Considering the impact of COVID-19 on suicide risk among individuals in prison and during reentry

Sean M. Mitchell (Department of Psychological Sciences, Texas Tech University, Lubbock, Texas, USA)
Nikki L. La Rosa (Department of Psychological Sciences, Texas Tech University, Lubbock, Texas, USA)
Julianne Cary (Department of Psychological Sciences, Texas Tech University, Lubbock, Texas, USA)
Sarah Sparks (Department of Psychological Sciences, Texas Tech University, Lubbock, Texas, USA)

Journal of Criminal Psychology

ISSN: 2009-3829

Article publication date: 4 January 2021

Issue publication date: 3 August 2021

1625

Abstract

Purpose

This paper mains to bring attention to the potential impact COVID-19 could have on suicide risk among individuals who are incarcerated and those reentering the community after incarceration (i.e. reentry), with particular emphasis on the USA, as well as provide possible solutions to mitigate suicide risk.

Design/methodology/approach

This paper provides an overview of the association between the COVID-19 pandemic policies and suicide, the vulnerabilities specific to prisoners during the COVID-19 pandemic, relevant suicide risk factors among prisoners, the possible impact of COVID-19 on suicide risk during reentry and proposed solutions for moving forward to mitigate both risks for COVID-19 and suicide.

Findings

This paper highlights that prisoners and individuals reentering the community are particularly vulnerable to COVID-19 and suicide risk and COVID-19-related stressors may further exacerbate known suicide risk factors (e.g. psychiatric symptoms, lack of positive social ties, low feelings of belonging, feelings of burden, economic problems) and suicidal thoughts and behaviors. This paper also discusses barriers (e.g. lack of funds, access to health and mental health care, COVID-19 testing and personal protective equipment) to managing COVID-19 and suicide risk within prisons and during reentry.

Originality/value

This paper provides a review of scalable solutions that could mitigate the impact of COVID-19 and suicide risk during this pandemic among prisoners and those reentering the community, such as psychoeducation, self-help stress management, telehealth services, increased access and reduced cost of phone calls, reduced or eliminated cost of soap and sanitization supplies in prisons and early release programs.

Keywords

Citation

Mitchell, S.M., La Rosa, N.L., Cary, J. and Sparks, S. (2021), "Considering the impact of COVID-19 on suicide risk among individuals in prison and during reentry", Journal of Criminal Psychology, Vol. 11 No. 3, pp. 240-253. https://doi.org/10.1108/JCP-10-2020-0044

Publisher

:

Emerald Publishing Limited

Copyright © 2020, Emerald Publishing Limited


Introduction

The suicide rate across the world and within the USA signifies a public health crisis. Worldwide, approximately 800,000 people die by suicide annually (World Health Organization, 2019). The most recent data from the USA indicate that 48,344 people died by suicide in 2018 at a rate of 14.2 suicides per 100,000 individuals making suicide the 10th leading cause of death in the USA at that time (Centers for Disease Control and Prevention, 2020). The suicide rate in the USA has also increased by 35% over the past 10 years (Hedegaard et al., 2020). Nested within these suicide rates, there are especially high-risk groups that are likely influencing this increase in suicides.

Individuals incarcerated in prisons are at elevated risk for suicidal thoughts and behaviors. Suicide rates among prisoners are 3 to 9 times higher than the general population across 24 countries (Fazel et al., 2017). Prisoners fall at the nexus of multiple public health crises (i.e. substance abuse, physical illness and mental health conditions) (Al-Rousan et al., 2017; Csete et al., 2016). This convergence likely contributes to their high vulnerability to suicidal thoughts and behaviors. Similarly, as individuals transition out of prison and back into the community (i.e. reentry), suicide rates are approximately 14 times higher than the suicide rates in the general population (Centers for Disease Control and Prevention, 2020; Noonan, 2015). Thus, prisoners are vulnerable to suicide inside prisons and during reentry, in terms of both individual and contextual factors. In this article we outline how the COVID-19 pandemic may exacerbate factors known to contribute to increased suicide risk among individuals in prisons and as they reenter the community, and we propose possible solutions.

