Health Spotlight: Serious Mental Illness

Solitary Confinement Creates and Exacerbates Mental Health Challenges

Many imprisoned people have mental health conditions. A 2021 report by the federal Bureau of Justice Statistics (BJS) analyzing data from 2016 estimated that 43% of people held in state prisons and 23% of people held in federal prisons had received diagnoses of mental health conditions. Spending time in solitary confinement can exacerbate existing mental illness and create additional health challenges.

The psychological and emotional harms of solitary confinement have been documented by many, including Stuart Grassian, Craig Haney, and Terry Kupers, who have described the harms of solitary confinement to include cognitive impairment, disturbances, psychosis, and permanent psychiatric disabilities.

Citing evidence of these harms, hundreds of healthcare professionals have signed an open letter to the Biden Administration calling for it to cease using solitary confinement in immigration detention. The letter outlines the “significant, and sometimes permanent, negative health outcomes” resulting from solitary confinement. See Letter: 475 Medical Professionals Demand an End to Solitary Confinement in U.S. Immigration Detention, May 31, 2024, https://phr.org/our-work/resources/letter-medical-professionals-demand-an-end-to-solitary-confinement-in-u-s-immigration-detention/.

Corrections' Standards

The American Correctional Association (ACA), which is a private, non-profit, non-governmental association and accrediting body for the corrections industry, has for many decades issued a variety of standards governing incarceration. In 2016, the ACA issued “Restrictive Housing Performance Based Standards.” Restrictive housing is an umbrella term used for people held in cell, generally for 22 hours or more. The ACA defined “extended restrictive housing” to be “[h]ousing that separates the offender from contact with general population while restricting an offender/inmate to his/her cell for at least 22 hours per day and for more than 30 days.” The ACA standards addressed subpopulations including individuals with “serious mental illness” which it defined as: “Psychotic Disorders, Bipolar Disorders, and Major Depressive Disorder; any diagnosed mental disorder (excluding substance use disorders) currently associated with serious impairment in psychological, cognitive, or behavioral functioning that substantially interferes with the person’s ability to meet the ordinary demands of living and requires an individualized treatment plan by a qualified mental health professional(s).” The ACA stated that correctional departments “will not place a person with serious mental illness in Extended Restrictive Housing."

Legislative Regulation

As reflected in the professional and ACA standards a consensus has emerged that individuals identified as having “serious mental illness” (SMI) should not be placed in solitary confinement, while a debate exists about how to define who falls within that category. Several states have enacted statutes, issued policies, or considered proposals to limit isolation for people who are seriously mentally ill.

In addition, Colorado forbids local jails, with some exceptions, from involuntarily placing a person in solitary confinement if the individual “is diagnosed with a serious mental illness,” experiences “significant auditory or visual impairment,” “is significantly neurocognitively impaired,” or “has an intellectual or developmental disability.” New York State’s 2021 statute HALT requires mental health assessments upon placement in solitary confinement and prohibits the use of solitary confinement for people diagnosed with “serious mental illness.

Judicial Decisions

In 1995, a federal district court judge sitting in the Northern District of California held in Madrid v. Gomez that putting individuals with existing mental illnesses in solitary confinement was unconstitutional. The judge concluded that California’s placing people in its profound isolation unit at Pelican Bay subjected the incarcerated people “to ‘unnecessary and wanton infliction of pain’ in violation of the Eighth Amendment of the United States Constitution.”

