), health insurance status (OR = 2.04, bias = 7.8%), need of another study language (OR = 0.21, bias = 39.4%), health literacy (OR = 2.20, bias = 10.0%), and region of origin (not included in the lasso regression model, bias = 9.2%). Clinical characteristics were not significantly associated with the main outcome and had low relative biases (≤ 2.7%). Refusers were more likely to have social vulnerabilities than consenters, but clinical vulnerabilities were similar in both groups. The non-response bias probably occurred in this prison population. Therefore, efforts should be made to reach this vulnerable population, improve participation in research, and ensure a fair and equitable distribution of research benefits.

Comparison of Audiovisual and Paper-Based Materials for 1-Time Informed Consent for Research in Prison: A Randomized Clinical Trial.

Importance: Few studies are available on informed consent (IC) among detained persons, even with ethics being a critical aspect of prison research. In IC research, audiovisual material seems to improve understanding and satisfaction compared with conventional paper-based material, but findings remain unclear. Objective: To compare audiovisual and paper-based materials for 1-time general IC for research in prisons. Design, Setting, and Participants: This cross-sectional randomized clinical trial was conducted in 2 corrections facilities in Switzerland (an adult prison and a juvenile detention center). The study was conducted from December 14, 2019, to December 2, 2020, in the adult prison and from January 15, 2020, to September 9, 2021, in the juvenile detention center. In the adult prison, study participation was offered to detained persons visiting the medical unit (response rate, 84.7%). In the juvenile detention center, all newly incarcerated adolescents were invited to participate (response rate, 98.0%). Interventions: Participants were randomized to receive paper-based conventional material or to watch a 4-minute video. Materials included the same legal information, as required by the Swiss Federal Act on Research Involving Human Beings. Main Outcomes and Measures: The main outcome was acceptance to sign the IC form. Secondary outcomes included understanding, evaluation, and time to read or watch the IC material. Results: The study included 190 adults (mean [SD] age, 35.0 [11.8] years; 190 [100%] male) and 100 adolescents (mean [SD] age, 16.0 [1.1] years; 83 [83.0%] male). In the adult prison, no significant differences were found between groups in acceptance to sign the IC form (77 [81.1%] for paper-based material and 81 [85.3%] for audiovisual material; P = .39) and to evaluate it (mean [SD] correct responses, 5.09 [1.13] for paper-based material and 5.01 [1.07] for audiovisual material; P = .81). Understanding was significantly higher in the audiovisual material group (mean [SD] correct responses, 5.09 [1.84]) compared with the paper-based material group (mean [SD] correct responses, 4.61 [1.70]; P = .04). In the juvenile detention center, individuals in the audiovisual material group were more likely to sign the IC form (44 [89.8%]) than the paper-based material group (35 [68.6%], P = .006). No significant difference was found between groups for understanding and evaluation. Adults took a mean (SD) of 5 (2) minutes to read the paper material, and adolescents took 7 (3) minutes. Conclusions and Relevance: Given the small benefit of audiovisual material, these findings suggest that giving detained adults and prison health care staff a choice regarding IC material is best. For adolescents, audiovisual material should be provided. Future studies should focus on increasing understanding of the IC process. Trial Registration: ClinicalTrials.gov Identifier: NCT05505058.

SARS-CoV-2 seroprevalence study after the first wave among persons living and working in an overcrowded Swiss prison.

PURPOSE: Prisons can be epicentres of infectious diseases. However, empirical evidence on the impact of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in prison is still scarce. This study aims to estimate the seroprevalence rates of anti-SARS-CoV-2 in the largest and most crowded Swiss prison and compare them with the seroprevalence rate in the general population. DESIGN/METHODOLOGY/APPROACH: A cross-sectional study was conducted in June 2020, one month after the first wave of SARS-CoV-2 in Switzerland. Groups included: people living in detention (PLDs) detained before the beginning of the pandemic (n = 116), PLDs incarcerated after the beginning of the pandemic (n = 61), prison staff and prison healthcare workers (n = 227) and a sample from the general population in the same time period (n = 3,404). The authors assessed anti-SARS-CoV-2 IgG antibodies. FINDINGS: PLDs who were incarcerated before the beginning of the pandemic had a significantly lower seroprevalence rate [0.9%, confidence interval (CI)95%: 0.1%-5.9%] compared to the general population (6.3%, CI 95%: 5.6-7.3%) (p = 0.041). The differences between PLDs who were incarcerated before and other groups were marginally significant (PLDs incarcerated after the beginning of the pandemic: 6.6%, CI 95%: 2.5%-16.6%, p = 0.063; prison staff CI 95%: 4.8%, 2.7%-8.6%, p = 0.093). The seroprevalence of prison staff was only slightly and non-significantly lower than that of the general population. ORIGINALITY/VALUE: During the first wave, despite overcrowding and interaction with the community, the prison was not a hotspot of SARS-CoV-2 infection. Preventive measures probably helped avoiding clusters of infection. The authors suggest that preventive measures that impact social welfare could be relaxed when overall circulation in the community is low to prevent the negative impact of isolation.

