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

Comparison of two suicide screening instruments for identifying high-risk individuals in prison

Increased suicide rates in prison are a serious concern. Early identification of inmates at risk is a component of effective suicide prevention. The present study examined two suicide screening instruments in a sample of men in the Berlin, Germany, prison system (n = 289). The Screening for Initial Risk Assessment (SIRAS) identified significantly more high-risk inmates than the Vienna Instrument for Suicidality in Correctional Institutions (VISCI) (66 vs. 24). The results further show that the agreement in the classification was evident only in inmates with suicidal ideation, but was otherwise quite low. This can be explained by the fact that the instruments differ in terms of the risk factors taken into account. Finally, it was found that inmates classified as high risk received more monitoring and psychiatric or psychological support, which supports the construct validity of the instruments. As there were no deaths by suicide in the sample, no statistical information on the predictive validity of the instruments could be provided. Although research in this area is challenging, methodologically sound studies are needed to inform practice.

Assisted death for prisoners and forensic patients: complexity and controversy illustrated by four recent cases

Medical assistance in dying (MAiD) (which includes euthanasia and assisted suicide) is available in an increasing number of countries. In Belgium, The Netherlands and Switzerland (and was due to be implemented in Canada from 2024) eligibility includes mental suffering in the absence of any physical disorder. There are particular ethical and legal issues when considering MAiD for those involuntarily detained in prisons and hospitals. We describe four recent cases that illustrate these complexities, and highlight issues of equivalence of healthcare and self-determination against concerns about the criteria for determining eligibility of those with non-terminal conditions as well as the objections raised by victims and families and the demands for justice.

Suicide Risk Screening and Assessment before and after the COVID-19 Pandemic in New Inmates

(1) Background: Suicide is the main cause of death in Italian prisons. The largest number of inmates who killed themselves was recorded during three years of the COVID-19 pandemic. This study aimed to explore psychosocial risk factors for suicide among inmates incarcerated before and after the onset of COVID-19. (2) Methods: At prison reception, inmates underwent clinical interviews and were assessed using the Blaauw Scale and Suicide Assessment Scale. Psychological distress, measured by the Symptom Checklist-90-R, was compared between inmates admitted before and after COVID-19. Regression analyses were run to examine psychosocial vulnerabilities associated with suicidal intent in newly incarcerated individuals at risk of suicide. (3) Results: Among the 2098 newly admitted inmates (93.7% male) aged 18 to 87 years (M = 39.93; SD = 12.04), 1347 met the criteria for suicide risk, and 98 exhibited high suicidal intent. Inmates who entered prison after the onset of COVID-19 were older and had fewer social relationships. They had a higher prevalence of recidivism and substance abuse, along with elevated levels of psychological distress. An increase in perceived loss of control, anergia, obsessive-compulsive symptoms, phobic anxiety, and paranoid ideation emerged as the factors most strongly associated with high suicidal intent. (4) Conclusions: These findings support the value of psychosocial screening in promptly identifying inmates at risk of suicide, enabling the implementation of targeted, multi-professional interventions. Future research should replicate these results, with a focus on longitudinal studies that monitor the same inmates throughout their incarceration period.

Racial Differences in Suicidal Behaviors and Post-Suicide Attempt Treatment: a Latent Class Analysis of Incarcerated Men's Experiences

Community-based research has found racial differences in suicide attempts for Black and White men and in how men are treated after a suicide attempt; however, prison-based research has largely not explored such differences. This study examined racial differences in the circumstances of incarcerated men's suicide attempts and investigated health care disparities in staff responses to these suicide attempts. With administrative data from three state prisons over a 5-year period, we conducted a latent class analysis to explore patterns of suicide attempts for 207 incarcerated men. We examined race as a predictor of class membership. Black men were more likely than White men to use a method of hanging/suffocation for attempting suicide, and they were also commonly subjected to segregation when they attempted suicide. Black men were less likely to receive health care post-attempt than White men. Given the findings of this study, several key researches, practices, and policy directions are needed to prevent suicide and promote the health and well-being of incarcerated men, particularly incarcerated Black men.

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.

The incidence and profile of self-harm among prisoners: findings from the Self-Harm Assessment and Data Analysis Project 2017-2019

PURPOSE

Internationally, rates of suicide and lifetime self-harm are higher in prisoners compared to the general population. This study aims to identify specific characteristics of self-harming behaviour and to establish a profile of prisoners who engage in self-harm.

DESIGN/METHODOLOGY/APPROACH

Data from the Self-Harm Assessment and Data Analysis Project (SADA) on self-harm episodes in prisons in the Republic of Ireland during 2017-2019 was used. Annual rates per 1,000 were calculated by age and gender.

