Murderers or thieves at risk? Offence-related suicide rates in adolescent and adult prison populations

Risk factors of suicide in prisons: a comprehensive retrospective cohort study in France, 2017-2020

PURPOSE

Suicide is a leading cause of death in prison and the suicide rates are several times higher in the prison population than in the general population in most countries. Of the studies that have investigated risk factors for suicide in prison, few have controlled for possible confounding factors. The aim of this study is to identify risk factors of suicide among people in French prisons, over a four-year period.

METHODS

All incarcerations that occurred in France during 2017-2020 were eligible. Sociodemographic, criminal and prison characteristics were collected for each incarceration from data of the National Prison Service. Survival univariate and multivariate analyses were performed with a Cox regression model.

RESULTS

358,522 incarcerations were included, of which 449 ended in suicide during the follow-up. The median length of prison stay was 5.1 months. The median age at prison entry was 30 years and 95.8% of incarcerations involved men. The overall suicide rate was 173 [157-189] per 100,000 person-years. Factors associated with suicide in the multivariate model (p < 0.05) were the early stage of incarceration and in particular the first week (HR = 7.6 [5.4-10.8]), violent offences and in particular homicide (HR = 3.0 [2.1-4.2]), French (HR = 1.7 [1.2-2.4]) and other European nationalities (HR = 2.1 [1.4-3.3]), age above 40 (HR = 2.0 [1.5-2.6]), pre-trial incarceration (HR = 1.8 [1.4-2.3]), being separated (HR = 1.6 [1.1-2.3] and having a high school diploma (HR = 1.4 [1.0-1.8]).

CONCLUSIONS

Factors associated with suicide in prison are complex and involve individuals' criminal history as well as conditions of incarceration. These characteristics may be relevant to focus suicide prevention efforts.

Suicide risk in male incarcerated individuals in Spain: clinical, criminological and prison-related correlates

BACKGROUND

Prison suicide is a complex phenomenon that may be influenced by individual, clinical, social and environmental factors. In Spain, few studies have explored the relationship with institutional, prison-related variables. The aim of this study is to examine correlates of suicide in a sample of male incarcerated individuals from 5 Spanish penitentiary centers.

METHODS

This present study entails a secondary data analysis, using data from the Prevalence of mental disorders in prisons study. This is a cross-sectional multicenter study conducted in 2007-2008 across 5 penitentiary centers in Spain. The Spanish version of the Plutchik suicide risk scale was used to assess the risk of suicide (those scoring ≥ 6 were considered to be at risk of suicide). Sociodemographic, clinical, criminological and prison-related data were collected via face-to face interviews and criminological data were confirmed using penitentiary records.

RESULTS

The final sample included 707 male incarcerated individuals (mean age 36.79 years ± 9.90 years). Several significant correlates associated with higher risk of suicide were identified including criminological factors (having committed a violent offense, being a recidivist), clinical factors (family history of mental disorders, the presence of mental disorders, having physical conditions, contact with a mental health specialist, medication treatment in the last 12 months), and prison-related determinants (workshop/training course participation) was significantly associated with lower suicide risk.

CONCLUSIONS

Several correlates within a comprehensive range of sociodemographic, criminological, clinical and prison-related variables were identified. This information is primordial for preventing suicide and reducing the existing risk. The findings may contribute to developing effective suicide prevention programs within Spanish prison services. Importantly, future research must continue to investigate the nature of suicidal outcomes among incarcerated individuals.

Suicidal Offenders and Non-Offenders with Schizophrenia Spectrum Disorders: A Retrospective Evaluation of Distinguishing Factors Using Machine Learning

Patients with schizophrenia spectrum disorders (SSD) have an elevated risk of suicidality. The same has been found for people within the penitentiary system, suggesting a cumulative effect for offender patients suffering from SSD. While there appear to be overlapping characteristics, there is little research on factors distinguishing between offenders and non-offenders with SSD regarding suicidality. Our study therefore aimed at evaluating distinguishing such factors through the application of supervised machine learning (ML) algorithms on a dataset of 232 offenders and 167 non-offender patients with SSD and history of suicidality. With an AUC of 0.81, Naïve Bayes outperformed all other ML algorithms. The following factors emerged as most powerful in their interplay in distinguishing between offender and non-offender patients with a history of suicidality: Prior outpatient psychiatric treatment, regular intake of antipsychotic medication, global cognitive deficit, a prescription of antidepressants during the referenced hospitalisation and higher levels of anxiety and a lack of spontaneity and flow of conversation measured by an adapted positive and negative syndrome scale (PANSS). Interestingly, neither aggression nor overall psychopathology emerged as distinguishers between the two groups. The present findings contribute to a better understanding of suicidality in offender and non-offender patients with SSD and their differing characteristics.

