Healtcare in The Prison and Probation Service

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					Prison/Probation service and Forensic
        Psychiatry in Sweden

               Maria Hägerstrand
     Health Care Development Administration
    Swedish Prison and Probation Service HQ
      Prison and Probation Service in Sweden

• The Prison and Probation Service
  is part of the legal system.
• The main tasks of the Prison and
  Probation Service are to
  implement sentences of prison
  and probation, to supervise
  conditionally released persons, to
  implement instructions for
  community service, and to carry
  out pre-sentence investigations in
  criminal cases.
 The organisation of the Swedish Prison- and Probation Service

                                                Ministry of Justice

                                                                                      National Parole Board
        Transport Service                           Head Office
                                                                                      30 Probation Enforcement Board

Northern                  Stockholm           Central             Eastern                Western             Southern
region                    region              region              region                 region              region
9 Prisons                 10 Prisons          9 Prisons           9 Prisons              12 Prisons          8 Prisons
5 Remand prisons          2 Remand prisons    5 Remand prisons    6 Remand prisons       5 Remand prisons    5 Remand prisons
                                                                  7 Probation auth.      7 Probation auth.   6 Probation auth.
7 Probation authorities   3 Probation auth.   6 Probation auth.
                       The Health Care system in the Swedish
                           Prison- and Probation Service

                                                         Health Care Developer
       Committee for
     Correctional Medicin      General Director
                                                         Senior Medical Advisor

Regional       Regional      Regional      Regional       Regional      Regional
Manager        Manager       Manager       Manager        Manager       Manager
for the        for the       for the       for the        for the       for the
Northern       Stockholm     Central                      Western       Southern
region         region        region                       region
                                           region                       region
Health Care    Health Care   Health Care                  Health Care
                                           Health Care                  Health Care
Coordinator    Coordinator   Coordinator                  Coordinator
                                           Coordinator                  Coordinator
Nurses         Nurses        Nurses        Nurses         Nurses        Nurses
Consultant     Consultant    Consultant    Consultant     Consultant    Consultant
physicians     physicians.   physicians.   physicians     physicians    physicians
                         The clients - in prison

 During their time in prison, it
 is the responsibility of the
 Prison and Probation Service
 to prepare the inmate for a
 better life in freedom
 afterwards, through training,
 work and various
 Most clients are men. Just
 over half of those who are
 sent to prison have been in
 prison before.

A very high percentage of the clients suffer from mental illness and severe drug
problems. According to recent drugstatistic 40 of 100 inmates are under treatment
with antidepressiv drugs. About 70% suffer from personality disorder and 25% from
ADHD. Over half of them have experience of injecting narcotics. Many have no
homes and poor finances. Inmates are people of all ages.
         The Prison system
• 5099 beds of which 261 are for women
• 10-11.000 new enrolled every year of which
  >700 are women
• 19% of the newly enrolled are <25 years
• 60% are judged to sentences under 6 months
• Just under 50% have earlier judgements to
• The Right to medical services for inmates are regulated by law.

• An inmate has the same right to medical service as other persons
  living in Sweden (The normalization principle)

• For practical reasons and due to security medical care is available in
  all prisons and remand prisons in Sweden. This service is provided
  by nurses (on duty during normal working hours and in some
  remand prisons there is a nurse on duty also at weekends and on
  public holidays) and consulting physicians (general medicine).

• Some facilities also have access to psychiatrists and about one third
  of the nurses have psychiatric training.
          Prison and mental illness

• All offenders, even if psychotic or mentally retarded, are legally
  responsible for there actions. Since 1965 Sweden do not deal with
  the concept of accountability/responsibility.

• If an offender at the time of the crime suffers from a “severe
  mental disorder” the court cannot sentence him/her to prison

• If the offender is still suffering from a “severe mental disorder” and
  is in need of psychiatric care at the time of the trial he/she can be
  sentenced to in-patient forensic psychiatric care.

