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. 2020 Oct 21;106:110150. doi: 10.1016/j.pnpbp.2020.110150

Stigmatization of psychiatric and justice-involved populations during the COVID-19 pandemic

Gary Andrew Chaimowitz a,b,⁎, Casey Upfold a, Luiza Paul Géa a,b, Aamna Qureshi a, Heather Marie Moulden a,b, Mini Mamak a,b, John McDonald Wilson Bradford a,b
PMCID: PMC7577257  PMID: 33098908

Abstract

Psychiatric and justice-involved populations are known to be stigmatized and particularly vulnerable to adverse outcomes during COVID-19. The increased attention toward vulnerable populations from healthcare authorities, the media, and the general public has made it critical to uncover any developing stigmatization toward these groups and the possible consequences. The prioritization of public safety and shift in the prioritization of resource allocation and service delivery could lead to a rise in negative perceptions toward these already stigmatized groups. Thus, it is imperative to consider how the unique characteristics of vulnerable groups may impact their physical and mental health as well as their care during this pandemic. In this paper, we describe the challenges that psychiatric, correctional, and forensic psychiatry populations have faced during COVID-19 and how a rise in stigmatization could lead to adverse outcomes. Specifically, we outline the influence of the media on public perceptions and how stigmatization may be reflected in the allocation of resources, policies, and related decision-making during COVID-19.

Keywords: Vulnerable populations, Correctional population, Forensic psychiatry, Stigma, COVID-19 pandemic

Highlights

  • •

    Psychiatric and justice-involved populations are vulnerable during COVID-19.

  • •

    Understanding perceptions toward vulnerable populations during COVID-19 is critical.

  • •

    Stigma toward vulnerable groups may increase during COVID-19.

  • •

    Stigma may be exacerbated by the media among vulnerable groups.

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    Stigma may affect the allocation of resources and healthcare access during COVID-19.

1. Introduction

The COVID-19 pandemic has caused drastic changes to daily life worldwide. Currently, the central priority is to mitigate the spread of the virus while strengthening the healthcare response. As such, strict precautionary measures have been introduced and differentially implemented across populations according to their needs. These new measures have significantly disrupted the structure of regular patient care across healthcare systems, and have disproportionately affected institutional settings such as hospitals, long-term care homes, and prisons.

The care of vulnerable populations has faced increased attention and discussion as their needs vary significantly from the general population (Fiorillo and Gorwood, 2020). Specifically, the media and healthcare authorities have largely focused on the impact of the virus on the elderly due to their well-documented mortality risk. With the shift in healthcare priorities and increased discussion of vulnerable populations, it is crucial to also consider the vulnerabilities of psychiatric and justice-involved populations, and the psychosocial impact of the current pandemic. As perceptions about resource allocation, service delivery, and healthcare priorities have shifted to COVID-19 related issues, the vulnerable and previously stigmatized psychiatric and justice-involved populations may be disproportionately affected (Logie and Turan, 2020).

The purpose of this article is to evaluate how known stigma associated with psychiatric and justice-involved populations may be exacerbated due to COVID-19, and to consider the adverse outcomes. For this review, we searched the current literature on COVID-19 and stigma for publications related explicitly to psychiatric and justice-involved populations. The search was performed from May to September 2020, and the main databases used include PubMed and PsychInfo, as well as the references from the selected articles. In an attempt to include relevant literature, and considering that COVID-19 is a relatively novel topic, evidence on stigma was also searched using other web search engines. The following keywords and appropriate variations were used: “COVID-19”, “stigma”, “psychiatric disorder”, “correctional system”, “forensic psychiatry”, “offenders”, “media”, and “public perception”.

2. Vulnerable groups and COVID-19

2.1. Psychiatric population

Aside from the devastating physical symptoms associated with the novel coronavirus, the pandemic has been shown to have a significant impact on mental health. Individuals with preexisting psychiatric disorders have been proposed to be more vulnerable to adverse mental and physical health outcomes from COVID-19 compared to the general population (Fiorillo and Gorwood, 2020; Yao et al., 2020). Those with mental disorders face challenges regarding access to medication, housing, food, and income during the pandemic which may exacerbate psychiatric symptoms and treatment compliance (Armitage and Nellums, 2020; Yao et al., 2020). Lack of accessibility (e.g. no transportation), financial strain, and/or a fear of becoming sick may also hinder individuals in seeking treatment for psychiatric symptoms (Armitage and Nellums, 2020; Fiorillo and Gorwood, 2020).

