A systematic review of behavioral health interventions for suicidal and self-harming individuals in prisons and jails

Mental Health, Drug Use, and Programming: Applying a Needs Assessment Framework in Arkansas' Largest Jail

Jail programming is rarely informed by site-specific health needs, diagnostic-specific screening tools that are validated, or the input of incarcerated individuals. Using the community needs assessment (CNA) framework, we aimed to fill these gaps among people incarcerated in the Pulaski County Regional Detention Facility (PCRDF), Arkansas' largest jail. Participants were 179 adults at the PCRDF who completed surveys and open-ended questions focused on (a) their mental and behavioral health and (b) programming needs at the facility. Using a concurrent transformative mixed-methods design, we descriptively analyzed surveys and conducted content analysis of the open-ended questions. Over half of participants reported clinically significant anxiety (62.6%), post-traumatic stress disorder (53.1%), and/or depression (50.3%) symptoms; positive substance use disorder screening was especially common (91.7%). Nearly all (97%) individuals queried desired more programming, with the most desired being mental health and substance use programs. Other desired programs included physical health, education, community reintegration, family support, recreation, nutrition, religious/spiritual services, and meditation. Our CNA ensured the input of those directly impacted during program-focused decision making and identified strategies to effectively implement and sustain jail-based programs. Such assessments can be a potential mechanism for addressing the burden of mental and behavioral health problems in jail populations.

Mortality in women with a history of incarceration in Norway: a 20-year national cohort study

BACKGROUND

Women carry a substantial burden of psychiatric, somatic and lifestyle-related morbidity in the prison context. By describing causes of death and estimating the risk and burden of mortality compared with the general population, this study investigates how mortality operates in this highly marginalized and under-researched population.

METHODS

In this registry-based study of all women incarcerated in Norwegian prisons from 2000 to 2019 (N = 11 313), we calculated crude mortality rates, years of lost life and, by using mortality in age-matched women from the general population as a reference, age-standardized mortality ratios and years of lost life rates.

RESULTS

Over a mean follow-up time of 10.7 years, at a median age of 50 years, 9% of the population had died (n = 1005). Most deaths (80%) were premature deaths from an avoidable cause. Drug-induced causes and deaths from major non-communicable diseases (NCDs) were most frequent (both 32%). Compared with women in the general population, women with a history of incarceration were more likely to die from any cause. Trends in annual age-standardized years of lost life rates suggest that the mortality burden associated with major NCDs has gradually replaced drug-induced causes.

CONCLUSIONS

Women with a history of incarceration die at a greater rate than their peers and largely from avoidable causes. The profile of causes contributing to the substantial burden of mortality placed on this population has changed over time and has important implications for future efforts to reduce morbidity and the risk of premature death following release from prison.

Efficiency of psychological interventions in the prevention of suicidal behavior and self-injury in penitentiary population: A systematic review

INTRODUCTION

Suicidal behavior is an important public health problem, with a high prevalence in penitentiary context. Nowadays, there is a wide variety of specific treatment programs, aimed to prevent suicidal and self-injurious behavior in incarcerated people. These programs show relative efficiency depending on the model of the psychological intervention applied. This systematic review evaluates the efficiency of suicidal and self-injurious behavior prevention programs in prisons.

METHOD

Empirical studies, evaluating prevention programs for suicidal and self-injurious behavior in penitentiary context were considered for inclusion. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) directives were followed. Studies from 1990 to 2022 were reviewed, based on the review developed by Winicov (2019) that covered the time lapse between 1990 and 2015. Articles from 2015 to 2022 were located by database research (EBSCOHost, ScienceDirect, PubMed & ProQuest).

RESULTS

44,050 potential studies were identified. Eighteen were included in this systematic review (9 studies by Winicov, 2019). 14 studies showed efficacy of intervention programs on self-injury behavior. The use of Cognitive Behavioral Therapy (CBT) reduced suicidal ideation. In addition, positive results were observed in 3 studies using third-generation therapies as an intervention.

CONCLUSIONS

Suicidal and self-injurious behavior in prison shows lower levels of incidence when specific treatment programs are applied. It's crucial to increase the evaluation in relation to the implementation of new treatment models (i.e., Dialectical Behavior Therapy - DBT, Acceptance and Commitment Therapy - ACT, Mindfulness, Functional Analytic Psychotherapy - FAP) as to better orientate prevention strategies. Further research is needed in gender sensitive interventions.

