jobs frequently due to impulsive, irresponsible, rule-violating, or aggressive behavior may display similar behavior in a therapeutic context, which is likely to result in the premature termination of treatment. Based on these considerations, a specific targeting of criminogenic needs such as self-control, anger issues, or lack of perseverance may provide positive improvements for both employability and treatment outcomes. Moreover, treatment approaches based on the Good Lives Model (GLM) would focus on employment and education issues, in order to equip individuals with the capabilities to achieve outcomes which were considered as desired and beneficial by the majority of the society (63). Tentative findings by Ullrich and Coid (23) as well as Yoon et al. (47) suggest that under certain circumstances, employment could act as a protective factor reducing the risk of reoffending.

#### Substance Abuse

Substance abuse emerged as a significant predictor of treatment dropout, but, paradoxically, was inversely related to the criterion variable: offenders who had a diagnosis of substance abuse were less likely to drop out of social-therapeutic treatment. This is remarkable considering that substance abuse is a risk factor and has previously repeatedly been linked to treatment dropout in violent offenders (2, 12, 14). In fact, substance abuse are especially difficult to treat and dropout rates from treatment programs for substance abuse are oftentimes higher than 50% (64). In drug abuse treatment programs, dropout is actually considered a risk factor, as it increases the likelihood of a relapse (65). Similar to the present results, the metaanalysis of Olver et al. (2) found a small negative correlation between substance use problems and sex offender treatment dropout (rw= −0.04), albeit this trend was not significant. Additionally, a study with 126 incarcerated sexual offenders also found that treatment completers were more likely to suffer from substance use disorder (66). The divergence in findings between sexual and violent offenders suggests that the relationship between dropout and substance abuse may be modulated by offender group. At present, we can only speculate why substance abuse is inversely related to treatment dropout. The finding may be explained by an increased allocation of resources to offenders with substance abuse. Being known as highrisk and difficult-to-treat individuals, offenders with substance abuse issues may have received additional treatment offers and were treated with particular attention to their needs. For example, the inmates of SothA-HH have access to an additional treatment for offenders with substance abuse. Future research is needed to investigate the role of substance abuse in predicting treatment dropout.

#### HCR-20 Sum Score

Every predictor for dropout already discussed is a component of the HCR-20: Therefore, an index as well as prior violent offense, psychopathic traits, substance abuse, and employment instability may contribute to a high risk indicated by HCR-20 sum score. Additionally, high HCR-20 sum scores can indicate clinical risk factors such as lack of insight, antisocial, and hostile attitudes or impulsivity, but also risk factors such as noncompliance and an antisocial environment that make a future without renewed violent delinquency unlikely. At the same time, all these factors probably contribute in part to making it more difficult to cooperate with and adapt to a social-therapeutic correctional facility.

#### Limitations

Several limitations should be noted and addressed by future research. First, data on the reasons for dropout could not be obtained. This could threaten the validity of the results, if participants who exit the SothA-HH due to a systemic factor, such as administrative transfer, were accidentally categorized as dropouts. It could render interpretation of the results difficult, as dropout due to administrative reasons cannot be explained in terms of offender characteristics or behavior but rather external circumstances beyond the offender's control. Despite this being theoretically problematic, exits due to systemic factors happen only rarely in practice and their number in the present sample should be negligible. Future research would benefit from more detailed information on dropout reasons as they could provide a better understanding of the nature of treatment attrition and its relationship to the independent variables under investigation. Second, the generalizability of the findings is limited to the present population. Although, the participation rate is with 81.5% satisfactory (especially for a prisoners' sample), we cannot exclude self-selection bias resulting from refusers. Moreover, cross-validation with a different sample is advised when assessing the model's performance in practice. This is of particular importance, as social-therapeutic treatment is distinct to the German penal system, posing a threat to external validity if transferring results to international contexts. Finally, the current study could not investigate if dropout from a social-therapeutic

#### REFERENCES

facility did in fact translate into the assumed higher recidivism rates. Future research should test this hypothesis to reach a better understanding of the relationships between diverse risk and protective factors, dropout, and recidivism risk.

#### CONCLUSION

Despite some limitations, the present study provides important insights into the relationship between numerous variables and treatment dropout. The results support the notion that dropouts represent a high-risk and high-need offender group with pronounced risk and psychopathy scores, violent offense histories, and higher unemployment rates. Violent index offense, unemployment at the time of incarceration, HCR-20 sum score, PCL-R Facet 1, and, surprisingly, absence of substance abuse disorder were identified as significant predictors of treatment dropout, raising important considerations for treatment practice. Further research is necessary to determine how these variables contribute to treatment dropout, and to examine which variables exert a possibly confounding influence on the relationship between unemployment and treatment dropout. Even though findings regarding the relationship between dropout and protective factors remain inconclusive, further research should investigate if reductions in treatment dropout may be achieved if programs were adapted to address strengths as well as deficits.

#### AUTHOR CONTRIBUTIONS

FB, IN, and PB designed the study. FB, DY, and MR collected the data. FB, IN, and ES analyzed and interpreted the data. IN wrote the initial draft of the manuscript in constant consultation with FB. FB, IN, ES, and PB had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of data analysis. All authors have contributed to, read, and approved the final version of the manuscript.

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The reviewer KD declared a past collaboration with one of the authors DY to the handling editor.

Copyright © 2019 Brunner, Neumann, Yoon, Rettenberger, Stück and Briken. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

# Confessions and Denials When Guilty and Innocent: Forensic Patients' Self-Reported Behavior During Police Interviews

#### Renate Volbert 1,2 \*, Lennart May 1 , Joscha Hausam1 and Steffen Lau3

1 Charité-–Universitätsmedizin Berlin, Institute of Forensic Psychiatry, Berlin, Germany, 2 Psychologische Hochschule Berlin, Berlin, Germany, 3 Department of Forensic Psychiatry, University Hospital of Psychiatry, University of Zurich, Rheinau, Switzerland

#### Edited by:

Birgit Angela Völlm, University of Rostock, Germany

#### Reviewed by:

Nubia G. Lluberes, University of Texas Health Science Center at Houston, United States Saul Kassin, John Jay College of Criminal Justice, United States

> \*Correspondence: Renate Volbert<EMAIL_ADDRESS>
#### Specialty section:

This article was submitted to Forensic Psychiatry, a section of the journal Frontiers in Psychiatry

Received: 24 September 2018 Accepted: 07 March 2019 Published: 29 March 2019

#### Citation:

Volbert R, May L, Hausam J and Lau S (2019) Confessions and Denials When Guilty and Innocent: Forensic Patients' Self-Reported Behavior During Police Interviews. Front. Psychiatry 10:168. doi: 10.3389/fpsyt.2019.00168 Several self-report studies together with analyses of exoneration cases suggest that suspects with mental disorder are especially prone to making false confessions. The present study asked 153 forensic patients in Germany about their behavior during suspect interviewing by the police. Self-reported ground truth of guilt and innocence was asked for, thereby taking into account that the risk of false confession is present only if a person has ever been interviewed when innocent. Indeed, surveying samples that include suspects who have never been interviewed when innocent may lead to underestimating the risk of false confessions. In the present study, all patients reported having been interviewed previously when guilty; and almost two-thirds (62%, n = 95), that they had also been interviewed at least once when innocent. These participants stated that they remained silent while being interviewed significantly more often when guilty (44%) compared to when innocent (15%). This corroborates laboratory research findings indicating that the right to remain silent is waived more often by innocent than by guilty suspects. Out of all 95 participants who were ever interviewed when innocent, 25% reported having made a false confession on at least one occasion. This result is in line with previous international research showing a high percentage of false confessions among suspects with mental disorder.

 However, for many reasons, it is difficult, if not impossible, to ascertain what the objective rates of false confessions might be, which offenses are confessed to falsely, and how frequently which different causal backgrounds emerge. Although most available knowledge on false confessions comes from analyses of exoneration cases (3, 4), self-report studies offer a further methodological approach.

### Prevalence Estimations of False Confessions Based on Analyses of Exoneration Cases

Founded in 2012, the National Registry of Exonerations has been documenting information about exonerations occurring in the United States from 1989 to the present (by 26.01.2019, this had amounted to 2,364 cases; www.law.umich.edu/special/ exoneration/Pages/about.aspx). For all offenses, the Registry reveals an average of 12% false confessions. At 23%, the proportion of false confessions for homicide is higher than that for all other offenses. However, a clear external criterion for the actual innocence of the exonerees does not exist for all cases listed in the National Registry of Exonerations. The Innocence Project in contrast, registers only cases in which the innocence of a previously convicted person has been confirmed by DNA analysis (362 cases by 26.01.2019; http:// www.innocenceproject.org). Evaluation of these cases, which are primarily violent crimes and sex offenses, reveals that in 28% of DNA exonerations, false confessions were a contributing factor (https://www.innocenceproject.org/dna-exonerations-inthe-united-states/).

In Germany, Peters (5, 6) analyzed about 963 cases of retrials between the years 1951 and 1964. In 724 of these cases, retrial led to an acquittal. Peters found that around 7% of the defendants who were acquitted in the retrial had originally made a confession. Assuming that the subsequently acquitted individuals actually were innocent, these are false confessions. However, as in the National Registry of Exonerations, no external criterion of actual innocence is available for all members of this German sample. Nonetheless, analyzing only a subsample that is more comparable to the sample in the Innocence Project reveals a similar proportion to that found in the United States: within the German sample, a false confession could be found in 5 out of 21 homicide cases (24%) in which the convicted was exonerated in the retrial proceeding after his or her innocence was confirmed. However, this investigation is more than 40 years old, and no recent information is available on the frequency of false confessions in Germany.

Analyses of exoneration samples refer typically to (a) cases of serious crimes that have a low base rate and (b) policeinduced false confessions (7) that were mostly withdrawn already at the end of the police interview but nonetheless led to a false—conviction (3). In contrast, voluntary false confessions, in which somebody confesses in the absence of any interrogation influence, are hardly ever found in exoneration samples; they may either not be prosecuted or convicted in the first place, or they are not withdrawn and no retrial is sought.

### Self-Reported Prevalence of False Confessions

Several studies have gathered self-reported information on false confessions in community samples as well as in samples of prison inmates. These reveal some consistent trends in the self-reported prevalence of false confessions [see, for a summary, (8, 9)]:

• Apart from one study in which nobody reported ever making a false confession (10), all studies—including those in community samples—revealed a small, but in no way negligible percentage of respondents who reported having already made at least one false confession (between 1.2 and 13.8% in community samples).

• When persons were surveyed who had already been interviewed repeatedly as suspects by the police, the proportion reporting having made a false confession in the past was larger and was almost always more than 10% and sometimes even more than 20% [between 6 and 24%; (8)].

However, several of the self-report studies were carried out in Iceland. Because false confession rates probably depend strongly on the given national boundary conditions (e.g., police interviewing practices), it is questionable whether these findings generalize to other countries. Although surveys from other countries are available (Bulgaria, Finland, Latvia, Lithuania, Norway, and Russia; 9), that also indicate differences between countries, findings are generally similar. However, no studies on self-reported false confession rates are available for Germany.

The most commonly self-reported motives for false confessions are succumbing to police pressure, protecting another person (the actual offender), and avoiding police detention (11). False confessions are self-reported most frequently for property offenses and serious traffic violations (11). In a study with mentally ill offenders (12), participants claimed that they made false confessions in order to stop police questioning, to protect the true perpetrator, because they succumbed to police pressure, or because they initially believed they were involved.

For logical reasons, suspects face the risk of making a coerced false confession only if the following preconditions are given: (a) the police suspects and interviews an innocent person; (b) the suspect waives the right to remain silent; and (c) there might be incriminating evidence, but evidence that definitely proves the guilt of the suspect is missing and cannot exist because of the suspect's innocence (13). Existing studies often neglect the very trivial fact that the risk of a false confession emerges only if a person has ever been interviewed when innocent. Hence, surveys of samples that include suspects who have never been interviewed when innocent may well-underestimate the prevalence of false confessions.

### Risk Factors for False Confessions

Studies on factors that may increase the likelihood of a false confession refer mostly to confessions that are policed-induced. These focus on investigative risk factors and refer to the police investigators' cognitive processes and behavior along with the influence of specific measures such as custody. Reviews of this literature can be found in Gudjonsson (14), Kassin (15), and Kassin et al. (2).

