key: cord-0991860-plxc2q5h
authors: Chaimowitz, Gary Andrew; Upfold, Casey; Géa, Luiza Paul; Qureshi, Aamna; Moulden, Heather Marie; Mamak, Mini; Bradford, John McDonald Wilson
title: Stigmatization of psychiatric and justice-involved populations during the COVID-19 pandemic
date: 2020-10-21
journal: Prog Neuropsychopharmacol Biol Psychiatry
DOI: 10.1016/j.pnpbp.2020.110150
sha: 33f9d77cb8e7638215a556b091b7169ed5928899
doc_id: 991860
cord_uid: plxc2q5h

Psychiatric and justice-involved populations are known to be stigmatized and particularly vulnerable to adverse outcomes during COVID-19. The increased attention toward vulnerable populations from healthcare authorities, the media, and the general public has made it critical to uncover any developing stigmatization toward these groups and the possible consequences. The prioritization of public safety and shift in the prioritization of resource allocation and service delivery could lead to a rise in negative perceptions toward these already stigmatized groups. Thus, it is imperative to consider how the unique characteristics of vulnerable groups may impact their physical and mental health as well as their care during this pandemic. In this paper, we describe the challenges that psychiatric, correctional, and forensic psychiatry populations have faced during COVID-19 and how a rise in stigmatization could lead to adverse outcomes. Specifically, we outline the influence of the media on public perceptions and how stigmatization may be reflected in the allocation of resources, policies, and related decision-making during COVID-19.

increased risk for maladaptive coping behaviours and/or worsening symptoms (Yao et al., 2020) . Combined, these factors may exacerbate psychiatric symptoms and increase the illness burden experienced by those living with mental illness during the COVID-19 pandemic.

Physical distancing measures have been near impossible to implement in correctional settings. Often, spaces for eating, sleeping, and living must be shared among many inmates, limiting almost any possibility for physical distance. Previous literature indicates that the inmate population is at an increased risk for poor health outcomes and psychological distress related to infectious diseases as compared to the general population (Kinner et al., 2020) . Additionally, COVID-19 related protective measures such as the restriction of movement inside prisons, the cancelation of activities, and lack of available communication with family and friends have the potential to exacerbate tensions and feelings of isolation (Sánchez et al., 2020) . The evidence supports correctional populations as vulnerable during the COVID-19 pandemic considering that the infrastructure of correctional facilities is conducive to the rapid spread of infectious diseases, including COVID-19 (Kinner et al., 2020) .

Due to the high population density within correctional facilities, infectious outbreaks in correctional settings have the potential to overwhelm healthcare services. Reducing the population within correctional settings is one of the main recommendations to reduce the spread of the virus in several countries. For example, in Canada, Ontario and the Northwest Territories have reduced their custodial population by 25% (Affleck and Barrison, 2020) . However, it is estimated that only 5% of inmates eligible for release within 80 countries have been released (Simpson and Butler, 2020) . It is critical that strategies for mitigating the spread of COVID-19 are not limited to the general population, but are also deemed essential for correctional populations.

Similar to psychiatric and correctional populations, forensic psychiatry patients are vulnerable to adverse health outcomes related to COVID-19. In Canada, individuals who committed a crime while experiencing symptoms of a mental disorder and are subsequently found not criminally responsible for the offence, or individuals who are found unfit to stand trial and/or their treatment progress and rehabilitation. In Ontario, most forensic psychiatry facilities restricted inpatients to hospital units. While helping to prevent community transmission, this increases the likelihood of patients congregating in communal areas, infringing on previous enjoyed liberties and limiting physical distancing .

For patients living in the community, programming and regular outpatient visits have been put on hold, creating a barrier to therapeutic communication and assessment of risk. While many healthcare settings have turned toward virtual care, many forensic psychiatry patients in the community are limited in their ability to communicate virtually. Some may not have electronic devices or are under conditions that prohibit access to online platforms and social media sites . Critically, liberty loss and restrictions, and the associated stress of both, can contribute to an exacerbation of symptoms and/or behavioural instability, increasing the illness burden experienced by patients.

