The impact of the COVID-19 pandemic on the psychosocial rehabilitation of forensic psychiatric patients in Austria

The coronavirus disease 2019 (COVID-19) pandemic led to increased psychological distress and far-reaching restrictions of freedom. In March 2020, Austrian penal authorities enacted various safety and protection measures to mitigate the propagation of COVID-19. While infection rates in penal institutions were low, restrictive conditions of detention limited the forensic care of offenders. This retrospective longitudinal observational study aimed to evaluate the impact of the pandemic on the psychosocial rehabilitation in forensic psychiatry. Administrative and clinical data obtained from 97 males treated at an inpatient forensic mental health institution were compared before (January 2019 – mid-March 2020) and after (mid-March 2020 – May 2021) the enactment of pandemic-related restrictive measures. The study outcomes related to rehabilitative activities, social contacts, psychopathological stability, and compliance with institutional regulations. During the pandemic, a decrease in individual one-day temporary releases (64 vs. 3, p < .001) and one-day group excursions (103 vs. 10, p < .001) was observed. Likewise, visits by relatives (1440 vs. 429, p < .001) and legal guardians (286 vs. 130, p = .009) decreased. Regarding compliance with institutional regulations, illegal activities decreased from 27 to 8 after enactment of restrictive measures (p = .024). In contrast, long-term temporary releases (122 vs. 188 weeks, p = .131) and admissions to the acute ward (141 vs. 143, p = .712) remained unchanged. Overall, this study demonstrates the substantial impact of COVID-19 on the psychosocial care of forensic psychiatric patients and implies the necessity for guidelines to uphold an appropriate standard of forensic rehabilitation during future pandemics.


Introduction
Detained persons are subjected to major restrictions of human rights, predominantly related to liberty, health, and private life. This is especially evident in times of crisis. (Kennedy, Mohan, & Davoren, 2021;McLeod et al., 2020). In Austria, forensic psychiatric patients undergo treatment at specialized mental health institutions that fall under the jurisdiction of the Ministry of Justice and differ from general psychiatric hospitals due to their heightened security measures. While sane offenders are sentenced to a time-limited prison term, the detention time of persons not found guilty by reason of insanity is potentially unlimited. The overarching goal is to reduce the likelihood of recidivism through medical and psychological treatments as well as psychoeducation. Even though these institutions closely resemble prisons, reintegration into society is facilitated by means of accompanied one-day temporary releases and group excursions, followed by unaccompanied long-term temporary releases.
Recently, the coronavirus disease 2019 , caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), led to tremendous impairments in private and everyday life of the entire population (Noor & Islam, 2020;Zaninotto, Iob, Demakakos, & Steptoe, 2022). In addition to the detrimental effects on the general population, the pandemic also caused disruptions in the penal system. In several states, overcrowding in prisons made social distancing nearly impossible, and the suspension of external service providers further aggravated the already limited availability of health services in prisons (Harm Reduction International, 2023;World Health Organization, 2021). Moreover, prolonged lockdowns and preventive quarantine resulted in deleterious effects on the well-being and already fragile mental health of detained persons, including anxiety, depression, and exacerbation of psychotic symptoms (Heitzman & Gosek, 2021;Johnson, Gutridge, Parkes, et al., 2021).
Focusing on forensic psychiatric patients, the aim of this study was to evaluate the impact of the COVID-19 pandemic on the psychosocial rehabilitation of this vulnerable population. Administrative and clinical data related to rehabilitative activities, social contacts, psychopathological stability, and compliance with institutional regulations were assessed before and after enactment of restrictive safety measures within Austrian correctional facilities.

Study population
This study was approved by the Ethics Committee of Lower Austria on 09-06-2021 (GS4-EK-4/727-2021) and performed according to the Declaration of Helsinki. In total, 97 male patients aged between 22 and 83 (mean = 46.24, SD = 13.68) were included in this study. The patients were found not guilty by reason of insanity and thus placed in forensic commitment (Maßnahmenvollzug) according to article 21(1) of the Austrian Criminal Code (Strafgesetzbuch [StGB]). By law, this entails potentially indefinite detention at a forensic mental health institution with a focus on psychiatric rehabilitation. Persons in temporary custody and prisoners that had not been committed to forensic treatment were excluded. All patients were admitted to the institution Justizanstalt Göllersdorf, located in Lower Austria, Austria between 01-01-2019 and 31-05-2021. Principal psychiatric diagnoses were classified using the International Classification of Diseases, 10th Revision (ICD-10; chapter V, F00 -F99: Mental and behavioral disorders) (World Health Organization, 1993). Criminal offenses were categorized into eight groups based on the nature of the crime, following the Austrian Criminal Code.
Demographic characteristics including clinical diagnoses and criminal offenses are presented in detail in Table 1.