[Suicide attempts in detention during the pandemic: Lessons learned]. / Tentatives de suicide en détention durant la période pandémique : quels enseignements ?

People living in detention are at high risk of suicidal behaviour, with an incidence of suicides 3- to 9-fold higher compared to the general population. During the SARS-CoV-2 pandemic, suicidality among some disadvantaged populations increased and this trend was also observed in Swiss prisons. This article describes the clinical, psychosocial, institutional, criminological, and judicial factors associated with an increased risk of suicide attempt, as well as those that may lead to increased depression and other psychiatric disorders in the context of the pandemic in detention. Solutions are proposed to limit the incidence and consequences of these events in this vulnerable population.

Les personnes vivant en détention sont exposées à un risque élevé de comportements suicidaires, avec une incidence des suicides 3 à 9 fois plus élevée que dans la population générale. Durant la pandémie de SARS-CoV-2, la suicidalité au sein de certaines populations défavorisées s'est accrue et cette tendance a été observée dans certaines prisons, notamment en Suisse. Cet article décrit les facteurs cliniques, psychosociaux, institutionnels, criminologiques et judiciaires qui sont associés à un risque augmenté de passage à l'acte suicidaire, ainsi que ceux pouvant conduire à une exacerbation de la dépression et d'autres troubles psychiatriques dans le contexte pandémique en détention. Des solutions sont proposées pour limiter l'incidence et les conséquences de ces événements au sein de cette population vulnérable.

[Migration and administrative detention: the challenges for medical practice]. / Migration et détention administrative : les défis pour la pratique médicale.

Administrative detention or deprivation of liberty of migrants is a response to a decision by the authorities to remove those who have refused to leave voluntarily. These people are incarcerated not for having committed a crime, but for staying illegally in Switzerland. They often find themselves in a precarious situation, suffering from psychological or somatic illnesses that may be linked to their migration path. In most cases, they do not wish to return to their country and have many psychological or physical defences to oppose the decision of the authorities organising the removal. The health care provider is therefore faced with many challenges in order to carry out the many tasks of prison medicine while respecting fundamental ethical principles.

La détention administrative, ou privation de liberté des personnes migrantes, répond à une décision de renvoi de la part des autorités des personnes ayant refusé de partir volontairement. Elles sont incarcérées pour seul motif : leur séjour illégal en Suisse. Elles sont souvent précarisées et souffrent de maladies psychiques ou somatiques. Dans la majorité des cas, ces personnes ne souhaitent pas repartir dans leur pays et présentent de nombreuses défenses psychologiques ou physiques pour s'opposer à la décision des autorités. Les récents changements légaux visant à faciliter le renvoi sont problématiques du point de vue de la déontologie médicale. Le soignant se trouve donc face à de ­nombreux défis pour accomplir les multiples missions de la ­médecine en milieu pénitentiaire en respectant les principes éthiques fondamentaux.

[Independent monitoring of prisons: The work of the European Committee for the Prevention of Torture in Switzerland]. / Monitoring indépendant des prisons - Activité du Comité européen pour la prévention de la torture en Suisse.

Prisons concentrate people with multiple vulnerabilities who are exposed to violations of human rights, without any exception, including Switzerland. Independent monitoring bodies play an important role in preventing ill-treatment in detention. The most effective monitoring body worldwide is the European Committee for the Prevention of Torture (CPT), which bases its work on a European Convention that guarantees unrestricted access to detention facilities and all documents, including medical documents, in the member states of the Council of Europe. This article summarizes the main recommendations made by the CPT during its most recent visits to Switzerland, with a focus on prisons in French-speaking Switzerland, and also presents its workings in relation to the visits.

Les prisons concentrent des personnes avec de multiples vulnérabilités qui y sont exposées à des violations des droits humains. Aucun des pays n'y fait exception, y compris la Suisse. Les organes indépendants de contrôle jouent un rôle important dans la prévention des mauvais traitements en détention. L'organe de contrôle le plus efficace au monde est le Comité européen pour la prévention de la torture (CPT), qui base son travail sur une Convention européenne qui garantit un accès illimité aux établissements de privation de liberté et à l'ensemble des documents, y compris médicaux, dans les États membres du Conseil de l'Europe. Cet article résume des recommandations essentielles formulées par le CPT lors des dernières visites en Suisse, avec un focus sur les prisons de la Suisse romande, et présente également son fonctionnement en lien avec les visites.

