Original Investigation | Public Health

Association of Restrictive Housing During Incarceration
With Mortality After Release
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

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.

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

DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included 229 274

Findings This cohort study included

individuals who were incarcerated and released from the North Carolina prison system from January

229 274 people who were released from

2000 to December 2015. Incarceration data were matched with death records from January 2000

incarceration in North Carolina from

to December 2016. Covariates included age, number of prior incarcerations, type of conviction,

2000 to 2015. Compared with

mental health treatment recommended or received, number of days served in the most recent

individuals who were incarcerated and

sentence, sex, and race. Data analysis was conducted from August 2018 to May 2019.

not placed in restrictive housing,
individuals who spent any time in

EXPOSURES Restrictive housing during incarceration.

restrictive housing were 24% more likely
to die in the first year after release,

MAIN OUTCOMES AND MEASURES Mortality (all-cause, opioid overdose, homicide, and suicide)

especially from suicide (78% more

and reincarceration.

likely) and homicide (54% more likely);
they were also 127% more likely to die of

RESULTS From 2000 to 2015, 229 274 people (197 656 [86.2%] men; 92 677 [40.4%] white

an opioid overdose in the first 2 weeks

individuals; median [interquartile range (IQR)] age, 32 years [26-42]), were released 398 158 times

after release.

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

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.

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, 1.241.91). 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).

+ Supplemental content
Author affiliations and article information are
listed at the end of this article.

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.
JAMA Network Open. 2019;2(10):e1912516. doi:10.1001/jamanetworkopen.2019.12516

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Introduction
Risk of death after incarceration is high.1,2 A study in Washington found that, in the first 2 weeks after
release, the risk of death among those who had been recently incarcerated was 12.7-fold that of their
nonincarcerated counterparts. Similarly, a recent North Carolina study found that, 1 year after release
from prison, people who were recently incarcerated were 40 times as likely to die of an opioid
overdose as their nonincarcerated peers.3 Social and economic instability attributable to poor access
to housing, employment, and health care likely contribute to increased risk of death during
community reentry.4,5 However, while the associations of incarceration with instability and mortality
after release have been drawn, little is known about how the conditions of confinement during
incarceration may be associated with mortality risk.
Restrictive housing, more commonly referred to as solitary confinement or segregation, is
defined as the practice of isolating individuals who are incarcerated in small cells for 22 to 24 hours a
day. People housed in these settings are exposed to social isolation, sensory deprivation, and physical
idleness. Additionally, these individuals have less access to programming, visitation, and other
privileges available to the general population. Correctional systems typically use restrictive housing
for disciplinary purposes (eg, when someone breaks a rule) or for administrative purposes (eg, to
isolate someone who may otherwise be at risk of experiencing or committing violence). In 2017, data
from 43 prison systems accounting for 81% of the imprisoned population in the United States
demonstrated that an average of approximately 4.5% of people who were incarcerated were also in
restrictive housing.6 Of these 43 prison systems, 30 tracked length of stay, reporting that most
individuals spent less than a year in restrictive housing settings; however, 25 systems reported that
more than 3500 people were held for more than 3 years, 67% of whom had been in restrictive
housing for more than 6 years.6 In 2015, the United Nations revised the Standard Minimum Rules on
the Treatment of Prisoners to include the Mandela Rules, which for the first time clearly defined
restrictive housing and provided guidelines on its use.7 Specifically, the rules call for an end to
prolonged restrictive housing, defined as a period of more than 14 days.7
Correctional systems rely on restrictive housing as a punishment for violating prison rules and
as a security measure, claiming that it provides protection and safety for those who may be unsafe if
housed with the general incarcerated population. However, reliance on restrictive housing is not
without risks. A growing body of literature has documented the association of restrictive housing
with the health of people who have been incarcerated.8-11 Individuals with mental illness are
overrepresented in most restrictive housing units. These individuals are particularly susceptible to
psychological deterioration while isolated in restrictive housing, which can manifest as reclusiveness,
social withdrawal, psychosis, self-harm, posttraumatic stress disorder, and suicide.12-14 However, to
our knowledge, no study has examined the association of restrictive housing with mortality after
release. We address this gap with the current study by examining how restrictive housing was
associated with mortality after release, including all-cause mortality, opioid overdose death,
homicide, and suicide, and reincarceration in North Carolina between 2000 and 2016. In addition,
we examined the association of mortality with the following: (1) repeated restrictive housing stays,
(2) time spent in restrictive housing using the Mandela Rules guidelines, and (3) the effect measure
modification in these associations by race, given the racial disparities in incarceration rates in the
United States.