Data collection
All study measures were retrospectively obtained from administrative and clinical data that was routinely recorded between January 2019 and May 2021. Initially, authors MK and MH qualitatively collected data from the respective court files (e.g., criminal offenses), the documentation system of the administrative department (e.g., reports of inappropriate behavior), and the electronic medical records operated by the Austrian penal authorities (e.g., diagnoses). Subsequently, qualitative data were converted into quantitative outcome parameters of interest.
Primary administrative outcomes included rates of one-day temporary releases and group excursions (both accompanied by the prison staff) as well as the cumulative length of unaccompanied long-term temporary releases that were authorized by the prison director (from three days up to several weeks). Further, the total number of visits by relatives and legal guardians was assessed. The utilization of video chat devices was evaluated after its first implementation in March 2020.
Psychopathological deterioration was assessed based on the total number of voluntary and involuntary admissions to the acute ward. Given that medical and nursing staff were present twenty-four-seven, transfers to the acute ward were considered as the standard procedure in case of acute psychopathological deterioration. The reasons and circumstances for the admissions were differentiated according to clinical data obtained from the electronic medical records: (I) necessity for seclusion (e.g., due to interpersonal conflicts and aggression towards others), (II) necessity for enforced intramuscular treatment due to acute self-endangerment, (III) psychiatric evaluation due to psychopathological deterioration, (IV) voluntary admissions requested by patients due to feelings of distress or conflicts with other prisoners, as well as (V) other reasons (e.g., nursing care in the context of medical disorders). In addition, transfers within a ward and transfers to other wards were compared (e.g., due to interpersonal conflicts, voluntary transfers  requested by patients, or illegal activities within a given ward). Outcome data related to compliance with institutional regulations were based on administrative penalties: (I) self-harm, (II) physical and non-physical assault to other patients and staff, (III) illegal activities including bartering, possession of mobile phones or other illegal devices, and other misdemeanors, (IV) urine tested positive for illegal substances, as well as (IV) other reasons (such as arson).

Statistical evaluation
All data were anonymized before statistical analyses with Microsoft Excel 2016 (Microsoft Corporation, Redmond, WA, USA) and R version 4.0.3 (R Foundation for Statistical Computing, Vienna, Austria). Since most restrictive measures were enacted in March 2020, 13-03-2020 was set as the cutoff date for statistical evaluation. The first study period lasted from January 2019 to mid-March 2020. The second study period lasted from mid-March 2020 to May 2021. For all outcome measures, absolute and relative frequencies were calculated. Primary analyses were performed by means of Wilcoxon signed-rank tests to test if the pairwise differences between the observations were symmetrically distributed around zero. Additionally, McNemar tests were calculated to evaluate if the number of affected patients changed after 13-03-2020. For all performed tests, a significance level of p < .05 was applied.

Theory
The first COVID-19 infection in Austria was registered on 25-02-2020, which resulted in a nationwide lockdown starting from 16-03-2020. The lockdown was gradually eased over the course of the pandemic and completely repealed on 01-05-2020. Increasing infections caused two more lockdowns, from 17-11-2020 to 06-12-2020 and from 26-12-2020 to 07-02-2021. Due to the initial lack of vaccination against SARS-CoV-2 and a nationwide shortage of protective equipment, such as medical mouth and nose protection masks as well as disinfectants, the Austrian penal authorities placed special emphasis on disease control. Consequently, rehabilitative efforts, social and professional visits, as well as psychological therapies by external therapists were intermittently suspended during the pandemic. Even though the safety measures were continuously adapted, conditions of detention were eventually compromised for more than a year due to recurrent infections. Albeit reducing the risk for disease transmission (Dolan, Wirtz, & Moazen, 2016;Kinner et al., 2020), the implemented restrictions impeded the already challenging psychosocial rehabilitation of forensic psychiatric patients relative to community settings.