The COVID-19 pandemic also poses a challenge for physicians to maintain service delivery for those with mental illness (Yao et al., 2020). Currently, healthcare services are transitioning to virtual contacts to meet the needs of mental health patients. However, complications may arise if patients are uncomfortable with virtual appointments or have limited or no access to the necessary electronic devices or internet. As a result, some patients are at an increased risk for maladaptive coping behaviours and/or worsening symptoms (Yao et al., 2020). Combined, these factors may exacerbate psychiatric symptoms and increase the illness burden experienced by those living with mental illness during the COVID-19 pandemic.

2.2. Correctional population

Physical distancing measures have been near impossible to implement in correctional settings. Often, spaces for eating, sleeping, and living must be shared among many inmates, limiting almost any possibility for physical distance. Previous literature indicates that the inmate population is at an increased risk for poor health outcomes and psychological distress related to infectious diseases as compared to the general population (Kinner et al., 2020). Additionally, COVID-19 related protective measures such as the restriction of movement inside prisons, the cancelation of activities, and lack of available communication with family and friends have the potential to exacerbate tensions and feelings of isolation (Sánchez et al., 2020). The evidence supports correctional populations as vulnerable during the COVID-19 pandemic considering that the infrastructure of correctional facilities is conducive to the rapid spread of infectious diseases, including COVID-19 (Kinner et al., 2020).

Due to the high population density within correctional facilities, infectious outbreaks in correctional settings have the potential to overwhelm healthcare services. Reducing the population within correctional settings is one of the main recommendations to reduce the spread of the virus in several countries. For example, in Canada, Ontario and the Northwest Territories have reduced their custodial population by 25% (Affleck, 2020). However, it is estimated that only 5% of inmates eligible for release within 80 countries have been released (Simpson and Butler, 2020). It is critical that strategies for mitigating the spread of COVID-19 are not limited to the general population, but are also deemed essential for correctional populations.

2.3. Forensic psychiatry population

Similar to psychiatric and correctional populations, forensic psychiatry patients are vulnerable to adverse health outcomes related to COVID-19. In Canada, individuals who committed a crime while experiencing symptoms of a mental disorder and are subsequently found not criminally responsible for the offence, or individuals who are found unfit to stand trial (i.e. unable to adequately participate in their legal proceedings on account of their psychiatric illness), come under the jurisdiction of the forensic psychiatry system (Criminal Code of Canada, 1985).

While separated from the correctional system, forensic psychiatry patients are subject to legally mandated loss of liberties and restrictions. Additionally, unlike civil psychiatric or other medical patients, forensic psychiatry patients require legally mandated therapeutic communication for the assessment and management of symptoms and risk of violence. The strict precautionary measures in place to mitigate the spread of COVID-19 have made therapeutic communication more complex as forensic psychiatry healthcare workers strive to uphold these measures, while at the same time managing the threat to public safety.

Although some institutional settings are releasing individuals into the community amid COVID-19, the detention and release of forensic psychiatry patients in Canada is predicated, in part, on whether the individual poses a significant risk to public safety, and whether the risk is manageable to a different setting (Criminal Code of Canada, 1985). Thus, some forensic psychiatric patients cannot live in the community due to the legal conditions placed on them and/or their treatment progress and rehabilitation. In Ontario, most forensic psychiatry facilities restricted inpatients to hospital units. While helping to prevent community transmission, this increases the likelihood of patients congregating in communal areas, infringing on previous enjoyed liberties and limiting physical distancing (Simpson et al., 2020).

For patients living in the community, programming and regular outpatient visits have been put on hold, creating a barrier to therapeutic communication and assessment of risk. While many healthcare settings have turned toward virtual care, many forensic psychiatry patients in the community are limited in their ability to communicate virtually. Some may not have electronic devices or are under conditions that prohibit access to online platforms and social media sites (Simpson et al., 2020). Critically, liberty loss and restrictions, and the associated stress of both, can contribute to an exacerbation of symptoms and/or behavioural instability, increasing the illness burden experienced by patients.