Depression in Male Inmates

Introduction: The prevalence of psychiatric morbidity is high among incarcerated individuals. Severe mental disorder is five to ten times higher among prisoners compared to the general population. Several factors are held to be responsible for the high prevalence of depression in prison: mainly poor living conditions (narrow room, loss of privacy), limited interpersonal relationships, and lack of mental health access. Inmates are at increased risk of all-cause mortality, suicide, self-harm, violence, and victimization while those with mental disorders are involved in conflicts and are more likely to be charged with prison rules. Purpose: To explore depression among male inmates. Methods and material: In the study, 101 male inmates were enrolled. Data were collected by the completion of a “self-rating depression scale (SDS)-Zung” which included participants’ characteristics. The statistical significance level was p < 0.05. Results: Of the 101 participants, 51.4% of inmates were under 40 years old, 54.5% were married, 45.6% had been convicted of homicide and 38.6% had a life sentence. Normal depression levels were experienced by 62.4% of the participants, while 21.8% were mildly depressed, 14.9% were moderately depressed and 1.0% severely depressed. Foreign prisoners had statistically significant higher scores of depression compared to Greeks (median 48 vs. 45, p = 0.012); those suffering from a chronic disease compared to those who did not (median 48 vs. 45, p = 0.038); those who had spent time in solitary confinement compared to those who had not (median 46 vs. 43.5, p = 0.038) as well as those who had not considered harming themselves compared to those who had thought of it (median 46 vs. 44, p = 0.017). Conclusion: Given that prison populations are marginalized and deprived of the rights that people in the community benefit from, establishing the prevalence of depression in male inmates and its associated characteristics may help to formulate recommendations for future prison health care services. Clinical, research, and policy efforts are needed to improve prison mental health.

Characteristics of persons who died by suicide in prison in France: 2017-2018

BACKGROUND

In northern countries, suicide rates among prisoners are at least three times higher for men and nine times higher for women than in the general population. The objective of this study is to describe the sociodemographic, penal, health characteristics and circumstances of suicide of French prisoners who died by suicide.

METHODS

This study is an intermediate analysis of the French epidemiological surveillance program of suicides in prison. All suicides in prison in 2017-2018 in France were included in the study. Archival sociodemographic and penal data and specific data on the circumstances of the suicidal act were provided by the National Prison Service. Health data was provided by physicians working in prison using a standardized questionnaire.

RESULTS

In 2017-2018, 235 prisoners died by suicide. The suicide rate was 16.8/10 000 person-years. Among suicide cases, 94.9% were male, 27.2% were under 30, 25.1% were aged 30 to 39, 27.7% were aged 40 to 49 and 20.0% were 50 or older. At the time of suicide, 48.5% were on custodial remand. Incarceration is associated with a threefold increase in the frequency of anxio-depressive disorders (24.6% in prison versus 8.2% before prison). The week before the suicidal act, 60% of prisoners visited the health unit and a significant event was detected for 61% of all cases. Suicide was less than 1 week after prison entry for 11.9% of prisoners, corresponding to a suicide rate 6.4 (CI_95% [4.3 - 9.5]) times higher than for the remaining time in prison, and was more than 1 year after entry for 33.7% of them.

CONCLUSIONS

The high frequency of events the week before suicide in our study suggests that events in prison could play a role in the occurrence of suicides. Comparative studies are needed to further explore the time association between events and suicide in prison. As most of prisoners who died by suicide visited the health unit the week before suicide, the identification of triggering factors could help psychiatrists and other health professionals to assess the short-term risk of suicide and to implement preventive measures.

[Suicides in the German prison system: frequency, risk factors, and prevention]

Gefangene haben ein hohes Suizidrisiko und die höchsten Suizidraten sind bei Untersuchungsgefangenen zu verzeichnen. Suizid ist die häufigste singuläre Todesursache in deutschen Gefängnissen. In diesem narrativen Übersichtsbeitrag werden zunächst die Gefängnispopulation und ihre allgemeine Gesundheitsversorgung beschrieben, wobei insbesondere auf psychiatrische und Substanzkonsumstörungen eingegangen wird. Der Hauptteil widmet sich der Prävalenz, den Ursachen und Risikofaktoren von Gefängnissuizid. Maßnahmen zur Suizidprävention werden dargestellt.