Methods
Study Design and Population
We conducted a retrospective cohort study to assess the association of restrictive housing with
mortality after release among individuals who were incarcerated in the North Carolina state prison
system from January 1, 2000, to December 31, 2015. Prison release data were obtained from the
North Carolina Department of Public Safety (NCDPS). The NCDPS data were linked to publicly

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Restrictive Housing During Incarceration and Mortality After Release

available North Carolina death records from January 1, 2000, to December 31, 2016. Person-time was
calculated from the day of release from prison until death, reincarceration, or the end of 2016.
Individuals who remained incarcerated throughout the study period, who died prior to release
(n = 59), or who died on the day of release (n = 959) did not contribute person-time and were
therefore excluded from the study. This is because, in most cases, when a death occurs in prison, the
individual’s record is marked with a release on the same day. The linkage, accrual of person-time, and
the sample have been described previously.3 The institutional review boards of the NCDPS and the
University of North Carolina at Chapel Hill approved this study, including a waiver for informed
consent because of the secondary nature of the data. All analyses were conducted between August
2018 and May 2019, and this study followed the Strengthening the Reporting of Observational
Studies in Epidemiology (STROBE) reporting guideline.

Exposure and Outcome Definitions
We considered 3 measures of restrictive housing, as follows: (1) the exposure of interest, a binary
measure (ie, yes or no) of being placed in restrictive housing during an incarceration, (2) the number
of restrictive housing placements during an incarceration (ie, 0, 1-2, >2), and (3) the amount of time
spent in restrictive housing during an incarceration (ie, 0 days, >0 to 14 days, >14 days) based on the
Mandela Rules.7
We examined 4 postrelease mortality outcomes, as follows: (1) all-cause death, (2) opioid
overdose death, (3) homicide death, and (4) suicide death. Because reincarceration was a significant
competing risk for these outcomes, we also examined its association with restrictive housing to
better contextualize the results. Mortality outcomes were examined in the linked NCDPS death
records data. A binary variable was created for each of the mortality outcomes. All-cause and causespecific death diagnoses were defined using the International Statistical Classification of Diseases
and Related Health Problems, Tenth Revision (ICD-10) codes from the North Carolina death records.
An opioid overdose death was identified using ICD-10 code T40.0 (opium), T40.1 (heroin), T40.2
(other opioids, commonly prescribed opioids), and T40.4 (other synthetic narcotics, commonly
fentanyl or its analogs). Homicide death was identified using ICD-10 codes X85 to Y09 and Y87.1.
Suicide death was identified using ICD-10 codes X60 to X84 and Y87.0. All outcomes were examined
at 2 weeks, 1 year, and complete follow-up after release; 1-year mortality after release was the
primary outcome measure.

Covariates
Covariate information was obtained from the NCDPS data. To identify potential covariates to control
for confounding in this study, we developed a directed acyclic graph, which helped identify a
minimally sufficient set of well-measured covariates that controlled for all measured
confounding.15,16 The minimally sufficient set of covariates included time-varying age (ie, <25, 25-50,
>50 years), number of prior incarcerations (ie, 0, 1-2, >2), drug-related convictions (ie, yes or no),
violence-related convictions (ie, yes or no), mental health treatment recommended (ie, yes or no),
mental health treatment received (ie, yes or no), quartiles of number of days served in the most
recent sentence (ie, <87, 87-177, 178-399, >399), and time-fixed sex (ie, male or female) and race (ie,
white or nonwhite). Drug-related conviction and violence-related conviction variables were
developed using cause of incarceration codes within the NCDPS data.

