Medicine in the Penal System

Intramural Health Care Through Video Consultations and the Need for Referrals and Hospital Admissions: Retrospective Quantitative Subanalysis of an Evaluation Study

BACKGROUND

In comparison to the general population, prison inmates are at a higher risk for drug abuse and psychiatric, as well as infectious, diseases. Although intramural health care has to be equivalent to extramural services, prison inmates have less access to primary and secondary care. Furthermore, not every prison is constantly staffed with a physician. Since transportation to the nearest extramural medical facility is often resource-intensive, video consultations may offer cost-effective health care for prison inmates.

OBJECTIVE

This study aims to quantify the need for referrals to secondary care services and hospital admissions when video consultations with family physicians and psychiatrists are offered in prison.

METHODS

In 5 German prisons, a mixed methods evaluation study was conducted to assess feasibility, acceptance, and reasons for conducting video consultations with family physicians and psychiatrists. This analysis uses quantitative data from these consultations (June 2018 to February 2019) in addition to data from a sixth prison added in January 2019 focusing on referral and admission rates, as well as reasons for encounters.

RESULTS

At the initiation of the project, 2499 prisoners were detained in the 6 prisons. A total of 435 video consultations were conducted by 12 physicians (3 female and 7 male family physicians, and 2 male psychiatrists during the study period). The majority were scheduled consultations (341/435, 78%). In 68% (n=294) of all encounters, the patient was asked to consult a physician again if symptoms persisted or got worse. In 26% (n=115), a follow-up appointment with either the video consultant or prison physician was scheduled. A referral to other specialties, most often psychiatry, was necessary in 4% (n=17) of the cases. Only in 2% (n=8) of the consultations, a hospital admission was needed. Usually, hospital admissions were the result of unscheduled consultations, and the videoconferencing system was the method of communication in 88% (n=7) of these cases, while 12% (n=1) were carried out over the phone. Reasons for admissions were severe abdominal pain, hypotension, unstable angina or suspected myocardial infarction, or a suspected schizophrenic episode.

CONCLUSIONS

Most scheduled and unscheduled consultations did not require subsequent patient transport to external health care providers. Using telemedicine services allowed a prompt patient-physician encounter with the possibility to refer patients to other specialties or to admit them to a hospital if necessary.

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.

[Depressive symptoms in older prisoners : Results of two studies]

BACKGROUND

The proportion of prisoners aged 60 years and above is steadily rising both nationally and internationally. With advancing age the risk of developing physical and mental illnesses also increases. International studies have demonstrated a higher prevalence of mental disorders among older prisoners compared to the general population; however, there are few data on this, at least for Germany.

OBJECTIVE

Collation of empirical data on the presence of depressive symptoms among older prisoners.

MATERIAL AND METHODS

There were two independent cross-sectional studies conducted in North Rhine-Westphalia (NRW) and Rhineland-Palatinate (RLP), which included prisoners aged 50 years and above. In NRW a purely quantitative survey of depressive symptoms was carried out using the German version of the patient health questionnaire (PHQ-D) and in RLP the quantitative measurements using the general depression scale short form (ADS-K) were supplemented by qualitative interviews.

RESULTS

In total, data from 315 inmates were available for a joint analysis (222 from RLP, 93 from NRW). Among the prisoners in RLP 63.4% exhibited mild to clinically significant depressive symptoms, while in NRW this was the case for 46.2%. The treatment with antidepressants was carried out only in a small proportion in both federal states.

DISCUSSION

Both surveys showed a clearly elevated prevalence of depressive symptoms compared to the non-prison population. The results also suggest a need for optimization in terms of treatment. Particularly concerning potential interactions with somatic illnesses, efforts should be made to improve the diagnostics and treatment of depressive symptoms.

[Inpatient Treatment of Mentally Ill Prisoners in General Psychiatric Departments and Hospitals]

BACKGROUND

Inpatient psychiatric treatment of prisoners is organized differently in Germany, depending on the structural conditions of the federal state and prison. There are very few findings on the different possibilities of treatment and the view of the hospitals on this issue.

OBJECTIVES

Our aim was to gain an up-to-date picture of inpatient treatment of prisoners in general psychiatric departments and hospitals and the challenges these institutions face.