Integrated Safety and Health Promotion among Correctional Workers and People Incarcerated: A Scoping Review

Improving safety and health for correctional workers and people who are incarcerated are widespread yet separate initiatives. Correctional workers and people who are incarcerated experience similar challenges involved with poor workplaces and living conditions, including mental health crises, violence, stress, and chronic health issues, and the available resources lack integration with respect to safety and health promotion. This scoping review sought to contribute to an integrated approach for correctional system safety and health resources and identify studies of correctional resources that address health promotion among correctional workers and people who are incarcerated. Guided by PRISMA, a search of gray literature, also termed peer-reviewed literature, published between 2013-2023 (n = 2545) was completed, and 16 articles were identified. Resources primarily targeted individual and interpersonal levels. At every level of intervention, resources improved the environment for both workers and those incarcerated, with trends of less conflict, more positive behaviors, and improved relations, access to care, and feelings of safety. The corrections environment is impacted by changes from both workers and people who are incarcerated and should be examined using a holistic approach. Future health and safety resources should target the larger correctional environment by utilizing practices, policies, and procedures to improve safety and health for incarcerated people and workers.

Sex differences in suicide, suicidal ideation, and self-harm after release from incarceration: a systematic review and meta-analysis

PURPOSE

People released from incarceration are at increased risk of suicide compared to the general population. We aimed to synthesise evidence on the incidence of and sex differences in suicide, suicidal ideation, and self-harm after release from incarceration.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, Web of Science and PubMed between 1 January 1970 and 14 October 2021 for suicide, suicidal ideation, and self-harm after release from incarceration (PROSPERO registration: CRD42020208885). We calculated pooled crude mortality rates (CMRs) and standardised mortality ratios (SMRs) for suicide, overall and by sex, using random-effects models. We calculated a pooled incidence rate ratio (IRR) comparing rates of suicide by sex.

RESULTS

Twenty-nine studies were included. The pooled suicide CMR per 100,000 person years was 114.5 (95%CI 97.0, 132.0, I² = 99.2%) for non-sex stratified samples, 139.5 (95% CI 91.3, 187.8, I² = 88.6%) for women, and 121.8 (95% CI 82.4, 161.2, I² = 99.1%) for men. The suicide SMR was 7.4 (95% CI 5.4, 9.4, I² = 98.3%) for non-sex stratified samples, 14.9 for women (95% CI 6.7, 23.1, I² = 88.3%), and 4.6 for men (95% CI 1.3, 7.8, I² = 98.8%). The pooled suicide IRR comparing women to men was 1.1 (95% CI 0.9, 1.4, I² = 82.2%). No studies reporting self-harm or suicidal ideation after incarceration reported sex differences.

CONCLUSION

People released from incarceration are greater than seven times more likely to die by suicide than the general population. The rate of suicide is higher after release than during incarceration, with the elevation in suicide risk (compared with the general population) three times higher for women than for men. Greater effort to prevent suicide after incarceration, particularly among women, is urgently needed.

Understanding the Self-Harming Behavior of Filipino Male Detainees (32-58 Years Old): A Descriptive Phenomenology

Self-harming behavior (SHB) has become a significant health issue among several populations, including adolescents, traumatized individuals, and persons deprived of liberty. Undoubtedly, incarceration takes a toll on inmates' mental health due to several stressful experiences while in custody. These taxing events make them vulnerable to maladaptive coping strategies, such as SHB. To date, many studies on this behavior have focused on high-income countries. Research has not explored much on this behavior among inmates in developing countries such as the Philippines. This phenomenological inquiry aims to characterize the experiences of select older male Filipino detainees engaged in SHB. Through vertical and horizontal analyses of the narratives shared, this study conceptualized the Self-Harming Behavior of Older Filipino Detainees as Tension and Compression. This model shows the forces that either pull or push the detainees to engage in self-injurious acts. Specifically, the seven themes surfaced: life dispositions, jail ecology, emotional baggage, physically and chemically-induced self-harming behavior, consequences, coping strategies, and cognizance. Findings from this inquiry may necessitate the provision of adequate and comprehensive prevention and intervention services for the self-harmers in jail, which are geared toward implementing a thorough psychological evaluation and promoting sound psychological well-being.

