In Germany, there are only a few empirical studies on the prevalence of mental disorders in prison that examine a large, representative sample of a prison population with standardized diagnostic instruments and provide a diagnosis according to international classification systems. One study (Konrad 2004) examined the prevalence of mental disorders according to ICD-10 using a diagnostic expert system for mental disorders (DIA-X; Wittchen and Pfister 1997) within a sample of German male prisoners sentenced for not paying their fines (Table 10.2). The large percentage of persons (10 %) with a lifetime prevalence of psychotic symptoms is impressive. Another study (Missoni et al. 2003) examined the prevalence of mental disorders according to ICD-10 within a sample of German male remand prisoners (Table 10.2). Notable is the large percentage of persons (40 %) with lifetime prevalence of single or recurrent depressive episodes. Most of these depressive episodes, classified as adjustment disorders, would not have arisen without imprisonment as a psychosocial stress factor or, to be more precise, a critical life event.

Due to the research deficit highlighted above, current data are not available to enable appropriate treatment planning with regard to the needs of mentally disturbed prisoners. Thus, no empirical basis exists for determining whether prisoners in Germany – as elsewhere (e.g. Lamb 2001) – have an increase in mental disorders attributable to inadequate dehospitalization programs.

In-prison treatment has to address inmate-specific problems and circumstances, including post-release services. This includes both the functional impact and the severity of psychiatric symptoms (Harris and Lovell 2001). The high prevalence of mental disorders speaks in favor of the standardized application of diagnostic screening instruments as a component of the admission procedure in prison. German criminal law requires a medical examination, but no standardized psychiatric diagnostics, for every prisoner upon entering prison. “Out-patient” psychiatric treatment in prison is provided after the prisoner is referred by the staff physician to a psychiatrist.

The obligatory physical examination upon entering prison also includes an evaluation of a history of addiction in order to address possible dependency disorders or withdrawal symptoms. This is usually done according to a predetermined protocol (for example, the use of methadone and/or diazepam in decreasing doses for opiate withdrawal). The prison physician must assess suicidal risk, even if standardized instruments (e.g. Dahle et al. 2005) are not used.

Inpatient psychiatric care of prisoners is subject to wide regional variations in Germany. Some federal states (Baden-Württemberg, Bavaria, Berlin, Saxony, North-Rhine Westphalia) have psychiatric departments in penal institutions managed within the prison system. In the other federal states, in-patient and out-patient psychiatric care of prisoners is provided by external institutions and consulting specialists (Missoni and Rex 1997). External institutions for in-patient psychiatric care include forensic-psychiatric secure hospitals and general psychiatric facilities.

In-patient psychiatric care of prisoners in general psychiatric facilities frequently conflicts with the safety concerns of prison authorities. Their objections are reflected in the attitude of care-providing institutions, which – if they do not flatly refuse to treat prisoners, like 2/3 of the facilities in North-Rhine Westphalia and Rhineland-Palatinate do, question the treatment indication, willingness to be treated or responsiveness of the hospitalized patient and point out detrimental effects to the institution ranging from spoiling the therapeutic atmosphere to demotivating compliant patients and provoking recidivism (Konrad and Missoni 2001). It has been specifically stated that prison transferees disturb other patients, cause disciplinary difficulties and have a more demanding attitude. Based on the total number of hospitalized prisoners in North-Rhine Westphalia and Rhineland Palatinate in 1997, 0.1–2.3 % received in-patient psychiatric treatment in general psychiatric hospitals during their imprisonment (Konrad and Missoni 2001).

There are currently ten university institutes of forensic psychiatry and/or psychotherapy in Germany, which mainly provide expert opinions. Their involvement in psychiatric-psychotherapeutic care of prisoners as well as research projects and training of prison personnel is limited: only 2–7 prisoners are psychiatrically and 15 prisoners are psychotherapeutically treated by a university psychiatrist or psychologist on an out-patient basis. None of the university psychiatric institution in Germany offer in-patient psychiatric care for prisoners (Missoni and Konrad 1999).

There are no binding criteria in the German penal system for admission to a (n) (in-patient) psychiatric ward, especially no legal codes comparable to those governing hospitalization under civil law (so called PsychKG). In practice, prisoners who pose a danger to themselves, for example, after a suicide attempt or other self-destructive behavior, are frequently admitted. A special legal basis regulating hospitalization to psychiatric wards within the penal system does not exist; the penal detention code or criminal laws, which are federal law, neither stipulate nor prohibit psychiatric prison wards.