The medical services provided for inmates are regulated by law. There are medical care service units in all prisons and remand prisons in Sweden. This means that there is a nurse on duty during normal working hours and in some remand prisons there is a nurse on duty even on weekends and public holidays. Some of the nurses have psychiatric training, but this is not a job requirement. Doctors visit the prisons mostly on a weekly basis and the larger prisons and remand prisons also have psychiatrists who visit the prisons regularly. The nurses are employed by the prisons while the doctors are contracted as consultants and are paid by the prisons. The doctors are mostly remunerated at the same rates as private doctors in the community, which is higher than the salaries in the County Council Hospitals. All health care is at the level of an outpatient unit. If an inmate needs medical care as an inpatient, he or she will be transported to the local County Council Hospital. There are no prison hospitals in Sweden.

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 difference in the prescription of medications with a potential to be abused among the various prisons (benzodiazepines, opioides). The committee has been very active in following up the prescription of these medications. There is a unique documentation system concerning the prescriptions in different prisons and remand prisons and of the different groups of medicines, classified according to the ATC system (Anatomical Therapeutic Chemical classification system). The Committee publishes statistics every year and these provide very good feedback for every doctor. Since 1983, the Committee has published Basläkemedel inom kriminalvården (Basic Pharmacotherapy in the Prison and Probation Service), a booklet with recommendations for medication for the most common symptoms and diseases in the prison population. There is a new edition every second or third year.

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 problems and consists of a non-structured questionnaire without screening for suicidal behaviour. The security staff in Swedish remand prisons are trained to recognize disturbed behaviour and contact the health services if necessary. Many of them are specially trained to recognize suicidal behaviour. The risk of parasuicide or suicide is highest in remand prisons. Screening for suicidal behaviour is carried out at the beginning of the detention by the security staff with the help of a standard form. If the suicide risk is high, medical staff gets involved in assessment and prevention.

All inmates with substance abuse problems are offered screening for HIV and hepatitis A, B and C, and those who have not had hepatitis B are vaccinated.

Inmates may be isolated from other prisoners, either at their own request or on a compulsory basis if necessary. A doctor must examine a prisoner if he or she has been continuously isolated for a period of 1 month.

Any prisoners who are kept isolated from other prisoners because they present a danger to their own life or health, or who are kept in mechanical restraints (bound by belt), must be examined by a doctor as soon as possible.

There are round-the-clock routines for handling emergency health cases at every prison. If there is medical staff at the prison, they make the first assessment, otherwise the inmate will be taken to the nearest hospital.

According to the Official Secrets Act there is restricted access to information about patients within the health care services. The medical staff do not share information with the security staff and the patients’ medical files are kept separate, accessible only to the medical staff. Sometimes, mostly in cases of suicidal or self-destructive behaviour, the security staff form part of the treatment group; in this case they have access to the information about the patient they need.

The quality of psychiatric care in a prison is likely to meet the public mental health standards. Most of the psychiatrists have been working for a long time with inmates and can handle their problems well. However, most of the psychiatrists are not trained in addiction medicine and there is a need for this training.

All inmates who want to meet a psychiatrist are allowed to do so. In Sweden there is a shortage of psychiatrists in public health care services. Collaboration with the public mental health care services varies from region to region. If there is a need for psychiatric hospital care, mostly as compulsory treatment, inmates have to be referred to a Public Psychiatric Hospital. The staff in those units are usually not trained to handle the special problems of inmates (substance abuse and aggressiveness) and this mostly results in an early return to the prison. In some cities there are special wards which treat patients mostly from prisons (for example in Stockholm) and there the cooperation between the public mental health care services and the prisons is better.

Compulsory psychiatric care of inmates in Sweden is regulated by the Forensic Psychiatric Care Act, which is different from the Compulsory Psychiatric Care Act. Compulsory psychiatric care is only allowed at a psychiatric clinic and never in prison. For security reasons, the wards that can accept inmates for compulsory treatment must be approved by the government.

There are psychologists employed in every region, but the number varies from region to region. These psychologists are involved in both psychotherapy and treatment programs. Some prisons have consulting psychologists as well. Most of the psychologists have had psychodynamic training, but some of them work with cognitive methods but there are a few cognitively trained psychologists. Accessibility to a psychologist varies from prison to prison; in some places the psychiatrist assesses the need for psychological treatment, in other places the selection of clients to meet the psychologist is not made on the basis of evidence but on the demand of the inmate.

There are three diagnostic groups that are clearly overrepresented in the prison population: substance abuse disorders, personality disorders (including psychopathy) and ADHD (Attention-Deficit/Hyperactivity Disorder). The treatment of withdrawal symptoms is very common in remand prisons and is similar to the treatment used in addiction clinics. There are special treatment programs for preventing relapses into substance abuse and for sex offenders. Both drug addicts and sex offenders are placed in special wings with treatment programs. These inmates are generally not allowed to meet other prisoners. The drug addicts are protected from contact with drugs and the sex offenders from harassment by the other prisoners. Concerning personality disorders, there are cognitive training programs to reduce criminality and aggression. There are projects in some prisons for the diagnosis and treatment of ADHD.

Tobacco smoking has not been permitted in prisons, except in open-air areas, since January 2008. Inmates are given help for smoking cessation. The result is a decreasing number of inmates who smoke but an increasing number of inmates who use snuff.

Since 1987 (with an interruption from June 1999 to February 2002) an HIV-epidemiological study has been carried out at the main remand prison in Stockholm. All persons arrested or detained who were identified by injection marks or otherwise as illicit drug users were invited to participate in a voluntary study consisting of an HIV and hepatitis test and an interview on risk behaviour. This study helped to spread information about HIV and about possibilities for testing and improved the early identification of new cases. The number of HIV-tested drug addicts in Sweden is high and seroprevalence is low. This study developed into a program for screening inmates with substance abuse for HIV and hepatitis in all remand prisons in Sweden.