Statistical Analysis
We used Cox proportional hazard regression to examine the association of restrictive housing with
mortality after release, with the Lin, Wei, and Weissfeld17 robust variance estimator to account for
person-level clustering. To adjust for time-varying confounding, we used inverse probability of
exposure weighted marginal structural models.18-20 The inverse probability weights for restrictive
housing were calculated as follows: w = P of restrictive housing / P of restrictive housing | age,
number of prior incarcerations, drug-related conviction, violence-related conviction, mental health

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recommendation and treatment, and days served, where w indicates inverse probability weight and
P indicates probability.
The inverse probability weights were derived using logistic regression.18-20 Marginal structural
Cox proportional hazard models were then weighted along with adjustment for time-fixed sex and
race to estimate the adjusted hazard ratios (aHRs) and 95% CIs.18-20 Competing risks owing to
reincarceration and other causes of deaths were addressed by censoring the person-time at the time
of such events. An interaction term between exposure and race was added to examine raceassociated estimates, and aHRs, 95% CIs, and P for interaction from the regression models
were noted.
We conducted sensitivity analysis to examine the following: (1) the association of the percenttime spent in restrictive housing during an incarceration period with mortality after release and
reincarceration and (2) the outcomes of alternative statistical adjustment with a 5-category mental
health treatment recommendation based on an in-prison mental health screening inventory: no
intervention; outpatient intervention with psychologist or clinical social worker; outpatient
pharmacological intervention with psychiatrist, psychologist, or clinical social worker; long-term
residential and pharmacological intervention with psychiatrist, psychologist, or clinical social worker;
or acute inpatient intervention with psychiatrist, psychologist, or clinical social worker. All data
analyses were conducted using SAS version 9.4 (SAS Inc).

Results
Between January 1, 2000, and December 31, 2015, 229 274 people were released 398 158 times
from the state prison system in North Carolina; 197 656 (86.2%) were men, 92 677 (40.4%) were
white, and they had a median (interquartile range [IQR]) age of 32 years (26-42) years. However,
2094 people (0.9%) with 10 245 incarcerations (2.6%) who were missing restrictive housing
information and covariate information were excluded, leaving a final sample of 387 913 releases
(Table 1). More than one-third of the individuals (87 050 [38.0%]) were incarcerated multiple times
(range, 2-31). Overall, the 229 274 individuals included in the study accrued 1 974 823
nonincarcerated person-years during the 16-year study period. The median (IQR) time spent in prison
was 176 (86-395) days. Most people released had less than high school education (148 827 [65.2%]).
Individuals screened positive for substance use disorder in 268 893 of 387 913 incarcerations
(69.3%) and were recommended for mental health treatment at intake in 47 166
incarcerations (12.2%).

Characteristics of Those Who Were in Restrictive Housing
During 130 551 of 387 913 incarcerations (33.7%), people were placed in restrictive housing. In 59 476
incarcerations (15.3%), a person was placed in restrictive housing once, and in 71 075 incarcerations
(18.3%), a person was placed in restrictive housing 2 or more times. In 89 336 restrictive housing
episodes (68.4%), the duration of restrictive housing was for more than 14 days. Compared with
incarceration episodes during which people were not placed in restrictive housing, episodes with
restrictive housing involved individuals who were more likely to be younger (median [IQR] age, 34
[26-42] years vs 30 [24-38] years), to be male (113 384 [83.4%] vs 84 272 [90.3%]), to have had less
than a high school education (82 587 [61.0%] vs 66 240 [71.2%]), to have been recommended for
mental health treatment (27 427 [10.7%] vs 19 739 [15.1%]), to have received in-prison mental health
treatment (5927 [2.3%] vs 13 276 [10.2%]), to have had a violence-related conviction (39 869
[15.5%] vs 38 268 [29.3%]), and to have had longer sentences (median [IQR], 129 [71-238] days vs
382 [180-1010] days). Compared with incarceration episodes without restrictive housing,
incarceration episodes with restrictive housing included lower proportions of people with substance
use disorders (181 870 [70.7%] vs 87 023 [66.7%]) and people with drug-related convictions
(62 082 [24.1%] vs 23 270 [17.8%]) (Table 1).