There are also personal risk factors for false confessions. These are personal characteristics of the suspect such as, in particular, young age, and mental disorder. Gross and Shaffer (4) analyzed 873 cases registered in the National Registry of Exonerations and found that youths and persons with mental impairment were particularly vulnerable: whereas the false confession rate among adults with no known psychological disorders or mental impairment was 8% (56/719); that among the under-18s, was 42% (39/92); and that among persons with a psychological disorder or mental impairment, was even 75% (53/70).

Mental problems have also been identified as a risk factor in self-report studies. Two out of three studies in which more than 20% reported having made a false confession in the past have investigated persons with mental disorders [(12): 22%; (16) cited in (8): 23%]. Participants claiming to have confessed falsely also reported having higher levels of illicit drug use and substance misuse treatment; more adverse life events (17); and higher levels of victimization, anxiety, depression, and anger (18) compared to people who never made a false confession. Self-reported false confessors were also found to have more antisocial personality characteristics than non-false confessors (10).

Self-report studies also show that false confessions occur more often among persons with a delinquent lifestyle: in comparison to non-false confessors, false confessors had been interviewed more often as suspects (19), arrested more often (11), sentenced more often to life imprisonment, had more years of offending (12), served more frequently and longer in prison, were younger at the time of their first criminal conviction and imprisonment (20), and had more delinquent peers (18). However, these variables might reflect at least in part the fact that people with a more extensive criminal history are interviewed more often by the police, and this, in turn, may increase the probability that they will be suspected falsely.

#### True Confessions

To identify specific features of false confessions, they have to be compared with the conditions in which true confessions emerge. Unfortunately, there are still surprisingly few estimates of how often suspects confess at all during police interviewing. Moston and Emgelberg (21) found that general confession rates ranged from 42 to 64% in the United States and from 55 to 62% in Great Britain.

Nonetheless, confession rates vary greatly depending on the sample. In Germany, Bippert (22) analyzed the files of 106 male defendants who had been convicted of homicide offenses, and found that 67% confessed during the course of the police interview. In retrospective interviews with 56 incarcerated male adolescents, Kraheck-Brägelmann (23) found that 45% made a full and 50% a partial confession. In a self-report study, Sigurdsson and Gudjonsson (24) also found a true confession rate of 92% among Icelandic prison inmates. However, these studies analyzed only cases that were prosecuted further. Thus, they probably included a disproportionately high number of cases in which strong evidence might have affected the decision to confess.

A review of all 743 suspects (irrespective of whether or not cases were further prosecuted) from one police department in Germany across the span of 1 year—thus including a variety of offenses—showed that 35% confessed, 15% denied the alleged offense, and 50% made no statement (25). A study in Great Britain with unselected police interviews revealed a confession rate of 39% (26). Note that these studies were unable to control whether either allegations or confessions were true or false.

Reported reasons for true confessions are, among others, the perceived strength of evidence (21, 27, 28), a need to clear one's conscience, police pressure (24), custodial pressure, and a desire to be released from police detention (29).

Research contrasting true and false confessions is almost nonexistent. One exception is Sigurdsson and Gudjonsson's (10) within-sample analysis of 51 alleged false confessor inmates in Iceland. This compared the false confession experience with the experience of their current true confession. Significant differences were found for external pressure (found to be higher for false than for true confessions), internal pressure, perception of proof, and legal rights (all found to be higher for true confessions). Another exception is Redlich et al. (30) betweensubject design with which they studied 30 true and 35 selfreported false confessors with mental illness in the United States. False confessors reported significantly more external and less internal pressure than true confessors. Taken together, true confessions show at least a partial overlap with the factors associated with false confessions (14). However, true and false confessions differ in terms of the prevalence and distribution of the reported motives.

The current study is the first to survey the behavior of forensic patients in suspect police interviews in Germany. Forensic patients are offenders who are ordered by criminal courts to either (a) detention and treatment in a secure psychiatric hospital (section 63 of German Criminal Law) or (b) detention in a secure custodial addiction treatment unit (section 64 of German Criminal Law). As pointed out above, the available studies suggest that false confessions are particularly frequent in this population. The goal of the present study was to determine whether a German sample would reveal a comparable proportion of false confessions to that found within this group in international studies. In one aspect, the present study goes beyond most previous research on selfreported false confessions: it takes into account that a risk of making a police-induced false confession is given only if suspects are interviewed when innocent and waive their right to remain silent. Therefore, we asked participants explicitly whether they had ever been interviewed by the police when they were innocent. Subsequently, we analyzed self-reported participants' behavior separately if interviewed when guilty vs. if interviewed when innocent; and we also calculated the proportion of truthful (true confessions and true denials) and false statements (false confessions and false denials) as well as the proportion of patients exercising their right to remain silent. We consider that viewing the proportion of selfreported false confessions as the proportion of cases in which someone has been interviewed when innocent provides a more appropriate estimate of the risk of making a false confession than estimates based on samples that include participants who have never been interviewed when innocent. By asking participants about their behavior while being interviewed when guilty and being interviewed when innocent, we also gathered information on true confessions, false denials, or decisions to remain silent.

#### METHODS AND MATERIALS

#### Participants

Participants were 153 patients (7 female and 146 male) with a mean age of 33.69 years (SD = 10.71, range from 20 to 67) detained in six forensic hospitals in Germany. Originally, 159 patients were recruited, but 6 were dropped because of language/communication difficulties.  The distribution of ICD diagnoses was as follows (multiple diagnoses possible): mental/behavioral disorders due to psychoactive substance use (68%); personality disorders (31%); mental retardation (22%); schizophrenia, schizotypal, and delusional disorders (12%); and others (5%).

#### Procedure

The study was approved by the Ministries of Social Affairs and Health responsible for forensic hospitals in the respective Federal States. Patients were informed about the survey by their physician or psychotherapist. Those willing to participate were asked to register on a list. Participants were interviewed individually by one of four interviewers. Before the beginning, interviewers explained the purpose of the study again, assured patients that their data would be used anonymously, and emphasized that they could drop out of the study at any time without having to fear any negative consequences. After that, patients were asked whether they were willing to sign a consent for both the interview and access to information on their current diagnosis (ICD-10) and sentence. After they consented, the questionnaire was read aloud and patients' answers were documented. Patients whose capability to give informed consent was questionable were not interviewed. Interviews lasted between 5 and 30 min depending on how many police interview constellations were reported by the patient.

### Measures

#### Questionnaire

A questionnaire was developed to gather information on the patients' behavior during police interviews. The first question asked whether the police had ever interviewed them as a suspect for an offense they had actually committed. If they answered in the affirmative, participants were asked how often they were interviewed in this way and whether they had remained silent, denied the offense, or confessed during these suspect interviews. Those who claimed to have confessed were asked about the reasons for their true confessions (presented in a yes/no format; multiple reasons were possible, see **Appendix**).

Next, patients were asked whether the police had ever interviewed them as a suspect for an offense they had not committed. If they answered in the affirmative, they were asked how often this had occurred and whether they had remained silent, denied the offense, or confessed during the interview. If suspects claimed they had made a false confession, they were asked about the number of false confessions, the offenses, and the reasons for these false confessions (yes/no format; multiple answers possible, see **Appendix**). Furthermore, they were asked about their age at the time of the false confession. We also asked patients whether they had been in a prison or in a forensic hospital before.

When answering questions on the reasons for making true or false confessions, patients were given a list of categories derived from the literature [see also (12)]. These categories could be subdivided further: suspects might, for example, infer mitigation because of wishful thinking, because minimization tactics were used, or because an explicit promise was made. However, given that these are retrospective data gathered from a relatively small sample of people with mental health problems, such distinctions were not made. Because the available studies indicate that reasons for making true or false confessions overlap, and the current study aimed to compare reasons for making true confessions with those for making false confessions, set response categories were preferred to an open response format.

#### Information on Current Sentence and Diagnoses

Information on patients' current sentences and diagnoses (ICD-10) was provided by the responsible psychiatrist.

## RESULTS

All participants confirmed that the police had interviewed them over at least one offense they had actually committed, with a range from 1 to 150 interviews (M = 14.71, SD = 23.14, Mdn = 6.00). A total of 95 (62%) reported that they were also interviewed as a suspect over at least one offense they had not committed, with a range from 1 to 50 interviews (M = 3.04, SD = 5.65, Mdn = 2.00).

Patients who reported having been interviewed when both guilty and when innocent did not differ significantly in terms of prior imprisonment, prior forensic treatment, or diagnoses from those who stated that they had never been interviewed when innocent—with one exception: the percentage of patients diagnosed with schizophrenia, schizotypal, and delusional disorders was significantly smaller in the subsample with guilty and innocent interviews (6%) than in the subsample with only guilty interviews (20%; Fisher exact test p =0.015).

### Self-Reported Confessions, Denials, and Exercising the Right to Remain Silent

**Table 1** displays the distribution of confessions, denials, and exercises of the right to remain silent in both conditions. Because measurements were repeated in the subsample of 95 patients who were interviewed when both innocent and guilty, whereas this was not the case for the remaining 58 patients, individual McNemar's chi-square tests were computed for each of the three interview variants (confessions, denials, exercise of the right to remain silent) in the 95 patients who reported both types of interviews (guilty/innocent). Results showed significant differences (all p < 0.001) between interviews in which patients were interviewed when guilty vs. innocent for all three interview variants. Participants reported more confessions when guilty (78%) than when innocent (25%), and more denials when innocent (79%) than when guilty (35%). They also reported significantly more frequently waiving their right to remain silent when innocent (85%) than when guilty (56%).

#### False Confessions

A total of 24 patients reported having made at least one false confession. This represents 16% of the whole sample TABLE 1 | Reported behavior during interviews when guilty and when innocent (in brackets: frequencies for the subgroup that reported having been interviewed when both guilty and innocent).

Multiple answers possible; therefore, percentages do not add up to 100. Number of affirmative answers (n).

(24/153). But this percentage is somewhat misleading, because 58 patients were not at risk of confessing falsely, having never been interviewed when innocent. How these 58 patients would have behaved had they been interviewed when innocent remains an open question. Of the 95 participants who had been interviewed when innocent, 25% (24/95) reported having confessed falsely at least once. The prevalence rate increased further to 28% when including only those participants who (a) were interviewed when innocent and (b) made a statement (24/86). These 24 patients reported a total of 38 false confessions, ranging from 1 to 7 false confessions per patient. Fifteen of the 24 patients reported having been convicted after making a false confession. False confessions referred to property offenses (n = 15), violent offenses (n = 7), homicide (n = 2), drug offenses (n = 2), and other offenses not covered by these categories (n = 7).

#### Reasons for Confessions

"Strong evidence" (65%) and "hope for mitigation of sentence" (41%) were the most frequently reported reasons for true confessions, whereas the most frequent reason for false confessions was "protecting the real perpetrator" (63%). A substantial minority of participants reported "hope for release from custody," "interviewing pressure," and "feeling of physical discomfort (e.g., being overtired)" as reasons for true and for false confessions (**Table 2**). The group of 24 false confessors was, in a sense, divided: the 15 patients who claimed to have protected the actual perpetrator named only three other reasons (2 x being pressured by the real perpetrator, 1 x hope for mitigation of sentence). All other reasons were given by the remaining 9 false confessors.

### Differences Between Confessors and Non-confessors

Fisher exact tests were calculated to examine differences in diagnoses and prior delinquency between (a) guilty confessors and guilty non-confessors and (b) innocent false confessors and innocent non-confessors. Results are displayed in **Table 3**.

#### Guilty Confessors vs. Guilty Non-confessors

Compared to guilty confessors, guilty non-confessors were more often diagnosed with a mental and behavioral disorder due to psychoactive substance use (ICD-10 F10–F19; 64 vs. 86%; Fisher exact test, p = 0.026). No other significant differences were found. TABLE 2 | Self-reported reasons for true and false confessions.

aAsked for true confessions only.

bAsked for false confessions only.

cFor example: "I am not able to lie" or "My family should not know." dFor example: "I did it out of love" or "I wanted to be part of the clique." Multiple answers possible; therefore, percentages do not add to 100.

#### Innocent False Confessors vs. Innocent Non-confessors

No significant differences were found.

