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Incarceration and Health
CHRISTOPHER WILDEMAN
Abstract
In this essay, I start by briefly discussing the foundational research in this area, which,
similar to the study of the consequences of mass imprisonment more broadly, is
mostly new. Indeed, all of the foundational research in this field (with the exception
of The Prison Community and The Society of Captives), which considered the mental
and physical health of current and former inmates, as well as their mortality risks,
was conducted only in the past 25 years. In general, this research finds that (i) the
imprisonment period appears to have negative effects on mental health but some
paradoxical benefits for physical health and mortality and (ii) former inmates have
more health problems and higher mortality risk than a comparison group in the free
population. After reviewing this literature, I then review some new research in this
area, which shows how incarceration shapes (i) the mental health of current and former inmates, (ii) the health of women connected to current and former inmates, and
(iii) the health of the children of current and former inmates. This new research is
unique not just because of the breadth of outcomes it considers but also because
it uses much more rigorous methods to tease out causal relationships (especially
for mental health). I close by discussing directions for research, focusing especially
on overcoming obstacles to causal inference, considering effects on inequality, and
further returning to the roots of this field, which focused on the acute effects of incarceration on the mental health of inmates.
INTRODUCTION
Prisons and jails have long housed not only the socially marginalized but
also some of the least healthy members of the population. Indeed, current
and former prison and jail inmates have long been known to have higher
rates of mental and physical health problems than the free population. With
but a few exceptions, they have also been known to have exceptionally high
mortality rates relative to the free population, painting a portrait of current
and former prison and jail inmates as a population both physically and mentally unhealthy—and also at risk of premature mortality. Thus, while some
researchers have focused on the so-called healthy prisoner effect whereby
individuals who are very unhealthy cannot commit some crimes—especially
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.
1
2
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
those that require great strength or fortitude—the fact remains that most prisoners are less healthy than we would expect a matched individual of the
same age, sex, race, and class from the free population to be.1 As Christopher
Muller and I have argued elsewhere (Muller & Wildeman, 2012; Wildeman
& Muller, 2012), it is not a novel observation that inmates are unhealthy relative to the free population. Indeed, as inmates are disadvantaged relative to
the free population in almost every domain—including their probabilities of
being employed, married, or stably housed on the outside, for instance—we
would expect them to be in poor health regardless of whether they experienced incarceration. The core questions then are not whether the incarcerated
are in worse health than the free population but whether incarceration actually causes these differences in health. Relatedly, we might be interested in
whether mass imprisonment—the historically and comparatively extreme
rates of incarceration present in the United States today and concentrated
among young low-education minority men living in poor neighborhoods
(Garland, 2001)—has affected racial disparities in physical and mental health,
a topic of great interest not only for sociologists (who are acutely interested
in inequality), but also for public health professionals.
In this essay, I address the relationship between incarceration and health.
Specifically, I start by discussing foundational research showing how poor
the mental and physical health of current and former inmates is and the
degree to which incarceration is responsible for that ill health. At the same
time, I discuss the paradoxical mortality benefits of current incarceration for
young minority men. In the next section, I discuss cutting-edge research in
this area, which seeks to extend the health consequences of mass imprisonment beyond individuals and to families and communities. By looking
beyond current and former inmates, this research shows that the effects of
mass imprisonment on racial disparities in health may be greater than suspected, extending to the women and children connected to the mostly male
penal population. In this way, research on the spillover effects of the prison
boom on health offers a unique opportunity to consider how the prison boom
affects the health of women. This is especially important because research on
the health consequences of the prison boom has focused mostly, if not exclusively, on men. I close by discussing some of the most promising directions
for future research, focusing especially on obstacles to causal inference and
the need to return to an era where we acknowledge the fact that the incredibly negative consequences of current incarceration for mental health cannot
be ignored—even though this is an area of research that has received far too
little attention.
1. As the penal population ages, moreover, the costs associated with caring for this increasingly ill
population could become quite great—a topic worthy of an entire additional article, and one I do not
focus on in this specific entry.
Incarceration and Health
3
FOUNDATIONAL RESEARCH
Although much research on the consequences of incarceration for health
is quite new, two truly exceptional studies from an earlier era stick out as
forerunners in this field, The Prison Community, which was published by
Donald Clemmer in 1940 (Clemmer, 1940), and The Society of Captives, which
was published by Gresham Sykes in 1958 (Sykes, 1958). Although predominantly concerned not with the mental health of inmates but with the social
structure of the prison, each of these fascinating studies documented how
imprisonment affected the well-being of inmates, highlighting especially
the many ways in which imprisonment could either exacerbate existing
mental health problems or create new mental health problems for previously
healthy inmates. They also documented the complex and varying ways
in which imprisonment could affect mental health, firmly documenting a
well-known but rarely-tested idea that the effects of imprisonment on health
are likely moderated by unique traits of prisons and inmates.
