Preventing Suicide in Prison Inmates

Suicide is a common cause of death in prisons, with rates substantially higher than in the general population. It is a worldwide problem, and one that appears to be recently on the rise. Studies from England and Wales in 2016 reported its highest incidence of suicide since 1999, with the rate among male prisoners 5 to 6 times higher than the general population, and among female prisoners as much as 20 times higher.¹

Suicide in prisons is multifactorial, with contributing factors that include medical and mental health issues as well as those involving family, lack of purposeful activity, and conditions of the specific prison environment, as well as the stress of adjusting to incarceration.

Patterns of Suicide in Prison

A 2013 report by Lindsay M. Hayes, MA, who served as a suicide prevention consultant to the US Justice Department’s Civil Rights Division and conducted the only 5 national studies of jail, prison, and juvenile suicide, pointed to a number of suicide trends in prisons, including²:

• The rate of suicides among inmates remained consistent during the first few days to first few months of confinement.
• The majority occurred during waking hours.
• Most suicides did not occur while inmates were under the influence of drugs or alcohol.
• The occurrence of suicide was significantly related to a pending court date.
• The suicide rate in prisons and jails in the United States went down during the previous 20 years, largely because of suicide prevention efforts.

By far, the most suicides among inmates occur soon after incarceration.^1-4 A Hayes study from 2012 found that nearly one-quarter of newly arrested prisoners died within the first 24 hours, and more than half died between 2 days and 4 months of confinement.²

Attempted Suicide

Rates of attempted suicide are also high among prisoners. An epidemiologic study from England and Wales by Hawton and colleagues³ reported that during the years from 2004 to 2009, the incidence of self-harm among male prisoners was 5% to 6%, and 20% to 24% among female prisoners. A history of 5 or more attempts was highly associated with risk for subsequent suicide.³

These attempts were carried out with high suicidal intent, and were often repeated. A 2016 review of the literature by Marzano et al⁵ showed that on average, female inmates were likely to commit self-harm 8 times per year, and most near-lethal attempts occurred soon after incarceration. These risks were all significantly reduced when suicide risk management procedures were being followed.⁵

Methods and Opportunities

Most suicides in prison occur by hanging, when inmates are held in isolation or segregation cells, and at times when observation is light.^4,6 Many reports have indicated that successful suicide can occur within only a few inches from a supporting surface or floor. Strangulation by these methods can take several minutes and is accomplished using ligatures fashioned from sheets, clothing, or shoelaces, strung from any secure protrusion. Second to that are injuries from self-cutting and stabbing that cause significant blood loss or injury leading to death.

A 2007 report by the World Health Organization⁴ pointed to a strong influence of housing assignments in prison on suicide attempts, citing a “disproportionate” number of suicides that occur in solitary housing situations. Within the prison environment, psychological distress about bullying, conflicts with other inmates, disciplinary actions by prison staff, and hearing bad news regarding family or legal matters exacerbate the stress of imprisonment, where feelings of hopelessness and the sudden narrowing of future prospects leads to desperation and suicidal thoughts.

A number of nonenvironmental factors also contribute to increased risk for suicide in prison, including poor social and family support, a history of mental illness and/or emotional problems, withdrawal from substance abuse, and a history of prior suicide attempts.^4,6 Seena Fazel, MD, from the Department of Psychiatry at the University of Oxford in the United Kingdom, explained to Psychiatry Advisor that in the participants in studies she collaborated on in Wales and England, “social support, which can come from a variety of sources including family, was a risk factor for severe self-harm episodes in prison.” She also noted that separation from family could be a contributing factor. “When we systematically reviewed the literature in 2008,⁶ there was a slight increase in suicide risk for those who were married,” she said.

Juvenile offenders, especially those who have never been incarcerated before, are particularly vulnerable to distress over separation from family and fears of the future, which, coupled with lessened coping skills and naturally excessive emotional responses, puts them at the highest risk for inmate suicide.⁴

Prevention Strategies

Although the rates of suicide in prisons have decreased with the implementation of known screening programs and suicide prevention strategies, there is still a long way to go. According to the 2013 Hayes report, “many jail suicides occur in facilities lacking comprehensive suicide prevention programs, with only 20% having written policies encompassing all the essential components.”²

Hayes² and others outlined the essential features of an effective suicide prevention program, which include annual training and retraining of all correctional, medical, and mental health staff; evaluations of inmates at intake and ongoing screening/assessment for suicide risk; and procedures for effective communication about prisoner state of mind and suicide risk between outside entities (particularly from local jail transport) and correctional facilities, and between facility staff and the suicidal inmate.

Physical prevention strategies need to include suicide-resistant housing and clothing, as well as restrictions and careful supervision during showers, telephone calls, and visiting hours, commensurate with risk level.

Procedures for emergency response to a suicide attempt include prompt reporting to the facility’s chain of command and notification of the family of a suicide victim, as well as multidisciplinary examination of the inmate suicide through a mortality review. “Correctional facility officials should not conclude that an inmate suicide was not preventable unless they have demonstrated that their facility initiated and maintained a comprehensive suicide prevention program,” Hayes wrote.

“The role of suicide risk assessment is a complicated area,” Dr Fazel cautioned. “Identification and rapid evidence-based treatment of drug and alcohol withdrawal, and identification and clear pathways to treatment for prisoners with mental illness, are important. If risk assessment can be linked to risk management and has been validated in prisoners, it can be considered. But the performance of such assessments needs to be carefully examined, with information on the rates of true and false positives and negatives.”

References

1. Fazel S, Ramesh T, Hawton K. Suicide in prisons: an international study of prevalence and contributory factors. Lancet Psychiatry. 2017;4:946-952.
2. Hayes LM. Suicide prevention in correctional facilities: reflections and next steps. Int J Law Psych. 2013;36:188-194.
3. Hayes L. National study of jail suicide: 20 years later. J Correct Health Care. 2012;18:233-245.
4. World Health Organization. Preventing suicide in jails and prisons. http://www.who.int/mental_health/prevention/suicide/resource_jails_prisons.pdf. Updated 2007. Accessed December 11, 2017.
5. Hawton K, Linsell L, Adeniji T, Sariasia A, Fazel S. Self-harm in prisons in England and Wales: an epidemiologic study of prevalence, risk factors, clustering, and subsequent suicide. Lancet. 2014;383:1147-1154.
6. Fazel S, Cartwright J, Norman-Nott A, Hawton K. Suicide in prisoners: a systematic review of risk factors. J Clin Psychiatry 2008;69:1721-1731.