Pathologizing Normal Human Behavior: Violence and Solitary Confinement in an Urban Jail

Mental health care and incarceration are inextricably linked in the United States. In NYC, the Department of Health’s bureau of Correctional Health Services analyzed the relationship between race, adolescence and solitary confinement with regard to entry into the jail mental health service. Records of individuals in their first jail admission (n= 48,193) were examined, including race, age, jail entry, mental health diagnosis, treatment and placement in solitary confinement. Most patients receive their mental health diagnosis within 7 days of admission (67%). Among the 2,577 patients in our cohort who received their mental health diagnosis after day 7 of admission, 879 (34%) experienced solitary confinement while only 8% of those patients who were diagnosed within the first 7 days ever experienced solitary confinement (X2=835.7, df=1, p<.0001). Adolescents received their mental health diagnosis further into their incarceration (58 days vs 36 days for adults). After adjustment for length of stay, the risk ratios for adolescents (as compared to adults) is 3.4 for solitary confinement and 1.2 for entering the mental health service 1.2 (p<.0001 for both). Adolescents were more at risk of receiving a mental health diagnosis within 10 days of solitary confinement (RR= 4.4). When adjusted for length of stay, the risk ratio for African-Americans and Hispanics being diagnosed with a mental health problem is 0.53 and 0.43 respectively (p<0.001 for both). In contrast, only 1.8% of Non-Hispanic white patients were ever placed in solitary confinement, compared to 6.9% of African American and 4.8% of Hispanic patients.  When adjusted for length of stay, the risk ratio for African-Americans and Hispanics going into solitary confinement is 2.7 and 1.8, respectively (p<0.001 for both). Adolescence and race appear to be important characteristics in our jail mental health service. Late entry to the mental health service appears to occur as part of a punishment construct, often occurring within days of the actual entry to solitary confinement. Adolescent and non-White patients are at dramatically increased risk of this type of entry to the mental health service, as well as for entry into solitary confinement. The large amount of mental health diagnoses around the entry into solitary confinement, particularly of minority and adolescent patients, raises the specter of pathologizing normal human behavior in a manner that may not serve the interests of patients, harkening back to the discredited diagnosis of drapetomania. Further analysis is required to better characterize the factors that contribute to these disparities.