The body in isolation: The physical health impacts of incarceration in solitary confinement

Longitudinal changes in depression and anxiety during the COVID-19 pandemic and the impact of COVID-related factors

OBJECTIVE

This study is an investigation of five specific COVID-related stressors and their longitudinal impact on adult depression and anxiety.

METHOD

A total of 592 adults comprised the initial sample at Time 1 in April/May 2020. Follow-ups were conducted about a month later, again in March 2021 and then in March 2022.

RESULTS

Applied linear mixed effect models showed a significant decrease in mean depression scores and anxiety scores from Time 1 to both Times 3 and 4. Neither change over time in anxiety or depression were found to be related to COVID diagnosis, COVID hospitalization, or COVID death. Self-quarantine was related to changes over time in both depression and anxiety, and household quarantine was related to changes over time in depression.

CONCLUSION

While the fallout of the pandemic continues, it is important to understand how these factors may be affecting mental health to better understand where intervention is necessary.

The Impact of the COVID-19 Pandemic and a Physical Therapy Program on Students' Health Outcomes

The COVID-19 pandemic affected many aspects of everyday life including school, fitness regimens, and social interactions. The purpose of this study is to understand how COVID-19 restrictions affect the cardiovascular and mental health of Doctor of Physical Therapy (DPT) students as they progressed through the program. Data collection occurred in 16 DPT students (8F:8M, 24±3 years) over a total of 3 visits from 2020 to 2022, during high, moderate, and low COVID-19 restrictions. Outcome measures included VO2max, Venous Occlusion Plethysmography (VOP), %fat mass measured via DEXA, Perceived Stress Scale (PSS) and International Physical Activity Questionnaire (IPAQ). A RM-ANOVA with pairwise comparisons was utilized. Significance was set prior at an α level of 0.05. There was a significant increase (p<0.05) from visit 1 to 2 in VO2max, VOP baseline, BMI, and METs. There was a significant decrease (p<0.05) from visit 2 to 3 in VO2max. Finally, a significant increase in visit 3 was seen from visit 2 in VOP peak. Overall, there was no significant difference observed for PSS and %fat mass (p>0.05). Between high and moderate restrictions, there was an increase in VO2max, VOP baseline, and METs. However, between moderate and low restrictions, only VOP Peak increased. This could be attributed to gyms being closed and limiting the type of physical activity a person could do to exercises like running or walking. When restrictions were lifted, traveling to and from classes, traveling to gyms, and socializing all increased, limiting the time for physical activity.

Reimbursing incarcerated individuals for participation in research: A scoping review

BACKGROUND

Little is known about global practices regarding the provision of reimbursement for the participation of people who are incarcerated in research. To determine current practices related to the reimbursement of incarcerated populations for research, we aimed to describe international variations in practice across countries and carceral environments to help inform the development of more consistent and equitable practices.

METHODS

We conducted a scoping review by searching PubMed, Cochrane library, Medline, and Embase, and conducted a grey literature search for English- and French-language articles published until September 30, 2022. All studies evaluating any carceral-based research were included if recruitment of incarcerated participants occurred inside any non-juvenile carceral setting; we excluded studies if recruitment occurred exclusively following release. Where studies failed to indicate the presence or absence of reimbursement, we assumed none was provided.

RESULTS

A total of 4,328 unique articles were identified, 2,765 were eligible for full text review, and 426 were included. Of these, 295 (69%) did not offer reimbursement to incarcerated individuals. A minority (n = 13; 4%) included reasons explaining the absence of reimbursement, primarily government-level policies (n = 7). Among the 131 (31%) studies that provided reimbursement, the most common form was monetary compensation (n = 122; 93%); five studies (4%) offered possible reduced sentencing. Reimbursement ranged between $3-610 USD in total and 14 studies (11%) explained the reason behind the reimbursements, primarily researchers' discretion (n = 9).

