Self-harm among inmates of the Berlin prison system.

Introduction: Self-harming behavior in prisoners is a prevalent phenomenon, with international studies estimating a 4% prevalence rate. However, studies on self-injurious behavior in the German prison system are currently lacking. Therefore, our study aims to conduct an initial assessment. Methods: The Criminological Service for the Berlin Prison System distributed questionnaires on incidents of self-harm to all Berlin prisons, except for juvenile detention centers. The questionnaires were supplemented with medical data, such as psychiatric diagnoses and medication. Results: 62 questionnaires were returned, which could be attributed to 52 inmates. Compared to the average population in the Berlin prison system, the study sample exhibited variations in age, gender distribution and nationality. 94% of the inmates received a psychiatric diagnosis. Two-thirds of the male inmates had substance use disorders, while 83% of the female inmates had emotionally unstable personality resp. borderline disorders. Prior to self-harm, 87% of the inmates were administered psychiatric medication. Discussion: Our study found similarities between the study population and international studies in the distribution of certain characteristics. We assume that many of the postulated risk factors can also apply to Berlin prisoners. However, the study is limited by the small number of cases and the absence of a control group.

Erratum: Six Nations: a clinical scenario comparison of systems for prisoners with psychosis in Australia, Bolivia and four European nations - ERRATUM.

[This corrects the article DOI: 10.1192/bji.2022.16.].

Mental health intervention research in Latin American correctional settings: A scoping review.

BACKGROUND: The Latin American prison population has grown faster than anywhere else globally over the past two decades, reaching a total of 1.7 million people at any given time. However, research on mental health prevention and treatment interventions in Latin American prisons remains scarce. AIMS: This study aimed to systematically review and synthesize research on prison mental health interventions conducted in the region. METHODS: We used a two-stage scoping review design guided by the JBI Manual for Evidence Synthesis. Searches took place in December 2021 in nine databases using descriptors and synonyms. First, all prison mental health research in Latin America was retained. Secondly, using title and abstract screening, all research possibly related to interventions was retained for full text evaluation. Studies reporting interventions were assessed by country, language, institution, population, intervention type, intervention focus and outcomes. RESULTS: N = 34 studies were included in this review. These were 13 case reports, seven expert consensus papers and 14 quantitative studies (four randomized controlled trials, nine cohort studies, one quasi-experimental study). Fourteen interventions were targeted at promoting prosocial behavior, seven studies each aimed to improve mental health and to treat substance use disorders. Six studies involved the treatment of sexual offending behavior, and 3 focused on reducing criminal recidivism. Psychoeducation (n = 12) and motivational interviewing (n = 5) were the most frequent intervention types studied. Promising data from trials showed that anger management, depression, substance use and reoffending could be successfully addressed through interventions. CONCLUSIONS: Implementation and effectiveness research of mental health interventions in Latin American prisons is scarce. Addressing mental health, substance use and prosocial behavior outcomes should be considered in future research. There is a particular dearth of controlled trials describing quantifiable outcomes.

Availability of opioid agonist treatment and critical incidents in Forensic Clinics for Dependency Diseases in Germany.

