Prison healthcare in a pandemic

The Covid-19 crisis has presented Irish prisons with significant additional challenges in protecting the physical and
mental health of prisoners. Emily Clarke Gifford reports

According to a recent report by the Irish Penal Reform Trust (IPRT), Irish prisons and Covid-19: One year on, there were over 4,200 people in custody at the start of the pandemic. It said the Irish Prison Service (IPS), prison staff and prisoners were to be commended for working together to keep the number of Covid-19 cases in Irish prisons low to date. However, the report underlined that the pandemic “has had a devastating impact on people in prison”.

Dr John Devlin, Clinical Director at the IPS, said that “prisons are very vulnerable” in terms of the current crisis. However, he said Irish prisons had been “fortunate” in managing to keep out Covid-19 during the first and second waves of the pandemic. Speaking to the Medical Independent (MI), Dr Devlin said the biggest healthcare challenges in prisons related to mental health, addiction, and lifestyle issues. In addition to these problems, “we’ve always had a challenge in relation to making sure our prisons are free of tuberculosis (TB).” (See panel on page 12).

Outbreak control

Irish prisons have had significantly smaller Covid-19 outbreaks in comparison to some other countries.
Dr Devlin said there were “massive explosive outbreaks” in several jurisdictions, but this had not occurred in Irish prisons. Covid-19 has been “hugely challenging” to many prisons worldwide, with hundreds of cases and a number of deaths in different jurisdictions.

“Thankfully we haven’t seen that. We know from experience in other countries what can happen. I think we’ve been fairly reasonably successful in terms of controlling Covid so far.” As of late July, there had been 11 Covid-19 outbreaks in Irish prisons. Some outbreaks involved six or seven people including staff members, Dr Devlin said. The most recent outbreak, at time of writing, occurred in Loughan House, Co Cavan. Dr Devlin said there was one positive case in a prisoner in this incident.

Across all Irish prisons, there had been no Covid-19-related deaths among prisoners or staff and no referrals to hospital. Dr Devlin said the IPS meets weekly with the HSE to review all measures in place to mitigate the spread of Covid-19. In the case of an outbreak, a management team implements an emergency response plan that establishes an outbreak control team immediately. Dr Devlin explained that “we have a whole template of measures” involving 30-to-40 actions to limit the impact of an outbreak.

Outbreak control meetings are held daily to evaluate the measures in place and determine what additional steps may need to be implemented. To prevent these outbreaks, health checks have been carried out on everyone entering prisons. Additionally, restrictions were put in place for visitations and the number of face-to-face groups were reduced in line with national restrictions.

“These are the kinds of measures that you had to [take] to reduce your big contacts between individuals,” said Dr Devlin.

“It was inevitable that sometime Covid would appear by virtue of the fact that it’s so prevalent in the community.”
Commenting on an outbreak in May at Mountjoy Prison, Dublin, Dr Devlin said “we were fortunate that we detected it quite early”. Cocooning measures were put in place in April 2020 to protect the most vulnerable of the prison population. Dr Devlin explained that people aged over-70 consorted, worked, and trained together while being kept away from the general prison population.

People with pre-existing health conditions also followed the same cocooning regime. According to the IPRT, 52 per cent of Ireland’s female prison population were cocooning due to their chronic health needs. All cocooned prisoners were offered an FFP2 mask to help provide protection from SARS-CoV-2. Cocooning officially ceased in June 2020, but prisoners could maintain this regime if they wished.

Vaccination

According to Dr Devlin, since December, the IPS had made submissions to the national public health emergency team, HSE and Department of Health in relation to making prisoners and prison staff a priority in the vaccine roll-out.
He said: “In our view, there’s only one solution at the end of the day and that’s that staff and prisoners need to be vaccinated at the earliest opportunity.”

The vaccination roll-out began in March with the most at-risk groups. This was determined based on age and significant underlying conditions in prisoners. As of 29 July, over 5,195 vaccines had been administered to prisoners, with a number of prisons completing the first and second doses of an mRNA vaccine, according to Dr Devlin.
The IPS initiated a communications programme to address any concerns relating to vaccine hesitancy.
Dr Devlin told MI the median average vaccine acceptance rate was 93 per cent.

“We’re very anxious that we complete that as soon as we can, because it is a vulnerable setting and at the end of the day, when we get high levels of vaccinations, that will stop Covid in its tracks and we’re very much in favour of that.”

General healthcare

Dr Devlin explained that a “significant percentage” of the prison population may have health challenges before they enter prison. These conditions can relate to homelessness, smoking and drug use. As a result, these prisoners “have a tendency to get chronic diseases more frequently than the general population”. Infectious diseases other than Covid-19 also present issues for prison healthcare, particularly blood-borne viruses including hepatitis C, hepatitis B and human immunodeficiency virus (HIV).

“Those would be the ongoing challenges; certainly Covid has just added an extra layer onto that,” said Dr Devlin.
The impact of the pandemic on hospitals was felt in prisons as there were a limited number of outpatient appointments available. To address the health needs of prisoners, a “blended model of treatment” was introduced. This involved video and telephone consults with some face-to-face consults for those deemed to be urgent or a priority.
Not only was this beneficial for delivering general healthcare, but also to “maintain a level of service for addictions services and also for mental health services”, Dr Devlin noted.

