Background: Patients in forensic mental health care experience internal and external coercion; the latter comprises different levels of institutional restraint. These restrictions of individual freedom are mainly justified by the safety interests of third parties and are not necessarily in the patients’ best interests. The effects of such a setting on mentally disordered offenders’ psychological state and treatment course are not fully understood. Assessing both patients’ perception of restraint and psychopathological symptoms would allow us to better understand how restraint and psychopathology interact and how they might influence treatment. Methods: In 184 forensic psychiatric inpatients, we assessed perception of institutional restraint with an adapted version of the Measuring the Quality of Prison Life (aMQPL) questionnaire and current psychological state with the Brief Symptom Checklist (BSCL) and Beck Hopelessness Scale (BHS). Results: Perceived institutional restraint (as expressed in the aMPQL subscales Transparency of procedures and decisions , Fairness , and Respect ) was associated with a higher general level of psychological symptoms. Furthermore, patients who perceived a lack of institutional transparency and respect were more likely to have higher scores for hostility, depression, and suicidal ideation. We also found age and sex differences, with higher levels of psychological symptoms in younger and female patients. The diagnosis and duration of detention did not relate to perceived restraint. Discussion: Our results indicate that certain aspects of institutional restraint in long-term forensic inpatient settings correlate with certain psychological symptoms. The observed association might be explained by different kinds of factors: institutional (custodial focus), individual (self-efficacy, diagnosis, and personality), and situational (duration of detention). Although not all of these explanatory factors were addressed by the present study design, forensic mental health professionals should be aware of the relationship between perceived institutional restriction and psychopathology because it might influence treatment course and outcome.

Background: Suicides are more common in forensic patients than in the general population. Two reasons for this discrepancy are discussed: (1) Suicides are the consequence of maladaptation to the restrictive living conditions in forensic psychiatry, and (2) suicides are explained by the demographic, social, and psychosocial characteristics of the inmates themselves, i.e., suicides happen because the inmates belong to a particularly vulnerable group. Therefore, the present study aimed to analyze the relationship between quality of life, as an indicator of the restrictive living conditions, and hopelessness, depression, and suicide ideations in a sample of forensic patients. Methods: We assessed quality of life with a German version of the Measuring the Quality of Prison Life questionnaire that had been adapted to forensic hospitals (MQPL-forensic) and depressive symptoms with the Beck Depression Inventory, hopelessness with the Beck Hopelessness Scale, and suicide ideations with the Beck Scale for Suicide Ideation. The study included a total of 159 patients in 12 German forensic psychiatric hospitals who had been admitted in accordance with Section 64 of the German Criminal Code. We analyzed the relationships between quality of life and depression, hopelessness, and suicide ideations on the patient and hospital levels. Hospital characteristics were generated by aggregating the MQPL-forensic variables measured at the patient level. Results: In generalized estimating equation models, the MQPL-forensic total score and almost all the subscale scores were significant negative predictors of depressive symptoms, hopelessness, and suicide ideations at the patient and hospital levels. At the patient level, patients who experienced a supportive welcome at the hospital, good relationships with their therapists, respectful interactions, transparent decisions, and supportive therapeutic approaches were significantly less depressed, less hopeless, and less likely to consider suicide. At the hospital level, good relationships with therapists and respectful interactions were significant negative predictors of these variables.

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Zusammenfassung Ziel der Studie Überprüfung des Zusammenhangs zwischen Depression, Selbstaggression und nach außen gerichteter Aggression. Methodik Mittels Mediatoranalyse wurde ein möglicher Mediatoreffekt der Selbstaggression auf den Zusammenhang von Depression und externalisierter Aggression an einer Stichprobe depressiver Patienten (n = 134) untersucht. Ergebnisse Selbstaggression mediiert den Zusammenhang von Depression und externalisierter Aggression. Schlussfolgerung Personen mit depressiver Erkrankung, die Aggression nach außen richten, richten diese auch auf sich selbst.

Background: In Germany, a large proportion of mentally ill offenders spends many years in a forensic psychiatric hospital. To ensure that the highly restrictive living conditions in these closed institutions meet patient needs, research must assess and analyze patient quality of life. For this purpose, we adapted the Measuring the Quality of Prison Life questionnaire to measure the quality of life in forensic psychiatric hospitals from the patient perspective. This study aimed to assess the reliability (internal consistency) and construct validity of the adapted questionnaire.Methods: To evaluate the questionnaire, a one-time survey was carried out at 13 forensic psychiatric hospitals in Germany. Item characteristics and internal consistency of the scale and subscales were calculated and the factor structure was tested using confirmatory factor analysis. To test of responsiveness we compared the mean quality of life between the 13 hospitals and further investigated whether the patients' evaluation of quality of life is depending on age and duration of accommodation.Results: The analysis of the psychometric properties revealed very good item characteristics and very good to excellent internal reliability. Construct validity was demonstrated. Patient's quality of life was significantly associated with age and duration of accommodation.Discussion: The adapted Measuring the Quality of Prison Life questionnaire is a reliable and valid instrument for measuring quality of life in forensic psychiatric hospitals and can be used in the future to compare hospitals and identify the strengths and weaknesses of each.