Jan Bulla

Entlasschancen multimorbider Patienten im psychiatrischen Maßregelvollzug

OBJECTIVE to determine the chances of discharge of forensic psychiatric patients (section 63 of the German Legal Code) diagnosed with comorbid psychiatric and somatic disorders. METHODS N = 364 patients were evaluated. Diagnostic groups were compared with regard to types and frequencies of comorbid diagnoses, and treatment duration. RESULTS Both personality disorders as main diagnoses and comorbid personality disorders were associated with prolonged inpatient treatment. Substance dependence in addition to a personality disorder was an aggravating factor. Comorbid somatic disorders affected treatment duration of patients diagnosed with a psychotic disorder. CONCLUSIONS Somatic comorbidity may negatively interact with the treatment of psychiatric problems in schizophrenic patients and thus affect the prospects of discharge in this patient group.

Predictors of re-offending in German substance-abusers in legal detention: a prospective population-based cohort study

Abstract This study aimed to evaluate whether the elapsed time after release to first re-offense is longer for those who complete coerced forensic addiction treatment than for those who fail to complete the treatment. It is also aimed to identify predictors of re-offending for both those who complete such treatments as compared with those who do not. Two hundred and sixty-one patients discharged from five German forensic addiction clinics were investigated on 65 anamnestic, socio-demographic, and therapeutic process variables. One hundred and fifty-one patients were prematurely discharged and returned to prison (group A; time at risk [TAR] = 58.7 months), 110 finished treatment successfully (group B; TAR = 44.2 months). Federal Criminal Register data were used for follow-up. Univariate survival analyses and multivariate stepwise Cox-regression models were computed. Twelve predictors in group A revealed a four-factor model: age at admission to treatment, duration of concurrent prison sentence, number of entries in the criminal register, and attendance at prior substitution programs. The model for group B covered five out of eight predictors: regular working activities before first diagnosis of mental illness, type of main offense, (secondary) traffic offenses, outpatient rehabilitation treatments, and escapes during treatment. Successful completers of forensic addiction treatment are slower to re-offend than non-completers.

Socioeconomic disadvantage and schizophrenia in migrants under mental health detention orders

Background: Migrants with mental hospital orders according to section 63 of the German criminal code are overrepresented in relation to their numbers in the general population. Subgroups originating from certain world regions are diagnosed with schizophrenia at a much higher rate than others. In the present literature, there is a strong evidence for a substantial correlation between migration, social disadvantage and the prevalence of schizophrenia. Aims: This study investigates the relationship between countries of origin, the risk of becoming a forensic patient and the proportion of schizophrenia spectrum disorders. Method: Data from a comprehensive evaluation tool of forensic inpatients in the German federal state of Baden-Württemberg (FoDoBa) were compared with population statistics and correlated with the Human Development Index (HDI) and Multidimensional Poverty Index (MPI). Results: For residents with migration background, the risk ratio to receive a mental hospital order is 1.3 in comparison to non-migrants. There was a highly significant correlation between the HDI of the country of origin and the risk ratio for detention in a forensic psychiatric hospital. The proportion of schizophrenia diagnoses also correlated significantly with the HDI. In contrast, the MPI country rankings were not associated with schizophrenia diagnoses. Conclusion: Two lines of explanations are discussed: first, higher prevalence of schizophrenia in migrants originating from low-income countries, and second, a specific bias in court rulings with regard to involuntary forensic treatment orders for these migrant groups.

Coercion as part of a psychoanalytically based therapy: Case report on the treatment of a forensic outpatient

Abstract This paper presents the four-year forensic outpatient treatment of a male patient in his mid-30s who was diagnosed with a schizoaffective disorder and had previously been held on unlimited detention due to several assaults. At the beginning, several coercive measures had to be taken. Over time, both the therapeutic alliance and the patients psychic structure improved remarkably. The patient explained at the end of therapy that, despite being forced into treatment, he also felt recognized and held while he had been in deep distress. Several explanations of how coercion and the therapeutic process may correlate are discussed: essentially, the complex and dialectical relationships between inner and outer reality, therapeutic space, and social structures are reflected. Cautiously but consistently introducing outer reality as well as validating the patients realistic perceptions contributed to strengthening his ego functions.

Welche Maßregelvollzug-Patienten erhalten nach der stationären Behandlung eine Weisung für die forensische Ambulanz?

OBJECTIVE In the Federal State of Baden-Württemberg an administrative regulation specifies which patients should be assigned to forensic outpatient treatment. Empirically, little is known about the clinical and criminological factors supporting these decisions. METHODS A complete survey of forensic inpatients in Baden-Württemberg was undertaken. RESULTS From 476 patients released from unlimited detention (§ 63 StGB) 235 (45.6 %) received a court order for forensic aftercare between 2009 and 2012. Social, forensic, and psychiatric history differed only slightly compared with patients not assigned. Schizophrenia as diagnosis was overrepresented, personality disorder and paraphilia underrepresented. Both groups differed most with respect to the duration of detention. CONCLUSIONS The decision for forensic outpatient treatment seems to be determined by process variables of inpatient treatment but not by criminological risk factors. This contradicts the R-N-R principles by Andrews and Bonta.