METHODS

We conducted an anonymous online survey of the frequency, extent, and challenges of inpatient treatment of prisoners. Approximately 460 chief physicians of German general psychiatric departments and hospitals were invited to participate in this survey. In addition to descriptive statistics, we calculated group differences by type of hospital and by subjective responsibility for inpatient care of prisoners.

RESULTS

A total of 74 chief physicians surveyed participated; 51.4% of the surveyed hospitals provided psychiatric inpatient treatment to prisoners in 2020. Group differences between the different types of hospitals were found only for the presence of anticipated anxiety among regular inpatients. Various differences were found between responsible and non-responsible hospitals, especially with regard to organizational aspects.

DISCUSSION

For the treatment of mentally ill prisoners, various organizational challenges as well as fears of hospital staff and fellow patients were mentioned by the participants. The type of hospital appears to play a subordinate role here, whereas the responsibility of the hospital for the inpatient treatment of mentally ill prisoners might be more decisive for anticipated concerns and barriers.

[Hepatitis C in prisons : Treatment and barriers to the elimination goals of the United Nations]

BACKGROUND

Despite general advances in the treatment of people with hepatitis C in Germany, it is unclear to what extent this also applies to specific key populations, such as prisoners.

METHODS

In a short survey conducted in June 2021, the ministries of justice in the federal states were asked about data collection and diagnostic methods as well as the prevalence of infections caused by the hepatitis C virus (HCV) and HCV treatment among prisoners in Germany. In addition, expert interviews were conducted regarding HCV treatment barriers and missed opportunities in prisons.

RESULTS

It is evident that there is no complete and comprehensive data collection within the ministries of justice. Prevention measures, such as opiate substitution therapy in prison, are available in all participating federal states. More specific offers and measures (e.g., razor and syringe exchange) are only found in a few cases and are sometimes subject to a charge. Experts point out that although treatment in prison generally complies with the equivalence principle: it is more difficult to reach the target group.

CONCLUSIONS

Comprehensive education and counselling on HCV treatment, consistent HCV testing and treatment, and preventive measures to avoid (re-)infection are important for successful HCV elimination in prisons.

Implementing interprofessional video consultations with general practitioners and psychiatrists in correctional facilities in Germany: results from a mixed-methods study

BACKGROUND

Adequate health care in correctional facilities is often limited by staff shortage, which entails time-consuming consultations with physicians outside of these facilities. Video consultations (VC) have been implemented in many different health care settings and may also be useful in correctional facilities. As part of a pilot project, synchronous VC were implemented in five correctional facilities in Germany in June 2018. The aim of this study was to describe the implementation process from the providers' perspective and to identify factors promoting or inhibiting the implementation process of VC with a focus on interprofessional collaboration between nursing staff and telemedicine physicians.

METHODS

As part of the mixed-methods evaluation of the pilot project, site visits to the five correctional facilities were carried out. Nursing staff from the five correctional facilities (n=49) and telemedicine physicians (n=10) were asked to participate in interviews and a questionnaire survey. Interviews were analyzed using qualitative content analysis and questionnaires were evaluated using descriptive statistical methods. The results from both data sources were integrated and discussed in the framework of Normalization Process Theory.

RESULTS

Interviews were conducted with 24.5% (n=12) of nursing staff and 20.0% (n=2) of telemedicine physicians, while questionnaires were returned by 22.5% (n=11) of nursing staff and 33.3% (n=3) of telemedicine physicians. VC with general practitioners and psychiatrists were perceived as an additional support during times when physicians were absent from the correctional facilities. Allocating telemedicine physicians to specific correctional facilities might further improve interprofessional collaboration with nursing staff during VC. Inhibiting factors comprised the lack of integrating nursing staff into the implementation process, increased workload, insufficient training and the implementation of VC at an inconvenient time.

CONCLUSIONS

To summarize, VC are a promising supplement to face-to-face health care in correctional facilities despite several limitations. These might be compensated by improving interprofessional cooperation and by integrating telemedicine physicians into local health care teams.