Der Anteil von Männern unter Gefangenen in Deutschland ist mit 94 % (2020) wie in allen Teilen der Welt sehr hoch. Die meisten Gefangenen sind jungen oder mittleren Alters. Die durchschnittlichen jährlichen Suizidraten bei Männern und Frauen in deutschen Gefängnissen entsprechen mit 105,8/100.000 bzw. 54,7/100.000 denen der meisten Länder in der Europäischen Union (Vollerhebung 2000–2011). Die Suizidraten bei männlichen deutschen Gefangenen sind in den Jahren 2000–2013 unabhängig vom Alter kontinuierlich zurückgegangen. Bei weiblichen Gefangenen stiegen sie dagegen an, wobei die Ursachen hierfür nicht bekannt sind. Es gibt Hinweise darauf, dass psychiatrische Erkrankungen nicht erkannt worden waren.

Wichtige suizidpräventive Maßnahmen sind die Unterbringung in Gemeinschaft und die Vermeidung von Isolation, beispielsweise durch das Angebot von Arbeit. Zudem stehen validierte deutschsprachige Screeninginstrumente zur Verfügung, um ein Suizidrisiko frühzeitig zu erkennen. Für eine wirksame Gefängnissuizidprävention bedarf es der Identifikation von Hochrisikopersonen, des Angebots geeigneter suizidpräventiver Maßnahmen sowie der Entwicklung teambezogener Maßnahmen beim Gefängnispersonal.

Suicide in prison and after release: a 17-year national cohort study

Background

People in prison have an extremely high risk of suicide. The aim of this paper is to describe all suicides in the Norwegian prison population from 2000 to 2016, during and following imprisonment; to investigate the timing of suicides; and to investigate the associations between risk of suicide and types of crime.

Methods

We used data from the Norwegian Prison Release study (nPRIS) including complete national register data from the Norwegian Prison Register and the Norwegian Cause of Death Register in the period 1.1.2000 to 31.12.2016, consisting of 96,856 individuals. All suicides were classified according to ICD-10 codes X60-X84. We calculated crude mortality rates (CMRs) per 100,000 person-years and used a Cox Proportional-Hazards regression model to investigate factors associated with suicide during imprisonment and after release reported as hazard ratios (HRs).

Results

Suicide accounted for about 10% of all deaths in the Norwegian prison population and was the leading cause of death in prison (53% of in deaths in prison). The CMR per 100,000 person years for in-prison suicides was 133.8 (CI 100.5–167.1) and was ten times higher (CMR = 1535.0, CI 397.9–2672.2) on day one of incarceration. Suicides after release (overall CMR = 82.8, CI 100.5–167.1) also peaked on day one after release (CMR = 665.7, CI 0–1419.1). Suicide in prison was strongly associated with convictions of homicide (HR 18.2, CI 6.5–50.8) and high-security prison level (HR 15.4, CI 3.6–65.0). Suicide after release was associated with convictions of homicide (HR 3.1, CI 1.7–5.5).

Conclusion

There is a high risk of suicide during the immediate first period of incarceration and after release. Convictions for severe violent crime, especially homicide, are associated with increased suicide risk, both in prison and after release.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10654-021-00782-0.

Suicide after reception into prison: A case-control study examining differences in early and late events

OBJECTIVE

Prisoners constitute a high-risk group for suicide, with suicide rates about 5 to 8 times higher than in the general population. The first weeks of imprisonment are a particularly vulnerable time, but there is limited knowledge about the risk factors for either early or late suicide events.

METHODS

Based on a national total sample of prison suicides in Germany between 2005 and 2017, suicides within the first 2 (4 and 8) weeks after reception into prison were matched by age and penalty length with cases that occurred later. Factors that potentially influence the timing of suicide were investigated.

RESULTS

The study has shown that 16.7% (31.5%) of all 390 suicides in German prisons occurred within the first two weeks (two months) of imprisonment. Factors that facilitate adaptation to the prison environment (e.g. prior prison experience) were negatively associated with early suicide events. Factors that hindered the adaptation process (e.g. withdrawal from illicit drugs) were observed more frequently in early suicide events than in late ones. These factors are active at different times of imprisonment.

