Maryland psychiatrist Annette Hanson, MD, hasn’t changed her morning routine much since the coronavirus pandemic began. She still avoids putting on a necklace or earrings, which could be torn away or used as a ligature, and heads to work.
Dr. Annette Hanson
The only difference is that Dr. Hanson wears easy-to-clean scrubs instead of business attire. “That way I can strip down and shower as soon as I get home. I’m not sure that’s necessary, but I’m being cautious,” said Dr. Hanson, a forensic psychiatrist who is an assistant professor of psychiatry at the University of Maryland and at Johns Hopkins University, both in Baltimore.
As many of her colleagues shelter in place and work from home with the help of telemedicine, prison psychiatrists such as Dr. Hanson continue to evaluate and treat patients in person – behind bars. That hasn’t changed. But so much else has, from the elimination of family visits to the suspension of many court hearings, leaving already vulnerable inmates in limbo.
“Prisons continue to be a poor place to receive mental health care. The setting is destructive to physical and mental health, and the pandemic has made it worse,” said Bandy X. Lee, MD, MDiv, of Yale University, New Haven, Conn., who treats inmates in several states.
Like the inmates they treat, “The most challenging part is to continue care in a system that has essentially been frozen in place,” Dr. Hanson said.
As of June 9, nearly 44,000 inmates in federal and state prisons had tested positive for coronavirus, according to the Associated Press and the Marshall Project. At least 500 people have died. Those numbers do not include inmates and staff members in local jails or juvenile detention centers.
Statistics about COVID-19 in prison staff members are incomplete since only 20 states reported them, and it’s not clear where they contracted the virus. Even so, at least 9,180 cases in staff members were reported, along with 38 deaths, the AP/Marshall Project report.
Using telemedicine is impossible at many jails and prisons, forcing many psychiatrists to protect themselves and their patients as best they can. At the Los Angeles County Jail, which does not use telemedicine, group sessions have been greatly reduced. Instead, psychiatrists are spending more time talking to inmates at the doors to cells or modules, said supervising psychiatrist Joseph R. Simpson, MD, PhD.
The risk of transmission still exists, he said. “Our health system has a comprehensive testing, monitoring, and isolation system in place now to slow the spread and flatten the curve,” Dr. Simpson said. “However, once COVID enters any correctional facility, preventing it from spreading entirely is difficult or impossible given the nature of the living arrangements.”
In interviews, psychiatrists said inmates are more stressed by the limitations spawned by the pandemic than the risk of infection. Many facilities have banned in-person visits, and telephone calls are an expensive alternative, said Nicolas Badre, MD, who treats inmates at jails in the San Diego region.
“That one lifeline you had is no longer there. The second lifeline is that your public defender will get you a plea deal, but they’ve postponed hearings,” he said. “I’ve seen cases of folks who are more anxious and more depressed because COVID is delaying their case or because they’re unable to speak with their families and friends.”
Dr. Nicolas Badre
Restrictions on contact with people on the outside are especially difficult for inmates at risk of psychosis, Dr. Badre said. “You add those two [limitations], and how does that not sound to someone with schizophrenia like the government is out to get you? And when someone asks you to wear a mask, how do you trust them?”
According to Dr. Lee, some patients with severe mental illness are unable to comprehend the risk of the pandemic, and they fail to protect themselves. While she’s begun to rely on telemedicine, “it’s a very blunt instrument. Many of my patients are very sick and less able to interact with a screen. And sometimes you’re exhausted at the end of the day because you’ve been yelling at the screen and trying different ways to gain the attention of individuals who are responding to external stimuli and can’t engage.”
The pandemic has improved conditions in prisons and jails on one front: Many are releasing inmates to lower the risk of spreading infection. And Dr. Badre said, “a lot of people are doing just fine, finding themselves to be completely resilient and finding meaning at this time.”
Other than anxiety, the psychiatrists did not report seeing higher percentages of any specific conditions. And they said they are not prescribing any more medications than before COVID-19. But many of the perennial treatments for anxiety – improving the diet, getting out and exercising, developing a hobby, reaching out to others – can be difficult at the best of times behind bars. Those treatments might be impossible now.
At the juvenile justice system in the Chicago area, for example, the pandemic has forced the cancellation of activities such as writing, taking art classes, and barber training. In-person visits are banned, too. “For a lot of them, seeing their family relieves stress, makes them feel more hopeful. It gives them a sense of normalcy to hug their mom,” said Yana Oskin, MD.
But it’s still possible to urge the young people to read, write, work with puzzles, and exercise daily even if it’s just in their rooms, she said. “While their movements have been limited, they do still get to go outside. If they can’t go to the gym, the recreation specialist comes to their pod.”
And while some psychiatrists and older inmates might not be thrilled to have to adjust to therapy via screen during the pandemic, young people are a different story. Dr. Oskin is working with them via telemedicine, which allowed at least one inmate to gain a kind of victory.
“We have an assistant who sets up Skype visits, and the camera was not angled properly,” she recalled. “She couldn’t figure out. The kid sat down and fixed it in 2 seconds.”
Dr. Hanson is the coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has no other disclosures. Dr. Lee is the author of “Violence: An Interdisciplinary Approach to Causes, Consequences and Cures” (Wiley Blackwell, 2019). She has no other disclosures. Dr. Simpson is coauthor of “Neuroimaging in Forensic Psychiatry: From the Clinic to the Courtroom” (Wiley Blackwell, 2012). He has no other disclosures. Dr. Badre and Dr. Oskin reported no disclosures.