HIV and HCV among drug users and people living in prisons in Germany 2022: WHO elimination targets as reflected in practice

People who inject drugs (PWID) and prisoners are considered key populations at risk for human immunodeficiency virus (HIV) and/or Hepatitis C Virus (HCV). In 2016, the Joint United Nations Program on HIV/AIDS (UNAIDS) was implemented to eliminate HIV and AIDS by 2030 and the World Health Organization (WHO) presented the first strategy to eliminate viral hepatitis by 2030 as well. Following the objectives of the WHO and the United Nations, the German Federal Ministry of Health (BMG) presented the first integrated overall strategy for HIV and HCV in 2017. This article discusses the situation of PWID and prisoners in Germany with regard to HIV and HCV five years after the adoption of this strategy, on the basis of available data and against the background of the most recent practice in the field. In order to meet the elimination goals by 2030, Germany will have to improve the situation of PWID and prisoners substantially, mainly through the implementation of evidence-based harm reduction measures as well as the promotion of diagnosis and treatment in prisons and in freedom.

Diagnostic accuracy of screening algorithms to identify persons with active pulmonary tuberculosis at prison entry: protocol of a systematic review and network meta-analysis

Prison inmates are a high-risk group for tuberculosis (TB) infection and disease due to the increasing number of vulnerable fringe groups, risk factors (e.g., alcohol and drug addictions), contagious diseases (HIV, hepatitis), and their high-risk behavior. Compared to the general population, TB incidence and prevalence rates are significantly higher among prison inmates. Early identification of potentially infectious pulmonary TB (PTB) and targeted care of sick inmates are essential to effectively control TB within the prison system. The WHO recommends combining active and passive case-finding in prisons. No study has been published comparing the broad spectrum of screening tools using a diagnostic accuracy network meta-analysis (NMA). We aim to identify the most accurate TB case-finding algorithm at prison entry that is feasible in resource-limited prisons of high-burden TB countries and ensures continuous comprehensive TB detection services in such settings. Evidence generated by this NMA can provide important decision support in selecting the most (cost-) effective algorithms for screening methods for resource-limited settings in the short, medium, and long terms.

[Dermatological video consultations for German prisons : Experiences from teledermatological consultations 2020 to 2022]

BACKGROUND

With increasing shortage of medical personnel also in the medical care in German correctional facilities, telemedicine has been used since 2016, initially in projects and then for regular medical care. Since 2019, there is the possibility of dermatological expertise in regular video consultations.

OBJECTIVE

The benefits of an interdisciplinary online consultation with video and store and forward technology for dermatological issues are highlighted in terms of efficiency and feasibility.

MATERIAL AND METHODS

A descriptive analysis of 450 dermatological video consultations for German correctional facilities from February 2020 to July 2022 was carried out with respect to procedures, indications and demand.

RESULTS

Requests were made via a standardised form with optional photographs, which were sent via a secure cloud to the dermatology department in store and forward mode. The majority of cases could be presented live in a regular weekly video consultation and only single cases required an acute presentation within 24 h. The spectrum of skin diseases was comparable to cases presenting to a dermatology outpatient clinic. The interdisciplinary consultation management together with colleagues from general medicine enabled the transfer of the cases to the medical personnel at the correctional facility on site for follow-up and further medical procedures. Treatment could be started in all cases without delay.

CONCLUSION

Teledermatology represents an important contribution to medical care in German correctional facilities and the interdisciplinary cooperation saves time and resources in the presentation and treatment of skin diseases.

Stimulant abuse as a coping strategy-Forensic and criminal consequences of stimulant abuse for neuroenhancement

Pharmacological neuroenhancement (PN) describes the use of divergent psychoactive substances to enhance mental performance (cognition) without medical need. This kind of substance abuse takes place predominantly in stressful situations. Users implicitly-or even explicitly-describe this kind of drug abuse to be a coping strategy. Regarding the decision making process whether to use PN drugs or not, users indicate that legal aspects to be decisive. However, the legal situation has been neglected so far. To elucidate the German legal situation, PN substances have to be divided into over-the-counter drugs, prescription drugs and illegal drugs. Amphetamines have the highest cognition-enhancing potential, followed by modafinil and caffeine-containing substances. It is pointed out that the use of both freely available and prescription PN substances and narcotics without medical indication have so far been largely exempt from punishment under German law. However, individuals (physicians, bus and truck drivers, etc.) taking PN substances may expose others at risk due to wrong decisions (driving or treatment), errors based on side effects of the used substances. Therefore, the protection of life and health of others could legitimize criminal regulation.