Restrictive measures enacted at the Justizanstalt Göllersdorf
Shortly after the first COVID-19 cases were recorded in Austria, farranging measures for infection prevention were effectuated at the Justizanstalt Göllersdorf (Table 2). This substantially impacted the psychosocial rehabilitation of the patients (Table 3). In mid-March, the number of external visitors was limited and therapies by external therapists were suspended. Contacts between wards were strongly limited, including mutual activities such as therapeutic groups (psychological, occupational, and music therapy) and physical exercise. In turn, visiting areas with protective walls made from acrylic glass were constructed and video chat devices were acquired to preserve social contacts.
The entire staff was divided into two teams to be able to maintain care in the event of a viral outbreak. In case of an infection cluster within one group, the unaffected team was ready to substitute. Daily screening of the staff was accomplished by means of temperature measurements and surveys concerning relevant symptoms such as coughing, throat pain, fatigue, and loss of taste as well as smell. Although the number of employees suffering from COVID-19 was not recorded, the overall incidence of sick days was negligible. Most notably, only four patients tested positive for SARS-CoV-2 during the entire study period. One of the patients experienced symptomatic progression of COVID-19 with subfebrile temperature, mild cough, and headache. The other three patients exhibited asymptomatic infections. All affected patients were isolated in their prison cells and received medical care under quarantine conditions. None of the patients showed serious complications and quarantine conditions were discontinued after negative polymerase chain reaction testing.

Rehabilitative activities
Before the outbreak of the pandemic, rehabilitative activities mainly depended on the psychopathological stability of the patients and their compliance with institutional regulations. After the enactment of restrictive measures, the rate of rehabilitative activities decreased significantly (Fig. 1A). In the first study period, 30 patients conducted 64 individual one-day temporary releases. In contrast, only three temporary releases were completed in the second study period (V = 513.0, p < .001) (Fig. 1B). The evaluation of one-day group excursions showed a similar pattern. First, a total of 103 excursions were conducted, whereby 15 out of 28 patients were able to participate multiple times. Afterwards, only 10 excursions were conducted with 10 patients (V = 345.0, p < .001) (Fig. 1C). The McNemar tests also yielded significant results (p < .001) for one-day temporary releases and group excursions.
Interestingly, COVID-19 did not impact long-term temporary releases. During both study periods, patients were allowed to leave the institution for several weeks within the framework of long-term Table 2 Summary of the restrictive safety measures enacted at the Justizanstalt Göllersdorf after the first occurrence of COVID-19 infections in Austria on 02-25-2020.

February 2020
Suspension of guided tours for educational purposes, networking meetings, group therapies, and access to the cafeteria for visitors; implementation of daily fever screening; establishment of visiting areas with protective walls March 2020 Suspension of rehabilitative activities, educational events, external therapies, and access to the in-house cafeteria for patients; admittance of external visitors only in urgent cases; closing of residential wards during the day; separated physical exercising in the courtyard; staff division April 2020 General mask obligation; establishment of video chat communication; readmittance of external visitors (max. one person per patient) June 2020 Suspension of staff division; re-establishment of external therapies and mutual activities within the institution; reopening of residential wards July 2020 Admittance of two visitors per patient; extension of the maximum number of participants in group therapies; re-establishment of oneday activities in exceptional cases; loosening of the mask obligation September 2020 Reintroduction of general mask obligation; re-establishment of educational events with a limited number of participants November 2020 Release of administrative trainees; suspension of one-day activities and external therapies; Extension of video chat communication (i. e., for external therapies); reintroduction of psychological group therapies (with restrictions); testing of patients for COVID-19 in justified cases January 2021 Extension of COVID-19 testing for patients and staff; readmittance of visitors (max. two persons per patient) March 2021 Suspension of therapeutic groups (psychological, occupational, and music therapy) -exeptions were allowed in urgent cases within the ward; closing of the residential wards during the day; separated physical exercising in the courtyard; admittance of external visitors only in urgent cases April 2021 Visits of relatives were allowed behind protective glass walls; reintroduction of therapeutic groups and mutual physical exercising; extension of COVID-19 testing of staff and patients June 2021 Visits were allowed without protective glass walls; increased visiting time of relatives; rescinding of the mask obligation; reestablishment of rehabilitative activities and mutual activities within the institution temporary releases in order to facilitate their final release. From January 2019 to March 2020, 13 patients left the Justizanstalt Göllersdorf for collectively 122 weeks. During the pandemic, the cumulative length of long-term temporary releases added up to 188 weeks (18 patients; V = 79.5, p = .131). The McNemar test was not significant (p = .302).