Background: Prevalence of substance use disorders, especially opioid use disorders, is high in patients admitted into forensic psychiatric settings. Opioid agonist treatment is a safe, well-established, and effective treatment option for patients that suffer from opioid dependence. Surprisingly, data on the availability and practice of opioid agonist treatment (OAT) options in German Forensic Clinics for Dependency Diseases is rare. Furthermore, essential data on the prevalence of critical incidents such as violent behavior, relapse, or escape from the clinic are missing for this particular treatment setting. Materials and methods: We conducted an observational study on all forensic addiction treatment units in Germany (Sect. 64 of the German Criminal Code). A questionnaire on the availability and practice of OAT was sent to all Forensic Clinics for Dependency Diseases in Germany. Following items were assessed: availability and the total number of patients that received an OAT in 2018, available medication options, specific reasons for start and end of OAT, number of treatments terminated without success, number of successful treatments, and critical incidents such as violent behavior, relapse, escape and reoffending. We compared the forensic clinics that offered OAT with those that did not offer this treatment option. The data were analyzed descriptively. Mean and standard deviation was calculated for metric scaled variables. For categorical variables, absolute and relative frequencies were calculated. The two groups (OAT vs. Non-OAT institutions) were compared concerning the given variables by either using Fishers exact test (categorical variables), t-test (normally distributed metric variables), or Wilcoxon-test (metric variables not normally distributed). Results: In total, 15 of 46 Forensic Clinics for Dependency Diseases participated in the study (33%). In total, 2,483 patients were treated in the participating clinics, 18% were relocated into prison due to treatment termination, and 15% were discharged successfully in 2018. 275 critical incidents were reported: violence against a patient (4%), violence against staff (1.6%), escape (4.7%) and reoffending in (0.5%). In seven clinics treating 1,153 patients, an OAT was available. OAT options in forensic clinics were buprenorphine/naloxone, buprenorphine, methadone, and levomethadone. Regarding critical incidents and successful discharge, no differences were detected in the clinics with or without an OAT. In the clinics that offered an OAT, we found a significantly higher rate of treatment termination without success (p < 0.007) in comparison to clinics without an OAT program. Ninety-nine patients received an OAT, and this treatment was ended due to illegal drug abuse (57%), refusal to give a urine drug sample (71%), and cases where the OAT was given away to other patients (85%). Conclusion: In Forensic Clinics for Dependency Diseases in Germany, OAT is not available in every institution, and thus, access is limited. Critical incidents such as violent behavior against staff or patients and escape are not uncommon in these forensic treatment settings. Further studies are needed to enhance the understanding of OAT practice and the risks for patients and staff.

[Suicides in the German prison system: frequency, risk factors, and prevention]. / Suizide im deutschen Strafvollzug: Häufigkeit, Risikofaktoren und Prävention.

Prisoners have a high risk of dying by suicide and the highest suicide rates are recorded among prisoners on remand. A death by suicide is the most common single cause of death in German correctional institutions. This narrative overview first describes the prison population and its general healthcare needs by paying particular attention to psychiatric and substance use disorders. The main section attends to the prevalence, causes, and risk factors of prison suicide. Suicide prevention measures are presented.As in all parts of the world, the proportion of young men among prisoners in Germany is very high (94% in 2020). Most prisoners are young or middle-aged. The average annual suicide rates among men (105.8/100,000) and women (54.7/100,000) in German prisons are similar to those of most countries in the European Union (full census 2000-2011). Suicide rates among male German prisoners declined continuously from 2000-2013, regardless of age. In contrast, they increased among female prisoners; the reasons for this are not known. Evidence suggests that psychiatric disorders have not been identified.Important suicide prevention measures include shared accommodation and avoidance of solitary confinement, for example by offering work. In addition, validated German-language screening instruments are available to detect suicide risk at an early stage. For effective prison suicide prevention, identifying high-risk individuals, offering appropriate suicide prevention interventions, and developing team-based interventions among prison staff are required.

Prevalence of Opioid Dependence and Opioid Agonist Treatment in the Berlin Custodial Setting: A Cross-Sectional Study.

BACKGROUND: Among people living in detention, substance use is highly prevalent, including opioid dependence. Opioid agonist treatment (OAT) has been established as an evidence-based, first-line treatment for opioid dependence. Despite high prevalence of opioid dependence, conclusive data regarding its prevalence and the OAT practice in German prisons is scarce; rather, the existing data widely diverges concerning the rates of people in detention receiving OAT. MATERIALS AND METHODS: We conducted a cross-sectional survey of all detention facilities in Berlin. On the date of data collection, a full census of the routine records was completed based on the medical documentation system. For each opioid dependent individual, we extracted sociodemographic data (i.e., age, sex, and non-/German nationality, whether people experienced language-related communication barriers), information about OAT, comorbidities (HIV, hepatitis C, schizophrenia), and the detention center, as well as the anticipated imprisonment duration and sentence type. The data was first analyzed descriptively and secondly in an evaluative-analytical manner by analyzing factors that influence the access to OAT of people living in detention. RESULTS: Among the 4,038 people in detention in the Berlin custodial setting under investigation, we identified a 16% prevalence of opioid dependence. Of the opioid-dependent individuals, 42% received OAT; 31% were treated with methadone, 55% were treated with levomethadone, and 14% were treated with buprenorphine. Access to OAT seemed mainly dependent upon initial receipt of OAT at the time of imprisonment, detention duration, the prisons in which individuals were detained, German nationality, and sex. The overall prevalence of HIV was 4-8%, hepatitis C was 31-42%, and schizophrenia was 5%. CONCLUSIONS: The prevalence of opioid dependence and access to OAT remains a major health issue in the custodial setting. OAT implementation must be especially intensified among male, non-German, opioid-dependent individuals with a short detention period. Treatment itself must be diversified regarding the substances used for OAT, and institutional treatment differences suggest the need for a consistent treatment approach and the standardized implementation of treatment guidelines within local prison's standard operating procedures. Testing for infectious diseases should be intensified among opioid-dependent people living in detention to address scarcely known infection statuses and high infection rates.