After the publication of these studies, however, interest in the mental health
effects of imprisonment—at least in the research community—dropped off
(but see Haney, 2003) in favor of considering the physical health consequences of imprisonment. Much of the emphasis in this field also shifted
from considering the effects of current imprisonment on health to thinking
instead about the health effects of prior imprisonment. Of the many excellent works in this area, two especially stick out. The first of these studies
shows that the ever-imprisoned are far more likely to suffer from a host of
infectious and stress-related diseases in adulthood but not more likely to
suffer from other disorders not linked to exposure to infectious disease or
chronic stress (Massoglia, 2008). By showing both what health conditions
a history of imprisonment is and is not associated with, this essay goes a
long way toward showing how imprisonment shapes health. The second
study, which uses a research design that controls for fixed but stable traits
of individuals, provides evidence that current imprisonment may enhance
health in some regard, while prior imprisonment may compromise health in
important ways (Schnittker & John, 2007).
This insight corresponded nicely with a widely confirmed but perplexing
finding on the relationship between imprisonment and mortality: The
currently imprisoned were somewhat less likely to die than members of the
free population matched on basic characteristics such as age, sex, and race
(Mumola, 2007; Patterson, 2010; Spaulding et al., 2011), with this association
being most pronounced for young African-American men, while former
prisoners—especially recently released prisoners—were at exceptionally
high mortality risk relative to individuals in the free population (Binswanger
et al., 2007; Spaulding et al., 2011). Although the reasons for this paradoxical
4
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
relationship are not completely clear, it looks as if prisoners—especially
those drawn from the most disadvantaged realms of society—experience
lower than expected mortality rates because of the decreased risk of homicide, better nutrition, and more consistent health care they experience while
imprisoned. Studies of post-release mortality provide less guidance in this
regard, although they also tend to suggest that decreased tolerance among
opioid users during the imprisonment period dramatically increases the risk
of overdose-related mortality upon release.
Foundational research in this area, therefore, provides support for three
conclusions. First, imprisonment likely has negative mental consequences
for many individuals. Second, the imprisonment period, if often bad for
mental health and a time when a nonnegligible number of people will contract potentially life-threatening infectious diseases, does seem to have some
positive effects on morbidity and mortality. Finally, prior imprisonment is
strongly tied not only with elevated mortality risk but also with higher rates
of infectious and stress-related disease.
CUTTING-EDGE RESEARCH
If the first wave of research on the relationship between incarceration and
health was distinctive in no small part for pointing out how the effects of
current imprisonment and having ever been imprisoned differ, cutting-edge
research in this area is distinctive not only for attempting to better isolate
a causal relationship between current and prior imprisonment and mental
health but also for showing that the health implications of mass imprisonment extend far beyond the individuals who churn through the system to
their romantic partners and children as well.
The first wave of cutting-edge research I want to highlight here is a return
to the origins of the research on the consequences of imprisonment for
individuals. Indeed, as I noted at the beginning of this essay and elsewhere
(Muller & Wildeman, 2012; Wildeman & Muller, 2012), the initial push of
research on the effects of imprisonment on individuals focused heavily on
mental health—an emphasis lost for quite a while after (Clemmer, 1940;
Sykes, 1958). In just the last few years, two articles have been published that
provide new insight into just how much current and recent imprisonment
affect mental health. The first of these articles, which considers effects on a
range of mental health outcomes and uses the timing of onset to establish
appropriate time-ordering of incarceration and mental health, finds that
the ever-imprisoned are far more likely to suffer from mood disorders,
especially dysthymia, than are the never-imprisoned (Schnittker, Massoglia,
& Uggen, 2012). A second study tests the effects of current and recent
imprisonment on the risk of having major depressive disorder—what we
Incarceration and Health
5
often call depression—finding that changes in incarceration are associated
with changes in depression, strong evidence that both current and prior
incarceration may increase the risk of being depressed (Turney, Wildeman,
& Schnittker, 2012). Thus, this new wave of research suggests that the mental
health consequences of imprisonment considered broadly in the first wave
of research may indeed be causal, at least for some key outcomes.
The second wave of cutting-edge research that deserves special attention
here has to do with the spillover effects of imprisonment on the health of
the family members—especially the romantic partners and children—of the
currently and formerly imprisoned. Driven by a growing body of research
documenting the consequences of incarceration for family life (Braman,
2004; Comfort, 2008), this wave of research seeks to broaden the thinking
on the health consequences of imprisonment. Of research in this area, far
more has considered the consequences of having a father imprisoned in the
past couple of years for children’s mental health and behavioral problems
(Geller, Cooper, Garfinkel, Schwartz-Soicher, & Mincy, 2012; Wakefield &
Wildeman, 2011) or risk of infant and child mortality (Wildeman, 2012;
Wildeman, Andersen, Lee, & Karlson, 2014) than the effects of having a
partner incarcerated on women’s health. In general, this research finds that
even relative to children with nonresident fathers, children with incarcerated
fathers fare worse on a host of outcomes. Although research in this area
is still in its infancy, these findings, when combined with research on the
massive racial and class disparities in the risk of paternal imprisonment
(Wildeman, 2009), suggest that the effects of mass imprisonment on future
health inequality may be far larger than anticipated (Wakefield & Wildeman,
2013).