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Mortality and Reincarceration Outcomes During the Study Period
A total 14 086 deaths occurred after release: 1321 (9.4%) opioid overdose deaths, 1461 (10.4%)
homicide deaths, and 635 (4.5%) suicide deaths (32 opioid overdose deaths were also suicides). In
addition, there were 178 032 reincarcerations from 2000 to 2016. Compared with individuals who
were incarcerated and not placed in restrictive housing, those who spent time in restrictive housing
were more likely to die in the first year after release of all causes (aHR, 1.24; 95% CI, 1.12-1.38),
especially from suicide (aHR, 1.78; 95% CI, 1.19-2.67) and homicide (aHR, 1.54; 95% CI, 1.24-1.91)
(Table 2). They were also more likely to die of an opioid overdose in the first 2 weeks after release
(aHR, 2.27; 95% CI, 1.16-4.43) and to become reincarcerated (aHR, 2.16; 95% CI, 1.99-2.34) (Figure).
We observed a dose-response for all-cause mortality, homicide, suicide, and reincarceration in
the first year after release: compared with individuals with no restrictive housing placements, those
with 2 or more restrictive housing placements had a greater risk of death or reincarceration (allcause mortality: aHR, 1.38; 95% CI, 1.14-1.66; homicide: aHR, 1.70; 95% CI, 1.20-2.40; suicide: aHR,

Table 1. Characteristics of Individuals Who Were Incarcerated by History
of Restricted Housing Exposure in North Carolina, 2000-2016
No. (%)
Characteristic

No Restrictive
Housing

Restrictive
Housing

Persons, No.

135 943

93 331

Incarcerations, No.

257 362

130 551

Person-Level Characteristicsa
Age, median (IQR), y

34 (26-42)

30 (24-38)

Men

113 384 (83.4)

84 272 (90.3)

White

58 828 (43.3)

33 849 (36.3)

Nonwhite

77 115 (56.7)

59 482 (63.7)

Marriedb

36 776 (14.3)

16 431 (12.6)

Mortality

9482 (7.0)

4604 (4.9)

Race/ethnicity

Opioid overdose

867 (0.6)

454 (0.5)

Homicide

702 (0.5)

759 (0.8)

Suicide

363 (0.3)

272 (0.3)

Did not complete high school

82 587 (61.0)

66 240 (71.2)

High school graduate
or completed GED

50 272 (37.2)

25 254 (27.1)

Some college

2437 (1.8)

1543 (1.7)

Educationc

Incarceration-Level Characteristicsd
Mental health treatment
recommendede

27 427 (10.7)

19 739 (15.1)

Mental health treatment
receivedf

5927 (2.3)

13 276 (10.2)

Substance use disorder

181 870 (70.7)

87 023 (66.7)

Drug-related conviction

62 082 (24.1)

23 270 (17.8)

Violence-related conviction

39 869 (15.5)

38 268 (29.3)

Incarceration length,
median (IQR), d

129 (71-238)

382 (180-1010)

Reincarceration

118 921 (45.8)

60 139 (46.1)

Abbreviations: GED, general education degree; IQR, interquartile range.
a

Individuals categorized into restrictive housing if they were ever in
restrictive housing.

b

Data for 255 individuals missing.

c

Data for 1022 individuals missing.

d

Individuals categorized into restrictive housing for each incarceration.

e

Data for 712 incarcerations missing.