Social contacts
The frequency of visits decreased significantly after the outbreak of the pandemic due to strict visitation regulations ( Fig. 2A). Before the enactment of restrictive measures, a total of 1440 visits by relatives of 58 patients were recorded. Afterwards, only 394 visits took place (44 patients; V = 1461.0, p < .001) (Fig. 2B). 37 patients (38.14%) were represented by a legal guardian, including all patients with a substance use disorder, intelligence disorder, and developmental disorder. Out of all patients under guardianship, 15 patients were visited 286 times by their legal guardians during the first study period. This number decreased significantly to 122 visits during the second study period (12 patients; V = 112.0, p = .003) (Fig. 2C). Although the absolute frequency of visits decreased, the number of patients visited by legal guardians did not change significantly. McNemar tests yielded p-values of 0.006 and 0.371 for visits by relatives and legal guardians, respectively.
Video chat communication was established at the Justizanstalt Göllersdorf to maintain social contacts during the pandemic. From mid-March 2020 to May 2021, 16 patients utilized video chat devices to communicate with their relatives and legal guardians (165 interactions). Since the devices were not routinely used before the outbreak of the COVID-19 pandemic, no statistical comparison could be applied here.

Psychopathological stability
At the Justizanstalt Göllersdorf, patients were most commonly diagnosed with schizophrenic disorders, personality disorders, and comorbid substance use disorders (Table 1). In case of psychopathological deterioration, patients were usually admitted to the acute ward. While 141 admissions (48 patients) were recorded between January 2019 and mid-March 2020, 143 admissions (42 patients) were carried out between mid-March 2020 and May 2021 (V = 872.5, p = .712). In the first study period, 25 patients were admitted once, three patients were admitted twice, and 20 patients even more frequently (up to 19 admissions). After the outbreak of the pandemic, 20 patients were admitted once, six patients were admitted twice, and 16 patients more often. The McNemar test did not yield significance (p = .511).
Concerning the reasons for the admissions to the acute ward, the performed analyses did not yield significant results. The most frequent reason for involuntary admission to the acute ward was the necessity for observation of the patients' psychopathological condition, with 89 of 141 admissions (63%) in the first and 81 of 143 admissions (57%) in the second study period (V = 723.0, p = .567). Seclusion was imposed 27 and 29 times (V = 64.5, p = .872), respectively. The number of coercive measures was equally low in both study periods, with three and four enforced intramuscular injections (V = 1.0, p = 1.000). Reasons for voluntary admissions to the acute ward included feelings of distress and irritability as well as conflict prevention. Although admissions at the request of patients differed between the two study periods, the results were not significant (eight vs. 18 voluntary transfers; V = 9.5, p = .250). Likewise, admissions related to medical conditions and nursing care did not change (14 vs. 11 admissions; V = 76.0, p = .674).
The number of transfers to other prison cells only changed insignificantly. While transfers to other wards decreased from 34 to 23 after the outbreak of the pandemic (V = 210.0, p = .191), transfers within a ward increased slightly (77 vs. 89; V = 712.0, p = .478).

Compliance with institutional regulations
Overall, filed reports referring to inappropriate behavior remained largely unchanged after the outbreak of the COVID-19 pandemic (V = 381.5, p = .877). Solely illegal activities (such as possession and bartering of electrical devices) decreased significantly from 27 to eight reports (p = .024). The number of reports regarding aggressive behavior showed an insignificant increase from 17 to 29 (self-harm; V = 12.0, p = .430) and from 47 to 53 (physical and non-physical assault to others; V = 186.5, p = .497). Likewise, positive urine drug tests showed no difference (eight vs. seven patients tested positive for drugs; V = 11.5, p = .915). Other types of reports of inappropriate behavior (e.g, arson, abusive language, and sexual assaults) also remained unchanged, with Table 3 Impact of restrictive measures enacted at the Justizanstalt Göllersdorf after outbreak of the COVID-19 pandemic.   27 and 23 reports (V = 126.5, p = .705), respectively.

