# A national study of persons who died by suicide in French prisons over the period 2017-2021

Alexis Vanhaesebrouck, Amélie Tostivint, Imane Khireddine-Medouni, Thomas Lefèvre, Maria Melchior, Nolwenn Regnault, Christine Chan Chee

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Alexis Vanhaesebrouck, Amélie Tostivint, Imane Khireddine-Medouni, Thomas Lefèvre, Maria Melchior, et al.. A national study of persons who died by suicide in French prisons over the period 2017-2021. Archives of Suicide Research, 2026. hal-05531240

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# A national study of persons who died by suicide in French prisons over the period 2017–2021

## Author details

Alexis Vanhaesebrouck<sup>1,2*</sup>, Amélie Tostivint<sup>3</sup>, Imane Khireddine-Medouni<sup>2</sup>, Thomas Lefèvre<sup>1,4</sup>, Maria Melchior<sup>5</sup>, Nolwenn Regnault<sup>2</sup>, Christine Chan Chee<sup>2</sup>

1 Interdisciplinary Research Institute on Social issues (IRIS), UMR 8156-997, UFR SMBH,

Université Sorbonne Paris Nord, Paris, France

2 Santé publique France (SpF), Saint-Maurice, France

3 Health division of the National Prison Service, Ministry of Justice, Paris, France

4 Department of legal and social medicine, Hôpital Jean-Verdier (AP-HP), Bondy, France

5 Sorbonne Université, INSERM, Pierre Louis Institute of Epidemiology and Public Health,

Department of Social Epidemiology, Mental Health, and Addictions, Paris, France

* alexis.vanhaesebrouck@iplesp.upmc.fr

## ORCID

- Alexis Vanhaesebrouck: 0000-0002-8145-0809

- Nolwenn Regnault: 0000-0002-0781-1450

- Thomas Lefèvre: 0000-0003-3038-479X

- Maria Melchior: 0000-0002-2377-619X

- Imane Khireddine-Medouni: 0000-0003-4458-6392

- Christine Chan Chee: 0000-0003-3795-4513

For the purpose of Open Access, a CC-BY public copyright licence has been applied by the authors to the present document and will be applied to all subsequent versions up to the Author Accepted Manuscript arising from this submission.
<figure><img src="image_2.png" /></figure>

CC-BY 4.0 (https://creativecommons.org/licenses/by/4.0/)
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# Abstract

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## Objective

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Suicide is a leading cause of death in prisons worldwide. The objective of this study was to describe the sociodemographic, clinical and criminal characteristics of people incarcerated in France who died by suicide, as well as the circumstances surrounding each suicide.

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## Method

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We included all cases of suicide by people incarcerated in France (i.e., European and overseas territories) over the period 2017-2021. The National Prison Service provided sociodemographic and criminal data, as well as data on the circumstances surrounding the suicides. Health data were collected by health units located in all the country's prisons using a standardised questionnaire.

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## Results

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We included 598 suicide cases in the study. Mental disorders were more prevalent during (63.7%) than before (47.8%, p<0.001) incarceration. In the week before suicide, 60% of cases had visited their prison's health unit and a traumatic criminal-, prison-, familial- or health-related event was identified in 61% of all cases. Persons who died during the SARS-CoV2 pandemic were more likely to have children (77.7% vs 61.1%, p=0.001). The overall suicide rate was 17.5 [CI95% 16.1-18.9] per 10,000 person-years. It increased (p<0.05) with age, was twice as high during pre-trial incarceration and six times higher during the first week of imprisonment. In terms of gender, it was 9.9 [9.1-10.7] and 41.0 [27.0-59.7] times higher among men and women, respectively, than among their counterparts in the general population.

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## Conclusions

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Suicide in prisons is a major health issue. Suicide prevention measures must be reinforced.

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## Highlights

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* In prison, the suicide rate is 6 times higher during the first week than after

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* The suicide rate of women in prison is 40 times higher than in general population

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* Prisoners who died during the SARS-CoV2 pandemic were more likely to have children

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## Keywords

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Suicide • Prison • Social epidemiology • Social psychiatry

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## Word count

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Introduction, Method, Results and Discussion (without the captions of tables and of the figure): 4797 words

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Abstract: 241 words
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# A national study of persons who died by suicide in French prisons over the period 2017–2021

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## Introduction

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In 2024, approximately 11.5 million people were held in penal institutions throughout the world [1]. Suicide is a leading cause of death in prisons [2, 3]. From 2000 to 2021, suicide rates among incarcerated people in 82 countries and jurisdictions were two to six times higher among men and 10 to 32 times higher among women than in the general population [4]. According to a meta-analysis of individual factors associated with suicide in prison, which combined the results of 77 studies published between 1973 and 2020, the factors most strongly associated are clinical in nature [5]; these include suicidal ideation during incarceration, a history of suicide attempts, and suffering from a mental disorder at the time of suicide. Additional factors include single-cell occupancy, being charged with or convicted for homicide, pre-trial incarceration and no social visits. Studies carried out in France have also highlighted the importance of factors that are rarely investigated in comparative studies elsewhere, such as disciplinary solitary confinement, the first two months of imprisonment, and being placed in custody under an expulsion order (i.e., for illegal immigrants) [6-9].

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In France, the average number of people in prison continues to rise, from 30,000 in 1970 (56 per 100,000 inhabitants) to 80,000 in 2025 (116 per 100,000 inhabitants) [7, 10, 11]. The current prison population rate in France remains well below the rate in the United States, which was recently estimated at 580 per 100,000 inhabitants [12], but is slightly higher than the European median of 104.8 per 100,000 inhabitants [13]. All prisons are under the authority of the French Ministry of Justice. They exclude police custody and administrative detention centres for illegal immigrants, which are under the authority of the Ministry of the Interior. There are more than 180 prisons in France. The average density is 136 incarcerated people per 100 places, compared to a median value of 94 for European countries [13]. The main types of facility include remand prison (69.0% of incarcerated people), standard security prison for long sentences (23.8%) and high security prison for long sentences (2.0%). Remand prison is devoted to pre-trial incarceration and persons serving the outstanding part of a sentence (i.e., sentence duration minus period already spent in custody) if less than two years.

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The suicide rate among people incarcerated in France has increased by a factor of 2 to 3 since the middle of the 20th century [7, 8, 14] and is now one of the highest in the world [4]. In recent years, the suicide rate was approximately 17 per 10,000 person-years (PY), which corresponds to approximately 120 suicides each year [8]. Suicide prevention measures were implemented by the French prison administration as early as the 1960s [15]. At the turn of the 21st century, suicide was defined as a public health problem and incarcerated people were given the same health rights as the general population [16–19]. In this context, suicide prevention in incarcerated people became part of the public health policy agenda [20–23]. One of the objectives of suicide prevention programs in France is to improve the quality of data on suicide in prisons in order to strengthen suicide prevention. To meet this objective, the National Public Health Agency set up an epidemiological monitoring program for suicides among incarcerated people, in collaboration with the National Prison Service (Ministry of
Justice) and prison-based health units. The intermediate results (2017-2018) were published in a previous paper [24]; this article presents the final results (2017-2021).

Few studies to date have provided detailed descriptive data on incarcerated people who die by suicide [25-27]. The health characteristics of this specific population have rarely been investigated, and never in France. Furthermore, the SARS-CoV2 pandemic occurred during the study. Pandemic-related protective measures may have exacerbated the isolation of incarcerated people by limiting visits and access to certain activities. While some authors expected an increase in suicide rates in prisons during the SARS-CoV2 pandemic [28], to our knowledge, only one study provided empirical data on an increase in suicide attempts [29] and none on suicide deaths. Finally, previous comparisons of suicide rates between prisoners and the general population of France have not considered age differences between these two populations [4], or have done so only marginally [14]. The primary objective of the present study was to describe the sociodemographic, clinical and criminal characteristics of incarcerated people in France who died by suicide over the period 2017-2021, and to characterize the circumstances surrounding these suicides. The secondary objective was 1) to compare the clinical characteristics of persons who died by suicide in prison before and during imprisonment; 2) to compute suicide rates in this population according to standardized data collected on inmates' characteristics; 3) to compare the suicide rate in the prison population with that in the general population. In light of these objectives, the added value of this study lies in 1) reporting for the first time on the mental health of prisoners who died by suicide in France; 2) describing a large number of characteristics that could provide new avenues for prevention; 3) being the first study to assess the impact of the SARS-CoV2 pandemic and of the last week of detention on the suicide rate of incarcerated people; 4) being the first study to compare suicide rates between incarcerated people and the general population of France accurately standardising on age.

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# 131 Materials and Methods

## 132 Population and settings

This study included all cases of suicide among incarcerated people in France (i.e., European France and overseas territories) recorded by the National Prison Service between 1 January 2017 and 31 December 2021. Suicide is defined by the French Ministry of Justice as a self-inflicted act with the intention of dying, resulting in death [30]. The cause of death is determined by the prison administration; when it considers the cause to be uncertain, it asks the public prosecutor for the results of forensic investigations, including an autopsy. Cases for which prison health units, independently of the prison administration's findings, attributed a cause of death different from suicide were excluded from the study. Irrespective of whether the suicide occurred inside or outside prison facilities, we considered the death to be the 'suicide of an incarcerated person' if that person had the administrative status of an inmate on the date of the suicidal act that caused his/her death.

## 143 Data

For the present study, the National Prison Service provided sociodemographic and criminal data, as well as data on the circumstances surrounding the suicides in question. It extracted most of these data from the computer application GENESIS [31] which was developed to help with the daily management of incarcerated people. Sociodemographic data included age at the time of suicide, gender, nationality, marital status, number of children, level of education and employment status before prison. Criminal data included previous incarcerations, main offence, criminal status at the time of suicide (pre-trial/sentenced), inter-prison transfer, visits from a relative or a volunteer prison visitor and type of facility (remand prison/standard security prison for long sentences/high security prison for
long sentences/other). The prison's geographically distance from the prisoner's home or from the home of the person to contact in the event of a problem was also collected. If it was located more than 45 minutes by car from either of these two homes, the prison was considered 'distant'. Data on the circumstances of suicides included the date of the fatal suicidal act, the time between entry into prison and this act, the time to release for sentenced persons, location, method used, the hour the body was discovered, the presence or not of a suicide note, and the time from the fatal suicidal act to death.

Health data were collected using standardised questionnaires; these were completed by prison health unit staff using data from the deceased inmates' medical records. These data related to three different periods: prior to prison, during prison, and the week before suicide. Data collected for the first two periods included regular consumption or not of tobacco, cannabis, opioids and other illegal drugs, mental disorders, suicide attempts, self-harm behaviour, psychiatric or psychological follow-up lasting more than three months, opioid substitution therapy, other psychotropic drug therapy, and admission to a psychiatric ward. Data specific to prison stay included somatic diseases, episodes of agitated behaviour, threats of suicide, medical follow-up for more than three months, and date of last medical appointment before suicide. Mental and somatic disorders were classified using the International Statistical Classification of Diseases and Related Health Problems, 10th Revision [32]. Data collected for the week before the suicidal act included psychotropic drug therapy, opioid substitution therapy, compliance with psychotropic drug therapy, suicidal ideation, an episode of agitated, impulsive or aggressive behaviour, and the occurrence of a traumatic criminal-, prison-, familial- or health-related event.