3. Stigmatization and COVID-19

Stigma is manifested through the marginalization and social isolation of certain groups, which is often based on characteristics and perceived social responsibility of their illness and/or circumstances (Bhat et al., 2020; Logie and Turan, 2020). Although COVID-19 related restrictions are essential to mitigate virus transmission, it is important to acknowledge that they may increase stigmatization against psychiatric and justice-involved populations. It is conceivable that public perceptions toward vulnerable populations could be influenced in the face of a global pandemic, including the exacerbation of negative attitudes toward already stigmatized groups. Critically, these developing perceptions may be seen in media coverage of the COVID-19 pandemic, allocation of healthcare resources, and the development of public health policies.

3.1. Media

During a time when media coverage of vulnerable populations has increased, investigating the influence of the media on stigmatization toward psychiatric and justice-involved populations has become particularly relevant. Currently, media outlets are emphasizing the importance of self-protection amidst the COVID-19 pandemic. This messaging may influence public perception of psychiatric and justice-involved populations and can have serious implications in the development of policies regarding public safety. A recent study found that public attention online was more likely to be driven by media coverage than data regarding the incidence rate of COVID-19 (Gozzi et al., 2020). As emerging evidence indicates the influence of media coverage, it is crucial to evaluate how stigmatization of mental illness and justice-involved individuals may present within the media during COVID-19.

The depiction of mental illness in the media often includes exaggerated descriptions of violence and crime that are contrary to what is truly observed (McGinty et al., 2016; Stout et al., 2004; Wahl, 1992). For instance, a recent study indicated that citizen journalism about mental illness was more likely to have a positive tone and address recovery and stigma whereas television clips in professional journalism were more likely to have a negative tone and focus on crime, violence, and legal issues (Carmichael et al., 2019). Print media coverage of homicides has also been found to include more bold and sensationalized titles and comments by those close to the victims when the homicide was committed by a person with a mental illness as compared to homicides committed by someone without a mental illness (McKenna et al., 2007). Similarly, on social media mental illness is more likely to be stigmatized and trivialized compared to physical conditions (Robinson et al., 2019). The portrayal of dangerousness and unpredictability related to mental illness in the media overlaps with media coverage of justice-involved populations and directly affects perceptions of the forensic psychiatry population who are subject to these two highly stigmatized labels. During a pandemic, when self-protection is emphasized in the media, such portrayals may inadvertently heighten discrimination.

Additionally, the media has been shown to discuss the genetic basis of mental illness which has the potential to also influence the stigmatization of this vulnerable group (Dubugras et al., 2011). For example, content analysis of a prestigious Brazilian newspaper found that articles written about schizophrenia (SZ), a common mental illness found in forensic psychiatry populations, included discussion of the genetic basis of the disorder alongside stigmatizing themes of violence (Dubugras et al., 2011). Research suggests that the consideration of SZ as a genetic disorder compared to an environmental disorder is more often associated with stigmatizing views (Serafini et al., 2011). Although scientific evidence shows possible neuroanatomical genetic markers for SZ (Fusar-Poli et al., 2014), current literature suggests that believing SZ has a genetic cause may lead to increased stigma and a desire for social distance, and might influence perceptions of others' attitudes toward SZ regarding dangerousness and unpredictability in the population (Serafini et al., 2011). Critically, deterministic beliefs related to incorrect assumptions about the role of genetics in mental illness may contribute to stigma and discrimination during this pandemic where all citizens must rely on others to follow precautions to mitigate the spread of COVID-19.

Notably, mainstream and social media have been identified as main contributors to stigmatization against justice-involved populations and those with mental illness, giving rise to negative attitudes and discrimination (Stout et al., 2004). This is likely to persist during the pandemic, similar to what has been observed with the elderly population. For example, a rise in negative perceptions of the elderly has been evident on social media, including jokes, ridicule, and content suggesting that the lives of older adults are less valuable and that mortality within this population is inevitable (Fraser et al., 2020; Jimenez-Sotomayor et al., 2020). This demonstrates how personal characteristics may be stigmatized and conflated with certain outcomes. Taken together, it is clear that stigma is perpetuated throughout a variety of media outlets, making it critical to examine how these negative perceptions evolve during a pandemic. Misinformation, stigmatization, and public concerns about dangerousness regarding these vulnerable groups during COVID-19 could influence policy development and decision-making for stakeholders, potentially leading to adverse outcomes for these populations.