In 2019, a federal appellate court (the Fourth Circuit) affirmed a trial level judge’s ruling in Porter v. Clarke that the conditions of confinement on death row violated the Eighth Amendment. The complaint, filed in 2014, alleged that the “permanent, unmitigated segregation” of death row prisoners “subjects them to an inhumane existence unrelated to any legitimate penological goal, amounting to the imposition of cruel and unusual punishment violating the Eighth Amendment.” The judges stated that individuals on death row spent years “alone, in a small . . . cell” with “no access to congregate religious, educational, or social programming” and that such conditions presented “an objective risk of serious psychological and emotional harm . . . ” The court explained, “The challenged conditions on Virginia’s death row deprived inmates of the basic human need for meaningful social interaction and positive environmental stimulation. The undisputed evidence established that that deprivation posed a substantial risk of serious psychological and emotional harm and that State Defendants were deliberately indifferent to that risk.” To remedy the constitutional violation, the district court prohibited solitary confinement for twenty-three hours a day and required the creation of policies “relating to cell time, visitation, and recreation that defendants, in their professional expertise, believe satisfy both the Eighth Amendment and the prison’s need for security.”

In 2017, in Braggs v. Dunn, a federal district judge sitting in Alabama concluded that the Alabama Department of Corrections’ [ADOC] “horrendously inadequate” mental health services violated the constitutional prohibition against cruel and unusual punishment. The judge concluded that the department “subjected mentally ill prisoners to a substantial risk of serious harm” and acted with deliberate indifference to that risk. The court wrote that “despite being repeatedly informed that significant deficiencies existed, ADOC has disregarded and failed to respond reasonably to the actual harm and substantial risks of serious harm posed by its deficient mental-health care system.” The judge rejected ADOC’s arguments that its leaders lacked the authority to fix the problems and that a federal court could not order a state to spend money on prisons. In a series of orders issued in 2018 and thereafter, the judge required ADOC to screen for mental health problems before putting people in solitary confinement and move people with “serious mental illness” out of solitary confinement. As of 2023, an appeal was pending and the case ongoing.

Differing Definitions of Serious Mental Illness

In 2021, as in prior years, the national survey of corrections agencies asked about whether jurisdictions had individuals with serious mental illness in solitary confinement. As of July 2021, aggregating the numbers reported by twenty-eight jurisdictions, a total of 1,138 people were, under each jurisdiction’s definition, seriously mentally ill and in solitary confinement. The reminder is that jurisdictions vary in their definitions of serious mental illness. The 2022 CLA-Liman Report Appendix, available here, included 36 jurisdictions’ definitions of “serious mental illness.” Below are six examples.

Alabama: “Psychotic disorders, bi-polar disorders, & major depressive disorder; any diagnosed mental disorder (excluding substance abuse disorders) currently associated with serious impairment in psychological, cognitive, or behavioral functioning that substantially interferes with the person's ability to meet ordinary demands of living and requires an individualized treatment plan by a qualified mental health professional(s).”

Hawaii: “Any individual who displays serious and persistent mental health disease as determined by the Department of Health and/or our internal medical staff.”

Iowa: “Serious mental illness is defined as Major Depression, Schizophrenia, Bipolar, and Organic Mental Disorders (Dementia).”

Washington: “A substantial disorder of thought or mood which significantly impairs judgment, behavior, capacity to recognize reality or cope with the ordinary demands of life within the prison environment and is manifested by substantial pain or disability. Serious mental illness requires a mental health diagnosis, prognosis and treatment, as appropriate, by mental health staff. It is expressly understood that this definition does not include inmates who are substance abusers, substance dependent, including alcoholics and narcotics addicts, or persons convicted of any sex offense, who are not otherwise diagnosed as seriously mentally ill.”

Oklahoma: “A substantial disorder of thought or mood which significantly impairs judgment, behavior, capacity to recognize reality or cope with the ordinary demands of life within the prison environment and which is manifested by substantial suffering or disability. Most current version of the DSM is used to identify those with SMI.”

South Carolina: “Anyone requiring mental health care equivalent to Intensive Outpatient, or higher level of care; or anyone requiring placement in a Behavioral Management Unit or Secure Mental health unit due to an inability to effectively conform their behavior to facility rules as a result psychiatric illness and/or extreme personality disorder.”

What were the rules regulating life in a cell?

The rules listed are the formal, reported policies that do not necessarily translate into the actual lived experiences of people in solitary confinement.

The table below presents data from 28 jurisdictions reporting on the number of people held in prison and held in solitary confinement.