## 172 Statistical methods

All quantitative variables were transformed into categorical variables. We analysed the distribution of suicides over time by performing conformity tests with a uniform distribution for cases' birthday, the month of the year, the day of the week, and the time of the day. Health data were available only for suicide cases with a completed health questionnaire and we assessed their representativeness by comparing their sociodemographic and criminal characteristics with those of all suicide cases. The characteristics of cases were compared before and after 17 March 2020, as this was the date when France implemented its first SARS-CoV2-related lockdown. All the above-mentioned comparisons were made using a chi-square test when all the expected cases were greater than or equal to five, or a G-test otherwise.

Suicide incidence rates were computed for all incarcerated people and according to year, gender, age, nationality, criminal status, suicide during the first week in prison, suicide during the last week of prison sentence, as well as according to whether the suicide occurred before or after 17 March 2020. Rates were computed by dividing the number of suicides by the number of PY. With the exception of the first and last weeks of detention, PY were obtained by multiplying the average number of incarcerated people by the length of the observation period. This average number was calculated using the figures provided by the National Prison Service; depending on the characteristic, these figures are published on a monthly or quarterly basis [10]. We estimated PY for the first and last weeks of incarceration from the number of prison admissions and releases during the observation period, respectively. Each admission or release was considered as contributing to one person-week. We calculated 95% confidence intervals for suicide rates based on the Poisson distribution law. We compared suicide rates using a Poisson regression model [33].

We compared suicide rates among incarcerated people with those among the general population for the period 2017-2021, separately for men and women, using indirect age standardization. The age groups used were 13-24, 25-34, 35-44, 45-54, 55-64 and 65-74 years. In the general population, people under 13 years old (reflecting the minimum legal age for imprisonment in France) and those over 74 years old were excluded. For the prison population, people aged 65 and over were assigned to
the 65-74 age group. Suicide rates by age and gender in the general population were provided by the National Public Health Agency.

Analyses were carried out using R software (R version 4.1.3.).

## Ethics

This study was approved by the Comité consultatif sur le traitement de l'information en matière de recherche dans le domaine de la santé (CCTIRS, n°16 081) and the Commission nationale de l'informatique et des libertés (CNIL, DR-2017-210). All elements of the study were performed in accordance with the principles stated in the Declaration of Helsinki.

## Results

This study included 598 suicides among incarcerated people in France between 2017 and 2021 (see Supplementary Figure A).

## Sociodemographic characteristics

Median age was 36 (Q1-Q3 [28-46]) years, and 27 suicides (4.5%) involved women (Table 1). Non-French nationals accounted for 22.0% of suicides. Half of all the cases were single (51.4%) and two-thirds had at least one child (65.3%). A quarter had a high school diploma or higher (25.0%). Before prison, 52.5% were unemployed.

<table><caption>**Table 1** Sociodemographic characteristics of suicide cases</caption><thead><tr><th rowspan="2"></th><th colspan="2">All cases</th><th colspan="2">Cases with health data</th><th rowspan="2">p-value</th></tr><tr><th>n=598</th><th>%</th><th>n=467</th><th>%</th></tr></thead><tbody><tr><td>Gender</td><td></td><td></td><td></td><td></td><td>0.985</td></tr><tr><td>Women</td><td>27</td><td>(4.5)</td><td>21</td><td>(4.5)</td><td></td></tr><tr><td>Men</td><td>571</td><td>(95.5)</td><td>446</td><td>(95.5)</td><td></td></tr><tr><td>Age (years)</td><td></td><td></td><td></td><td></td><td>0.953</td></tr><tr><td>16-19</td><td>15</td><td>(2.5)</td><td>10</td><td>(2.1)</td><td></td></tr><tr><td>20-29</td><td>164</td><td>(27.5)</td><td>126</td><td>(27)</td><td></td></tr><tr><td>30-39</td><td>168</td><td>(28.1)</td><td>130</td><td>(27.9)</td><td></td></tr><tr><td>40-49</td><td>147</td><td>(24.6)</td><td>114</td><td>(24.5)</td><td></td></tr><tr><td>50-86</td><td>103</td><td>(17.3)</td><td>86</td><td>(18.5)</td><td></td></tr><tr><td>Missing</td><td>1</td><td></td><td>1</td><td></td><td></td></tr><tr><td>Nationality</td><td></td><td></td><td></td><td></td><td>0.730</td></tr><tr><td>French</td><td>464</td><td>(78.0)</td><td>355</td><td>(76.3)</td><td></td></tr><tr><td>Other European country</td><td>60</td><td>(10.1)</td><td>54</td><td>(11.6)</td><td></td></tr><tr><td>African country</td><td>51</td><td>(8.6)</td><td>41</td><td>(8.8)</td><td></td></tr><tr><td>Other country</td><td>20</td><td>(3.4)</td><td>15</td><td>(3.2)</td><td></td></tr><tr><td>Missing</td><td>3</td><td></td><td>2</td><td></td><td></td></tr><tr><td>Marital status</td><td></td><td></td><td></td><td></td><td>0.976</td></tr><tr><td>Single</td><td>284</td><td>(51.4)</td><td>219</td><td>(50.5)</td><td></td></tr><tr><td>Living with a partner</td><td>196</td><td>(35.5)</td><td>156</td><td>(35.9)</td><td></td></tr><tr><td>Divorced</td><td>61</td><td>(11.1)</td><td>50</td><td>(11.5)</td><td></td></tr></tbody></table>
<table><thead><tr><th rowspan="2"></th><th colspan="2">All cases</th><th colspan="2">Cases with health data</th><th rowspan="2">p-value</th></tr><tr><th>n=598</th><th>%</th><th>n=467</th><th>%</th></tr></thead><tbody><tr><td>Widow er</td><td>11</td><td>(2.0)</td><td>9</td><td>(2.1)</td><td></td></tr><tr><td>Missing</td><td>46</td><td></td><td>33</td><td></td><td></td></tr><tr><td>Children</td><td></td><td></td><td></td><td></td><td>0.365</td></tr><tr><td>0</td><td>164</td><td>(34.7)</td><td>142</td><td>(37.5)</td><td></td></tr><tr><td>1</td><td>106</td><td>(22.4)</td><td>75</td><td>(19.8)</td><td></td></tr><tr><td>≥ 2</td><td>203</td><td>(42.9)</td><td>162</td><td>(42.7)</td><td></td></tr><tr><td>Missing</td><td>125</td><td></td><td>88</td><td></td><td></td></tr><tr><td>Education</td><td></td><td></td><td></td><td></td><td>0.870</td></tr><tr><td>None or primary school</td><td>16</td><td>(3.7)</td><td>9</td><td>(2.7)</td><td></td></tr><tr><td>Lower secondary school</td><td>197</td><td>(46.0)</td><td>160</td><td>(47.8)</td><td></td></tr><tr><td>Upper secondary school</td><td>108</td><td>(25.2)</td><td>83</td><td>(24.8)</td><td></td></tr><tr><td>High school diploma</td><td>70</td><td>(16.4)</td><td>54</td><td>(16.1)</td><td></td></tr><tr><td>Third level education</td><td>37</td><td>(8.6)</td><td>29</td><td>(8.7)</td><td></td></tr><tr><td>Missing</td><td>170</td><td></td><td>132</td><td></td><td></td></tr><tr><td>Employment before prison</td><td></td><td></td><td></td><td></td><td>0.723</td></tr><tr><td>Employed</td><td>209</td><td>(46.1)</td><td>162</td><td>(44.4)</td><td></td></tr><tr><td>Unemployed</td><td>238</td><td>(52.5)</td><td>197</td><td>(54)</td><td></td></tr><tr><td>Student or retired</td><td>6</td><td>(1.3)</td><td>6</td><td>(1.6)</td><td></td></tr><tr><td>Missing</td><td>145</td><td></td><td>102</td><td></td><td></td></tr></tbody></table>

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## Criminal characteristics

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For just under half the sample, suicide occurred during their first incarceration (47.0%, see Supplementary Table A). The main suspected or convicted crimes were homicide (22.1%), sexual offence (20.0%), and physical assault (19.5%). Nearly half (47.1%) the sample were in pre-trial incarceration. A third had stayed in different facilities during their imprisonment (34.5%). Three quarters were in remand prisons (78.0%). Forty-two per cent were located in a geographically distant prison (see above), and a third had received visits from a relative or volunteer prison visitor (35.9%).

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## Health characteristics

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Health data were available for 467 (78.1%) cases (see Supplementary Figure A). Their characteristics did not differ from those of all the 598 cases (Table 1, Supplementary Table A).

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Prior to incarceration, 80.3%, 45.0%, 17.0% and 26.9% of cases, respectively, regularly consumed tobacco, cannabis, opioids and other drugs (Table 2). With the exception of tobacco, which is permitted for adults in French prisons, substance use was less frequently reported during incarceration. Just under a half (47.8%) of the sample had at least one mental disorder before prison and 63.7% during imprisonment. During imprisonment, psychotic disorders accounted for 14.6% of all cases, depressive disorders for 15.6% of cases, anxiety disorders for 15.3%, and personality disorders for 12.4%. Half the sample (49.5%) had at least one somatic disease during imprisonment. The most common diseases affected the circulatory system (8.0%), the respiratory system (8.0%), the musculoskeletal system (7.8%), and the endocrine system/nutrition (7.5%).