If research on the health effects of paternal incarceration on children is in its
infancy, research on the health effects of partner incarceration on women is
still in its gestational stage. Indeed, as of the writing of this essay, I was able
to locate only one published article linking the incarceration of a romantic
partner with women’s physical health and just one article on the topic that
considers the effects of having a romantic partner incarcerated on women’s
mental health. This work finds that having a family member incarcerated
increases women’s risk of having a host of cardiovascular disease risk factors
(Lee, Wildeman, Wang, Matusko, & Jackson, 2014) and that having a romantic
partner incarcerated increases women’s risk of having a major depressive disorder and decreases their happiness (Wildeman, Schnittker, & Turney, 2012).
Although this area is so very new, I nonetheless mention it because it suggests that the effects of mass imprisonment for public health—and health
disparities—may not be linked just to the men who cycle through the system
but also to the women and children who they leave behind.
6
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
Thus, while the first wave of research suggested that the mental health consequences of confinement might be acute (Clemmer, 1940; Sykes, 1958) and
carefully outlined a sometimes-paradoxical relationship between imprisonment and physical health (Binswanger et al., 2007; Massoglia, 2008; Mumola,
2007; Patterson, 2010; Schnittker & John, 2007; Spaulding et al., 2011), the
second wave of research in this area showed that the mental health consequences speculated in the first wave of research appear to be driven by
incarceration (Schnittker et al., 2012; Turney et al., 2012) and pointed in the
direction of broader spillover effects on the health of families, including both
children, (Wildeman, 2012; Wildeman et al., 2014), female romantic partners
(Wildeman et al., 2012), and female family members more broadly (Lee et al.,
2014).
KEY ISSUES FOR FUTURE RESEARCH
Although research on the relationship between incarceration and health
has made great strides in the past 10 years, a number of key issues for
future research nonetheless remain. These include providing stronger tests
of causality, thinking about how much mass imprisonment shapes health
inequalities, and (again) returning to the study of the health consequences
of confinement.
Suggesting the full range of ways that researchers working in this area
might overcome obstacles to causal inference is beyond the scope of this
essay, and hearing about a battery of statistical tests is likely not to be of interest to most readers of this essay, so I do not dwell on the nitty-gritty of this.
Nonetheless, the importance of this issue cannot be overstated. Indeed, without designing stronger causal tests of the incarceration–health relationship,
we cannot know whether diminishing the incarceration rate will help, harm,
or have no effect on the men and women for whom incarceration has become
common. Thus, until we know whether any of these effects are causal, we
cannot formulate effective policies that enhance population health.
A second key issue for future research in this area, which necessitates having credible causal estimates, involves deciphering the degree to which mass
imprisonment has actually done anything to increase health disparities.
On the face of it, that might seem like an odd statement as imprisonment
is unequally distributed and appears to have mostly negative effects on
health. Yet, as I have noted elsewhere (Muller & Wildeman, 2012; Wildeman
& Muller, 2012), the magnitude of the effects of mass imprisonment is
influenced not just by the magnitude of causal effects and the distribution
of imprisonment in the population but also by a host of other factors.
It is for this reason that mass imprisonment could explain nearly none
of black–white disparities in earnings and marriage (Western, 2006) but
Incarceration and Health
7
nearly all of black–white disparities in AIDS (Johnson & Raphael, 2009).
Future research must thus directly test for effects of mass imprisonment
on inequality rather than talking about these effects without testing for
them.
A final issue, and one I have again raised in parallel work (Muller &
Wildeman, 2012; Wildeman & Muller, 2012) has to do with whether thinking
about causal effects of imprisonment on inequality is even the right path.
Indeed, the foundational research in this area focused first and foremost on
the “pains of imprisonment” (Sykes, 1958) and their implications for the
mental health and well-being of the imprisoned. As this field moves forward,
I think this is an issue that all of us working in it will need to grapple with:
Are we interested in identifying causal effects, thinking about inequality in
health, or showing the extent of human suffering in prisons and jails? The
answer to that question is in many ways the key for this field as it moves
forward.
REFERENCES
Binswanger, I. A., Stern, M. F., Deyo, R. A., Heagerty, P. J., Cheadle, A., Elmore, J.
G., & Koepsell, T. D. (2007). Release from prison—a high risk of death for former
inmates. New England Journal of Medicine, 356(2), 157–165.
Braman, D. (2004). Doing time on the outside: Incarceration and family life in Urban America. Ann Arbor, MI: University of Michigan Press.
Clemmer, D. (1940). The prison community. New Braunfels, TX: Christopher Publishing House.
Comfort, M. (2008). Doing time together: Love and family in the shadow on the prison.
Chicago, IL: University of Chicago Press.
Garland, D. (Ed.) (2001). Mass imprisonment: Social causes and consequences. Thousand
Oaks, CA: Sage.
Geller, A., Cooper, C. E., Garfinkel, I., Schwartz-Soicher, O., & Mincy, R. B. (2012).
Beyond absenteeism: Father incarceration and child development. Demography,
49(1), 49–76.
Haney, C. (2003). Mental health issues in long-term solitary confinement and ‘supermax’ confinement. Crime and Delinquency, 49(1), 124–156.