Suicide risk and COVID-19 in the general population

Before we discuss the possible impact of COVID-19 on suicide risk in prisons and during reentry, we must first acknowledge that we know relatively little about the full extent of COVID-19’s direct impact (or indirect impact via its bearing on other risk factors) on suicidal thoughts and behaviors. Such information is unlikely to become available in the immediate future; however, preliminary data provide initial insights. April 2020 data indicated that life stressors, depressive symptoms, and recent suicidal thoughts and behaviors were not associated with the state-level implementation of stay-at-home or physical distancing mandates among the general population (Bryan et al., 2020). However, those who reported relationship strain and legal problems also reported increased suicide ideation, and suicide attempt rates were higher among those with serious injuries or illness, regardless of state mandates (Bryan et al., 2020). Another study indicated that stay-at-home mandates were not significantly correlated with suicide risk (i.e. frequency and intensity of past two-week suicide ideation plans and impulses); however, stay-at-home mandates were indirectly linked to increased suicide risk via low feelings of belonging and increased loneliness (Gratz et al., 2020). As time passed from April to June 2020, it appears the possible impact of stay-at-home mandates has changed; by June 2020, those under stay-at-home mandates were 1.8 times more likely to report any suicide ideation and 2.25 times more likely to report moderate to severe suicide ideation than those without such mandates (Killgore et al., 2020). Furthermore, Sheffler et al. (2020) specifically discussed the implications of COVID-19-related policies that may impact older adults by increasing the feelings of social isolation and burden on others and may negatively impact their health functioning because of prolonged stress. This may lead to increased suicidal thoughts and behaviors among a group whose suicide risk is already elevated. These findings highlight the dynamic nature of our understanding of suicide risk in the general population during the COVID-19 pandemic. In addition, it appears that it is not physical isolation that may increase suicide risk; instead, physical isolation is likely relevant if low feelings of belonging and loneliness are also present. Although not conducted among individuals in prison or during reentry, these studies provide information from which we can glean the potential impacts on these individuals.

Some studies have identified possible risk factors that indirectly impact suicide risk during COVID-19, which may be relevant to those in prisons and during reentry. For example, recent job loss was indirectly associated with suicide risk via increased feelings of burden on others (Gratz et al., 2020). Similarly, among people in Japan, those who were younger, had employment problems, had lower income, did not have children and received psychiatric treatment had elevated suicide ideation during the pandemic, relative to others (Sueki and Ueda, 2020). Thus, initial findings indicate the economic impacts of COVID-19 may be associated with increased suicide risk among individuals in the general population, which, as we discuss below, is likely relevant to the prisons and during reentry.

Why focus on COVID-19’s impact on prisons and community reentry?

At the time of writing this article (October 4, 2020), there have been approximately 35 million identified cases of COVID-19 around the world, which have resulted in approximately 1 million deaths (The New York Times, 2020). The USA accounts for approximately 7.4 million of the identified COVID-19 cases and 210,000 deaths (about 21% of the world’s COVID-19 deaths) (The New York Times, 2020). Therefore, the USA has been significantly impacted by COVID-19, which may be especially problematic for the US prison population, given that the USA exceeds all other countries in its incarceration rate and the size of its incarcerated population. By 2007, the USA had 743 prisoners per 100,000 residents, a prevalence rate 2.3 times greater than the developed nation with the next highest rate (Wildeman and Wang, 2017). In addition, almost 600,000 prison inmates are released back into the community annually (Hughes and James, 2002), and these individuals may lack the recourses to navigate the challenges created by the COVID-19 pandemic effectively. The rising rates of COVID-19, the sizeable population of prison inmates in the USA and the large number of individuals reentering the community post-incarceration without stable resources create a perfect storm of elevated risk for suicide. We must consider the potential impact of COVID-19 on mental health, suicide risk factors, and suicidal thoughts and behaviors among incarcerated individuals and those reentering the community after incarceration during this global pandemic.

Individuals in prisons are particularly vulnerable to the effects of pandemics. We need only to look back to the 1918 influenza pandemic to see this troubling trend. For example, a public health report outlined the increasing cases of the 1918 influenza pandemic from the California State Prison at San Quentin, wherein approximately half of all prisoners fell ill during the first of three waves of that pandemic (Stanley, 1919). Over 100 years later, despite advances in modern medicine and technology, another global epidemic, COVID-19, has surged through prisons yet again. At present, over 7.4 million COVID-19 positive cases have been reported in the USA (The New York Times, 2020), with at least 138,105 of these cases being people in prisons, as of September 29, 2020 (The Marshall Project, 2020). It should be noted that the number of new COVID-19 cases for incarcerated individuals is more than doubling weekly and thus represents a focal point of public health concern (The Marshall Project, 2020).