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<table><caption>**Table 2** Health characteristics of suicides cases (n = 467)</caption><thead><tr><th rowspan="2"></th><th colspan="2">History<br>before prison</th><th colspan="2">During prison</th><th colspan="2">The week<br>before suicide</th></tr><tr><th>n</th><th>%</th><th>n</th><th>%</th><th>n</th><th>%</th></tr></thead><tbody><tr><td colspan="7"><strong>REGULAR SUBSTANCE USE</strong></td></tr><tr><td>Tobacco</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>334</td><td>(80.3)</td><td>297</td><td>(79.6)</td><td>-</td><td>-</td></tr><tr><td>No</td><td>82</td><td>(19.7)</td><td>76</td><td>(20.4)</td><td>-</td><td>-</td></tr><tr><td>Missing</td><td>51</td><td></td><td>94</td><td></td><td></td><td></td></tr><tr><td>Cannabis</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>180</td><td>(45.0)</td><td>75</td><td>(29.0)</td><td>-</td><td>-</td></tr><tr><td>No</td><td>220</td><td>(55.0)</td><td>184</td><td>(71.0)</td><td>-</td><td>-</td></tr><tr><td>Missing</td><td>67</td><td></td><td>208</td><td></td><td></td><td></td></tr><tr><td>Opioids</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>67</td><td>(17.0)</td><td>13</td><td>(5.0)</td><td>-</td><td>-</td></tr><tr><td>No</td><td>328</td><td>(83.0)</td><td>247</td><td>(95.0)</td><td>-</td><td>-</td></tr><tr><td>Missing</td><td>72</td><td></td><td>207</td><td></td><td></td><td></td></tr><tr><td>Other drugs</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>103</td><td>(26.9)</td><td>21</td><td>(8.4)</td><td>-</td><td>-</td></tr><tr><td>No</td><td>280</td><td>(73.1)</td><td>230</td><td>(91.6)</td><td>-</td><td>-</td></tr><tr><td>Missing</td><td>84</td><td></td><td>216</td><td></td><td></td><td></td></tr><tr><td colspan="7"><strong>DISEASES</strong></td></tr><tr><td>Somatic diseases</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>At least one disease</td><td>-</td><td>-</td><td>189</td><td>(45.9)</td><td>-</td><td>-</td></tr><tr><td>Infectious disease</td><td>-</td><td>-</td><td>17</td><td>(4.1)</td><td>-</td><td>-</td></tr><tr><td>Cancer</td><td>-</td><td>-</td><td>8</td><td>(1.9)</td><td>-</td><td>-</td></tr><tr><td>Endocrine or nutritional disease</td><td>-</td><td>-</td><td>31</td><td>(7.5)</td><td>-</td><td>-</td></tr><tr><td>Disease of the circulatory system</td><td>-</td><td>-</td><td>33</td><td>(8.0)</td><td>-</td><td>-</td></tr><tr><td>Disease of the musculoskeletal system</td><td>-</td><td>-</td><td>32</td><td>(7.8)</td><td>-</td><td>-</td></tr><tr><td>Disease of the nervous system</td><td>-</td><td>-</td><td>26</td><td>(6.3)</td><td>-</td><td>-</td></tr><tr><td>Disease of the eye</td><td>-</td><td>-</td><td>5</td><td>(1.2)</td><td>-</td><td>-</td></tr><tr><td>Disease of the ear</td><td>-</td><td>-</td><td>8</td><td>(1.9)</td><td>-</td><td>-</td></tr><tr><td>Disease of the respiratory system</td><td>-</td><td>-</td><td>33</td><td>(8.0)</td><td>-</td><td>-</td></tr><tr><td>Disease of the digestive system</td><td>-</td><td>-</td><td>24</td><td>(5.8)</td><td>-</td><td>-</td></tr><tr><td>Diseases of the skin</td><td>-</td><td>-</td><td>10</td><td>(2.4)</td><td>-</td><td>-</td></tr><tr><td>Diseases of the urinary system</td><td>-</td><td>-</td><td>11</td><td>(2.7)</td><td>-</td><td>-</td></tr><tr><td>Injury</td><td>-</td><td>-</td><td>19</td><td>(4.6)</td><td>-</td><td>-</td></tr><tr><td>No disease</td><td>-</td><td>-</td><td>223</td><td>(54.1)</td><td>-</td><td>-</td></tr><tr><td>Missing</td><td>-</td><td>-</td><td>55</td><td></td><td></td><td></td></tr><tr><td>Mental disorder</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>At least one disorder</td><td>194</td><td>(47.8)</td><td>262</td><td>(63.7)</td><td>-</td><td>-</td></tr><tr><td>Schizophrenia</td><td>22</td><td>(5.4)</td><td>26</td><td>(6.3)</td><td>-</td><td>-</td></tr></tbody></table>
<table><thead><tr><th rowspan="2"></th><th colspan="2">History<br>before prison</th><th colspan="2">During prison</th><th colspan="2">The week<br>before suicide</th></tr><tr><th>n</th><th>%</th><th>n</th><th>%</th><th>n</th><th>%</th></tr></thead><tbody><tr><td>Other psychotic disorder</td><td>25</td><td>(6.2)</td><td>34</td><td>(8.3)</td><td>-</td><td>-</td></tr><tr><td>Bipolar disorder</td><td>9</td><td>(2.2)</td><td>7</td><td>(1.7)</td><td>-</td><td>-</td></tr><tr><td>Depressive disorder</td><td>43</td><td>(10.6)</td><td>64</td><td>(15.6)</td><td>-</td><td>-</td></tr><tr><td>Anxiety disorder</td><td>28</td><td>(6.9)</td><td>63</td><td>(15.3)</td><td>-</td><td>-</td></tr><tr><td>Personality disorder</td><td>31</td><td>(7.6)</td><td>51</td><td>(12.4)</td><td>-</td><td>-</td></tr><tr><td>No disorder</td><td>212</td><td>(52.2)</td><td>149</td><td>(36.3)</td><td>-</td><td>-</td></tr><tr><td>Missing</td><td>61</td><td></td><td>56</td><td></td><td></td><td></td></tr></tbody></table>

## SELF-HARM AND SUICIDAL BEHAVIOUR

<table><tbody><tr><td><strong>Self-harm</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>75</td><td>(23.6)</td><td>77</td><td>(20.4)</td><td>-</td><td>-</td></tr><tr><td>No</td><td>243</td><td>(76.4)</td><td>301</td><td>(79.6)</td><td>-</td><td>-</td></tr><tr><td>Missing</td><td>149</td><td></td><td>89</td><td></td><td></td><td></td></tr><tr><td><strong>Suicide attempt</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>147</td><td>(39.3)</td><td>116</td><td>(28.1)</td><td>-</td><td>-</td></tr><tr><td>No</td><td>227</td><td>(60.7)</td><td>297</td><td>(71.9)</td><td>-</td><td>-</td></tr><tr><td>Missing</td><td>93</td><td></td><td>54</td><td></td><td></td><td></td></tr><tr><td><strong>Suicide threat</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>-</td><td>-</td><td>127</td><td>(31.4)</td><td>-</td><td>-</td></tr><tr><td>No</td><td>-</td><td>-</td><td>278</td><td>(68.6)</td><td>-</td><td>-</td></tr><tr><td>Missing</td><td>-</td><td></td><td>62</td><td></td><td></td><td></td></tr><tr><td><strong>Suicide ideation</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>-</td><td>-</td><td>-</td><td>-</td><td>94</td><td>(23.5)</td></tr><tr><td>No</td><td>-</td><td>-</td><td>-</td><td>-</td><td>306</td><td>(76.5)</td></tr><tr><td>Missing</td><td>-</td><td></td><td>-</td><td></td><td>67</td><td></td></tr></tbody></table>

## HEALTH CARE

<table><tbody><tr><td><strong>Regular follow-up by the health unit<sup>a</sup></strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>-</td><td>-</td><td>232</td><td>(79.5)</td><td>-</td><td>-</td></tr><tr><td>No</td><td>-</td><td>-</td><td>60</td><td>(20.5)</td><td>-</td><td>-</td></tr><tr><td>Missing</td><td>-</td><td></td><td>5</td><td></td><td></td><td></td></tr><tr><td><strong>Psychological or psychiatric follow-up<sup>a</sup></strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>252</td><td>(61.9)</td><td>202</td><td>(73.2)</td><td>-</td><td>-</td></tr><tr><td>No</td><td>155</td><td>(38.1)</td><td>74</td><td>(26.8)</td><td>-</td><td>-</td></tr><tr><td>Missing</td><td>60</td><td></td><td>44</td><td></td><td></td><td></td></tr><tr><td><strong>Admission to a psychiatric ward</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>155</td><td>(38.6)</td><td>141</td><td>(32.4)</td><td>-</td><td>-</td></tr><tr><td>No</td><td>247</td><td>(61.4)</td><td>294</td><td>(67.6)</td><td>-</td><td>-</td></tr><tr><td>Missing</td><td>65</td><td></td><td>32</td><td></td><td></td><td></td></tr><tr><td><strong>Opioid substitution treatment</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>58</td><td>(14.4)</td><td>46</td><td>(10.7)</td><td>44</td><td>(10.0)</td></tr><tr><td>No</td><td>345</td><td>(85.6)</td><td>382</td><td>(89.3)</td><td>398</td><td>(90.0)</td></tr><tr><td>Missing</td><td>64</td><td></td><td>39</td><td></td><td>25</td><td></td></tr></tbody></table>

Other psychotropic treatment
<table><thead><tr><th rowspan="2"></th><th colspan="2">History<br>before prison</th><th colspan="2">During prison</th><th colspan="2">The week<br>before suicide</th></tr><tr><th>n</th><th>%</th><th>n</th><th>%</th><th>n</th><th>%</th></tr></thead><tbody><tr><td>Yes</td><td>233</td><td>(58.0)</td><td>249</td><td>(57.6)</td><td>282</td><td>(63.7)</td></tr><tr><td>No</td><td>169</td><td>(42.0)</td><td>183</td><td>(42.4)</td><td>161</td><td>(36.3)</td></tr><tr><td>Missing</td><td>65</td><td></td><td>35</td><td></td><td>24</td><td></td></tr><tr><td colspan="7">Compliance to psychotropic treatments</td></tr><tr><td>Yes</td><td>-</td><td>-</td><td>-</td><td>-</td><td>168</td><td>(86.6)</td></tr><tr><td>No</td><td>-</td><td>-</td><td>-</td><td>-</td><td>26</td><td>(13.4)</td></tr><tr><td>Missing</td><td>-</td><td>-</td><td>-</td><td>-</td><td>92</td><td></td></tr><tr><td colspan="7">Last visit to health unit before suicide</td></tr><tr><td>&lt; 1 week</td><td>-</td><td>-</td><td>269</td><td>(60.4)</td><td>-</td><td>-</td></tr><tr><td>From 1 week to 1 month</td><td>-</td><td>-</td><td>111</td><td>(24.9)</td><td>-</td><td>-</td></tr><tr><td>&gt; 1 month</td><td>-</td><td>-</td><td>37</td><td>(8.3)</td><td>-</td><td>-</td></tr><tr><td>Follow-up interrupted</td><td>-</td><td>-</td><td>28</td><td>(6.3)</td><td>-</td><td>-</td></tr><tr><td>Missing</td><td>-</td><td>-</td><td>22</td><td></td><td>-</td><td>-</td></tr><tr><td colspan="7">OTHERS</td></tr><tr><td colspan="7">Traumatic event</td></tr><tr><td>At least one event</td><td>-</td><td>-</td><td>-</td><td>-</td><td>184</td><td>(61.3)</td></tr><tr><td>Related to the criminal situation</td><td>-</td><td>-</td><td>-</td><td>-</td><td>56</td><td>(18.5)</td></tr><tr><td>Related to the prison situation</td><td>-</td><td>-</td><td>-</td><td>-</td><td>42</td><td>(14.0)</td></tr><tr><td>Related to the family situation</td><td>-</td><td>-</td><td>-</td><td>-</td><td>36</td><td>(11.9)</td></tr><tr><td>Related to health</td><td>-</td><td>-</td><td>-</td><td>-</td><td>7</td><td>(2.3)</td></tr><tr><td>No event</td><td>-</td><td>-</td><td>-</td><td>-</td><td>116</td><td>(38.7)</td></tr><tr><td>Missing</td><td>-</td><td>-</td><td>-</td><td>-</td><td>167</td><td></td></tr><tr><td colspan="7">Episode of agitated behaviour</td></tr><tr><td>Yes</td><td>-</td><td>-</td><td>95</td><td>(23.2)</td><td>84</td><td>(20.9)</td></tr><tr><td>No</td><td>-</td><td>-</td><td>314</td><td>(76.8)</td><td>317</td><td>(79.1)</td></tr><tr><td>Missing</td><td>-</td><td>-</td><td>58</td><td></td><td>66</td><td></td></tr></tbody></table>

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One-quarter (23.6%) and two-fifths (39.3%) of the sample had either practiced self-harm behaviour or attempted suicide before imprisonment; these percentages were 20.4% and 28.1% during incarceration, respectively (Table 2). Moreover, during imprisonment, 31.4% of the sample had threatened to kill themselves before dying by suicide.