Johnson, R. C., & Raphael, S. (2009). The effects of male incarceration dynamics on
acquired immune deficiency syndrome infection rates among African American
women and men. Journal of Law and Economics, 52(2), 251–293.
Lee, H., Wildeman, C., Wang, E. A., Matusko, N., & Jackson, J. S. (2014). A heavy burden? The cardiovascular health consequences of having a family member incarcerated. American Journal of Public Health, 104(3), 421–427.
Massoglia, M. (2008). Incarceration as exposure: The prison, infectious disease, and
other stress-related illnesses. Journal of Health and Social Behavior, 49(1), 56–71.
Muller, C., & Wildeman, C. (2012). Punishment and inequality. The SAGE handbook
of punishment and society (pp. 169–185). Thousand Oaks, CA: Sage.
8
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
Mumola, C. J. (2007). Medical causes of death in state prisons, 2001–2004. Washington, DC: Bureau of Justice Statistics. Retrieved from http://bjs.ojp.usdoj.gov/
content/pub/pdf/mcdsp04.pdf.
Patterson, E. J. (2010). Incarcerating death: Mortality in U.S. state correctional facilities, 1985–1998. Demography, 47(3), 587–607.
Schnittker, J., & John, A. (2007). Enduring stigma: The long-term effects of incarceration on health. Journal of Health and Social Behavior, 48(1), 115–130.
Schnittker, J., Massoglia, M., & Uggen, C. (2012). Out and down: Incarceration and
psychiatric disorders. Journal of Health and Social Behavior, 53(4), 448–462.
Spaulding, A. C., Seals, R. M., McCallum, V. A., Perez, S. D., Brzozowski, A. K., &
Steenland, N. K. (2011). Prisoner survival inside and outside of the institution:
Implications for health-care planning. American Journal of Epidemiology, 173(5),
479–487.
Sykes, G. (1958). The society of captives: A study of a maximum security prison. Princeton,
NJ: Princeton University Press.
Turney, K., Wildeman, C., & Schnittker, J. (2012). As fathers and felons: Explaining
the effects of current and recent incarceration on major depression. Journal of Health
and Social Behavior, 53(4), 465–481.
Wakefield, S., & Wildeman, C. (2011). Mass imprisonment and racial disparities in
childhood behavioral problems. Criminology and Public Policy, 10(3), 791–817.
Wakefield, S., & Wildeman, C. (2013). Children of the prison boom: Mass incarceration
and the future of American Inequality. New York, NY: Oxford University Press.
Western, B. (2006). Punishment and inequality in America. New York, NY: Russell Sage
Found.
Wildeman, C. (2009). Parental imprisonment, the prison boom, and the concentration
of childhood disadvantage. Demography, 46(2), 265–280.
Wildeman, C. (2012). Imprisonment and infant mortality. Social Problems, 59(2),
228–257.
Wildeman, C., Andersen, S. H., Lee, H., & Karlson, K. B. (2014). Parental incarceration
and child mortality in Denmark. American Journal of Public Health, 104(3), 428–433.
Wildeman, C., & Muller, C. (2012). Mass imprisonment and inequality in health and
family life. Annual Review of Law and Social Science, 8(1), 11–30.
Wildeman, C., Schnittker, J., & Turney, K. (2012). Despair by association? The mental
health of mothers with children by recently incarcerated fathers. American Sociological Review, 77(2), 216–243.
FURTHER READING
Binswanger, I. A., Stern, M. F., Deyo, R. A., Heagerty, P. J., Cheadle, A., Elmore, J.
G., & Koepsell, T. D. (2007). Release from prison—a high risk of death for former
inmates. New England Journal of Medicine, 356(2), 157–165.
Comfort, M. (2008). Doing time together: Love and family in the shadow on the prison.
Chicago, IL: University of Chicago Press.
Haney, C. (2003). Mental health issues in long-term solitary confinement and ‘supermax’ confinement. Crime and Delinquency, 49(1), 124–156.
Incarceration and Health
9
Sykes, G. (1958). The society of captives: A study of a maximum security prison. Princeton,
NJ: Princeton University Press.
Wildeman, C., & Muller, C. (2012). Mass imprisonment and inequality in health and
family life. Annual Review of Law and Social Science, 8(1), 11–30.
CHRISTOPHER WILDEMAN SHORT BIOGRAPHY
Christopher Wildeman is an Associate Professor of Policy Analysis and
Management at Cornell University. Since 2013, he has also been a visiting
fellow at the Bureau of Justice Statistics. He received his PhD in Sociology
and Demography from Princeton University in 2008. From 2008 to 2010,
he was a Robert Wood Johnson Foundation Health & Society Scholar at
the University of Michigan. And from 2010 to 2014, he was an Assistant
(2010–2013) and later Associate (2013–2014) Professor of Sociology at Yale
University. His research interests revolve around the consequences of
mass imprisonment for inequality, with emphasis on families, health, and
children. He is also interested in child welfare more broadly, especially as
relates to child maltreatment and foster care. He is the 2013 recipient of the
Ruth Shonle Cavan Young Scholar Award from the American Society of
Criminology and the Distinguished New Scholar Award from the American
Society of Criminology’s Division on Corrections and Sentencing.
