Reducing the incidence of suicide by prisoners is part of national strategies for suicide prevention in the USA, 1 UK, 2 Ireland 3 and other countries, 4 and is highlighted in a recent World Health Organization statement on mental health in prisons. 5 Relative to age-adjusted rates in the general population, suicide rates in male prisoners are five times higher in England and Wales, Reference Fazel, Benning and Danesh6 and large proportionate excesses have been found in the USA Reference DuRand, Burtka, Federman, Haycox and Smith7 and some mainland European countries. Reference Fazel, Grann, Kling and Hawton8 Potentially modifiable factors have been the focus of suicide prevention guidelines in prisons, Reference Konrad, Daigle, Daniel, Dear, Frottier and Hayes9,Reference Daigle, Daniel, Dear, Frottier, Hayes and Kerkhof10 although there has been little attention to specific psychiatric disorders. A recent systematic review showed that clinical factors have strong associations with suicide in prison, but which diagnoses and their relative contributions were uncertain. Reference Fazel, Cartwright, Norman-Nott and Hawton11 Part of the reason for this is that investigating risk factors for prison suicide has principally been based on examination of official records, or use of the psychological autopsy approach, which aims to build a retrospective picture of the deceased's mental state at the time of death in order to develop a profile of the prisoner. Reference Hawton, Appleby, Platt, Foster, Cooper and Malmberg12 As this method relies primarily on medical records for information on clinical factors, it is limited by the quality of these. Reference Fruehwald, Matschnig, Koenig, Bauer and Frottier13–Reference Shaw, Baker, Hunt, Moloney and Appleby15
In this study, we addressed this limitation by assessing psychiatric disorders in male prisoners who made near-lethal suicide attempts and comparing them with those of a matched control group of prisoners who had never made a similar attempt in prison. Reference Marzano, Rivlin, Fazel and Hawton16 The validity of the near-lethal method is supported by two pieces of evidence. First, survivors of medically serious suicide attempts are epidemiologically similar to individuals who die by suicide. Reference Beautrais17,Reference Daniel and Fleming18 Second, individuals who have made a medically serious suicide attempt are twice as likely as other people who have attempted suicide to subsequently complete suicide. Reference Rosen19 Furthermore, the near-lethal method has been piloted in prisons. Reference Borrill, Snow, Medlicott, Teers and Paton20 However, the pilot study only included 15 male prisoners, there was no control group and psychiatric morbidity was not investigated.
Method
Participating prisons
We requested information from the Ministry of Justice Safer Custody and Offender Policy Group on prisons within 100 miles of Oxford that had relatively high rates of serious suicide attempts and completed suicides. Nineteen prisons were identified, including three young offenders' institutes (prisoners aged 18–21), three Category A (maximum security) prisons, 12 Category B prisons (establishments for those who do not require maximum security but for whom escape must be made difficult) and one Category C prison (for prisoners who cannot be housed in open conditions but who are unlikely to try to escape).
Participant identification
Near-lethal suicide attempts were defined as acts that could have been lethal had it not been for intervention or chance, and/or involved methods that are associated with a reasonably high chance of death. Reference Kresnow, Ikeda, Mercy, Powell, Potter and Simon21 Detailed criteria were developed to aid prison officers refer suitable cases to the study (Appendix). The criteria are based on the physical danger and consequences of the act, an approach that is in line with that used in previous investigations of near-lethal suicide attempts in the community. Reference Kresnow, Ikeda, Mercy, Powell, Potter and Simon21 They intentionally do not include suicidal intent. This is because basing the criteria only on the lethality of the act includes in the study both those with high suicidal intent and those whose actions may have very nearly caused death but may not have been motivated by suicidal intentions. Such cases would be recognised by most researchers as being within a broad conceptualisation of suicide.
Cases were interviewed within 4 weeks of the suicide attempt. Controls were prisoners who had not made a near-lethal suicide attempt while in prison. They were matched with cases by age (5 years older or younger) and by type/category of prison. Identification of controls was done randomly from the Ministry of Justice's daily list of prisoners using these two matching criteria. All participants were aged 18 years and over.