### DISCUSSION

The current study examined German forensic patients' selfreports on their behavior while being interviewed by the police when either innocent or guilty. All patients stated that they were interviewed by the police for at least one offense they had actually committed. Almost two-thirds of the forensic patients (62%) reported that they had also been interviewed at least once in the past when innocent. Little is known about how often people undergo a suspect interview when they are actually innocent. The results of our study suggest that being interviewed as a suspect when innocent is not a rare experience for people with a criminal record.

Most patients in the current study (81%) reported having made a true confession when they were guilty during at least one of the police interviews. The majority also reported having made a truthful statement during police interviews when innocent (79% true denials). Taken together, the most frequent behavior during police interviews was reported to be making a truthful statement, irrespective of whether patients were guilty or innocent [see also (9)]. Notwithstanding, a substantial proportion of false denials (31%) and false confessions (25%) was also revealed.

TABLE 3 | Frequencies and percentages of ICD-10 diagnoses and self-reported delinquency by confessors and non-confessors split for interviews when guilty and innocent.

\*p < 0.05.

### True Confessions

The prevalence of true confessions (81%) in the current study exceeded the range of confession rates found in international studies [43–76%; (21)]. However, studies with samples of incarcerated inmates have also revealed comparable or even higher prior confession rates (20, 23).

#### False Confessions

The percentage of self-reported false confessions within the whole sample was 16% (24/153) and thus in the range of comparable surveys of prison inmates in other countries [6– 24%: (8)]. Nonetheless, the proportion of false confessions within the whole sample was slightly lower than the 22% reported by Redlich et al. (12) who also surveyed a sample of offenders with mental disorders.

However, by calculating a proportion of self-reported confessions within a whole sample, one might wellunderestimate the actual prevalence: suspects face the risk of making a false confession only if they are (a) interviewed when innocent and (b) waive their right to remain silent. This is at least true for police-induced confessions. People can, however, come forward to the police with a voluntary false confession without being suspected before. In these cases, a suspect interview would not be conducted without the confession in the first place. From the examples patients mentioned during the survey, it can nonetheless be assumed that this was often not the case in the current sample. Participants reported on cases in which, for example, they knew the real perpetrator but were mistaken for the culprit by the police. Or they were interviewed for an offense they actually had committed while they were additionally alleged to have committed a crime for which they were not responsible.

Whereas, the percentage of self-reported false confessions within the whole sample was 16%, this rose to 25% (24/95) in the subgroup of participants who had at some time been interviewed when innocent. Put differently, one in four forensic patients who ever had the opportunity to make a false confession claimed to have done so. Out of those suspects who made a statement while being interviewed when innocent, 28% (24/86) reported having falsely confessed in at least one of these interviews. Altogether, we view the proportion of false confessions that refer solely to interviews when innocent as a more appropriate estimate for the risk of making a false confession in a police interview than the proportion reported in most previous studies that gave only the overall prevalence (proportion of false confessions within the whole sample).

In line with other self-report studies, property offenses were the most common type of offenses for which the patients claimed to have confessed falsely [e.g., (11)].

### Waiving the Right to Remain Silent

Whether patients denied, confessed, or exercised their right to remain silent during the police interviews differed significantly between interviews when guilty and when innocent. For denials and confessions, these results are rather trivial. Less trivial, however, is the result that significantly more patients stated that they had waived their right to remain silent at least once while being interviewed when innocent (85%) compared to interviewed when guilty (63% when looking at the total sample; 56%, when looking at the 95 participants who were interviewed when both guilty and innocent). This result is in line with Kassin's claim that "innocence puts innocents at risk" [2005; see also (2)]. A series of experimental studies have demonstrated that innocent suspects are more forthcoming than guilty suspects [e.g., (31, 32)]. Hence, the field data from the current study support these previous findings.

### Reasons for Confessions

Focusing on the suspects' confessions, we asked them why they gave a true or false confession. Overall, the most frequently reported reason for a false confession was to protect the real perpetrator (15/24; 63%). This reason for false confessions is frequently reported in all self-report studies. However, the percentage in the current study was even higher than in other self-report studies (11, 12). In contrast, interviewing pressure (6/24; 25%) was claimed less frequently in comparison to the percentages reported in international studies [e.g., (11, 12)]. Whether these differences are due to differences in the way police carry out their interviews in different countries or to different samples characteristics cannot be determined from the current data.

It should, however, be emphasized that police interviewing pressure still constitutes the second most frequently reported reason for a false confession in the current study. Moreover, a combination of different situational factors resulting from police interrogation tactics (interviewing pressure, claims by the police that the evidence was strong, hope to be released from custody, hope for mitigation of sentence) were reported by almost 40% of all cases (9/24). These factors point to substantial social-psychological influences. Even when protecting the real perpetrator is given as the reason, in many cases such constellations do not represent the classic version of a voluntary false confession in which a person confesses in the absence of any external influence (7). It is far more often the case that these patients were interviewed as suspects for an offense that was actually committed by a person they knew and that they then confessed during the police interview. Many of these patients would possibly not have falsely confessed without the situational effects of interrogation.

With respect to true confessions, the most commonly reported reason was that the evidence was strong. This suggests that strength of evidence is crucial for the decision to make a true confession, and this is once more in line with existing empirical evidence (21).

Taken together, some motives were inherently found to be exclusive to true confessions (evidence was actually strong) or false confessions (protecting the real offender, being pressured by the real offender), but there is also an overlap of motives reported for both kinds of confession (interview pressure by the police, hope for release from custody). Nonetheless, possible responses were limited by the categories used in this study. To explore the reasons for true and false confessions in a more differentiated way, future research should include interviews with true and false confessors.

### Differences Between Confessors and Non-confessors

In the current study, prior imprisonment tended to be more prevalent among innocent false confessors compared to innocent non-confessors (71 vs. 57%). However, this difference was not statistically significant. Although this lack of significance may be due to the small number of cases, one might also argue that a longer criminal history will be associated with a higher number of suspect interviews and thus with a higher probability of being interviewed when innocent. Previous findings showing an association between criminal history and false confession (11) might simply reflect the heightened probability of being interviewed occasionally when innocent. However, in the current sample, participants who were interviewed only when guilty did not differ in terms of prior imprisonment and prior forensic treatment from those who were interviewed when guilty and when innocent.

Patients diagnosed with a mental retardation did not selfreport higher false confession rates than other patients. This was rather unexpected in light of existing research on the vulnerability of suspects with low intelligence [e.g., (33)]. The present result may be due partly to a self-selection process: patients with more severe intellectual deficits probably did not volunteer to participate in this study or could not be included because they lacked the capacity to give informed consent or had difficulties in understanding and answering the questions.

#### Limitations

Some limitations have to be addressed: first, the sample probably does not represent the population of forensic patients in Germany. Participation required sufficient intellectual capacity to understand the questionnaire, maintain attention for a period of time, and communicate with basic German language skills. This might have excluded patients who may be even more prone to false confessions. Second, reports are based on persons and not interviews. Asking participants to report an interview behavior that they had displayed at least once in the past may have distorted the data on participants with multiple police interviews. They may well have shown the reported behavior only in one exceptional situation that deviated from their typical—more frequently shown—interview behavior. However, this approach can certainly be used as a basis to estimate whether a certain interview behavior (e.g., a false confession) has ever been shown. Nonetheless, the study is further limited by the questionable validity of self-report information with its susceptibility to motivational and memory errors. There is a lack of external criteria to corroborate the reported information on behavior during police interviews. Nevertheless, it should be emphasized that the percentages of self-reported false confessions in international studies are quite similar to those in the current study. In addition, those groups that have already proven to be vulnerable on the basis of exoneration file studies also prove to have higher false confession rates in self-report studies than others, and this can be viewed as supporting the validity of the selfreport data.

### CONCLUSIONS

Results of the current study confirm previous international selfreport studies showing that a false confession is not a rare event. Rates are similar to those found in the international literature on persons with mental disorder.

Until recently, these findings had received little attention in German law enforcement practice (34). However, in 2017, the German Parliament passed legislation requiring certain suspect interviews by the police, including interviews of underage suspects and of suspects with mental disorder or disorders, to be audio- or videotaped from 2020 onward (35).

The current study shows—together with other self-report studies [e.g., (12)]—that examining only exoneration cases might lead to the wrong impression that false confessions occur mainly in response to severe allegations. Proven false confessions in exoneration cases typically refer to offenses such as homicide or sexual assault that have a low base rate. In contrast, self-report studies suggest that false confessions occur frequently in more prevalent but less serious crimes. Self-reported false confessors name the protection of the true perpetrator as a frequent reason for a false confession [see also (8, 9)]. However, this does not necessarily mean that people enter the police station and confess to a crime despite never being suspected. In contrast, the patients were often erroneously interviewed as suspects for an offense that was actually committed by a person they knew, and they only made a false confession during the course of the police interview. Because many of the false confessors also stated reasons that indicate the situational effects of the suspect interviews, substantial social-psychological influences should be assumed in these cases. Based on the current data, it is not possible to state conclusively whether the circumstance that the patients knew the true offender was the actual reason for a false confession; or made them more vulnerable to interrogative influences in the sense that a false confession may constitute the alternative to betraying a peer. Future research should address this question by including interviews with innocent confessors and non-confessors.

#### REFERENCES

### DATA AVAILABILITY

The raw data supporting the conclusions of this manuscript will be made available by the authors, without undue reservation, to any qualified researcher.

### AUTHOR CONTRIBUTIONS

RV and SL contributed the conception and design of the study. LM, JH, and SL organized the data acquisition and carried out data collection. LM performed the statistical analysis. LM wrote the first draft of the manuscript. RV wrote parts of the manuscript and revised the draft. All authors read and approved the submitted version.

### FUNDING

We acknowledge support from the Open Access Publication Fund of Charité–Universitätsmedizin Berlin and the German Research Foundation (DFG).

### ACKNOWLEDGMENTS

We would like to thank Bianca Pöschel for her help in preparing the study and collecting data.

der Rechtspsychologischen Forschung. Weinheim: Psychologie Verlags Union (1997). p. 287–301.

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2019 Volbert, May, Hausam and Lau. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

## APPENDIX

Why did you truly confess? Because the evidence was strong. I wanted to ease my conscience. Because of the interviewing pressure. I was hoping to get released from custody. I was hoping to get a more lenient punishment. I was physically not well (e.g., overtired) Other: Why did you falsely confess?

I wanted to protect the real perpetrator. I was pressured by the real perpetrator to confess. Because of the interviewing pressure. The police claimed the evidence to be strong. I was physically not well (e.g., overtired) I was hoping to get released from custody. I was hoping to get a more lenient punishment. I wanted to attract attention. I felt guilty. I was convinced to be the perpetrator. Other:

# Suicide in Older Prisoners in Germany

Annette Opitz-Welke1,2 \*, Norbert Konrad2 , Justus Welke3 , Katharina Bennefeld-Kersten4 , Ulrich Gauger 2 and Alexander Voulgaris 5

1 Justizvollzugskrankenhaus in der JVA Plötzensee, Berlin, Germany, 2 Institut fúr Forensische Psychiatrie der Charité Berlin, Berlin, Germany, 3 Federal Joint Committee, Berlin, Germany, 4 Institut für Suizidforschung, Reßdorf, Germany, 5 Institut für Sexualforschung und Forensische Psychiatrie, Universitätsklinikum Hamburg Eppendorf, Hamburg, Germany

As in many countries, the numbers of older prisoners are rising in Germany, but scientific information on this group is scarce. For the current study, a survey was used that included all prison suicides in Germany between the years of 2000 and 2013. Suicide rates of the elderly prisoners exceeded the suicide rates of the general population and the same age group. We observed a continuous decrease in the suicide rate of elderly prisoners. When compared to the younger suicide victims in prison, significantly more elderly suicide victims were: female, of German nationality, remand prisoners, or serving a life sentence. In Germany, elderly prisoners are a vulnerable subpopulation of the prison population. Higher suicide rates than in the same age group in the general population indicate unmet needs regarding mental disorders and their specific treatment.