f

Data for 12 incarcerations missing.
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2.29; 95% CI, 0.99-5.27; reincarceration: aHR, 1.89; 95% CI, 1.82-1.96). However, a dose response
was not observed for opioid overdose deaths (aHR, 1.24; 95% CI, 0.77-1.98) (Table 2). Similarly, we
found that those who spent more than 14 consecutive days in restrictive housing had a greater risk of
all-cause mortality, homicide, suicide and reincarceration within 1 year after release but not of opioid
overdose deaths than those with 0 days of restrictive housing (all-cause mortality: aHR, 1.34; 95% CI,
1.15-1.56; homicide: aHR, 1.61; 95% CI, 1.23-2.11; suicide: aHR, 1.81; 95% CI, 1.08-3.06; reincarceration:
aHR, 1.72; 95% CI, 1.66-1.76; opioid overdose death: aHR, 1.24; 95% CI, 0.80-1.92) (Table 3). Further,
the association of restrictive housing with opioid overdose death and suicide after release was more
pronounced among white individuals compared with nonwhite individuals (opioid overdose death:
aHR, 1.38 [95% CI, 1.03-1.83] vs aHR, 0.82 [95% CI, 0.37-1.80]; suicide: aHR, 2.00 [95% CI, 1.26-3.15]
vs aHR, 1.18 [95% CI, 0.53-2.59]) (Table 2). The association of restrictive housing with homicide and
reincarceration was higher for nonwhite individuals compared with white individuals (homicide: aHR,
1.67 [95% CI, 1.32-2.12] vs aHR, 1.10 [95% CI, 0.63-1.90]; reincarceration: aHR, 1.48 [95% CI, 1.441.52] vs aHR, 1.42 [95% CI, 1.37-1.47]) (Table 2).
Sensitivity analyses suggested that the association of the percent-time spent in restrictive
housing during incarceration with mortality after release had a dose-response relationship, such that
increasing percent-time spent in restrictive housing was associated with greater mortality after
release (eTable in the Supplement). Adjustment with a 5-category mental health treatment
recommendation variable only changed the effect estimates at the third decimal place, suggesting
that the time-varying binary mental health variables used in the main analysis produced results that
were robust to confounding from mental health disorders.

Table 2. Association of Restrictive Housing During Incarceration With 1-Year Mortality After Release and Reincarceration in North Carolina, 2000-2016
Deaths or
Reincarcerations,
No.

Person-Years

Overall

None

1557

236 433

1 [Reference]

1 [Reference]

1 [Reference]

Any

847

117 634

1.24 (1.12-1.38)

1.29 (1.12-1.46)

1.19 (1.01-1.37)

1

365

54 280

1.17 (1.03-1.33)

1.28 (1.08-1.52)

1.05 (0.87-1.28)

≥2

482

57 162

1.38 (1.14-1.66)

1.33 (1.03-1.73)

1.42 (1.08-1.85)

None

36 751

236 433

1 [Reference]

1 [Reference]

1 [Reference]

Any

22 558

117 634

1.46 (1.42-1.49)

1.42 (1.37-1.47)

1.48 (1.44-1.52)

1

9163

54 280

1.22 (1.19-1.25)

1.19 (1.14-1.24)

1.24 (1.20-1.28)

≥2

13 395

57 162

1.89 (1.82-1.96)

1.83 (1.72-1.96)

1.92 (1.84-2.01)

None

227

236 433

1 [Reference]

1 [Reference]

1 [Reference]

Any

105

117 634

1.27 (0.97-1.67)

1.38 (1.03-1.83)

0.82 (0.37-1.80)

1

53

54 280

1.26 (0.91-1.74)

1.31 (0.93-1.85)

1.01 (0.41-2.45)

≥2

52

57 162

1.24 (0.77-1.98)

1.45 (0.88-23.8)b

0.34 (0.11-1.03)b

None

230

236 433

1 [Reference]

1 [Reference]

1 [Reference]

Any

207

117 634

1.54 (1.24-1.91)

1.10 (0.63-1.90)

1.67 (1.32-2.12)

1

78

54 280

1.29 (0.97-1.72)

0.82 (0.40-1.65)

1.43 (1.04-1.96)

≥2

129

57 162

1.70 (1.20-2.40)

2.04 (0.77-5.41)

1.61 (1.17-2.21)

None

86

236 433

1 [Reference]

1 [Reference]

1 [Reference]

Any

57

117 634

1.78 (1.19-2.67)