Prisoners comprise a vulnerable population with a high prevalence of chronic and infectious diseases and mental illness (Akiyama et al., 2020). Much like the upwelling of COVID-19 cases in nursing homes because of high-risk elderly populations confined to living in close proximity, prisoners are also at risk for COVID-19 quickly spreading in the confined living conditions with unavoidable contact with others (Wang et al., 2020). Prison overcrowding is a unique yet pressing concern. Overcrowding has been linked to increased transmission of infection, with the Institute for Crime and Justice Policy Research (2020) reporting that 59% of prisons worldwide exceed their prison occupancy levels (Simpson and Butler, 2020). Additionally, there has been a shift upward in the average age of prisoners. Longer and a majority non-violent offense sentences have resulted in an older inmate population, with state prisons witnessing a 400% increase in inmates aged 55 years and older between 1993 and 2013 (Hawks et al., 2020). The combination of confinement, overcrowding and the aging prison population creates especially dangerous conditions for prisoners that warrants additional attention to ensure their safety.

Preventing the spread of COVID-19 in prisons has proven an exceedingly difficult task. Because of crowded living conditions, poor ventilation and inadequate hygiene, prisoners are exposed to inevitable environmental risk factors that make it nearly impossible to socially distance or isolate in dormitory-style cells (Montoya-Barthelemy et al., 2020). Further, prisoners often suffer from poor hygiene, as they are strictly limited in hygienic supplies (e.g. soap, cleaning supplies), sanitization materials (e.g. alcohol-free hand sanitizer) and lack spare clothing or bedding materials (World Health Organization, 2020). This may facilitate the spread of COVID-19.

Similarly, prisons typically have limited medical supplies, comparable to an outpatient health facility and cannot provide sufficient personal protective equipment or adequately treat increasing rates of prisoners who have contracted COVID-19 (Saloner et al., 2020; Williams, 2020). Even if health-care systems in prisons were not severely underfunded and undersupplied, medical copays cost a substantial percentage of prisoners’ income that can limit those with symptoms from seeking medical care (Montoya-Barthelemy et al., 2020). This can also have an especially detrimental impact on incarcerated women and members of minority groups, who typically have higher rates of chronic illness and specific health concerns, including pregnancy (Montoya-Barthelemy et al., 2020).

Inconsistent testing procedures are also problematic. Some prisons provide COVID-19 tests only to inmates with symptoms of the illness, which is concerning given that 60% of COVID-19 cases may be asymptomatic (Blair et al., 2020). Such testing procedures create a barrier to containing COVID-19 spread in prisons. Additionally, more than 500,000 correctional officers and medical staff are employed inside USA prisons (Bureau of Labor Statistics, 2020a). As essential workers who come into contact with inmates, they risk contracting and transmitting COVID-19 from inside prisons and the outside community.

Although the rates confirmed COVID-19 cases have been fluctuating from week to week across the USA and globally, COVID-19 cases have been significantly higher and continue to rise in prisons. History appears to be repeating itself, as it did in 1918 at San Quentin. Prisons contain individuals and create a context for a high risk for COVID-19 transmission, leaving a vulnerable population ill-equipped to maintain health and safety during this global pandemic. Given the high risk for COVID-19 among prison inmates, we must turn our attention to how this pandemic may be detrimental to their mental health and may increase suicide risk among this already high-risk population.