Stigma is manifested through the marginalization and social isolation of certain groups, which is often based on characteristics and perceived social responsibility of their illness and/or circumstances (Bhat et al., 2020; Logie and Turan, 2020) . Although COVID-19 related restrictions are essential to mitigate virus transmission, it is important to acknowledge that they may increase stigmatization against psychiatric and justice-involved populations. It is conceivable that public perceptions toward vulnerable populations could be influenced in the face of a global pandemic, including the exacerbation of negative attitudes toward already stigmatized groups. Critically, these developing perceptions may be seen in media coverage of the COVID-19 pandemic, allocation of healthcare resources, and the development of public health policies.

During a time when media coverage of vulnerable populations has increased, investigating the influence of the media on stigmatization toward psychiatric and justiceinvolved populations has become particularly relevant. Currently, media outlets are emphasizing the importance of self-protection amidst the COVID-19 pandemic. This messaging may influence public perception of psychiatric and justice-involved populations and can have serious implications in the development of policies regarding public safety. A recent study found that public attention online was more likely to be driven by media coverage than data regarding the incidence rate of COVID-19 (Gozzi et al., 2020) . As emerging evidence indicates the influence of media coverage, it is crucial to evaluate how stigmatization of mental illness and justiceinvolved individuals may present within the media during COVID-19.

The depiction of mental illness in the media often includes exaggerated descriptions of violence and crime that are contrary to what is truly observed (McGinty et al., 2016; Stout et al., 2004; Wahl, 1992) . For instance, a recent study indicated that citizen journalism about mental illness was more likely to have a positive tone and address recovery and stigma whereas television clips in professional journalism were more likely to have a negative tone and focus on crime, violence, and legal issues (Carmichael et al., 2019) . Print media coverage of homicides has also been found to include more bold and sensationalized titles and comments by those close to the victims when the homicide was committed by a person with a mental illness as compared to homicides committed by someone without a mental illness (McKenna et al., 2007) . Similarly, on social media mental illness is more likely to be stigmatized and trivialized compared to J o u r n a l P r e -p r o o f physical conditions (Robinson et al., 2019) . The portrayal of dangerousness and unpredictability related to mental illness in the media overlaps with media coverage of justice-involved populations and directly affects perceptions of the forensic psychiatry population who are subject to these two highly stigmatized labels. During a pandemic, when self-protection is emphasized in the media, such portrayals may inadvertently heighten discrimination.

Additionally, the media has been shown to discuss the genetic basis of mental illness which has the potential to also influence the stigmatization of this vulnerable group (Dubugras et al., 2011) . For example, content analysis of a prestigious Brazilian newspaper found that articles written about schizophrenia (SZ), a common mental illness found in forensic psychiatry populations, included discussion of the genetic basis of the disorder alongside stigmatizing themes of violence (Dubugras et al., 2011) . Research suggests that the consideration of SZ as a genetic disorder compared to an environmental disorder is more often associated with stigmatizing views (Serafini et al., 2011 ). Although scientific evidence shows possible neuroanatomical genetic markers for SZ (Fusar-Poli et al., 2014) , current literature suggests that believing SZ has a genetic cause may lead to increased stigma and a desire for social distance, and might influence perceptions of others' attitudes toward SZ regarding dangerousness and unpredictability in the population (Serafini, et al., 2011) . Critically, deterministic beliefs related to incorrect assumptions about the role of genetics in mental illness may contribute to stigma and discrimination during this pandemic where all citizens must rely on others to follow precautions to mitigate the spread of COVID-19.

