Forensic psychiatry in the time of coronavirus: The Italian security residences put to the test in a public health emergency.

The COVID‐19 emergency has significantly affected the functioning of almost all activities in Italy. Health‐care services have been heavily involved. Even those not on the frontline dealing with the outbreak have had to immediately change their operational procedures. , Hospitals have been largely adapted to the reception of COVID‐positive patients and local residential facilities have set up barriers both to the entry of new patients and to outside visitors. Many patients returned home where isolation could be guaranteed. Even in prisons, visits by external staff were suspended and procedures for inmates’ release, when legally possible, were accelerated. With the definitive closure of forensic psychiatric hospitals in Italy, security residences (REMS) have been established in all regions. REMS are territorial psychiatric rehabilitative health facilities for offenders who are mentally incapacitated and considered to be highly dangerous to society; each REMS can accommodate 20 patients. Most of the offenders are treated in the ordinary psychiatric residential facilities, which in our region treat 2500 patients, with about 10% of them offenders.

With the start of the COVID‐19 Phase 1, characterized by the total lockdown of the population, an operational procedure adapted from the guidelines laid down at the national level by the National Health Authority was prepared in Piedmont specifically for the two local REMS. The application of these regulations has led to various modifications, some of which are particularly significant. First of all, inclusion in REMS was limited to people already in prison or people who were difficult to control in the community during lockdown. The waiting list to enter the REMS was, therefore, blocked and court orders were temporarily put on hold, particularly where clinical and safety monitoring were guaranteed in the patients’ current placements. Swab‐positive COVID patients have been managed in isolation within REMS if they are asymptomatic or paucisymptomatic and are directed to hospitals if they present more severe symptoms. The REMS that had positive cases among their patients had to be divided into two zones – COVID and COVID‐free zones, respectively – with separate routes of entry. Comprehensive use of appropriate personal protective equipment was also initiated.

The facilities have been equipped to allow video contact with relatives and, in the case of REMS, also with lawyers and magistrates; all physical contact with people from the outside has been suspended.

Group‐level activities have been reorganized, also in a participatory way with the help of patients; team meetings and all activities involving the simultaneous presence of several people have also been regulated. Only activities involving a limited number of patients together have been maintained if physical distancing and the use of surgical masks is guaranteed in large and well‐ventilated spaces, or, when possible, outdoors.

Activities outside the perimeter of the facility, even if authorized by the Judicial Authority, have been limited to situations deemed essential by the facility manager, based on the patient's condition, excluding individuals under health surveillance (i.e., those placed in isolation after testing positive for COVID‐19).

Patients have been actively supported in complying with prevention regulations, actively promoting distancing from other patients and staff, as well the use of the surgical masks and frequent hand‐washing.

The coronavirus outbreak has led to a broad psychological impact for all people, but particular consideration must be given to the burden on those offending patients, already limited in their freedom, placed in a condition of isolation within the REMS because they are COVID‐positive. Overall, however, the restrictions imposed by the pandemic have been well‐accepted by patients and no increase in hostile or violent behavior has been observed. Even on days when the presence of staff has been limited for precautionary contagion‐prevention reasons, there has been good cooperation from patients in the organization of community life. The perception that the whole of society is in a condition of limited freedom similar to the one they already experience may have reduced the subjective perception of constraint.

An adequate time perspective will allow more reliable evaluations in the coming months but the COVID emergency is already allowing us to confirm that it is appropriate to limit the number of beds in structures of last resort, such as the REMS (in Piedmont 40 beds for 4.356 million inhabitants ). The reason for this is that it becomes extremely complicated, should the need arise again, to transfer these patients to their homes or to a halfway house by revoking detention security measures.

Based on the experience gathered in Piedmont, this strongly community‐based approach has two main requisites: (i) sufficient resources to make territorial projects feasible; and (ii) the commitment of community health services to implementing the territorial projects, as opposed to the tendency to institutionalize offending patients, resulting in a rapid saturation of beds in REMS.

Disclosure statement

The authors declare no conflict of interest.