CONCLUSIONS

The majority of research conducted to date in carceral settings globally has not reimbursed incarcerated participants. Increased transparency regarding reimbursement (or lack thereof) is needed as part of all carceral research and advocacy efforts are required to change policies prohibiting reimbursement of incarcerated individuals. Future work is needed to co-create international standards for the equitable reimbursement of incarcerated populations in research, incorporating the voices of people with lived and living experience of incarceration.

Gender differences in oral health among prisoners: a cross-sectional study from Taiwan

BACKGROUND

The prevalence of oral diseases among Taiwanese prisoners has rarely been investigated. This study aimed to estimate the gender-specific prevalence of oral disease in a sample of Taiwanese prisoners.

METHODS

We included 83,048 participants from the National Health Insurance (NHI) Program. Outcomes were measured using the clinical version of the International Classification of Diseases, Ninth Revision (ICD-9-CM). For prevalence, we provide absolute values and percentages. We also performed a χ2 test to assess sex and age group differences in the percentage of disease in the oral cavity, salivary glands, and jaw.

RESULTS

The prevalence rate of oral diseases was 25.90%, which was higher than that of the general population. The prevalence of oral diseases in female prisoners was higher than that in male prisoners (p < 0.001), and the prevalence of oral diseases in prisoners aged ≤ 40 was higher than that of prisoners aged > 40. Among all cases of diagnosed oral diseases, the top three diseases were dental hard tissue diseases (13.28%), other cellulitis and abscesses (9.79%), and pruritus and related conditions (2.88%), respectively. The prevalence of various oral diseases in female prisoners was significantly higher than that in male prisoners.

CONCLUSION

Oral disease is common among Taiwanese prisoners. Female prisoners had a higher prevalence of oral, salivary gland, and jaw diseases than male prisoners. Therefore, early prevention and appropriate treatment are required and also a need for gender-specific oral disease products given the differences in the prevalence of oral disease among male and female prisoners.

Medical Mismanagement in Southern US Immigration and Customs Enforcement Detention Facilities: A Thematic Analysis of Secondary Medical Records

Detention facilities in the southern US hold a large percentage of individuals detained in the US and have amassed numerous reports of medical mismanagement. The purpose of this study was to evaluate expert declarations of individuals residing in these facilities to assess the appropriateness of medical care provided. We analyzed 38 medical expert declarations from individuals in detention from 2020 to 2021. A thematic analysis was conducted to explore the management of medical conditions. Major themes include inadequate workup, management and treatment of medical conditions, psychiatric conditions, and medical symptoms. Subthemes identified include incorrect workup, failure to refer to a specialist, incorrect medications and/or treatments, missed or incorrect diagnoses, and exacerbation of chronic conditions. This study supports growing evidence of medical mismanagement and neglect of individuals while in immigration detention. Enhanced oversight and accountability around medical care in these facilities is critical to ensure the quality of medical care delivered meets the standard of care.

Palliating in Avoidable Death: Reconciling Psychiatrists' Roles as Treaters on Death Row With Participation in a System of Overt Harm

ABSTRACT

Although nations across the globe have eliminated capital punishment, the United States remains one of the few countries in the Americas and Europe that still uses execution. There has been little discussion around the implications of psychiatry's involvement in providing care to incarcerated individuals awaiting death. The following perspective examines the United States as an example of a democratic and highly developed country where the death penalty remains an undeniable reality; the piece provides a brief discussion on psychiatry's relationship with end-of-life care to provide context for subsequent discussion on the role of the psychiatrist on death row in the United States. Medicolegal and ethical considerations are further outlined to identify specific concessions that might be made by the US criminal justice system to truly allow death row psychiatrists to practice to the highest standard of compassionate care.

Evaluation of a prison violence prevention program: impacts on violent and non-violent prison infractions

BACKGROUND

Individuals who commit acts of violence in prisons are often placed in highly controlled environments called restrictive housing (i.e., solitary confinement), which can have severe physical and mental health consequences and does not reduce violence. As such, North Carolina prisons have introduced the rehabilitative diversion unit (RDU) to reduce the use of restrictive housing and reduce violence in prison.