Discussion
The sudden outbreak and unpredictable course of the pandemic led to far-reaching safety and protection measures throughout the world. According to human rights organizations, the pandemic aggravated the situation of detained persons due to excessive confinement and quarantine (Amnesty, 2021;Harm Reduction International, 2023). On the grounds that more restrictive conditions of detention reduce the risk for transmission of SARS-CoV-2, numerous European penal authorities suspended external service providers and psychological group counseling (Kennedy et al., 2021;Montanari et al., 2021;Puzzo, Aldridge-Waddon, Stokes, Rainbird, & Kumari, 2022). In line with these reports, our study highlights the substantial impact of COVID-19 on forensic care in terms of rehabilitative activities and visitations in Austria. Although initially considered provisional, most of the restrictive measures were eventually continued for more than a year, which led to a significant delay of the psychosocial rehabilitation process. In contrast, study outcomes related to psychopathological stability and compliance with institutional regulations did not change significantly after the outbreak of the pandemic.
Despite publicly available data, comparison of COVID-19 infection rates is complicated due to inconsistent testing strategies in most states. While > 42,000 infections (3.3%) were recorded in prisons in the United States by June 2020 (Saloner, Parish, Ward, DiLaura, & Dolovich, 2020), < 1% of all prisoners were tested positive in Spain (0.7%), Belgium (0.5%), Italy (0.3%), and the Czech Republic (0.2%) by September 2020 (Aebi & Tiago, 2020). According to the European Prison Observatory (htt p://www.prisonobservatory.org), considerably fewer infections were recorded in Austria (0.04%) and Portugal (0.03%) within the same time period. Even by January 2021, only 184 cases (2.2%) were recorded among 8400 Austrian prisoners (Kogler, 2021). Although these numbers suggest that disease control was rather effective, our data show that the enacted measures concomitantly limited treatment efforts. Notably, a similar impact on therapeutic activities and temporary releases was reported in other states (Heitzman & Gosek, 2021;Kennedy et al., 2021;Montanari et al., 2021;Puzzo et al., 2022). To prevent overcrowding of prisons and to facilitate alternatives to detention, updated regulations for the release of prisoners were approved in 21 out of 27 member states of the European Union in June 2020 (European Parliament, 2020). In line with these regulations, ongoing long-term releases that were authorized by the responsible court in Lower Austria in 2020 were extended in most cases. Consequently, our study showed no decrease in the rate of long-term temporary releases after the outbreak of the pandemic. However, the decision about the final release from forensic commitment is usually made one or two years after the approval of oneday temporary releases. It is therefore not surprising that the judicial consequences of the impaired rehabilitation process emerged just recently. From 2019 to 2021, between eight and eleven persons were released from forensic commitment by the responsible state court each year. In 2022, only five patients were released within the jurisdiction of this court, which can be attributed to the overall decline in rehabilitative activities after the outbreak of the pandemic.
The fact that freedom-restricting measures are among the basic methods of infection control, leads to conflicts between public health and human rights positions (Pont et al., 2021). Persons in detention are particularly prone to human rights violations due to the deprivation of natural protective mechanisms such as social support and access to reliable information. Adequate service changes are therefore needed to keep restrictions at a minimum level and to maintain the treatment process during a pandemic. While the implementation of video chat communication improves the patient's wellbeing, telehealth may constitute an alternative to conventional care in prisons (Tian, Venugopalan, Kumar, & Beard, 2021;Wegel, Wardak, & Meyer, 2022). Provided that physical distancing measures are followed, rehabilitative activities such as outdoor exercises should not be suspended. As to that, recent guidelines related to COVID-19 outline important principles grounded in human rights law that must be respected in prisons and other places of detention (Harm Reduction International, 2023;Wallace, Hagan, Curran, et al., 2020;World Health Organization, 2021).
Offenders frequently exhibit a history of previous traumas and may struggle to cope with traumatic situations (Belet et al., 2020). Since the perceived threats of COVID-19 and institutional restraints were associated with aggressive tendencies (Deng & Feng, 2021;Franke, Büsselmann, Streb, & Dudeck, 2019), we assumed an increase in aggressive behavior among the inmates. Surprisingly, the present results do not suggest a major deterioration of psychopathology in most patients after the outbreak of the pandemic. Admissions to the acute ward, self-harm, and assaults did not change significantly. While transfers to other prison cells were mainly conducted after occurrence of interpersonal conflicts, no significant change was observed in this respect either. These findings contrast previous studies, reporting increased psychological distress due to COVID-19 in vulnerable groups (Kozloff, Mulsant, Stergiopoulos, & Voineskos, 2020;Yao, Chen, & Xu, 2020;Zhu et al., 2020). Although a recent publication further suggested that violent incidents in forensic mental health institutions increased during the pandemic, the study did not find increased rates of damage to property and also showed a decrease in non-physical assaults to staff (Puzzo et al., 2022). The fact that physical and non-physical assaults were not subdivided in our study may explain the differing results related to aggressive behavior. It can be argued that recent restrictions of freedom had merely a minor impact on the patients' psychopathology compared to community settings due to the pre-existent oppressive environment in penal institutions. Moreover, the low staff turnover and an increased alertness of the medical and prison staff regarding potential psychopathological deterioration could have positively affected study outcomes after the outbreak of the pandemic. The insignificant findings could also be attributed to an overall reduced perception of threat, commonly caused by interpersonal conflicts with other patients. While some patients indeed expressed psychological distress due to the restrictive measures, others felt relieved that they did not have to quarrel with fellow inmates. In that regard, physical distancing measures surely limited opportunities for bartering in the courtyard and during mutual therapeutic activities, which caused a significant decrease of reports related to illegal activities.
Multiple unbudgeted measures were implemented by the staff of the Justizanstalt Göllersdorf to prevent interpersonal conflicts and feelings of distress among patients. Besides daily governance meetings with the prison director and a crisis team, extraordinary psychiatric and psychological consultations were provided at each ward, which may have exerted protective effects in terms of mental health. Aside from that, prisoners made their own mouth and nose protective masks at the inhouse workshops as a substitute for occupational therapy. Eventually, video chat communication was implemented within the Austrian penal system to facilitate communication with legal guardians, courts, lawyers, and relatives. The patients almost unanimously emphasized the benefit of this communication method, which could be another explanation for the insignificant results regarding psychopathological decompensation. Notably, the number of patients who received visits from relatives and legal guardians in the first study period and the number of patients who maintained social contacts in the second study period, including those who used video chat devices, were comparable (73 patients vs. 72 patients).
Given the methodology of this study, multiple limitations have to be considered. While the general population was affected by several separate lockdowns, the pandemic-related restrictions within Austrian penal institutions were maintained for the entire second study period. Due to the unforeseen nature of the pandemic, we could not examine questionnaires on psychopathological functioning, health, well-being, or perceived social support. Consequently, we relied on retrospective data analysis of partial indicators, such as transfers to the acute ward and reports of inappropriate behavior, to assess psychopathological deterioration. Given the personal susceptibility of the prison staff to the new and stressful situation, the frequency of filed reports referring to inappropriate behavior might have been biased in the second study period. Moreover, only men were included in this study, as no women are treated at our institution. The 13-03-2020 was chosen as the cut-off date between both study periods, since the most far-reaching restrictions such as suspension of visits by relatives and legal guardians were applied on this day. Since study data could not be collected after patients were transferred to other penal institutions, approximately 50 patients that were not admitted to the Justizanstalt Göllersdorf for the whole study period had to be excluded from the study sample. However, since patients were not excluded according to their diagnoses or offenses, we do not expect a systematic bias impacting the present findings. Given that structural and therapeutic conditions in penal institutions vary across states, our observations can only partially be generalized to other forensic institutions.