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Among cases imprisoned for more than three months, 79.5% were followed up by the health unit; specifically 73.2% had psychological or psychiatric follow-up. Two-fifths (39%) of the sample had been admitted to a psychiatric ward before imprisonment and 32.4% during imprisonment. In 60.4% of cases, the last visit to the health unit was less than one week before suicide occurred.

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## Circumstances surrounding suicide

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A traumatic event occurred for 61.3% of cases the week before suicide occurred; these events were often related to their criminal situation (e.g., sentencing, request for a lighter sentence being denied) (18.5% of all cases), the prison situation (e.g., violence, disciplinary actions) (14.0%) or one's family situation (11.9%, Table 2). In the week before suicide, suicidal ideation was identified in 23.5% of cases, 20.9% had an episode of agitated behaviour, 10% were receiving opioid substitution treatment,

<footnote>a During the stay in prison, suicides occurring during the first three months were excluded.</footnote>
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and 63.7% were receiving another psychotropic treatment; adherence to these treatments in the previous week was high (86.6%).

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Eleven percent of suicides occurred during the first week of imprisonment and 67.3% during the first year (see Supplementary Table B). No association was found with birthdays (p=0.118) or with the month of the year p=0.811). The number of suicides varied according to the day of the week (p=0.018), being higher on Mondays (15.9%) and Tuesdays (18.4%) and lower on Wednesdays (11.2%), Thursdays (13.9%) and Fridays (11.4%). Suicides were more likely to be discovered at certain times of the day (p<0.001, Figure 1a). Among persons in the general prison population (i.e., not in solitary confinement or other special detention regimes) and those in the arrival section, those who were living alone in cells (n=296, 66.4%) were more often discovered in the early morning (Figure 1b), whereas those who shared their cell (n=150, 33.6%) were more often discovered during daytime activities (Figure 1c). Among those who shared their cell, 61.1% of suicides occurred in the absence of fellow inmates. When fellow inmates were absent (n=91), they were most often in the prison yard (66.7%) or at prison work (13.8%).

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<figure><img src="image_3.png" /><figcaption>**Figure 1** Discovery of the suicide according to hour of the day (%)</figcaption></figure>

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(a) All cases of suicide (n=591);

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(b) Cases of suicide in the general prison population or in the arrival section who lived alone in their cell (n=296);

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(c) Cases of suicide in the general prison population or in the arrival section who shared their cell (n=150);

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Sixty percent of cases occurred in the general prison population, 16.6% in solitary confinement, 16.0% in the arrival section, and 6.9% in health units (see Supplementary Table C). The vast majority of cases died by hanging (93.1%). A third (32.0%) left a suicide note. For 13.4%, death occurred at least one day after the suicidal act, while death was certified as having taken place outside the prison grounds for 15.2% of cases.

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## Changes in the characteristics of suicide cases associated with the SARS-CoV2 pandemic

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Incarcerated people who died by suicide on or after the 17 March 2020 (n=213) (i.e., start of France's first SARS-CoV2 pandemic lockdown) did not differ significantly in terms of age (p=0.480) or gender
(p=0.800) from those who died before that date (n=385). In terms of other characteristics, those who died by suicide on or after 17 March 2020 were more likely to be nationals of an African country (12.3% vs 6.5%) and less likely to be nationals of a European country (5.7% vs 12.5%) (p=0.009). Moreover, they were more likely to have children (77.7% vs 61.1%, p=0.001) and to be employed (56.8% vs 41.7%, p=0.013). In addition, they were less likely to be incarcerated in a prison geographically distant from where their relatives lived (see above for definition) (29.0% vs 48.6%, p<0.001), less likely to receive visits (28.9% vs 39.9%, p=0.009), and less likely to leave a suicide note (16.6% vs 41.4%, p<0.001). Furthermore, in those who died on or after 17 March 2020, death was more likely to occur on the day as the suicidal act (91.1% vs 84.2%, p=0.019) and to occur inside the prison premises (90.1% vs 81.7%, p=0.026).

Among people incarcerated for more than three months with available health data, those who died on or after 17 March 2020 (n=86) were less likely to have been regularly followed up by the prison's health unit than those who died before this date (n=211) (71.1% vs 82.8%, respectively; p=0.017), and less likely to have psychological or psychiatric follow-up (65.4% vs 76.3%, p=0.048). No difference between these two groups was found for somatic diseases (p=0.919) or mental disorders (p=0.190) during imprisonment.

## Suicide rates

The global suicide rate was 17.5 per 10,000 PY (CI$_{95\%}$ [16.1-18.9]). It increased with age (p<0.001), was twice as high for persons in pre-trial incarceration (p<0.001) and six times higher during the first week of imprisonment (p<0.001, Table 3). No difference was found for the other characteristics assessed.

<table><caption>**Table 3** Suicide rate among incarcerated people</caption><thead><tr><th></th><th>Number of Suicides (%)</th><th>PY (%)</th><th>Suicide rate /10,000 PY</th><th>CI<sub>95%</sub></th><th>p-value</th></tr></thead><tbody><tr><td>Global</td><td>598 (100)</td><td>341 067.3 (100)</td><td>17.5</td><td>[16.1 - 18.9]</td><td></td></tr><tr><td>Gender</td><td></td><td></td><td></td><td></td><td>0.145</td></tr><tr><td>Men</td><td>571 (95.5)</td><td>327 676.8 (96.6)</td><td>17.4</td><td>[16.0 - 18.9]</td><td></td></tr><tr><td>Women</td><td>27 (4.5)</td><td>11 682.7 (3.4)</td><td>23.1</td><td>[14.4 - 31.8]</td><td></td></tr><tr><td>Age (years)</td><td></td><td></td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>13-29</td><td>179 (30.0)</td><td>144 334.4 (42.3)</td><td>12.4</td><td>[10.6 - 14.2]</td><td></td></tr><tr><td>30-49</td><td>315 (52.8)</td><td>155 883.8 (45.6)</td><td>20.2</td><td>[18.0 - 22.4]</td><td></td></tr><tr><td>&gt;49</td><td>103 (17.2)</td><td>41 289.3 (12.1)</td><td>24.9</td><td>[20.1 - 29.8]</td><td></td></tr><tr><td>Nationality</td><td></td><td></td><td></td><td></td><td>0.560</td></tr><tr><td>French</td><td>464 (78.0)</td><td>262 304.5 (76.9)</td><td>17.7</td><td>[16.1 - 19.3]</td><td></td></tr><tr><td>Other country</td><td>131 (22.0)</td><td>78 848.8 (23.1)</td><td>16.6</td><td>[13.8 - 19.5]</td><td></td></tr><tr><td>Criminal status</td><td></td><td></td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>Pre-trial</td><td>280 (47.1)</td><td>103 471.0 (30.3)</td><td>27.1</td><td>[23.9 - 30.2]</td><td></td></tr><tr><td>Sentenced</td><td>314 (52.9)</td><td>237 596.3 (69.7)</td><td>13.2</td><td>[11.8 - 14.7]</td><td></td></tr><tr><td>Year</td><td></td><td></td><td></td><td></td><td>0.634</td></tr><tr><td>2017</td><td>110 (18.4)</td><td>69 279.0 (20.3)</td><td>15.9</td><td>[12.9 - 18.8]</td><td></td></tr></tbody></table>
<table><thead><tr><th></th><th>Number of<br>Suicides (%)</th><th>PY (%)</th><th>Suicide<br>rate<br>/10,000<br>PY</th><th>CI<sub>95%</sub></th><th>p-value</th></tr></thead><tbody><tr><td>2018</td><td>124 (20.7)</td><td>70 291.7 (20.6)</td><td>17.6</td><td>[14.5 - 20.7]</td><td></td></tr><tr><td>2019</td><td>119 (19.9)</td><td>71 146.8 (20.9)</td><td>16.7</td><td>[13.7 - 19.7]</td><td></td></tr><tr><td>2020</td><td>119 (19.9)</td><td>63 306.8 (18.6)</td><td>18.8</td><td>[15.4 - 22.2]</td><td></td></tr><tr><td>2021</td><td>126 (21.1)</td><td>67 011.5 (19.6)</td><td>18.8</td><td>[15.5 - 22.1]</td><td></td></tr><tr><td>17 March 2020<sup>a</sup></td><td></td><td></td><td></td><td></td><td>0.364</td></tr><tr><td>Before this date</td><td>385 (64.4)</td><td>225 781.4 (66.2)</td><td>17.1</td><td>[15.3 - 18.8]</td><td></td></tr><tr><td>On or after this date</td><td>213 (35.6)</td><td>115 364.1 (33.8)</td><td>18.5</td><td>[16.0 - 20.9]</td><td></td></tr><tr><td>Suicide occurred during first<br>week of imprisonment</td><td></td><td></td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>66 (11.0)</td><td>7 164.2 (2.1)</td><td>92.1</td><td>[69.9 - 114.3]</td><td></td></tr><tr><td>No</td><td>532 (89.0)</td><td>333 903.1 (97.9)</td><td>15.9</td><td>[14.6 - 17.3]</td><td></td></tr><tr><td>Suicide occurred during last<br>week of sentence<sup>b</sup></td><td></td><td></td><td></td><td></td><td>0.184</td></tr><tr><td>Yes</td><td>2 (0.6)</td><td>3 992.5 (1.7)</td><td>5.0</td><td>[0 - 12.0]</td><td></td></tr><tr><td>No</td><td>312 (99.4)</td><td>233 603.8 (98.3)</td><td>13.4</td><td>[11.9 - 14.8]</td><td></td></tr></tbody></table>

CI: Confidence interval; PY: person-years

<sup>a</sup>First day of the first SARS-CoV2 pandemic lockdown in France <sup>b</sup>Sentenced persons only

## Comparison of suicide rates between incarcerated persons and the general population

In the general French population, over the period 2017-2021, the suicide rate per 10,000 PY was 2.0 for men and 0.6 for women. The rate among incarcerated people was 9.9 times higher for men (SMR=9.9 [9.1-10.7]) and 41.0 times higher for women (SMR=41.0 [27.0-59.7]) (Table 4) than in the general population.

