Management of suicidal and self-harming behaviors in prisons: systematic literature review of evidence-based activities

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.

Public Health and Prisons: Priorities in the Age of Mass Incarceration

Mass incarceration is a sociostructural driver of profound health inequalities in the United States. The political and economic forces underpinning mass incarceration are deeply rooted in centuries of the enslavement of people of African descent and the genocide and displacement of Indigenous people and is inextricably connected to labor exploitation, racial discrimination, the criminalization of immigration, and behavioral health problems such as mental illness and substance use disorders. This article focuses on major public health crises and advances in state and federal prisons and discusses a range of practical strategies for health scholars, practitioners, and activists to promote the health and dignity of incarcerated people. It begins by summarizing the historical and sociostructural factors that have led to mass incarceration in the United States. It then describes the ways in which prison conditions create or worsen chronic, communicable, and behavioral health conditions, while highlighting priority areas for public health research and intervention to improve the health of incarcerated people, including decarceral solutions that can profoundly minimize-and perhaps one day help abolish-the use of prisons.

Knowledge of evidence-based practices for PTSD among mental health court judges

Mental health courts offer access to community-based care for defendants with psychiatric disorders, including posttraumatic stress disorder (PTSD). However, limited information is available on how judges make treatment decisions about evidence-based practices. In this qualitative study, we interviewed mental health court judges to evaluate: (1) perspectives toward the role of PTSD in criminal behavior; (2) knowledge about evidence-based practice for PTSD; (3) treatment decisions for defendants with PTSD; and (4) treatment decisions for defendants at risk for suicide, a common comorbidity with PTSD. We hypothesized that mental health court judges would report low familiarity with evidence-based practices for PTSD despite wide recognition of the impact of trauma on criminal behavior. Methods: Mental health court judges (N = 11, 60% women, 60% between 50-59 years) were recruited from 7 states in the US and completed a demographics questionnaire and semi-structured qualitative interview that was transcribed and double-coded. Results: Judges in mental health court unanimously agreed that PTSD is highly prevalent among their defendants, but that they had not having received formal education about evidence-based practices for PTSD. They reported relying on their team members to provide recommendations for treatment planning and viewed their role as the enforcer of the treatment teams' suggestions. Finally, judges also reported that suicide prevention is an important consideration and that there is a need for universal suicide risk assessments. Conclusions: These findings have implications for continuing education among judges in mental health court, and we recommend mandated training to increase awareness of evidence-based practices for PTSD and suicide prevention.

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.

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.

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.

Interventions to reduce suicidal thoughts and behaviours among people in contact with the criminal justice system: A global systematic review

BACKGROUND

People who experience incarceration die by suicide at a higher rate than those who have no prior criminal justice system contact, but little is known about the effectiveness of interventions in other criminal justice settings. We aimed to synthesise evidence regarding the effectiveness of interventions to reduce suicide and suicide-related behaviours among people in contact with the criminal justice system.

METHODS

We searched Embase, PsycINFO, MEDLINE, and grey literature databases for articles published between 1 January 2000 and 1 June 2021. The protocol was registered with PROSPERO (CRD42020185989).

FINDINGS

Thirty-eight studies (36 primary research articles, two grey literature reports) met our inclusion criteria, 23 of which were conducted in adult custodial settings in high-income, Western countries. Four studies were randomised controlled trials. Two-thirds of studies (n=26, 68%) were assessed as medium quality, 11 (29%) were assessed as high quality, and one (3%) was assessed as low quality. Most had considerable methodological limitations and very few interventions had been rigorously evaluated; as such, drawing robust conclusions about the efficacy of interventions was difficult.

INTERPRETATION

More high-quality evidence from criminal justice settings other than adult prisons, particularly from low- and middle-income countries, should be considered a priority for future research.

FUNDING

This work was funded by the Australian government's National Suicide Prevention Taskforce. RB is supported by a National Health and Medical Research Council (NHMRC) Emerging Leader Investigator Grant (EL2; GNT2008073). MW is supported by a NHMRC Postgraduate Scholarship (GNT1151103). SF was funded by the NIHR HTA Programme (HTA Project:16/159/09).

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.

