Prisoner suicide: a multilevel problem
Authors: Sarah Larney, Michael Farrell
Journal: The Lancet Psychiatry (2017)

Seena Fazel and colleagues1Fazel S Ramesh T Hawton K Suicide in prisons: an international study of prevalence and contributory factors.Lancet Psychiatry. 2017; 4: 946-952Summary Full Text Full Text PDF PubMed Scopus (120) Google Scholar present data from multiple countries confirming that suicide continues to occur at higher rates in prisoner populations compared with non-incarcerated people in the surrounding community. Prevention of suicide is a key task for correctional institutions but identifying individuals most at risk of suicide in prison is not simple, with the limitations of risk assessment for accurately identifying individuals most at risk of suicide having been acknowledged.2Horton M Wright N Dyer W et al.Assessing the risk of self-harm in an adult offender population: an incidence cohort study.Health Tech Assess. 2014; 18: 1-151Crossref PubMed Scopus (11) Google Scholar, 3National Institute for Health and Care ExcellenceSelf-harm in over 8s: long-term management. National Institute for Health and Care Excellence, London2011Google Scholar This problem has led researchers to investigate the role of institutional, systemic, and environmental factors that might influence prisoner suicide, in the hope of identifying modifiable targets for intervention. Using administrative data from 24 countries, Fazel and colleagues1Fazel S Ramesh T Hawton K Suicide in prisons: an international study of prevalence and contributory factors.Lancet Psychiatry. 2017; 4: 946-952Summary Full Text Full Text PDF PubMed Scopus (120) Google Scholar have examined the influence of a range of systemic and environmental factors on prisoner suicide rates, but report little that is encouraging or could be used to reduce suicide rates. National prisoner suicide rates were not associated with suicide rates in the general population; overcrowding; the ratio of prisoners to any of prison officers, health-care workers, or educational staff; daily spend per prisoner; population turnover; justice system or health system management of health-care services; the rate of forensic psychiatric patients; and length of incarceration. The only factor associated with prisoner suicide rates was the incarceration rate, but lower suicide rates were associated with higher incarceration rates, hardly a worthy target. As Fazel and colleagues note, the association is probably due to the greater heterogeneity of prisoner populations in those countries with higher incarceration rates. One limitation of these findings is that they do not include analysis at the level of the institution. The study was done at the national level, which could mask some variation in suicide rates between prisons within a country that might provide clues towards suicide prevention. In the prison system of England and Wales, institution-level factors predicting higher suicide rates included larger population size, lower security rating, and higher population turnover.4van Ginneken EFJC Sutherland A Molleman T An ecological analysis of prison overcrowding and suicide rates in England and Wales, 2000–2014.Int J Law Psychiatry. 2017; 50: 76-82Crossref PubMed Scopus (28) Google Scholar The inclusion of institution-level factors in multilevel analyses of suicide rates might prove useful in further identifying sources of variation that could be targeted in prevention interventions. Notably, with one exception, all of the included countries in Fazel and colleagues' analyses are high-income (with Croatia being an upper-middle income nation). Data for the health and mortality of prisoners in low-income and middle-income countries are sparse but extremely poor conditions in terms of overcrowding, hygiene, access to health care, and inadequate provision of food are often reported, particularly in low-income countries. It is unclear how these poor conditions might influence suicide rates. Overcrowding does not seem to relate to suicide rates in the countries where it has been examined, but extreme overcrowding of the kind seen in low-income countries (with occupancy levels of 200% or greater, as compared with 84–134% in the countries analysed) and a high proportion of long-term remand detainees might create additional stressors that promote suicidality. Data from a more diverse range of countries will improve our understanding of the influence of system and environmental factors on prisoner suicide risk. Collection of such data would require the allocation of dedicated resources for the development of data collection systems within prisons in low-income and middle-income countries. Although complex multilevel analyses and data from low-income and middle-income countries might provide additional information to inform suicide prevention strategies in prison, it seems reasonable to suggest that an effective intervention to reduce suicides in prison would be to dramatically reduce incarceration of people with severe mental illness, while simultaneously improving access to psychiatric care and social welfare systems. It could be argued that this will shift suicides in prison to community settings, but this seems unlikely given the role of incarceration itself as a stressor that triggers suicidal behaviour.5Marzano L Hawton K Rivlin A Fazel S Psychosocial influences on prisoner suicide: a case-control study of near-lethal self-harm in women prisoners.Soc Sci Med. 2011; 72: 874-883Crossref PubMed Scopus (83) Google Scholar, 6Rivlin A Fazel S Marzano L Hawton K The suicidal process in male prisoners making near-lethal suicide attempts.Psychol Crime Law. 2013; 19: 305-327Crossref Scopus (27) Google Scholar Failing this, the key to suicide prevention in prisons is unlikely to be located in individual-level risk assessments and interventions; rather, a whole-of-institution approach is required to create a humane environment that promotes the safety and wellbeing of all people who are incarcerated. This approach would include ensuring purposeful activity and adequate time out of cells for people in custody; avoidance of unnecessarily punitive disciplinary actions; and accessible support for prisoners experiencing psychological distress, including peer-based programmes.7Howard League for Penal ReformPreventing Prison Suicide. Howard League for Penal Reform, London2016Google Scholar We declare no competing interests. Suicide in prisons: an international study of prevalence and contributory factorsMany countries in northern and western Europe have prison suicide rates of more than 100 per 100 000 prisoners per year. Individual-level information about prisoner health is required to understand the substantial variations reported and changes over time. Full-Text PDF Open Access