key: cord-0953126-noiyejrd
authors: Scarpa, Franco
title: COVID-19 and Forensic Mental Health in Italy
date: 2020-12-09
journal: Forensic science international. Mind and law
DOI: 10.1016/j.fsiml.2020.100038
sha: 76dfa8056d87d1afe9787e3f45e16153a9845aba
doc_id: 953126
cord_uid: noiyejrd

nan

During the lockdown, according to governmental orders, the residences for mental health patients closed their doors and all patients were locked inside, without any contact with external family or any social activity outside. The patients accepted the closure of the in-out movement because they understood the goal of their protection against the virus. In addition, the special services provided in hospital for acute episodes of psychotic illness had to define a specific area for the patients who were suspected to be positive for Sars-Cov2 upon admission, or if they had contact with an affected person. These patients had to wait inside these areas (so called "bolla") until they had a negative result on a molecular test. The Italian Society of Epidemiological Psychiatry provided "operating instructions" to be adopted for residences, ambulatory services, and psychiatric wards of mental health departments (Fabrizio Starace and Maria Ferrera, 2020).

It is noteworthy to mention that in 1978, after the introduction of Law 180, all psychiatric hospitals in Italy were progressively closed and only small residential communities, not more than 20 beds each, became the site for the treatment of psychiatric patients (Italian Ministry of Health, 2013). Some of the services for acute illnesses were specifically adapted for Covid-19 psychiatric patients but, in any case, very few psychiatric patients suffered from Covid-19. At the same time, the new forensic facilities for psychiatric patients who had committed crimes and were sentenced to a "security measure", called the Residenze per Esecuzione delle Misure di Sicurezza (REMS), had to adopt special measures to prevent the admission of infected patients. They applied equivalent rules as other healthcare settings such as encouraging hand washing, the use of protective face masks, social distancing, halting family visitations, and so on. The second wave, that has been prevalent in Italy since October 2020, has forced the psychiatric services to adopt the same system of halting outside social visits from family and friends.

Most activities were interrupted, with exceptions made for emergency medical interventions or special justice needs. Specialists had to cease their external, therapeutic activities and individual therapeutic plans were exclusively confined inside the REMS. Admissions and discharges were strongly limited during the lockdown period because the residential facilities for patients, similar to the forensic REMS, were locked and refused to admit patients discharged from the REMS. In short, all the systems of the residential facilities, forensic or not, were essentially "frozen" during the lockdown that lasted almost two months.

During this first period of the lockdown, the Courts limited their activity to urgent trials, so consequently very few consultations were conducted by forensic psychiatrists and only a limited number of new admissions to the REMS were requested. The pause led to an increase to the socalled "waiting list" for the admission to a REMS. This meant that psychiatric patients who had committed crimes, evaluated as socially dangerous and sentenced to a security measure in a REMS, remained free, hosted inside a community residential service or inside a prison, awaiting the time when a bed inside a REMS became available. During the second wave these issues seem to be less frequent and the turn-over of patients is running somewhat smoother. This is because it is now easier for patients to have a molecular test in a few days and they therefore can move to other facilities more quickly.

To prevent the spread of Sars-Cov2, special attention was given to the personnel of the REMS because the risk of spreading the virus inside these facilities could be very high. The fact that nurses, doctors, and other members of staff work in other facilities (mainly residences for elderly people), meant that they could have an increased risk of being infected. Consequently, they could potentially be a vehicle for the spread of Sars-Cov2 inside the REMS. As a result, the obligatory use of individual protective tools was introduced inside all REMS; these included body temperature checks at the gate for any member of staff and frequent hand washing after every contact. The distance of 1 meter between people was made mandatory to avoid the diffusion of droplets (in some regions of Italy, the local authorities recommended 1.80 meters distance as a precaution).

Given that visits from relatives were forbidden, as an alternative, the patients had the possibility to talk to them using a virtual call on a tablet, smartphone, or computer. Patients are not allowed to have a mobile phone, so the staff provided the use of tablets and computers for video calling. Prior to any video calls, the line would be checked by the personnel to ensure that it was connected to the right people. The visits of lawyers, of the external services staff, or any other persons, were restricted to essential ones and were allowed only when any other method could not be adopted (e.g. phone calls, video calls, mail or other available tool).