3.2. Allocation of resources

During a time of global crisis, social categorization may be inadvertently emphasized in the interest of public and personal safety (Ayalon et al., 2020; Logie and Turan, 2020). Consequently, social categorization during a pandemic may outline who is deserving of support and who is not (Logie and Turan, 2020). As COVID-19 has put an unprecedented burden on healthcare, ethical questions regarding the prioritization of resources (e.g. ventilators) have arisen in response to a shortage of materials. Some countries have already faced critical shortages of supplies (Cesari and Proietti, 2020; Ranney et al., 2020). Policy and/or triage decisions regarding the allocation of resources have the potential to highlight social disparities in healthcare experienced by already stigmatized groups. For example, age became a criterion in the allocation of healthcare resources in Italy during the peak of their first wave of COVID-19 (Cesari and Proietti, 2020), potentially marginalizing the elderly population (Ayalon et al., 2020). In this dire situation, the implicit inclusion of age as a determinant for resource allocation illustrates the possibility that some previously unrelated patient characteristics can be introduced into triage decision-making.

As such, it is important to address whether justice-involvement and/or psychiatric illness will become a criterion for the allocation of resources, including the provision of healthcare services outside of COVID-19 treatment. The discrepancy in the allocation of resources has been evident in the lack of testing and personal protective equipment within correctional settings despite being high risk for the spread of COVID-19 (Sánchez et al., 2020). Additionally, there is a growing concern that psychiatric symptoms may be considered less important compared to physical illness during the pandemic (Fiorillo and Gorwood, 2020; Hategan and Abdurrahman, 2020). Ultimately, increased stigmatization could potentially disadvantage vulnerable populations in the triage priority for limited resources.

Media coverage on the allocation of resources may reinforce stigma around justice-involved individuals and psychiatric disorders, further ostracizing these vulnerable populations. Thus, in the event of healthcare resource shortages, the media and public opinion may also influence the development of related policies, creating the possibility that features of justice-involved or psychiatric populations may be subject to scrutiny in this context. For example, a Brazilian correctional population was found to be omitted from state or municipal contingency plans in Rio de Janeiro, ultimately excluding this vulnerable population from COVID-19 policies that were established for the general population (Sánchez et al., 2020).

3.3. Adverse outcomes

Stigmatization toward psychiatric and justice-involved populations during COVID-19 may also arise when physical distancing measures become synonymous with avoidance or social isolation from these groups. Indeed, previous research has demonstrated that an understanding of a mental disorder as a genetic disorder may increase the desire for social distance and stigma (Angermeyer and Matschinger, 2005; Serafini et al., 2011). A study conducted by Angermeyer and Matschinger (2005) found that an increase in the public's knowledge of biological and hereditary causes of SZ between 1990 and 2001 corresponded with an increase in desire for social distance. For example, the number of respondents that rejected a neighbour with SZ and those that would not rent a room to an individual with SZ increased. Similarly, another study found that despite the rise of differentiated views regarding causal attributions of mental disorders over 50 years, views of dangerousness had increased (Phelan et al., 2000). Preexisting stigma may be exacerbated with the addition of physical distancing measures during COVID-19, resulting in adverse outcomes for these vulnerable populations.

Lack of social interaction is a well-documented risk factor for mental disorders (Fiorillo and Gorwood, 2020). Social isolation and the experience of stigmatization during the pandemic may result in a reluctance to seek health care and treatment for both COVID-19 and psychiatric symptoms (Serafini et al., 2011; Yao et al., 2020). Accordingly, individuals may hide their mental illness, or the worsening of psychiatric symptoms, in order to avoid discrimination (Bhat et al., 2020). This may delay treatment and lead to the use of maladaptive coping strategies in place of seeking help. Similarly, perceived stigma in correctional and forensic psychiatry populations has been shown to create barriers to rehabilitation and is related to poor adjustment in the community (Mezey et al., 2016; Moore and Tangney, 2017; West et al., 2014). Individuals with a criminal history who anticipate stigma have been found to withdraw from social situations in order to avoid stigmatization and discrimination (Moore and Tangney, 2017). In forensic psychiatry patients, the experience of self-stigma has been found to be related to decreases in self-esteem and likelihood of medication adherence (West et al., 2014). Furthermore, media portrayals of dangerousness and unpredictability can adversely influence individuals' decisions to seek treatment, thus interfering with early detection and intervention of psychiatric and COVID-19 related symptoms (West et al., 2014). Indeed, negative perceptions related to mental illness and justice involvement may be combined with emerging stigma toward COVID-19 positive patients, resulting in a double stigma, or triple stigma for forensic psychiatry patients, that could present as an additional barrier to seeking treatment (Fiorillo and Gorwood, 2020).