Prisoners making a near-lethal suicide attempt were excluded from the study if they declined to take part (15 individuals), could not speak English (8), were considered too dangerous (4) or too seriously mentally ill (1), or because staff shortages or absences meant that the 4-week time limit within which an interview had to be conducted had been missed (6). A further eight prisoners were released from prison or transferred to a non-participating prison before an interview could be arranged. Those included in the case group were significantly more likely than those excluded to be White (52/60 (87%) v. 25/42 (60%), odds ratio (OR) = 4.4, 95% CI 1.7–11.6) and to be on a life sentence (13/39 (33%) v. 2/23 (9%) OR = 5.1, 95% CI 1.0–24.9). Other recorded sociodemographic and criminological characteristics did not differ significantly between the included and excluded prisoners.
Interviews
Following training in use of the instruments and questionnaires employed in the research, and piloting at a large adult male local prison, one of the authors (A.R.) conducted semi-structured face-to-face interviews with 60 cases and 60 controls. A total sample size of 120 was calculated to provide sufficient power to determine important differences in psychiatric characteristics. After participants' written consent had been obtained, the interviews took place in private in the prison and lasted for 90–120 min. Participants were offered support both before and after the interviews from a prison officer, chaplain, Samaritan, Listener (trained peer support) or psychologist.
Sociodemographic and criminal history information was gathered using an adapted version of a structured questionnaire used in the Oxford Monitoring System for Attempted Suicide. Reference Hawton, Harriss, Hall, Simkin, Bale and Bond22 The following information regarding a participant's medical and psychiatric history was collected: history of in-patient or out-patient psychiatric treatment, current psychotropic medication, current contact with a mental health professional (including a psychiatrist, psychologist, counsellor or community psychiatric nurse), and previous self-harm (with and without suicidal intent). For cases, we also administered the Beck Suicide Intent Scale (SIS) to assess severity of suicidal intent associated with near-lethal acts. Reference Beck, Schuyler, Herman, Beck, Resnik and Lettieri23
Psychiatric morbidity was assessed with the Mini International Neuropsychiatric Interview (MINI), Reference Sheehan, Lecrubier, Harnett-Sheehan, Amorim, Janavs and Weiller24 which includes Axis I (psychiatric) and II (personality) disorders for DSM–IV 25 and ICD–10 26 diagnoses. The MINI has been demonstrated to have good to very good validity, reliability (interrater and test–retest), and sensitivity and specificity indices. Reference Amorim, Lecrubier, Weiller, Hergueta and Sheehan27–Reference Lecrubier, Sheehan, Weiller, Amorim, Bonora and Sheehan29 When compared with the Structured Clinical Interview for DSM–III–R (SCID), Reference Spitzer, Williams, Gibbon and First30 the MINI had good to very good kappa values (apart from current drug dependence, which was the only diagnosis with a κ<0.5). Except for dysthymia, obsessive–compulsive disorder, and current drug dependence, sensitivity was 0.70 or above for all disorders. For major depression, lifetime mania, current and lifetime panic disorder, lifetime agoraphobia, lifetime psychotic disorder, anorexia and post-traumatic stress disorder (PTSD), positive predictive values have been found to be above 0.75. Other advantages of the MINI include its relatively brief administration time (15–20 min) and ease of use. Reference Sheehan, Lecrubier, Sheehan, Janavs, Weiller and Keskiner28,Reference Lecrubier, Sheehan, Weiller, Amorim, Bonora and Sheehan29 The MINI has also been used in prisons. Reference Black, Arndt, Hale and Rogerson31–Reference Falissard, Loze, Gasquet, Duburc, de Beaurepaire and Fagnani33 However, previous research in prisoners Reference Falissard, Loze, Gasquet, Duburc, de Beaurepaire and Fagnani33 and our pilot work suggested that the MINI may overdiagnose certain disorders. We therefore made the following modifications: a diagnosis of mania (current or lifetime) was only made when prisoners met criteria for elation/expansiveness (i.e. irritable mood alone was insufficient to reach a diagnosis); and a diagnosis of obsessive–compulsive disorder was dependent on meeting criteria for both obsessions and compulsions.