• The definition of “severe mental disorder” is legal and not a
  medical term. It includes psychotic disorders, severe depressive
  disorders with risk of suicide, and in some cases severe
  personality disorders, but not mental retardation. Persons with
  severe autistic disorders have also been excluded from criminal
Psychiatric service in prison vs Forensic Psychiatry

       • The psychiatrists who consults are mostly specialists in
         general psychiatry and not forensic psychiatry. Their ordinary
         service are in General psychiatric clinics or Addiction

       • There is no formal cooperation between The Prison and
         Probation Service and The National Board of Forensic
         Medicine or the forensic care in the different counties

       • There are no prison hospitals in Sweden. If an inmate needs
         inpatient treatment, he/she is referred to the Psychiatric
         Emergency Unit at the nearest Hospital.
         Committee for Correctional Medicine
• The Swedish Prison and Probation Service has had a
  Committee for Prison Medicine since 1981.
• The reason for the establishment of this committee was the
  unexplainable differences in the prescription of the
  medications used as drugs (benzodiazepines, opiates).
• Since 1983 the Committee has published Essential medicines
  in the Prison and Probation Service; a booklet with
  recommendations for medication for the most common
  symptoms and diseases in the prison population.
• The latest edition is named Correction medicine – manual and
  essential medicines, and is completed with care programs for
  some of the most common psychiatric disorders
Health screening
• There is a health screening program for inmates in remand
  prisons. This is carried out by nurses.

• This screening program is for both mental and somatic

• The security staff in Swedish remand prisons are trained to
  recognize deviant behavior and contact the health services.

• Many of The security staff are specially trained to recognize
  suicidal behavior. The risk of parasuicide or suicide is
  highest in the remand prisons.
        Screening for suicide risks
• All persons arriving at a remand prison are asked about risk factors
  for suicide and if they have present suicide thoughts (so called
  suicide screening) by the correctional staff according to a special

• If they give positive answers they also should be investigated by the
  medical staff (all nurses are trained in suicidology). In anticipation of
  such they can be monitored either constant or intermittent.

• Some cases are transported to a Psychiatric Emergency Unit for
       Psychiatric treatment in prison
• Inmates that needs out-patient treatment can have that treatment in

• The quality of psychiatric care in a prison is likely to meet the
  general mental health standards.

• Most of the consulting psychiatrists are very experienced with
  inmates and are well equipped to handle their problems.

• Almost all medication is administered under supervision; the
  treatment in prisons is in that way followed much more closely than

• Compulsory treatment is not possible
Cooperation projects toghether with the Counties
 • Common out-patient treatment (Forensic out-patient clinic
   in Stockholm, Järntorgsmottagningen i Gothenburg and an
   out-patient clinic in Malmoe)
 • Screening for Adhd in Norrtälje and Storboda
 • ITOK (Integrated team for opiateaddicts in Kriminalvården)
   and similar program in Malmoe
 • ITOK-NPF (Integreted team for treatment of inmates with
   neuropsychiatric disorders
 • Seperate wards for adjustment of maintenance treatment
   for opiatedependence (Fosie, Högsbo, Storboda and
New laws for compulsary psychiatric treatment
  • Accountability/responsibility imposed as a condition for
    legal action
  • Persons with severe mental illness will be sentenced to
    prison, but must start their enforcement in hospital
  • Former forensic psychiatric clinics will be clinics with
    certain agreement with the prison system
  • Persons with dementia and mental retardation will
    execute their sentence at separate wards suited to their
  • Inmates with severe mental illness, could after the
    sentence, if there is a risk for relapse, be forced by court
    to live in sheltered accommodations
Forensic psychiatry in the future
• Expanded investigation activities (accountability, severe
  mental illness, dementia/retardation
• No certain clinics, but clinics with agreement with The
  Prison system
• Need for the competence for both follow-up and
  assessment of recurrence-risk
• Establishment of out-patient clinics where inmates with
  mental illness can be refered
Responsibility of Forensic psychiatry (Optimistic)

Prevention   Prison-    In-patient   Out-patient   Cuntinued
support      services   care         care          support



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