Preventing self-harm and suicide in prisoners: job half done

Abstract

Prison populations have grown worldwide, and now exceed 10 million people globally.1Walmsley R World prison population list, ninth edition.http://www.idcr.org.uk/wp-content/uploads/2010/09/WPPL-9-22.pdfDate: May, 2011Google Scholar Although some countries have clear and independent mechanisms of inspection, scant information is available about the conditions in which many prisoners are held. By necessity, published work in prisons represents a skewed sample of those countries from which evidence is made available. We must bear this discrepancy in mind because we know so little.What we do know is that prisoners have high levels of mental health morbidity.2Fazel S Seewald K Severe mental illness in 33 588 prisoners worldwide: systematic review and meta-regression analysis.Br J Psychiatry. 2012; 200: 364-373Crossref PubMed Scopus (536) Google Scholar Suicide is the prevailing cause of death in prison worldwide, with mortality rates more than three times higher than the general population.3Slade K Edelmann R Can theory predict the process of suicide on entry to prison? Predicting dynamic risk factors for suicide ideation in a high-risk prison population.Crisis. 2013; (published online Nov 13.)http://dx.doi.org/10.1027/0227-5910/a000236PubMed Google Scholar The risk of death is highest in the early period after prison reception.4UK Ministry of JusticeSafety in custody statistics: deaths in prison custody 1978–2012.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192434/safety-custody-deaths-dec-12.xlsDate: April 25, 2013Google Scholar In male prisoners, deaths occur most typically in local adult prisons that take people directly from the courts, whereas self-harm happens widely in female prisons.5UK Ministry of JusticeSafety in custody statistics, England and Wales: update to December 2012—Ministry of Justice statistics bulletin.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192431/safety-custody-dec-2012.pdfDate: April 25, 2013Google Scholar Mental disorder, substance misuse, white ethnic origin, violent offending, awaiting trial, and having suicidal ideas are risk factors for death, many of which are common globally.6Felthous A Suicide behind bars: trends, inconsistencies, and practical implications.J Forensic Sci. 2011; 56: 1541-1555Crossref PubMed Scopus (35) Google Scholar Although most risk factors for suicide are also prevalent in the general population, their frequency in prison is alarming.2Fazel S Seewald K Severe mental illness in 33 588 prisoners worldwide: systematic review and meta-regression analysis.Br J Psychiatry. 2012; 200: 364-373Crossref PubMed Scopus (536) Google ScholarWriting in The Lancet, Keith Hawton and colleagues7Hawton K Linsell L Adeniji T Sariaslan A Fazel S Self-harm in prisons in England and Wales: an epidemiological study of prevalence, risk factors, clustering, and subsequent suicide.Lancet. 2013; (published online Dec 16.)http://dx.doi.org/10.1016/S0140-6736(13)62118-2PubMed Google Scholar provide important confirmation of risk factors for self-harm and suicide in prison. They did a 6-year epidemiological study in the prison population of England and Wales and recorded 139 195 self-harm incidents among 26 510 prisoners over 5 years. High annual self-harm rates were noted, in 5–6% of male inmates and 20–24% of female prisoners. Self-harm incidents accumulated in younger people and those of white ethnic origin, and an association was noted with prison type, serving a life sentence, or being unsentenced. Violent offending behaviour raised the risk of self-harm in female prisoners, and recurrence was common. The reported clustering of self-harm in time and location (adjusted intra-class correlation 0·15, 95% CI 0·11–0·18) highlights the importance of the prison context in understanding self-harm.Hawton and colleagues showed a temporal link between self-harm and completed suicide; 109 suicides in prison were reported in individuals who self-harmed, and more than half the deaths occurred within a month of self-harm. These findings indicate the importance of swift intervention after an incident of self-harm, and this work has already had an effect on the way the Prison Service in England and Wales manages people at risk.8UK Ministry of JusticeManagement of prisoners at risk of harm to self, to others and from others (safer custody): Prison Service Instruction 2011-64.http://www.justice.gov.uk/offenders/psis/prison-service-instructions-2011Date: Sept 9, 2013Google Scholar The risk factors identified for self-harm are similar to those identified elsewhere for suicide, thereby challenging the notion that self-harming behaviour and suicide might represent different entities: instead, a direct link seems to exist for many prisoners. Hawton and colleagues make a vital contribution to answering the questions of who self-harms and how often does it happen, which complements previous work to address why people self-harm and what methods work to reduce self-harm and suicidal behaviour.9Rivlin A Fazel S Marzano L Hawton K The suicidal process in male prisoners making near-lethal suicide attempts.Psychol Crime Law. 2011; 19: 305-327Crossref Scopus (25) Google Scholar, 10Marzano L Fazel S Rivlin A Hawton K Near-lethal self-harm in women prisoners: contributing factors and psychological processes.J Forensic Psychiatry Psychol. 