<table><caption>**Table 4** Age-standardised comparison of suicide rates in the prison population and the general population, according to gender</caption><thead><tr><th></th><th>Cases observed</th><th>Cases expected<sup>a</sup></th><th>SMR</th><th>CI<sub>95%</sub></th></tr></thead><tbody><tr><td>Men</td><td>571</td><td>57.7</td><td>9.9</td><td>[9.1 - 10.7]</td></tr><tr><td>Women</td><td>27</td><td>0.7</td><td>41.0</td><td>[27.0 - 59.7]</td></tr></tbody></table>

CI: Confidence interval; SMR: Standardized mortality ratio

<sup>a</sup>Cases expected in the prison population if in each age group (13-24, 25-34, 35-44, 45-54, 55-64 and 65-74 years) the suicide rate were identical to that observed in the general population.
333 Discussion

334 Main results

335 Over the period 2017-2021, 598 persons incarcerated in France died by suicide. The corresponding
336 suicide rate was 17.5 per 10,000 PY, which increased with age. It was twice as high during pre-trial
337 incarceration and six times higher during the first week of imprisonment. With the exception of
338 psychotic disorders and bipolar disorders, all assessed mental disorders were more prevalent during
339 incarceration than before it. Sixty percent of cases visited the prison's health unit the week before
340 suicide, and a traumatic event was identified for 61% of the study sample. Although the overall suicide
341 rate did not differ during the SARS-CoV2 pandemic, there were differences for certain characteristics.
342 Over the whole study period, the suicide rate for incarcerated people was 10 times higher for men and
343 40 times higher for women than for their counterparts in the general population.

344 Mental disorders

345 During imprisonment, psychotic disorders accounted for 14.6% of all cases and depressive disorders
346 for 15.6%. These figures are higher than those in a meta-analysis of incarcerated persons covering 24
347 countries [34]. However, they are not higher than those reported in previous French studies [35–37],
348 for example 12.1-17.0% and 17.9-24.0%, respectively, in a study by Falissard et al. [35]. Our findings
349 contradict current evidence about suicide in the general population and in prisons, which shows a
350 strong positive correlation between these mental disorders and the risk of suicide [5, 38]. This is
351 probably due to an underestimation of the prevalence of mental disorders in our study. Specifically,
352 while the study by Falissard et al. was based on individual clinical examination by two psychiatrists
353 and used the Mini International Neuropsychiatric Interview [35], our study was based on medical
354 records. Furthermore, although all people entering prison are offered a medical examination, this does
355 not systematically include a full psychiatric examination. Mental disorders are therefore likely to be
356 under-diagnosed in routine practice.

357 Circumstances of the suicide

358 We found a higher frequency of suicides at the beginning of the week. This finding does not
359 correspond with those of Favril et al, who found no variation according to the day of the week in
360 Belgium [25]. One possible explanation could be the French prison administration's guidelines on
361 reporting bad news: as staffing levels are reduced on week-ends, they should not be announced at the
362 end of the week and should wait until the beginning of the following week. The frequency of suicides
363 could therefore be slightly higher at the beginning of the week.

364 Another finding is that 16.6% of suicide occurred in solitary confinement, which is consistent with
365 previous studies examining suicide [7, 9, 39] and suicidal ideation [40]. Developing alternatives to
366 solitary confinement may be an interesting avenue to prevent suicide among incarcerated people.

367 Also, hanging is the most common method of suicide, accounting for 93% of cases. Hanging is
368 systematically reported in more than 80% of inmate suicide cases internationally [27, 41–75]. The
369 international association for suicide prevention recommended to eliminate or minimize hanging points
370 and unsupervised access to lethal materials [2]. In France, several measures of this type can be
371 implemented if a risk of suicide is detected: cell sharing, tearable clothing, or temporary placement in
372 a completely smooth cell in the event of a suicide crisis.

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# Changes in the characteristics of suicide cases associated with the SARS-CoV2 pandemic

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The overall suicide rate of incarcerated people in France did not change during the SARS-CoV2 pandemic. This finding is not consistent with previous studies in other contexts, for example, an increase of suicide attempts in a Swiss prison in 2020 [29], and the negative impact of the pandemic on mental health of incarcerated people in several countries [76, 77]. However, our study provides indirect evidence of the dislocation of family ties of incarcerated people during the pandemic, also reported in other studies [28, 76–78]. Despite not being geographically distant (see definition above), incarcerated people in our study who died by suicide during the pandemic were less likely to have received visits. In France, prison visits were prohibited during the first lockdown. After 11 May 2020 (i.e., end of first lockdown), visits were permitted but less frequently and under more restrictive conditions [79, 80], including the installation of Plexiglas panes. A previous study found that the latter action may have discouraged visits from young children [79], something which may having seriously impacted prisoners’ mental health. This is suggested in our study by the increase in the number of parents among suicide cases, from 61% before the pandemic to 78% during it. Overall, facilitating the maintenance of family ties appears to be an interesting avenue for preventing suicide among incarcerated people.

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We also found that suicide notes were less frequent during the pandemic, which may suggest general difficulties in obtaining stationery at this time. The less frequent follow-up by prison health units during the pandemic, and the greater proportion of suicide deaths in the prison premises during that period – which one might interpret as indicating fewer cases of hospitalisation following a suicidal act – suggest that health care of incarcerated people was disrupted during the pandemic. This may reflect a loss of opportunity for people at risk of suicide.

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# Suicide rate: prison population versus the general population

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For persons of the same age, the suicide rate for incarcerated people in France was 10 times higher for men and 40 times higher for women than for their counterparts in the general population. These figures reflect an ever-widening gap since the 1980s, when the associated rates were 4 and 10 times higher, respectively [81]. This increase is linked both to a fall in the suicide rate among the general population [82, 83] and to an increase in the suicide rate among incarcerated people [7, 14].

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The suicide rate in prisons is higher than in the general population in most countries [4]. This difference is regularly explained both by the incarceration of particularly vulnerable people (*importation* model) and by the deleterious effects of imprisonment (*deprivation* model) [2, 3, 84–88]. However, the gap between the prison and general populations in France is one of the highest in the world [4].

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There are also greater disparities for women in most countries: suicide rates in prison are typically between 10 and 32 times higher than in general population, compared with 2 to 6 times for men [4]. Several factors are likely to contribute to this difference: 1) the incarceration of more vulnerable people among women than men, particularly in a context where women are less frequently incarcerated [4, 89, 90]. For example, childhood maltreatment, which is a risk factor for suicidal behaviour [91], is more prevalent among incarcerated women [92]; 2) greater deprivation for women imprisoned because of their ultra-minority status [93–96]. In particular, the frequent association of this minority situation with a policy of non-gender mixing in prisons can limit the access of imprisoned women to healthcare, certain jobs, education and activities in prison [94–96]; 3) greater stigmatisation of women who break the law, linked to the role assigned to women by social gender norms as
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guarantors of the moral order [95–97]. This could contribute to women being abandoned by their partners more often than men in prison, as suggested by qualitative studies [96, 98].

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## Strengths and limitations

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This study has several strengths. First, as it is an exhaustive, national-level investigation based on a 5-year period, its results can be considered representative of the French context. Its national scale also ensured that a large number of suicides could be included, thereby increasing the study's statistical power. Second, we measured a large number of characteristics. To our knowledge, this is the first study to present the health characteristics of suicides among incarcerated people in France. Third, we also collected detailed information on the circumstances surrounding the suicides.

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The study also has limitations. First, we had no control group for most of the characteristics. Accordingly, we could not determine to what extent the characteristics presented were associated with suicide or not. Second, the study data were initially collected as part of different routine activities (medical follow-up, detention management) and not for research purposes. Some information was not systematically collected or may have been measured inaccurately. In particular, there was a large percentage of missing data on health data; accordingly, the frequency of certain characteristics, such as mental disorders, was probably underestimated. Third, when classifying deaths as suicide, the results of forensic investigations are taken into account by the National Prison Service only if the cause is deemed uncertain by the prison administration in view of the apparent circumstances surrounding the death. Some deaths may therefore have been misclassified. In addition, the most complex (i.e., uncertain) deaths must be discussed at a National Prison Service commission, which has not met since 2018. These cases are not accessible to researchers and therefore some suicides that occurred between 2018 and 2021 were not included in our study. The number of cases awaiting assessment is not known, but is probably marginal compared with the total number of cases given that previous meetings of this commission led to only five and two suicides being added in 2016 and 2017, respectively.

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## Conclusion

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Suicide is a major health issue in prisons in France and over the world. Strengthening efforts to restrict access to lethal means could help reduce the frequency of suicides. However, suicide prevention cannot be separated from concern for the mental health of incarcerated people. Our findings suggest the importance of maintaining family ties for their mental health. Suicides have multiple causes, and studies evaluating prison suicide prevention programmes emphasise the importance of a multimodal approach to effective prevention [99].

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Furthermore, current approaches to suicide prevention among incarcerated people are mainly focused on the period spent in prison. When we consider that in the United States, for example, more than a quarter of suicides in the general population are attributed to people who have been incarcerated in the previous two years [100], we may wonder to what extent certain suicides are not prevented but merely postponed. Therefore, it could be beneficial for prevention to develop perspectives that focus more on people's life trajectories, for example by looking at the continuity of medical and social follow-up upon entry into and release from prison, or the impact of imprisonment on these individuals' lives.
459 Acknowledgements

460 We are grateful to the Social Policies and Partnerships Office of the National Prison Service (French
461 Ministry of Justice), for their work in collecting data. We would also like to thank he physicians of the
462 health units for people incarcerated in France for their participation in the design of the study
463 questionnaire and in collecting data. Our thanks to Philippe Pirard from the National Agency of Public
464 Health, for providing us with data on suicide mortality by age in the general population. Finally, thank
465 you to the reviewers for their insights and comments which helped improve this manuscript.

466

467 Declaration of interest statement

468 Funding details

469 This study was conducted within the framework of suicide surveillance carried out by *Santé publique France* (*SpF*), the French National Public Health Agency. It received no specific grant from any
470 funding agency, or from commercial or not-for-profit sectors.
471

472 Disclosure of interest

473 The authors report there are no competing interests to declare.

474 Data availability statement

475 The data are not publicly available. The agreement signed between the French National Public Health
476 Agency and the National Prison Service stipulates that the data collected for this specific study cannot
477 be used for other purposes due to the sensitivity of individual data on incarcerated people.

