Mental Health Issues during Covid-19 Pandemic in Portuguese Prisons

During imprisonment, inmates face many difficulties to adapt to prison life well depicted in either classical works or recent research. They usually face many struggles related to the lack of contact with their families. For instance, the less the number of prison visits, the higher levels of aggressiveness and, consequently, the lower levels of adaptation. Additionally, this population is already problematic in “normal conditions” of their imprisonment. When facing crisis – such as the Covid-19 pandemic – their mental and emotional conditions become even worst. Inmates may experience higher levels of anxiety and stress due to the uncertain and high-risk circumstances they are all living. In addition, the deprivations of the support from their families, combined with the higher risk they are exposed due to the danger of Covid-19 virus’ contamination, substantially increase their concerns and could contribute to their lack of adjustment. The present chapter refers to the policies implemented by the Portuguese Prison Administration to deal with the Covid-19 pandemic and a provisional balance of its effects after one year of implementation. Besides information regarding inmate’s mental health conditions during pandemic, data on recidivism rates and criminal activity will also be discussed concerning their implication for future penitentiary policies.


Introduction
Over time, it has been highly reported the prevalence of mental health issues within places of confinement in general, and within prisons particularly [1][2][3].Often, such problems already exist before incarceration but are severely exacerbated during the sentence.The overrepresentation of psychopathology within the prison context is a reflection of both the vulnerabilities that these individuals usually show and the lack of healthful conditions of penitentiaries.Indeed, prison settings are thought to have the potential to damage individual well-being and social functioning.When entering in prison, individuals often are confronted with a new reality, facing a set of challenges.The concept of prisonization refers to the process of individuals' enculturation into the culture of imprisonment, which usually entails the learning and adoption of maladaptive "norms" [4].Indeed, other studies underlined the pejorative effect of the "prison code" on inmates' adjustment and rehabilitation [5].Besides, imprisonment affects not only the adjustment and well-being while in prison, but also the ability to retain supportive networks after release.All these concerns should be attended during the condemnation in order to minimize the negative impact of prison on individuals' lives.
Despite the origin of this problem is undoubtedly old, this reality has been receiving special attention give the exceptional conditions we are living, all over the world, as a result of the pandemic Covid-19.Worldwide, efforts have been made to minimize the pejorative effects of the pandemic.In fact, the coronavirus pandemic affected individual lives as well as institutions functioning, including correctional facilities [6].Firstly, people mobilized themselves for social distance to prevent virus expansion, which is actually particularly difficult within prisons due to their close proximity during their routines [7].In addition, this population is typically more vulnerable since their health profile is often more severe compared with the community [8,9], and they are usually facing poorer hygiene conditions, poorer nutrition, and drug addiction problems [7].During the pandemic, decision-makers imposed some restrictions to prevent a serious outbreak.Such constraints also raised adverse conditions for inmates' mental well-being, increasing their difficulties to adapt to the prison environment.
The present chapter presents an overview of the prison setting and the problem of mental health within this context.Secondly, it refers to the policies implemented by the Portuguese Prison Administration to deal with the Covid-19 pandemic and a provisional balance of its effects after one year of implementation.Finally, information regarding inmate's mental health conditions during the pandemic, data on recidivism rates, and criminal activity will also be discussed concerning their implication for future penitentiary policies.

Prison environment and mental health
Prison life relates to a constellation of difficulties and challenges that can affect in a tremendous way inmates' mental well-being.Frequent sources of problems refer to conflicts with others, dissatisfaction with lifestyle in prison, frustration regarding the restrictions, lack of future direction, and loneliness or depression [10][11][12].The importance of social climate has also been studied in the context of imprisonment [12,13].Indeed, adaptation of prisoners is generally multidimensional and different factors -social, material, emotional, and moral -affects the way people adapt to the environment.Previous studies emphasized the dreadful effect of the prison atmosphere on individuals' mental well-being.Nurse, Woodcock and Ormsby [12] found that prisoners often report the pain resulted from their isolation, assuming to have some maladaptative coping strategies to deal with the tedium, such as drug misuse.
The prevalence of psychopathology in prison has been highly reported.Prison populations are known to exceed the incidence of mental health disorders in the general population [10,14].Previous systematic reviews focused on mental health disorders found robust evidence of a higher occurrence of psychopathology among prisoners [15][16][17].Overall, inmates seem to be more likely to be diagnosed with personality disorder [18], anxiety, mood disorders, risk of suicidal behaviors [19,20], and substance use disorders [19,21].According to some studies, the problem of overcrowding reinforces these difficulties [22] and is often associated with negative effects on prisoners [23].
Notwithstanding the detrimental conditions of the prison, which increase the risk to develop mental illnesses, it is also important to note that many offenders already reported symptoms before imprisonment, and those symptoms contributed to criminal behavior [24,25].Thus, we must acknowledge that imprisonment is both a cause and a consequence of psychological maladjustment.
Despite the prevalence of mental illness in prisons, the barriers to treatment seem to increase an inadequate reaction to this problem.Indeed, previous studies underlined that imprisonment itself gives rise to some difficulties for mental health treatment [10].Often, these barriers start with the reception of inmates since they usually show reluctance to ask for help by themselves [26].Additionally, the screening at reception often presents some limitations regarding mental health since it gives a bigger focus on physical health [27].Besides, the screening is commonly conducted by staff who does not have previous training about mental health issues [28], which contributes to the inappropriateness of such assessments.

