The Management of COVID-19 in Forensic Psychiatric Institutions

Both mental health agencies and DOCs share the goal of minimizing COVID-19 exposure and spread in their populations. Solely from an infection prevention perspective, the ideal scenario would be to stop all movement between institutions. However, other important goals, such as providing treatment to incompetent defendants sent by the courts and returning competent defendants to court to face their charges, must be considered as well. In our institution, movement between the hospital, DOC facilities, and the courts came to a standstill in the early stage of the pandemic. As the situation persisted for weeks, it became clear that systems had to slowly return to normal operations. To this end, communication with correctional systems allowed for the development of shared expectations, such as offering COVID-19 tests to individuals who were anticipated to move between institutions. This cooperation required planning and coordination because the different systems had variable access to testing and the time for test results to return varied. Each agency also developed protocols for how to manage infection risk for patients who refuse testing prior to transfer but who must be accepted by the institution because of a court order, typically leading to the medical isolation of the individual in his or her new setting for up to 14 days.

During a pandemic, criminal courts severely limit their operations, with most courts handling only arraignments and “high-priority” matters. From the forensic hospital’s perspective, all competency restoration cases should be considered high priority for the court because making a final determination about competency allows the hospital to discharge patients and reduce the institutional population among which infection can spread. However, courts may not share this view. Finding allies within the court system, such as a chief administrative judge, clerk, or case flow coordinator, is essential. In addition, it is useful to have a point person at the hospital to coordinate videoconference hearings, troubleshoot with IT professionals, and interface with judges and other court personnel to ensure a smooth process. During a pandemic, there must also be mechanisms for continued work with probate courts around matters such as civil commitment, conservatorship, and involuntary medication, and the well-being of additional stakeholders, including conservators, family members, and court-appointed attorneys and physician evaluators, must be considered. Investing in videoconferencing equipment that allows for remote criminal and probate court hearings is money well spent because it ultimately may decrease length of stay, census, and accordingly, the hospital’s risk of spreading the infection.

Even when courts are willing to work with the hospital to resolve patients’ criminal matters, challenges may still arise. For example, the logistics of conducting hearings via videoconference can be complex, particularly in contentious cases, cases where repeated communication between the patient/defendant and the attorney is necessary, and cases where multiple exhibits and physical evidence must be presented. Institutions must identify a mechanism to permit attorney-client contact during or after proceedings to allow attorney-client communication. For instance, suspending the hearing, excusing everyone except the patient/defendant and an agency police officer from the room, and permitting communication via telephone, although not foolproof, can help to ensure that the patient/defendant’s rights are respected.

Forensic hospitals must collaborate with criminal courts or quasi-judicial administrative bodies that oversee the treatment and/or release of insanity acquittees. Often, these judicial bodies require the hospital to obtain permission before deviating from a court-ordered treatment plan. In a pandemic, such procedures may be impractical, given the large number of patients who would need modifications to their treatment plans. For example, prescribed group therapies may no longer be occurring in an effort to prevent infection spread, and other treatment and monitoring activities may be curtailed because of staffing shortages or social-distancing guidelines. In such instances, maintaining close collaboration with the entity overseeing the management of insanity acquittees is crucial. Assigning a hospital staff member to keep track of deviations from patients’ treatment plans and to inform the oversight body of such deviations is key.

In the early stages of a pandemic, one of the chief questions facing a forensic hospital is how to handle the care of patients who have been living in the community part-time as a gradual transition out of the hospital. Returning patients from the community to the hospital should ideally be avoided to prevent the spread of infection. Hospitals must decide whether to keep these patients entirely in the community or the hospital. These determinations are best made after considering factors such as the patient’s risk of clinical decompensation, the ability to maintain adequate monitoring in the community, available community treatment resources, and the patient’s preferences.