2011; 22: 863-884Crossref Scopus (26) Google Scholar However, additional work is now needed to address these questions, to reduce self-harm in prison further.5UK Ministry of JusticeSafety in custody statistics, England and Wales: update to December 2012—Ministry of Justice statistics bulletin.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192431/safety-custody-dec-2012.pdfDate: April 25, 2013Google ScholarAlthough this work by Hawton and colleagues will assist practice in prisons in England and Wales, a broad range of risk factors have been incorporated into assessment training and processes provided by the Prison Service for some years.8UK Ministry of JusticeManagement of prisoners at risk of harm to self, to others and from others (safer custody): Prison Service Instruction 2011-64.http://www.justice.gov.uk/offenders/psis/prison-service-instructions-2011Date: Sept 9, 2013Google Scholar To mitigate against diminishing returns through expansion, we need to understand why most prisoners do not self-harm and why some who harm themselves are propelled towards suicide whereas others are not. The answers to these questions do not necessarily sit with further examination of over-represented groups, but instead could be studied by focusing on process,3Slade K Edelmann R Can theory predict the process of suicide on entry to prison? Predicting dynamic risk factors for suicide ideation in a high-risk prison population.Crisis. 2013; (published online Nov 13.)http://dx.doi.org/10.1027/0227-5910/a000236PubMed Google Scholar including specific investigation of prisoners from groups with enhanced vulnerabilities—eg, inmates who are foreign nationals, or people with neurodevelopmental problems, including those with learning difficulties. For many individuals, including 102 female prisoners reported by Hawton and colleagues who accounted for around 17 000 self-harming incidents, an examination that goes beyond generalised risk factors is crucial.In England and Wales, a welcome and sustained reduction in the overall number of self-inflicted prison deaths has been noted, from 96 in 2004 to 60 in 2012.4UK Ministry of JusticeSafety in custody statistics: deaths in prison custody 1978–2012.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192434/safety-custody-deaths-dec-12.xlsDate: April 25, 2013Google Scholar This fall has happened after several initiatives were introduced, including safer custody measures through the ACCT (Assessment, Care in Custody, and Teamwork) process,8UK Ministry of JusticeManagement of prisoners at risk of harm to self, to others and from others (safer custody): Prison Service Instruction 2011-64.http://www.justice.gov.uk/offenders/psis/prison-service-instructions-2011Date: Sept 9, 2013Google Scholar enhanced mental health services, and piecemeal environmental improvements. Although disentangling specific causal factors can be difficult from a pure research perspective, in view of confounders, the evaluative focus of the Independent Advisory Panel on Deaths in Custody allows cautious optimism. With attention now turning to self-harm management, available evidence indicates a key role for multi-agency collaboration, in which “suicide is everyone's concern”,11Her Majesty's Inspectorate of Prisons for England and WalesSuicide is everyone's concern: a thematic review by HM Chief Inspector of Prisons for England and Wales.http://www.justice.gov.uk/downloads/publications/inspectorate-reports/hmipris/thematic-reports-and-research-publications/suicide-is-everyones-concern-1999-rps.pdfDate: May, 1999Google Scholar rather than being the sole preserve of health-care staff. As such, collaboration between organisations—with responsibility held jointly—could be an important preventive measure, for both self-harm and suicide. Prison officers can provide practical support, which could calm distress and play a central part in identification and management of risk, and have a key role in recognition of undetected psychiatric morbidity.12Birmingham L Prison officers can recognise hidden psychiatric morbidity in prisoners.BMJ. 1999; 319: 853Crossref PubMed Google Scholar To harness this potential and thereby avoid so-called silo working, a focus on effective joint systems and a widening of the scope of specialist training and supervision (currently only available to a few prison workers in the UK) is recommended.Despite clear gains in the care of prisoners and prevention of self-harm and suicide in prisons in England and Wales, much work remains to be done. Linking epidemiological samples and ground-level improvements is not easy. A renewed approach is needed that seeks to understand better the connection between suicidal ideation and completed suicide. We need to invest in the wide inclusion of all people who, on the ground, can listen to prisoners who are experiencing distress, mobilise concern, and help to deliver joined-up care.We declare that we have no conflicts of interest. We thank Tim Exworthy for remarks on this Comment. Prison populations have grown worldwide, and now exceed 10 million people globally.1Walmsley R World prison population list, ninth edition.http://www.idcr.org.uk/wp-content/uploads/2010/09/WPPL-9-22.pdfDate: May, 2011Google Scholar Although some countries have clear and independent mechanisms of inspection, scant information is available about the conditions in which many prisoners are held. By necessity, published work in prisons represents a skewed sample of those countries from which evidence is made available. We must bear this discrepancy in mind because we know so little. What we do know is that prisoners have high levels of mental health morbidity.2Fazel S Seewald K Severe mental illness in 33 588 prisoners worldwide: systematic review and meta-regression analysis.Br J Psychiatry. 