The specific case of pretrial detainees
The remand detention is a measure to be applied for a person accused of committing a crime to prevent his/her criminal activity or inhibit unlawful interference with the investigation at the pre-trial stage.This measure should be applied as last resort, and only when other non-custodial alternatives don't seem to be appropriate [29].
The negative effect of pre-trial detention has been greatly reported [30,31].Previous studies underlined that those who are in prison awaiting trial are more likely to have mental disorders as well as to exhibit suicidal behaviors [32,33].In addition to the difficulties also shared by the sentenced prisoners, these individuals suffer from the uncertainty of their prisoner status since they do not know how their future will be [34].Despite this, they are usually excluded from the health care services and interventions due to their (presumably) provisional stay in prison.
Studies reported that pre-trial inmates usually present high rates of mental illness, particularly: depression, substance misuse, adjustment disorders, anxiety, PTSD, and personality disorders [35][36][37][38][39]. Considering the higher propensity for these individuals to develop adjustment and mental health problems, we expect that during a crisis such as the Covid-19 pandemic, these rates become (even more) underestimated.Therefore, the importance to ensure pre-trial detention is used only when it is strictly necessary is quite relevant, in order to prevent the development of psychological disorders as well as to diminish the problem of overcrowding in prisons.

Prison changes during the pandemic and the Portuguese example
As mentioned, during imprisonment, inmates face many difficulties to adapt to prison life, well depicted in classical works [40][41][42] but also in recent research [43,44].They usually face many struggles related to the lack of contact with their families.For instance, a study conducted by Gonçalves and Gonçalves [45] found that the less the number of visits in prison, the higher levels of aggressiveness, and consequently, the lower levels of adaptation.Considering this population is already problematic in "normal conditions" of their imprisonment, during times of crisis -such as the Covid-19 pandemic -their mental and emotional conditions become even worst [46].A study conducted by Carvalho et al. [47] emphasized these difficulties, pointing the overlap of challenges felt during this time.Indeed, inmates may experience higher levels of anxiety and stress due to the uncertain and high-risk circumstances they are all living in.On the other hand, the concerns with physical health (to heal those who are contaminated and to prevent further contaminations) could result in fewer resources to treat mental illness.Besides, demands for professionals and staff also face additional burden, related with the danger of contagious for themselves and their families.Knowing that the spread of disease could easily occur within prisons, the anxieties related to the Covid-19 pandemic are not exclusive of inmates, also affecting those who have to take care of them [48].
Given the high number of prisons in affected countries, an outbreak within prison settings could result in a massive and unsustainable overwhelm of the prison health care services.In Portugal, at the beginning of the pandemic (March 1st, 2020), the prison population was 12.737 (11.869 men and 868 women), with a rate of occupation of 98,5%.Hence, the full capacity of the system was almost reached (https://dgrsp.justica.gov.pt).Nevertheless, and if it is true that in 2019 the Portuguese prison system as a whole had finally turned the page of a chronic overcrowded situation, this problem persists in several facilities related to the rate of the surrounding population, namely in the two main cities, Lisbon, Oporto and some local prisons.
When the pandemic reached the country, the government and the prison administration adopted some preventive measures in a global framework, to avoid the disease's dissemination among prisoners, prison staff, and visitors [5].Consequently, visits were suspended for a certain period, prisoners' transfers were interrupted (except for security reasons), and other daily activities -educational, recreational, and religious -have been temporarily shut down.The contingency plan foresaw: (i) the establishment of infirmaries and emergency wards; (ii) the readjustment of cleaning and sanitization schedules according to the orientations of the Portuguese Directorate-General Health; and (iii) the reallocation of inmates, ensuring that those more vulnerable (i.e., elderly and/or with chronic illness) were separated from the other prisoners.
Besides, several other measures were approved for reducing overcrowding and consequently, the danger of an outbreak.The authorities decide to pardon the sentences to inmates over 65 years with a history of chronic disease and who have not committed severe and violent crimes.Overall, from April 11th of 2020 to March 1st of 2021, 1702 inmates obtained pardons in their sentences and were consequently released.Also, the time of condemnation was decreased for those who were convicted by a non-violent/non-severe crime and whose sentence was shorter than 2 years or was being served for more than two years.Besides, those who already were in the open regime had the opportunity to leave prison for 45 days furloughs, a renewable measure if the criteria used to provide it go on valid.In this sense, during the period mentioned, the prison administration allowed 887 temporary leaves and go on evaluating eligible candidates for this measure.So far, from the 887 temporary leaves that were approved, 40 of them had finished the sentence during the leave, 386 had been granted with a conditional release (from those, 40 in advance), and in 105 of the cases, the measure was revoked due to non-compliance.Furthermore, during this period, 14 inmates have returned voluntarily to prison, and the other 13 did not see their furloughs renewed following a decision from the General Director of the Prison Services.Finally, the pre-trial imprisonment was reevaluated, ensuring this condition was only applied in cases where another measure was not suitable.Therefore, since March 2020 and over one year period, the number of male prisoners remained above the 11,000 threshold, while for women only recently the threshold of 800 was, again, exceeded (see Figure 1).
Since part of the prison population had the opportunity to temporarily go to their homes, levels of stress, and fear may decrease as a result of the familiar and social support, as well as the sense of higher protection against the disease.The consequences of such releases should be understood not only from the point of view of the pandemic situation but also from the perspective of the rehabilitative process of the prisoners.Specifically, it could be important to assess how these inmates' DOI: http://dx.doi.org/10.5772/intechopen.97798behavior was influence by the provisionally discharge, evaluating if this measure had a positive or negative impact on their adjustment.The discernment about how prisoners behaved while out of prison (i.e., either they recidivate or not), as well as how they will adjust in prison after the return might have important practical implications.Officially, as far as it is possible to recognize, of the 1702 inmates that obtained pardons in their sentences, only 170 (9,99%) of them have already returned to prison due to re-offenses, which means that until now, only a minor portion failed in maintaining a prosocial behavior.