Preventing suicidal and self-Injurious behavior in correctional facilities: A systematic literature review and meta-analysis

BACKGROUND

Rates of suicide and self-harm are elevated in carceral institutions. Inmates are a vulnerable group since they are exposed to multiple risk factors. This paper critically reviews empirical research on programs to prevent suicidal and self-harmful behaviors in correctional facilities and summarizes effect sizes across studies.

METHODS

We searched PsychINFO, PubMed, IEEEXPLORE and the CRISE Documentation Centre Database to identify relevant articles published before June 2022. Inclusion criteria were: peer-reviewed and with outcome data on effectiveness of prevention activities. Two reviewers independently assessed 905 articles to determine inclusion eligibility. Quality was assessed by two independent reviewers using the Quality Assessment Tool for Quantitative Studies. Meta-analyses using random-effect models were used to pool effect sizes for each outcome. This review was conducted in accordance with PRISMA guidelines.

FINDINGS

Twenty-four of the 905 articles, published between 1980 and 2022, were included. Studies were frequently conducted in the United States (n=13; 54%) and used varying study designs; most frequently pre-post with no control group (n=9; 38%). Sample sizes and interventions varied considerably. Most were of moderate quality (n=21; 88%). On average, prevention programs in correctional facilities were effective in decreasing suicide deaths (pooled rate ratio of 0·35 [95% CI 0·23 to 0·55; p<0·001]; I²=68·01%), incidents of self-harm (pooled Hedges'g of -0·54 (95% CI: -1·03 to -0·05; p=0·031]; I²=81·34%), and suicidal ideation (pooled Hedges'g of -0·39 [95% CI: -0·65 to -0·14; p=0·003]; I²=47·09%).

INTERPRETATION

Prevention activities are effective in reducing suicide death, self-harm and suicidal ideation in correctional settings. Multicomponent programs, which include several preventive activities, seem to be most effective in reducing suicide deaths. Future evaluation studies should control for confounding variables by including control groups, having larger samples and limiting attrition. Standards for suicide prevention in jails and prisons should be included in National suicide prevention strategies.

FUNDING

None.

Gender and Racial Disparity Among US Forensic Psychiatry Fellows: Broken System by Default

Diversity enhances the performance of the healthcare system by providing better patient outcomes and reducing physician burnout. In this study, we explored the gender and racial trends in the recruitment of women and racial minorities into forensic psychiatry fellowship programs in the US. Retrospective data analysis was performed by utilizing the data from the Accreditation Council for Graduate Medical Education (ACGME)'s annual Data Resource Books from the year 2007 to 2021. Demographic data, including gender and race, were extracted for forensic psychiatry fellows. The number of female trainees increased significantly to become a majority, i.e., 58.8% of all forensic psychiatry trainees in 2020-2021 were female compared to 27.78% of women forensic psychiatry fellows in 2007-08. Between 2011-12 and 2020-2021, there was a relative increase in White (Non-Hispanic), Asian/Pacific Islander and Black (Non-Hispanic) forensic psychiatry fellows, by 54.75%, 114.4%, and 0.36% respectively. Despite the overall increase in the numbers of ethnic minorities in US psychiatry residency and fellowship programs, racial minorities remain significantly under-represented in forensic psychiatry fellowship programs. We need to revise policies to promote underrepresented minorities in medicine (URMM) in forensic psychiatry.

Non-Suicidal Self-Injury in Russian Patients with Suicidal Ideation

BACKGROUND

Nonsuicidal self-injury (NSSI) is recognized as a public health concern for its association with unfavorable outcomes, including suicidal behavior. The aim of this study is to identify factors associated with NSSI among patients with nonpsychotic mental disorders (NPMD) and suicidal ideation in Russia.

METHODS

A retrospective cohort study was conducted in the Moscow Research and Clinical Center for Neuropsychiatry between November 2017 and May 2019. The sample was composed of consecutive patients with lifetime suicidal ideation (from the Self-Injurious Thoughts and Behavior Interview) seen in the center's psychiatric ward for NPMD. The patients were divided into two groups: those with and without lifetime NSSI. Sociodemographic variables, psychiatric diagnosis, family history of mental disorders, history of physical or sexual abuse, sexual behavior, ad-hoc psychiatric treatments, suicidal ideation, plans, and gestures or attempts were investigated.