2012; 200: 364-373Crossref PubMed Scopus (536) Google Scholar Suicide is the prevailing cause of death in prison worldwide, with mortality rates more than three times higher than the general population.3Slade K Edelmann R Can theory predict the process of suicide on entry to prison? Predicting dynamic risk factors for suicide ideation in a high-risk prison population.Crisis. 2013; (published online Nov 13.)http://dx.doi.org/10.1027/0227-5910/a000236PubMed Google Scholar The risk of death is highest in the early period after prison reception.4UK Ministry of JusticeSafety in custody statistics: deaths in prison custody 1978–2012.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192434/safety-custody-deaths-dec-12.xlsDate: April 25, 2013Google Scholar In male prisoners, deaths occur most typically in local adult prisons that take people directly from the courts, whereas self-harm happens widely in female prisons.5UK Ministry of JusticeSafety in custody statistics, England and Wales: update to December 2012—Ministry of Justice statistics bulletin.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192431/safety-custody-dec-2012.pdfDate: April 25, 2013Google Scholar Mental disorder, substance misuse, white ethnic origin, violent offending, awaiting trial, and having suicidal ideas are risk factors for death, many of which are common globally.6Felthous A Suicide behind bars: trends, inconsistencies, and practical implications.J Forensic Sci. 2011; 56: 1541-1555Crossref PubMed Scopus (35) Google Scholar Although most risk factors for suicide are also prevalent in the general population, their frequency in prison is alarming.2Fazel S Seewald K Severe mental illness in 33 588 prisoners worldwide: systematic review and meta-regression analysis.Br J Psychiatry. 2012; 200: 364-373Crossref PubMed Scopus (536) Google Scholar Writing in The Lancet, Keith Hawton and colleagues7Hawton K Linsell L Adeniji T Sariaslan A Fazel S Self-harm in prisons in England and Wales: an epidemiological study of prevalence, risk factors, clustering, and subsequent suicide.Lancet. 2013; (published online Dec 16.)http://dx.doi.org/10.1016/S0140-6736(13)62118-2PubMed Google Scholar provide important confirmation of risk factors for self-harm and suicide in prison. They did a 6-year epidemiological study in the prison population of England and Wales and recorded 139 195 self-harm incidents among 26 510 prisoners over 5 years. High annual self-harm rates were noted, in 5–6% of male inmates and 20–24% of female prisoners. Self-harm incidents accumulated in younger people and those of white ethnic origin, and an association was noted with prison type, serving a life sentence, or being unsentenced. Violent offending behaviour raised the risk of self-harm in female prisoners, and recurrence was common. The reported clustering of self-harm in time and location (adjusted intra-class correlation 0·15, 95% CI 0·11–0·18) highlights the importance of the prison context in understanding self-harm. Hawton and colleagues showed a temporal link between self-harm and completed suicide; 109 suicides in prison were reported in individuals who self-harmed, and more than half the deaths occurred within a month of self-harm. These findings indicate the importance of swift intervention after an incident of self-harm, and this work has already had an effect on the way the Prison Service in England and Wales manages people at risk.8UK Ministry of JusticeManagement of prisoners at risk of harm to self, to others and from others (safer custody): Prison Service Instruction 2011-64.http://www.justice.gov.uk/offenders/psis/prison-service-instructions-2011Date: Sept 9, 2013Google Scholar The risk factors identified for self-harm are similar to those identified elsewhere for suicide, thereby challenging the notion that self-harming behaviour and suicide might represent different entities: instead, a direct link seems to exist for many prisoners. Hawton and colleagues make a vital contribution to answering the questions of who self-harms and how often does it happen, which complements previous work to address why people self-harm and what methods work to reduce self-harm and suicidal behaviour.9Rivlin A Fazel S Marzano L Hawton K The suicidal process in male prisoners making near-lethal suicide attempts.Psychol Crime Law. 2011; 19: 305-327Crossref Scopus (25) Google Scholar, 10Marzano L Fazel S Rivlin A Hawton K Near-lethal self-harm in women prisoners: contributing factors and psychological processes.J Forensic Psychiatry Psychol. 