2.00 (1.26-3.15)

1.18 (0.53-2.59)

1

27

54 280

1.55 (0.95-2.50)

1.95 (1.16-3.30)b

0.37 (0.08-1.68)b

≥2

30

57 162

2.29 (0.99-5.27)

2.30 (0.79-6.71)

2.17 (0.81-5.81)

Restrictive Housing
Placements

Adjusted Hazard Ratio (95% CI)a
Among White Individuals

Among Nonwhite Individuals

All-Cause Mortality

Reincarceration

Opioid Overdose Deaths

Homicide Deaths

Suicide Deaths

a

Adjusted for age, sex, race, prior incarcerations, time in incarceration, violence-related
convictions, drug-related convictions, mental health screening recommendation, and
mental health treatment receipt.

b

P value for interaction < .05.

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Figure. Association of Restrictive Housing During Incarceration With Mortality After Release
and Reincarceration in North Carolina, 2000-2016
All-cause mortality
2 wk
1y
All
Reincarceration
2 wk
1y
All
Opioid overdose death
2 wk
1y
All
Homicide
2 wk
1y
All

All hazard ratios are adjusted for sex, race, and timevarying factors including age, prior incarcerations, time
in incarceration, violence-related convictions, drugrelated convictions, mental health screening
recommendation, and mental health treatment
receipt. The x-axis is on a logarithmic scale. Whiskers
represent 95% CIs.

Suicide
2 wk
1y
All
-4

-2

0

2

4

Adjusted Hazard Ratio (95% CI)

Table 3. Association of Time Spent in Restrictive Housing During Incarceration With 1-Year Mortality After Release and Reincarceration in North Carolina, 2000-2016
Time Spent in Restrictive
Housing, d

Deaths or
Reincarcerations, No.

Adjusted Hazard Ratio (95% CI)a
Person-Years

Overall

Among White Individuals

Among Nonwhite Individuals

All-Cause Mortality
0

1557

236 433

1 [Reference]

1 [Reference]

1 [Reference]

>0 to 14

269

40 365

1.17 (1.01-1.35)

1.30 (1.07-1.57)

1.04 (0.83-1.29)

>14

580

77 265

1.34 (1.15-1.56)

1.36 (1.10-1.69)

1.31 (1.07-1.62)

Reincarceration
0

36 751

236 433

1 [Reference]

1 [Reference]

1 [Reference]

>0 to 14

5886

40 365

1.11 (1.08-1.15)

1.13 (1.07-1.19)

1.11 (1.06-1.15)

>14

16 671

77 265

1.72 (1.66-1.76)

1.63 (1.55-1.71)b

1.77 (1.71-1.83)b

Opioid Overdose Deaths
0

227

236 433

1 [Reference]

1 [Reference]

1 [Reference]

>0 to 14

41

40 365

1.35 (0.95-1.92)

1.41 (0.98-2.05)

1.05 (0.37-2.95)

>14

64

77 265

1.24 (0.80-1.92)

1.41 (0.89-2.24)

0.50 (0.18-1.41)

Homicide Deaths
0

230

236 433

1 [Reference]

1 [Reference]

1 [Reference]

>0 to 14

54

40 365

1.21 (0.87-1.66)

1.25 (0.60-2.60)

1.20 (0.84-1.72)

>14

153

77 265

1.61 (1.23-2.11)

0.82 (0.40-1.67)b

1.84 (1.36-2.48)b

Suicide Deaths

a

0

86

236 433

1 [Reference]

1 [Reference]

1 [Reference]

>0 to 14

21

40 365

1.72 (1.01-2.94)

2.23 (1.26-3.94)

0.31 (0.04-2.31)

>14

36

77 265

1.81 (1.08-3.06)

1.90 (1.01-3.55)

1.56 (0.64-3.76)

Adjusted for age, sex, race, prior incarcerations, time in incarceration, violence-related
convictions, drug-related convictions, mental health screening recommendation, and
mental health treatment receipt.

b

P value for interaction < .05.