Suicide risk, prisons, community reentry, and COVID-19

Suicide risk factors among prisoners

Although it is outside the scope of this paper to comprehensively review all risk factors for suicide among prisoners, we will highlight risk factors that may increase prisoners’ suicide risk when compounded with COVID-19’s impact on the prison system. First, it is notable that individuals with mental illness are disproportionally represented in prisons, given that 10.6% of adults in the general population are estimated to suffer from mental illness symptoms compared to 39.8%–49.2% in prisons (James and Glaze, 2006). Moreover, as many as 15% of prisoners have four or five comorbid mental disorders (Sirdifield et al., 2009). Various psychiatric presentations and symptoms have been linked to increased suicide risk among prisoners. For example, prisoners with at least one psychiatric disorder were significantly more likely to report suicidal thoughts and behaviors; however psychiatric symptoms may be more strongly linked to suicidal thoughts than identifying which prisoners are at greatest risk for acting on their suicidal thoughts (Favril et al., 2020a). Other data indicate that prisoners with a history of suicide attempt(s) reported significantly more depressive symptoms, anxiety symptoms, eating disorders, and psychosis than prisoners with no such history (Hakansson et al., 2010). The relatively high percentage of mental illness among prisoners indicates that this is a population that may be particularly vulnerable to additional COVID-19-related stressors.

Social factors are also vital considerations for prisoners’ suicide risk. Prisoners who were visited by family members and who had families who could provide financial support reported more positive adjustment to prison than prisoners who did not have these resources (Aday, 1994). Similarly, hope and the perceived availability of social support are linked to lower levels of suicide ideation among prisoners who had been identified by prison staff as high-risk for self-harm or suicide (Pratt and Foster, 2020), and greater social support was linked to lower suicide ideation among prisoners with major depressive disorder (Richie et al., 2019). On the other hand, low feelings of belonging, a moderate to severe lack of perceived social support, insufficient contact with friends and family, and a lack of social contact with prison staff and other inmates are associated with increased suicide ideation among prisoners (Dhingra et al., 2020; Favril et al., 2017; Jenkins et al., 2005; Mandracchia and Smith, 2015). Congruently, a recent meta-analysis of predictors of self-harm (self-harm may have included non-suicidal self-injury and/or suicidal behaviors) among prisoners indicated that poor social support, a lack of social connection and a lack of visitation are linked to an increased risk of self-harm (Favril et al., 2020b). In general, many prisoners who attempted suicide, lacked relationships inside prisons, spent much of their time alone, had difficulties with other inmates, had fewer visits, wrote fewer letters and missed specific people (Liebling, 1993; Stoliker, 2018). A lack of visitation may especially impact prisoners who are older, Black, and have been incarcerated more frequently, as these individuals are visited less often (Cochran et al., 2014).

Relationship difficulties outside of prison were stressful for prisoners and tended to occur around the time of a suicide crisis (Dexter and Towl, 1995). Likewise, psychological autopsies revealed that about 50% of prisoners who died by suicide experienced conflicts with other inmates, 42% had recent disciplinary infractions, 40% were fearful of physical harm, and 65% had recently received negative news from friends or family in the community (Way et al., 2005). These findings emphasize the importance of prisoners maintaining positive social ties in the community and prison and to be cognizant of those who may not be visited as often.

As prisoners remain isolated, they may also experience a variety of negative symptoms. Segregation has been linked to suicidal thoughts among prisoners (Bonner, 2006; Stoliker, 2018), and Haney (2003) suggests many adverse psychological effects of prison isolation, including negative affect and attitudes, insomnia, anxiety, withdrawal, hallucinations, paranoia, hopelessness, depression, self-mutilation, suicide ideation, and suicide attempts. Additionally, imprisonment with higher deprivation levels and lower personal autonomy has been linked to increased suicide rates (Roma et al., 2013). Meta-analytic findings further support the link between solitary confinement and self-harm in prisons (Favril et al., 2020b). Therefore, the prison environment is an important consideration for prisoner suicide risk.

Prisoners may not be well-equipped with effective coping skills to manage additional COVID-19-related stressors, which is problematic given that prisoners who reported suicide ideation and attempts also reported lower resilience (Sarchiapone et al., 2009). Prisoners at risk of attempting suicide reported ineffective coping strategies (Dexter and Towl, 1995). Most prisoners used reactive problem-solving strategies (i.e. there was no planning or consideration of consequences before attempting to cope with a situation) to cope with stress, and they did not plan how to maintain their strategy or consider the consequences of their chosen strategy (Dexter and Towl, 1995). Most prisoners also used avoidance problem-solving strategies (i.e. attempt to escape the stressful situation or thoughts) (Dexter and Towl, 1995). The lack of effective coping strategies may be a barrier to navigating COVID-19-related crises that could reduce the risk of suicidal thoughts and behaviors.

How might COVID-19 exacerbate suicide risk among prisoners?