However, he said the number of addiction counselling sessions reduced by up to 20 per cent during the pandemic.
Addictions in Irish prisons mainly involve alcohol, benzodiazepines, cannabis, opiates and “more recently agents called the novel psychoactive substances”, outlined Dr Devlin.

Mental health

According to Dr Emma Regan, Head of Psychological Services at the IPS, a mental health protocol is implemented during outbreaks. This includes using iPads to communicate with people who are at risk; manned telephones for psychological first aid; care packages with activities for those in isolation; and daily contact between prison officers and prisoners to check on any concerns they may have and to offer support.

The IPRT’s report outlined that isolation and loneliness during the pandemic had severely impacted the mental health and wellbeing of people in prison. For some, Covid-19 isolation requirements “have felt like solitary confinement or additional punishment”, it noted. Dr Regan told MI “the biggest challenge we face in the psychology service has been the impact of Covid and increased isolation on people’s mental health”.

She explained that isolation does not mean being “locked up in a cell for a prolonged period” of time. It relates to
not having family visits, not seeing members of the community, and not having access to usual prison services for a
long duration. According to the IPRT report, “people in prison have experienced severely reduced contact with families, lack of purposeful activity, limited access to education/work/training and long hours spent in cells.”

Dr Regan explained that the inability to access regular services or see family impacts on prisoners’ routines, which are “really important in terms of managing people’s mental health”. She said: “There’s no doubt that people felt more trapped, and more hopeless and helpless, isolated, [because] of having nothing to look forward to when they were in custody.”

Prisoners’ mental health deteriorates when they are required to spend increased time in their cells and have a lack of interaction with their families. This leads to feelings of “hopelessness, anxiety, depression, and potentially more of a risk to self”, said Dr Regan.

“Their sense of wanting to look well and to have a reason to shower and to shave, and to get up in the morning, just reduces. I think that for most people, our sense of pride in ourselves almost deteriorates.” The less people engage in personal care, the more it impacts on their self-esteem, self-worth and motivation to do regular things that generate wellbeing. Dr Regan said this is the same for both prisoners and the general public. However, the confinements of prison can exacerbate feelings of isolation.

“We’re all human in or outside custody and that lack of engagement with other people has meant that people’s standards dropped and that impacts on all of our mental health.” A number of measures have been put in place to help protect the wellbeing of prisoners, including fortnightly newsletters. The newsletter was first circulated at the beginning of the pandemic to communicate with prisoners about Covid-19 in the general community. It contains information on mental healthcare within the confinements of a prison cell. Dr Devlin said from an early stage “we were conscious of the fact that we need to really communicate well with people who are in custody”.

In-cell TVs have been in prisons for almost 20 years. Dr Regan said while there is no formal research, “there was a reduction in self-harm and suicide” when the TVs were first introduced. The TV channels have regular films as well as mindfulness programmes. A podcast, The Two Norries, is also available. The podcast has been “important” to the psychological services as it is by two men who were previously in prison and had a successful recovery, offering some hope to prisoners.

Dr Regan noted “there’s real legitimacy in that because the two men that are doing interviews have been through the prison system, so I think that’s been a really important piece for us”. The IPRT suggests that the IPS introduce in-cell tablets as part of e-learning developments to give prisoners more access to education.

Psychology

Last year, 1,300 referrals were made to the prison’s psychological services. Dr Regan said there is usually one-third of the prison population on the waiting list. The waiting period to see a psychologist is based on the length of time the prisoner is on the list, combined with their estimated release date to ensure they are seen before they are released.
However, in cases of self-harm, suicide or challenging behaviours such as personality disorders, this is highlighted by the multidisciplinary teams. The prisoner is then reviewed and prioritised, Dr Regan explained.

One of the psychologists sought to measure the levels of depression and anxiety in people who had been in isolation due to an outbreak. From those who responded, 83 per cent scored within the clinical range (or borderline) for depression and 96 per cent scored within the clinical range for anxiety, Dr Regan said. She noted that all prisoners can contact the Samaritans mental health service through a direct link with the prison. Last year, phone calls to the Samaritans went from an average of 4,000 to 12,000 calls.

As referenced in the IPRT report, poor mental health is experienced disproportionately among both male and
female prisoners. Dr Regan explained that female prisoners’ “pathways to offending tend to be more closely associated with deprivation, trauma, addiction, mental health, and social marginalisation”. Although men also have these
experiences, “for women there tends to be more layers of that because they may be more vulnerable.”

She added, “this inevitably leads to more significant, or vulnerability to, mental health difficulties and personality disorder difficulties, which we then end up seeing in prison.” Additionally, factors such as motherhood can lead to women feeling “distress, guilt, anxiety [and] depression”. In the UK, it was found that only 5 per cent of female prisoners’ children were cared for at home when the mother went to prison. However, most children continued to be cared for at home when the father was imprisoned, noted Dr Regan. Female prisoners tend to experience more isolation as they get fewer visitations from their partners, she added.