Implications for practice
The results presented above urge critical considerations and should be discussed among practitioners and decision-makers.The costs of imprisonment for mental health are well-reported.If non-custodial alternatives were found to be effective to reduce recidivism, the use of prison should be discussed.In fact, if we found that offenders were capable to not engage in trouble, new policies regarding the decision about prison sentences for certain types of offenders might be pondered, and so, the problem of prison overcrowding and the pejorative outcomes that result from the imprisonment could be minimized.As we noticed, prisons usually lack adequate treatment conditions, and overcrowding is a problem highly reported worldwide.Reducing the rates of incarceration seems to be an urgent concern since it allows, not only to avoid the impact of incarceration for those who do not represent a danger to society but also to provide more adequate conditions for those who need to be confined, due to the seriousness of their crimes or their dangerousness for society.
A careful judgment of the overall impact of the modifications that the Covid-19 pandemic imposed on the Portuguese prison system cannot be overlooked, and as it is commonly said, crisis usually arrange for opportunities to implement appropriate reforms.As shown in Figure 1, during the first wave (March to July), as a consequence of the described policies, overall, the number of inmates had decreased.The downsizing was perceived until July, the month after which the situation started to invert.This change had accompanied the evolution of the pandemic.However, Portugal had faced a more difficult time between January and March 2021.We noticed that during this period, the prison population has already increased, but at a slow rate and never reaching the pre-Covid-19 beginning.In fact, despite the catastrophic situation in Portugal between January and March 2021, the correctional system did not seem to be a problematic place for virus dissemination during the second wave.All the measures that were taken to avoid the overcrowding during this time allowed to keep in control the pandemic situation within prisons, noting that, currently, out of a universe of more than 20000 individuals (including inmates, workers, and young interns), no deaths by Covid-19 were registered, and currently, only 14 cases are positive.At this point, more than 25500 tests were administered, and about 7775 vaccines have been administered, the first ones to inmates that were declared legally insane but dangerous thus confined to forensic facilities.

Conclusion
The current state of the Portuguese prisons and the measures taken to deal with the Covid-19 pandemic raised several questions.First of all, there was quite a big protest from the right-wing political forces clamming that the release of several prisoners would provoke growth in crime and intensify public fear.The data proved to be contrary to this alarmist claim.Consequently, it seems that the prison services have done an adequate job in assessing those inmates that should be released, and if the criteria of the length of the sentence and the type of crime committed may be relevant, it seems that assessing the risk of (violent) recidivism using adequate tools has to be preponderant.Additionally, it might be that for those prisoners who saw their sentences partially pardoned, the previous experience of serving time could be sufficiently punitive to discourage further reoffending.Again, the "pains of imprisonment" seem to play an important role and have to be reconsidered in the way prison sentences are applied [49].Therefore, the Portuguese penal system should reflect on how prison sentences are assigned since, in most individuals, the purpose of rehabilitation might be fully achieved with community sentences, sending only to prison those truly dangerous.These considerations would provide a better sense of justice and the use of prison sentences as more discretional rather than proverbial [50].
The absence of a regular screening procedure for mental health issues when prisoners enter the correctional system and while they are serving their sentences, unable us to depict an effective analysis of this problem in the Portuguese prison system.Nevertheless, during 2020, official reports recently presented depict an unusual increase of prison suicides that ought to be explained, whether as result of the pandemic measures or some other reasons.
Finally, the diminishing of criminal activity might be due to several causes.The absence of victims and a more effective policing might cause a deflection in crime during the first semester of pandemics.Nevertheless, this effect seems to be discouraging only for a short period.Indeed, it seems that it takes more than a pandemic situation to deter crime.