Association of Restrictive Housing During Incarceration With Mortality After Release [2019]

Question Is restrictive housing, otherwise known as solitary confinement, during incarceration associated with an increased risk of mortality after release into the community?

Findings This cohort study included 229 274 people who were released from incarceration in North Carolina from 2000 to 2015. Compared with individuals who were incarcerated and not placed in restrictive housing, individuals who spent any time in restrictive housing were 24% more likely to die in the first year after release, especially from suicide (78% more likely) and homicide (54% more likely); they were also 127% more likely to die of an opioid overdose in the first 2 weeks after release.

Meaning The results of this study suggest that exposure to restrictive housing as a condition of confinement is associated with an increased risk of death during community reentry.

Abstract
Importance Restrictive housing, otherwise known as solitary confinement, during incarceration is associated with poor health outcomes.

Objective To characterize the association of restrictive housing with reincarceration and mortality after release.

Design, Setting, and Participants This retrospective cohort study included 229 274 individuals who were incarcerated and released from the North Carolina prison system from January 2000 to December 2015. Incarceration data were matched with death records from January 2000 to December 2016. Covariates included age, number of prior incarcerations, type of conviction, mental health treatment recommended or received, number of days served in the most recent sentence, sex, and race. Data analysis was conducted from August 2018 to May 2019.

Exposures Restrictive housing during incarceration.

Main Outcomes and Measures Mortality (all-cause, opioid overdose, homicide, and suicide) and reincarceration.

Results From 2000 to 2015, 229 274 people (197 656 [86.2%] men; 92 677 [40.4%] white individuals; median [interquartile range (IQR)] age, 32 years [26-42]), were released 398 158 times from the state prison system in North Carolina. Those who spent time in restrictive housing had a median (IQR) age of 30 (24-38) years and a median (IQR) sentence length of 382 (180-1010) days; 84 272 (90.3%) were men, and 59 482 (63.7%) were nonwhite individuals. During 130 551 of 387 913 incarcerations (33.7%) people were placed in restrictive housing. Compared with individuals who were incarcerated and not placed in restrictive housing, those who spent any time in restrictive housing were more likely to die in the first year after release (hazard ratio [HR], 1.24; 95% CI 1.12-1.38), especially from suicide (HR, 1.78; 95% CI, 1.19-2.67) and homicide (HR, 1.54; 95% CI, 1.24-1.91). They were also more likely to die of an opioid overdose in the first 2 weeks after release (HR, 2.27; 95% CI, 1.16-4.43) and to become reincarcerated (HR, 2.16; 95% CI, 1.99-2.34).

Conclusions and Relevance This study suggests that exposure to restrictive housing is associated with an increased risk of death during community reentry. These findings are important in the context of ongoing debates about the harms of restrictive housing, indicating a need to find alternatives to its use and flagging restrictive housing as an important risk factor during community reentry.

Lauren Brinkley-Rubinstein, PhD; Josie Sivaraman, MSPH; David L. Rosen, PhD, MD; David H. Cloud, JD, MPH; Gary Junker, PhD; Scott Proescholdbell, MPH; Meghan E. Shanahan, PhD; Shabbar I. Ranapurwala, PhD
JAMA Network Open. 2019;2(10)
DOI: 10.1001/jamanetworkopen.2019.12516
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