The increased rates of psychiatric disorders among prisoners may also present a challenge during the COVID-19 pandemic. Those with psychiatric symptoms may be at elevated risk for suicide during this pandemic (Sueki and Ueda, 2020). This, coupled with prisoners’ difficulties accessing adequate health care and prisoners’ lack of effective coping strategies (Dexter and Towl, 1995; Montoya-Barthelemy et al., 2020), may increase suicide risk among prisoners with mental illness as they struggle to cope with additional COVID-19-related stressors.

Increased isolation and lack of interactions with individuals in the community because of restricted visitation during COVID-19 may further increase feelings of isolation and decreased connectedness among prisoners. To prevent the spread of COVID-19 and quarantine ill individuals, some facilities have increased the time spent in cells, some reporting up to 23 hours per day (Hewson et al., 2020b). Although this may help reduce the likelihood of a COVID-19 outbreak within the prison, it may come at a cost. Increased social isolation, feeling disconnected from others and solitary confinement have been linked to increased risk of suicidal thoughts and behaviors (Dhingra et al., 2020; Favril et al., 2020b; Mandracchia and Smith, 2015; Van Orden et al., 2010). Prisoners already experience increased disconnection and social isolation from their loved ones compared to those in the community, which has been linked to suicide risk (Favril et al., 2020b; Way et al., 2005). Moreover, as the prison population’s age increases, older prisoners may have increased feelings of social isolation and burden on others, which has been a concern among older adults in the community during the COVID-19 pandemic (Sheffler et al., 2020). Feelings of burden on others have also been linked to increased suicide risk among prisoners (Dhingra et al., 2020; Mandracchia and Smith, 2015). Financial hardships because of COVID-19 may increase feelings of burden among prisoners who rely on family for financial support while incarcerated. Furthermore, feelings of isolation and burden due to COVID-19 precautions may have additional deleterious effects on prisoners’ mental health and suicide risk.

Furthermore, negative news from friends and family in the community has been linked to increased suicide risk among prisoners (Way et al., 2005), which may be particularly relevant if they are informed a loved one has died from COVID-19 and experience feelings of grief and loss. Loss of a loved one may also decrease feelings of belonging as their connections to the community are unavailable. Relatedly, positive interactions and financial support from family is associated with positive adjustment in prison (Aday, 1994; Pratt and Foster, 2020; Richie et al., 2019); however, with stay-at-home mandates and the economic impact of COVID-19, family members may be less able to provide such support to prisoners. This could result in reduced positive adjustment to prison.

How might COVID-19 exacerbate suicide risk during community reentry?

According to the Bureau of Justice Statistics, nearly 95% of prison inmates in the USA will be released from prison during their lifetime, with 80% of them being released on parole (Bureau of Justice Statistics, 2020b). Additionally, the rates of incarceration during the COVID-19 pandemic have decreased by 8% (Sharma, 2020). In anticipation of the virus, USA officials in New Jersey and New York began releasing hundreds of inmates in March 2020 to decrease overcrowding in correctional facilities (Eligon, 2020; Kindy, 2020). Several other states, including California, Washington and Pennsylvania, have also published potential plans to release prison inmates because of the pandemic (Eligon, 2020; Sharma, 2020). Because of the lack of medical supplies and the inability to social distance in correctional facilities, as mentioned above, several sources have suggested the release of prison inmates who have served the majority of their sentence. The release of the most vulnerable inmates (i.e. the elderly, those with chronic health conditions, etc.) is thought to be essential to their survival (Williams et al., 2020). Although this may combat the spread of COVID-19 throughout a correctional facility, there are also dire downsides to releasing inmates at this time, which could impact suicide risk during reentry.