Notably, mainstream and social media have been identified as main contributors to stigmatization against justice-involved populations and those with mental illness, giving rise to negative attitudes and discrimination (Stout et al., 2004) . This is likely to persist during the pandemic, similar to what has been observed with the elderly population. For example, a rise in negative perceptions of the elderly has been evident on social media, including jokes, ridicule, and content suggesting that the lives of older adults are less valuable and that mortality within this population is inevitable (Fraser et al., 2020; Jimenez-Sotomayor et al., 2020) . This demonstrates how personal characteristics may be stigmatized and conflated with certain outcomes. Taken together, it is clear that stigma is perpetuated throughout a variety of media outlets, making it critical to examine how these negative perceptions evolve during a pandemic. Misinformation, stigmatization, and public concerns about dangerousness regarding these vulnerable groups during COVID-19 could influence policy development and decision-making for stakeholders, potentially leading to adverse outcomes for these populations.

During a time of global crisis, social categorization may be inadvertently emphasized in the interest of public and personal safety (Ayalon et al., 2020; Logie and Turan, 2020) . Consequently, social categorization during a pandemic may outline who is deserving of support and who is not (Logie and Turan, 2020) . As COVID-19 has put an unprecedented burden on healthcare, ethical questions regarding the prioritization of resources (e.g. ventilators) have arisen in response to a shortage of materials. Some countries have already faced critical shortages of supplies (Cesari and Proietti, 2020; Ranney et al., 2020) . Policy and/or triage decisions regarding the allocation of resources have the potential to highlight social disparities in healthcare experienced by already stigmatized groups. For example, age became a criterion in the allocation of healthcare resources in Italy during the peak of their first wave of COVID-19 (Cesari and Proietti, 2020) , potentially marginalizing the elderly population (Ayalon et al., J o u r n a l P r e -p r o o f 2020). In this dire situation, the implicit inclusion of age as a determinant for resource allocation illustrates the possibility that some previously unrelated patient characteristics can be introduced into triage decision-making.

As such, it is important to address whether justice-involvement and/or psychiatric illness will become a criterion for the allocation of resources, including the provision of healthcare services outside of COVID-19 treatment. The discrepancy in the allocation of resources has been evident in the lack of testing and personal protective equipment within correctional settings despite being high risk for the spread of COVID-19 (Sánchez et al., 2020) . Additionally, there is a growing concern that psychiatric symptoms may be considered less important compared to physical illness during the pandemic (Fiorillo and Gorwood, 2020; Hategan and Abdurrahman, 2020) . Ultimately, increased stigmatization could potentially disadvantage vulnerable populations in the triage priority for limited resources.

Media coverage on the allocation of resources may reinforce stigma around justiceinvolved individuals and psychiatric disorders, further ostracizing these vulnerable populations. Thus, in the event of healthcare resource shortages, the media and public opinion may also influence the development of related policies, creating the possibility that features of justiceinvolved or psychiatric populations may be subject to scrutiny in this context. For example, a Brazilian correctional population was found to be omitted from state or municipal contingency plans in Rio de Janeiro, ultimately excluding this vulnerable population from COVID-19 policies that were established for the general population (Sánchez et al., 2020) .

Stigmatization toward psychiatric and justice-involved populations during COVID-19 may also arise when physical distancing measures become synonymous with avoidance or social isolation from these groups. Indeed, previous research has demonstrated that an understanding of a mental disorder as a genetic disorder may increase the desire for social distance and stigma (Angermeyer and Matschinger, 2005; Serafini et al., 2011) . A study conducted by Angermeyer and Matschinger (2005) found that an increase in the public's knowledge of biological and hereditary causes of SZ between 1990 and 2001 corresponded with an increase in desire for social distance. For example, the number of respondents that rejected a neighbour with SZ and those that would not rent a room to an individual with SZ increased. Similarly, another study found that despite the rise of differentiated views regarding causal attributions of mental disorders over 50 years, views of dangerousness had increased (Phelan et al., 2000) . Preexisting stigma may be exacerbated with the addition of physical distancing measures during COVID-19, resulting in adverse outcomes for these vulnerable populations.

