psychiatry behind bars: the young inmate profile in psychiatric treatment at a special prison...

XVI World Congress of Psychiatry

“Focusing on Access, Quality and Human Care”

Madrid, 14-18 September 2014Susana Pinto Almeida, Psychiatrist at CHL & EP Leiria

Sofia Fonseca, Psychiatrist at CHL & EP Leiria

PSYCHIATRY BEHIND BARS: THE YOUNG INMATE PROFILE IN PSYCHIATRIC TREATMENT AT A

SPECIAL PRISON FACILITY

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THE YOUNG INMATE PROFILE IN PSYCHIATRIC TREATMENT AT A SPECIAL PRISON FACILITY

Leiria Prison was once called “PRISON – SCHOOL”

It remains the only prison in Portugal for young offenders from 16 to 21 years of age but they can stay until 25 years of age

Today there are 243 inmates

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ARCHITECTURAL DESIGN

• This facility comprehends:

• 5 Operational Units

• 1 Drug Free Unit

• 1 Health Care Unit

• 1 School Unit

• 1 Vocational Training Unit

• Administrative/Maintenance/Logistics Units

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LODGING

• Inmates are lodged in individual cells

• The larger Units are divided in two Wings

• Each Unit or Wing has its own refectory, balneary and courtyard

• The remand are separated from the convicted and the open regime from the common regime

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SPECIFIC PROGRAMS

1. Program aimed at Sex Offenders;

2. Program aimed at convicted inmates/prisoners for road traffic offenses;

3. Recidivism Prevention Program;

4. Integrated Program for Suicide Prevention;

5. Emotional skills promotion Program;

6. Emotional Stabilization Program;

7. Initiation Program to restorative practices;

8. Program of moral and ethical development;

9. Program aimed at young people convicted of violent crimes; a i m e d a t y o u n g p e o p l e c o n v i c t e d o f

10. Motivation Program aimed at inmates/prisoners with addictive behaviors;

11. Skills training Program for employability;

12. Prevention of Domestic Violence Program (developing);

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THE YOUNG INMATE PROFILE IN PSYCHIATRIC TREATMENT AT A SPECIAL PRISON FACILITY• Portuguese Code of execution of sentences and measures involving deprivation of Liberty -

Law no. 115/2009 of October 12

Article 7

Rights of the inmate

1 – The execution of sentences and measures involving the deprivation of liberty should ensure the following inmates´ rights, namely:

a) The protection of their life, health, personal integrity and freedom of conscience; inmates should not be submitted to torture, or to cruel, inhuman or degrading treatment; (…)

h) To take part in work, education, teaching, training, religious, socio-cultural, civic and sport activities and in programs aimed at the treatment of specific problem areas;

i) To access National Health Service, in the same conditions ensured to all citizens;

(…)

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THE YOUNG INMATE PROFILE IN PSYCHIATRIC TREATMENT AT A SPECIAL PRISON FACILITY• Portuguese Code of execution of sentences and measures involving deprivation of Liberty -

Law no. 115/2009 of October 12

Article 19

Inmate´s evaluation

1 –Upon arrival to prison, the inmate is lodged in a specific sector, destined to admission, where he should stay for a maximum period of 15 days. The inmates´ evaluation should immediately take place, starting through the gathering of elements which, within 72 hours following admission, must allow the prison governor to determine:

a) Healthcare that should be given to the inmate, following clinical evaluation;

(…)

2 – The evaluation of the sentenced inmate takes into account namely the nature of the crime committed, the length of the sentence, the family and social environment, the education, the health status, his possible vulnerability, the risks for his security and that of others and the risk of escape and it´s consequence for the community and the victim.

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• Portuguese Code of execution of sentences and measures involving deprivation of Liberty - Law no. 115/2009 of October 12

Article 25

Release

1 – Whenever possible, the inmate should be examined by the doctor prior to his release. In the case the doctor declares, in writing, that the inmates´ immediate release represents risk to his life or health, the prison governor, upon inmate´s consent, can authorize his permanence in the institution for the time strictly necessary until admission into an adequate health facility on the outside, and should request the participation of the competent health and social care services.

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• Portuguese Code of execution of sentences and measures involving deprivation of Liberty - Law no. 115/2009 of October 12

Article 26

Lodging

1 – Inmates are lodged in individual cells.

2 – Inmates can be lodged in common, taking into account the execution regimes and due to family reasons, for treatment and to prevent physical or psychological risks, provided that order and security reasons do not object to it.

(…)

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THE YOUNG INMATE PROFILE IN PSYCHIATRIC TREATMENT AT A SPECIAL PRISON FACILITY• Portuguese Code of execution of sentences and measures involving deprivation of Liberty - Law no. 115/2009

of October 12

Article 35

Imposed healthcare

1 – Inmates cannot be forced to have surgical interventions, medical-surgical treatments or to be fed, except in the situations mentioned in this article and those provided by law.