Psychosis in German prisoners: Comparison of the clinical appearance of psychotic disorder of an imprisoned population with a not detained community group.

Surveys confirm risk factors for the incarceration of patients with psychosis including homelessness and comorbidity. There is also agreement that severe psychosis can lead to violence. Data describing prisoners with psychosis in Germany are scarce. We aimed to compare patients with psychosis in a prison hospital and patients with psychosis in a community hospital. Demographic data were collected, as well as comorbidity in the form of substance dependence and a psychiatric assessment using the German version of the 18-item Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS). In the prison hospital group more patients were homeless (17 versus 2%) and non-German (36 versus 4%). There were also more patients with substance dependence or abuse in the prison hospital group. The total scores of BPRS and PANSS were lower in the prison hospital group (BPRS, 43.8 versus 51.2; PANSS, 71.5 versus 83.7). We assume that social disintegration for mentally disturbed offenders prior to incarceration hindered effective treatment. To avoid further social disintegration and possible further deterioration of mental health status of released offenders, which may lead to reoffending after imprisonment, discharge management after release from prison should be improved.

Applicability of two violence risk assessment tools in a psychiatric prison hospital population.

The risk of violent behavior is known to be higher for patients who suffer from a severe mental disorder. However, specific prediction tools for clinical work in prison psychiatry are lacking. In this single-center study, two violence risk assessment tools (Forensic Psychiatry and Violence Tool, "FoVOx," and Mental Illness and Violence Tool, "OxMIV") were applied to a prison hospital population with a primary psychotic or bipolar disorder and subsequently compared. The required information on all items of both tools was obtained retrospectively for a total of 339 patients by evaluation of available patient files. We obtained the median and inter-quartile range for both FoVOx and OxMIV, and their rank correlation coefficient along with 95% confidence intervals (CIs)-for the full cohort, as well as for cohort subgroups. The two risk assessment tools were strongly positively correlated (Spearman correlation = 0.83; 95% CI = 0.80-0.86). Such a high correlation was independent of nationality, country of origin, type of detention, schizophrenia-spectrum disorder, previous violent crime and alcohol use disorder, where correlations were above 0.8. A lower correlation was seen with patients who were 30 years old or more, married, with affective disorder and with self-harm behavior, and also in patients without aggressive behavior and without drug use disorder. Both risk assessment tools are applicable as an adjunct to clinical decision making in prison psychiatry.

Identifying Violent Behavior Using the Oxford Mental Illness and Violence Tool in a Psychiatric Ward of a German Prison Hospital.