#### Edited by:

Athanassios Douzenis, National and Kapodistrian University of Athens Medical School, Greece

#### Reviewed by:

Georgia Kalemi, University General Hospital Attikon, Greece Elmar Habermeyer, Psychiatric University Hospital Zurich, Switzerland

#### \*Correspondence:

Annette Opitz-Welke<EMAIL_ADDRESS>
#### Specialty section:

This article was submitted to Forensic Psychiatry, a section of the journal Frontiers in Psychiatry

Received: 24 September 2018 Accepted: 01 March 2019 Published: 29 March 2019

#### Citation:

Opitz-Welke A, Konrad N, Welke J, Bennefeld-Kersten K, Gauger U and Voulgaris A (2019) Suicide in Older Prisoners in Germany. Front. Psychiatry 10:154. doi: 10.3389/fpsyt.2019.00154 Keywords: prison, suicide, older prisoners, male prisoners, mental health care, suicide rate

## INTRODUCTION

For the longest time in history, prison was a matter of the young. Today, in Europe and North America the number of elderly prisoners is rising, although they are still a minority in prison (1). Currently, about 10–16% of the prison population in the western world is over 50 years old and about 3% is over 60 (2). Reasons for the growing number of elderly prisoners are manifold. One unspecific factor is that life expectancy is increasing in general, leading also to aging prison populations (3). Furthermore, older prisoners tend to receive longer sentences often as a consequence of repetitive reoffending (4).

In general, the cut-off age for older persons is 60 years (5), but it has been variously discussed that prison inmates should be considered as old at an earlier age, mostly because analysis of mortality rates revealed that aging is accelerated for persons with a history of incarceration when compared to the general population (6). Therefore, studies on older prisoners have been using different age-groups ranging from 40 to 65 years (3, 6, 7). Comparing frequencies and percentages of age used to denote older inmates, the most common minimum age criterion was 50+ years (8). Findings from an interview study with ex-convicts with a mean age of 55.8 years suggested that this group was characterized by a specific combination of health problems, combining symptoms of post-traumatic stress disorder, social-sensory disorientation, and alienation (9).

In many aspects older prisoners are a vulnerable group. They lack in physical strength compared to their younger inmates what puts them at risk of bullying, harassment, and violence. Due to overcrowding and inadequate resources, they may face more difficulties in getting their specific needs met. In addition, the prison environment of today is not designed to meet the needs of patients at risk for dementia (10). On the other hand, incarceration may actually have health

**123**

benefits especially for men of the lower or middle class, because life in prison offers regular meals, the possibility to rest often and access to health care services (11, 12). Evaluating data on 87 longterm prisoners over an average period of 14.6 years, Dettbarn was unable to prove a damaging effect of long-term imprisonment (13). Analyzing the cause of death in male prisoners in England and Wales over a period of 20 years, a lower standardized mortality ratio (SMR) was revealed for prisoners compared to the general population and the SMR for the age band 60+ was lower than for the younger age bands (14).

Regarding the prevalence of severe mental disorders, there is evidence that prisoners all over the world are more often mentally ill and that they are affected prematurely by cognitive impairment (15, 16). According to Fazel et al. 10% of male and 14% of female prisoners are diagnosed with severe depression (17). Furthermore, suicide is a leading cause of death in prison (18). Regarding the prevalence of cognitive impairment in older prisoners, a study of Kingston et al. showed that 12% of the examined prisoners aged 50+ years demonstrated signs of cognitive impairment and 50% were diagnosed with a mental disorder. In spite of the high proportion of mentally impaired older prisoners, only 18% received an appropriate, prescribed medication. Therefore, Kingston pointed out that the mental health needs of older prisoners tended to be undetected and untreated. Interviews with prisoners aged 59+ years in England and Wales revealed a high prevalence of depressive disorders, which was five times higher than that found in other studies of younger prisoners and elderly men in the community (19). In an interview study with 124 prisoners aged 50+ years, Barry et al. demonstrated that a past alcohol dependence and a poor self-rated health were associated with elevated suicidal ideation. Altogether, in their study, 22% of the older prisoners were showing current suicidal ideation and 12% were reporting active suicidal ideation (20).

### THE AIM OF THE STUDY

As in many other countries, the number of older prisoners (age ≥ 50 years) in Germany continuously increased from 2000 to 2013 (21–24). Sound scientific evidence on this matter is scarce. To our knowledge, our study is the first publication on elderly German prisoners who committed suicide. For the first time, a suicide rate of elderly German prisoners will be determined using data of an exhaustive nationwide suicide survey. Our hypotheses are:

### MATERIALS AND METHODS

Data on all prison suicide events in Germany from the years 2000 to 2013 were collected from a survey using a specific questionnaire on each suicide event in prison. The survey was completed via the reports on exceptional events found in the routine prison documentation and was endorsed by the respective ministries of justice of the German Federal Lands. The respective federal institutions rated the questionnaires, and only 3 Federal Lands were not able to provide the rating of the questionnaires. In these federal lands, the "Generalakten" (Summary files for each prisoner that contain all respective data) were extracted by one of the authors (25). The survey of suicide events in prison comprised a period of 14 years, from January 2000 to December 2013.

The questionnaire that was used for the survey assessed socioeconomic data, data concerning the execution of the sentence and data concerning the course of imprisonment. The items of the questionnaire refer to the history of the prisoner. Since only aggregated data are published, no concern exists for disclosure of personal data. All items, except date of birth, were coded dichotomously. In German prisons, documented medical data is confidential and therefore not part of the "Generalakten." For that reason, information gained by health professionals is not included. Some variables were assessed incompletely, these are marked by an asterisk.

Sociodemographic data: gender, date of birth, country of birth, nationality, religion∗ , marital status∗ , number of children, housing before incarceration∗ , education∗ , professional qualification∗ , employment before incarceration∗ .

Data on the execution of the sentence and circumstances of the suicide: pre- or post-trial status, number of prior incarcerations, homicide, sexual offenses, actual sentence in month, alcohol/drug involved in actual offense, substance abuse, addiction therapy∗ , remand status, symptoms of alcohol withdrawal∗ , symptoms of drug withdrawal∗ , criminal behavior at a young age, criminal behavior involving close friends or relatives∗ , mental disorder∗ .

Data concerning the course of imprisonment: aggressive behavior, suicidal behavior, physical attacks, social contacts∗ , privileges∗ , escape, disciplinary measures∗ , bullying∗ , date of suicide, cause of death, suicide note, security measures∗ .

In accordance with publications on the elderly prison population, we chose the cut-off age of 50 years for older prisoners in our study (8). For calculating the suicide rates, the number of all subjects imprisoned in the respective years from 2000 to 2013 was taken from the annually published volumes of the German official demographic statistics (26). These reports provided the numbers of prisoners in 5-year age categories (e.g., 20–25, 25–30). Trends in the suicide rates were analyzed by linear regression for the years 2000 to 2013 and age groups (old vs. young) were compared using an ANCOVA-approach. The model we defined uses the suicide rate as dependent and year and age as independent variables. Both suicide rate and year were treated as numeric, while age was coded as 0/1. With that approach, the interaction effect of age and year can be tested. The suicide rates were standardized in order to make them comparable. Subsequently, a linear model was defined in order to test the interaction effect of the age groups and the year. Due to the small number of female prisoners that committed suicide in our sample, we focused the analyses for trends in prison and in the community on male subjects.

Data were analyzed using Pearson's Chi² test for r × c tables. These univariate analyses were done in order to get an overview regarding the possible relationships between variables. In order to identify factors describing the group of the elderly prisoner population, a logistic regression model was developed. Because variables with too many missing cases potentially bias the results, only those variables with at least 60% of valid values were used. The cut-of value of at least 60% valid cases was chosen arbitrary. The model was developed including in a first step all variables as independent predictors for the outcome to belong to the group of elderly prisoners that committed suicide. In a second step, only the statistically significant predictors from step 1 were considered. We presented the p-values and the odds-ratios with the confidence intervals. The statistical analyses were conducted with the statistical software R (ver. 3.5.0).

#### RESULTS

In the period between the years 2000 to 2013 in total 30 women and 1,037 men died from suicide in German prisons. One hundred seventy-seven men and 11 women (17.6% of all suicide victims) were 50 years of age or older at the time of their death. The suicide rates in prison were consistently higher in the group of older prisoners (age ≥ 50 years). The summary suicide rate from 2000 to 2013 for all age groups was 1,249 per 100,000 prisoners; for younger prisoners (<50) 1,157 per 100,000, for older prisoners 2,042 per 100,000 prisoners.

The suicide rates for men by year and age group were calculated for the prison population as well as for the general population (**Table 1**).

A downward trend in the suicide rates in prison applied to both age groups in male prisoners. The downward trends between the group of younger and older prisoners differed

TABLE 1 | Male suicide rates in German prisons and in general population <50 vs. ≥50 years per 100,000 from 2000 to 2013.

not significantly (Interaction year × age 0.13, t-statistic 1.75, p = 0.09). Parallel to the findings in the prison system, a downward trend in the suicide rates for the general German male population applied to both age groups, but did not differ statistically significantly either (Interaction year × age 0.04, tstatistic 0.65, p = 0.52). Although the suicide rates of the older prisoners declined continuously from 2000 to 2013, the suicide rates were still higher in comparison to the suicide rates of younger prisoners (**Figure 1**).

**Table 2** shows variables with potential impact on suicidal behavior. Between the younger and older (age ≥ 50 years) suicide victims, there was no statistically significant difference regarding remand status, the perception of high suicide risk by prison personnel, reported bullying preceding the suicide, history of former suicide attempts or special security measures applied. There was a significant difference between the age categories concerning drug withdrawal symptoms, but not for alcohol. Female gender, lifelong sentence, a conviction for crimes against close relatives and sexual offenses were significantly more often positive in the elderly suicide victims. Furthermore, there were statistically significant lower proportions of older suicide victims with a non-German nationality.

To create a regression model, variables with missing data in more than 40% of the cases were excluded. Consequently, the following items were excluded: bullying, mental disorder, crime involving a close relationship, drug, and alcohol withdrawal and security measures. The initial model included 6 variables (**Table 3**).

The stepwise removal of variables in the analysis resulted in a model with 4 independent variables: gender, remand status, lifelong sentence, and German nationality (**Table 4**).

The odds ratios indicate that being female, of German nationality, in remand custody or lifelong sentenced as independent predictors to belong to the elderly group.

#### DISCUSSION

As hypothesized, between the years 2000 to 2013 the suicide rates of German prisoners aged 50 years and older were higher than the suicide rates of prisoners younger than 50 years. The suicide rates were in general higher in both age groups of prisoners than in the community. We observed a downward trend in both age groups and were able to identify characteristics in the older prisoners who committed suicide in prison that differed statistically significantly from the younger prisoners. The relevant factors that we identified were being female, German nationality, remand custody status, and a lifelong sentence. These factors proved to be independent predictors for belonging in the group of older prisoners that committed suicide.

The finding that the suicide rate of older prisoners exceeds the suicide rate of the younger prisoners is in accordance with results from Donahue et al. who identified older prisoners as a new vulnerable group. According to their findings, elderly prisoners are characterized by a combination of mental and physical health problems and a high rate of vulnerability, and victimization (27). A systematic review of middle-aged and older adults supported a

significant association between functional disability and suicidal ideation with depression as a mediator between the two (28).

Kammerer and Spohr interviewed 18 men aged between 65 and 76 and asked them about their situation. The results showed that offers focused on the specific needs of this age group were rated positively, but that further need was apparent (22).

Looking at variables independently in association with age in German prison suicide victims revealed that the items "remand status" and "lifelong sentence" were associated with an increased risk of death by suicide in the group of older prisoners when compared to younger male suicide victims. Higher suicide rates in older remand prisoners may indicate a reduced ability of this age group to cope with imprisonment. In addition, elder men may be disadvantaged regarding physical strength and assertiveness in conflicts with younger inmates, which may result in difficulties to adapt to the prison environment and could lead to a depressive mood and suicidal ideation. Liem and Kunst introduced the idea that older prisoners frequently demonstrate a unique set of mental health problems related to post-traumatic stress disorder. They interviewed ex-prisoners who were released after serving a lifelong sentence and found a specific cluster of mental health problems characterized by institutionalized personality traits, social-sensory disorientation, and alienation. The authors argue that untreated or undertreated mental health problems hinder the successful re-entry into society. Furthermore, these mental health problems may explain the high prevalence of illicit drug abuse, the social withdrawal and (at least partly) the elevated suicide rate (9). According to our findings, Fazel et al. revealed an association between prison suicide events and being sentenced to life in prison in a systematic review (18). Our findings, that older prisoners with a lifelong sentence have a higher risk of committing suicide than their younger counterparts, support the assumption of Turner et al. that older prisoners face a "double burden," facing a de facto lifelong sentence when incarcerated at an older age (4). Elevated suicide risk in this group may thus be an expression of hopelessness and unmet social needs.