[Suicides in the German prison system: frequency, risk factors, and prevention]

Gefangene haben ein hohes Suizidrisiko und die höchsten Suizidraten sind bei Untersuchungsgefangenen zu verzeichnen. Suizid ist die häufigste singuläre Todesursache in deutschen Gefängnissen. In diesem narrativen Übersichtsbeitrag werden zunächst die Gefängnispopulation und ihre allgemeine Gesundheitsversorgung beschrieben, wobei insbesondere auf psychiatrische und Substanzkonsumstörungen eingegangen wird. Der Hauptteil widmet sich der Prävalenz, den Ursachen und Risikofaktoren von Gefängnissuizid. Maßnahmen zur Suizidprävention werden dargestellt.

Der Anteil von Männern unter Gefangenen in Deutschland ist mit 94 % (2020) wie in allen Teilen der Welt sehr hoch. Die meisten Gefangenen sind jungen oder mittleren Alters. Die durchschnittlichen jährlichen Suizidraten bei Männern und Frauen in deutschen Gefängnissen entsprechen mit 105,8/100.000 bzw. 54,7/100.000 denen der meisten Länder in der Europäischen Union (Vollerhebung 2000–2011). Die Suizidraten bei männlichen deutschen Gefangenen sind in den Jahren 2000–2013 unabhängig vom Alter kontinuierlich zurückgegangen. Bei weiblichen Gefangenen stiegen sie dagegen an, wobei die Ursachen hierfür nicht bekannt sind. Es gibt Hinweise darauf, dass psychiatrische Erkrankungen nicht erkannt worden waren.

Wichtige suizidpräventive Maßnahmen sind die Unterbringung in Gemeinschaft und die Vermeidung von Isolation, beispielsweise durch das Angebot von Arbeit. Zudem stehen validierte deutschsprachige Screeninginstrumente zur Verfügung, um ein Suizidrisiko frühzeitig zu erkennen. Für eine wirksame Gefängnissuizidprävention bedarf es der Identifikation von Hochrisikopersonen, des Angebots geeigneter suizidpräventiver Maßnahmen sowie der Entwicklung teambezogener Maßnahmen beim Gefängnispersonal.

Seroprevalence and associated factors of HIV and Hepatitis C in Brazilian high-security prisons: A state-wide epidemiological study

The prevalence of hepatitis C virus (HCV) and the acquired immunodeficiency virus (HIV) is much higher in prisons than in community settings. Some explanatory factors for this burden include putative aspects of the prison environment, such as unprotected sexual relations and sexual violence, use of injectable drugs and syringe sharing. Nonetheless, efforts in better understanding the dynamics of both HCV and HIV are scarce in developing countries such as Brazil, which poses a risk not only to the inmates but to the community as well. In this investigation, we sought to determine the seroprevalence and sociodemographic and behavioral risk factors associated with HIV and anti-HCV antibodies among men detained at high-security institutions. This is an epidemiological, proportionally stratified observational study including 1,132 inmates aged 18 to 79 years-old (M_age = 32.58±10.18) from eleven high-security prisons located in the State of Paraná, Brazil. We found that HIV and anti-HCV prevalence were 1.6% (95% CI: 1.0–2.5) and 2.7% (95% CI: 1.0–2.5), respectively. Risk factors associated with HIV included not receiving intimate visits (OR = 8.80, 95% CI: 1.15–66.88), already having another sexually transmitted infection (OR = 3.89, 95% CI: 1.47–10.29), and reporting attendance in HIV preventive campaigns (OR = 4.24, 95% CI: 1.58–11.36). Moreover, anti-HCV seroprevalence was associated with higher age (OR = 4.03, 95% CI: 1.61–10.07), criminal recidivism (OR = 2.58, 95% CI 1.02–6.52), and the use of injectable drugs (OR = 7.32, 95% CI 3.36–15.92). Although prisons might increase the risk for acquiring and transmitting HIV and HCV, the adoption of permanent epidemiological surveillance programs could help reducing the circulation of viruses, involving strategies focusing on screening, treating, and preventing infections to assure proper prisoner health. Moreover, these policies need to take place inside and outside the prison environment to offer continued assistance to former prisoners once they leave the institution.

