[Healthcare research in forensic commitment or poking around in the dark : Consensus paper on the necessity for more uniform and better data]

[The situation in the German forensic commitment-Results of a survey by the DGPPN]

BACKGROUND AND OBJECTIVE

In German forensic psychiatry detention under Sections 63 and 64 of the German Penal Code have been repeatedly reformed over the past years; however, despite the most recent amendments to the law on detention, clinics and state authorities warn of insufficient capacities and worrying conditions. Media reports paint a defiant picture. At the same time, there is a lack of valid data that would allow an objective description of the situation in forensic psychiatry. Against this background the management of institutions in Germany has been surveyed.

MATERIAL AND METHODS

The survey was conducted as an online survey and sent to all 78 forensic hospitals in Germany. The survey covered topics such as structural data of the facilities, the occupancy and staffing situation, incidents, support from supervisory authorities and funding agencies, and patient characteristics. The results are presented descriptively.

RESULTS

Of the 78 facilities contacted, 45 (approximately 60%) participated at least partially in the survey. Many of the clinics (68.5%) complained of significant overcrowding. A clear lack of staff and rooms was reported, at the same time it was stated that patients do not receive adequate treatment. Approximately 1 in 5 patients have a length of stay for more than 10 years and one third of the clinics reported an increasing number of physical assaults by patients.

CONCLUSION

This overview shows that the forensic psychiatric hospitals are in very different but generally strained situations. A significant number of clinics are under great pressure. Financial, structural, spatial and personnel resources were described as insufficient to properly and professionally fulfill the legal mandate. The treatment standards presented by the DGPPN in 2017 are not met in many clinics.

Protocol for the CONNECT Study: A National Database and Prospective Follow-Up Study of Forensic Mental Health Patients in Germany

In Germany, the most frequently used legal section to order forensic mental health treatment is § 63 of the Penal Code (Strafgesetzbuch; StGB). This disposition is primarily aimed at individuals with major mental illnesses who are not fully responsible for a criminal act they committed. Despite evaluation and follow-up studies being conducted within individual hospitals or federal states we lack key epidemiological data on this patient group across the whole country. The present study aims to fill this gap by conducting an annual survey of all eligible forensic mental health hospitals to develop a database of basic clinical, legal and demographic data. Staff at participating hospitals will complete an online survey answering questions about individual patients using routinely collected hospital records. Over the duration of the study, eight-and-a-half years, we aim to collect data on approximately N = 6,450 patients. Alongside important clinical data, we will use official reconviction data at 3- and 6-year follow-ups to investigate the number and types of crimes committed by discharged patients. We aim to extend the scientific literature on factors associated with reconviction in the Risk-Needs-Responsivity model by also measuring the extent to which treatment engagement and programme completion during care predicts reconviction. This study protocol describes the background and theoretical framework for this study, its methods of data collection and analysis, and steps taken to ensure compliance with ethical and data protection principles.

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.

[Structural Features and Use of Coercive Measures in Forensic Psychiatry Throughout Germany]

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.