When comparing the groups of younger and older prisoners that committed suicide, we surprisingly observed no differences in the prevalence of mental disorders. The low prevalence of mental disorders in our data set is in stark contrast to findings from medical chart reviews, which report much higher rates of depression and mental disorders in general in older prisoners from 38 to 61% (7, 21, 27). The low prevalence of mental disordersin this group may be a result of the specific difficulties in older prisoners expressing their needs. According to de Smet et al. who studied factors related to the quality of life in older prisoners, psychiatric symptoms seemed to be noted less often in this age group because "older prisoners seem to be poorer self-advocates" than their younger mates (29).

Comparing older German and non-German suicide victims revealed a lower suicide rate in older non-German prisoners. This result is in line with findings from Radeloff et al. who described a significantly higher suicide rate among male German prisoners

\*p <0.05; \*\*p<0.01; \*\*\*p <0.001.

in comparison to male non-German prisoners (30). This finding contrasts with scientific evidence that immigration is a risk factor for death by suicide (31, 32). Some findings support the idea that a lower suicide risk of immigrants can be explained by descending from a population with a lower suicide risk than the host population (33).

Female prisoners have been described as a vulnerable group before and the suicide rate in this group has increased in Germany from 2000 to 2013 (34, 35). Specific factors connected to the prison setting that contribute to the suicide risk in incarcerated women are so far unknown (36). When compared to male prisoners, the increasing suicide rates in female prisoners in Germany was not linked to a more unfavorable risk profile regarding known risk factors for prison suicide. An analysis of routine data on prisoners who died by suicide in Germany between 2000 and 2013 revealed no significant gender difference regarding most characteristics, especially mean age, nationality, pre- and post-trial status, proportion of individuals serving a life sentence, and proportion of individuals who exhibited criminal behavior at a young age, previous suicide attempts and known history of psychiatric disorder (34).

Although the suicide rate of the prison population was substantially higher than that of the resident population, we found no difference when comparing the trends of suicide rates between the years 2000 to 2013, despite the rising number of older prisoners in the same time span. Factors that contribute to the differences in suicide risk between detainees and the resident population and to the positive trend in male prison suicide rates are not yet understood (37, 38). Although mental disorders, especially depression, are proved to be more common in prisoners than in the general population, the elevated suicide TABLE 3 | Logistic regression analyses.

\*p < 0.05; \*\*\*p < 0.001.

TABLE 4 | Variables independently associated with suicide events in older prisoners.

\*p < 0.05; \*\*\*p < 0.001.

rate among prisoners cannot be explained with individual factors sufficiently (39–41).

### LIMITATION AND OUTLOOK

The main limitations of our study were that there was no control group and that for many items the data was incomplete. Another limitation was that the data source did not include the medical charts so that the prevalence of mental disorders is surpassingly underreported. Future research will include the medical records and should have a case-control design, comparing the cases, who died from suicide, with a matched group of prisoners who survived. The matching variable will be calendar month. From all prisoners admitted in the same month (e.g., September 2005) as the case, one person will be chosen at random as a control.

### CONCLUSION

In Germany, the number of elderly prisoners is rising. Our findings did not foster the assumption that mental disorders in general or depression are more common among older suicide victims in prison when compared to their younger counterparts. The fact, that hints for mental disorder or suicidal ideations are documented only in few cases, may indicate underreporting of mental disorder in younger as well as in older prisoners. As expected, the suicide rates in male prisoners in Germany with an age of 50 years and older showed a downward trend.

### ETHICS STATEMENT

According to current legal regulation, no approval from the local ethics committee was required for the current study. After having signed a formal obligation, the authors were allowed by prison Administration of Lower Saxony to use routine data for research purposes. We attached the respective form that was completed and signed by researchers that participated in the data assessment (see **Supplementary Data Sheet 1**). The results of the survey are anonymous, name, address before incarceration, and other personal information is not included. Since only aggregated data will be published, no concern exists about disclosure of personal data.

#### AUTHOR CONTRIBUTIONS

AO-W and NK designed the study. KB-K collected the data. AO-W, AV, UG, and JW analyzed and interpreted the data. AO-W and AV wrote the initial draft of the manuscript and had full access to all the data in the study and take responsibility for

#### REFERENCES

the integrity of the data and the accuracy of data analysis. All authors have contributed to, read, and approved the final version of the manuscript.

### ACKNOWLEDGMENTS

We acknowledge support from the German Research Foundation (DFG) and the Open Access Publication Fund of Charité – Universitätsmedizin Berlin.

### SUPPLEMENTARY MATERIAL

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt. 2019.00154/full#supplementary-material

Supplementary Data Sheet 1 | Formal obligation.

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2019 Opitz-Welke, Konrad, Welke, Bennefeld-Kersten, Gauger and Voulgaris. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

# Validating the Utility of the Wilson Sex Fantasy Questionnaire With Men Who Have Sexually Offended Against Children

#### *Ross M. Bartels1\*†, Robert J. B. Lehmann2† and David Thornton3*

*1 School of Psychology, University of Lincoln, Lincoln, United Kingdom, 2 Department of Psychology, Medical School Berlin, Berlin, Germany, 3 Sand Ridge Secure Treatment Center, Mauston, WI, United States*

The Wilson Sex Fantasy Questionnaire (WSFQ) assesses the use of 40 specific sexual fantasies, which are grouped into four overarching themes (Intimate, Exploratory, Impersonal, and Sadomasochistic). It also includes two items that reflect characteristics associated with children.   Results showed that SOCs scored lower on each subscale than both community groups. On the two child-related items, the SOCs and C-SIs scored higher than C-NSIs. For the "Sex with someone much younger than yourself" item, younger SOCs had greater scores than younger C-NSIs, while older C-NSIs had greater scores than older SOCs. Construct validity was assessed using the SOC sample by examining relationships between WSFQ variables and 1) the self-reported use of deviant sexual fantasies assessed *via* the Thoughts and Fantasies Questionnaire and 2) offending behavior derived from crime scene data. The WSFQ Intimacy subscale was unrelated to any deviant sexual fantasies, while the other subscales were most strongly associated with sadistic fantasies. The child-related WSFQ items were most strongly associated with sexual fantasies about prepubescent children. Very few relationships were observed between the WSFQ variables and crime scene behaviors. The implications of the results are discussed, along with the study's limitations and suggestions for future research.

 The content of the mental imagery generally reflects one's sexual interest (2) and is experienced as sexually arousing (3).

#### *Edited by:*

*Norbert Konrad, Charité Medical University of Berlin, Germany*

#### *Reviewed by:*

*Stelios Panagiotis Kympouropoulos, University General Hospital Attikon, Greece Till Amelung, Charité Medical University of Berlin, Germany*

> *\*Correspondence: Ross Bartels<EMAIL_ADDRESS>
*†These authors share first authorship.*

#### *Specialty section:*

*This article was submitted to Forensic Psychiatry, a section of the journal Frontiers in Psychiatry*

*Received: 14 September 2018 Accepted: 22 March 2019 Published: 09 April 2019*

#### *Citation:*

*Bartels RM, Lehmann RJB and Thornton D (2019) Validating the Utility of the Wilson Sex Fantasy Questionnaire With Men Who Have Sexually Offended Against Children. Front.  Bartels and Gannon (7) highlight two ways, however, in which it may occur. The first refers to heightening an individual's risk or propensity to sexually offend. That is, for those with a sexual interest in children, sexual fantasizing may psychologically and physiologically energize an individual (i.e., increase their sense of "wanting"), thus preparing them for engagement in sexually appetitive behavior (8, 9). When combined with masturbation and orgasm, this sense of wanting may be relieved in the short term but heightened in the medium term. The second link to offending is based on the idea that sexual fantasizing can create behavioral scripts (e.g., explicit or implicit plans) that an individual may enact in real life (5, 10, 11). Again, the inclusion of masturbation (and subsequent orgasm) is likely to strengthen the sexual meaning of the script, potentially increasing the likelihood of enacting the imagery in real life. Regardless of the exact causal mechanism, researchers have found that sexual fantasies about children are associated with contact sex offending behavior against children (4, 12, 13). While causality cannot be inferred from these findings given their correlational nature, sexual fantasizing is arguably an important factor to consider in the assessment and treatment of individuals who have sexually offended against children (SOCs). Thus, it is important for clinicians and researchers to have a reliable and valid tool for assessing sexual fantasy use.

One of the oldest and often used measures is the Wilson Sex Fantasy Questionnaire or WSFQ (14). The WSFQ includes a list of 40 sexual fantasy themes ranging from "the normal and innocuous to the deviant and relatively obscene" (15, p. 61). Each item is scored on a six-point scale ranging from Never (0) to Regularly (5), across five different contexts (i.e., Daytime fantasies, Fantasies during intercourse or masturbation, Dream while asleep, Have done in reality, and Would do in reality). When assessing the frequency of sexual fantasy use, Wilson (15) advises only using responses for Daytime fantasies, since scores for the other four contexts all highly correlate with Daytime fantasies. The WSFQ is composed of four factor analytically derived themes, each containing 10 items, namely, Intimate, Exploratory, Impersonal, and Sadomasochistic (14). This factor structure has been supported in subsequent confirmatory analyses, particularly in men (16).

Only a few published studies have used the WSFQ with SOCs1 . In one of the first studies, Baumgartner et al. (19) found that the WSFQ had very good internal consistency as indicated by Cronbach's α (Intimate = .92; Exploratory = .86; Impersonal = .83; Sadomasochistic = .86; total score = .95). Below, we outline the studies that provide information about various forms of validity for the WSFQ.

Baumgartner et al. (19) also found that SOCs (*n =* 64) scored higher than nonsexual offenders (*n* = 41) on the Intimate and Exploratory subscales (*d* = 0.57 and 0.44, respectively). Crucially, they argued that two WSFQ items reflect themes associated with children (i.e., "Having sex someone much younger than yourself " and "Seducing an innocent") and found that SOCs scored significantly higher than nonsexual offenders on these two items (*d* = 0.77 and 0.55, respectively). Baumgartner et al. (19) also compared their data to those reported in previous studies using college males (*N =* 116) (20), as well as nonoffending fetishists (*N =* 24), sadomasochists (*N =* 34), and men with numerous sexual interests (*N =* 14) (15). The SOCs did not differ from college males on any subscales and reported lower Exploratory, Impersonal, and Sadomasochistic scores than the sadomasochistic and sexually variant males. However, they were unable to compare differences on the two child-related items.

Using a sample of 95 SOCs, Gannon et al. (21) examined differences between SOC subtypes (established by cluster analyzing data from a battery of measures). They identified five clusters, which they termed "Impulsive," "Boy predators," "Intimacy deficits," "Generally antisocial," and "Multiple dysfunction." Discounting the "Multiple dysfunction" group due to a very small sample size (*n =* 4), it was found that, in contrast to the other groups, the "Boy predators" reported significantly higher scores on all WSFQ subscales, indicating higher levels of sexual fantasizing in general.

Other researchers have examined the WSFQ in relation to sexual recidivism in SOCs. Using an exploratory factor analysis with a sample of 495 SOCs, Allan et al. (22) found that the WSFQ subscales (pre-treatment) loaded on to a single factor.  This factor, however, essentially represents the total WSFQ score and so does not provide any insight into the participants' specific sexual interests.  A similar result was found by Stevens et al. (23) using a sample of 218 SOCs. Here, the same "Sexual Interests" factor (using WSFQ data) correlated with sexual recidivism, even after controlling for socially desirable responding (*r*pb = .24). In addition, Stevens et al. (23) found that each WSFQ subscale was significantly associated with sexual recidivism (*r*pb for Intimate = .15, Exploratory *= .*24, Impersonal = .19, Sadomasochistic = .18). Using the same dataset, Beggs and Grace (24) also found that positive change scores (following treatment) on the Sadomasochistic subscale were associated with reduced sexual recidivism (*r* = −.22).

Only a few studies have provided convergence data in terms of correlating the WSFQ with other indicators of deviant sexual interest.  The WSFQ total also correlated strongly with the total score from a 90-item version of O'Donohue and Letourneau's (26) Paraphilic Fantasy

1 Some researchers have adapted the WSFQ by adding, removing, and/or amending items (17, 18). For the purposes of this paper, however, only studies using the original WSFQ are discussed.