METHODS

We evaluated the effect of the RDU on prison infractions. We compared rates of infractions by type (including violent infractions) among men enrolled in the RDU and men who were eligible for the RDU but placed in restrictive housing for control purposes (RHCP). We also evaluated sustained program impacts by comparing the hazard of first infraction among these same two groups of men after program completion, when they had returned to the general prison population. Finally, we compared the hazard of first promotion to a less restrictive custody level (medium custody) when these men had returned to the general prison population.

RESULTS

The primary analytic cohort was made up of 3128 men contributing 897,822 person-days. Adjusted rates of violent infractions were lower in the RDU than in RHCP (adjusted rate ratio: 0.6; 95% CI: 0.4, 1.1). All other categories of infractions, including drug-related infractions, occurred at higher rates during RDU, as compared to RHCP. In analyses of sustained program impacts, for most categories of infractions, there were no differences in the hazard of first infraction post-RDU and post-RHCP. However, the hazard of violent infraction post-RDU was higher (adjusted hazard ratio: 2.1; 95% CI: 1.1, 4.0) than post-RHCP. The hazard of promotion to a less restrictive custody level was higher post-RDU (adjusted hazard ratio: 17.4; 95% CI: 7.2, 42.2) than post-RHCP.

CONCLUSIONS

We found the RDU program may be effective in reducing violence for men enrolled in the program, but that these benefits were not sustained. Continued programming may be a useful tool to transition men from the programmatically intensive environment of the RDU to the general prison population. Additionally, we recommend the expansion of evidence-based treatment for substance use disorder.

Nowhere Else to Go-Solitary Confinement as Mental Health Care

This Viewpoint examines the clinical, ethical, and legal concerns of the use of solitary confinement to manage acute psychiatric distress among incarcerated people.

'Cocooning' in prison during COVID-19: Findings from recent research in Ireland

The advent of COVID-19 prompted the enforced isolation of elderly and vulnerable populations around the world, for their own safety. For people in prison, these restrictions risked compounding the isolation and harm they experienced. At the same time, the pandemic created barriers to prison oversight when it was most needed to ensure that the state upheld the rights and wellbeing of those in custody. This article reports findings from a unique collaboration in Ireland between the Office of the Inspector of Prisons - a national prison oversight body - and academic criminologists. Early in the pandemic, they cooperated to hear the voices of people 'cocooning' - isolated because of their advanced age or a medical vulnerability - in Irish prisons by providing journals to this cohort, analysing the data, and encouraging the Irish Prison Service to change practices accordingly. The findings indicated that 'cocooners' were initially ambivalent about these new restrictions, both experiencing them as a punishment akin to solitary confinement, and understanding the goal of protection. As time passed, however, participants reported a drastic impact on their mental and physical health, and implications for their (already limited) agency and relationships with others, experienced more or less severely depending on staff and management practices. The paper also discusses the implications for prison practices during and following the pandemic, understanding isolation in the penological context, and collaboration between prison oversight bodies and academics.

Self-injury and the embodiment of solitary confinement among adult men in Louisiana prisons

Solitary confinement is a harrowing human rights and public health problem that is currently inflicted as a routine punishment for a litany of prison rule violations, a reactionary tactic to quell resistance to prison conditions, and as a destination of last resort for people serious mental illnesses (SMI) who are especially vulnerable to its harms. An extensive body of research has documented clusters of psychiatric symptoms-emotional distress, cognitive deficits, social withdrawal, anxiety, paranoia, sleeplessness, and hallucinations-linked to solitary confinement that often manifest in decompensating behaviors, which include self-injury and suicide. This study summarizes the historical evolution of solitary confinement, recaps its linkages to self-injury and suicidality, and offers a theoretical framework grounded in ecosocial theory, and supplemented with concepts from theories of dehumanization and carceral geography. Findings bolster extant evidence on the harms of solitary confinement by focusing on whether and how exertions of power by prison staff to deploy mechanisms of dehumanization-as a pathway between SMI and self-injury among a cross section of adult men (n = 517) exposed to solitary confinement in Louisiana prisons in 2017. Findings reinforce the need for structural interventions that diffuse forms of carceral power and practices that continue to subject people to isolation, dehumanization, and violence.