Health care disparities for incarcerated adults after a suicide attempt

OBJECTIVE

Incarcerated adults have high rates of fatal and nonfatal suicidal behaviors. Suicide prevention recommendations stress the need for the provision of health care for incarcerated adults after suicide attempts, yet prison policies and practices often focus instead on punitive responses to suicidal behaviors. Existing research is limited regarding factors that predict the provision of health care to incarcerated adults post-suicide attempt. The current study examined individual, incident, and institutional factors as predictors of health care to incarcerated adults post-suicide attempt.

METHOD

We used data from critical incidents reports for suicide attempts (N = 495) to conduct mixed-effects logistical regression models.

RESULTS

Staff responded to suicide attempts by placing incarcerated adults under direct observation (with no care) or in segregation at odds two and three times higher than of providing health care, particularly in prisons for men. Race was a significant factor; incidents involving Black men were less likely than incidents involving white men to include staff requesting health care, and incidents involving Black women were less likely than incidents involving white women to include requesting and providing health care.

CONCLUSIONS

This study's findings highlight factors predicting health care responses to suicide attempts and the need to address and prevent health care disparities in prisons.

Peer-based interventions targeting suicide prevention: A scoping review

Peers of individuals at risk for suicide may be able to play important roles in suicide prevention. The aim of the current study is to conduct a scoping review to characterize the breadth of peer-delivered suicide prevention services and their outcomes to inform future service delivery and research. Articles were selected based on search terms related to peers, suicide, or crisis. After reviews of identified abstracts (N = 2681), selected full-text articles (N = 286), and additional references (N = 62), a total of 84 articles were retained for the final review sample. Types of suicide prevention services delivered by peers included being a gatekeeper, on-demand crisis support, crisis support in acute care settings, and crisis or relapse prevention. Peer relationships employed in suicide prevention services included fellow laypersons; members of the same sociodemographic subgroup (e.g., racial minority), workplace, or institution (e.g., university, correctional facility); and the shared experience of having a mental condition. The majority of published studies were program descriptions or uncontrolled trials, with only three of 84 articles qualifying as randomized controlled trials. Despite a lack of methodological rigor in identified studies, peer support interventions for suicide prevention have been implemented utilizing a diverse range of peer provider types and functions. New and existing peer-delivered suicide prevention services should incorporate more rigorous evaluation methods regarding acceptability and effectiveness.

Suicide Rates in Nordic Prisons 2000-2016

OBJECTIVE

To compare suicide rates of people in prison and the general population in the Nordic countries.

METHODS

Data on deaths by suicide and person-years for people in prison and the general population were obtained for the Nordic countries during 2000-2016. Age-standardized rate ratios were calculated.

RESULTS

The suicide rate in the Nordic countries overall was 110.1 (95% CI = 98.1, 122.2) per 100,000 person-years for people in prison. A significant decline was noted for the suicide rate of people in prison between 2000 and 2016 (p < 0.0001). The age-standardized mortality ratio was 7.4 (95% CI = 5.9-8.2) for males and 17.8 (95% CI = 7.3-33.2) for females in Denmark, Iceland, and Norway.

CONCLUSION

Despite a decreasing trend over time, excess suicide mortality was noted for people 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.

Suicide Prevention Programs

This chapter presents a narrative synthesis of the evidence relating to the effectiveness of 13 different approaches (interventions) that have been incorporated into national suicide prevention programs. These approaches are presented in an analytic framework that distinguishes between national and community-based multilevel programs, prevention, and treatment/maintenance. The primary source of evidence are six reviews of reviews published since 2005, supplemented by a small number of systematic reviews and primary studies. We report strongly supportive evidence concerning the effectiveness of structural interventions (restrictions on access to bridges, tall buildings, and railways) and restriction on access to pharmacological agents. Weakly supportive evidence of effectiveness is available for community-based multilevel programs; restrictions on access to firearms and ligature points in institutional settings; settings-based programs (in schools, communities, workplaces, prisons, and the armed forces); education and training targeted at primary care physicians; lithium; cognitive behavioral therapy and dialectical behavioral therapy; and brief contact. There is insufficient or conflicting evidence concerning the effectiveness of the remaining approaches. We conclude that the evidence base for effective suicide prevention is far from convincing. Major improvement in the extent and quality of collaboration between researchers, policymakers, and practitioners and a considerable increase in funding for evaluation studies in suicide prevention are required if the current knowledge gap about effective interventions is to be bridged.