Previous literature has documented the challenges that former prison inmates face during reentry, such as health care disparities, unemployment, a lack of adequate housing, social and familial conflicts and substance abuse problems (Binswanger et al., 2007). Many of these challenges have also been linked to increased suicide risk (Binswanger et al., 2007; Dooley, 1990; Van Orden et al., 2010; Zlodre and Fazel, 2012). An additional stressor related to reentry that is specific to non-USA citizen prisoners is the impact a criminal record can have on legal resident status. Fear of deportation and immigration proceedings occurring earlier than expected because of early release, combined with the uncertainty of being forcibly separated from family members and social support networks amid a pandemic, can contribute to increased risk of suicide, both before and after release (Absolam, 2019). Furthermore, a study investigating the mortality rates following release from incarceration found that former inmates had a risk of death 12.7 times higher than the average member of society, specifically in the two weeks following release from prison (Binswanger et al., 2007). The leading causes of death for this sample included cardiovascular disease, lung cancer, drug overdose, suicide and homicide (Binswanger et al., 2007). More specifically, during reentry, suicide rates are approximately 14 times higher than in the general population (Noonan, 2015; Centers for Disease Control and Prevention, 2020). Therefore, it is likely that the suicide risk-related stressors experienced during reentry may intensify during the COVID-19 pandemic.

Thus, recently released inmates have an increased need for higher-quality health and mental health care because of the high prevalence of life-threatening underlying health conditions. Often during release, inmates are not provided with linkage to medical or mental health care, disrupting their continuity of care (Binswanger et al., 2007). It is imperative that inmates with underlying health conditions (i.e. diabetes, cancer, etc.) receive continued treatments once released (Fox et al., 2014). Former inmates who do not have health insurance or access to medical care may be unable to receive testing and treatment for COVID-19. This puts recently released inmates at an increased risk of mortality from the virus (Williams et al., 2020). These health-related stressors and lack of access to care stressors will likely intensify during this pandemic. Without the proper health care infrastructure, prisoners are being released into a community that cannot support them, especially during the COVID-19 pandemic, leaving these individuals vulnerable to COVID-19 and an increased risk for suicide.

In addition to the lack of adequate health care, inmates also face unemployment challenges during reentry (Binswanger et al., 2007), which is particularly salient during this pandemic. The stigma surrounding hiring former inmates has shown to be a significant barrier to job attainment and success for those with a history of criminal justice involvement (Batastini et al., 2017). Specifically, 60% of justice-involved individuals in the USA report unemployment one year post-release (Petersilia, 2001). In July 2020, 16.9 million people reported being unemployed, while 9.6 million (57%) were unable to work because their place of employment had closed because of the pandemic (Bureau of Labor Statistics, 2020b). The reality of the current labor market in the USA and the underlying stigmatization toward hiring former inmates has likely created a substantial barrier to gainful employment during the pandemic for those recently released from incarceration. This is particularly concerning given the link between unemployment and elevated suicide risk, especially during the COVID-19 pandemic (Gratz et al., 2020; Sueki and Ueda, 2020; Van Orden et al., 2010), that may be further exacerbated among those with a history of criminal justice involvement.

Moving forward and proposed solutions

There are limitations and barriers to implementing wide-sweeping changes to the criminal justice system to improve incarcerated people’s lives during the COVID-19 pandemic. Unfortunately, the consideration and welfare of inmates are not typically prioritized. Despite overt similarities for risks associated with COVID-19 to nursing home populations or group homes for children, inmates do not generally receive the same levels of societal empathy or safeguarding (Wang et al., 2020). However, there are obtainable solutions which can be implemented at the facility level, which could reduce the increased risk COVID-19 poses on incarcerated individuals (Hewson et al., 2020a; Hewson et al., 2020b; Montoya-Barthelemy et al., 2020). We aim to provide practical solutions and consider their feasibility given low staffing levels at prisons, coupled with the increased workload COVID-19 has placed on already overburdened staff (Ferdik and Smith, 2017), which are outlined below and summarized in Table 1.

Increased social isolation and low feelings of belonging are risk factors for suicide ideation and attempts. Inmates are especially impacted by COVID-19 in this regard, both in terms of physical isolation if placed in quarantine within the facility and the reduction or cancellation of visitations and further limitations placed on phone calls or video calls for inmates (Brennan, 2020; Calati et al., 2019; Van Orden et al., 2010). Increasing support methods within prisons will be crucial to mitigating the impact of COVID-19 on inmates’ mental health and suicide risk. In place of visitation from family and friends from the community, alternative methods to increase support and decrease feelings of isolation are warranted. Some suggestions include additional availability of secure telephones and materials to write letters and allowing peer support from within the prison via telephone (Hewson et al., 2020b; Novisky et al., 2020). Furthermore, by eliminating the cost of phone calls and increasing the allowed time for contacting family and friends, there is a potential to decrease social isolation while also limiting in-person visitation (Brooks et al., 2020; Courtet et al., 2020; Klonsky and May, 2015). Similarly, providing free access to the phones for accessing helplines, such as the National Suicide Prevention Lifeline (https://suicidepreventionlifeline.org), could help identify inmates who may be actively suicidal and may reduce feelings of isolation by providing access to speak with trained helpline volunteers.