Disparities in use of disciplinary solitary confinement by mental health diagnosis, race, sexual orientation and sex: Results from a national survey in the United States of America

BACKGROUND

Solitary confinement is still used in prisons in the USA, despite its links to poor health. Past research suggests that there may be disparities by race, ethnicity, sex and mental disorders regarding who is placed in solitary confinement, although nationwide studies have been sparse.

AIMS

To explore possible disparities by race, ethnicity, sex, sexual orientation, adverse childhood experiences and mental disorders in solitary confinement as a disciplinary action for adults incarcerated in USA prisons.

METHODS

Data come from a recently released national survey of 24,848 adults incarcerated in the USA-the 2016 Survey of Prison Inmates. Logistic regression models were used to identify disparities in the use of disciplinary action and solitary confinement as a disciplinary action, while controlling for type of rule violation.

RESULTS

After controlling for rule violation type, solitary confinement was used as a disciplinary action at higher rates for people who: were multiracial, as compared to white (aOR = 1.30), male, as compared to female (aOR = 1.46), bisexual, as compared to heterosexual (aOR = 1.64), had multiple mental disorders, as compared to none (aOR = 1.22) or had more adverse childhood experiences (aOR = 1.13).

CONCLUSIONS

Findings highlight demographic and health disparities in the use of solitary confinement, which may further widen health disparities. More effective implementation of policies to reduce the use of solitary confinement are still needed. Mental health professionals should have an active role in advising on measures when mental disorder is a factor and must ensure adequate treatment of disorders in prison or transfer to health facilities.

Triaged out of Care: How Carceral Logics Complicate a ‘Course of Care’ in Solitary Confinement

Incarceration, along with its most restrictive iteration, solitary confinement, is an increasingly common experience in America. More than two million Americans are currently incarcerated, and at least one-fifth of incarcerated people will experience solitary confinement. Understanding the barriers to care people experience in prison, and especially in solitary confinement, is key to improving their access to care during and after incarceration. Drawing on in-depth qualitative interviews with a random sample of 106 people living in solitary confinement and a convenience sample of 77 people working in solitary confinement in Washington State, we identify two key barriers to care that people in solitary confinement face: cultural barriers (assumptions that incarcerated people do not need or do not deserve care) and structural barriers (physical spaces and policies that make contacting a healthcare provider difficult). While scholarship has documented both the negative health consequences of solitary confinement and correctional healthcare providers’ challenges navigating between the “dual loyalty” of patient care and security missions, especially within solitary confinement, few have documented the specific mechanisms by which people in solitary confinement are repeatedly triaged out of healthcare access. Understanding these barriers to care is critical not only to improving correctional healthcare delivery but also to improving healthcare access for millions of formerly incarcerated people who have likely had negative experiences seeking healthcare in prison, especially if they were in solitary confinement.

Losing Years Doing Time: Incarceration Exposure and Accelerated Biological Aging among African American Adults

Research suggests that incarceration exposure increases the prevalence of morbidity and premature mortality. This work is only beginning to examine whether the stressors of the incarceration experience become biologically embedded in ways that affect physiological deterioration. Using data from a longitudinal sample of 410 African American adults in the Family and Community Health Study and an epigenetic index of aging, this study tests the extent to which incarceration accelerates epigenetic aging and whether experiences with violence moderate this association. Results from models that adjust for selection effects suggest that incarceration exposure predicted accelerated aging, leaving formerly incarcerated African American individuals biologically older than their calendar age. Direct experiences with violence also exacerbated the effects of incarceration. These findings suggest that incarceration possibly triggers a stress response that affects a biological signature of physiological deterioration.