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-
Incarceration and Health
CHRISTOPHER WILDEMAN
Abstract
In this essay, I start by briefly discussing the foundational research in this area, which,
similar to the study of the consequences of mass imprisonment more broadly, is
mostly new. Indeed, all of the foundational research in this field (with the exception
of The Prison Community and The Society of Captives), which considered the mental
and physical health of current and former inmates, as well as their mortality risks,
was conducted only in the past 25 years. In general, this research finds that (i) the
imprisonment period appears to have negative effects on mental health but some
paradoxical benefits for physical health and mortality and (ii) former inmates have
more health problems and higher mortality risk than a comparison group in the free
population. After reviewing this literature, I then review some new research in this
area, which shows how incarceration shapes (i) the mental health of current and former inmates, (ii) the health of women connected to current and former inmates, and
(iii) the health of the children of current and former inmates. This new research is
unique not just because of the breadth of outcomes it considers but also because
it uses much more rigorous methods to tease out causal relationships (especially
for mental health). I close by discussing directions for research, focusing especially
on overcoming obstacles to causal inference, considering effects on inequality, and
further returning to the roots of this field, which focused on the acute effects of incarceration on the mental health of inmates.
INTRODUCTION
Prisons and jails have long housed not only the socially marginalized but
also some of the least healthy members of the population. Indeed, current
and former prison and jail inmates have long been known to have higher
rates of mental and physical health problems than the free population. With
but a few exceptions, they have also been known to have exceptionally high
mortality rates relative to the free population, painting a portrait of current
and former prison and jail inmates as a population both physically and mentally unhealthy—and also at risk of premature mortality. Thus, while some
researchers have focused on the so-called healthy prisoner effect whereby
individuals who are very unhealthy cannot commit some crimes—especially
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.
1
2
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
those that require great strength or fortitude—the fact remains that most prisoners are less healthy than we would expect a matched individual of the
same age, sex, race, and class from the free population to be.1 As Christopher
Muller and I have argued elsewhere (Muller & Wildeman, 2012; Wildeman
& Muller, 2012), it is not a novel observation that inmates are unhealthy relative to the free population. Indeed, as inmates are disadvantaged relative to
the free population in almost every domain—including their probabilities of
being employed, married, or stably housed on the outside, for instance—we
would expect them to be in poor health regardless of whether they experienced incarceration. The core questions then are not whether the incarcerated
are in worse health than the free population but whether incarceration actually causes these differences in health. Relatedly, we might be interested in
whether mass imprisonment—the historically and comparatively extreme
rates of incarceration present in the United States today and concentrated
among young low-education minority men living in poor neighborhoods
(Garland, 2001)—has affected racial disparities in physical and mental health,
a topic of great interest not only for sociologists (who are acutely interested
in inequality), but also for public health professionals.
In this essay, I address the relationship between incarceration and health.
Specifically, I start by discussing foundational research showing how poor
the mental and physical health of current and former inmates is and the
degree to which incarceration is responsible for that ill health. At the same
time, I discuss the paradoxical mortality benefits of current incarceration for
young minority men. In the next section, I discuss cutting-edge research in
this area, which seeks to extend the health consequences of mass imprisonment beyond individuals and to families and communities. By looking
beyond current and former inmates, this research shows that the effects of
mass imprisonment on racial disparities in health may be greater than suspected, extending to the women and children connected to the mostly male
penal population. In this way, research on the spillover effects of the prison
boom on health offers a unique opportunity to consider how the prison boom
affects the health of women. This is especially important because research on
the health consequences of the prison boom has focused mostly, if not exclusively, on men. I close by discussing some of the most promising directions
for future research, focusing especially on obstacles to causal inference and
the need to return to an era where we acknowledge the fact that the incredibly negative consequences of current incarceration for mental health cannot
be ignored—even though this is an area of research that has received far too
little attention.
1. As the penal population ages, moreover, the costs associated with caring for this increasingly ill
population could become quite great—a topic worthy of an entire additional article, and one I do not
focus on in this specific entry.
Incarceration and Health
3
FOUNDATIONAL RESEARCH
Although much research on the consequences of incarceration for health
is quite new, two truly exceptional studies from an earlier era stick out as
forerunners in this field, The Prison Community, which was published by
Donald Clemmer in 1940 (Clemmer, 1940), and The Society of Captives, which
was published by Gresham Sykes in 1958 (Sykes, 1958). Although predominantly concerned not with the mental health of inmates but with the social
structure of the prison, each of these fascinating studies documented how
imprisonment affected the well-being of inmates, highlighting especially
the many ways in which imprisonment could either exacerbate existing
mental health problems or create new mental health problems for previously
healthy inmates. They also documented the complex and varying ways
in which imprisonment could affect mental health, firmly documenting a
well-known but rarely-tested idea that the effects of imprisonment on health
are likely moderated by unique traits of prisons and inmates.