Questionnaire (*r = .*73) (27). Given that only the WSFQ total was used, a greater frequency of fantasizing across a range of themes is associated with sexual preoccupation (i.e., sexual compulsivity and sensation-seeking) and paraphilic sexual fantasies in general.

 This is rather surprising given the oft-described importance of sexual fantasies in forensic practice (28). This lack of research may be due to the range of issues pertaining to the study of sexual fantasies. For one, sexual fantasizing is a covert activity and is not externally identifiable outside of self-report. Moreover, from the point of view of someone who has offended, there may be little reward for being truthful about the content and use of one's sexual fantasies in a forensic setting. They may even anticipate negative consequences for doing so (e.g., longer sentences, postsentence restrictions and requirements, stigma, physical violence threats from other inmates). As such, offenders are likely to have an understandable tendency for dissimulation. Accordingly, clinical subjective self-report data (e.g., WSFQ) may be of limited value in forensic assessments as they are easy to fake and may be biased by distorted self-perception and/or introspective abilities.

As indicated above, there has been little validation of the WSFQ for use with SOCs. Most studies have primarily focused on the WSFQ subscales, have not accounted for sexual interest in children within comparison groups, and only examined its relationship with sexual offending behavior in terms of sexual recidivism. Thus, the aim of the present study was to further test the validity of the WSFQ for use with SOCs, taking into account the above issues. This goal was approached in three ways.

The first was to examine differential validity by comparing a sample of male SOCs with a sample of community males on the WSFQ subscales and child-related items.    We also predicted that SOCs would not differ from those with a sexual interest in children.

Second, we examined construct validity by correlating the WSFQ (i.e., its subscales and the two child-related items) with child-related and sadistic fantasies measured *via* another questionnaire designed to assess the use of offense-related sexual fantasies.

Third, construct validity was tested again. This was done by examining whether the WSFQ subscales and child-related items correlated with four behavioral themes identified in SOCs by Lehmann et al. (32) using crime scene data. These behavioral themes include a) Fixation (characterized by a persistent attraction to children), b) Regression [characterized by nonparaphilic sexual excitation and victim availability (e.g., in family setting) in response to intimacy deficits], (c) Criminality (where sexual abuse occurs in the context of generalized criminal behavior), and (d) Sexualized Aggression (characterized by offenses that involve overtly expressive aggression including behavioral indicators of sexual sadism). Accordingly, we hypothesized a positive relationship between the nonsexually deviant behavioral themes of Regression and Criminality and the normative and innocuous Intimate subscale. On the basis of the dissimulation hypothesis, we expected negative relationships between deviant behavioral themes (Fixation, Sexualized Aggression) and the WSFQ data.

### METHOD

#### Sample

The offender sample was composed of 54 male individuals who had sexually offended against a child (i.e., aged 13 and younger), recruited from a secure treatment facility in the state of Wisconsin in the USA. The ages ranged from 25 to 73 years (*M* = 46.9, *SD* = 10.2).  Fifty-two (96.30%) reported being "single," with one participant reporting being in a relationship, and another not providing his relationship status. Of the 50 participants with available information, the majority (77.8%, *n =* 42) had undergone or were undergoing some form of psychological treatment for their offending behavior at the time of data collection.

The non-offending sample was composed of 101 community males, who were all recruited online. The age of the community sample ranged from 18 to 51 years (*M =* 25.01, *SD =* 6.80), with 12 preferring not to provide their age. Fifty-seven of the nonoffending sample (56.4%) reported being a relationship, while 44 (43.6%) reported being single.

### Data

Sexual fantasy data for the SOC sample were initially collected as part of a larger, distinct project led by one of the first authors. This initial project was aimed at exploring new indirect measures of sexual interest in children and offense-supportive cognition (33). Offense-related data were also available in some of the participants' case files (*n =* 37). This allowed crime scene behaviors to be coded in the current study (see below for details). Sexual fantasy data for the community sample were drawn from a distinct online project examining child-related sexual interests in community males (Henek and Bartels, in preparation). Data for this initial project were collected online (using Qualtrics) *via*  various social media platforms and forums (e.g., Twitter, Reddit).  In the current study, only the WSFQ data were used (for the group difference analyses).

 Each item is scored using a six-point scale (0 = Never, 5 = Regularly). The WSFQ is composed of four 10-item subscales: Exploratory (e.g., *Sex with two other people*), Intimate (e.g., *Having intercourse with a loved partner*), Impersonal (e.g., *Watching others having sex*), and Sadomasochistic (e.g., *Whipping or spanking someone*). Using the sample as a whole in the present study (*N =* 155), the WSFQ subscales showed acceptable to good levels of internal consistency: Impersonal (α = .68), Exploratory (α = .74), Sadomasochistic (α = .85), and Intimate (α = .87). The total score showed excellent internal consistency (α = .92).

Two specific sexual fantasy items were also of particular interest in this study.  While these two items do not directly refer to children (e.g., a 50-year-old who fantasizes about a 25-year-old movie star may rate high on the former item), it has been argued that they involve "partners whose qualities could be seen as matching those of children (innocence and aged significantly younger)" (19, p. 28). We were additionally interested in the "Having incestuous sexual relations" item as it could reflect the offending behavior predominantly engaged in by SOC with a "regression" propensity (32). Please note that this item is rather vague and does not directly refer to children as well. Nonetheless, it was included given the exploratory nature of this part of the paper.

#### Thoughts and Fantasies Questionnaire

This is an unpublished questionnaire created by the third author for use in practice. It is designed to assess clients' use of five specific deviant sexual fantasies during their time in treatment, namely, Abduction, Forcing, Children under 13 years, Children between 13 and 17 years old, and Sexual sadism. In addition, sexual fantasies involving the client's past victim/s are also assessed. For each theme, a respondent first states whether they have experienced the sexual fantasy using a Yes/No format. If they respond with a "Yes," they are required to answer a further set of open-ended questions (e.g., how often the fantasy was used, when it was last used, and how long it lasted). It also asks the respondent to write out the fantasy. In the present study, data from this measure were only available from the SOC sample.

#### The Interest in Child Molestation Scale (ICM) (34)

The ICM is a vignette-based self-report measure designed to assess community participants' interest in sexual activity with

children. The ICM is composed of five vignettes, each describing a hypothetical scenario of sexual activity with a child (age not specified). After reading each vignette, participants are required to report their level of sexual arousal, behavioral propensity (i.e., whether they would do the same), and general enjoyment. Each item is rated on a seven-point Likert scale (e.g., 1 = Not at all sexually aroused, 7 = Very strongly sexually aroused). Three of the vignettes involve low force and two involve high force. The ICM produces an overall score, a low-force subscale score, and a high-force subscale score. Previous studies using the ICM indicate that the low-force subscale is a particularly reliable and valid measure for assessing sexual interest in children in community samples (34, 35). On this basis, only the low-force subscale was administered to the community males in Henek and Bartels' study (Henek and Bartels, in preparation). As there are nine items on the low-force subscale (rated on a Likert scale ranging from 1 to 7), the lowest possible score participants can obtain is 9 (i.e., no selfreported proclivity), with the highest possible score being 63.

In a study exploring pupillary responses as a method for assessing sexual interest, the ICM was used in a way to ensure that participants were solely interested in adults (36). Similarly, in the present study, the low-force subscale of the ICM (α = .82) was used to identify community males with a sexual interest in children (i.e., a score greater than 9). Of the 101 participants, 22 were identified as having some sexual interest in children (*M* = 14.55, *SD =* 5.60). These individuals were categorized as a "sexual interest in children" community group (C-SI), with the remaining 79 categorized as a "no sexual interest in children" community group (C-NSI).

### Coding

The offense-related information present in the offender participants' case files was independently coded by two research assistants. This involved coding for the presence of 39 crime scene behaviors using the coding scheme devised by Lehmann et al. (32). Of the 54 available case files, 37 provided specific details that could be sufficiently coded. To determine inter-rater reliability for each variable, Cohen's κ was computed. For seven variables (i.e., victim masturbates, offender offers money, offender films/photos victim, longer offense, ritualistic behavior, offender humiliates victim, and offender drugged victim), κ could not be computed due to a lack of variance. These variables, however, had high percent agreement (range = 95%–100%). For seven variables (affection, fondle, offender makes promises, luring, offender makes sexual comment, searching, and offender not deterred), κ coefficients were low (<.45) (37). Nevertheless, the variables aforementioned were included on the basis of the high percent agreement (range = 82%–92%) and because they were needed to compute propensity scores in order to test the link between the WSFQ and crime scene behavior (see **Supplementary Material** for full details). The κ coefficients for the remaining variables ranged from .52 to 1.00 (median = .76). After these initial codings, the first author examined each case file independently in order to provide the final decision on whether the crime scene behavior was present or not. Finally, following Lehmann et al. (32), the "present" crime scene variables associated with each behavioral theme (i.e., Fixation, Regression, Criminality, and Aggression) were averaged. This resulted in a continuous Thematic Sum Score (TSS) for the four behavioral themes.

#### Analyses

Differences between the SOC, C-SI, and C-NSI groups on each WSFQ variable were assessed using one-way MANOVAs. Also, since the SOC group were (on average) older than the two comparison groups, we examined whether any group effect on the two child-related WSFQ items were moderated by participant age. Next, in the SOC sample only, relationships between WSFQ variables and the child-related and sadistic themes of the Thoughts and Fantasies Questionnaire were examined using rank-biserial correlations (controlling for age). Finally, for those SOCs with available crime scene data (*n =* 37), Spearman's Rho correlations (controlling for age) were run to explore whether scores on the WSFQ were associated with the TSS scores derived from crime scene data. Given the multiple correlations (i.e., 38), a Bonferroni correction was employed to adjust for the familywise error rate (α changed from .05 to .0013).

### RESULTS

#### Differential Validity

A one-way, independent-samples MANOVA was used to compare the three groups (SOC vs. C-SI vs. C-NSI) on the four WSFQ subscales (i.e., Intimate, Exploratory, Impersonal, and Sadomasochistic). A significant multivariate main effect of Group was observed [Wilks' λ = 0.69, *F*(8, 298) = 7.48, *p* < .001, ηp 2 = 0.17]. As shown in **Table 1**, there was a significant main effect of Group for each WSFQ variable, except for Exploratory (*p* = .09). This lack of difference on the Exploratory subscale was in line with our hypothesis with respect to SOCs and C-SIs, but not SOCs and C-NSIs. *Post hoc* comparisons indicated that C-NSIs used Intimate fantasies significantly more so than SOCs (*p = .*001, *d =* 0.62). While this is counter to our hypothesis derived from Baumgartner et al.'s (19) findings, it is understandable that community males with no interest in children would report higher scores on this normative subscale. The lack of a difference between SOCs and C-SIs was, however, as expected. For Impersonal fantasies, C-SI had significantly greater scores than both the SOC (*p = .*001, *d* = 0.92) and C-NSI (*p* = .03, *d* = 0.65). The C-SIs also reported using Sadomasochistic fantasies more often than SOCs (*p* < .001, *d* = 1.17), as did the C-NSIs (*p* < .001, *d =* 1.08).

A second independent-samples MANOVA was conducted to examine group differences for the two specific WSFQ items of interest (i.e., "Having sex with someone much younger," "Seducing an innocent"). There was a significant multivariate main effect of Group [Wilks' λ = 0.88, *F*(4, 302) = 3.50, *p* = .001, ηp 2 = 0.06]. A significant main effect was observed for both items (*p'*s < .01; see **Table 2**). *Post hoc* comparisons revealed that SOCs scored significantly higher than C-NSIs on "Sex with someone much younger" (*p = .*001, *d =* 0.67), as did C-SIs (*p* = .001, *d* = 0.82). For "Seducing an innocent," SOCs reported marginally greater and non-negligible scores (based on effect size) than C-NSIs (*p = .*056, *d* = 0.44), while C-SIs reported significantly greater scores than C-NSIs (*p* = .02, *d* = 0.62). These findings were in line with our hypotheses.