Conclusion
The unavailability of vaccinations and uncertain health-related risks at the beginning of the pandemic surely created a critical situation, urging immediate and strict measures within the penal system. While the present results imply that the pandemic catalyzed positive byproducts such as video chat communication, the efforts to mitigate viral transmission impaired the overarching psychosocial rehabilitation of forensic psychiatric patients in Austria. Given the fact that the farreaching measures lasted for approximately 14 months highlights the need for national and international guidelines with the goal to retain acceptable standards of care during a pandemic. International organizations emphasize the importance of contingency planning to enable an adequate health response during future pandemics. Key principles include secure conditions of detention as well as the need for psychological and behavioral support. Moreover, qualitative research on the experiences of detained people is recommended to ensure that their needs are adequately addressed. Keeping in mind that this group of patients' principal reason for detention is a psychiatric disorder, a prolonged treatment process may constitute a violation of human rights regarding the right to liberty, health, and private life.

Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethics approval and data availability statement
Informed consent was not required and the responsible Ethics Committee of Lower Austria (GS4-EK-4/727-2021) raised no objections to this study according to the principles of the Declaration of Helsinki. Study data are not publicly available due to privacy restrictions.

Author contributions
MK contributed to the conceptualization of the study, data curation, methodology, the investigation process, and wrote the original draft of the manuscript. AD administered the project and provided the resources. MH contributed to data curation. LY performed formal analysis and contributed to methodology as well as visualization of the work. UR contributed to methodology and revised the initial draft. AK supervised the research activity and contributed to the conceptualization of the study, methodology, as well as the investigation process. All authors critically reviewed and approved the manuscript.

Declaration of Competing Interest
MK, AD, UR, and AK were involved in the treatment process of the patients. With relevance to this work, all authors declare no conflicts of interest.