A Systematic Review of Reviews of Correctional Mental Health Services Using the STAIR Framework

BACKGROUND

Rising demand for correctional mental health services (CMHS) in recent decades has been a global phenomenon. Despite increasing research, there are major gaps in understanding the best models for CMHS and how to measure their effectiveness, particularly studies that consider the overall care pathways and effectiveness of service responses. The STAIR (Screening, Triage, Assessment, Intervention, and Re-integration) model is an evidence-based framework that defines and measures CMHS as a clinical pathway with a series of measurable, and linked functions.

METHOD

We conducted a systematic review of the reviews of CMHS elements employing PRISMA guidelines, organized according to STAIR pillars. We assessed the quality of included studies using the AMSTAR-2 criteria. Narrative reviews were read and results synthesized.

RESULTS

We included 26 review articles of which 12 were systematic, metaanalyses, and 14 narrative reviews. Two systematic reviews and seven narrative reviews addressed screening and triage with strong evidence to support specific screening and triage systems. There was no evidence for standardised assessment approaches. Eight systematic reviews and seven narrative reviews addressed interventions providing some evidence to support specific psychosocial interventions. Three systematic reviews and six narrative reviews addressed reintegration themes finding relatively weak evidence to support reintegration methods, with interventions often being jurisdictionally specific and lacking generalizability.

CONCLUSIONS

The STAIR framework is a useful way to organize the extant literature. More research is needed on interventions, assessment systems, care pathway evaluations, and reintegration models.

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.

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

This article reviews evaluation studies of interventions aimed at preventing and reducing incidents of suicide and self-harm among incarcerated individuals. Study design, sample characteristics, intervention procedures, study measures, and relevant results of each study are reviewed. The outcomes of interest include severity and frequency of self-harm episodes and suicidal ideation, scores on adaptive coping methods, scoring on the Beck Hopelessness scale and risk scores. The six evaluated studies are peer-reviewed, published between 1990 and 2015, and took place in the United States, the United Kingdom, and Pakistan. Treatment modalities widely vary across studies and include cognitive behavioral therapy, dialectical behavioral therapy, peer programming, staff intervention training, and uniquely-designed courses that incorporate various aspects from other treatment modalities. Due to the nature of the studies, only one multi-randomized controlled trial was identified. All identified studies had a pre- and post-treatment design either lacking a comparison group or containing 1–2 comparison groups and conduct follow-up of varying times. While Cognitive Behavioral Therapy (CBT) interventions and uniquely-tailored intervention programs suggest promising results, the general absence of comparison groups, the shortage of relevant evaluation studies and the inconsistency of behavioral outcome measurements compromise the capacity of this review. Further, definitional variances, particularly for self-injury (self-harm, non-suicidal self-injury [NSSI], deliberate self-harm, suicidal behavior, etc.) affect the ability to synthesize study results. This article aims to synthesize the literature results to identify the most effective interventions that would benefit from additional research.

Pattern of self-injurious behavior and suicide attempts in Italian custodial inmates: A cluster analysis approach

Self-injurious behaviors and suicide attempts are more frequent in prison settings than in the general population and represent a crucial problem. The aims of this work are to assess the prevalence of self-injurious behaviors and suicide attempts in an Italian prison setting, to determine whether inmates could be differentiated based on profiles of psychological distress and impulsiveness, and to assess the predictive power of the proposed profiles. A sample of 1422 male inmates of a north Italian penitentiary was assessed upon admission with a clinical interview and completed a set of self-report questionnaires to assess psychological distress and impulsiveness; the number of self-injurious behaviors and suicide attempts occurring in the first year of detention was recorded. A cluster analysis approach was used. Prevalence of self-Injurious behaviors and suicide attempts is similar to what has been observed in previous work. Cluster analysis revealed four clusters: dysregulated (high impulsivity and distress), impulsive (high impulsivity and mean distress), mildly distressed (mean impulsivity and moderate distress) and well-balanced (low impulsivity and distress). The four clusters help to discriminate subjects more at risk of self-injurious behaviors and suicide attempts and are confirmed by the inclusion of risk factors such as marital status and relatives'/social support. Clinical implications are discussed.