Ethical approval
The study had ethical approval from the Central Office for Research Ethics Committees (Ethics number 06/MRE12/83), and the Prison Service (Reference PG 2006 063).
Statistical analyses
All analyses were conducted using the Statistical Package for the Social Sciences (SPSS, Version 15.0 for Windows) and STATA (Version 9.0 for Windows). A 95% (P<0.05) significance level was adopted. In the results, unless otherwise specified, denominators for both cases and controls are 60. Odds ratios, 95% confidence intervals and associated P-values for analyses of categorical factors were calculated using McNemar's test to account for matching of cases and controls. For continuous data, paired sample t-tests and Wilcoxon signed ranks tests (for non-normally distributed data) were used.
Possible confounders (ethnicity, marital status, prior employment, educational qualifications, index offence, remand status, previous prison spells, and sentence length greater than 18 months) were assessed using conditional logistic regression. We examined whether confounders were each independently associated with having made a near-lethal attempt in prison and with specific psychiatric disorders. Confounders were then introduced and left in the model if they altered the odds ratio by more that 10%. Reference Mickey and Greenland34,Reference Tong and Lu35 No confounder fulfilled both these criteria.
We looked at risk of near-lethal suicide attempts according to diagnostic subgroups using conditional logistic regression (as the data were matched on age and prison type/category). Where the number of discordant pairs of cases and controls was less than 10, we do not report odds ratios.
Results
Near-lethal suicide attempts
Hanging or ligaturing accounted for two-thirds (n = 40, 67%) of the near-lethal suicide attempts. There were also 12 (20%) incidents of severe cutting, 3 (5%) self-asphyxiations, 3 (5%) overdoses of paracetamol and/or ibuprofen, 1 (2%) ingestion of foreign objects (plastic knives) and 1 (2%) self-immolation.
All but one incident (59, 98%) took place in the prisoners’ own cells. Most of these were in the prisioners’ normal location (46, 77%), ten (17%) were in segregation units and four (7%) were in the prison healthcare centre. The majority of prisoners in the case group were not identified as ‘at risk’ at the time of the incident. Only 24 (40%) were on an open ACCT (Assessment, Care in Custody and Teamwork) document, which is the formal system for registering and monitoring prisoners thought to be at risk of suicide and self-harm in prisons in England and Wales. 36 Over one-third (18/49, 37%) of individuals in the case group were withdrawing from drugs or alcohol at the time of the incident. The mean Beck Suicide Intent score was 19.0 (s.d. = 5.4, range 2–29). By comparison, the mean score for males assessed at a general hospital in England following an incident of self-harm or self-poisoning has been reported to be 10.6. Reference Harriss, Hawton and Zahl37
Sociodemographic and criminological variables
Near-lethal suicide attempts were associated with being White, having no educational qualifications, having been in prison previously, having been imprisoned for less than 30 days and having been in the current prison for less than 30 days (Table 1).