The day-of-invitation effect on participation in web-based studies.

Several methods have been proposed to promote participation in web-based research. Here, we examine a technique that is available at no cost: Inviting respondents per e-mail on a particular day of the week. We base our reasoning on such a day-of-invitation effect upon theories on variations in mood and work performance over the week. We conducted five experiments with large and heterogeneous samples to find out whether such effects apply for response rate (i.e., visiting the first page of a study) and retention rate (i.e., completing the study) in web-based studies. We found evidence of a small but significant day-of-invitation effect. Response rate is high at the beginning of the workweek and falls to a low on Friday. Exploratory analyses showed that this decline is higher for employed (vs. nonemployed) persons. Effects on retention rate appear to follow a less straightforward pattern. We discuss possible mechanisms that might account for the day-of-invitation effect and recommend inviting participants on Monday or Tuesday.

Suicide attempts and Covid-19 in prison: Empirical findings from 2016 to 2020 in a Swiss prison.

Disadvantaged populations have an increased risk of suicide and suicide attempts because of the Covid-19 pandemic. To date, few studies focused on people living in detention, who have a high burden of mental health problems and are exposed to severe control measures. Our study investigated whether there was an increase in suicide attempts in prison. Data were collected in the largest Swiss pre-trial prison (Champ-Dollon) for the pre-pandemic and the pandemic periods. We identified a statistically significant 57%-increase of suicide attempts. Mitigation measures, access to mental health care, and access to vaccination are needed to protect this vulnerable population.

Vulnerable patients forgo health care during the first wave of the Covid-19 pandemic.

During the first wave of the Covid-19 pandemic, access to health care was limited, and patients encountered important delays for scheduled appointments and care. Empirical data relying on patients' reports of forgoing health care are scarce. This study investigated Covid-19-related self-reports of forgoing health care in a sample of vulnerable outpatients in Geneva, Switzerland. We collected data from 1167 adult outpatients, including clinically vulnerable patients (with chronic diseases), geriatric patients (involved in a health care network for people aged 60 or older), and socially vulnerable patients (involved in a migrant health program or a mobile outpatient community care center) in June 2020. Data on sociodemographic factors, forgoing health care, and anti-SARS-CoV-2 antibodies were collected. Of the patients, 38.5% reported forgoing health care. Forgoing health care was more frequent for younger patients, women, patients with a low level of education, and patients with a chronic disease (p < .001). There was no significant association between the presence of anti-SARS-CoV-2 antibodies and forgoing health care (p = .983). As the decrease in routine management of patients might have important and unpredictable adverse health consequences, avoiding delayed health care is crucial.

Relationship between benzodiazepine prescription, aggressive behavior, and behavioral disinhibition: a retrospective study in a Swiss prison.

BACKGROUND: Benzodiazepines are commonly prescribed in prisons amidst the controversies surrounding their potential role in causing behavioral disinhibition and aggressive behavior and their association with use and trafficking of illicit and addictive substances. The present study aimed to (1) ascertain the relationship between benzodiazepine prescription (including their dosage and duration of use) and aggressive behavior and behavioral disinhibition in prison and (2) investigate whether there was an association between benzodiazepine prescription, (including their dosage and duration of use) and using and trafficking illicit and addictive substances during imprisonment. METHODS: Data were extracted from the electronic database of an "open" Swiss prison (n = 1206, 1379 measures) over a 5-year period (2010-2015). Measures included benzodiazepine prescription, duration of benzodiazepine use and mean dosage, and punishable behaviors (physical and verbal aggression, disinhibited but not directly aggressive behaviors, property damage or theft, substance-related offenses, and rule transgression). We assessed the relationship between benzodiazepine prescription and punishable behaviors after propensity score matching. Logistic regressions were also used to test the relationship of benzodiazepine use duration and dosage with punishable behaviors among participants who received benzodiazepines. RESULTS: After propensity score matching, benzodiazepine prescription was not significantly associated with any punishable behavior. Among detained persons who took benzodiazepines, there was no significant association of dosage and duration of use with offenses involving illicit or addictive substance use or trafficking. CONCLUSIONS: Our study did not empirically support the occurrence of increased aggressive or disinhibited behaviors or increased risk of substance abuse in detained persons who received benzodiazepines in prison. This suggests a need to reconsider restrictions in prescribing benzodiazepines in the prison setting.

Immunoglobulin deficiencies in treated patients suffering from rheumatoid arthritis.