Background: Although there is evidence that individuals who suffer from severe mental disorders are at higher risk for aggressive behavior, only a minority eventually become violent. In 2017, Fazel et al. developed a risk calculator (Oxford Mental Illness and Violence tool, OxMIV) to identify the risk of violent crime in patients with mental disorders. For the first time, we tested the predictive validity of the OxMIV in the department of psychiatry at the prison hospital in Berlin, Germany, and presented findings from our internal validation. Materials and Methods: We designed a cohort study with 474 patients aged 16-65 years old who met the inclusion criteria of schizophrenia-spectrum or bipolar disorder and classified the patients into two groups: a violent group with 191 patients and a nonviolent group with 283 patients. Violence was defined as the aggressive behavior of a patient with the necessity of special observation. We obtained all the required information retrospectively through patient files, applied the OxMIV tool on each subject, and compared the results of both groups. Sensitivity, specificity, and positive/negative predictive values were determined. We used logistic regression including variable selection and internal validation to identify relevant predictors of aggressive behavior in our cohort. Results: The OxMIV score was significantly higher in the violent group [median 4.21%; Interquartile range (IQR) 8.51%] compared to the nonviolent group (median 1.77%; IQR 2.01%; p < 0.0001). For the risk of violent behavior, using the 5% cutoff for "increased risk," the sensitivity was 44%, and the specificity was 89%, with a positive predictive value of 72% and a negative predictive value of 70%. Applying logistic regression, four items were statistically significant in predicting violent behavior: previous violent crime (adjusted odds ratio 5.29 [95% CI 3.10-9.05], p < 0.0001), previous drug abuse (1.80 [1.08-3.02], p = 0.025), and previous alcohol abuse (1.89 [1.21-2.95], p = 0.005). The item recent antidepressant treatment (0.28 [0.17-0.47]. p < 0.0001) had a statistically significant risk reduction effect. Conclusions: In our opinion, the risk assessment tool OxMIV succeeded in predicting violent behavior in imprisoned psychiatric patients. As a result, it may be applicable for identification of patients with special needs in a prison environment and, thus, improving prison safety.

Suicide in Older Prisoners in Germany.

As in many countries, the numbers of older prisoners are rising in Germany, but scientific information on this group is scarce. For the current study, a survey was used that included all prison suicides in Germany between the years of 2000 and 2013. Suicide rates of the elderly prisoners exceeded the suicide rates of the general population and the same age group. We observed a continuous decrease in the suicide rate of elderly prisoners. When compared to the younger suicide victims in prison, significantly more elderly suicide victims were: female, of German nationality, remand prisoners, or serving a life sentence. In Germany, elderly prisoners are a vulnerable subpopulation of the prison population. Higher suicide rates than in the same age group in the general population indicate unmet needs regarding mental disorders and their specific treatment.

Foreign National Patients in German Prison Psychiatry.

INTRODUCTION: Over the past few years, the share of foreign national prisoners in the European and American justice systems has increased at a disproportionately high rate, yet studies on mental health issues among this diverse group are rare. Recent research suggests a range of factors leading to mental health vulnerability in foreign national prisoners, including language barriers, isolation, cultural misunderstanding, and legal standing. Relevant findings of topic-related studies indicate that under-referral to mental health services due to missed or misinterpreted symptoms is a major risk for foreign national prisoners. AIMS: We aimed to investigate the disparities regarding the percentage of foreign national patients who were treated in high-security hospitals compared to the psychiatric ward of prison hospitals-after adjusting for diagnosis, age, marital status, and substance abuse. We hypothesized that foreign national patients were underrepresented in compulsory, high-security mental health care. We also aimed to explore citizenship-related institutional disparities concerning diagnoses and self-harmful behavior. METHOD: From 2010 to 2015, data collected from high-security hospitals in the federal state of Baden-Wurttemberg and the psychiatric ward of a Berlin prison hospital was evaluated by comparing nationality, diagnosis, and self-harm using Fisher's exact test and χ²-test. The odds ratios for citizenship-related differences in diagnosis and institution of treatment were evaluated by using logistic regression. RESULTS: Mentally ill foreign national patients were significantly less likely to be treated in high-security hospitals rather than prison hospital psychiatry (adjusted for diagnosis, age at admission, marital status, and substance abuse; adjusted OR = 0.5). Foreign nationals and Germans in prison hospital psychiatry showed no significant disparities in diagnosis; however, in high-security hospitals, foreign nationals were more likely to have been diagnosed with schizophrenia/psychotic or neurotic/stress-related disorders and were less likely to have been diagnosed with personality disorders than German patients. Additionally, foreign nationals were more likely to commit self-harm than Germans in prison hospital psychiatry, but significant citizenship-related differences could not be verified in high-security hospital patients. CONCLUSION: Treatment conditions of foreign national patients in prison psychiatry must be improved. To achieve this, the psychiatric assessment and (mental) health-related aspects of these patients should be further investigated.