Given that the "child-related" WSFQ items do not actually explicitly refer to children (but rather youth and innocence), it is possible that the older participants interpreted them innocuously (e.g., in terms of a much younger *adult*). This could account for why SOCs scored high on these items, as they were significantly older than C-NSIs and C-SIs (both *p*'s < .001). Thus, to examine whether participant age had a moderating effect on the link between group and the item "Sex with someone much younger," we used the PROCESS macro for SPSS (38). As there were three groups, the independent variable was specified as being multicategorical using indicator coding (39), with SOCs coded as the reference group. Age was found to have a significant moderating effect [Δ*R*2 = 0.07, *F*(2, 137) = 6.83, *p* = .002]. However, this was only in relation to the difference between SOCs and C-NSIs (*b* = .12, *SE* = .03, *t* = 3.60, *p* < .001), not between SOCs and C-SIs (*b* = .09, *SE* = .06, *t* = 1.62, *p = .*11). As shown in **Figure 1**, the conditional effects revealed that, at lower age levels (−1 *SD* below the mean), scores on the "Someone much younger" item were greater for SOCs than for C-NSIs (*b* = 1.51, *SE* = 0.61, *t =* 2.47, *p* = .02). There was no difference between the two groups at medium (mean) age levels (*b* = .06, *SE* = 0.44, *t =* 0.14, *p* = .87), but at higher age levels (+1 *SD* above the mean), C-NSIs showed greater scores on the item (*b* = 1.64, *SE* = 0.62, *t* = 2.64, *p* = .009). Conversely, the relationship between group and "Seducing an innocent" was found to not be moderated by participant age, Δ*R*2 = 0.005, *F*(2, 137) = 0.34, *p* = .71 (see **Figure 2**).

TABLE 1 | Descriptive and inferential statistics for group differences on each Wilson Sex Fantasy Questionnaire (WSFQ) scale.

 Groups that share superscripts (i.e., a or b) do not significantly differ (p < .05, Bonferroni corrected).*

#### TABLE 2 | Descriptive and inferential statistics for group differences on child-related WSFQ items.

 Groups that share superscripts (i.e., a or b) do not significantly differ (p < .05, Bonferroni corrected). Groups that share an m subscript are marginally different.*

#### Construct Validity: Correlations Between Sexual Fantasy Measures

Data from both sexual fantasy measures were available for all SOCs. Rank-biserial correlations (controlling for age) between the WSFQ variables and the dichotomous responses on the Thoughts and Fantasies Questionnaire (TFQ) themes are presented in **Table 3**. As shown, only four correlations survived the Bonferroni correction for multiple testing. In line with our hypotheses, the Sadomasochistic subscale showed a positive relationship with the Sadistic theme of the TFQ (*r*rb = .46) (convergent validity), as did the Impersonal subscale to a stronger degree (*r*rb = .51). As expected, the Intimate subscale did not correlate with any of the examined TFQ themes (discriminant validity). Also as hypothesized, the "Sex with someone much younger" and "Seducing an innocent" WSFQ items both showed moderate-tostrong, positive correlations with the Child <13 TFQ theme (*r*rb = .43 and .48, respectively). No significant relationships were found between the single WSFQ items and the postpubescent (Child 13–17 years) TFQ theme.

#### Construct Validity: Relationship Between Sexual Fantasies and Behavioral Themes

Crime scene data and sexual fantasy data were available for 37 SOCs.  SOC, sex offenders against children.*

*Results in bold typeface indicate significant results after Bonferroni correction (α = .0013).*

derived from crime scene information (i.e., TSS scores). None of the observed relationships were significant after applying the Bonferroni correction. Thus, we did not find support for the hypothesis that the nondeviant themes (Regression and Criminality) would correlate with the Intimate subscale. However, from looking at the size of the correlations, two relationships are worth noting (both of which were significant before corrections). First, the Intimate subscale showed a moderate negative relationship with the "Sexualized Aggression" TSS (*r*rho = −.34) and, in line with expectations, the Regression theme showed a moderate relationship with "Incestuous sexual relations" (*r*rho = .33). Also, in line with the dissimulation hypothesis, both behavioral themes indicating sexual deviance (Fixation and Sexualized Aggression) consistently showed negative relations with the WSFQ data (except between Fixation and the Sadomasochistic subscale).

### DISCUSSION

The present study investigated the utility of the Wilson Sex Fantasy Questionnaire (WSFQ) in relation to its use with individuals who have sexually offended against children (SOC). Previous research using the WSFQ with SOC samples have 1) focused primarily on the broad subscales and total score (which provide no information about child-related sexual fantasy themes), 2) failed to account for sexual interest in children within the comparison group/s, and 3) focused on sexual recidivism, rather than specific offending behaviors. The present study aimed to take into account these three points.

Counter to our hypotheses, which were based on the findings of Baumgartner et al. (19), SOCs did not score higher than community males with no sexual interest in children (C-NSIs) on the Intimate and Exploratory subscales. Rather, C-NSIs scored higher than SOCs on the Intimate subscale. As predicted, SOCs and community males with a self-reported sexual interest in children (C-SIs) did not differ on these two subscales. In addition, SOC's scores on the Sadomasochistic subscale were much lower than that reported by C-SIs and C-NSIs, while C-SIs reported using Impersonal sexual fantasies more frequently than both the SOCs and C-NSIs. These findings could suggest some level of dissimulation of sexual fantasies in SOCs compared to community males. However, SOCs have been found to score lower than sadomasochistic and sexually variant men on the Sadomasochistic subscale, as well as the Exploratory and Impersonal subscales (19).

TABLE 4 | Spearman correlations between the WSFQ variables and Thematic Sum Scores, controlling for age.

*\*p < .05. WSFQ = Wilson Sex Fantasy Questionnaire. Results in bold typeface indicate significant results after Bonferroni correction (α = .0013).*

Thus, the community males in the present study may have been particularly sadomasochistic. Indeed, our C-NSI group had much higher scores on the Sadomasochistic subscale than the college males in Plaud and Bigwood's (20) study (*M =* 12.76 vs. 4.9, respectively). Thus, it is possible that the present study used a biased (self-selected) community sample (i.e., one composed of sadistic and/or sexually variant individuals). However, as social desirability was not accounted for in this study, the dissimulation hypothesis cannot be discounted.

As hypothesized, the SOCs scored higher on the two childrelated WSFQ items ("Seducing an innocent" and "Having sex with someone much younger than yourself ") than the C-NSI group, as did the C-SIs. These results provide partial support for Baumgartner et al.'s (19) proposition that these two WSFQ items assess fantasy content related to children.

It should be noted, however, that the difference between SOCs and C-NSIs for "Sex with someone much younger" was moderated by participant age. This reflected a relatively stable level of fantasy use in the SOCs, but an increase in use for the C-NSIs. Thus, at a younger age, SOCs scored higher than C-NSIs, while at an older age, C-NSIs scored higher than SOCs. A similar trend was also observed for C-SIs (see **Figure 1**). This highlights an issue with the ambiguous terminology for this particular item (40). That is, the phrase "someone much younger" can mean different things for younger and older individuals. For younger men, it may be more likely to be interpreted as "children," which could account for why the SOCs (and C-SIs) scored greater than C-NSIs at a younger age. For older men, though, the item may be more likely be interpreted as a much younger adult.

In terms of convergence, correlational analyses (controlling for age) indicated that, within the SOC sample, the two child-related WSFQ items were most strongly associated with sexual fantasies about children under 13 years old (as measured by the Thoughts and Fantasies Questionnaire; TFQ). These findings provide further validation that these two items may tap a sexual interest in child-related characteristics. Other notable correlations were in relation to the Sadomasochistic and Impersonal subscales, both of which showed strong links with sexual fantasies about sadistic acts on the TFQ.

After correcting for multiple correlations, none of the relationships (controlling for age) were significant in relation to the behavioral themes derived from crime scene data. However, focusing on the size of the correlations, the Intimate subscale showed a moderate, negative association with the Sexualized Aggression theme (potentially attesting to discriminant validity).  This aligns with Lehmann et al.'s (32) findings showing that the Regression theme was related to the closeness of the victim–offender relationship, indicating proximity to incestuous relations. However, despite the size of the correlations, it should be emphasized that they did not survive the conservative Bonferroni correction we applied. A clear pattern of relationships was observed, however, that suggested some level of dissimulation in the SOCs.  Thus, subjective self-report data may be of less value when assessing individuals in forensic contexts.

Nevertheless, taken together, the current findings offer some implications for research and practice. First, "Seducing an innocent" and "Sex with someone much younger than yourself " from the WSFQ both substantially correlated with sexual fantasies about young children in SOCs and distinguished sexually deviant community males (and SOCs at younger ages) from those with no sexual interest in children. Joyal et al. (40) argued that these two items are ambiguous and so, on their adapted WSFQ, they removed "Seducing an innocent" and amended the latter to "Sex with someone much younger (legally) than me." However, our findings suggest that these two items may reflect characteristics associated with children (i.e., "youth" and "innocence"), as suggested by Baumgartner et al. (19). It could be argued that individuals with a sexual interest in children may find these characteristics particularly appealing and, thus, incorporate them into their sexual fantasies (with fantasies involving children being the extreme manifestation of these characteristics). This is analogous to "dominance"—a characteristic associated (but not synonymous) with rape—that is sexually fantasized about by men who have sexually aggressed (41, 42). Taken together, researchers and clinicians may be able to use the "Seducing an innocent" and "Sex with someone much younger" WSFQ items as proxies for assessing child-related sexual fantasies, or as a means to identify the potential use of such fantasies. Arguably, this may be a more favorable approach, as items that overtly ask about fantasies involving children are likely to provoke faked responses. As our data suggest, however, it should be kept in mind that the ambiguity of the "Sex with someone much younger" item introduces issues for older respondents.

Second, this study highlights an important consideration for future comparative studies on the topic of SOC's sexual fantasies. That is, a sexual interest in children should be taken into account when collecting data from comparison groups. This will allow researchers to either screen out those with an interest in children (providing a purer comparison group) or form two comparison groups based on the presence or absence of a sexual interest in children (as in this study). Failing to account for a sexual interest in children within comparison groups will likely lead to biased interpretations (e.g., about the target and/or comparison group, or the measure that is being tested).

#### Limitations and Future Research

In addition to potentially having recruited a biased online sample of community males, further limitations should be noted. First, other comparison groups could have been included, such as a group of nonsexual offenders or a sexual offender comparison group (e.g., rapists). If these groups were found to score lower on the child-related items, it would provide further validation of the WSFQ for use with SOC populations. Second, the majority of the SOC sample had received treatment for their offending behavior. Since treatment has been shown to significantly reduce scores on the Exploratory, Impersonal, and Sadomasochistic WSFQ subscales (43), it is possible that similar reductions had also occurred for many of the SOCs in this study. In spite of this possibility, the child-related items still correlated with the prepubescent child theme on the TFQ in SOCs. Third, most SOCs self-reported as being "single," whereas many of the non-offender participants were in relationships. This may have affected the use of normative sexual fantasies, potentially accounting for why SOCs did not score higher than C-NSIs on the Intimate subscale. Fourth, it is important to note that social desirable responding was not accounted for. Thus, given the possible indication of dissimulation in this study, future research should include impression management measures to control for response biases.

 First, due to a lack of sufficient crime scene information, only data from a much smaller sample could be coded. A larger sample with more detailed crime scene information would have been more desirable. Second, the sexual fantasy data in this study were collected (often long) after the offending behavior had occurred. Therefore, it is possible that the SOCs had been fantasizing about behaviors and targets unrelated to their prior offending behavior (either due to treatment-related or age-related changes). Future research should consider using a sample of recently convicted SOCs or those at a pre-treatment stage.

#### Conclusion

The results of this study suggest that using the WSFQ with SOCs may be more useful than just assessing broad fantasy themes (*via*  subscales). That is, two items ("Seducing an innocent" and "Sex with someone much younger") contain characteristics associated with children. As such, they may be useful proxies for assessing child-related sexual fantasies for occasions when asking directly about children is problematic or particularly sensitive. However,

#### REFERENCES

given their vague terminology, issues with interpretation of these items (especially in older individuals) is something that should be carefully considered. The Sadomasochistic subscale also appears to be a valid means for assessing sadistic interests within SOCs. Further work is still needed regarding convergent validity (e.g., with other measures of sexual interest), predictive validity in relation to sexual recidivism, and differential validation (e.g., between SOC subtypes).

#### ETHICS STATEMENT

This specific study was carried out in accordance with the recommendations of the "British Psychological Society" guidelines and was approved by the School of Psychology Research Ethics Committee at the University of Lincoln. All participants tested in person provided written informed consent, while those who took part online provided informed consent by clicking the relevant response (i.e., "I Agree").

