Solitary confinement, post-release health, and the urgent need for further research

People who experience incarceration have an increased risk of poor health outcomes and death following their release from prison.1Binswanger IA Stern MF Deyo RA et al.Release from prison—a high risk of death for former inmates.N Engl J Med. 2007; 356: 157-165Crossref PubMed Scopus (1041) Google Scholar Understanding the causal and mitigating factors of these outcomes is made difficult by the intersection of multiple risk factors for both poor health outcomes and incarceration. Additionally, the effects of the conditions of incarceration are not well understood. Solitary confinement is one of the most controversial environments of incarceration discussed in the health literature. Although the physical conditions of solitary confinement vary across and within jurisdictions, it generally refers to people being held in cells for 22–24 hours a day, with little or no contact with others. The United Nations Standard Minimum Rules for the Treatment of Prisoners, known as the Nelson Mandela Rules, prohibit prolonged solitary confinement (rule 43.1b), defined as exceeding 15 consecutive days.2UN General AssemblyUnited Nations standard minimum rules for the treatment of prisoners (the Nelson Mandela rules).https://www.unodc.org/documents/justice-and-prison-reform/Nelson_Mandela_Rules-E-ebook.pdfDate: 2015Date accessed: January 6, 2020Google Scholar A growing body of research is shaping our understanding of the acute physical, psychological, and emotional effects of solitary confinement at the individual and population levels.3WHOPrisons and health. World Health Organization, Geneva2014Google Scholar, 4Cloud DH Drucker E Browne A Parsons J Public health and solitary confinement in the United States.Am J Public Health. 2015; 105: 18-26Crossref PubMed Scopus (63) Google Scholar Currently, there is little research investigating the lasting effects of solitary confinement after people leave prison. Experience of solitary confinement during recent incarceration has been found to be associated with post-traumatic stress disorder symptoms after release5Hagan BO Wang EA Aminawung JA et al.History of solitary confinement is associated with post-traumatic stress disorder symptoms among individuals recently released from prison.J Urban Health. 2018; 95: 141-148Crossref PubMed Scopus (37) Google Scholar and with increased likelihood of reincarceration.6Brinkley-Rubinstein L Sivaraman J Rosen DL et al.Association of restrictive housing during incarceration with mortality after release.JAMA Netw Open. 2019; 2e1912516Crossref PubMed Scopus (34) Google Scholar In The Lancet Public Health, Christopher Wildeman and Lars Andersen make an important new contribution to this literature with their study examining the association between the experience of solitary confinement and mortality after release.7Wildeman C Andersen LH Solitary confinement placement and post-release mortality risk among formerly incarcerated individuals: a population-based study.Lancet Public Health. 2019; 5: e107-e113Summary Full Text Full Text PDF Scopus (30) Google Scholar In their study, Wildeman and Andersen used data from Danish administrative registers and from the Danish Prison and Probation Service to examine the records of all 13 776 people who served a prison sentence in Denmark that started and ended in 2006–11.7Wildeman C Andersen LH Solitary confinement placement and post-release mortality risk among formerly incarcerated individuals: a population-based study.Lancet Public Health. 2019; 5: e107-e113Summary Full Text Full Text PDF Scopus (30) Google Scholar The authors followed each person for up to 5 years after release. A higher proportion of people who had been placed in solitary confinement (4·5%) than of people who had not been placed in solitary confinement (2·8%) died during this follow-up period (p<0·0001). Statistical analyses showed that those who had been placed in solitary confinement versus those who hadn't were more likely to die during the 5 years after release (hazard ratio for death by any cause 1·599, 95% CI 1·268–2·017). They found that this difference was largely driven by non-natural deaths which were higher among those who had been placed in solitary confinement. The authors note substantial differences between those who experienced solitary confinement and those who did not. Those who were placed in solitary confinement were younger, had lower educational attainment, were more likely to be identified as having a background that is an ethnic minority in Denmark, and served longer sentences and a higher proportion of them were convicted of violent crimes and held in high security facilities. The authors found that controlling for these covariates strengthened the association between solitary confinement, all-cause mortality, and mortality from unnatural causes. These findings are corroborated by a recent study by Brinkley-Rubinstein and colleagues, who found an association between solitary confinement and increased risk of all-cause mortality, suicide, homicide and opioid-related overdose after release from prison in North Carolina, USA.6Brinkley-Rubinstein L Sivaraman J Rosen DL et al.Association of restrictive housing during incarceration with mortality after release.JAMA Netw Open. 2019; 2e1912516Crossref PubMed Scopus (34) Google Scholar Additionally, Brinkley-Rubinstein and colleagues reported a dose–response relationship; individuals with multiple exposures to solitary confinement (two or more episodes) and those who experienced longer episodes (more than 14 days) had elevated risk of all-cause mortality, suicide, and homicide in the first year after release. In this study, most (68%) of episodes of solitary confinement lasted more than 14 days. By contrast, Wildeman and Andersen's study showed that even short exposure to solitary confinement is a marker of increased risk of mortality.7Wildeman C Andersen LH Solitary confinement placement and post-release mortality risk among formerly incarcerated individuals: a population-based study.Lancet Public Health. 2019; 5: e107-e113Summary Full Text Full Text PDF Scopus (30) Google Scholar They reported that 1662 (12%) of 13 776 people experienced solitary confinement during the incarceration included in their study and the median time spent in solitary confinement was 5 days. Most people (75%) experienced solitary confinement once during their sentence, and 93% once or twice. This study's results should be cause for concern in jurisdictions which use solitary confinement both more frequently and for longer periods of time (months or even years). Although the authors are rightly cautious in their interpretation and do not suggest that a causal determination can be made from these data, the association between relatively little exposure to solitary confinement and increased risk of death indicates an urgent need for further research into the effects of the conditions of confinement on outcomes after release. This study also highlights gaps in our understanding about the use and experience of solitary confinement in other settings. Globally, millions of people are incarcerated8Walmsley R World Prison Population List. Institute for Criminal Policy Research, University of London, London2018http://www.prisonstudies.org/sites/default/files/resources/downloads/wppl_12.pdfDate accessed: January 6, 2020Google Scholar for much longer periods of time than are common in the Danish model. This study's sobering results highlight the need for more research to understand the use and effects of solitary confinement as well as the mechanisms through which solitary confinement might affect health and wellness in the short and long term. We declare no competing interests. Solitary confinement placement and post-release mortality risk among formerly incarcerated individuals: a population-based studyThe results from these analyses indicate that solitary confinement placement might be a key moderator of the association between a history of incarceration and post-release outcomes. Our findings suggest that incarcerated individuals ever placed in solitary confinement are a vulnerable population in need of interventions. Full-Text PDF Open Access

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