Immunoglobulins and antibodies to immunoglobulins (autoimmunoglobulins) have been identified to be implicated in the pathogenesis of rheumatoid arthritis (RA). Immunoglobulin deficiencies have been suggested to account for the increased risk of infections in RA patients. This study was carried out to determine the prevalence of immunoglobulin deficiencies in patients with RA and the identification of putative contributing factors. Immunoglobulin levels in blood samples of patients with rheumatoid arthritis were evaluated by an immunonephelometric assay. Demographic and disease related data (including age, sex, smoking habits, disease duration and activity, inflammatory markers) were assessed, and associations were identified by regression analysis. 539 patients were enrolled between 2011 and 2013. The most common immunoglobulin (Ig) deficiencies were those of IgM (24.5%) and IgG (19.9%). Most frequent deficiencies of subclasses were observed for IgG1 (42.3%), followed by IgG4 (10.4%), IgG2 (7.2%), and IgG3 (5.4%). Regression analyses revealed that deficiencies of IgM, IgG, IgG1, and IgG2 were more prevalent in older patients. In addition, smoking was associated with IgG2 deficiency, and IgA deficiency was associated with female sex. Occurrence of infections was significantly increased in patients with IgG, IgG2, and IgG4 deficiencies. RA patients displayed high rates of IgG and IgM deficiencies. In consequence, the assessment of immunoglobulin status should precede the application of immune modulating drugs to prevent a potential risk of infectious diseases. Prospective studies are needed to investigate the influence of immune modulating drugs on IgG and IgG subclass levels.

COVID-19-The Case for Rethinking Health and Human Rights in Prisons.

This article considers health and human rights implications for people deprived of liberty during the COVID-19 crisis. The health risks of incarceration for individual and community health, particularly in overcrowded and underresourced prisons and detention centers, are well known, but with the COVID-19 pandemic have become a public health emergency.Physical distancing in prisons is hardly manageable, and protective means are poor or lacking. Emergency releases have been shown to be feasible in terms of public safety but lack sustainability in reducing the number of people living in detention, and, globally, only a small proportion of them have been released. Without controlling the infection inside prisons, global efforts to tackle the spread of the disease may fail. People living in detention are not only more vulnerable to infection with COVID-19 but they are also especially vulnerable to human rights violations induced by inappropriate restrictions under the pretext of infection control. Therefore, alternatives for detention should be promoted and the number of incarcerated people radically decreased.This article calls on policymakers and all professionals involved in public health and criminal justice not to waste the opportunities provided by the crisis but to act now.

COVID-19 Inmate Risk Appraisal (CIRA): development and validation of a screening tool to assess COVID-19 vulnerability in prisons.

OBJECTIVES: To develop and validate a screening tool designed to identify detained people at increased risk for COVID-19 mortality, the COVID-19 Inmate Risk Appraisal (CIRA). DESIGN: Cross-sectional study with a representative sample (development) and a case-control sample (validation). SETTING: The two largest Swiss prisons. PARTICIPANTS: (1) Development sample: all male persons detained in Pöschwies, Zurich (n = 365); (2) Validation sample: case-control sample of male persons detained in Champ-Dollon, Geneva (n = 192, matching 1:3 for participants at risk for severe course of COVID-19 and participants without risk factors). MAIN OUTCOME MEASURES: The CIRA combined seven risk factors identified by the World Health Organization and the Swiss Federal Office of Public Health as predictive of severe COVID-19 to derive an absolute risk increase in mortality rate: Age ≥60 years, cardiovascular disease, diabetes, hypertension, chronic respiratory disease, immunodeficiency and cancer. RESULTS: Based on the development sample, we proposed a three-level classification: average (<3.7), elevated (3.7-5.7) and high (>5.7) risk. In the validation sample, the CIRA identified all individuals identified as vulnerable by national recommendations (having at least one risk factor). The category "elevated risk" maximised sensitivity (1) and specificity (0.97). The CIRA had even higher capacity in discriminating individuals vulnerable according to clinical evaluation (a four-level risk categorisation based on a consensus of medical staff). The category "elevated risk" maximised sensitivity and specificity (both 1). When considering the individuals classified as extremely high risk by medical staff, the category "high risk" had a high discriminatory capacity (sensitivity =0.89, specificity =0.97). CONCLUSIONS: The CIRA scores have a high discriminative ability and will be important in custodial settings to support decisions and prioritise actions using a standardised valid assessment method. However, as knowledge on risk factors for COVID-19 mortality is still limited, the CIRA may be considered preliminary. Underlying data will be updated regularly on the website (http://www.prison-research.com), where the CIRA algorithm is freely available.