[Acceptance of Video Consultations in Correctional Facilities from the Patients' Perspective - Results from the Mixed-Methods Evaluation of a Pilot Project in Baden-Württemberg]

OBJECTIVE

Video consultations have proven themselves in international penal systems. Amidst a lack of medical staff, video consultations were offered in five correctional facilities in Baden-Württemberg in 2018 as part of a pilot project. This evaluation study aimed at assessing the acceptance of video consultations among patients.

METHODS

The mixed-methods evaluation consisted of site visits, interviews, questionnaires and an analysis of medical treatment data.

RESULTS

A total of 305 video consultations were conducted between June and December 2018. Among the most frequent reasons for encounter were feeling anxious/nervous/tense, sleep disturbance, headache and drug abuse. Including familiar medical staff and offering training for the involved physicians were important factors that enabled a trusting communication.

CONCLUSION

Video consultations were seen as a useful addition to existing health care. However, they were considered less suitable for both emergencies and physical examinations.

Increased incarceration rates drive growing tuberculosis burden in prisons and jeopardize overall tuberculosis control in Paraguay

Incarcerated populations are at high-risk to develop tuberculosis (TB), however their impact on the population-level tuberculosis epidemic has been scarcely studied. We aimed to describe the burden and trends of TB among incarcerated populations over time in Paraguay, its clinical and epidemiological differences and the population attributable fraction. This is an observational, descriptive study including all TB cases notified to the National TB control Program in Paraguay during the period 2009–2018. We also used case registries of prisoners diagnosed with tuberculosis from the Minister of Justice. The population attributable fraction of TB in the community due to incarcerated cases was estimated through Levin’s formula. The characteristics of TB cases in and outside of prison were compared as well as the characteristics of TB in prisons were modified over time. During 2009–2018, 2764 (9.7%) of the 28,534 TB reported cases in Paraguay occurred in prisons. The number of prisoners in Paraguay increased from 6258 in 2009 to 14,627 in 2018 (incarceration rate, 101 to 207 per 100,000 persons) while the number of TB cases among prisoners increased by 250% (n = 192 in 2009 versus n = 480 in 2018). The annual TB notification rate among male prisoners was 3218 and 3459 per 100,000 inmates in 2009 and 2018, respectively. The percentage of all TB cases occurring among prisoners increased from 7.1% in 2009 to 14.5% in 2018. The relative risk of TB in prisons compared to community was 70.3 (95% CI, 67.7–73.1); the overall population attributable risk was 9.5%. Among the 16 penitentiary centers in the country, two of them—Tacumbú (39.0%) and Ciudad del Este (23.3%)—represent two thirds of all TB cases in prisons. TB among inmates is predominantly concentrated in those 20–34 years old (77.3% of all), twice the percentage of cases for the same age group outside of prison. Our findings show that the TB epidemic in prisons represents one of the most important challenges for TB control in Paraguay, especially in the country’s largest cities. Appropriate TB control measures among incarcerated populations are needed and may have substantial impact on the overall TB burden in the country.

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.

Opioid substitution therapy for people living in German prisons-inequality compared with civic sector

BACKGROUND

The above-average proportion of people with opioid use disorder living in prisons is a worldwide reality, and the need to treat these people was recognized internationally more than 20 years ago. Studies have shown that substitution therapies are best suited to treat opioid use disorder and reduce the risk of HIV and hepatitis C transmission and overdose. However, huge health inequalities exist in and outside of prison due to the different implementation of opioid substitution therapy (OST). People living in prisons are entitled to the best possible health care. This is established by the Universal Declaration of Human Rights and by the International Convention on Economic, Social and Cultural Rights. Solely the imprisonment, and not the loss of fundamental human rights, constitutes the punishment.

METHODS

A qualitative literature search using PubMed and Google Scholar was performed in order to identify relevant publications.

RESULTS

This review shows the inequality in availability of opioid substitution therapy for people living in prison compared with people outside of prison in Germany. It also gives possible reasons and evidence for this inequality, showing that continuing or initiating OST in prison is more beneficial for the health of people living in prison than abstinence-oriented treatment only.

CONCLUSION

It is important that drug use disorder is treated as a serious illness also in prison. Joint efforts are needed to provide people living in prison with the best possible treatment and to minimize the adverse effects of drug use. Therefore, with laws, policies, and programs that conform to international human rights standards, each state must ensure that people living in prison receive the same health care as people outside of prison.