Lack of social interaction is a well-documented risk factor for mental disorders (Fiorillo and Gorwood, 2020) . Social isolation and the experience of stigmatization during the pandemic may result in a reluctance to seek health care and treatment for both COVID-19 and psychiatric symptoms (Serafini et al., 2011; Yao et al., 2020) . Accordingly, individuals may hide their mental illness, or the worsening of psychiatric symptoms, in order to avoid discrimination (Bhat et al., 2020) . This may delay treatment and lead to the use of maladaptive coping strategies in place of seeking help. Similarly, perceived stigma in correctional and forensic psychiatry populations has been shown to create barriers to rehabilitation and is related to poor adjustment in the community (Mezey et al., 2016; Moore and Tangney, 2017; West et al., 2014) . Individuals with a criminal history who anticipate stigma have been found to withdraw from social situations in order to avoid stigmatization and discrimination (Moore and Tangney, 2017) . In forensic J o u r n a l P r e -p r o o f psychiatry patients, the experience of self-stigma has been found to be related to decreases in self-esteem and likelihood of medication adherence (West et al., 2014) . Furthermore, media portrayals of dangerousness and unpredictability can adversely influence individuals' decisions to seek treatment, thus interfering with early detection and intervention of psychiatric and COVID-19 related symptoms (West et al., 2014) . Indeed, negative perceptions related to mental illness and justice involvement may be combined with emerging stigma toward COVID-19 positive patients, resulting in a double stigma, or triple stigma for forensic psychiatry patients, that could present as an additional barrier to seeking treatment (Fiorillo and Gorwood, 2020) .

This additional stigma is also evident for individuals released from institutional settings. During a time when public health and self-protection are prioritized, the release of inmates or psychiatric patients from institutional settings has been opposed by concerns of public safety and/or the spread of COVID-19 (Sánchez et al., 2020) . For example, in Canada, while the presiding practice has been to release inmates when possible, some crown prosecutors resist the implementation of these COVID-19 protective measures, citing concerns of public confidence in the justice system (Bell, 2020) . In addition, the actual release of inmates or psychiatric patients from institutional settings has been met with perceptions from the public that pose challenges to their reintegration into the community. It has been reported that landlords may be refusing rental to recently released inmates due to fear of contagion, and that this population is facing high rates of unemployment independent of preexisting discrimination in the hiring process (Montoya- Barthelemy et al., 2020) . Forensic psychiatry patients may also be subject to similar outcomes as stigmatization has been found to negatively influence their housing and employment opportunities (West et al., 2014) .

We acknowledge that the present review has limitations. First, due to the narrative aspect of this review, only papers and other publications considered relevant by the authors have been used. Although it might have created a potential bias, efforts were made to minimize any author tendencies. Secondly, as the COVID-19 pandemic is still developing, conclusions cannot be drawn at this point regarding the hypothesized exacerbation of stigma toward vulnerable populations. Our group is currently investigating the impact of COVID-19 on stigma towards the vulnerable groups discussed in this review.

Currently, it is unknown how the COVID-19 pandemic will impact public perception of justice-involved and psychiatric populations. Given the well-established negative views surrounding these groups, it is conceivable that stigmatization may evolve in the face of the pandemic as concerns over resources and personal and public health continue to grow. We hypothesize that stigma toward vulnerable populations will increase in severity as the pandemic continues in distinct waves, especially due to fast-paced media coverage of the pandemic. As a result, it is possible that vulnerable populations will experience more discrimination in their daily lives, such as difficulties with employment and housing. Furthermore, those living with a mental illness may experience worsening psychiatric symptoms, raising their need for healthcare and increasing the burden on the healthcare system. Due to exacerbated stigma toward mental illness during this pandemic, individuals may hesitate to access care at an appropriate time, leading to what would be an avoidable deterioration of mental health. Additionally, with such rapid media coverage of changes in public policy and differing groups, vulnerable populations may face J o u r n a l P r e -p r o o f harmful social consequences such as feeling increasingly isolated by the public or possibly those in their personal social circles. It is also conceivable that reductionist coverage of vulnerable populations in the media would negatively influence public policy decision-making, further affecting the lives of those who identify as a part of a vulnerable population.