FINDINGS

The rate of self-harm between 2017 and 2019 was 31 per 1,000 prisoners for men and six times higher at 184 per 1,000 prisoners for women. The rate of self-harm was twice as high among prisoners on remand than sentenced prisoners (60.5 versus 31.3 per 1,000). The highest rates of self-harm among sentenced prisoners were observed among 18-29-year-old men (45 per 1,000) and women (125 per 1,000). The rate of self-harm was higher among women prisoners in all age groups. Contributory factors associated with self-harm were mainly related to mental health but also linked to a prisoner's environment and relationships.

PRACTICAL IMPLICATIONS

There is a need to ensure access to timely and suitable mental health services, including both appropriate referral and provision of evidence-based mental health interventions to address the needs of these cohorts.

ORIGINALITY/VALUE

To the best of the authors' knowledge, this is the first national study to systematically examine incidence and patterns of self-harm among the prison population in Ireland. The recording of severity/intent of each episode is novel when assessing self-harm among the prison population.

Do Homicide Perpetrators Have Higher Rates of Delayed-Suicide Than the Other Offenders? Data from a Sample of the Inmate Population in Italy

Homicide-suicide can be defined as homicide followed by the suicide of the perpetrator shortly afterward. In the so-called "homicide-delayed suicide", homicide and suicide occur but within a wide and not strictly defined timeframe. This study analyzes data concerning the suicide of 667 inmates in Italy between 2002 and 2015, considering homicide perpetrators compared to all offenders. The analyses revealed that inmates who had committed homicide were more likely to commit suicide (71% versus 45%; χ2 = 10.952, p = 0.001) and the odds of suicide increase concerning 1.58 times among homicide perpetrators. The time-to-suicide interval after homicide ranges between 0 to 9.125 days (mean = 1.687,9; SD = 2.303,1). Moreover, the intimate-homicide offenders who committed suicide had a significantly shorter survival time after the offense than did the other non-intimate offenders who died by suicide (t test, t = -3.56, df = 90, p = 0.001). The link between homicide and higher suicide risk in homicide perpetrators should be highlighted because of all the homicide offenders passing through the criminal justice system. Superior knowledge about the path of homicide-delayed suicide will be of particular use to professionals in evaluating and treating homicide inmates.

Suicide in prisons: describing trends and staff knowledge and preparedness to address suicide

PURPOSE

Suicide prevention and intervention in prisons is a challenge. Prisons were not designed to be clinical facilities, yet with the growing numbers of people who face mental health challenges in prisons, staff require knowledge and skills to adequately address mental health crises, especially suicide. This study aims to: describe trends in suicide attempts and completions within one state's prison system and measure staff knowledge and preparedness to address suicide.

DESIGN/METHODOLOGY/APPROACH

This research uses a nonexperimental research design and two data sources. Administrative data from 2000 to 2017 on serious suicide attempts and completions were analyzed, and all correctional staff employed in the state's Department of Corrections were surveyed at one point in time. Univariate and bivariate analyses were conducted.

FINDINGS

The number of serious suicide attempts trended up but completed suicides decreased. Correctional staff demonstrated high suicide knowledge of risk factors and warning signs of suicide. Staff who viewed a media-based suicide training displayed significantly more knowledge of suicide and perceived greater preparedness compared to staff who did not or did not recall viewing the training.

ORIGINALITY/VALUE

Corrections staff play a key role in preventing suicides in prison. Innovative intervention is needed to increase suicide awareness, improve communication and enhance prevention skills.

Prevalence and risk factors for suicide attempts in prison

Suicidal behaviour represents a substantial burden of morbidity and mortality in prisons worldwide. We aimed to synthesise the evidence on prevalence and risk factors for suicide attempts during incarceration. In this systematic review and meta-analysis, we searched four bibliographic databases for studies (published up to May 31, 2022) reporting on adults sampled from the general prison population who attempted suicide while incarcerated and an unselected comparison group. A total of 20 studies comprising 19,882 individuals (6.5% women) in 20 countries were eligible for inclusion. The pooled prevalence of suicide attempts during incarceration was 8.6% (95% CI 6.1-11.2) in men and 12.2% (95% CI 7.1-17.2) in women. Across all 36 risk factors studied, the strongest associations were found for suicidal ideation, previous self-harm, and markers of psychiatric morbidity. Prison-related risk factors included solitary confinement, victimisation, and poor social support while incarcerated. Sensitivity analyses indicate that risk factors for near-lethal suicide attempts are similar to those for suicide attempts more generally. In addition to providing a synthesis of previous work, our systematic review highlights several key limitations of the extant literature, which provide directions for future research.