After the publication of these studies, however, interest in the mental health
effects of imprisonment—at least in the research community—dropped off
(but see Haney, 2003) in favor of considering the physical health consequences of imprisonment. Much of the emphasis in this field also shifted
from considering the effects of current imprisonment on health to thinking
instead about the health effects of prior imprisonment. Of the many excellent works in this area, two especially stick out. The first of these studies
shows that the ever-imprisoned are far more likely to suffer from a host of
infectious and stress-related diseases in adulthood but not more likely to
suffer from other disorders not linked to exposure to infectious disease or
chronic stress (Massoglia, 2008). By showing both what health conditions
a history of imprisonment is and is not associated with, this essay goes a
long way toward showing how imprisonment shapes health. The second
study, which uses a research design that controls for fixed but stable traits
of individuals, provides evidence that current imprisonment may enhance
health in some regard, while prior imprisonment may compromise health in
important ways (Schnittker & John, 2007).
This insight corresponded nicely with a widely confirmed but perplexing
finding on the relationship between imprisonment and mortality: The
currently imprisoned were somewhat less likely to die than members of the
free population matched on basic characteristics such as age, sex, and race
(Mumola, 2007; Patterson, 2010; Spaulding et al., 2011), with this association
being most pronounced for young African-American men, while former
prisoners—especially recently released prisoners—were at exceptionally
high mortality risk relative to individuals in the free population (Binswanger
et al., 2007; Spaulding et al., 2011). Although the reasons for this paradoxical
4
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
relationship are not completely clear, it looks as if prisoners—especially
those drawn from the most disadvantaged realms of society—experience
lower than expected mortality rates because of the decreased risk of homicide, better nutrition, and more consistent health care they experience while
imprisoned. Studies of post-release mortality provide less guidance in this
regard, although they also tend to suggest that decreased tolerance among
opioid users during the imprisonment period dramatically increases the risk
of overdose-related mortality upon release.
Foundational research in this area, therefore, provides support for three
conclusions. First, imprisonment likely has negative mental consequences
for many individuals. Second, the imprisonment period, if often bad for
mental health and a time when a nonnegligible number of people will contract potentially life-threatening infectious diseases, does seem to have some
positive effects on morbidity and mortality. Finally, prior imprisonment is
strongly tied not only with elevated mortality risk but also with higher rates
of infectious and stress-related disease.
CUTTING-EDGE RESEARCH
If the first wave of research on the relationship between incarceration and
health was distinctive in no small part for pointing out how the effects of
current imprisonment and having ever been imprisoned differ, cutting-edge
research in this area is distinctive not only for attempting to better isolate
a causal relationship between current and prior imprisonment and mental
health but also for showing that the health implications of mass imprisonment extend far beyond the individuals who churn through the system to
their romantic partners and children as well.
The first wave of cutting-edge research I want to highlight here is a return
to the origins of the research on the consequences of imprisonment for
individuals. Indeed, as I noted at the beginning of this essay and elsewhere
(Muller & Wildeman, 2012; Wildeman & Muller, 2012), the initial push of
research on the effects of imprisonment on individuals focused heavily on
mental health—an emphasis lost for quite a while after (Clemmer, 1940;
Sykes, 1958). In just the last few years, two articles have been published that
provide new insight into just how much current and recent imprisonment
affect mental health. The first of these articles, which considers effects on a
range of mental health outcomes and uses the timing of onset to establish
appropriate time-ordering of incarceration and mental health, finds that
the ever-imprisoned are far more likely to suffer from mood disorders,
especially dysthymia, than are the never-imprisoned (Schnittker, Massoglia,
& Uggen, 2012). A second study tests the effects of current and recent
imprisonment on the risk of having major depressive disorder—what we
Incarceration and Health
5
often call depression—finding that changes in incarceration are associated
with changes in depression, strong evidence that both current and prior
incarceration may increase the risk of being depressed (Turney, Wildeman,
& Schnittker, 2012). Thus, this new wave of research suggests that the mental
health consequences of imprisonment considered broadly in the first wave
of research may indeed be causal, at least for some key outcomes.
The second wave of cutting-edge research that deserves special attention
here has to do with the spillover effects of imprisonment on the health of
the family members—especially the romantic partners and children—of the
currently and formerly imprisoned. Driven by a growing body of research
documenting the consequences of incarceration for family life (Braman,
2004; Comfort, 2008), this wave of research seeks to broaden the thinking
on the health consequences of imprisonment. Of research in this area, far
more has considered the consequences of having a father imprisoned in the
past couple of years for children’s mental health and behavioral problems
(Geller, Cooper, Garfinkel, Schwartz-Soicher, & Mincy, 2012; Wakefield &
Wildeman, 2011) or risk of infant and child mortality (Wildeman, 2012;
Wildeman, Andersen, Lee, & Karlson, 2014) than the effects of having a
partner incarcerated on women’s health. In general, this research finds that
even relative to children with nonresident fathers, children with incarcerated
fathers fare worse on a host of outcomes. Although research in this area
is still in its infancy, these findings, when combined with research on the
massive racial and class disparities in the risk of paternal imprisonment
(Wildeman, 2009), suggest that the effects of mass imprisonment on future
health inequality may be far larger than anticipated (Wakefield & Wildeman,
2013).