2011; 22: 863-884Crossref Scopus (26) Google Scholar However, additional work is now needed to address these questions, to reduce self-harm in prison further.5UK Ministry of JusticeSafety in custody statistics, England and Wales: update to December 2012—Ministry of Justice statistics bulletin.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192431/safety-custody-dec-2012.pdfDate: April 25, 2013Google Scholar Although this work by Hawton and colleagues will assist practice in prisons in England and Wales, a broad range of risk factors have been incorporated into assessment training and processes provided by the Prison Service for some years.8UK Ministry of JusticeManagement of prisoners at risk of harm to self, to others and from others (safer custody): Prison Service Instruction 2011-64.http://www.justice.gov.uk/offenders/psis/prison-service-instructions-2011Date: Sept 9, 2013Google Scholar To mitigate against diminishing returns through expansion, we need to understand why most prisoners do not self-harm and why some who harm themselves are propelled towards suicide whereas others are not. The answers to these questions do not necessarily sit with further examination of over-represented groups, but instead could be studied by focusing on process,3Slade K Edelmann R Can theory predict the process of suicide on entry to prison? Predicting dynamic risk factors for suicide ideation in a high-risk prison population.Crisis. 2013; (published online Nov 13.)http://dx.doi.org/10.1027/0227-5910/a000236PubMed Google Scholar including specific investigation of prisoners from groups with enhanced vulnerabilities—eg, inmates who are foreign nationals, or people with neurodevelopmental problems, including those with learning difficulties. For many individuals, including 102 female prisoners reported by Hawton and colleagues who accounted for around 17 000 self-harming incidents, an examination that goes beyond generalised risk factors is crucial. In England and Wales, a welcome and sustained reduction in the overall number of self-inflicted prison deaths has been noted, from 96 in 2004 to 60 in 2012.4UK Ministry of JusticeSafety in custody statistics: deaths in prison custody 1978–2012.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192434/safety-custody-deaths-dec-12.xlsDate: April 25, 2013Google Scholar This fall has happened after several initiatives were introduced, including safer custody measures through the ACCT (Assessment, Care in Custody, and Teamwork) process,8UK Ministry of JusticeManagement of prisoners at risk of harm to self, to others and from others (safer custody): Prison Service Instruction 2011-64.http://www.justice.gov.uk/offenders/psis/prison-service-instructions-2011Date: Sept 9, 2013Google Scholar enhanced mental health services, and piecemeal environmental improvements. Although disentangling specific causal factors can be difficult from a pure research perspective, in view of confounders, the evaluative focus of the Independent Advisory Panel on Deaths in Custody allows cautious optimism. With attention now turning to self-harm management, available evidence indicates a key role for multi-agency collaboration, in which “suicide is everyone's concern”,11Her Majesty's Inspectorate of Prisons for England and WalesSuicide is everyone's concern: a thematic review by HM Chief Inspector of Prisons for England and Wales.http://www.justice.gov.uk/downloads/publications/inspectorate-reports/hmipris/thematic-reports-and-research-publications/suicide-is-everyones-concern-1999-rps.pdfDate: May, 1999Google Scholar rather than being the sole preserve of health-care staff. As such, collaboration between organisations—with responsibility held jointly—could be an important preventive measure, for both self-harm and suicide. Prison officers can provide practical support, which could calm distress and play a central part in identification and management of risk, and have a key role in recognition of undetected psychiatric morbidity.12Birmingham L Prison officers can recognise hidden psychiatric morbidity in prisoners.BMJ. 1999; 319: 853Crossref PubMed Google Scholar To harness this potential and thereby avoid so-called silo working, a focus on effective joint systems and a widening of the scope of specialist training and supervision (currently only available to a few prison workers in the UK) is recommended. Despite clear gains in the care of prisoners and prevention of self-harm and suicide in prisons in England and Wales, much work remains to be done. Linking epidemiological samples and ground-level improvements is not easy. A renewed approach is needed that seeks to understand better the connection between suicidal ideation and completed suicide. We need to invest in the wide inclusion of all people who, on the ground, can listen to prisoners who are experiencing distress, mobilise concern, and help to deliver joined-up care. We declare that we have no conflicts of interest. We thank Tim Exworthy for remarks on this Comment. Self-harm in prisons in England and Wales: an epidemiological study of prevalence, risk factors, clustering, and subsequent suicideThe burden of self-harm in prisoners is substantial, particularly in women. Self-harm in prison is associated with subsequent suicide in this setting. Prevention and treatment of self-harm in prisoners is an essential component of suicide prevention in prisons. Full-Text PDF Open Access