Table 1 Sociodemographic, criminological and psychiatric history characteristics of male prisoners who made near-lethal suicide attempts (cases) and those who had not (controls)
| Cases n = 60 | Controls n = 60 | ||||||
|---|---|---|---|---|---|---|---|
| Variable | n | (%) | n | (%) | χ2 | OR (95% CI) | P |
| Sociodemographic | |||||||
| Age (years) | |||||||
| 18–21 | 11 | (18) | 10 | (17) | |||
| 22–29 | 20 | (33) | 21 | (35) | |||
| 30–39 | 22 | (37) | 17 | (28) | |||
| 40–49 | 5 | (8) | 11 | (18) | |||
| 50+ | 2 | (3) | 1 | (2) | |||
| White ethnicity v. Black and minority ethnic | 52 | (87) | 42 | (70) | 2.7 (1.0–6.8) | 0.040 | |
| Singlea | 41 | (68) | 46 | (77) | 0.7 (0.3–1.5) | 0.321 | |
| Parent or guardian of children | 35 | (58) | 31 | (52) | 1.3 (0.6–2.8) | 0.451 | |
| Educational qualifications (none v. any) | 21 | (35) | 11 | (18) | 2.4 (1.0–5.9) | 0.048 | |
| Unemployedb | 35 | (58) | 29 | (48) | 1.6 (0.7–3.3) | 0.261 | |
| Criminological | |||||||
| Previous prison spell(s) | 54 | (90) | 40 | (67) | 4.5 (1.5–13.3) | 0.007 | |
| Remand status | 21 | (35) | 12 | (20) | 2.3 (0.9–5.6) | 0.068 | |
| Less than 30 days since being imprisoned | 17 | (28) | 1 | (2) | 17.0 (2.3–127) | 0.006 | |
| Less than 30 days in current prison | 25 | (42) | 1 | (2) | 25.0 (3.4–185) | 0.002 | |
| Psychiatric history | |||||||
| Previous psychiatric in-patient treatment | 20 | (33) | 3 | (5) | 9.5 (2.2–40.8) | 0.002 | |
| Previous psychiatric out-patient treatment | 21 | (35) | 5 | (8) | 5.0 (1.7–14.6) | 0.003 | |
| Previous self-harmc in prisond | 41 | (68) | 5 | (8) | 36.0 | < 0.0001 | |
| Previous self-harmc outside prison | 38 | (63) | 20 | (33) | 3.3 (1.5–7.2) | 0.004 | |
Psychiatric history
Near-lethal suicide attempts were associated with a history of psychiatric treatment and self-harm (Table 1).
Current psychiatric disorder
Psychiatric disorders were present in all cases and 62% of controls (Table 2). Excluding substance use disorders, 58 (97%) cases and 21 (35%) controls had a psychiatric disorder (OR = 38.0, 95% CI 5.2–277). Comorbidity of disorders was particularly prevalent in cases. Most psychiatric diagnoses were associated with near-lethal suicide attempts, especially depression, psychosis, panic disorder and any anxiety disorder. Alcohol misuse was related to near-lethal suicide attempts but this association did not reach statistical significance.
Table 2 Comparisons of current psychiatric disorders between male prisoners who made near-lethal suicide attempts (cases) and those who had not (controls)
| Cases n = 60 | Controls n = 60 | |||||
|---|---|---|---|---|---|---|
| Disorder | n | (%) | n | (%) | Odds ratio (95% CI) | P |
| Mood disorders | ||||||
| Major depression | 52 | (87) | 11 | (18) | 42.0 (5.8–305) | < 0.001 |
| With melancholic features | 43 | (71) | 9 | (15) | 35.0 (4.8–255) | < 0.001 |
| Dysthymiaa | 2 | (3) | 1 | (2) | ||
| Maniab | 0 | (0) | 0 | (0) | ||
| Hypomaniab | 0 | (0) | 1 | (2) | ||
| Any | 54 | (90) | 13 | (22) | 42.0 (5.8–305) | < 0.001 |
| Anxiety disorders | ||||||