478 Consent to participate

479 Not applicable.
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712 100. Miller TR, Weinstock LM, Ahmedani BK, et al (2024) Share of Adult Suicides After Recent Jail Release. JAMA Netw Open 7(5):e249965. https://doi.org/10.1001/jamanetworkopen.2024.9965

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## Article information

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727

### Title

728

A national study of persons who died by suicide in French prisons over the period 2017–2021

729

730

### Journal name

731

Archives of Suicide Research

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733

### Author names

734

Alexis Vanhaesebrouck¹,², Amélie Tostivint³, Imane Khireddine-Medouni², Thomas Lefèvre¹,⁴, Maria

735

Melchior⁵, Nolwenn Regnault², Christine Chan Chee²,⁸

736

737

### Author affiliation

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1 Interdisciplinary Research Institute on Social issues (IRIS), UMR 8156-997, UFR SMBH,

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Université Sorbonne Paris Nord, Paris, France

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2 Santé publique France (SpF), Saint-Maurice, France

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3 Health division of the National Prison Service, Ministry of Justice, Paris, France

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4 Department of legal and social medicine, Hôpital Jean-Verdier (AP-HP), Bondy, France

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5 Sorbonne Université, INSERM, Pierre Louis Institute of Epidemiology and Public Health,

744

Department of Social Epidemiology, Mental Health, and Addictions, Paris, France

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746

747
<table><caption>Table A. Criminal characteristics of suicide cases (n=598)</caption><thead><tr><th rowspan="2"></th><th colspan="2">All cases</th><th colspan="2">Cases with health data</th><th rowspan="2">p</th></tr><tr><th>n=598</th><th>%</th><th>n=467</th><th>%</th></tr></thead><tbody><tr><td>Previous incarceration</td><td></td><td></td><td></td><td></td><td>0.528</td></tr><tr><td>Yes</td><td>228</td><td>(53.0)</td><td>177</td><td>(48.6)</td><td></td></tr><tr><td>No</td><td>202</td><td>(47.0)</td><td>187</td><td>(51.4)</td><td></td></tr><tr><td>Missing</td><td>168</td><td></td><td>103</td><td></td><td></td></tr><tr><td>Main offence</td><td></td><td></td><td></td><td></td><td>1</td></tr><tr><td>Homicide</td><td>131</td><td>(22.1)</td><td>103</td><td>(22.2)</td><td></td></tr><tr><td>Sexual offence</td><td>119</td><td>(20.0)</td><td>92</td><td>(19.8)</td><td></td></tr><tr><td>Physical assault</td><td>116</td><td>(19.5)</td><td>93</td><td>(20)</td><td></td></tr><tr><td>Burglary or theft offence</td><td>95</td><td>(16.0)</td><td>75</td><td>(16.1)</td><td></td></tr><tr><td>Drug-related offence</td><td>49</td><td>(8.2)</td><td>37</td><td>(8.0)</td><td></td></tr><tr><td>Other</td><td>84</td><td>(14.1)</td><td>65</td><td>(14.0)</td><td></td></tr><tr><td>Missing</td><td>4</td><td></td><td>2</td><td></td><td></td></tr><tr><td>Criminal status</td><td></td><td></td><td></td><td></td><td>0.901</td></tr><tr><td>Pre-trial</td><td>280</td><td>(47.1)</td><td>221</td><td>(47.4)</td><td></td></tr><tr><td>Sentenced</td><td>314</td><td>(52.9)</td><td>245</td><td>(52.6)</td><td></td></tr><tr><td>Missing</td><td>4</td><td></td><td>1</td><td></td><td></td></tr><tr><td>Inter-prison transfer</td><td></td><td></td><td></td><td></td><td>0.992</td></tr><tr><td>Yes</td><td>204</td><td>(34.5)</td><td>160</td><td>(34.5)</td><td></td></tr><tr><td>No</td><td>388</td><td>(65.5)</td><td>304</td><td>(65.5)</td><td></td></tr><tr><td>Missing</td><td>6</td><td></td><td>3</td><td></td><td></td></tr><tr><td>Type of facility</td><td></td><td></td><td></td><td></td><td>0.399</td></tr><tr><td>Remand prison</td><td>455</td><td>(78.0)</td><td>360</td><td>(78.6)</td><td></td></tr><tr><td>SSPLS</td><td>109</td><td>(18.7)</td><td>85</td><td>(18.6)</td><td></td></tr><tr><td>HSPLS</td><td>10</td><td>(1.7)</td><td>10</td><td>(2.2)</td><td></td></tr><tr><td>Other</td><td>9</td><td>(1.5)</td><td>3</td><td>(0.7)</td><td></td></tr><tr><td>Missing</td><td>15</td><td></td><td>9</td><td></td><td></td></tr><tr><td>Prison 'distant'</td><td></td><td></td><td></td><td></td><td>0.216</td></tr><tr><td>Yes</td><td>228</td><td>(41.9)</td><td>192</td><td>(44.9)</td><td></td></tr><tr><td>No</td><td>316</td><td>(58.1)</td><td>236</td><td>(55.1)</td><td></td></tr><tr><td>Missing</td><td>54</td><td></td><td>39</td><td></td><td></td></tr><tr><td>Visit from a relative or volunteer</td><td></td><td></td><td></td><td></td><td>0.788</td></tr><tr><td>Yes</td><td>201</td><td>(35.9)</td><td>161</td><td>(36.5)</td><td></td></tr><tr><td>No</td><td>359</td><td>(64.1)</td><td>280</td><td>(63.5)</td><td></td></tr><tr><td>Missing</td><td>38</td><td></td><td>26</td><td></td><td></td></tr></tbody></table>

HSPLS: high security prison for long sentences; SSPLS: standard security prison for long sentences
<table><caption>Table B. Time of suicide (n=598)</caption><thead><tr><th></th><th>n</th><th>%</th><th>p</th></tr></thead><tbody><tr><td>Time between entry into prison and suicide</td><td></td><td></td><td></td></tr><tr><td>&lt;1 week</td><td>66</td><td>(11.1)</td><td></td></tr><tr><td>1 week to 1 month</td><td>52</td><td>(8.8)</td><td></td></tr><tr><td>1 to 3 months</td><td>96</td><td>(16.2)</td><td></td></tr><tr><td>3 to 6 months</td><td>96</td><td>(16.2)</td><td></td></tr><tr><td>6 to 12 months</td><td>90</td><td>(15.2)</td><td></td></tr><tr><td>1 to 3 years</td><td>108</td><td>(18.2)</td><td></td></tr><tr><td>3 to 5 years</td><td>39</td><td>(6.6)</td><td></td></tr><tr><td>≥ 5 years</td><td>47</td><td>(7.9)</td><td></td></tr><tr><td>Missing</td><td>4</td><td></td><td></td></tr><tr><td>Time between suicide and scheduled release<sup>a</sup></td><td></td><td></td><td></td></tr><tr><td>&lt;1 week</td><td>2</td><td>(0.7)</td><td></td></tr><tr><td>1 week to 1 month</td><td>13</td><td>(4.2)</td><td></td></tr><tr><td>1 to 3 months</td><td>43</td><td>(14.1)</td><td></td></tr><tr><td>3 to 6 months</td><td>54</td><td>(17.6)</td><td></td></tr><tr><td>6 to 12 months</td><td>56</td><td>(18.3)</td><td></td></tr><tr><td>1 to 3 years</td><td>74</td><td>(24.2)</td><td></td></tr><tr><td>3 to 5 years</td><td>26</td><td>(8.5)</td><td></td></tr><tr><td>≥ 5 years</td><td>38</td><td>(12.4)</td><td></td></tr><tr><td>Missing</td><td>8</td><td></td><td></td></tr><tr><td>Suicide on birthday</td><td></td><td></td><td>0.118</td></tr><tr><td>Yes</td><td>4</td><td>(0.7)</td><td></td></tr><tr><td>No</td><td>593</td><td>(99.3)</td><td></td></tr><tr><td>Missing</td><td>1</td><td></td><td></td></tr><tr><td>Month of the year</td><td></td><td></td><td>0.811</td></tr><tr><td>January</td><td>47</td><td>(7.9)</td><td></td></tr><tr><td>February</td><td>47</td><td>(7.9)</td><td></td></tr><tr><td>March</td><td>46</td><td>(7.7)</td><td></td></tr><tr><td>April</td><td>43</td><td>(7.2)</td><td></td></tr><tr><td>May</td><td>46</td><td>(7.7)</td><td></td></tr><tr><td>June</td><td>56</td><td>(9.4)</td><td></td></tr><tr><td>July</td><td>62</td><td>(10.4)</td><td></td></tr><tr><td>August</td><td>48</td><td>(8.0)</td><td></td></tr><tr><td>September</td><td>57</td><td>(9.5)</td><td></td></tr><tr><td>October</td><td>49</td><td>(8.2)</td><td></td></tr><tr><td>November</td><td>47</td><td>(7.9)</td><td></td></tr><tr><td>December</td><td>50</td><td>(8.4)</td><td></td></tr><tr><td>Day of the week</td><td></td><td></td><td>0.018</td></tr><tr><td>Monday</td><td>95</td><td>(15.9)</td><td></td></tr><tr><td>Tuesday</td><td>108</td><td>(18.1)</td><td></td></tr><tr><td>Wednesday</td><td>67</td><td>(11.2)</td><td></td></tr><tr><td>Thursday</td><td>83</td><td>(13.9)</td><td></td></tr><tr><td>Friday</td><td>68</td><td>(11.4)</td><td></td></tr><tr><td>Saturday</td><td>93</td><td>(15.6)</td><td></td></tr></tbody></table>
<table><thead><tr><th></th><th>n</th><th>%</th><th>p</th></tr></thead><tbody><tr><td>Sunday</td><td>84</td><td>(14.0)</td><td></td></tr><tr><td>Hour of day</td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>[0,3)</td><td>53</td><td>(9.0)</td><td></td></tr><tr><td>[3,6)</td><td>61</td><td>(10.3)</td><td></td></tr><tr><td>[6,9)</td><td>109</td><td>(18.4)</td><td></td></tr><tr><td>[9,12)</td><td>76</td><td>(12.9)</td><td></td></tr><tr><td>[12,15)</td><td>59</td><td>(10.0)</td><td></td></tr><tr><td>[15,18)</td><td>107</td><td>(18.1)</td><td></td></tr><tr><td>[18,21)</td><td>67</td><td>(11.3)</td><td></td></tr><tr><td>[21,24)</td><td>59</td><td>(10.0)</td><td></td></tr><tr><td>Missing</td><td>7</td><td></td><td></td></tr></tbody></table>