2 – Inmates can be forced to have surgical interventions and medical-surgical treatments in case of danger to their life or serious threat to the body or health of others.

3 – Inmates can be forced to have surgical interventions and medical-surgical treatments, as well as to be fed, in case of danger to their life or serious threat to their own bodies or health and if their condition doesn´t allow them to think straight and evaluate the sense and the consequences of their refusal.

(…)

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THE YOUNG INMATE PROFILE IN PSYCHIATRIC TREATMENT AT A SPECIAL PRISON FACILITY• Portuguese Code of execution of sentences and measures involving deprivation of Liberty - Law no.

115/2009 of October 12

Article 37

Duties of the medical staff

1 – The doctor or any other person legally authorized working at the prison unit should follow up the evolution of inmates´ physical and mental health, and specifically:

a) Ensure that the inmates are observed as frequently as required by this Code and by General Regulation;

b) Keep the inmates´ individual medical record updated, registering all complaints and results of medical exams as well as detailed description of accidental injury from direct action of the inmate itself or others;

c) Create, along with the outside health services, the necessary conditions to continue medical treatment after the inmate is released.

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THE YOUNG INMATE PROFILE IN PSYCHIATRIC TREATMENT AT A SPECIAL PRISON FACILITY• Portuguese Code of execution of sentences and measures involving deprivation of Liberty - Law no.

115/2009 of October 12

Article 37

Duties of the medical staff

2 – Medical staff should immediately communicate in writing to the prison governor:

a) The existence of diseases requiring special measures to reduce the risk of transmissibility;

b) Symptoms of deprivation of drugs, medicines or alcohol;

c) The psychological or emotional pressure resulting from the deprivation of liberty, particularly in the case of inmates placed in a security regime;

d) The existence of signs indicating physical violence;

e) Physical or mental health problems which might difficult the social reintegration process;

f) Any change to inmates´ physical and mental ability to work and perform any other activities provided by the prison unit.

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THE YOUNG INMATE PROFILE IN PSYCHIATRIC TREATMENT AT A SPECIAL PRISON FACILITY• Portuguese Code of execution of sentences and measures involving deprivation of Liberty - Law no. 115/2009 of October 12

Article 92

Isolated cell

1 – The placement of inmates in cells isolated from other inmates in prison can only be made when there is a serious escape risk or attempt to free any inmate, or when, due to the inmates´ behavior there is a serious risk of practicing violent acts towards personal legal goods, their own or others´, or patrimonial goods, if lesser special measures reveal to be ineffective or inadequate.

2 – The placement of an inmate in an isolated cell excludes life in common as well as communication with other inmates and it limits the contacts with the outside world; also the time spending outdoor can be reduced, notwithstanding the limitations set forth by § 2 of article 51.

3 – The inmate must be observed by a doctor or a nurse within a maximum of twenty four hours after this measure has been implemented.

(…)

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Article 93

Security room

1 – The placement of inmates in a security room can only be carried out in a situation of serious changes to his psycho-emotional conditions, representing serious risk for the practice of acts towards personal legal goods, their own or others´, or patrimonial goods, if lesser special measures reveal to be ineffective or inadequate (…).

2 – The inmate placed in a security room should be immediately examined by the doctor and must be subjected to medical examination on a daily basis, for as long as this special security measure lasts.

3 – The doctor should inform the prison governor, in writing and after each medical examination, of the inmate´s medical condition as well as of the possible need to cease this special security measure.

4 – If 10 days have passed and the reasons that led to the placement of the inmate in a security room prevail, he should be transferred to a prison hospital or any other adequate hospital (…).

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Article 109

Medical assistance

1 – Inmates serving the disciplinary measures mentioned in the paragraphs f) and g) of § 1, of article 105, stay under medical surveillance and should be observed as frequently as stated by the doctor who must state his recommendations in writing when he finds necessary to interrupt or change the execution of a disciplinary measure.

2 – The prison´s doctor shall be consulted before a disciplinary measure is applied to inmates under psychiatric medical treatment or to those revealing suicide tendencies and also, in case of pregnancy, puerperium or after an abortion, in what concerns the disciplinary measures mentioned in paragraphs f) and g) of § 1, of article 105 and in remaining cases, when exceptional circumstances so justify it.

Article 105

Disciplinary measures

(…)

f) Mandatory stay in the lodgment for a maximum of 30 days;

g) Confinement in a disciplinary cell for a maximum of 21 days;

(…)

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• Descriptive study conducted between 01/11/2012 and 31/08/2014 with authorization of the Directorate-General of Prison Services (DGSP), Ministry of Justice.