Providing resources focusing on the intersection of the stresses related to incarceration and the COVID-19 pandemic could be especially beneficial. Psychoeducation and self-help stress management sessions are also relatively cost-effective and scalable interventions to improve coping skills for stress and suicide risk factors during the pandemic (Bergmans and Links, 2002; Eccleston and Sorbello, 2002). Group or individual sessions with mental health professionals conducted via telehealth could support help-seeking and provide a lifeline for those considering suicide (Leonard, 2004; Wheeler and Hinton, 2017; Young and Badowski, 2017). However, it is recognized that widespread access to computers and reliable internet connections may pose limitations to fully implementing this solution (Edge et al., 2020). Printed materials and access to pre-recorded informational videos related to coping with mental health symptoms and suicidal thoughts or relaxation and stress management systems for group or individual sessions could also be helpful. Much like we have in other areas of service (e.g. primary care), we must consider ways to adapt the resources for prisoners to ensure they receive necessary care.

As previously mentioned, medical copays and limited medical supplies are barriers to health care for inmates (Montoya-Barthelemy et al., 2020). The elimination, or at a minimum, temporary suspension of copays could improve access to medical services and potentially aid suicide crisis management. An especially salient outcome is the potential reduction of feelings of being a burden on family and friends who may provide money for access to health services and who may experience financial hardship because of the pandemic. Additionally, the provision of personal protective equipment, including necessities such as soap for increased handwashing, sanitation supplies, and spare, clean clothing, could reduce the increased risk of contracting COVID-19 and the additional stresses of lacking these basic hygiene items or accruing the funds to pay for these items from commissary (Friedersdorf, 2020).

One possible way to remove the barriers of increased costs to facilities, if they implement these provisions and services, is to hold publicly traded corporations that benefit from inmate labor accountable and petition monetary and supply donations to the facilities where their employees are housed (Schwartzapfel, 2014; Montoya-Barthelemy et al., 2020). Although many changes to the criminal justice system, including actions to improve the quality of life for inmates, require arduous legal and administrative processes and are constrained by the limited amounts of funding, public petitions and social pressure could bring timely and much-needed aid and publicization of these issues (Maxouris, 2020; Shao, 2009).

Another proposed action that has already been used by some is early release programs, which we discussed above (Hummer, 2020; Simpson and Butler, 2020). Although most inmates are unlikely to be released early, an early release could positively affect the mental health of the small number of people released. However, when contemplating early release programs, it is essential to note, transitional periods are high-risk times for the shift from suicidal thoughts to suicidal behaviors (Binswanger et al., 2007; Kariminia et al., 2007). Consideration should be given to previously mentioned barriers to reentry during the pandemic, including the flux in family or home dynamics, financial hardship, risk of illness and general uncertainty because of COVID-19 (Shepherd and Spivak, 2020). Additional support for individuals released early because of COVID-19, including informational pamphlets for local services and health-care options, could also help address the increased suicide risk recently released individuals may face. Without the proper procedures to minimize suicide risk during reentry, we may be releasing inmates into a situation that is just as or more stressful than their incarceration.

Conclusion

Prisoners are at elevated risk for suicidal thoughts and behaviors, as well as contracting COVID-19. As prisoners reenter the community, their risk is also elevated. Risk factors for suicide among these individuals may be magnified by the individual and contextual impacts of COVID-19. Therefore, we must be proactive in acknowledging this problem and developing methods to mitigate risk. Now more than ever, we must consider reentry programming to improve the continuity of care as individuals leave prison and reintegrate into the community. In addition, finding scalable, low-cost methods of reducing suicide and COVID-19 risk among prisoners may allow prisoners to adjust to COVID-19 stressors and decrease suicide risk adaptively. We must not let history repeat itself.