To improve the treatment of substance abusers in prisons, the CDG (Central Drug Group) was started up in 2001. The CDG is a specialist group connected to the Head Office, which prepares action plans, provides support and ensures quality. As a result of their work there are outreach teams in remand prisons, special units for motivation and treatment and therapeutic communities with evidence-based treatment programs. All these programs are now incorporated in the routine activities and the CDG has been disbanded. For the assessment of substance abuse the ASI (Addiction Severity Index) and MAPS (Monitoring Area Phase System) are used. Treatment of heroin addicts with buprenorphine or methadone starts before their release from prison if necessary, but the treatment is usually not provided during the whole sentence.

The aim of the Swedish Prison and Probation Service is to offer a drug-free environment to all inmates. In the battle for this goal there are some improved security arrangements – for example, sniffer dogs are now used.

There are no needle-exchange programs in prisons in Sweden. Annual random screening of urine-samples in the Stockholm region shows declining numbers of drug-positive results during the last 6 years. Eighty-six percentage of inmates were clean from all analysed drugs (14 % were drug positive samples, refusers or diluted urine samples). The main drugs used in prison are benzodiazepines, cannabis, buprenorphine and androgen anabolic streoids.

The budget for mental health care is a part of the overall prison budget. The nurses’ salaries are negotiated by their Trade Union, which is generally and traditionally very strong in Sweden. Up to now, the doctors have negotiated their appointment every second or third year with the Governor of the prison. These Governors are not medically trained, so they have a limited capacity to judge the doctors’ ability to work with the inmates. This has resulted in big differences in the doctors’ competence in prison medicine and addiction medicine. From 2006 onwards, negotiations concerning doctors’ appointments have been the responsibility of the Regional Director. In addition, there has been a centrally-placed coordinator for medical services in every region to assist the Regional Director since 2006.

The number of nurses has decreased during the last few years. The goal is that one nurse will be responsible for 100 inmates in the prisons.

There is no limit to the cost of medicine and every inmate is offered all necessary medication, but there is a central discussion about costs and the medical units try to use the cheaper generic medicines. This is similar to the situation in the general public, where pharmacists are supposed to provide patients with the cheapest generics.

The Forensic Psychiatric Act was passed in 1992. The purpose of this new act was to reduce the number of offenders sentenced to forensic psychiatric care and the number of forensic psychiatric assessments and to limit the number of forensic psychiatric assessments. This has also resulted in an increased number of prison inmates with psychiatric problems. There are no central statistics in Sweden about the number of inmates treated for mental disorders apart from suicide rates and substance abuse. However, the epidemiology of mental disorders has been investigated several times during the last 15 years.

To assess the need for psychiatric care in the prison system, Westin (1992) carried out an investigation in all the prisons in Sweden. A questionnaire was sent to the various prisons to find out how many inmates they had with a psychiatric illness (psychosis) and with other psychiatric disturbances (all those with a need of psychiatric care but without psychosis) and how many of them had substance abuse problems.

This questionnaire was completed mostly by nurses, sometimes by psychiatrists or by one of the security staff. The highest numbers of inmates with a psychiatric illness and disturbance were reported by psychiatrists. Therefore the results of the investigation might underestimate the problem. Table 20.2 shows the findings of this study.

A study carried out by Levander et al. (1997) assessed a prison population in South Sweden using structured interviews. The dropout rate was more than 50 % due to difficulties in speaking Swedish or English or in getting transport to other prisons. 30 % of the inmates had a lifetime prevalence of an Axis I disorder and 28 % at the time of the assessment; 75 % had a personality disorder and 23 % had a PCL-R score ≥ 26; 41 % suffered from dyslexia. Substance abuse figures were also high with 17 % for alcohol and sedatives, 24 % for narcotics and 19 % for alcohol and narcotics.

In another study, 50 inmates on Gotland (an island South-East of the mainland) were assessed. Personality disorders and/or substance abuse were diagnosed in 75 % of prisoners, psychopathy in 25 %, dyslexia in 50 %, and an Axis I diagnosis in 33 %. About 25 % had symptoms of ADHD.

During one year (September 1996–1997) Holmberg et al. (1999) investigated a total of 12,687 individuals who were detained at any time during the observation period. Of these, 294 inmates (2.3 %) received psychiatric treatment in hospital or in a psychiatric unit at least once. Inmates convicted of murder/manslaughter, arson, rape or unlawful threat were two to five times more likely to require psychiatric treatment than the general prison population. Furthermore, their average individual number of psychiatric inpatient days was approximately twice that of inpatients convicted of other types of crime.

While 10 % of the total study population underwent a pre-trial forensic psychiatric examination, 45 % of those who ended up receiving psychiatric treatment during their prison term had been investigated by a forensic psychiatric specialist before being tried in court.

There are central statistics of suicide rates within the prison system. The number of suicides has been stable at a low level throughout, see Table 20.3.

The Remand Prison Study is an ongoing study in Stockholm Remand Prison, it was later extended to the Gothenburg Remand Prison. The aim of the study is to assess drug abuse and provide screening for hepatitis A, B and C and HIV. Interviewing and taking blood samples are carried out by nurses; if a blood test is positive in any one of the analyses a doctor informs the individual about the result and invites the patient to follow up. Tables 20.4 and 20.5 show substance misuse, age of amphetamine and opiate users, number of intravenous drug users (IDU) who were HIV tested before the interview and the number of new HIV positive cases (Remand Prison Study, Non-published data).