• Authors: Susana Pinto Almeida; Sofia Fonseca (Psychiatrists Leiria Prison)

• Cooperation of Dr.ª Maria Helena Cardoso, Clinical Psychologist, Coordinator of the Health Care Unit.

• Objective: to define the socio-demographical, clinical and legal profile of the inmate at the Psychiatric Consultation of the Leiria Prison Facility.

• Method: the data were collected by consulting inmates´ individual clinical and legal files and a formulary was designed and filled for this purpose, with the chosen socio-demographical, clinical and legal items.

• Program used IBM SPSS Statistics 20.

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• Prison population 01/10/2011 = 206 inmates



• 86 new inmates 01/10/2011 - 31/10/2012

• 290 inmates/year

• Age (mean) = 21,5 years

• Inmates under psychiatric care – 01/10/2011 to 31/10/2012 = 76

• Inmates under psychiatric care – 1/11/2012 to 31/08/2014 = 94

• Around 25% of prison population a year (1:4)

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• 76 Inmates under psychiatric care – 01/10/2011 to 31/10/2012

• Data collected from 38 clinical files (50%)

• 54 new inmates under psychiatric care – 1/11/2012 to 31/08/2014


• 130 inmates under psychiatric care – 01/10/2011 to 31/08/2014


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• SOCIO DEMOGRAPHIC (7)

• Age

• Marital status

• Nationality

• Academic qualifications

• Professional activity

• Residence

• Household

• CLINICAL (18)

• Consultation requesting entity

• Referral reasons

• Family psychiatric history

• Previous mental/behavior disorder

• Medication prior to arrest

• Type of psychiatric evaluation

• Psychiatric follow up

• Diagnosis at first evaluation

• Major psychiatric disorder

• Alcohol abuse

• Drug abuse

• Type of drugs

• Clinical intervention

• Personality disorder/Impulsive traits

• Risk of suicide

• Suicide attempt

• Self harm

• Prison Hospital admission

• LEGAL (10)• Legal situation

• Prior judicial history

• Offences

• Indictment/conviction for more than 1 offence

• Sentence

• Prior misdemeanors history

• Disciplinary measures

• Occupation/Activity

• Temporary leave

• Distance from home


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YOUNG INMATE PROFILE - RESULTS

Marital status (n=70)

Single (n=66; 94%)

Married (n=4; 6%)

Age (n=70)

Mean 20,7; Min 17; Max 24; s.d. 1,9

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Nacionality (n=70)

Portuguese (n=56; 80%)

Other (n=14; 20%)

Nacionality (n=243)

Portuguese (n=235; 97%)

Other (n=8; 3%)

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YOUNG INMATE PROFILE - RESULTSAcademic qualifications (n=70)

Unschooled (n=5; 7%)

Level 1 - 4 years (n=16; 23%)

Level 2 - 6 years (n=34; 48%)

Level 3 - 9 years (n=11; 16%)

Secondary (n=4 6%)

Academic qualifications at entry (n=243)

Unschooled (n=11; 5%)

Level 1 (n=50; 20%)

Level 2 (n=113; 46%)

Level 3 (n=60; 25%)

Secondary education (n=5; 2%)

Higher education (n=2; 1%)

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Professional activity (n=70)

Employed (n=15; 21%)

Unemployed (n=48; 69%)

Student (n=7; 10%)

Profissional activity (n=243)

Yes (n=53; 22%)

No (n=190; 78%)

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Residence (n=70)

Rural (n=19; 27%)Urban (n=51; 73%)

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Household (n=70)

Parents (n=49; 70%)Wife/girlfriend (n=9; 13%)None (n=3; 4%)Family members (n=9; 13%)

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Requesting entity (n=70)

General practitioner (n=23; 33%)

Psychiatrist (n=24; 34%)

Nurse/Psychologist (n=19; 27%)

Administration (n=2; 3%)

Inmate (n=2; 3%)

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Referral reasons (n=70)

Anxiety/Depression/Insomnia (n=50; 71%)

Psychosis (n=3; 4%)

Drugs/Alcohol withdrawal (n=4; 6%)

Suicide ideation (n=8; 12%)

Behavior disorder (n=3; 4%)

Legal (n=2; 3%)

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Family psychiatric history (n=70)

Yes (n=8; 11%)No (n=20; 29%)Unknown (n=42; 60%)

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Medication prior to arrest (n=70)

Yes (n=22; 31%)

No (n=48; 69%)

Previous mental/behavior dis-order (n=70)

Yes (n=35;50%)

No (n=35; 50%)

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Psychiatric follow-up (n=70)

Yes (n=46; 66%)

No (n=24; 34%)

First psychiatric evaluation (n=70)

Yes (n=53; 80%)

No (n=17; 20%)

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Diagnosis at first evaluation (n=70)