| Panic | 11 | (18) | 2 | (3) | 10.0 (1.3–78) | 0.028 |
| Agoraphobiaa | 6 | (10) | 2 | (3) | ||
| Social anxiety | 19 | (32) | 2 | (3) | 9.5 (2.2–40.8) | 0.002 |
| Generalised | 18 | (30) | 1 | (2) | ||
| Non-generalised | 1 | (2) | 1 | (2) | ||
| Obsessive–compulsivea | 4 | (7) | 2 | (3) | ||
| Post-traumatic stress | 21 | (35) | 3 | (5) | 7.0 (2.1–23.5) | 0.002 |
| Generalised anxietya | 1 | (2) | 3 | (5) | ||
| Any | 37 | (62) | 12 | (20) | 6.0 (2.3–15.5) | < 0.001 |
| Substance use disorders | ||||||
| Alcohol | 22 | (37) | 14 | (23) | 1.9 (0.8–4.2) | 0.123 |
| Drug | 42 | (70) | 27 | (45) | 2.9 (1.3–6.4) | 0.010 |
| Any | 46 | (77) | 31 | (52) | 3.5 (1.4–8.7) | 0.007 |
| Psychotic disorders | ||||||
| With mood disorderb | 4 | (7) | 0 | (0) | ||
| Without mood disorder | 11 | (18) | 1 | (2) | 11.0 (1.4–85) | 0.022 |
| Any | 15 | (25) | 1 | (2) | 15.0 (2.0–113) | 0.009 |
| Eating disorders | ||||||
| Anorexiab | 0 | (0) | 0 | (0) | ||
| Anorexia (binge eating/purging type)b | 1 | (2) | 0 | (0) | ||
| Bulimiab | 1 | (2) | 0 | (0) | ||
| Anyb | 2 | (3) | 0 | (0) | ||
| Any current disorderb | 60 | (100) | 37 | (62) | ||
| 2+ current disorders | 52 | (87) | 20 | (33) | 17.0 (4.1–70) | < 0.001 |
| 3+ current disorders | 40 | (67) | 8 | (13) | 9.0 (3.2–25.3) | < 0.001 |
| 4+ current disorders | 27 | (45) | 3 | (5) | 9.0 (2.7–29.7) | < 0.001 |
Lifetime psychiatric disorders
Recurrent depression and all psychoses were associated with near-lethal suicide attempts (Table 3). Although cases were more likely than controls to meet criteria for antisocial personality disorder, the difference was not statistically significant.
Table 3 Comparisons of lifetime psychiatric disorders between male prisoners who made near-lethal suicide attempts (cases) and those who had not (controls)
| Cases n = 60 | Controls n = 60 | |||||
|---|---|---|---|---|---|---|
| Disorder | n | (%) | n | (%) | OR (95% CI) | P |
| Mood disorders | ||||||
| Major depression | 30 | (50) | 6 | (10) | 9.0 (2.7–29.7) | < 0.0001 |
| Mania | 16 | (27) | 5 | (8) | 3.8 (1.2–11.3) | 0.019 |
| Hypomania | 8 | (13) | 4 | (7) | 2.0 (0.6–6.6) | 0.258 |
| Any | 41 | (68) | 13 | (22) | 5.0 (2.2–11.3) | < 0.0001 |
| Psychotic disorders | ||||||
| With mood disordera | 4 | (7) | 2 | (3) | ||
| Without mood disorder | 13 | (22) | 1 | (2) | 13.0 (1.7–99) | 0.013 |
| Any | 17 | (28) | 3 | (5) | 8.0 (1.8–34.8) | 0.006 |
| Any lifetime disorder | 47 | (78) | 16 | (27) | 5.4 (2.4–12.2) | < 0.0001 |
| 2+ lifetime disorders | 18 | (30) | 2 | (3) | 17.0 (2.3–128) | 0.006 |
| 3+ lifetime disordersb | 6 | (10) | 0 | (0) | ||
| Antisocial personality disorder | 36 | (60) | 27 | (45) | 1.7 (0.9–3.4) | 0.133 |
Psychiatric treatment at the time of the interview
Significantly more cases than controls were receiving psychiatric treatment and psychotropic medication at the time of the interview (Table 4). However, there was a discrepancy between the number of cases diagnosed using the MINI with a current episode of major depression (52, 87%) and those being prescribed antidepressants (22, 37%).