Altogether, it is clear that the aggravation of stigma toward vulnerable populations during a pandemic would have a multitude of severe outcomes, both on a societal and individual level. It is therefore imperative that future research works to understand whether changes in stigma toward vulnerable populations are occurring and how, and determine the effects of these changes so they can be mitigated. Such research can also help inform decisions of how to address mental health literacy for the public during a pandemic. Currently, our group is working to investigate public perceptions of psychiatric and justice-involved populations during the COVID-19 pandemic to contribute to this line of research. As the COVID-19 pandemic will continue with distinct waves, it is critical to understand its impact on stigma toward vulnerable populations in an effort to mitigate adverse psychological and other health outcomes, and to inform COVID-19 related public policy and decision-making by stakeholders.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Latest News Regarding Inmates and the COVID-19 Crisis

Trend analysis based on data from two population surveys in Germany

The COVID-19 response must be disability inclusive

Aging in Times of the COVID-19 Pandemic: Avoiding Ageism and Fostering Intergenerational Solidarity

Judges release growing number accused of violent crimes due to COVID-19 fears

Development of social stigmatization during a pandemic caused by COVID-19

Media coverage of mental illness: a comparison of citizen journalism vs. professional journalism portrayals

COVID-19 in Italy: Ageism and Decision Making in a Pandemic

Criminal Code of Canada, R.S.C., 1985, c. C-46 [WWW Document

A two-year cross-sectional study on the information about schizophrenia divulged by a prestigious daily newspaper

The consequences of the COVID-19 pandemic on mental health and implications for clinical practice

Ageism and COVID-19: what does our society's response say about us?

Neuroanatomical markers of genetic liability to psychosis and first episode psychosis: a voxelwise meta-analytical comparison

Collective response to the media coverage of COVID-19 Pandemic on Reddit and Wikipedia

Hidden in plain sight: Addressing the unique needs of high risk psychiatric populations during COVID-19 pandemic

Coronavirus, Ageism, and Twitter: An Evaluation of Tweets about Older Adults and COVID-19

Prisons and custodial settings are part of a comprehensive response to COVID-19

How Do We Balance Tensions Between COVID-19 Public Health Responses and Stigma Mitigation? Learning from HIV Research

Trends In News Media Coverage Of Mental Illness In The United States: 1995-2014

Media Coverage of Homicide Involving Mentally Disordered Offenders: A Matched Comparison Study

Stigma and discrimination in mentally disordered offender patients -a comparison with a non-forensic population

COVID-19 and the Correctional Environment: The American Prison as a Focal Point for Public Health

Managing the concealable stigma of criminal justice system involvement: A longitudinal examination of anticipated stigma, social withdrawal, and postrelease adjustment

Public conceptions of mental illness in 1950 and 1996: What is mental illness and is it to be feared?

Critical Supply Shortages -The Need for Ventilators and Personal Protective Equipment during the Covid-19 Pandemic

Measuring attitudes towards mental health using social media: investigating stigma and trivialisation

COVID-19 in prisons: an impossible challenge for public health?

Stigmatization of schizophrenia as perceived by nurses, medical doctors, medical students and patients

Management of COVID-19 Response in a Secure Forensic Mental Health Setting

Covid-19, prison crowding, and release policies

Images of mental illness in the media: identifying gaps in the research

Mass media images of mental illness: A review of the literature

Triple Stigma of Forensic Psychiatric Patients: Mental Illness, Race, and Criminal History

Patients with mental health disorders in the COVID-19 epidemic

The authors declare no conflict of interests.

Journal Pre-proof