RESULTS

Six thousand, two hundred and four consecutive patients were screened for suicidal ideation. Out of a total of 361 patients (87.3% females) with suicidal ideation, 217 (60.1%) reported NSSI. Variables independently associated with NSSI included age <25 years (OR 6.0, CI 2.5-14.7), dissatisfaction with the perceived parenting style (OR 3.3, CI 1.5-7.4), bullying (OR 2.6, CI 1.0-6.5), severe body modifications (OR 11.9, CI 1.1-134.3), experience with illicit drugs (OR 4.4, CI 1.9-10.3), and eating disorders (OR 4.9, CI 2.0-11.8).

LIMITATIONS

Retrospective design, referral population, single center study, and exclusion of psychotic patients.

CONCLUSIONS

NSSI is associated with age <25 years old, dissatisfaction with perceived parenting style, bullying, severe body modifications, lifetime experience of illicit drug-use, and lifetime eating disorders.HIGHLIGHTSNonsuicidal self-injury is a significant public health concern for its association with suicidal behavior.60.1% of Russian patients with non-psychotic mental disorders (NPMD) and suicidal ideation reported lifetime NSSI.NSSI in Russian patients with NPMD and suicidal ideation is associated with age less than 25 years, dissatisfaction with perceived parenting style, bullying, severe body modifications, lifetime experience of illicit drug use, and lifetime eating disorders.

Effectiveness of Nonsuicidal Self-Injury Interventions among Incarcerated Women in Correctional Facilities and Secure Settings: An Integrative Review

Nonsuicidal self-injury (NSSI) is prevalent among incarcerated women in correctional facilities. This poses a challenge in selecting appropriate intervention. This integrative review aimed to identify effective interventions for managing NSSI among incarcerated women. Whittemore and Knafl's framework for integrative reviews was used, and eight databases were searched with 11 papers meeting the inclusion criteria. Six interventions for NSSI for incarcerated women were identified as promising in reducing the rate of NSSI. Data did not support the effectiveness of gender-specific interventions for incarcerated women. There is a need for further research to identify appropriate interventions to target NSSI among incarcerated women.

Epidemiology, Risk Factors, and Prevention of Suicidal Thoughts and Behaviour in Prisons: A Literature Review

Suicide is a global public health concern that affects all echelons of society, albeit not equally so. Compared with adults in the general population, incarcerated offenders are at increased risk to consider, attempt, and die by suicide, which represents a substantial burden of morbidity and mortality in prisons worldwide. This review synthesises recent literature pertaining to the epidemiology, risk factors, and prevention of suicidal thoughts and behaviour among prisoners, and outlines a framework which emphasises the interplay between individuals (importation) and their surroundings (deprivation). The available evidence suggests that prison-specific stressors may exacerbate risk of suicide in an already vulnerable population characterised by complex health and social care needs. Emerging data point to differential mechanisms through which prisoners come to think about suicide and subsequently progress to suicidal behaviour. As risk of suicide is determined by a complex web of synergistically interacting factors, its management and prevention demands a cross-sectoral policy and service response that includes targeted interventions aimed at high-risk prisoners in combination with population strategies that promote the health and wellbeing of all people in prison.

Non-Suicidal Self-Injury Among Incarcerated Adolescents: Prevalence, Personality, and Psychiatric Comorbidity

Introduction: Incarcerated adolescents represent a risk group for non-suicidal self-injury (NSSI), but research on this population has been limited and no studies have been conducted in Russia. To address this deficit, this study examined NSSI and the factors associated with it among youth in a juvenile correctional facility in Russia. Methods: NSSI and psychopathology were assessed using a psychiatric interview and self-report questionnaire in 368 incarcerated male adolescents aged 14-19 years (mean age 16.4 years, S.D. 0.9) from Northern Russia. Results: 18.2% (N = 67) of the study participants had a history of NSSI and also had higher rates of anxiety, post-traumatic stress disorder (PTSD), depression, community violence exposure and scored higher on most of the Youth Self-Report problem scales. In addition, 31.3% of the NSSI group reported previous suicidal ideation and had thought about a specific suicide method compared to 12.0% in the No-NSSI group. Adolescents with NSSI also differed significantly from the No-NSSI group on self-directedness (lower) and self-transcendence (higher) personality traits. Conclusion: NSSI is common in incarcerated adolescents in Russia and is associated with extensive psychiatric comorbidity, suicidal ideation and specific personality traits.

