Strategies Mitigating the Impact of the COVID-19 Pandemic on Incarcerated Populations

More than 300 million Americans in more than 40 states have been urged to stay at home in an effort to mitigate the public health crisis caused by the spread of COVID-19. These directives cannot apply to the nation’s incarcerated population or most employees of the nation’s penitentiary system who are deemed essential workers. Early research from Wuhan, China, indicates that those forced to live under quarantine may suffer from a higher rate of posttraumatic stress symptoms¹ and that health care workers—who cannot avoid exposures—have an elevated rate of anxiety, depression, and distress.²

In correctional settings, inmates are experiencing the worst of both of these worlds: they are mandated to comply with modified isolation policies to prevent the further spread of COVID-19 and are unable to control their own risk of viral exposure because of communal usage of showers, toilets, dining facilities, and telephones. Continuing to provide psychiatric care to the incarcerated—who already suffer from high rates of mental illness—during this pandemic is critical. If we are unable to attend to the psychological needs and physical safety of inmates and correctional staff, we risk large-scale rioting as occurred in the Italian prison system; increasing rates of suicide; and the possibility that some correctional staff will walk off the job, exacerbating the safety risks to all of those who remain.

The rate of mental illness in the incarcerated population is higher than that of the general public. In addition to adverse life experiences resulting in posttraumatic stress disorder, approximately one in seven inmates suffers from either psychosis or major depression and one in five suffers from a substance use disorder.³ These populations are likely to be among the least capable of managing the anxiety and fear caused by the current outbreak.

Their fears are warranted: underlying medical conditions are associated with increased mortality in patients with COVID-19, and those with psychotic illnesses suffer from higher rates of diabetes, obesity, metabolic syndrome, and cardiovascular disease, a significant portion of which may be attributed to long-term use of antipsychotic medications, which are critical for their psychiatric stability. Those with schizophrenia have a life expectancy that is approximately 14.5 years shorter than that of the general population in part because of these comorbidities.⁴

Prisons have experienced some of the largest COVID-19 outbreaks during the pandemic,⁵ and to reduce transmission rates, many states are releasing inmates deemed low risk and moving the remaining population into individual cells. In Illinois, the Department of Corrections has eliminated all family visits and placed facilities with confirmed cases on lockdown, effectively stopping all inmate movements except for those necessary for medical care. The governor has also limited the movement of prisoners from jails to prisons.

Although these interventions are necessary to reduce the risk of further disease transmission, they may have unintended consequences. Restricting inmates to individual cells, possibly for weeks at a time, is likely to impose a severe psychological burden. Confining inmates to their cells is not equivalent to placing them in solitary confinement, but it is reasonable to think that restricting prisoners’ ability to interact with family and peers will adversely affect their psychological well-being. Being incarcerated is itself a risk factor for suicide; prisoners kill themselves at several times the rate of the general population.³ Further isolating these individuals without adequately addressing their psychological needs may exacerbate these disparities.

The US Supreme Court has repeatedly affirmed that the Eighth Amendment’s prohibition of “cruel and unusual punishment” requires that jails and prisons provide basic medical care including mental health services for those incarcerated. To be sure, many may have concerns about prioritizing the health of inmates when so many nonincarcerated Americans are suffering from COVID-19. But the mental health of the incarcerated cannot be walled off from the public health of the community at large. Six thousand prisoners at facilities throughout Italy in March rioted after family visits were restricted. Twelve prisoners reportedly died, 16 prisoners escaped, and 40 guards were injured. Rioting linked to COVID-19 has also broken out in prisons in Washington, Louisiana, New York, and Kansas. The barbwire fences of jails and prisons are more porous than they may appear.

Ensuring that the psychiatric needs of inmates are met will be particularly challenging. Jails and prisons—never organized around mental health care—have reluctantly become some of the largest providers of psychiatric services in the country. Even before the current pandemic, they struggled to provide basic psychological care and to recruit and retain psychiatrists who already are in short supply throughout the country and may not want to work in remote facilities that are perceived as dangerous. The use of telemedicine has helped address these barriers, although access to this technology is not universally available.⁶ During the current pandemic, the federal government has waved HIPAA (Health Insurance Portability and Accountability Act of 1996) penalties for providers who use non–HIPAA-compliant videoconferencing software. Psychiatry departments around the country, including our own at Northwestern University Feinberg School of Medicine, have rapidly converted large portions of clinical care to telepsychiatry. Radically scaling up these services for the incarcerated population should be an urgent priority.

Managing mental illness in the correctional system requires a multipronged approach. First, releasing as many prisoners as possible will reduce transmission rates and itself be essential for the psychological well-being of those who remain incarcerated. This pandemic has emphasized the critical problem of prison overcrowding and harsh sentencing policies⁷; thus priority for release should be given to those of advanced age with medical comorbidities who are least likely to present a threat to society and those nearing the end of their terms. Second, providing personal protective equipment for correctional staff who interact with inmates should be a high priority, both for moral and practical reasons. Correctional staff are on the “front lines,” providing a critical service to the community as much as other first responders. If we do not protect them adequately, we risk further spread of the infection, which will affect their willingness and ability to work.

Third, all states should waive in-state licensure requirements for telemedicine during the current emergency to help facilitate a ramp up in psychiatric services for inmates. Fourth, expanding access to virtual family visits via videoconferencing and all forms of telepsychiatry in the country’s departments of corrections should be an urgent priority, particularly for those suffering from severe mental illness. Virtual crisis counseling and group therapy could help manage anxiety, irritability, and fear in the prison population as well as the psychological strain of what is likely to be prolonged use of isolation measures. Scaling up these services might decrease the risk of suicide, aggressive behaviors, and rioting.

Prisoners are among the most vulnerable members of society, particularly during an infectious disease outbreak. If we fail to address their mental health needs as well as the risk of contagion behind prison walls, we risk making their vulnerability our own.