1. Prison Psychiatry

2.  It is basically a primarily legal philosophical and political problem whether or not mentally disordered persons "belong" in prison.  Countries applying the construct of criminal responsibility or incompetence to stand trial can prevent mentally disordered persons from being imprisoned.  Secure confinement can then be ordered in a forensic psychiatric institution, if necessary.

3.  Of course this principle does not prevent people from becoming mentally unwell when put in a prison environment, nor does the presence or a history of mental disorder automatically results in the absence of criminal responsibility.  The still high prevalence of mental disorders in prisoners has been impressively demonstrated in more recent surveys.

4. S.Fazel, K. Seewald Severe mental illness in 33588 prisoners worldwide: systematic review and meta-regression analysis The British Journal of Psychiatry 2012; 200: 364-373  109 Studies from 24 Countries 1966-2010  33588 prisoners (average 30,5 years old)  Among them 28361 (=84,4%) Men  Men:3,6% psychotic disorder 10,2% „major depression“  Women:3,9% psychotic disorder 14,1% „major depression“

5. S.Fazel, J. Danesh Serious mental disorder in 23000 prisoners: a systematic review of 62 surveys Lancet 2002; 359: 545-550  62 Studies from 12 western countries  22790 prisoners (average 29 years old)  Among them 18530 (=81%) Men  Men: 3,7% psychotic disorder 10% major depression 65% personality disorder  Women: 4% psychotic disorder 12% major depression 42% personality disorder

6. Forensic patients (Old West-German states including West Berlin), Prisoners and Patients in general psychiatric hospitals (Old West-German states including West Berlin 1970-1990, as of 1995 unified Germany) Forensic psychiatry according to §§ 63,64 German Penal Code In comparison Year Psychiatric hospital (§63) Detoxification centre (§64) Prison Gen. Psychiat. (availabl.beds) 1970422217935209117596 1975349418334271115922 1980259363242027108904 198524729904821294624 1990248911603917870570 1995290213734651663807 2000409817746079854802 2005564024736353353021(2004) 2010656930216069353061 (2008) Source: Federal Office of Statistics, Wiesbaden, Germany

7.  In comparison to the general population, prisoners have an increased risk of suffering from a mental disorder that transcends countries and diagnoses.  Psychotic disorders increase the risk of suicide, which as a rule is considerably higher in prisoners than in the general population. Suicide is the leading cause of death in penal institutions, especially during the early stage of confinement.  For mentally disordered prisoners, there is often an increased risk of being victimized, as well as the potential for high rates of decompensation and deterioration.

8.  If one accepts that mentally disordered prisoners should be treated in penal institutions (possibly even hospitalized), then the principle of "equivalence" with therapeutic levels of care in the community, should prevail in the care of incarcerated mentally disordered persons.  It is doubtful whether the majority of prisoners with mental disorders receive appropriate care such as that mandated by the European Convention on Human Rights and other international charters.  The United Nations International Resolutions (esp. Standard minimum rules for the treatment of prisoners), the Council of Europe (esp. Recommendation No R (98) 7 on the Ethical and organizational aspects of health care in prison), the World Medical Association (esp. Declaration of Tokyo 1975), the World Psychiatric Association (esp. Declaration of Hawaii 1977) as well as the Oath of Athens (International Council of Prison Medical Services) touched prison psychiatry but lack of more detailed guidelines in dealing with mentally disordered prisoners.

9. Standards  In-prison treatment has to address inmate-specific problems and circumstances, including post-release services. This includes both an orientation to the function level and the severity of psychiatric symptoms.  The high prevalence of mental disorders speaks in favor of the standardized application of diagnostic screening instruments as a component of the admission procedure in prison.  In accordance with the principle of equivalence, every prisoner suffering from a mental disorder should receive appropriate treatment equal to the care that such a patient would receive when not in prison.  Prisoners suffering from serious mental disorder should be kept and cared for in a hospital facility which is adequately equipped and possesses appropriately trained staff.  Inpatient treatment is not restricted to distribution of medication for mentally disordered locked up 23 hours the day in their cell but infers the availability of a multidisciplinary psychiatric team comprising psychiatrists, psychologists, psychotherapists, occupational therapists and counsellors.

10.  In those cases where the use of close confinement of mentally disordered patients cannot be avoided, it should be reduced to an absolute minimum and be replaced with one-to-one continuous nursing care as soon as possible.  Consent to medical treatment should also be sought from a patient suffering from a mental disorder, insofar as his/her ability to understand is not impaired.  Furthermore, obtaining the patient’s consent, especially in the case of psychiatric pathology, is essential if a “therapeutic alliance” is to be formed likely to make the patient more committed to the medical treatment offered.