Table 4 Comparisons of current psychiatric treatment and current medication between male prisoners who made near-lethal suicide attempts (cases) and those who had not (controls)
| Cases n = 60 | Controls n = 60 | ||||||
|---|---|---|---|---|---|---|---|
| Variable | n | (%) | n | (%) | χ2 | OR (95% CI) | P |
| Current psychiatric treatment a,b | 14 | (23) | 1 | (2) | 13.0 | < 0.001 | |
| Psychiatrist onlyc | 3 | (5) | 1 | (2) | |||
| Mental health nurse onlyc | 6 | (10) | 0 | (0) | |||
| Psychiatristc and mental health nursec | 4 | (7) | 0 | (0) | |||
| Psychologist onlyc | 1 | (2) | 0 | (0) | |||
| On medication | 40 | (67) | 13 | (22) | 28.0 (3.8–206) | 0.001 | |
| Psychotropic medicationa | 33 | (55) | 4 | (7) | 29.0 | < 0.001 | |
| Antidepressantsa | 22 | (37) | 4 | (7) | 18.0 | < 0.001 | |
| Mood stabilisersc | 4 | (7) | 0 | (0) | |||
| Major tranquillisersa | 11 | (18) | 0 | (0) | |||
| Benzodiazepines and other sedatives | 17 | (28) | 2 | (3) | 16.0 (2.1–121) | 0.007 | |
| Medication for physical disorders | 12 | (20) | 4 | (7) | 5.0 (1.1–22.8) | 0.038 | |
| Opiatesc | 6 | (10) | 6 | (10) | |||
| Otherc | 4 | (7) | 2 | (3) | |||
Discussion
We used a standardised diagnostic instrument in an interview study of 120 male prisoners in 19 prisons in England to investigate associations with near-lethal suicide attempts. We found that clinical factors were strongly associated with near-lethal suicide attempts, particularly current and recurrent depression, current and lifetime psychosis, current anxiety disorders and previous self-harm.
Current psychiatric disorders
Cases were significantly more likely to be suffering from any mood disorder (particularly major depression) than controls, anxiety (notably panic, PTSD and social anxiety), psychotic disorders, and to have comorbid disorders. In the general population, completed suicide is also associated with these disorders. Reference Harris and Barraclough38 However, although alcohol misuse is a risk factor for suicide in the general population, Reference Conner and Duberstein39 it was not strongly associated with near-lethal suicide attempts in this prisoner population. In previous research on suicide by prisoners, similar associations were identified with any psychiatric diagnosis in an Austrian case–control study Reference Fruehwald, Matschnig, Koenig, Bauer and Frottier13 and with psychosis in a recent US investigation. Reference Baillargeon, Penn, Thomas, Temple, Baillargeon and Murray40 However, the findings on the role of comorbidity and anxiety disorders have not, to our knowledge, been previously reported. Reference Fazel, Cartwright, Norman-Nott and Hawton11
After depression, alcohol and drug disorders, PTSD was the most prevalent disorder in the cases, and was also associated with a near-lethal suicide attempt. Post-traumatic stress disorder has received little attention in suicide research in prisons Reference Goff, Rose, Rose and Purves41 and, considering its potential treatability, further research investigating its role in suicide risk is warranted.
Lifetime psychiatric disorders
Apart from hypomania, all lifetime Axis I diagnoses, and comorbidity, were associated with near-lethal suicide attempts in prison. Antisocial personality disorder is a risk factor for suicide in the general population, Reference Duberstein and Conwell42 and we found a non-significant trend to this effect in prisoners who had made near-lethal suicide attempts. This is in line with previous research findings regarding the association between antisocial personality disorder and suicidal behaviour in prisoners Reference Jenkins, Bhugra, Meltzer, Singleton, Bebbington and Brugha43 and probably reflects the high frequency of this disorder in the general prison population.