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Discussion
To our knowledge, this study is the first to examine the association of restrictive housing with
mortality after release. We found that people who had spent any time in restrictive housing during
incarceration in a state prison in North Carolina were significantly more likely to die of all causes in the
first year after release than those who did not. In addition, our results demonstrated that death by
suicide and homicide in the first year and opioid overdose in the first 2 weeks after release were more
common among those who had experienced restrictive housing compared with those who were
incarcerated but never in restrictive housing. Further, the risk of death and reincarceration was higher
among individuals with more restrictive housing placements and among those who spent more than
14 consecutive days in restrictive housing placements.
Previous research has shown that the period after release is a time of increased risk of death for
all who have experienced recent incarceration.1,3 Our results go a step further and suggest that
exposure to restrictive housing, as a condition of confinement, may be a contributing factor to the
risk of death during community reentry. Our findings also point to an exacerbation of risk when
people are placed in restrictive housing repeatedly and for longer periods, underscoring the
importance of the Mandela Rules guidelines. However, for opioid overdose and reincarceration, any
time at all in restrictive housing is associated with increased risk. We also found differences in risk by
racial group that mirror known population-level mortality trends (eg, white individuals are at
increased risk of opioid overdose compared with nonwhite individuals).21-23 These results can be
used to identify people for linkage to trauma-informed, community-based substance use and mental
health treatment, overdose prevention and harm reduction, and wraparound care and services.
In recent years, much energy has been devoted to improving the carceral environment and
limiting the use of restrictive housing because of its potential negative effects on those who
experience it. In 2010, the American Bar Association published guidelines for reforming the use of
restrictive housing that advised against long-term restrictive housing for disciplinary purposes and
advocated for the allowance of more programming and out-of-cell time and the close monitoring of
mental health deterioration. Similarly, in 2016, the Department of Justice issued recommendations
concluding that although the use of restrictive housing—particularly when used to ensure
safety—may sometimes be necessary, it should be rare.24 The same year, the American Correctional
Association issued similar recommendations relevant to the use of restrictive housing.25 Empirical
studies documenting the consequences of restrictive housing on health outcomes have played a
prominent role in advancing state and local reforms and advocacy. Findings from this study
contribute to this body of literature.
In 2015, the NCDPS, in collaboration with the Vera Institute of Justice, began implementing
important reforms in the use of restrictive housing.26 At this time, NCDPS prohibited the use of
restrictive housing among individuals younger than 18 years, mandated staff training, and created 2
units: the Therapeutic Diversion Unit, which acts as an alternative to restrictive housing for people
with severe mental illness, and the Rehabilitative Diversion Unit, which aids in transition from
restrictive housing to the general prison population. These types of programs are an initial step to
eliminating the harms that restrictive housing may have on health outcomes after release. Other
possible interventions could include providing individuals who have experienced restrictive housing
with more comprehensive, trauma-informed discharge planning services that include linkage to
mental health and substance use treatment providers and increased access to stabilizing resources
in the community, such as housing and employment opportunities.27 It also underscores the
importance of overdose education and naloxone distribution programs at reentry from incarceration.

Limitations
Despite this article’s important findings, this study has limitations. It is important to note that, given
the observational study design, which was necessary given the ethical concerns of conducting a
randomized clinical trial, and limited data set available, there may be additional unmeasured

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confounders that we were not able to control for, such as diagnosis of comorbid mental or substance
use–related health conditions, criminogenic risk, and the cause of restrictive housing that may
increase risk of mortality and reincarceration. However, we used surrogate measures for these
factors including time-varying (at each incarceration period) in-prison mental health and substance
use screenings, treatments received, length of each incarceration period, and drug-related or
violence-related convictions for each incarceration. We also conducted sensitivity analyses that
underscored the robustness of the study results. Despite these limitations, this study aids in
identification of a group of individuals at high risk on whom public health interventions could focus,
including those related to the current overdose epidemic.1-3 Future research should build on our
findings and more clearly identify the pathways via which restrictive housing affects mortality after
release, which will lead to additional interventions for prevention of mortality after release.