The population prevalence of solitary confinement

Solitary confinement is a severe form of incarceration closely associated with long-lasting psychological harm and poor post-release outcomes. Estimating the population prevalence, we find that 11% of all black men in Pennsylvania, born 1986 to 1989, were incarcerated in solitary confinement by age 32. Reflecting large racial disparities, the population prevalence is only 3.4% for Latinos and 1.4% for white men. About 9% of black men in the state cohort were held in solitary for more than 15 consecutive days, violating the United Nations standards for minimum treatment of incarcerated people. Nearly 1 in 100 black men experienced solitary for a year or longer by age 32. Racial disparities are similar for women, but rates are lower. A decomposition shows that black men’s high risk of solitary confinement stems primarily from their high imprisonment rate. Findings suggest that harsh conditions of U.S. incarceration have population-level effects on black men’s well-being.

"We just needed to open the door": a case study of the quest to end solitary confinement in North Dakota

Solitary confinement is a widespread practice in US correctional facilities. Long-standing concerns about the physical and mental health effects of solitary confinement have led to litigation, legislation, and community activism resulting in many prison systems introducing policies or implementing legal mandates to reduce or eliminate its use. Yet little is known about the nature and effectiveness of policies that states have adopted to reduce their use of solitary confinement and exactly how various reforms have actually impacted the lives of people living and working in the prisons where these reforms have taken place.

METHODS

We conducted an embedded case study, analyzing changes in policies and procedures, administrative data, and focus groups and interviews with incarcerated persons and staff, to describe the circumstances that led to changes in solitary confinement policies and practices in the North Dakota Department of Corrections and Rehabilitation (ND DOCR) and the perceived impact of these changes on incarcerated persons and prison staff. .

RESULTS

North Dakota's correctional officials and staff members attributed the impetus to change their solitary confinement policies to their participation in a program that directly exposed them to the Norwegian Correctional Service's philosophy, policies, and practices in 2015. The ensuing policy changes made by North Dakota officials were swift and resulted in a 74.28% reduction in the use of solitary confinement between 2016 and 2020. Additionally, placements in any form of restrictive housing decreased markedly for incarcerated persons with serious mental illness. In the two prisons that had solitary confinement units, rule infractions involving violence decreased at one prison overall and it decreased within the units at both prisons that were previously used for solitary confinement. Although fights and assaults between incarcerated people increased in one of the prison's general population units, during the initial months of reforms, these events continued to decline compared to years before reform. Moreover, incarcerated people and staff attributed the rise to a concomitant worsening of conditions in the general population due to overcrowding, idleness, and double bunking. Both incarcerated persons and staff members reported improvements in their health and well-being, enhanced interactions with one another, and less exposure to violence following the reforms.

CONCLUSIONS

Immersing correctional leaders in the Norwegian Correctional Service' public health and human rights principles motivated and guided the ND DOCR to pursue policy changes to decrease the use of solitary confinement in their prisons. Ensuing reductions in solitary confinement were experienced as beneficial to the health and wellness of incarcerated persons and staff alike. This case-study describes these policy changes and the perspectives of staff and incarcerated persons about the reforms that were undertaken. Findings have implications for stakeholders seeking to reduce their use of solitary confinement and limit its harmful consequences and underscore the need for research to describe and assess the impact of solitary confinement reforms.

