French forensic mental health system during the COVID-19 pandemic

Many facilities involved in caring people diagnosed with mental health disorders who committed crime had to adapt to COVID-19 pandemic in France. Particularly, the impact of the COVID-19 pandemic on incarcerated people was the subject of many concerns. The COVID-19 pandemic also posed major challenges in secure psychiatric hospitals and for psychiatrist experts. Rapid changes in working practices occurred. Finally, the lockdown period was associated with an increase in domestic violence, especially gender-based violence and child abuse and neglect. Overall, the COVID-19 pandemic emphasized the well-known limitations of the French mental health system to manage people diagnosed with mental health disorders who committed crime and the urgent need for better recognition of forensic psychiatry in France.

A major reorganization of the mental health system took place all over the world as a result of the COVID-19 outbreak (Pfefferbaum & North, 2020). Forensic psychiatry services have been significantly impacted by these changes (Kennedy et al., 2017). In France, as highlighted by a recent narrative review, forensic psychiatry is not yet an established academic field (Fovet et al., 2020a). However, many facilities involved in caring people diagnosed with mental health disorders who committed crime had to adapt to this unprecedented crisis.
First and foremost, the impact of the COVID-19 pandemic on incarcerated people was the subject of many concerns particularly because of the high prevalence of medical conditions in correctional facilities (Bhugra, 2020;Liebrenz et al., 2020). On March 16, 2020, the French government imposed a national lockdown which was immediately associated with specific measures for jails and prisons. Especially, visitations, group-based programs and interventions of external stakeholders were suspended. In addition, the prison population decreased by 10,000, as a result of early releases and reduced incarceration. All these adjustments prevented the massive spread of the virus in correctional settings but they also had major consequences on the psychiatric system for prisoners (Fovet et al., 2020b). Mental healthcare workers implemented specific measures such as increased hand-hygiene measures, use of facial mask or physical distancing in the correctional environment. The clinical activity was also considerably redesigned: routine psychiatric procedures were drastically reduced with priority given to consultations for recently admitted prisoners, vulnerable people and psychiatric emergency situations. All of these changes had three main objectives: (i) to prevent an infection's spread, (ii) to ensure continuity of treatment for the many French prisoners suffering from mental disorders (Fovet et al., 2020c), (iii) to support incarcerated persons in the particular context of COVID-19 pandemic. As of September 21, 443 cases and 1 death among incarcerated persons have been reported. A few minor security problems (inmates refusing to re-enter cells at a scheduled time and degradations) in approximately 30 of the 188 French correctional facilities were also reported by the prison administration.
As people with severe mental illness are among the most vulnerable populations (Kahl & Correll, 2020), the COVID-19 pandemic posed a major challenge in secure psychiatric hospitals (such as "specially equipped hospital units", UHSAs or "units for difficult patients", UMDs) (Simpson et al., 2020). Rapid changes in working practices occurred, including staff training, increased hygiene measures, disinfection, physical distancing, patients' education about COVID-19 risks, rotation of on-unit psychiatrists and ending visitor access. After an initial total cessation of admissions (except psychiatric emergency situations), systematic screening, testing and quarantine of newly admitted patients were implemented in several facilities. An isolation unit (i.e. a unit to provide a therapeutic space for persons recovering from COVID-19 with other patients who have similar infection) was created in 8 UHSAs out of 9 and in all UMDs. Only a few COVID-19 infections were managed in DOI of original article: https://doi.org/10.1016/j.fsiml.2020.100028. UMDs (none in UHSA) and no inpatients died. In contrast, many staff members have been diagnosed with COVID-19, leading to substantial organizational problems in several units.
Outside of these "closed" facilities, the activity of psychiatrist experts was totally interrupted (except in the cases of an urgent and justified request from the judge) during the lockdown period before increasing dramatically in late summer 2020. Recently, forensic mental telehealth assessment has been proposed by several judges but most of the French psychiatrist experts are rather opposed to this way of conducting courtsanctioned psychiatric evaluations. Concerns reported include the restricted ability to evaluate mental state when a range of non-verbal channels of information are compromised by videoconferencing. In fact, "resource centres for professional caregivers working with sexual offenders" (CRIAVS) are the only French forensic facilities that have been able to implement telemedicine in their daily practice (team support, patient evaluation) but with great heterogeneity depending on local practices. The follow-up of people on probation with court-order care was generally provided via telemedicine, telephone and/or email. Medical coordinators maintained their activity but courts were closed and dealt only with emergency situations until June 2020.
Among the negative consequences of the measures adopted by the French government to tackle the spread of COVID-19 on society, the increase in domestic violence, especially gender-based violence and child abuse and neglect, must be highlighted. Domestic violence is strongly associated with epidemics. Movement restrictions, loss of income, isolation, overcrowding, and stress definitely put women and children at a disproportionally increased risk of harm during the COVID-19 outbreak (Chandan et al., 2020;Mengin et al., 2020;Thibaut & Van Wijngaarden-Cremers, 2020). An unusually high number of people with severe psychiatric disorders who committed severe violent acts, particularly homicides followed by suicide attempts was also noticed during the lockdown period (Horn et al., 2020).
Overall, the COVID-19 pandemic emphasized the well-known limitations of the French mental health system to manage people diagnosed with mental health disorders who committed crime (Fovet et al., 2015). The deincarceration policy during the lockdown period also revealed the persistent difficulties to coordinate correctional and community health care services for these patients, highlighting the urgent need for better recognition of forensic psychiatry in France.

Declaration of competing interest
None for this paper (TF, FT, AP, HJS, PT, CL).