Full Text Article

Introduction

Owing to their contagiousness and severity, pandemics throughout history have challenged both public health officials and the general public to effectively and rapidly respond as well as implement health strategies to reduce disease spread and minimize fatalities.  Crises like the COVID-19 and Spanish Flu pandemics provide data that can be leveraged to shape current and future pandemic responses.  

Developing an effective response to pandemics has been especially challenging in correctional facilities, given their crowded conditions.  Due to restricted communication and mobility in these facilities and the precipitousness and spread of many pandemic diseases, people living in prison during the time of pandemics often experience a significant amount of stress and uncertainty. 

Several aspects of incarceration may contribute to anxiety and fear among people living in correctional facilities, making this an at-risk population during pandemics.  Educational attainment and health literacy may be low among people experiencing incarceration and access to information is tightly controlled, possibly contributing to misinformation and uneasiness [1]. Further, medical mistrust, prevalent among people in correctional facilities before outbreaks due to systemic racism, historical discrimination, and stigma, may be exacerbated in the wake of the existential threats pandemics present [2].  Due to limitations on in-person visitations in correctional facilities imposed during pandemics, many people living in these facilities lack the support network formed by family and friends they would normally rely on [3]. The health effects of visitation on the behavior, mental health, and recidivism of people who are incarcerated are largely unknown due to the heterogeneity of visits, but it has been theorized that visitation may help combat feelings of social isolation and improve behavior and reentry outcomes [4]. 

Lastly, being quarantined and isolated as a result of contracting or being exposed to pathogens may further exacerbate feelings of loneliness, helplessness, and sadness.  Indeed, health professionals in correctional facilities fear people in these facilities may refrain from disclosing symptoms of diseases like COVID-19 so as to avoid further segregation [5]. Correctional facilities should realize that destabilizing events like pandemics can significantly impact the mental well-being of the people living there.

Correctional facilities nationwide need to prioritize the mental health of people experiencing incarceration during the ongoing pandemic and any future ones by implementing compassionate and effective protocols focused on alleviating anxiety, fear, and loneliness.  Here are some suggestions and recommendations based on literature review and opinions of the experts taking care of people who are incarcerated:

1. Employ medical isolation wisely and sparingly.  Examples of effective isolation procedures can be found by examining the response to the COVID-19 pandemic.  The CDC recommends physical isolation (i.e., separate housing areas and bathrooms) for people in prison who have tested positive for COVID-19, are suspected to have COVID-19, or have had close contact with individuals with confirmed or suspected COVID-19 [9]. However, in following this guideline, correctional facilities should strive to minimize the resemblance of medical isolation to solitary confinement, which has been historically used as punishment and linked to adverse psychological outcomes [6-8]. A possible solution includes “cohorting,” a practice encouraged by the CDC for housing confirmed COVID-19-positive patients together when individual spaces are limited [7,9]. If medical isolation is absolutely necessary, patients should only be isolated for the essential amount of time [9,10]. Furthermore, the staff should provide people living in these facilities, including those in medical isolation, plentiful access to reading material and television to improve their experience, better distinguish the isolation from a disciplinary measure, and lessen the risk for negative psychological impacts [5,7].

2. Encourage good diets, exercise, and sleep.  These practices may help people who are incarcerated cope with heightened emotions during pandemics [10]. Correctional facilities may consider developing a schedule where people in prison are allowed to spend more time outside while maintaining social distancing [11]. If funds are available, detention facilities could consider investing in and widely distributing cost-effective earplugs, eye masks, and other non-medical sleep aids, organizing sleep hygiene workshops led by healthcare professionals, or distributing pamphlets educating on good sleep hygiene.  Lastly, jail staff could encourage people living in jail to limit unhealthy purchases from the commissary.

3.  Increase access to mental health professionals and counselling.  While it may seem advantageous to divert mental health staff at detention facilities to other healthcare responsibilities, this should be avoided as much as possible [12]. In addition to maintaining in-person mental healthcare, prisons could explore the use of new technologies to provide expanded and socially-distant diagnostic and therapeutic services to people in prison during pandemics [10]. Jails and prisons could also advocate for their states to waive in-state telemedicine licensure requirements so that people in prison can access broader psychological services [12]. People who are incarcerated may benefit from self-help pamphlets or handbooks on psychological care related to pandemics [13]. Lastly, supplying multiple options for crisis counselling for people living in jail, especially for those with pre-existing mental illness, may prevent nervousness, irritability, and fear [14].