This additional stigma is also evident for individuals released from institutional settings. During a time when public health and self-protection are prioritized, the release of inmates or psychiatric patients from institutional settings has been opposed by concerns of public safety and/or the spread of COVID-19 (Sánchez et al., 2020). For example, in Canada, while the presiding practice has been to release inmates when possible, some crown prosecutors resist the implementation of these COVID-19 protective measures, citing concerns of public confidence in the justice system (Bell, 2020). In addition, the actual release of inmates or psychiatric patients from institutional settings has been met with perceptions from the public that pose challenges to their reintegration into the community. It has been reported that landlords may be refusing rental to recently released inmates due to fear of contagion, and that this population is facing high rates of unemployment independent of preexisting discrimination in the hiring process (Montoya-Barthelemy et al., 2020). Forensic psychiatry patients may also be subject to similar outcomes as stigmatization has been found to negatively influence their housing and employment opportunities (West et al., 2014).

3.4. Limitations

We acknowledge that the present review has limitations. First, due to the narrative aspect of this review, only papers and other publications considered relevant by the authors have been used. Although it might have created a potential bias, efforts were made to minimize any author tendencies. Secondly, as the COVID-19 pandemic is still developing, conclusions cannot be drawn at this point regarding the hypothesized exacerbation of stigma toward vulnerable populations. Our group is currently investigating the impact of COVID-19 on stigma toward the vulnerable groups discussed in this review.

4. Conclusion

Currently, it is unknown how the COVID-19 pandemic will impact public perception of justice-involved and psychiatric populations. Given the well-established negative views surrounding these groups, it is conceivable that stigmatization may evolve in the face of the pandemic as concerns over resources and personal and public health continue to grow. We hypothesize that stigma toward vulnerable populations will increase in severity as the pandemic continues in distinct waves, especially due to fast-paced media coverage of the pandemic. As a result, it is possible that vulnerable populations will experience more discrimination in their daily lives, such as difficulties with employment and housing. Furthermore, those living with a mental illness may experience worsening psychiatric symptoms, raising their need for healthcare and increasing the burden on the healthcare system. Due to exacerbated stigma toward mental illness during this pandemic, individuals may hesitate to access care at an appropriate time, leading to what would be an avoidable deterioration of mental health. Additionally, with such rapid media coverage of changes in public policy and differing groups, vulnerable populations may face harmful social consequences such as feeling increasingly isolated by the public or possibly those in their personal social circles. It is also conceivable that reductionist coverage of vulnerable populations in the media would negatively influence public policy decision-making, further affecting the lives of those who identify as a part of a vulnerable population.

Altogether, it is clear that the aggravation of stigma toward vulnerable populations during a pandemic would have a multitude of severe outcomes, both on a societal and individual level. It is therefore imperative that future research works to understand whether changes in stigma toward vulnerable populations are occurring and how, and determine the effects of these changes so they can be mitigated. Such research can also help inform decisions of how to address mental health literacy for the public during a pandemic. Currently, our group is working to investigate public perceptions of psychiatric and justice-involved populations during the COVID-19 pandemic to contribute to this line of research. As the COVID-19 pandemic will continue with distinct waves, it is critical to understand its impact on stigma toward vulnerable populations in an effort to mitigate adverse psychological and other health outcomes, and to inform COVID-19 related public policy and decision-making by stakeholders.

Funding

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

Author statement

GAC conceptualized the main idea. GAC, CU, LPG and AQ wrote the original manuscript draft. All authors (GAC, CU, LPG, AQ, HMM, MM and JMWB) reviewed, edited and approved the final manuscript.

Declaration of Competing Interest

None.

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