CONCLUSION

At reception, particular attention should be paid to the following factors associated with early suicide events: widowed marital status, lack of prison experience, and drug dependency.

Personal, Criminal and Social Predictors of Suicide Attempts in Prison

Previous epidemiological analyses indicate that specific demographic and criminal factors might be associated with suicide attempts during incarceration. However, there is a relative lack of research examining the role of social variables such as perceived social support. Data from 943 male inmates enrolled from three correctional facilities in Spain were collected. Participants completed self-report measures of the demographic, penitentiary and sentence-related, social support and suicide attempts variables. Approximately 1 in 11 inmates indicated that they had attempted suicide during incarceration. Inmates who were 50 years or above and who were serving longer sentences were significantly more likely to attempt suicide. Perceived social support was not associated with suicide attempts. These characteristics might be included in the development of intervention programs for incarcerated individuals.

Using Life Trajectories Analysis to Characterize Suicide Attempts in Prison

Background: Suicide in prison is a major problem and several risk factors have been identified in the literature (e.g., period of incarceration, depressive disorders). Aims: The study examined the impact of several risk factors for suicide attempts before and during incarceration using life trajectory analysis of inmates by interviews with informants. Method: The lifetime of inmates with a history of suicide attempts (ISA; n = 20) or without (IWSA; n = 29) was recounted on a life chart according to four main domains (health, life events, relationships, and judiciary domain) organized in two different periods (predetention and current detention). Life charts were compared between the two groups and a predictive model of suicide risk was constructed using logistic regression and receiving operating characteristic curve analysis. Results: Before detention, more depressive experiences were observed in ISA than in IWSA, and ISA reported more behavioral disorders than IWSA during current detention. Moreover, the total burden for ISA was greater than that for IWSA. The predictive model identified three dimensions for differentiating ISA from IWSA: mood disorders before detention, behavioral disorders, and the quality of relationships with nuclear family during detention. Limitations: Interviews with inmates would have been informative. Conclusion: The accumulation of life events and behavioral manifestations should be incorporated in the developmental trajectory as a therapeutic model regarding suicide in prison.

Risk factors for suicide in prisons: a systematic review and meta-analysis

BACKGROUND

Rates of suicide among people in prison are elevated compared with people of similar age and sex who are living in the community. Improving assessments and interventions to reduce suicide risk requires updated evidence on risk factors. We aimed to examine risk factors associated with suicide in prisoners.

METHODS

We did an updated systematic review and meta-analysis of risk factors for suicide among people in prison. We searched five biblographic databases for articles published between Jan 1, 2006, and Aug 13, 2020, and one database for articles published between Jan 1, 1973, and Aug 13, 2020. Eligible studies reported risk factors in individuals who died by suicide while in prison and in controls from the general prison population. Two reviewers independently extracted data for each study using a standardised form. We calculated random-effects pooled odds ratios (ORs) for the association of suicide with demographical, clinical, criminological, and institutional risk factors, and investigated heterogeneity using subgroup and meta-regression analyses. This systematic review is registered with PROSPERO, CRD42020137979.

FINDINGS

We identified 8041 records through our searches, and used 77 eligible studies from 27 countries, including 35 351 suicides, in the main analysis. The strongest clinical factors associated with suicide were suicidal ideation during the current period in prison (OR 15·2, 95% CI 8·5-27·0), a history of attempted suicide (OR 8·2, 4·4-15·3), and current psychiatric diagnosis (OR 6·4, 3·6-11·1). Institutional factors associated with suicide included occupation of a single cell (OR 6·8, 2·3-19·8) and having no social visits (OR 1·9, 1·5-2·4). Criminological factors included remand status (OR 3·6, 3·1-4·1), serving a life sentence (OR 2·4, 1·3-4·6), and being convicted of a violent offence, in particular homicide (OR 3·1, 2·2-4·2).

INTERPRETATION

Several modifiable risk factors, such as psychiatric diagnosis, suicidal ideation during the current period in prison, and single-cell occupancy, are associated with suicide among people in prison. Preventive interventions should target these risk factors and include improved access to evidence-based mental health care. Understanding other factors associated with suicide might improve risk stratification and resource allocation in prison services.

FUNDING

Wellcome Trust, National Institute for Health Research Applied Research Collaboration Oxford and Thames Valley.