After the end of the first lockdown, in anticipation of a new second Covid-19 wave, the REMS adopted a rigorous protocol for the admission of patients; any new patients can only be admitted after a negative molecular test for Sars-Cov2. After their admission, every 60 days the patients and the personnel are checked using a Covid-19 antibodies serology test and they can receive the flu vaccine. Twice a day the patients are checked for their body temperature. In addition, they are given a face mask and the staff provide them with advice about maintaining physical distance and periodical hand washing or prevention behaviors. This enables a strong monitoring of the risk of Covid-19 and the ability to detect possible suspected cases as soon as possible.

Should a patient test positive for Sars-Cov2, they have to be transferred to the Covid-19 wards inside the acute psychiatric wards, which have a specific Covid-19 treatment function or beds for Covid-19 patients inside the ordinary medical wards of the hospital. The patients who suffered from very strong acute symptoms of Covid-19 had to be hospitalized within the intensive care units or resuscitation beds of the wards inside general hospitals.

During the lockdown, Italian prisons were faced with the same task of preventing the spread of Sars-Cov2. Italian prisons host more than 60,000 inmates and are strongly overcrowded (Italian Ministry of Justice, 2020); in some of them, the inmates have a narrow individual space inside their cell and they have a very limited time window for daily open air walks. This means that it is difficult for them to respect physical distance. Prisoners do not have a sufficient air exchange and consequently the risk of a huge diffusion of the virus is high (Ristretti Orizzonti Periodical, 2020).

At the beginning of the lockdown, the Italian government and Justice Minister opted for a restriction on family visits. In the days leading up to this decision by the government, in some of the jails the prisoners protested, burning furniture, sheets, beds and shouting in order to express their opposition to the restrictions. Some asked for legal provisions that could allow them to receive an alternative measure to their detention, especially if they were affected by comorbidities that could be a major risk factor for Covid-19 (such as obesity, diabetes, high blood pressure, low immunological response etc. (Regional Health Agency of Tuscony, 2015)).

In some prisons, the protests led to riots that resulted in the complete vandalism of wards and, in some cases, of entire buildings. Kidnapping of personnel and escapes from the prison also occurred. In a couple of jails, 13 prisoners died. Most of these casualties were discovered at the end of the riots but some of them whilst they were ongoing. Currently, many judicial inquiries are in progress with the aim of understanding what happened during these protests and riots (mainly if they were spontaneous or planned in advance by a central direction) and to definitively identify the causes of the deaths (Ristretti Orizzonti, 2020).

It would seem that most deaths were caused by acute overdoses in prisoners with drug addictions. In some cases, it was verified that they had taken an overdose of methadone, or other medications, that were possibly stolen from the infirmary storage of the prison. The judicial inquiries will take more time to have the definitive results and the relatives, rights' defense movements and politicians have called for answers and to understand what really happened during the protests and riots (Antigone, 2020) . After the riots, the government approved a decree that allowed many prisoners, affected by comorbidities which increase the risk of death from Covid-19, to remain in detention at their home or in a therapeutic environment (Official Gazette of the Italian Republic, 2020).

Currently all the jails must provide an anti-Covid plan outlining strategies to prevent the spread of the infection. Adopted measures include: body temperature checks at the gates for all the personnel and visitors; use of face masks; frequent hand washing; social distancing; encouraging working at home for administrative personnel where their presence is not essential; and limiting the presence of volunteers and any other non-essential exterior contact. Furthermore, the most important measure provides a track of preventive seclusion, lasting 14 days (or until there is a negative molecular test 7-8 days after entrance).

Currently, Italy, as with the whole of Europe, is facing a second wave of infections and the number of Covid-19 cases is rising. New scenarios lie ahead and the REMS, jails, and the health systems must fight again. Despite the measures that the prison system and health services in prison had introduced to stop, or slow down, the spread of Sars-Cov2, the number of infected people is increasing, both for inmates and for the staff (including guards, nurses or doctors) (Stella, 2020) . Some suggestions for further preventing the spread of Sars-Cov2 are provided below:

-Decrease prisoner numbers -Provide a special track for inmates entering a prison, such as a dedicated ward where they can isolate for 14 days -Strong cooperation between the health system and prison staff (it is helpful to underline that health system is managed by the National Health System) -Frequent testing of the personnel working inside prisons

The author has no competing interests to declare.

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