Germany's Psychiatric Blind Spot: Behind Prison Walls

Medscape

a day ago

In this interview with Coliquio , a Medscape Network platform, Gregor Gross, MD, from the psychiatric department at Straubing Prison in Straubing, Germany, discussed the challenges and insights of providing psychiatric care within the German prison system. As a specialist in psychiatry and psychotherapy, Gross offered candid insights into working at the intersection of acute mental health crises, systemic understaffing, and occasional moments of unexpected therapeutic success. It's a conversation about caring for society's most marginalized individuals — and what can happen when their psychiatric illnesses are overlooked.
Why is a dedicated psychiatric unit necessary in prisons?
Mental health disorders are significantly more prevalent among inmates than in the general population. Nearly half of all prisoners struggle with substance abuse. Approximately 25% of male inmates suffer from depression, and among female inmates, the rate is about 33%. Psychotic disorders are present in roughly 4% of the prison population, and ADHD is also relatively common, affecting about 10%. At Straubing Prison, around half of the inmates are under continuous psychiatric care, which is not an exception.
Does incarceration itself trigger these mental health issues?
Most inmates enter prison with preexisting mental health conditions; many have been incarcerated multiple times and are familiar with the environment, which reduces stress. However, first-time inmates often develop adjustment disorders, typically manifesting as temporary depressive reactions. These usually subside after a few weeks or months. In general, the prison environment rarely causes severe psychiatric problems on its own.
Are there specific groups of inmates who are particularly vulnerable?
Yes, especially those serving substitute custodial sentences. These individuals have committed minor offenses, such as shoplifting or fare evasion, and are unable to pay fines due to psychiatric or social issues, leading to incarceration. Repeated imprisonment exacerbates their underlying problems rather than resolving them.
Does the justice system inadvertently create its own inmates?
Unfortunately, yes. A revolving-door effect occurs where individuals are released only to return shortly after for similar minor offenses they cannot afford to rectify financially. The root causes of their behavior are never addressed, indicating a clear need for political intervention.
The suicide rate in prisons is reportedly high. How is this managed?
At Straubing, we conduct systematic, scientifically validated suicide screenings upon intake and during high-risk situations, such as post-sentencing or pre-release. These periods often induce anxiety about the future, posing real suicide risks.
What measures are taken if someone is at high risk?
Immediate, intensive psychiatric care is provided. Often, this support is sufficient to navigate the crisis. We also have cells equipped with camera surveillance, and some inmates request placement there due to fear of impulsive actions. Coercive measures are rare and used only when there's an acute suicide risk, which may include removing clothing to prevent self-harm, substituting with paper garments. Despite precautions, the prison suicide rate remains 10 times higher than in the general population. Therefore, peer-support programs, like the model project in Munich where trained inmates assist newcomers, are vital and should be expanded.
How adequate is psychiatric care in German prisons overall?
Frankly, it's significantly below what's necessary. Despite the high number of mentally ill inmates, many facilities lack psychiatric services. Nationwide, there are only about 30 prison psychiatrists for approximately 60,000 inmates, equating to over 1000 cases per doctor. Many positions remain unfilled due to a shortage of qualified professionals. Consequently, prison medical staff without psychiatric training often have to fill the gap, which is far from ideal.
Would transferring mentally ill inmates to regular hospitals be beneficial?
In theory, yes, but it's rarely feasible in practice. Many hospitals refuse inmates due to capacity issues or stigma, perceiving their symptoms as criminal behavior rather than illness. Additionally, the presence of correctional officers disrupts hospital routines, leading to infrequent acceptance of such transfers.
How can more psychiatrists be attracted to work in prisons?
A major issue is the lack of exposure to prison psychiatry during medical education and specialist training. Yet, it's an incredibly engaging field. If medical students and residents experienced this work firsthand, they would appreciate its professional and human relevance, potentially increasing interest in this specialty.
What other steps are being taken to address the care deficit?
The German Society for Psychiatry and Psychotherapy, Psychosomatics, and Neurology has established a working group to assess the actual needs for psychiatric care in prisons. The goal is to obtain reliable data to accurately determine the extent of the deficit, which is essential for advocating political improvements. The principle of equivalence dictates that medical care in prisons must be comparable to that outside; incarceration should not result in inferior healthcare, especially psychiatric services.
Can telemedicine help alleviate the problem?
In some German federal states, telepsychiatry is well established in prisons. However, it's intended as a supplement, not a replacement. Effective psychiatric treatment requires personal contact and a cohesive team, including on-site nurses and therapists, which cannot be fully replicated through video consultations.
Are there inmates who particularly benefit from prison psychiatric services?
Yes, notably individuals with migration backgrounds. Many lacked access to psychiatric care in their home countries or in Germany due to inadequate healthcare systems or language barriers. In prison, we can often diagnose conditions like depression, psychosis, or ADHD for the first time, offering opportunities they might never have received otherwise.