Effects of the COVID-19 pandemic on the mental health of prisoners.

Prisoners are a vulnerable group, with multiple complex health needs and worse health outcomes relative to the general population worldwide. To date, little focus has been given to the effects of the COVID-19 pandemic on the mental health of prisoners; an area of concern given their high rates of pre-existing mental disorders, suicide, and self-harm, and the links between poor mental health, suicide, and self-harm, and reoffending behaviour.1, 2, 3

Suspension of jury trials and delays to court hearings in many countries, including the UK, have increased the time spent on remand for many prisoners. Remand is a period in which offenders are especially vulnerable and often ruminate about legal outcomes and have distress, uncertainty, and anxiety about their future; these emotions could be intensified by the unpredictability of the COVID-19 pandemic. Suicide and self-harm rates are high in prisons globally,1, 2 particularly in prisoners who are on remand; extending this period could heighten the risk.5, 6 Better assistance to prepare vulnerable prisoners for trial could help to improve the situation; yet, increased need within core-business clinical services, such as inpatient forensic services, might increase the difficulties of balancing court liaison work with other responsibilities. Upholding the importance of this balance is essential to preventing further delays to court hearings and missed opportunities for diversion away from prisons and into health systems for offenders with severe mental illness, or assessment of suitability for the Community Sentence Treatment Requirements programme.

Prison visits are temporarily suspended in many countries worldwide, including the UK. Visits help offenders to maintain contact with the outside world, promoting successful reintegration back into society and reducing recidivism. The loss of such visits could lessen the use of social support for mitigating against and coping with mental distress, and the risk of suicide and self-harm. This scarcity of social support might make adjustment to prison more difficult, risking the use of maladaptive coping strategies. Contact with loved ones should be maintained wherever possible. Secure phone handsets are available in approximately half of prisons in England and Wales, and this warrants extension. Other communication methods should be encouraged, such as writing letters, increased access to telephone landlines, and use of the prison voicemail service. Emotional support from other prisoners should also be facilitated, for example, by providing telephone access to Listeners in Samaritans' Listener scheme.

Mirroring wider society, many recreational and occupational prison activities have halted worldwide. Substitute activities are scarce in prisons, where access to equipment and the internet are restricted. Increased time spent in cells (up to 23 h per day), scarcity of activities, and little or no contact with other inmates, especially for people isolating or shielding because of COVID-19, will mimic solitary confinement. Even short periods in solitary confinement are associated with psychological consequences, including anger, depression, anxiety, paranoia, psychosis, and exacerbation of underlying mental illness, and increased mortality after release from prison. Prisons should explore and evaluate strategies for promoting mental wellbeing, such as exercise in cells, mindfulness, wellbeing applications, and telephone psychological therapies.

Furthermore, in England and Wales, the number of prison staff absent from work has doubled, reducing human contact for prisoners, potentially limiting the availability of support for mental and physical health, and making careful supervision of prisoners who are at high risk of self-harm or suicide increasingly difficult. The global recognition of prison officers as frontline workers, for COVID-19 testing, is crucial; this must continue and increase, along with ensuring provision of personal protective equipment, to ensure workforce safety and adequate staffing.

The pandemic has enhanced interagency working and encouraged clinicians to advocate for whole prisons and communities, creating a collective sense of value among offenders and within wider society. This sense of value has manifested as increased camaraderie among prisoners, staff, and community members. The importance of acts of kindness in promoting positive mental wellbeing should not be underestimated. This positivity should be strengthened and encouraged to ensure that it is not a fleeting honeymoon effect.

In many countries, including the UK, offenders who are at low risk of reoffending are eligible for early release, mitigating many of the difficulties previously mentioned. However, this poses new challenges, and implementation has been slow, potentially adding further confusion and disappointment. Offenders will be entering an anxious community, which has undergone substantial changes due to the COVID-19 pandemic. Providing prisoners with accurate and relevant information about the pandemic is important for ensuring preparation and improving adherence to physical distancing measures. This information will further emphasise offenders' roles and inclusion within wider society, potentially reducing anxiety and fostering trust, resilience, and empowerment in offenders. Opportunities for stringent follow-up of physical and mental health could be lessened in the context of decreased community staffing and face to face professional contact. This is concerning given the risks of recidivism and the high rates of mortality and suicide following release from prison.1, 10 Prisons and community health providers should collaborate closely to ensure that the health risks are communicated and adequate follow-up plans are made, including considering telehealth appointments where appropriate.

In summary, COVID-19 presents substantial challenges to offender populations. Measures have been, and should continue to be, implemented to reduce disease transmission within prisons; however, these measures are not cost free and their consequences to mental health should be decreased wherever possible. The effects of the pandemic are considerable but they also create opportunities for new, innovative methods of supporting prisoners and for strengthening links between health care, criminal justice, and government agencies, with potential long-lasting benefits.