<sup>a</sup> Sentenced persons only

752

753
<table><caption>Table C. Other circumstances of suicide (n=598)</caption><thead><tr><th></th><th>n</th><th>%</th></tr></thead><tbody><tr><td><strong>Location of suicidal act</strong></td><td></td><td></td></tr><tr><td>General detention cell</td><td>358</td><td>(60.2)</td></tr><tr><td>Arrival section</td><td>95</td><td>(16.0)</td></tr><tr><td>DSC</td><td>83</td><td>(13.9)</td></tr><tr><td>NDSC</td><td>16</td><td>(2.7)</td></tr><tr><td>Psychiatric unit in prison</td><td>17</td><td>(2.9)</td></tr><tr><td>Hospital</td><td>24</td><td>(4.0)</td></tr><tr><td>Private home<sup>a</sup></td><td>2</td><td>(0.3)</td></tr><tr><td>Missing</td><td>3</td><td></td></tr><tr><td><strong>Method</strong></td><td></td><td></td></tr><tr><td>Hanging</td><td>553</td><td>(93.1)</td></tr><tr><td>Self-poisoning</td><td>14</td><td>(2.4)</td></tr><tr><td>Suffocation</td><td>11</td><td>(1.9)</td></tr><tr><td>Cutting</td><td>9</td><td>(1.5)</td></tr><tr><td>Self-strangulation</td><td>4</td><td>(0.7)</td></tr><tr><td>Fire</td><td>3</td><td>(0.5)</td></tr><tr><td>Missing</td><td>4</td><td></td></tr><tr><td><strong>Hanging: ligature point</strong></td><td></td><td></td></tr><tr><td>Cell window</td><td>207</td><td>(39.4)</td></tr><tr><td>Sanitary</td><td>105</td><td>(20.0)</td></tr><tr><td>Bed</td><td>88</td><td>(16.7)</td></tr><tr><td>Cell bar</td><td>56</td><td>(10.6)</td></tr><tr><td>Heater or line pipe</td><td>34</td><td>(6.5)</td></tr><tr><td>Other</td><td>36</td><td>(6.8)</td></tr><tr><td>Missing</td><td>27</td><td></td></tr><tr><td><strong>Hanging: ligature</strong></td><td></td><td></td></tr><tr><td>Bed linen</td><td>356</td><td>(70.2)</td></tr><tr><td>Belt or other clothes</td><td>68</td><td>(13.4)</td></tr><tr><td>Lace or cord</td><td>37</td><td>(7.3)</td></tr><tr><td>Electronic equipment</td><td>21</td><td>(4.1)</td></tr><tr><td>Other</td><td>25</td><td>(4.9)</td></tr><tr><td>Missing</td><td>46</td><td></td></tr><tr><td><strong>Suicide note</strong></td><td></td><td></td></tr><tr><td>Yes</td><td>173</td><td>(32.0)</td></tr><tr><td>No</td><td>368</td><td>(68.0)</td></tr><tr><td>Missing</td><td>57</td><td></td></tr><tr><td><strong>Location of death</strong></td><td></td><td></td></tr><tr><td>General detention cell</td><td>321</td><td>(54.3)</td></tr><tr><td>Arrival section</td><td>84</td><td>(14.2)</td></tr><tr><td>DSC</td><td>71</td><td>(12.0)</td></tr><tr><td>NDSC</td><td>16</td><td>(2.7)</td></tr><tr><td>Psychiatric unit in prison</td><td>10</td><td>(1.7)</td></tr><tr><td>Hospital</td><td>87</td><td>(14.8)</td></tr><tr><td>Medical transport</td><td>1</td><td>(0.2)</td></tr></tbody></table>
<table><thead><tr><th></th><th>n</th><th>%</th></tr></thead><tbody><tr><td>Private home<sup>a</sup></td><td>1</td><td>(0.2)</td></tr><tr><td>Missing</td><td>7</td><td></td></tr><tr><td>Days between the suicidal act and death</td><td></td><td></td></tr><tr><td>0</td><td>518</td><td>(86.6)</td></tr><tr><td>1</td><td>29</td><td>(4.8)</td></tr><tr><td>≥ 2</td><td>51</td><td>(8.5)</td></tr></tbody></table>

755 DSC: Disciplinary solitary confinement; NDSC: Non-disciplinary solitary confinement

756 <sup>a</sup> Incarcerated people may be allowed to leave prison from a few hours to a few days in order to prepare their reintegration into society

757

758
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<figure><img src="image_4.png" /><figcaption>Figure A. Flow chart of the study</figcaption></figure>

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Note: Persons in semi-open facilities generally do not visit the prison's health units. The health questionnaires were qualified as inoperable when all items were missing.

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# Response to reviewers' comments

We would like to thank the two reviewers for their comments, which have helped to improve the quality of the manuscript.

## Reviewer: 1

* A key limitation of this study is the absence of a control group. The reported prevalence of mental and somatic disorders among suicide cases raises the question of whether these rates are higher than in the overall prison population in France. The same concern applies to other reported variables, such as the proportion with traumatic events (61%) or solitary confinement (17%). Without corresponding data for the overall prison population (the comparison group), it is not possible to determine whether these prevalences are disproportionately high, and thus their significance for suicide risk remains unclear. Therefore, it would be useful to provide more information about the French prison population, against which to benchmark the data presented. Specifically, how does nationality, education, main offence, traumatic events, solitary confinement, health care, suicide attempts etc. in prisoners who have died by suicide compare to those of French prisoners more generally? Please include.

We agree that the absence of a control group is a major limitation of the study. This is the first limitation that we reported in the dedicated paragraph of the manuscript (page 10). The creation of a control group was discussed when the study was set up. However, following a warning from health unit representatives about the risk of compromising the study's response rate, it was decided to stick to a study based to suicide cases. Under these conditions, the results of our study were compared with external data whenever possible. These comparisons took the form of suicide rate calculations, as for gender, or were simply mentioned in the discussion, as for psychiatric disorders. There are no national data relative to the level of education, traumatic events, solitary confinement, health care or suicide attempts of incarcerated people during the study period. For main offence, national data are provided only for sentenced people whereas our suicide cases include people on remand. We considered that these data were not comparable because nearly half of suicides occurred during pre-trial incarceration, and the proportion of suicides occurring during pre-trial incarceration depends greatly on the type of (suspected or confirmed) main offence.

Following the reviewer's comments, we made the following change: in Table 3, we added the percentage of suicides and person-years. This allows for a direct comparison of the prevalence of different characteristics between suicide cases and the overall prison population, independently of the calculation of suicide rates.

* Recent meta-analyses have provided comprehensive insights into rates (Mundt, 2024) and risk factors (Zhong, 2021) of prison suicides. Against this compelling evidence base, it is not clear to me what novel contribution the present study offers. This novelty/add-value (if anything) of the current study should be explicitly stated in the introduction. Relatedly, the discussion devotes considerable space to reiterating well-established risk factors (especially mental disorders) despite the absence of a control group (which is a major limitation and therefore cannot say anything about the contribution of mental disorders – or any other factors for that matter – to suicide risk; see my previous comment). Therefore, this emphasis on (mental) health factors in the discussion seems misplaced and should be revised. Instead, in my view the more novel contribution of the study appears to lie in its analysis of the circumstances surrounding suicides – such as day of the week, presence of a suicide note, suicide method, cell occupancy, and so on. These aspects warrant more discussion as they could provide
812 context-specific insights that extend beyond what is already known from risk-factor research. It would
813 be particularly valuable to situate these findings in relation to other descriptive studies of prison
814 suicides in other countries (briefly mentioned in the introduction). Also, the significant variation by
815 day of the week of suicide raises important questions: what might explain this pattern?

816 We thank the reviewer for this comment. Indeed, the added value of this study has not been made
817 explicit. We modified the end of the Introduction (page 4) as follows:

818 "Few studies to date have provided detailed descriptive data on incarcerated people who die by
819 suicide [25-27]. The health characteristics of this specific population have rarely been investigated,
820 and never in France. Furthermore, the SARS-CoV2 pandemic occurred during the study. Pandemic-
821 related protective measures may have exacerbated the isolation of incarcerated people by limiting
822 visits and access to certain activities. While some authors expected an increase in suicide rates in
823 prisons during the SARS-CoV2 pandemic [28], to our knowledge, only one study provided empirical
824 data on an increase in suicide attempts [29] and none on suicide deaths. Finally, previous
825 comparisons of suicide rates between prisoners and the general population of France have not
826 considered age differences between these two populations [4], or have done so only marginally [14].
827 [...]
828

828 In light of these objectives, the added value of this study lies in 1) reporting for the first time on the
829 mental health of prisoners who died by suicide in France; 2) describing a large number of
830 characteristics that could provide new avenues for prevention; 3) being the first study to assess the
831 impact of the SARS-CoV2 pandemic and of the last week of detention on the suicide rate of
832 incarcerated people; 4) being the first study to compare suicide rates between incarcerated people
833 and the general population of France accurately standardising on age."

834 In addition, reporting and discussing mental disorders seems important to us because this is the first
835 study reporting on the mental health of incarcerated people who died by suicide in France. We agree
836 that a strong association between mental disorders and suicide has previously been reported in the
837 meta-analysis conducted by Zhong et al. However, while psychiatric disorders are grouped into a
838 single category in this meta-analysis and in sources studies, our study has the advantage of
839 distinguishing between different types of mental health disorders.

840 We recognise that it would be relevant to discuss some findings relating to the circumstances of the
841 suicides studied. We have halved the discussion on mental disorders (page 9). We also introduced a
842 section on the circumstances surrounding suicide, as follows (page 9):

843 "We found a higher frequency of suicides at the beginning of the week. This finding does not
844 correspond with those of Favril et al, who found no variation according to the day of the week in
845 Belgium [25]. One possible explanation could be the French prison administration's guidelines on
846 reporting bad news: as staffing levels are reduced on week-ends, they should not be announced at the
847 end of the week and should wait until the beginning of the following week. The frequency of suicides
848 could therefore be slightly higher at the beginning of the week.

849 Another finding is that 16.6% of suicide occurred in solitary confinement, which is consistent with
850 previous studies examining suicide [7, 9, 39] and suicidal ideation [40]. Developing alternatives to
851 solitary confinement may be an interesting avenue to prevent suicide among incarcerated people.

852 Also, hanging is the most common method of suicide, accounting for 93% of cases. Hanging is
853 systematically reported in more than 80% of inmate suicide cases internationally [27, 41-75]. The
854 international association for suicide prevention recommended to eliminate or minimize hanging points
855 and unsupervised access to lethal materials [2]. In France, several measures of this type can be
856 implemented if a risk of suicide is detected: cell sharing, tearable clothing, or temporary placement in
857 a completely smooth cell in the event of a suicide crisis."
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* SARS-CoV2 is presented somewhat abruptly in the introduction and requires additional contextualization to clarify its relevance. Why is this analysis important and what are possible hypotheses? In addition, a key limitation of this secondary objective is that it considers suicides only up to 2021, despite the fact that COVID-19 restrictions in European prisons extended into 2022. As a result, the analysis provides an incomplete picture. Please discuss/revise.

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We thank the reviewer for this comment. We added additional contextualization to the Introduction (page 4):

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"Furthermore, *the SARS-CoV2 pandemic occurred during the study. Pandemic-related protective measures may have exacerbated the isolation of incarcerated people by limiting visits and access to certain activities. While some authors expected an increase in suicide rates in prisons during the SARS-CoV2 pandemic [28], to our knowledge, only one study provided empirical data on an increase in suicide attempts [29] and none on suicide deaths."

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In addition, we agree that restrictions in European prisons extended into 2022 and that this period is not covered in our study. However, our aim is to investigate disparities in suicide risk in prisons depending on the presence or absence of the pandemic. From our point of view, since our study period covers both situations, a comparison is possible and can be contributory, provided sufficient statistical power. Here, even though the entire period of restrictions is not covered, we have national data for a 21-month period during the COVID-19 pandemic, which includes the most restrictive measures and all lockdowns in France. Furthermore, periods without a pandemic are not comprehensively covered in our study either, but we have national data for a 39-month period.