If research on the health effects of paternal incarceration on children is in its
infancy, research on the health effects of partner incarceration on women is
still in its gestational stage. Indeed, as of the writing of this essay, I was able
to locate only one published article linking the incarceration of a romantic
partner with women’s physical health and just one article on the topic that
considers the effects of having a romantic partner incarcerated on women’s
mental health. This work finds that having a family member incarcerated
increases women’s risk of having a host of cardiovascular disease risk factors
(Lee, Wildeman, Wang, Matusko, & Jackson, 2014) and that having a romantic
partner incarcerated increases women’s risk of having a major depressive disorder and decreases their happiness (Wildeman, Schnittker, & Turney, 2012).
Although this area is so very new, I nonetheless mention it because it suggests that the effects of mass imprisonment for public health—and health
disparities—may not be linked just to the men who cycle through the system
but also to the women and children who they leave behind.
6
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
Thus, while the first wave of research suggested that the mental health consequences of confinement might be acute (Clemmer, 1940; Sykes, 1958) and
carefully outlined a sometimes-paradoxical relationship between imprisonment and physical health (Binswanger et al., 2007; Massoglia, 2008; Mumola,
2007; Patterson, 2010; Schnittker & John, 2007; Spaulding et al., 2011), the
second wave of research in this area showed that the mental health consequences speculated in the first wave of research appear to be driven by
incarceration (Schnittker et al., 2012; Turney et al., 2012) and pointed in the
direction of broader spillover effects on the health of families, including both
children, (Wildeman, 2012; Wildeman et al., 2014), female romantic partners
(Wildeman et al., 2012), and female family members more broadly (Lee et al.,
2014).
KEY ISSUES FOR FUTURE RESEARCH
Although research on the relationship between incarceration and health
has made great strides in the past 10 years, a number of key issues for
future research nonetheless remain. These include providing stronger tests
of causality, thinking about how much mass imprisonment shapes health
inequalities, and (again) returning to the study of the health consequences
of confinement.
Suggesting the full range of ways that researchers working in this area
might overcome obstacles to causal inference is beyond the scope of this
essay, and hearing about a battery of statistical tests is likely not to be of interest to most readers of this essay, so I do not dwell on the nitty-gritty of this.
Nonetheless, the importance of this issue cannot be overstated. Indeed, without designing stronger causal tests of the incarceration–health relationship,
we cannot know whether diminishing the incarceration rate will help, harm,
or have no effect on the men and women for whom incarceration has become
common. Thus, until we know whether any of these effects are causal, we
cannot formulate effective policies that enhance population health.
A second key issue for future research in this area, which necessitates having credible causal estimates, involves deciphering the degree to which mass
imprisonment has actually done anything to increase health disparities.
On the face of it, that might seem like an odd statement as imprisonment
is unequally distributed and appears to have mostly negative effects on
health. Yet, as I have noted elsewhere (Muller & Wildeman, 2012; Wildeman
& Muller, 2012), the magnitude of the effects of mass imprisonment is
influenced not just by the magnitude of causal effects and the distribution
of imprisonment in the population but also by a host of other factors.
It is for this reason that mass imprisonment could explain nearly none
of black–white disparities in earnings and marriage (Western, 2006) but
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7
nearly all of black–white disparities in AIDS (Johnson & Raphael, 2009).
Future research must thus directly test for effects of mass imprisonment
on inequality rather than talking about these effects without testing for
them.
A final issue, and one I have again raised in parallel work (Muller &
Wildeman, 2012; Wildeman & Muller, 2012) has to do with whether thinking
about causal effects of imprisonment on inequality is even the right path.
Indeed, the foundational research in this area focused first and foremost on
the “pains of imprisonment” (Sykes, 1958) and their implications for the
mental health and well-being of the imprisoned. As this field moves forward,
I think this is an issue that all of us working in it will need to grapple with:
Are we interested in identifying causal effects, thinking about inequality in
health, or showing the extent of human suffering in prisons and jails? The
answer to that question is in many ways the key for this field as it moves
forward.
REFERENCES
Binswanger, I. A., Stern, M. F., Deyo, R. A., Heagerty, P. J., Cheadle, A., Elmore, J.
G., & Koepsell, T. D. (2007). Release from prison—a high risk of death for former
inmates. New England Journal of Medicine, 356(2), 157–165.
Braman, D. (2004). Doing time on the outside: Incarceration and family life in Urban America. Ann Arbor, MI: University of Michigan Press.
Clemmer, D. (1940). The prison community. New Braunfels, TX: Christopher Publishing House.
Comfort, M. (2008). Doing time together: Love and family in the shadow on the prison.
Chicago, IL: University of Chicago Press.
Garland, D. (Ed.) (2001). Mass imprisonment: Social causes and consequences. Thousand
Oaks, CA: Sage.
Geller, A., Cooper, C. E., Garfinkel, I., Schwartz-Soicher, O., & Mincy, R. B. (2012).
Beyond absenteeism: Father incarceration and child development. Demography,
49(1), 49–76.
Haney, C. (2003). Mental health issues in long-term solitary confinement and ‘supermax’ confinement. Crime and Delinquency, 49(1), 124–156.
