key: cord-0769909-q5utgnof authors: Raghuraman, Bharathram Sathur; Sorungbe, Oladipo; Jose, Sneha title: Optimism in times of despair– A perspective from a Forensic mental health rehabilitation unit date: 2020-08-29 journal: Asian J Psychiatr DOI: 10.1016/j.ajp.2020.102396 sha: e5236faf8039e57b267448ad422aef0c249a05cd doc_id: 769909 cord_uid: q5utgnof nan "Optimism in times of despair-A perspective from a Forensic mental health rehabilitation unit" The COVID-19 pandemic caught the world by surprise at the beginning of this year(WHO, 2020). The spread of infection by the virus has progressed at quite a frantic pace throughout the world with an ever increasing number of people being affected on a daily basis (Rajkumar, 2020) .There has also been growing research evidence (Tandon, 2020) aiding the COVID-19 mental health response across the globe. Apart from the debilitating physical health consequences that follows infection by the virus, there is also a significant psychological sequelae which could range from anxiety to severe mental illnesses (Pfefferbaum and North, 2020; Rajkumar, 2020) . Forensic mental health patients also represent a sub-section of these vulnerable population as most of them have severe mental illnesses. They also require ongoing clinical supervision in very restricted environments to allow for safe management of their mental illnesses and associated risks (Dudeck et al., 2016) . The Thomas Embling hospital is a secure forensic mental health hospital in Melbourne, Australia. The rehabilitation unit focuses on addressing offending issues, helping them with establishing and maintaining meaningful community linkages as well as developing and enhancing the relevant skills that would be required for their successful re-integrate back into the community. There are currently nineteen forensic patients resident in the unit at different stages of their rehabilitation. Initial reaction to the COVID-19 pandemic and the subsequent lockdown period Subsequently, following the declaration of a state of emergency in the State of Victoria and due to the risk of serious endangerment from the virus to the patients, the office of the chief psychiatrist formally suspended all non-urgent or non-medical community leaves. The first step taken by the team was to triage each patient based on their physical and mental health and any co-existing medical conditions and establish which patients were at a higher risk of physical J o u r n a l P r e -p r o o f health deterioration in the event of an infection by the virus. Such patients had regular screening and they were also provided with additional supports. At the unit level, a detailed structured weekly timetable with different daily activities and therapeutic group programs was put in place to keep patients engaged at all times as well as also help foster harmony on the unit. A daily "COVID-19 huddle" meeting was established which provided patients and staff members with updates on any new developments but also provided a safe space for all to express whatever concerns or frustrations they might be having. At the hospital level, some of the many measures included restrictions on visits, screening and temperature screening of anyone entering the hospital, extensive dissemination of information about the virus using multiple media sources, providing guidelines around screening and dealing with suspected cases of infection, strict implementation of social distancing rules, encouraging good hand hygiene practice, COVID-19 blitz testing for all staff members and patients and the early rollout of the seasonal flu vaccination across the whole hospital. What unfolded in the unit? For most of the above measures to be effective, it was vital that all patients and staff members fully cooperated and adhered to them. Most patients seemed to fully appreciate and understand the inherent risks associated with the COVID-19 outbreak and complied with most of the measures put in place to safeguard them. There was also a noted sense of comradery which appeared to develop among the patients and staff members on the unit, increased participation in group activities which manifested in a feeling of "we are all in this together". However, there were as expected some setbacks with a few patients experiencing early signs of a decompensating mental state or deteriorating clinical presentation which was promptly addressed accordingly. On review of the unit incident register it was noted that the total number of incidents classified as aggression /behavioral and self-harm were 27 in the period from March till April (Beginning of lockdown) .In the subsequent months of May till June (End of lockdown).the total number of similar incidents in the unit had decreased to 8 . On a positive note, many patients reported modest improvements to their physical health following the somewhat enforced smoking cessation. Other patients were noted to have presented with much improved mental states and better symptom control which was possibly linked to increased serum clozapine levels in these patient group (Lowe and Ackman, 2010) . On the overall, the main positive outcomes noted during this period included better patient engagement with staff members and co-patients, positive effects on both their physical and mental health for some noted based on regular mental state assessments, improved comradery, better community cohesion and a reduction in incidents reported on the unit. Although the crisis is not yet over, it is important to highlight and give some insight into how a somewhat vulnerable set of individuals who have historically been considered as been at a high risk of decompensating under significant stress or pressure have shown remarkable resilience during such a challenging and unprecedented period. There are definitely lessons to be learnt from this going forward. None. All authors have equally contributed and have read and approved the final manuscript. The association of adverse childhood experiences and appetitive aggression with suicide attempts and violent crimes in male forensic psychiatry inpatients Impact of tobacco smoking cessation on stable clozapine or olanzapine treatment Mental Health and the Covid-19 Pandemic COVID-19 and mental health: A review of the existing literature I would like to acknowledge the efforts of all staff and patients on my unit for their grit and determination during these testing times.