Factors associated with the transition from suicidal ideation to suicide attempt in prison

BACKGROUND

Although research has identified a wide range of risk factors for suicidal behavior in prisoners, it does not establish who is most likely to act on their suicidal thoughts while incarcerated.

METHODS

Self-report data were collected from a random sample of 1,203 adult men incarcerated across 15 prisons in Belgium, who represent 12% of all male prisoners nationwide.

RESULTS

One-third (33%) of participants reported having suicidal thoughts during their incarceration, of whom 26% attempted suicide in prison (9% of all prisoners). Factors independently associated with suicide attempt among prisoners with suicidal ideation were violent offending (adjusted odds ratio [aOR] = 2.64, 95% confidence interval [CI] 1.33-5.23), in-prison drug use (aOR = 2.30, 95% CI 1.25-4.22), exposure to suicidal behavior (aOR = 1.96, 95% CI 1.04-3.68), and a lifetime history of nonsuicidal self-injury (aOR = 1.90, 95% CI 1.08-3.36). While related to suicidal thoughts, markers of psychiatric morbidity and aspects of the prison regime were not associated with the progression to suicide attempt.

CONCLUSIONS

Many prisoners who think about suicide do not attempt suicide while incarcerated. Factors associated with suicidal ideation are distinct from those that govern the transition to suicidal behavior. Our findings lend support to the hypothesis that behavioral disinhibition might act as a catalyst in the translation of suicidal thoughts into action.

Risk factors for self-harm in prison: a systematic review and meta-analysis

BACKGROUND

Self-harm is a leading cause of morbidity in prisoners. Although a wide range of risk factors for self-harm in prisoners has been identified, the strength and consistency of effect sizes is uncertain. We aimed to synthesise evidence and assess the risk factors associated with self-harm inside prison.

METHODS

In this systematic review and meta-analysis, we searched four electronic databases (PubMed, Embase, Web of Science, and PsycINFO) for observational studies on risk factors for self-harm in prisoners published from database inception to Oct 31, 2019, supplemented through correspondence with authors of studies. We included primary studies involving adults sampled from general prison populations who self-harmed in prison and a comparison group without self-harm in prison. We excluded studies with qualitative or ecological designs, those that reported on lifetime measures of self-harm or on selected samples of prisoners, and those with a comparison group that was not appropriate or not based on general prison populations. Data were extracted from the articles and requested from study authors. Our primary outcome was the risk of self-harm for risk factors in prisoners. We pooled effect sizes as odds ratios (OR) using random effects models for each risk factor examined in at least three distinct samples. We assessed study quality on the basis of the Newcastle-Ottawa Scale and examined between-study heterogeneity. The study protocol was registered with PROSPERO, CRD42018087915.

FINDINGS

We identified 35 independent studies from 20 countries comprising a total of 663 735 prisoners, of whom 24 978 (3·8%) had self-harmed in prison. Across the 40 risk factors examined, the strongest associations with self-harm in prison were found for suicide-related antecedents, including current or recent suicidal ideation (OR 13·8, 95% CI 8·6-22·1; I²=49%), lifetime history of suicidal ideation (8·9, 6·1-13·0; I²=56%), and previous self-harm (6·6, 5·3-8·3; I²=55%). Any current psychiatric diagnosis was also strongly associated with self-harm (8·1, 7·0-9·4; I²=0%), particularly major depression (9·3, 2·9-29·5; I²=91%) and borderline personality disorder (9·2, 3·7-22·5; I²=81%). Prison-specific environmental risk factors for self-harm included solitary confinement (5·6, 2·7-11·6; I²=98%), disciplinary infractions (3·5, 1·2-9·7; I²=99%), and experiencing sexual or physical victimisation while in prison (3·2, 2·1-4·8; I²=44%). Sociodemographic (OR range 1·5-2·5) and criminological (1·8-2·3) factors were only modestly associated with self-harm in prison. We did not find clear evidence of publication bias.

INTERPRETATION

The wide range of risk factors across clinical and custody-related domains underscores the need for a comprehensive, prison-wide approach towards preventing self-harm in prison. This approach should incorporate both population and targeted strategies, with multiagency collaboration between the services for mental health, social care, and criminal justice having a key role.

FUNDING

Wellcome Trust.