Johnson, R. C., & Raphael, S. (2009). The effects of male incarceration dynamics on
acquired immune deficiency syndrome infection rates among African American
women and men. Journal of Law and Economics, 52(2), 251–293.
Lee, H., Wildeman, C., Wang, E. A., Matusko, N., & Jackson, J. S. (2014). A heavy burden? The cardiovascular health consequences of having a family member incarcerated. American Journal of Public Health, 104(3), 421–427.
Massoglia, M. (2008). Incarceration as exposure: The prison, infectious disease, and
other stress-related illnesses. Journal of Health and Social Behavior, 49(1), 56–71.
Muller, C., & Wildeman, C. (2012). Punishment and inequality. The SAGE handbook
of punishment and society (pp. 169–185). Thousand Oaks, CA: Sage.
8
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
Mumola, C. J. (2007). Medical causes of death in state prisons, 2001–2004. Washington, DC: Bureau of Justice Statistics. Retrieved from http://bjs.ojp.usdoj.gov/
content/pub/pdf/mcdsp04.pdf.
Patterson, E. J. (2010). Incarcerating death: Mortality in U.S. state correctional facilities, 1985–1998. Demography, 47(3), 587–607.
Schnittker, J., & John, A. (2007). Enduring stigma: The long-term effects of incarceration on health. Journal of Health and Social Behavior, 48(1), 115–130.
Schnittker, J., Massoglia, M., & Uggen, C. (2012). Out and down: Incarceration and
psychiatric disorders. Journal of Health and Social Behavior, 53(4), 448–462.
Spaulding, A. C., Seals, R. M., McCallum, V. A., Perez, S. D., Brzozowski, A. K., &
Steenland, N. K. (2011). Prisoner survival inside and outside of the institution:
Implications for health-care planning. American Journal of Epidemiology, 173(5),
479–487.
Sykes, G. (1958). The society of captives: A study of a maximum security prison. Princeton,
NJ: Princeton University Press.
Turney, K., Wildeman, C., & Schnittker, J. (2012). As fathers and felons: Explaining
the effects of current and recent incarceration on major depression. Journal of Health
and Social Behavior, 53(4), 465–481.
Wakefield, S., & Wildeman, C. (2011). Mass imprisonment and racial disparities in
childhood behavioral problems. Criminology and Public Policy, 10(3), 791–817.
Wakefield, S., & Wildeman, C. (2013). Children of the prison boom: Mass incarceration
and the future of American Inequality. New York, NY: Oxford University Press.
Western, B. (2006). Punishment and inequality in America. New York, NY: Russell Sage
Found.
Wildeman, C. (2009). Parental imprisonment, the prison boom, and the concentration
of childhood disadvantage. Demography, 46(2), 265–280.
Wildeman, C. (2012). Imprisonment and infant mortality. Social Problems, 59(2),
228–257.
Wildeman, C., Andersen, S. H., Lee, H., & Karlson, K. B. (2014). Parental incarceration
and child mortality in Denmark. American Journal of Public Health, 104(3), 428–433.
Wildeman, C., & Muller, C. (2012). Mass imprisonment and inequality in health and
family life. Annual Review of Law and Social Science, 8(1), 11–30.
Wildeman, C., Schnittker, J., & Turney, K. (2012). Despair by association? The mental
health of mothers with children by recently incarcerated fathers. American Sociological Review, 77(2), 216–243.
FURTHER READING
Binswanger, I. A., Stern, M. F., Deyo, R. A., Heagerty, P. J., Cheadle, A., Elmore, J.
G., & Koepsell, T. D. (2007). Release from prison—a high risk of death for former
inmates. New England Journal of Medicine, 356(2), 157–165.
Comfort, M. (2008). Doing time together: Love and family in the shadow on the prison.
Chicago, IL: University of Chicago Press.
Haney, C. (2003). Mental health issues in long-term solitary confinement and ‘supermax’ confinement. Crime and Delinquency, 49(1), 124–156.
Incarceration and Health
9
Sykes, G. (1958). The society of captives: A study of a maximum security prison. Princeton,
NJ: Princeton University Press.
Wildeman, C., & Muller, C. (2012). Mass imprisonment and inequality in health and
family life. Annual Review of Law and Social Science, 8(1), 11–30.
CHRISTOPHER WILDEMAN SHORT BIOGRAPHY
Christopher Wildeman is an Associate Professor of Policy Analysis and
Management at Cornell University. Since 2013, he has also been a visiting
fellow at the Bureau of Justice Statistics. He received his PhD in Sociology
and Demography from Princeton University in 2008. From 2008 to 2010,
he was a Robert Wood Johnson Foundation Health & Society Scholar at
the University of Michigan. And from 2010 to 2014, he was an Assistant
(2010–2013) and later Associate (2013–2014) Professor of Sociology at Yale
University. His research interests revolve around the consequences of
mass imprisonment for inequality, with emphasis on families, health, and
children. He is also interested in child welfare more broadly, especially as
relates to child maltreatment and foster care. He is the 2013 recipient of the
Ruth Shonle Cavan Young Scholar Award from the American Society of
Criminology and the Distinguished New Scholar Award from the American
Society of Criminology’s Division on Corrections and Sentencing.
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