Psychiatric treatment at the time of the interview
There was a discrepancy between the number of cases experiencing a current episode of major depression (52, 87%) and those being prescribed antidepressants (22, 37%). Research in the general population has also shown inconsistencies between the prevalence and treatment of depression, Reference Steffens, Skoog, Norton, Hart, Tschanz and Plassman44,Reference Kessler, Demler, Frank, Olfson, Pincus and Walters45 which is equally marked in people who have died by suicide. Reference Lonnqvist, Hawton and van Heeringen46 Nevertheless, unmet needs in relation to psychiatric illness in prison are considerable. Reference Fryers, Brugha, Grounds and Meltzer47 The reasons for this may include inadequate methods of detection, scarce resources and limited staff training. Reference Birmingham, Wilson and Adshead48,Reference Bluglass49
Only 14 (23%) cases were currently being seen by a mental health professional (psychiatrist, mental health nurse or psychologist), despite having made a serious suicide attempt less than 4 weeks previously. In addition to treatment for depression, unmet treatment needs for anxiety disorders, especially PTSD, social anxiety and panic disorder appear substantial.
Strengths and limitations of the study
Previous research investigating risk factors for suicide in prison has had a number of methodological limitations. These include the use of routinely collected cross-sectional data from variable quality prison and medical records Reference Fruehwald, Matschnig, Koenig, Bauer and Frottier13 that contain limited information on specific psychiatric diagnoses, particularly for controls. An advantage of this study was the ability to assess clinically the individual who undertook the act. In order to do this, we used the Mini International Neuropsychiatric Interview (MINI) for assessment of Axis I and Axis II diagnoses. However, although the MINI has several important strengths, including its validity, relatively brief administration time, acceptability to participants, ease of use and use in other prison research, Reference Sheehan, Lecrubier, Sheehan, Janavs, Weiller and Keskiner28,Reference Lecrubier, Sheehan, Weiller, Amorim, Bonora and Sheehan29,Reference Black, Arndt, Hale and Rogerson31–Reference Falissard, Loze, Gasquet, Duburc, de Beaurepaire and Fagnani33 the only Axis II diagnosis it includes is antisocial personality disorder, which was not found to be associated with near-lethal suicide attempts in this study. Further studies could seek to clarify the role of other personality disorders in near-lethal suicide attempts in prison since previous research is somewhat inconsistent. Limited previous research in prison has shown that personality disorders do not increase the risk of suicide 50,Reference Phillips51 whereas research in the community has shown that personality disorders (especially borderline, and possibly avoidant and schizoid) do increase risk of suicide. Reference Duberstein and Conwell42,Reference Lieb, Zanarini, Schmahl, Linehan and Bohus52
The prevalence rates in the control group for most psychiatric diagnoses generated by the MINI were approximately equivalent to those calculated in systematic reviews in the general male prison population. Reference Fazel and Danesh53 However, the rate of depression in the control group was higher than has been found in other studies using different diagnostic tools. Reference Fazel and Danesh53 This may be a consequence of the MINI overdiagnosing this disorder as other studies using it have also reported high rates of depression in prisoners. Reference Black, Arndt, Hale and Rogerson31,Reference Gunter, Arndt, Wenman, Allen, Loveless and Sieleni32
A disadvantage of face-to-face clinical assessment may include recall and self-presentation biases, and corroboration of information with key informants would have strengthened the study. Reference Hawton, Appleby, Platt, Foster, Cooper and Malmberg12 Also, psychiatric diagnoses were made based on information obtained through interview usually some weeks after the near-lethal suicide attempt and may not necessarily equate to those present at the time of the act. Although our sample size allowed for testing of associations with the main psychiatric diagnoses, it was underpowered to test significance for less frequent disorders. We did not have access to data about how many of the control participants were registered as being at risk of suicide (i.e. had ‘open’ ACCT documents).
We included 19 prisons of differing types and categories, which should make the study's findings generalisable in England and Wales.