4. Expand access to various means of communication.  Prisons could prioritize broadening telephone, videoconferencing, email, and mail privileges by waiving fees, redistributing telephones or computers, and providing supplies to write letters so that people living in jail can continue to connect with family and friends [11,14].  Additionally, facility staff could provide those in medical isolation with means of communication with other persons incarcerated, so that they may continue to mutually support each other despite being physically separated.  Providing these services may combat aggression, loneliness, depression as well as reduce risk of suicide and self-harm among people experiencing incarceration [14].

5. Commit to keeping people experiencing incarceration informed.  Correctional facilities could provide people living in jail with means to access news via television or radio and encourage consumption of reliable sources of information, as false information and conspiracy theories may stoke anxiety [10]. Moreover, staff could disseminate accurate, up-to-date information by distributing educational posters and pamphlets on pandemics and maintaining daily or weekly updates for people in jail via meetings or recorded briefings during outbreaks.  Staff could commit to sharing information about rapidly changing health protocols, case counts, and disease prevention.  In an environment marked by information and personal freedom deprivation, candid communication between staff and people in jail would be crucial in mitigating their anxiety.  These efforts may also promote adherence to pandemic preventive measures like mask wearing, hand washing, and social distancing among those living in jail.

6.  Advocate for decarceration.  The COVID-19 pandemic provides a specific example of the benefits of decarceration to people in jail.  Activists, legal scholars, researchers, and physicians called for the release of incarcerated people from jails and prisons during the global crisis, and many correctional facilities around the world and in the U.S. implemented policies to release certain individuals in order to make testing, quarantining, and social distancing more effective [3, 6, 15-17].   Decarceration has clear implications for minimizing the spread of pandemics within detention facilities, but it also may help to lessen the psychological impact of being incarcerated during pandemics by allowing individuals to reintegrate into their support networks and avoid the distress of isolation [18]. Detention facilities may consider the decarceration process in people who are mentally ill and incarcerated for minor criminal charges, in accordance with state laws, by transferring them to local psychiatric hospitals if possible.  Correctional facilities could also coordinate with the judicial system and law enforcement, based on state laws, to reduce the number of people admitted to jails and prisons as well as increase the number of people approved for community release and rehabilitation. 

7. Maintain transparency. Correctional health professionals should strive to create a supportive, transparent environment for the individuals living in their facility during pandemics by rounding more frequently, promptly addressing the questions and concerns of those who are incarcerated, and augmenting staff vigilance, counselling, and visibility.  Transparency could improve the mental health and well-being of people in jail and reduce their sense of isolation.

Correctional facilities charged with safeguarding the health of people who are incarcerated and their staff during current and future pandemics should not only reduce the spread of diseases but also address the concurrent mental health crises.  Incarcerated and non-incarcerated individuals alike are likely to experience negative mental health outcomes as a result of pandemics [19]. However, given the high prevalence of underlying psychiatric illness in people who are incarcerated as well as unique prison stressors, such as separation from loved ones, delays in legal proceedings, and loss of autonomy, the psychological impact of pandemics is likely be significantly heightened in correctional facilities [5,20]. Failure to placate anxieties, depression, and fears surrounding pandemics among people in these facilities may lead to behavioral difficulties and long-term psychological complications [14]. Correctional staff must be mindful of this population’s distinctive position in the setting of current and future pandemics and act quickly and effectively to implement policies that support their mental well-being.

Funding

Conflict of Interest Statements

Hien J. Piotrowski used no funding sources to write this report.
Brianne Lacy used no funding sources to write this report.
Dr. Waseem Ahmed used no funding sources to write this report.
Dr. Ank E. Nijawan used no funding sources to write this report.
COI: none

Funding for Other Projects: NIDA R34DA045592

Dr. Mustafa M. Husain used no funding sources to write this report.
Federal Grant Support for Other Projects: NIH, NIMH, NIA, NINDA, Brain Initiative, Stanley Medical Research Institute
Industry Grant Support for Other Projects: Alkmears, Avanir, Abbott (ANM), Cyberonics, Neuronetics, Brainsway, NeoSync
Consultant/Speakers Bureau: None

UT Southwestern Medical Center had no role in writing the report nor in the decision to submit the report for publication.

Financial Disclosure Statements

Hien J. Piotrowski had no financial disclosures.
Brianne Lacy had no financial disclosures.
Dr. Waseem Ahmed had no financial disclosures.
Dr. Ank E. Nijawan had no financial disclosures.
Dr. Mustafa M. Husain had no financial disclosures.