Prison Suicide in Comparison to Suicide Events in Forensic Psychiatric Hospitals in Germany.

Background: There is limited international as well as national research on suicide events in prisons and in forensic psychiatric hospitals. This retrospective study compares completed suicide events within these two high-risk populations in state institutions over a time period of 5 years from 2000 to 2004. Material and Methods: Data was collected through a nationwide survey: all forensic psychiatric hospitals within Germany were contacted via postal mail and received a questionnaire concerning the suicide events from 2000 to 2004. All federal lands of Germany were similarly assessed by a survey endorsed by the respective federal ministries of justice. All prison institutions (100%) participated in the survey, while 84% (53 units) of the forensic psychiatric hospitals nationwide contributed. A comparative statistical analysis was conducted using Fisher's exact test or the Mann-Whitney U-test (age). A multivariate logistic regression analysis was done to assess adjusted effects. For the Kaplan-Meier analysis, the months until suicide were analyzed followed by a Cox-regression analysis. Results: There was no statistically significant difference between the mean suicide rate in forensic psychiatric hospitals (123/100.000, 95% confidence interval: [0.00103, 0.00147]) and in the prison system (130/100.000, 95% confidence interval: [0.00109, 0.00154]). Patients who committed suicide in the forensic hospitals were, in comparison to the prison system, more likely to have committed a violent offense and have had a prior history of suicide attempts. The duration from admission into the institution to the suicide event was significantly shorter in the prison group. Also, younger people commited suicide earlier during their stay in a forensic psychiatric hospital or prison. Conclusions: While the results suggest a necessity to optimize data collection in the prison system (prior suicide events and history of mental disorder), it is important to discuss the current discharge arrangements within the forensic hospitals.

Implementation of a Suicide Risk Screening Instrument in a Remand Prison Service in Berlin.

In the present study, we examined the effects of implementing the suicide risk screening instrument SIRAS in a pre-trial detention facility for men in Berlin. Within a period of 3 months, all newly arriving prisoners were screened (n = 611) by social workers or prison officers. Cases of elevated suicide risk were immediately referred to a psychologist or medical staff the same day. Follow-up over a 6-month period showed that 14% of all incoming prisoners were classified as high-risk individuals. These individuals received significantly more psychological and psychiatric treatment and were significantly more likely to be accommodated in crisis intervention rooms and emergency community accommodation (shared prison cells). In addition, it was found that despite the increased amount of treatment in the high-risk group, the number of specific measures did not increase significantly compared to the pre-implementation phase (N = 1,510).

Medicine in the Penal System.

BACKGROUND: Infectious diseases, substance dependencies, and dental diseases are the most important health problems affecting incarcerated persons. In Germany, for example, prisoners are 48 to 69 times more likely to be infected with the hepatitis C virus (HCV) than the general population, and 7 to 12 times more likely to be infected with the human immunodeficiency virus (HIV). The prevalence of mental illnesses is also markedly higher in the incarcerated than in the general population. METHODS: This review is based on pertinent publications retrieved by a selective search in two databases (PubMed and Google Scholar) for any of the terms "health care," "primary health care," "mental health care"; "infectious disease," "opioid maintenance treatment," and "severe mental disorder" in conjunction with "prison," "jail," "detention," and "incarceration." RESULTS: Among prisoners in German prisons, approximately 20% consume heroin, 20-50% suffer from alcohol dependency and abuse, and 70-85% smoke. The prevalence of tuberculosis in German prisons in 2002 was 0.1%. The provision of needles to incarcerated persons has a preventive effect on infection with hepatitis C, hepatitis B, and HIV, yet programs of this type have been discontinued in most penal facilities. In a systematic review, psychotic disorders were found in 3.6% (95% confidence interval [CI]: [3.1; 4.2]) of male inmates and 3.9% [95% CI: 2.7; 5.0] of female inmates. 25% of incarcerated persons suffer from attention-deficit-hyperac- tivity disorder. Persons recently released from prison have an above average mortality, largely due to drug intoxication. CONCLUSION: An analysis of medical prescribing data reveals deficiencies in the provision of HCV treatment to all affected persons and in the provision of substitution treatment to persons with opiate dependency. In view of the known risks associated with imprisonment, greater emphasis should be placed on the provision of treatment for infectious diseases, substance dependencies, and mental illness, both in prison and in outpatient care after release.