#### AUTHOR CONTRIBUTIONS

RB formulated the research question and designed the study, analyzed the data, and cowrote the article. RL formulated the research question and designed the study, helped with interpretation of the findings, and cowrote the article. DT provided important intellectual content and proofread the article.

#### SUPPLEMENTARY MATERIAL

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2019.00206/ full#supplementary-material

population-based sample of Finnish male twins. *J Child Sex Abuse* (2015) 24:115–34. doi: 10.1080/10538712.2015.997410

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2019 Bartels, Lehmann and Thornton. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# Identifying Violent Behavior Using the Oxford Mental Illness and Violence Tool in a Psychiatric Ward of a German Prison Hospital

*Vincent Negatsch1\*, Alexander Voulgaris2, Peter Seidel3, Robert Roehle4,5,6 and Annette Opitz-Welke1*

*1 Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Forensic Psychiatry, Berlin, Germany, 2 Universitätsklinikum Hamburg-Eppendorf, Institute of Sexual Medicine and Forensic Psychiatry, Hamburg, Germany, 3 Department of Psychiatry and Psychotherapy, Prison Hospital Berlin, Berlin, Germany, 4 Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Biometry and Clinical Epidemiology, Berlin, Germany, 5 Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Coordinating Center for Clinical Studies, Berlin, Germany, 6 Berlin Institute of Health (BIH), Berlin, Germany*

#### *Edited by:*

*Thomas Nilsson, University of Gothenburg, Sweden*

#### *Reviewed by:*

*Märta Wallinius, Lund University, Sweden Daniel Passow, University Hospital Rostock, Germany*

*\*Correspondence: Vincent Negatsch<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Forensic Psychiatry, a section of the journal Frontiers in Psychiatry*

*Received: 20 September 2018 Accepted: 08 April 2019 Published: 23 April 2019*

#### *Citation:*

*Negatsch V, Voulgaris A, Seidel P, Roehle R and Opitz-Welke A (2019) Identifying Violent Behavior Using the Oxford Mental Illness and Violence Tool in a Psychiatric Ward of a German Prison Hospital. Front. Psychiatry 10:264. doi: 10.3389/fpsyt.2019.00264*

Background: Although there is evidence that individuals who suffer from severe mental disorders are at higher risk for aggressive behavior, only a minority eventually become violent. In 2017, Fazel et al. developed a risk calculator (Oxford Mental Illness and Violence tool, OxMIV) to identify the risk of violent crime in patients with mental disorders. For the first time, we tested the predictive validity of the OxMIV in the department of psychiatry at the prison hospital in Berlin, Germany, and presented findings from our internal validation.

Materials and Methods: We designed a cohort study with 474 patients aged 16–65 years old who met the inclusion criteria of schizophrenia-spectrum or bipolar disorder and classified the patients into two groups: a violent group with 191 patients and a nonviolent group with 283 patients. Violence was defined as the aggressive behavior of a patient with the necessity of special observation. We obtained all the required information retrospectively through patient files, applied the OxMIV tool on each subject, and compared the results of both groups. Sensitivity, specificity, and positive/negative predictive values were determined. We used logistic regression including variable selection and internal validation to identify relevant predictors of aggressive behavior in our cohort.

Results: The OxMIV score was significantly higher in the violent group [median 4.21%; Interquartile range (IQR) 8.51%] compared to the nonviolent group (median 1.77%; IQR 2.01%; p < 0.0001). For the risk of violent behavior, using the 5% cutoff for "increased risk," the sensitivity was 44%, and the specificity was 89%, with a positive predictive value of 72% and a negative predictive value of 70%.  The item recent antidepressant treatment (0.28 [0.17–0.47]. p < 0.0001) had a statistically significant risk reduction effect.

Conclusions: In our opinion, the risk assessment tool OxMIV succeeded in predicting violent behavior in imprisoned psychiatric patients. As a result, it may be applicable for identification of patients with special needs in a prison environment and, thus, improving prison safety.

Keywords: violence, prison, forensic psychiatry, schizophrenia, bipolar disorder, prediction tool

#### INTRODUCTION

Violent behavior in individuals with severe mental disorders has been widely reported. Several studies and reviews from the United States (1, 2) and Europe (3–5) can verify this, and especially, two groups of patients (schizophrenia and bipolar disorder) are at higher risk of committing a violent crime compared to the general population (6, 7). This opinion is not agreed upon by all experts in the field, due to the vast majority of individuals diagnosed with schizophrenia never committing any act of violence (8).

Analyzing data of more than 24,000 cases of schizophrenia and related disorders, Fazel et al. pointed out that the adjusted odds ratio of adverse outcomes, including violent behavior, was 7.5 in men and 11.1 in women compared to the general population. They concluded that schizophrenia and related disorders are associated with increased rates of violent crime (5). In patients with bipolar disorders, the odds ratio for violent crime was 5 (6). Recent surveys have determined a variety of risk factors for aggressive behavior and violent crime in patients with schizophrenia and bipolar disorders, such as substance use disorder (SUD) (4, 7), young age (9), previous violent crime (10), male gender, and disadvantaged neighborhoods (11). Results of population-based studies suggest that there is an increased risk of violent offending and violent ideation in individuals with severe mental disorders and indicate a higher risk of homicide and violent crime, especially in individuals with schizophrenia (3). On the other hand, there are protective factors regarding violent behavior, including intelligence (12), self-control (13), intimate relationship (14), and social network (15). Modern risk assessment instruments such as the SAPROF (*Structured Assessment of Protective Factors for Violence Risk*) and the START (*Short-Term Assessment of Risk and Treatability*) are designed to consider the positive qualities of inmates and focus on resilient factors (16–18). Comparing patients with schizophrenia who showed violent behavior to individuals with the same diagnosis who were not violent, Ekinci and Ekinci reported that depressive symptoms were predictors for nonviolent behavior (19).

Regarding the results of epidemiological research on the increased incidence of violent behavior in patients with mental disorders, understanding the individual and situational risk factors for aggressive behavior seems to be crucial for the improvement of general safety and for the prevention of further stigmatization (9). To reduce and manage the risk of future violent behavior, one of the main approaches is the use of risk assessment tools. Over 200 different tools are currently available (20), with a wide range in applicability. Studies from the United Kingdom have evaluated that over 60% of general psychiatric patients and 80% of forensic psychiatric patients are routinely assessed for violent risk (21, 22). Despite the broad clinical application, there are just a few risk assessment instruments that have been externally validated (23).

In 2018, Ramesh et al. conducted a systematic review and meta-analysis on the use of risk assessment tools for predicting violent behavior in a forensic psychiatric hospital. Out of nine violence risk assessment instruments, only two (the *Bröset Violence Checklist* and the *Dynamic Appraisal of Dynamic Aggression*) demonstrated high accuracy for the prediction of violence (24). The most common tool, the HCR-20 (*Historical, Clinical, Risk Management-20*), had a moderate accuracy, while the PCL-R (*Psychopathy Checklist-Revised*) and the VRAG (*Violence Risk Appraisal Guide*) scored poorly on accuracy regarding the prediction of inpatient violent behavior (24). Further investigations into this area of research point to similar, debatable results: risk assessment tools have a range of accuracy (25) and a "large variation of the item content" (26) and are not designed for specific populations (24). As a result, the duration of stay in forensic institutions, often depending on the specific "risk" posed by the individual, may be longer than necessary (27), with social (28) and economic (29) consequences (25).

In 2017, based on data from 75,158 individuals, Fazel et al. developed a simple, web-based risk calculator (Oxford Mental Illness and Violence tool, OxMIV) to identify the future risk of violent behavior in patients with schizophrenia-spectrum and bipolar disorders. They developed a 16-item model for patient stratification into "low-risk" or "increased-risk" categories to identify the risk of violent offending within 12 months. With a sensitivity of 62% and a specificity of 94% in external validation, these results are the best in this field so far (10).

Although the total numbers of psychiatric beds has been declining in Europe since 1990, the number of institutionalized forensic psychiatric patients is increasing in Germany (30) and Europe (31). In addition, in six South American countries, the prison population is increasing, while the number of psychiatric beds has been decreasing since 1990 (32). These findings from Mundt et al. were consistent with the assumption of an association between the numbers of psychiatric beds and the sizes of prison populations as hypothesized by Sharples Penrose in 1939 (32). Regarding this development, there could be a connection to the increased tendency for violent behavior in patients with severe mental disorders compared to the general population (5).

#### THE AIM OF THE STUDY

The prediction of violent behavior through risk assessment tools is increasingly important for the treatment of mentally disordered patients and for the prevention of future offenses in general psychiatric and especially in forensic psychiatric hospitals. With this in mind, the aim of our study was to test the predictive validity of the risk assessment tool OxMIV for the first time in patients with schizophrenia-spectrum or bipolar disorders in the department of psychiatry at the Berlin prison hospital in Germany to improve prison safety by identifying patients with special needs in a prison environment.

For this study, we have considered two hypotheses. First, we assumed that violent patients have a significantly higher score in the prediction tool compared to nonviolent patients (7, 33, 34). Second, we hypothesized that a previous violent crime and a SUD have a statistically significant effect regarding the violent behavior of psychiatric patients (10, 35, 36).

#### MATERIALS AND METHODS

#### Study Settings

For this retrospective study, a sample of 841 treatment episodes in the Berlin prison hospital between 1982 and 2017 was identified. Each treatment episode was defined as an inpatient stay by a patient in the department of psychiatry of the prison hospital in Berlin. For all identified treatment episodes, the patients were diagnosed with a schizophrenia-spectrum or a bipolar disorder (including schizophrenia, schizotypal, delusional, and other psychotic disorders) as well as previous comorbid depression in schizophrenia-spectrum disorder. The cases were pseudonymized with a personal number to protect private data. There were no connections between the names and the personal numbers.

In total, 841 treatment episodes where the patient had a schizophrenia-spectrum or bipolar disorder diagnosed could be assigned to 511 unique patients (see **Figure 1**). For patients with more than one inpatient stay, only the first stay in the prison hospital was included. Of these 511 patients, 36 patients had to be excluded from the study due to age (younger than 16 or older than 65) or death during the treatment. To ensure comparability within the violent group, one patient had to be excluded, because there was no necessity for special observation. Thus, 474 patients with a treatment episode at the Berlin prison hospital were included in our study (see **Figure 1**). In the last step, we formed two groups, a nonviolent group and a violent group; 191 patients who, for a certain period of time, had to stay under special observation due to violent behavior were included in the violent group, and 283 patients who demonstrated no violent behavior during their stay were assigned to the nonviolent group (see **Figure 1**).

### Procedures

The OxMIV is a prediction tool to identify those patients who are at low risk of violent offending. On the basis of 75,158 individuals with a schizophrenia-spectrum or bipolar disorder, the tool consists of 16 items, such as previous violent crime, drug and alcohol abuse, and socioeconomic and sociodemographic information (10). The final score classifies individuals into either a low-risk (<5%) or an increased-risk (>5%) group with a set point of 20%.

The required information on the 16 items was obtained by looking through the patient files for the whole treatment period. It is important to point out that we received the necessary information on the items previous drug abuse, previous alcohol abuse, previous self-harm, education level, parental violent crime, parental drug or alcohol use, sibling violent crime, recent treatment, personal income, and recent benefits through the admission interview with the medical doctor in the prison ward. These admission interviews take place within the first few days of imprisonment. For the item previous violent crime, we used official information from the Federal Central Criminal Register (Bundeszentralregister), which includes past convictions and is also available within the first days of imprisonment. In terms of the items parental violent crime, parental drug or alcohol use, and sibling violent crime, not all information was available for every patient. For these cases, we had to select "unknown." We defined schizophreniaspectrum disorder, bipolar disorder, and comorbid depression using the International Classification of Diseases (ICD), Ninth Version (ICD-9) (295, 297–299 excl. 299A, 296 excl. 296.2; 296 excl. 296D, 296.2, 300.4; 296D, 300E, 311 1979–1998) or Tenth Version (ICD-10) (F 20–29, F 30–31; F32–F34.1 1998–2018). In addition, comorbid alcohol and drug abuse disorders were based on the ICD-9 or Tenth Version (ICD-10) (F 11–19; 1998–2018).