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* I have significant concerns about the secondary objective to “compare the clinical characteristics of persons who died by suicide in prison before and during incarceration” which appears of limited value and validity. Even when medical records were available, they are severely limited by a lack of information (eg, drug use, self-harm, suicide ideation, and mental and somatic disorders that are not recorded), particularly for the period before imprisonment. Consequently, this before-during comparison yields little meaningful insight and is subject to substantial bias. Although the authors acknowledge this structural limitation in their discussion, the findings derived from this analysis have little validity and, more importantly, risk being misleading – therefore, this secondary objective should be omitted from the paper.

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Psychiatric disorders are a major risk factor for suicide among prisoners. From a prevention perspective, the question of whether these disorders existed prior to imprisonment or developed in prison is important and has not been thoroughly explored, due to the difficulty of collecting data on the period preceding incarceration.

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In our study, collecting data on mental health both before and during incarceration seemed to us to be an opportunity to study changes in mental health associated with incarceration. However, it is true that this question applies to all prisoners, whereas our data only covers cases of suicide. Furthermore, as pointed out, some items were not collected during both periods and others are incomplete. The comparison with the general prison population also suggests that their frequency may be underestimated.

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The comparison of clinical characteristics of persons who died by suicide in prison before and during imprisonment has been removed from the paper.

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* The analysis of cell occupancy (single vs. shared) focuses on the timing of suicide discovery, but I don't see why timing of discovery is interesting to examine? What's the relevance of this and what are possible hypotheses? This requires clarification. Also, the proportion of suicides occurring in single versus shared cells overall (irrespective of timing of discovery) should be reported. Furthermore, in cases where suicides took place in shared cells, it would be interesting to clarify whether fellow prisoners were present at the time of the event.

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We thank the reviewer for this comment. Timing of discovery is assumed to be related to the time of suicidal acts, given that incarcerated people are monitored very regularly. Firstly, identifying peak times can enable prison staff to be given instructions to be particularly vigilant at certain times. Secondly, it can prompt questions about factors associated with certain times, such as the occurrence of incidents, the availability of medical and prison staff in the event of difficulties, the presence or absence of fellow inmates in shared cells, etc.

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We specified in the results the distribution of incarcerated people who died by suicide according to the type of cell (page 7). Also, we specified the absence of fellow inmates for shared cells:

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"Among persons in the general prison population (i.e., not in solitary confinement or other special detention regimes) and those in the arrival section, those who were living alone in cells (n=296, 66.4%) were more often discovered in the early morning (Figure 1b), whereas those who shared their cell (n=150, 33.6%) were more often discovered during daytime activities (Figure 1c). Among those who shared their cell, 61.1% of suicides occurred in the absence of fellow inmates. When fellow inmates were absent (n=91), they were most often in the prison yard (66.7%) or at prison work (13.8%)."

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* Another key limitation of the manuscript is that the discussion of implications is underdeveloped. More attention is needed with respect to suicide prevention, screening, and intervention strategies. Integrating insights from the international evidence base would certainly strengthen the discussion.

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We agree that we did not focus on implications for suicide prevention.

931

We updated the discussion as follows:

932

- Prevention strategies have been discussed in the section on the circumstances surrounding suicide (see above and in the revised manuscript page 9)

933

- In the section on the SARS-Cov2 pandemic, we specified that family ties could be an interesting target for suicide prevention (page 9):

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"Overall, facilitating the maintenance of family ties appears to be an interesting avenue for preventing suicide among incarcerated people."

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- The Conclusion section was updated as follows (pages 10-11):

939

"Suicide is a major health issue in prisons in France and over the world. Strengthening efforts to restrict access to lethal means could help reduce the frequency of suicides. However, suicide prevention cannot be separated from concern for the mental health of incarcerated people. Our findings suggest the importance of maintaining family ties for their mental health. Suicides have multiple causes, and studies evaluating prison suicide prevention programmes emphasise the importance of a multimodal approach to effective prevention [99].

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Furthermore, current approaches to suicide prevention among incarcerated people are mainly focused on the period spent in prison. When we consider that in the United States, for example, more than a quarter of suicides in the general population are attributed to people who have been

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incarcerated in the previous two years [100], we may wonder to what extent certain suicides are not prevented but merely postponed. Therefore, it could be beneficial for prevention to develop perspectives that focus more on people's life trajectories, for example by looking at the continuity of medical and social follow-up upon entry into and release from prison, or the impact of imprisonment on these individuals' lives.”

* The authors should be transparent that this work represents an update of their recently published study (reference 22) by merely three years. And why was the update necessary?

We updated the Introduction as follows (page 3):

“The National Public Health Agency set up an epidemiological monitoring program for suicides among incarcerated people, in collaboration with the National Prison Service (Ministry of Justice) and prison-based health units. The intermediate results (2017-2018) were published in a previous paper [22]; this article presents the final results (2017-2021).”

This is not exactly an update, as the data of the intermediate results are included in the final results. The final period is longer, which allows for greater statistical power for certain tests and more accurate results for minority populations such as women or people sharing their cell. Also, the results related to the SARS-CoV2 pandemic are completely new.

## Reviewer: 2

Comments to the Author

The authors examined suicide cases during incarceration in France. The research question is interesting, and analyzing all cases appears valuable. The analysis is simple and straightforward. The specific comments to be addressed are as follows:

Comment:

“The overall suicide rate was 17.5 [16.1–18.9] per 10,000 person-years. It increased (p < 0.05) with age, was twice as high during pre-trial incarceration and six times higher during the first week of imprisonment. In terms of gender, it was 9.9 [9.1–10.7] and 41.0 [27.0–59.7] times higher among men and women, respectively, than among their counterparts in the general population.”

You need to explain what the values in parentheses represent (e.g., 95% CI) and how they were obtained.

We thank you for this comment. These are 95% CI. We updated the Statistical methods as follows (page 5):

“Suicide incidence rates were computed for all incarcerated people and according to year, gender, age, nationality, criminal status, suicide during the first week in prison, suicide during the last week of prison sentence, as well as according to whether the suicide occurred before or after 17 March 2020. Rates were computed by dividing the number of suicides by the number of PY. With the exception of the first and last weeks of detention, PY were obtained by multiplying the average number of incarcerated people by the length of the observation period. This average number was calculated using the figures provided by the National Prison Service; depending on the characteristic, these
figures are published on a monthly or quarterly basis [10]. We estimated PY for the first and last weeks of incarceration from the number of prison admissions and releases during the observation period, respectively. Each admission or release was considered as contributing to one person-week. We calculated 95% confidence intervals for suicide rates based on the Poisson distribution law. We compared suicide rates using a Poisson regression model [33].

Also, we have updated the Abstract to clarify, as was already the case in the Results, that these are 95% confidence intervals:

"The overall suicide rate was 17.5 [CI<sub>95%</sub> 16.1–18.9] per 10,000 person-years. It increased (p < 0.05) with age, was twice as high during pre-trial incarceration and six times higher during the first week of imprisonment. In terms of gender, it was 9.9 [9.1–10.7] and 41.0 [27.0–59.7] times higher among men and women, respectively, than among their counterparts in the general population."

Comment:
I can see that the authors largely focused on French studies in the Introduction and Discussion. Most readers are not familiar with the French incarceration system. Would you contextualize it by comparing France with other countries? This area of research should be frequently covered in U.S. studies.

We thank you for this comment. It is difficult to make accurate comparisons with the United States of America because, due to the dispersion of responsibilities among different political levels, to our knowledge there is no centralized source of data on all prisons for this country. We have added details about the French prison system in the Introduction (page 3):

"In France, the average number of people in prison continues to rise, from 30,000 in 1970 (56 per 100,000 inhabitants) to 80,000 in 2025 (116 per 100,000 inhabitants) [7, 10, 11]. The current prison population rate in France remains well below the rate in the United States, which was recently estimated at 580 per 100,000 inhabitants [12], but is slightly higher than the European median of 104.8 per 100,000 inhabitants [13]. All prisons are under the authority of the French Ministry of Justice. They exclude police custody and administrative detention centres for illegal immigrants, which are under the authority of the Ministry of the Interior. There are more than 180 prisons in France. The average density is 136 incarcerated people per 100 places, compared to a median value of 94 for European countries [13]. The main types of facility include remand prison (69.0% of incarcerated people), standard security prison for long sentences (23.8%) and high security prison for long sentences (2.0%). Remand prison is devoted to pre-trial incarceration and persons serving the outstanding part of a sentence (i.e., sentence duration minus period already spent in custody) if less than two years.

The suicide rate among people incarcerated in France has increased by a factor of 2 to 3 since the middle of the 20th century [7, 8, 12] and is now one of the highest in the world [4]."

Comment:
Apparently, the authors had information on solitary confinement, which alone is associated with suicidal behaviors, as published in Arch Sui Res. https://pubmed.ncbi.nlm.nih.gov/37937913/
The association with this factor should be analyzed or at least discussed.

We thank you for this reference. We discussed the results about solitary confinement as follows (page 9):
1038 "Another finding is that 16.6% of suicide occurred in solitary confinement, which is consistent with previous studies examining suicide [7, 9, 39] and suicidal ideation [40]. Developing alternatives to solitary confinement may be an interesting avenue to prevent suicide among incarcerated people."

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1043 Comment:
1044 "Incarcerated people who died by suicide on or after 17 March 2020 (n = 213) (i.e., the start of France's first SARS-CoV-2 pandemic lockdown) did not differ significantly in terms of age (p = 0.480) or gender (p = 0.800) from those who died before that date (n = 385). In terms of other characteristics, the former were more likely to be nationals of an African country (12.3% vs 6.5%) and less likely to be nationals of a European country (5.7% vs 12.5%) (p = 0.009)." It is unclear what exactly "the former" refers to here.

1050 We have rephrased the sentence to make it clearer page 7):

1051 "Incarcerated people who died by suicide on or after 17 March 2020 (n = 213) (i.e., the start of France's first SARS-CoV-2 pandemic lockdown) did not differ significantly in terms of age (p = 0.480) or gender (p = 0.800) from those who died before that date (n = 385). In terms of other characteristics, those who died by suicide on or after 17 March 2020 were more likely to be nationals of an African country (12.3% vs 6.5%) and less likely to be nationals of a European country (5.7% vs 12.5%) (p = 0.009)."

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1059 Comment:
1060 In the context of prevention, please elaborate on how the French system could restrict the means of suicide during incarceration. Given that most suicides occurred by hanging, such measures could be effective.

1063 We agree that the result that most suicides occur by hanging is striking. We discussed it as follows in a section on the circumstances of suicide (page 9):

1065 "Also, hanging is the most common method of suicide, accounting for 93% of cases. Hanging is systematically reported in more than 80% of inmate suicide cases internationally [27, 41–75]. The international association for suicide prevention recommended to eliminate or minimize hanging points and unsupervised access to lethal materials [2]. In France, several measures of this type can be implemented if a risk of suicide is detected: cell sharing, tearable clothing, or temporary placement in a completely smooth cell in the event of a suicide crisis."

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