In response to the COVID-19 pandemic, governments around the world have had to identify, implement, and refine regulatory practices to help decrease the spread of the virus and mitigate the impact on healthcare facilities and personnel. A new rapid review conducted by researchers in Canada highlights strategies considered most effective in managing COVID-19 in correctional facilities and other secure units, specifically for individuals with mental health issues. Here, we provide a summary of key findings and recommendations from the research, published in Victims & Offenders: An International Journal of Evidence-based Research, Policy, and Practice.
Measures taken to slow the spread of the virus around the world have impacted everyone; however, those in closed settings – such as institutions or correctional facilities – who also struggle with mental health issues have faced unique setbacks in care. In an effort to treat those with the virus, mental health resources and healthcare specialists have been shifted out of prisons and into hospitals or long-term care facilities. In addition, social distancing protocols have decreased access to outside mental health support and visitation for incarcerated individuals.
In an effort to better understand the impact of COVID-19 management strategies on incarcerated and institutionalized individuals with mental health issues, a group of researchers in Québec conducted a rapid review of international scientific publications from December 2019 to August 18, 2020 which contained terms related to psychiatry (including forensic psychiatry), correctional environments, and COVID-19.
The literature review yielded findings and conclusions based on analysis and synthesis of nine common themes that emerged with regard to strategies, challenges, and recommendations in managing COVID-19 in correctional facilities and institutions for individuals with mental illness.
Key Findings and Recommendations
The review’s authors identified nine key themes and provided findings and recommendations for each, summarized below with a focus on correctional facilities.
Theme 1: Increased vulnerability
- Morbidity and mortality rates are higher for individuals with mental illness.
- COVID-19 and psychotropic medications, when combined, can worsen respiratory symptoms.
- Limited access to psychotic substances can lead to an increase in withdrawal symptoms.
- Carefully consider the use of sedation to secure compliance.
- Be aware that increased isolation and social distancing measure may amplify the likelihood of psychiatric relapses and increase the risk of suicide or self-harming behaviors.
Theme 2: Organization of Mental Health Professionals
- Correctional facilities have significantly shifted their staff and personnel in response to the virus, requiring increased communication and more intentional coordination of mental health care.
- Isolation within correctional facilities can produce greater levels of fear, stress, or despair for both inmates and staff.
- Consider creating task forces composed of representatives from clinical and non-clinical areas that can debrief and problem solve daily.
- Improve communication between the facility and public via websites, intranet, and podcasts.
- Collaborate with community agencies to increase incarcerated individuals’ sense of community belonging.
- Keep staff members’ mental health and wellness in mind, using management strategies that prioritize wellness, recognition, supervision, and both peer and managerial support.
- Consider decreasing the size of healthcare teams in order to create “backup” systems that allow personnel to minimize risk of infection and have adequate time to rest between work hours.
Theme 3: Discharge and Release
- Traditionally criminalized groups (e.g., ethnic/racial minorities, substance users, people with mental health issues, those who are homeless) increases transmission of the virus in correctional settings.
- Recurrent movement between correctional facilities and the community increases risk of infection and spread of disease within both areas.
- Consider release strategies that focus on inmates who are older or have a low risk of recidivism.
- Transfer or hospitalize incarcerated individuals who test positive in order to allow for quarantine; and consider reassigning recovered staff who may possess higher immunity to areas with COVID-positive inmates.
- Transfer incarcerated individuals with mental health issues to community-based services instead.
Theme 4: Managing Secure Units
- Screening and isolation of newly detained individuals with mental health issues has become standard practice.
- Individuals with mental illness can display atypical COVID symptoms, and inmates may hide symptoms to avoid isolation.
- Commit to regular and thorough testing/screening protocols for all inmates and personnel.
- When an incarcerated person tests positive, test the entire unit and have a transfer protocol ready to help treat the infected individual.
- Consider creating separate corridors or sections within facilities for positive cases to help limit transmission, and isolate those positive for COVID-19 for 14 days when possible.
- Ensure these areas have seclusion rooms established for individuals displaying behavioral disturbances and ensure all personnel working in these areas have full PPE.
- Monitor inmates who test positive closely to determine if emergency services are necessary and have a plan in place to move quickly should transfer be required.
Theme 5: Protection Via Sanitation and Hygiene
- Correctional facilities have had difficulty obtaining PPE.
- Protective equipment carries the risk of being used as a weapon or ingested by inmates with mental health issues.
- Ensure all personnel wear masks and are trained on proper use of PPE; if equipment is limited, prioritize PPE for those working with positively diagnosed individuals.
- Provide separate changing rooms where staff can put on or remove PPE when working within COVID-positive areas of the facility.
- Closely monitor PPE and sanitation items (e.g., masks, hand sanitizer) when in the presence of incarcerated individuals with mental health issues.
- Everyone in the facility should be taught proper sanitizing and hygiene measures, such as hand washing, coughing safely, or disposing of personal care products.
- Surfaces, equipment, and food should be sanitized regularly.
Theme 6: Reducing Services or Activities
- Admissions to mental health facilities have been slowed down or put on hold, leaving inmates with mental health issues with no community option for treatment.
- Group activities pose an elevated risk for transmission of the virus, particularly within correctional facilities.
- Reduction of services has left some inmates in isolation for up to 23 hours per day, increasing the need for mental health care.
- Suspension of hearings and trials may leave people in remand centers longer, which can increase anxiety.
- Expand access to group activities where social distancing can be maintained.
- Limit the number of participants in group activities to ensure proper distancing protocols.
- Where possible, transition a group activity to an individual activity.
- Increase access to outdoor environments and consider allowing inmates greater access to entertainment, such as puzzles or books.
- Coordinate with psychiatric services available in the region and regularly screen for mental health issues for which follow-up might be needed.
- Prioritize inmates with serious mental health issues and pre-existing risk factors for appropriate care with trained professionals.
- Coordinate with court-liaison services to facilitate court processing.
Theme 7: Use of Remote Tech
- With in-person visits no longer allowed, remote technology provides an opportunity for inmates to stay connected to family members.
- Changes in telehealth reimbursement rules enables facilities greater access to remote care and treatment options.
- Consider adding videoconferencing and remote technology to the options inmates and families can use to communicate.
- Consider using remote technology to coordinate care visits with mental health specialists and management of medications for those with mental health issues.
- Consider using virtual team meetings to help staff reduce risk of exposure and infection.
Theme 8: Rights for Individuals
- Implementing isolation measures for individuals already in confinement poses ethical considerations for facilities and can exacerbate existing mental health issues for inmates.
- The use of sedation can worsen respiratory issues.
- Guidelines around isolation that are unclear or inconsistent are less likely to be understood or respected by inmates.
- Apply isolation measures or involuntary hospitalization with caution for individuals with mental health issues.
- Ensure isolation and quarantine protocols are created with individual rights in mind, and use these protocols only when other options affording more personal liberty (e.g., discharge) cannot be implemented.
- Regularly review restrictive protocols with inmates and inform individuals of changes to guidelines immediately.
Theme 9: Lasting Effects
- Incarcerated individuals are more at risk of developing pandemic acute distress disorder.
- New practices put in place in response to the pandemic may have been rapidly put in place without being critically evaluated.
- Research with a non-pandemic focus may not be as readily funded or supported, which may impact how it is conducted in correctional settings.
- Provide families with appropriate resources and support to help those transitioning out of correctional facilities.
- Coordinate regular mental health screenings and coordinate with community agencies when appropriate.
- Critically evaluate new guidelines and protocols to ensure changes in procedure are adopted with long-term impact in mind.