Implications
A number of potential implications arise from our findings. First, the high rate of psychiatric morbidity among suicidal prisoners suggests that many might benefit from alternative disposals, including hospital and community treatment orders. Reference Reed54,Reference Birmingham55 In addition, the marked difference in prevalence of psychiatric disorders between cases and controls contrasts with some expert opinion that has downplayed the role of mental illness in attempted and completed suicide in prisoners. Reference Liebling56,Reference Groves57
Second, in a population where self-harming and suicide attempts, and mental health problems, are relatively common, identifying those most likely to take their own lives may be difficult. Nevertheless, the finding that only 24 (40%) of the cases were identified as being ‘at-risk’ for suicide at the time of their attempt indicates that there may be scope for improving detection of those at risk of suicide, perhaps with a structured suicide screening tool. Reference Konrad, Daigle, Daniel, Dear, Frottier and Hayes9,Reference Frottier, Koenig, Seyringer, Matschnig and Fruehwald58 Our findings suggest that such an instrument should include questions regarding prisoners’ history of psychiatric contact, previous self-harming and suicidal behaviour (especially if this occurred while in prison), and current psychiatric disorders. However, further research is needed to test the predictive value of such a tool and, in particular, to what extent false positives are identified. Furthermore, detection should be considered an ongoing process occurring at various stages of custody, rather than only at reception. This may be important if a prisoner's circumstances change, for example, if he is transferred or about to be released, since there is evidence of increased psychological distress before release Reference Bukstel and Kilmann59 and elevated risk of suicide shortly after release. Reference Pratt, Piper, Appleby, Webb and Shaw60
Third, the discrepancy between the proportion of prisoners with psychiatric problems and those receiving pharmacological and/or psychological interventions suggests that in addition to better risk assessment, reviewing the treatment and management of common psychiatric disorders in at-risk prisoners should be considered. In the UK, responsibility for prison healthcare has recently been devolved to NHS primary care trusts (since April 2006). One possible area that may warrant further research is the efficacy and cost-effectiveness of interventions incorporating either pharmacological and psychosocial interventions or both. Any such research will be relevant to mental healthcare in prisons in other countries.
Although suicide and severe self-harming behaviours in prisoners are major problems in many countries, potentially modifiable risk factors have been little researched. We have attempted to assess the potential role of psychiatric disorders using a novel method, that of interviewing survivors of near-lethal suicide attempts, the findings of which should have relevance outside the UK.
Appendix Criteria for the identification of ‘near-lethal’ cases
| Method | Inclusion criteria |
|---|---|
| Attempted hanging Ligature use Self-strangulation | Unconscious after attempting to hang or use a ligature, or not unconscious but: (a)witnessed in suspension or using a ligature and physical evidence of asphyxiation; or (b)physical evidence of suspension or using a ligature |
| Self-asphyxiation Suffocation | Witnessed self-asphyxiating, or any other physical evidence of self-asphyxiation |
| Cutting Stabbing Wound aggravation or insertion | Sustained a puncture wound penetrating body cavity or major organ, or lacerations that damaged or severed tendons, arteries or large veins, or came very close to doing so |
| Ingesting, inhaling, injecting | |
| (a) level of consciousness | (a) objective evidence of altered level of consciousness, or unconscious at presentation or prior to medical facility |
| (b) biochemical abnormalities | (b) transferred or admitted to a prison healthcare unit, any outside hospital or accident and emergency department |
| Jumping from a considerable height | Witnessed jumping or any physical evidence of having jumped from a considerable height, likely to have led to serious injury |
| Other (e.g. setting fire to self) | Case referral determined on a case-by-case basis |
Acknowledgements
We are grateful to Tunde Adeniji, Debra Baldwin, Pat Baskerville, and Jenny Rees of the Ministry of Justice Safer Custody and Offender Policy Group for their support and advice, Mary Piper of the Department of Health, Jo Borrill and Jo Paton for their assistance with the study, Adam Spriggs of the Ministry of Justice for providing control data, and all Area and Local Suicide Prevention Coordinators who helped with recruitment for the study. We also thank Karen Smith of the Centre for Statistics in Medicine for statistical assistance. Lastly, we thank all the prisoners who participated in this study.
eLetters
No eLetters have been published for this article.