Restricted services

Dr Regan said that “the restricted access that we’ve had to people in custody has exacerbated [their mental health wellbeing] as well”. She said the psychology service’s waiting lists were completely suspended last year from mid-March until July 2020. This meant that all planned individual therapy engagement was put on hold. Prisoners were instead provided with emergency first aid by a telephone helpline. In July 2020, the services resumed under a blended model of treatment.

Last year, there was a reduction of 60 per cent in the group programmes. In September 2020, group programmes recommenced but they soon became “entirely restricted” when level five restrictions were reintroduced. There had been no group sessions thus far in 2021. Explaining the importance of group therapy, Dr Regan said “it’s one of the most effective ways of working with people, particularly around their mental health and criminogenic needs in prison because [witnessing the] challenge of [other] group members is really important and can be really effective”.

When the psychological teams do not have access to prisoners through individual and group work, it means they are not being assessed.

“It is highly likely that people have left prison at this stage, who were not seen for either an assessment of their mental health or an assessment of their criminogenic needs,” she said. Once prisoners are released into the community, the IPS psychological services do not have contact with them. Therefore the “opportunity” for further intervention is lost.

Future

Going forward, there is an emphasis on ensuring adequate mental health and addiction services in Irish prisons.
In 2020, a report from the Council of Europe’s anti-torture committee was critical of the care afforded to vulnerable prisoners in Ireland, notably those with a mental illness. Dr Devlin told MI that a Government taskforce on mental health and addiction met for the first time recently. This taskforce will tackle the challenges of mental welfare in prisons while looking at how the IPS can work better with the HSE. He said this will help to “unlock some of the additional services that we need”.

There are a small number of prisoners who are very vulnerable and need to be admitted to the Central Mental Hospital. The taskforce will look at how this type of care can be developed for such prisoners and will try to increase the capacity for people who need urgent care, Dr Devlin explained.

“That will set the scene for us in relation to going forward, aware of not just mental health, but our general health needs.” In August 2018, the terms of reference for a review of prison healthcare were agreed between the Department of Justice, Department of Health and IPS. The health needs assessment for Irish prisons has been delayed to ensure the report reflects the “current situation” of Covid-19 in prisons, according to the IPS. The report, due to be finalised in June, required clarification in light of the pandemic. It is currently being completed and will go to the relevant departments and IPS for consideration.

Community services

The IPRT noted that “many community organisations are reporting poor mental health among clients coming out of prison during the pandemic”. Dr Regan explained that it has been “difficult in terms of channelling people into community services”. She explained that the time of release is when people are most at risk of reoffending. When they have proper access to community services, they will be more successful in recovery.

“But if we’re not able to assess and find out what people’s needs are, we’re not able to refer into the community and get those reference services available to us,” she continued. Delays in accessing prisoners and providing risk assessments causes delays in their parole board reports. Dr Regan would like to see community-based services return in prisons as they are “really important in terms of people’s mental health and wellbeing” and help them leave prison safely.

“What we really need is to make sure that the community services [that were originally in prisons] are back in prisons, meeting with people and preparing them for release and developing relationships with them, so that they can transition out of prison and into those community services.” Dr Regan said that horticulture and animal therapy are some of the outdoor activities that can be implemented in prisons to promote wellbeing. She explained that developing a relationship with animals and being able to support and care for something, such as plants, helps prisoners with their compassion and is “really important for people who are in prison, particularly for a long time”.

TB in prisons – the need for early diagnosis

Increased testing for TB in prisons was recommended in a recently published paper titled, ‘The largest prison outbreak of TB in Western Europe investigated using whole-genome sequencing.’ The study was carried out by Trinity College Dublin (TCD), the Irish Mycobacteria Reference Laboratory (IMRL), St James’s Hospital, Dublin, and the Department of Public Health (HSE East). The paper describes an outbreak of TB in an Irish prison in 2011, leading to 34 people contracting TB from a single case.

In addition to the confirmed TB cases, the study found that half (50 per cent) of the prison staff who were close contacts of the case developed latent TB due to the exposure. Latent TB is an asymptomatic, non-infectious form of TB that can develop into an active form of TB at a later date. The report details how whole genome sequencing allowed the investigators to track the course of transmission and link TB cases from as recent as 2019 to an outbreak in 2011.

Prof Tom Rogers, Clinical Microbiology, TCD, and formerly Clinical Director, IMRL, St James’s Hospital, said: “This report demonstrates the power of whole genome sequencing to enhance epidemiological investigations of TB outbreaks over prolonged periods of time. The IMRL has created a national database of TB genomes which will facilitate future public health investigations of TB in Ireland.”

Dr Marcus Butler, Vice-President of the Irish Thoracic Society, said the study supports the “need for improving early TB diagnosis and care in the Irish prison system”.

Improving TB care in Irish prisons can be done through a three-step approach: Establishing a TB information and testing service in prisons; establishing a latent TB clinic at St James’s Hospital; and appointing a national TB lead to oversee this work as part of an integrated national TB control service. Dr Butler said the national control service should include TB screening for high-risk groups; an investment in contact tracing and TB surveillance; and an education and awareness programme for both the public and healthcare professionals.