Prison suicide in female detainees in Germany 2000-2013.

Specific risk factors for suicide among female prisoners were examined using an exhaustive sample of all suicides in German prisons between 2000 and 2013. The rate of prison suicide was lower among female (53,5/100,000) than among male prisoners (101/100,000). Differences between the genders regarding the various risk factors for prison suicide are few. Significant differences were observed only for bullying among men and higher percentages of drug withdrawal syndrome among women. Factors specific to the prison setting that contribute to suicide risk in incarcerated women should be examined.

Paraphilias.

PURPOSE OF REVIEW: The concept of paraphilia still carries an 'unwanted burden' of sexual norms because the pathologization of some sexual practices as paraphilic disorders is still based on the assumption that normal sexuality should be genitally organized with the aim of reproduction. The aim of this review is to give an impression of the ongoing discussion about the changes introduced with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the results of recent research in this area. RECENT FINDINGS: The release of DSM-5 in the spring of 2013 introduced a distinction between paraphilias and paraphilic disorders, implying a destigmatization of consenting adults engaging in unusual sexual behaviour. According to DSM-5 diagnostic criteria, paedophilic disorder is the only paraphilic disorder without an 'in remission' and an 'in a controlled environment' specifier. Today, antiandrogen treatment is offered to sex offenders in many countries as an additional treatment strategy alongside psychotherapy. SUMMARY: The introduction of DSM-5 offers the possibility to distinguish between paraphilia and paraphilic disorders. The aetiology of paraphilias is still unknown. Paraphilias are much more common in men than in women, but the reasons for this difference remain unknown. So far there is no clear consent on the best therapeutic approach for a paraphilic disorder.

Prison suicides in Germany from 2000 to 2011.

In many countries, suicide is the most frequent cause of prison deaths; moreover, the respective national penal suicide rates are consistently several times higher than the suicide rates in the general population. To assess the situation in German prisons, an assessment of all suicides in German prisons by means of a survey was carried out for the time from 2000 to 2011. The mean rate per year of prison suicides in Germany from 2000 to 2011 was 105.8 per 100,000 male inmates and 54.7 per 100,000 female inmates. Male prisoner suicide rates significantly declined during the period under investigation; no significant trend was evident for female prisoners in pre-trial detention but a noteworthy increase was apparent in the suicide rate of female sentenced prisoners. A significant positive relationship can be demonstrated between occupation density and the suicide rate for both men and women. These results should be taken as a challenge for further research on the reasons for the unexpected increase of suicide rate in female sentenced prisoners and as well on the effect of population density on prison suicide rate.

Prison psychiatry.

PURPOSE OF REVIEW: Prison psychiatry is a secluded area of the psychiatric care system, which in fact often provides treatment for those who do not have access to community-based healthcare systems. The aim of this review is to give an impression of the special challenges of psychiatric work behind bars and to emphasize current trends in prison psychiatry. RECENT FINDINGS: In prisoners, mental disorders are more common than in the general population. There is evidence that prison suicide rates do not reflect general population suicide rates, suggesting that variation in prison suicide rates possibly also reflects differences in the provision of psychiatric care. Good transitional preparation preceding release seems to be necessary to reduce the risk of poor health outcome, but is hard to achieve. Up to now, there is no clear decision on whether it is useful or possible to treat adult prisoners with attention-deficit/hyperactivity disorder with stimulants. SUMMARY: Prison psychiatry has to deal with a disproportionate burden of psychiatric disease in prisoners. Adequate psychiatric treatment options may reduce suicide behind bars. Further research should focus on the special needs of individuals who are out of reach of the conventional community-based health system.