COVID-19 in corrections: Quarantine of incarcerated people

Carceral settings in the United States have been the source of many single site COVID-19 outbreaks. Quarantine is a strategy used to mitigate the spread of COVID-19 in correctional settings, and specific quarantine practices differ state to state. To better understand how states are using quarantine in prisons, we reviewed each state's definition of quarantine and compared each state's definition to the Centers for Disease Control's (CDC) definition and recommendations for quarantine in jails and prisons. Most prison systems, 45 of 53, define quarantine, but definitions vary widely. No state published definitions of quarantine that align with all CDC recommendations, and only 9 states provide quarantine data. In these states, the highest recorded quarantine rate occurred in Ohio in May 2020 at 843 per 1,000. It is necessary for prison systems to standardize their definitions of quarantine and to utilize quarantine practices in accordance with CDC recommendations. In addition, data transparency is needed to better understand the use of quarantine and its effectiveness at mitigating COVID-19 outbreaks in carceral settings.

Reforming solitary confinement: the development, implementation, and processes of a restrictive housing step down reentry program in Oregon

BACKGROUND

Over the past decade there have been numerous and impassioned calls to reform the practice of solitary confinement in U.S. prisons. This article examines the development, implementation, and processes of a restrictive housing reentry program in the Oregon Department of Corrections. It draws on data from official documents, site observations, and interviews with 12 prison officials and 38 prisoners. The Step Up Program (SUP) seeks to improve the living conditions in restrictive housing over business-as-usual, alleviate physiological and psychological harms of solitary confinement, and use rehabilitative programming to increase success upon returning to the general prison population or community.

RESULTS

The impetus to change the culture and structure of restrictive housing was primarily the result of internal administrative reform. Prisoners assigned at random to housing assignments offered accounts of their daily activities suggesting that the SUP provides more time out-of-cell and greater access to other services and activities. Program participants preferred the living conditions in the SUP because they had more opportunities for social interaction and incentives for compliant behavior. However, views on the value of programming among respondents were mixed.

CONCLUSIONS

The launch of the SUP occurred in early 2020, which was soon followed by the COVID-19 pandemic. As a result, the program was never fully implemented as intended. As Oregon returns to more normal operations, it is possible that the SUP will be able to include even more out-of-cell time, greater socialization opportunities, and increased access to programming and other beneficial activities. As we await the opportunity to conduct prospective psychological and behavioral analyses, this study provides tentative support for the use of step down reentry programs in restrictive housing units.

TRIAL REGISTRATION

Open Science Framework, Preparing adults in custody for successful reentry: An experimental study of a restrictive housing exit program in Oregon. Registered 4 October 2019, https://osf.io/t6qpx/.

Window dressing: possibilities and limitations of incremental changes in solitary confinement

BACKGROUND

In light of mounting evidence of the physical and psychological harms associated with solitary confinement, many correctional systems, state legislators, courts, and even international human rights bodies are increasingly recommending and implementing reforms to mitigate the harms of solitary confinement, if not abolish the practice entirely. In this piece, we examine three specific infrastructural changes to solitary confinement conditions and practices implemented in Washington state prisons with such harm minimization goals in mind: (1) building so-called "nature imagery rooms" to play videos of outdoor spaces, (2) eliminating punishments for self-harm, and (3) conducting daily cell-front wellness checks.

RESULTS

Drawing on 183 in-depth qualitative interviews with both staff working in and people imprisoned in solitary confinement units conducted in Washington state restrictive housing units in 2017, we find that these three reforms not only resulted in limited successes but also generated new conflicts. Institutional logics such as deprivation, risk-management, and responsibilization ultimately impeded even the most modest attempts to mitigate the inherently harsh practice of solitary confinement. The limits of these reforms are due in part to individual choices made by people imprisoned in solitary confinement and staff working in these units, as well as the larger cultural norms that shape life in restrictive housing units.

CONCLUSIONS

Incrementalist reforms aimed at softening the environment of solitary confinement may actually serve to increase the strain and stress experienced by people confined to and working within them. Even the most well-intentioned reforms, like those attempted by the Washington DOC, should be scrutinized in order to determine if they are producing the desired outcomes, or instead, reproducing a different, but nonetheless damaging set of harms to people imprisoned in solitary confinement. Further, even well-intentioned reforms are often stymied by the underlying institutional logics of restrictive housing spaces.