[Suicide in prison: Epidemiology and prevention]

Suicide is one of the most important causes of death in prison around the world. In France, suicide rate for prisoners is 18.5 suicides per 10,000 inmates: seven times more common than in the general population. Among the risk factors identified in the literature, those most strongly associated with suicide in prison are physical isolation in custody, psychiatric history and history of suicide attempts. The prevention of suicide in prison involves several measures including treatment of psychiatric disorders, improvement of living conditions in custody, social support of prisoners and use of specific tools and programs by prison supervisors. No program for prevention of suicidal recurrence has ever been implemented. We propose to adapt « VigilanS », a program already applied in the general population, to the prison population.

Suicide Decedents in Correctional Settings: Mental Health Treatment for Suicidal Ideation, Plans, and/or Attempts

Based on 2005 to 2014 data from the National Violent Death Reporting System, this study examined mental health treatment status of suicide decedents in correctional settings, focusing on those with prior/recent suicide ideation/plans/attempts. Of all decedents ( N = 1,727), 30% had prior/recent suicidal ideation/plans/attempts, and of them, 64% had not received mental health treatment while incarcerated. Multivariable analysis showed that those with past-month crime/violence (as a proxy for recent incarceration) and those with an alcohol problem had higher odds of not having received treatment. Coroner/medical examiner and law enforcement reports show that other life stressors and fear of jail environment contributed to despair. The findings underscore the importance of suicide risk screening at or shortly after incarceration and providing necessary treatment and support.

Reflections on a project to prevent suicide and self-harm among prisoners identified as high risk in two prisons in Northern England

BACKGROUND

This article critically explores the implementation and evaluation of a project designed, delivered and evaluated by frontline staff to improve prison responses to prisoner suicide and self-harm. We begin by evidencing the need for the project and detail its content, delivery and attempts at evaluation. We draw on the reflections of the three practitioners most closely involved in its development, delivery and review in order to explore lessons learned for future staff-led projects including those aimed at tackling prison suicide and self-harm.

RESULTS

Findings from staff reflections suggest that the development, implementation and evaluation of the project were influenced by a combination of issues around: project focus, communication and professional relationships, the institutional environment, funding and time, roll-out and evaluation, and the need for a 'champion' role.

CONCLUSIONS

There is limited evidence that the project left a modest positive legacy in terms of impact. A more substantial legacy of the project is provided in terms of actionable learning points for future projects of this nature.

Suicide and suicides attempts in Italian prison epidemiological findings from the "Triveneto" area, 2010-2016

The aim of this observational study was to assess rates of suicide and suicide attempts, in relation to gender, age, place of birth and security levels, in north-eastern Italian prisons during 2010-2016, and investigate associations with prison overcrowding, offence type and prior self-harm and suicide attempts. The study was based on individual data on suicides and suicide attempts from 16 prisons, with an average yearly number of 3900 inmates during the study period, for all prisons combined. Descriptive and binomial regression analyses were performed. Rates of suicide and suicide attempts in Triveneto prisons were 1and 15 per 1000 inmates, respectively. >90% of suicides and suicide attempters were men aged between 21 and 49 years old, and most had committed violent offenses. Only half the prisoners who died by suicide and 30% of those who made a suicide attempt in custody were Italians. 'Cooperative witnesses' had the highest mean suicide attempt rate (30/1000 inmates). Fourteen per cent of suicides and 19% of attempters had a prior history of suicide attempts and self-injury. In binomial regression analyses, predictors of suicidal behaviour were being a male inmate in standard security conditions, with a mean age of 30 years. The study highlighted that there is a need for suicide prevention policies in Triveneto; these should take into account predictors of suicidal behaviours and individual characteristics of suicidal inmates. More research is warranted in order to both evaluate the effectiveness of prevention plans and better assess risk of suicide in specific groups, such as cooperative witnesses.

A 17-Year National Study of Prison Suicides in Belgium

BACKGROUND

Suicide is a leading cause of mortality in prisoners worldwide, yet empirical data on this matter are lacking in Belgium.

AIMS

This study sought to describe characteristics associated with a consecutive series of suicides in Belgian prisons from 2000 to 2016 inclusive, in order to inform suicide prevention strategies.

METHOD

All documented cases of suicide ( N = 262) were reviewed using a standardized assessment checklist. Official records were abstracted for prisoners' sociodemographic, criminological, and clinical information, as well as for suicide-related characteristics.