Adjustment disorder (n=28; 40%)

Anxiety/depression (n=17; 24%)

Psychosis (n=5; 7%)

Drug/alcohol abuse (n=4; 6%)

Mental deficiency (n=4; 6%)

Unknown (n=12; 17%)

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Major psychiatric disorder (n=70)


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Alcohol abuse (n=70)

Yes (n=17; 24%)

No (n=53; 76%)

Drug abuse (n=70)

Yes (n=53; 76%)

No (n=17; 24%)

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Drugs (n=53)

Heroin (n=2; 4%)

Cocain (n=2; 4%)

Cannabis (n=30; 56%)

2 or more drugs (n=19; 36%)

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Clinical intervention (n=70)

Pharmachological (n=31; 44%)

Adjust previous medication (n=30; 43%)

Other (n=6; 9%)

None (n=3; 4%)

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Personality disorder/Impulsive traits (n=70)


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Suicide Risk - Integrated Program for Suicide Preven-tion - PIPS (n=70)

Yes (n=4; 6%) No (n=61; 87%)

Unknown (n=5; 7%)

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Suicide attempt (n=70)

Yes (n=7; 10%)No (n=63; 90%)

Self harm (n=70)

Yes (n=12; 17%)No (n=58; 83%)

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Prison Hospital admission (n=70)

Yes (n=3; 4%)No (n=67; 96%)

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Prison (n=243; 15%; 85%) Consultation (n=67; 30%; 70%)

0102030405060708090

RemandConvicted

N=

6% lo

Legal situation

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Prior judicial events (n=67)

Yes (n=11; 16%)

No (n=56; 84%)

Misdemeanors history (n=70)

Yes (n=49; 70%)

No (n=21; 30%)

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YOUNG INMATE PROFILE - RESULTSOffences (n=67)

Robbery (n=26; 39%)

Theft (n=19; 28%)

Homicide/Homicide attempt (n=4; 6%)

Sexual nature (n=6; 9%)

Physical assault (n=6; 9%)

Others (n=6; 9%)

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Indictment/Conviction for more than 1 offence (n=67)

Yes (n=46; 69%)No (n=21; 31%)

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YOUNG INMATE PROFILE- RESULTS

Offences 857/207 sentenced inmates

Robbery (25%)

Theft (25%)

Road Traffic offences (16%)

Homicide/Homicide attempt (1%)

Sexual nature (1%)

Physical agression (4%)

Possession of illegal weapons (5%)

Drug Trafficking (4%)

Other (19%)

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Sentence• 46 convicted inmates (70%)

• Med 64 months – 5Y 4M (SD=32,5)

• Min 18 months – 1Y 6M

• Max 144 months – 12YSentence (n=207)

>10 years (5%)5 to 10 years (49%)2 to 5 years (36%)1 to 2 years (6%)< 1 year (4%)

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Disciplinary measures (n=67)

Yes (n=30; 45%)No (n=37; 55%)

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Occupation/Activity (n=67)

Yes (n=39; 58%)No (n=28; 42%)

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Temporary leave (n=46)

Yes (n=5; 11%)

No (n=41; 89%)

Distance from home (n=67)

>50Km (n=57; 85%)

<50Km (n=10; 15%)

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• Urban youth, 21 years of age

• Single, living with one parent at the time of the arrest

• Concluded the 9th grade

• Unemployed

• Referenced to psychiatric evaluation by the GP for anxiety/insomnia/depression symptoms

• Regularly uses cannabis

• Presenting with adjustment disorder at the first appointment

• Medicated with psychotropic drugs (symptomatic approach)

• No major psychiatric diagnoses but previous mental/behavior disorder

• Presents with personality disorder traits

• With regular psychological accompaniment

• 1st timer, with no prison background but history of misdemeanors

• Accused of more than one offence

• Convicted to a mean of 5Y6M for thievery or robbery offence(s)

• Unauthorized to temporary leave

• Subject to at least one disciplinary measure

• Participates in an activity/program

• Lives more than 50km away

THE YOUNG INMATE PROFILE - CONCLUSIONS

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• Limitations

• Study continuity

• Projects for structuring Psychiatry Consultation on Leiria Prisional Facility ?

• ?

XVI World Congress of Psychiatry

“Focusing on Access, Quality and Human Care”

Madrid, 14-18 September 2014Susana Pinto Almeida, Psychiatrist at CHL & EP Leiria

Sofia Fonseca, Psychiatrist at CHL & EP Leiria

PSYCHIATRY BEHIND BARS: THE YOUNG INMATE PROFILE IN PSYCHIATRIC TREATMENT AT A

SPECIAL PRISON FACILITY

psychiatry behind bars: the young inmate profile in psychiatric treatment at a special prison...

Health & Medicine