Conclusions
Restrictive housing has been the topic of much policy debate in recent years, during which research
has begun to uncover the harms of prolonged exposure. Our results go a step further than other
research that we are aware of and highlight the association of restrictive housing with mortality after
release. Specifically, our results demonstrate that restrictive housing is associated with a higher
likelihood of reincarceration and all-cause mortality, including deaths related to opioid overdose,
suicide, and homicide. Importantly, repeated placements and being in restrictive housing for more
than 14 days, the threshold of what constitutes torture according to the Mandela Rules, may further
exacerbate risk. These findings contribute significantly to the growing body of literature about
restrictive housing, suggesting a need to contemplate alternatives to its use and flagging restrictive
housing as an important risk factor that must be considered during discharge planning and in the
postrelease context for public health systems.

ARTICLE INFORMATION
Accepted for Publication: August 14, 2019.
Published: October 4, 2019. doi:10.1001/jamanetworkopen.2019.12516
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 BrinkleyRubinstein L et al. JAMA Network Open.
Corresponding Author: Lauren Brinkley-Rubinstein, PhD, Center for Health Equity Research, University of North
Carolina at Chapel Hill, 333 S Columbia St, 341b MacNider Hall, Chapel Hill, NC 27599 (lauren_brinkley@
med.unc.edu).
Author Affiliations: Center for Health Equity Research, University of North Carolina at Chapel Hill
(Brinkley-Rubinstein); Department of Social Medicine, University of North Carolina at Chapel Hill
(Brinkley-Rubinstein); Injury Prevention Center, University of North Carolina at Chapel Hill (Sivaraman, Shanahan,
Ranapurwala); Division of Infectious Diseases, University of North Carolina at Chapel Hill (Rosen); Department of
Behavioral Sciences and Health Education, Emory University, Atlanta, Georgia (Cloud); North Carolina Department
of Public Safety, Raleigh (Junker); North Carolina Department of Public Health, Raleigh (Proescholdbell);
Department of Epidemiology, University of North Carolina at Chapel Hill (Ranapurwala).
Author Contributions: Drs Brinkley-Rubinstein and Ranapurwala had full access to all of the data in the study and
take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Brinkley-Rubinstein, Cloud, Shanahan, Ranapurwala.
Acquisition, analysis, or interpretation of data: Brinkley-Rubinstein, Sivaraman, Rosen, Cloud, Junker,
Proescholdbell, Ranapurwala.
Drafting of the manuscript: Brinkley-Rubinstein, Sivaraman, Cloud, Ranapurwala.
Critical revision of the manuscript for important intellectual content: Brinkley-Rubinstein, Rosen, Cloud, Junker,
Proescholdbell, Shanahan, Ranapurwala.
Statistical analysis: Sivaraman, Rosen, Ranapurwala.

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Obtained funding: Proescholdbell, Shanahan.
Administrative, technical, or material support: Brinkley-Rubinstein, Junker, Proescholdbell, Shanahan,
Ranapurwala.
Supervision: Brinkley-Rubinstein, Ranapurwala.
Conflict of Interest Disclosures: Dr Junker reported being employed by the North Carolina Division of Public
Health. Dr Proescholdbell reported receiving grant funding from the US Centers for Disease Control and
Prevention (grant 5NU17CE002728; prinicipal investigator: Mr Proescholdbell) during the conduct of the study. Dr
Shanahan reported receiving grant funding from the Injury and Violence Prevention Branch of the North Carolina
Division of Public Health during the conduct of the study. Dr Ranapurwala reported receiving grant funding from
the North Carolina Division of Public Health during the conduct of the study. No other disclosures were reported.
Disclaimer: The opinions, conclusions, and viewpoints of this research do not necessarily reflect those of the
North Carolina Department of Public Safety or the North Carolina Department of Health and Human Services.
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SUPPLEMENT.
eTable. Association Between Percent-Time Spent in Restrictive Housing During Incarceration and 1-Year Mortality
and Reincarceration After Release in North Carolina, 2000-2016

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