RESULTS

Over the 17-year study period, suicides accounted for one third of all deaths in Belgian prisons. The average annual suicide rate in Belgium from 2000 to 2016 was 156.2 per 100,000 prisoners. Examination of all cases highlights both individual (psychiatric disorders and a history of suicide attempt) and situational (the early period of incarceration, interfacility transfers, and placement in solitary confinement) factors common in many prison suicides; some of them amenable to (clinical) management, which presents several potential avenues for suicide prevention.

LIMITATIONS

Given the absence of a matched control group, no conclusions could be ascertained regarding risk factors.

CONCLUSION

Suicide is a common, preventable cause of death among prisoners in Belgium. The results underscore the timely need for national standards and guidelines for suicide prevention in Belgian prisons.

Suicide Screening Tools for use in Incarcerated Offenders: A Systematic Review

Self-inflicted deaths in prisons in England and Wales, recently reported as the highest in over a decade, are a significant cause of mortality. A lack of guidelines surrounding the screening and identification of suicide risk of new prisoners along with a dearth of effective screening tools indicate the need for review. Our aims are to examine findings on the effectiveness of prison specific suicide screening tools used with adult prisoners. Papers were identified via systematic searches of databases, scanning grey literature, and reference checking. Included studies were published over the period between 2000-2016. PRISMA guidelines were followed. Studies were selected based on population - adult imprisoned offenders; intervention - suicide screening tool; comparators - participants screened vs. not screened outcome - suicide or attempted suicide. Data was extracted manually. A narrative synthesis presented the findings between different screening tools. Eight screening tools were critically appraised. Evidence suggested that the VISCI and Dutch screening tools are most effective in identifying those at risk and reducing suicide and/or self-harm behavior. Variance in methodological quality and associated factors indicate the need for further development of prospective studies to develop robust screening tools. This study is registered with PROSPERO (CRD42016035471).

Health professionals talk about the challenges of suicide prevention in two correctional centres in South Africa

Suicide is the leading cause of death among offenders in correctional facilities in many parts of the world. While epidemiological data have described the extent and scope of the problem, no research has documented the experiences and insights of health professionals who are tasked with providing care to suicidal offenders in South African correctional centres. It is within this context that we set out to document the experiences of a group of health professionals working in two correctional facilities in South Africa. We were interested in learning from them about their perceptions of the factors that contribute to suicidal behaviour among offenders and their suggestions for suicide prevention. In-depth semi-structured interviews were conducted with a group of health professionals ( N = 10). Data were analysed using thematic analysis and an inductive approach was adopted for coding the data. The participants describe a number of structural and contextual factors which they believe make correctional centres in South Africa unsafe, thus increasing the risk of suicidal behaviour among offenders and hindering suicide prevention efforts within the two correctional centres where data were collected. These factors include high levels of psychopathology, trauma, substance abuse, violence, gangsterism, overcrowding, inadequate mental health care resources, and problems relating to stigma. These findings highlight human rights and mental health issues facing offenders and draw attention to conditions within correctional centres that need attention as part of any national suicide prevention strategy in South Africa.

Suicidal ideation while incarcerated: Prevalence and correlates in a large sample of male prisoners in Flanders, Belgium

Prisoners constitute a high-risk group for suicide. As an early stage in the pathway leading to suicide, suicidal ideation represents an important target for prevention, yet research on this topic is scarce in general prison populations. Using a cross-sectional survey design, correlates of suicidal ideation while incarcerated were examined in a sample of 1203 male prisoners, randomly selected from 15 Flemish prisons. Overall, a lifetime history of suicidal ideation and attempts was endorsed by 43.1% and 20.3% of respondents, respectively. Approximately a quarter of all prisoners (23.7%) reported past-year suicidal ideation during their current incarceration, which was significantly associated with both imported vulnerabilities (psychiatric diagnoses and a history of attempted suicide) and variables unique to the prison experience (lack of working activity, exposure to suicidal behaviour by peers, and low levels of perceived autonomy, safety and social support) in the multivariate regression analysis. A first-ever period of imprisonment and a shorter length of incarceration (≤12months) were also associated with increased odds of recent suicidal ideation. Collectively, the current findings underscore the importance of both vulnerability factors and prison-specific stressors for suicidal ideation in prisoners, and hence the need for a multi-faceted approach to suicide prevention in custodial settings. In addition to the provision of appropriate mental health care, environmental interventions that target modifiable aspects of the prison regime could provide a substantial buffer for the onset and persistence of suicidal ideation in this at-risk population.

Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm

OBJECTIVE

To provide guidance for the organisation and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations.

METHOD

Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest and expertise in deliberate self-harm.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for deliberate self-harm provide up-to-date guidance and advice regarding the management of deliberate self-harm patients, which is informed by evidence and clinical experience. The clinical practice guidelines for deliberate self-harm is intended for clinical use and service development by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSION

The clinical practice guidelines for deliberate self-harm address self-harm within specific population sub-groups and provide up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

Prevention of Suicidal Behavior in Prisons

BACKGROUND

Worldwide, prisoners are at high risk of suicide. Research on near-lethal suicide attempts can provide important insights into risk and protective factors, and inform suicide prevention initiatives in prison.

AIMS

To synthesize findings of research on near-lethal attempts in prisons, and consider their implications for suicide prevention policies and practice, in the context of other research in custody and other settings.

METHOD

We searched two bibliographic indexes for studies in any language on near-lethal and severe self-harm in prisoners, supplemented by targeted searches over the period 2000-2014. We extracted information on risk factors descriptively. Data were not meta-analyzed owing to heterogeneity of samples and methods.

RESULTS

We identified eight studies reporting associations between prisoner near-lethal attempts and specific factors. The latter included historical, prison-related, and clinical factors, including psychiatric morbidity and comorbidity, trauma, social isolation, and bullying. These factors were also identified as important in prisoners' own accounts of what may have contributed to their attempts (presented in four studies).

CONCLUSION

Factors associated with prisoners' severe suicide attempts include a range of potentially modifiable clinical, psychosocial, and environmental factors. We make recommendations to address these factors in order to improve detection, management, and prevention of suicide risk in prisoners.

Mental health of prisoners: prevalence, adverse outcomes, and interventions

More than 10 million people are imprisoned worldwide, and the prevalence of all investigated mental disorders is higher in prisoners than in the general population. Although the extent to which prison increases the incidence of mental disorders is uncertain, considerable evidence suggests low rates of identification and treatment of psychiatric disorders. Prisoners are also at increased risk of all-cause mortality, suicide, self-harm, violence, and victimisation, and research has outlined some modifiable risk factors. Few high quality treatment trials have been done on psychiatric disorders in prisoners. Despite this lack of evidence, trial data have shown that opiate substitution treatments reduce substance misuse relapse and possibly reoffending. The mental health needs of women and older adults in prison are distinct, and national policies should be developed to meet these. In this Review, we present clinical, research, and policy recommendations to improve mental health care in prisons. National attempts to meet these recommendations should be annually surveyed.

Identifying risk of deliberate self-harm through longitudinal monitoring of psychological distress in an inpatient psychiatric population

BACKGROUND

While cross-sectional correlates of deliberate self-harm, such as psychological distress, have been identified; it is still difficult to predict which individuals experiencing distress will engage in deliberate self-harm, and when this may occur. Therefore, this study aimed to explore the ability of longitudinal measurements of psychological distress to predict deliberate self-harm in a psychiatric population.

METHOD

Participants (N = 933; age range 14-93 (M = 38.95, SD = 14.64; 70% female) were monitored daily in terms of suicidal ideation, depression, anxiety, worthlessness and perceptions of not coping. Latent Growth Curve Analysis was used to check if groups of inpatients reporting suicidal ideation, who shared early change in measures of psychological distress, existed. Logistic regression tested whether different groups were at higher (or lower) risks of deliberate self-harm.

RESULTS

Four groups were found. Of these, Non-Responders (high symptoms, remaining high) were more likely to engage in deliberate self-harm than patients with high, medium and low symptoms which improved over one week. Group membership was a greater predictor of deliberate self-harm than initial distress scores. Females and patients with personality disorders were significantly more likely to be Non-Responders.

CONCLUSIONS

Continuous monitoring and subsequent grouping of inpatients according to their early change in psychological distress provides a novel and practical approach to risk management. A lack of early improvement in psychological distress may indicate a higher risk of deliberate self-harm.