Considerations for reducing the risk for suicide in prisons during COVID-19

Proposed solution Reference
Increase social support methods within prisons to reduce social isolation
Additional communicative resources (e.g. secure telephones, writing materials for letter writing) to increase social connectedness Hewson et al. (2020b), Novisky et al. (2020)
Reduce or eliminate the cost of telephone calls & increase allotted time for contacting family and friends Brooks et al. (2020), Courtet et al. (2020)
Provide free, unlimited access to telephones devoted to mental health helplines, such as the National Suicide Prevention Lifeline
Reduce prisoner stress exacerbated by the combination of incarceration and COVID-19
Provide psychoeducation and self-help stress management interventions Bergmans and Links (2002), Eccleston and Sorbello (2002)
Increase accessibility to individual and/or group sessions with mental health professionals via telehealth services Leonard, (2004) Wheeler and Hinton (2017), Young and Badowski (2017)
Provide low-cost and easily accessible mental health materials and handouts, such as pre-recorded informational videos explaining coping skills Leonard (2004), Wheeler and Hinton (2017), Young and Badowski (2017)
Allocate medical resources and services to prisoners to reduce the risk of prisoners contracting COVID-19
Temporarily suspend, or ideally eliminate, medical copays to increase access to medical services and suicide crisis management Friedersdorf (2020), Montoya-Barthelemy et al. (2020)
Provide an increased amount of personal protective equipment, including soap for increased handwashing, sanitation supplies, and clean clothing Friedersdorf (2020), Montoya-Barthelemy et al. (2020)
Continue to advocate for criminal justice reform to improve the quality of life for prisoners
Maintain public petitions of injustice to increase social pressure and publicization of these issues Maxouris (2020), Shao (2009)
Hold publicly traded corporations who benefit from inmate labor accountable for their lack of adequate prisoner care Schwartzapfel (2014), Montoya-Barthelemy et al. (2020)
Petition monetary and supply donations to facilities where these employees are housed Schwartzapfel (2014), Montoya-Barthelemy et al. (2020)
Encourage early release and transitional support programs and interventions
Increase the amount of reentry planning and transitional aid provided to inmates, including halfway houses, work-release and/or drug-treatment programs, and employment opportunities Binswanger et al. (2007), Fox et al. (2014), Williams et al. (2020)
Provide educational support related to local services, mental health, and medical care options for the individuals released early due to COVID-19 Binswanger et al. (2007), Fox et al. (2014), Williams et al. (2020)

Note: For some considerations, citations are not provided, given these are the authors’ unique suggestions

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Acknowledgements

Funding: The time for this work was supported by the National Institute of Mental Health (L30 MH120575).

Corresponding author

Sean M. Mitchell is the corresponding author and can be contacted at: sean.mitchell@ttu.edu

About the authors

Sean M. Mitchell, is based at the Department of Psychological Sciences, Texas Tech University, Lubbock, Texas, USA. Sean M. Mitchell, PhD is an Assistant Professor in the Department of Psychological Sciences at Texas Tech University. He earned PhD in Clinical Psychology at Texas Tech University in 2018. He completed a postdoctoral fellowship in suicide prevention research at the University of Rochester Medical Center in 2019.

Nikki L. La Rosa, is based at the Department of Psychological Sciences, Texas Tech University, Lubbock, Texas, USA. Nikki L. La Rosa, MA, graduated from Florida State University with a bachelor’s degree in Psychology and Family and Child Sciences in 2015. She received master’s degree in Psychology in 2019. Her research interests focus on the relation between suicide and sexual trauma exposure. Her other interests include risk and protective factors for suicide in relation to the interpersonal theory of suicide.

Julianne Cary is based at the Department of Psychological Sciences, Texas Tech University, Lubbock, Texas, USA. Julianne Cary, MA, graduated from SUNY Oswego with a BA degree in Psychology in 2017 and received MA degree from Teachers College, Columbia University in 2020. She is currently a Doctoral student of Clinical Psychology at Texas Tech University with research interests in suicide risk and prevention.

Sarah Sparks is based at the Department of Psychological Sciences, Texas Tech University, Lubbock, Texas, USA. Sarah Sparks, MSc, earned BS from The University of Texas at Austin (2012) and MSc in the Psychology of Mental Health from the University of Edinburgh (2016). She is currently a Clinical Psychology Doctoral student at Texas Tech University. Her research interests include interpersonal factors and the risk of suicide ideation and suicide attempts in high-risk populations.

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