Assessing the risk of self-harm in an adult offender population: an incidence cohort study

Abstract

BackgroundSelf-harm is common among prisoners, particularly female prisoners. In 2007, concerned about the rising incidence, the prison service introduced a care-planning system called Assessment, Care in Custody, and Teamwork (ACCT). To date, it does not incorporate a standardised diagnostic test to estimate the risk of future self-harm.ObjectiveTo identify potential screening instruments, or items from those instruments, to predict the risk of self-harm among prisoners.ParticipantsPrisoners who had been assigned to an ACCT during the recruitment period.DesignA multistage prospective cohort study. Following a pilot study, instruments were administered to prisoners by interview at baseline, and followed up for 6 months (or until point of release if this was sooner) to ascertain self-harm status. Instruments were assessed for unidimensionality, scalability (Mokken) and quantitative structure (Rasch). Area under the curve (AUC) analysis was used to examine the ability of instruments and/or their items to predict future self-harm. Cox proportional hazards regression models were used to examine the multivariate predictive ability of the scales and various sociodemographic and sentencing factors.SettingThree prisons (including one women’s prison) in northern England.Main outcome measuresA set of standardised questionnaires, including the Prison Screening Questionnaire (PriSnQuest), Revised Borderline Symptom List-23 (frequency-based responses) (BSL-23-F), Self-Harm Inventory (SHI), Patient Health Questionnaire (PHQ-9) and the Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM), together with sociodemographic and sentencing data.ResultsIn total, 450 prisoners consented to participate in the study, of whom 26% were female. The mean age of participants was 31.2 years. Over half of male prisoners recruited were on remand, compared with just over one-fifth (22.6%) of female prisoners. The average tariff of those sentenced was 41 months, of which 14.7 months, on average, had been served. Just over one-third of ACCTs had been initiated because of a known self-harm event, and over one-quarter (27.8%) of participants self-harmed during the follow-up period. Thus, almost half (46.7%) of those entered into the study were reported to have self-harmed, either from their index ACCT, or subsequently, or both. Cutting was the most frequent behaviour (51%). All screening instruments showed some evidence of unidimensionality, and four out of five showed scaling criteria consistent with ordinal scaling, so verifying the validity of the cut points. However, many showed gender bias and failure to fit the Rasch measurement model. While a resolution was made in most cases, both ordinal raw scores and latent interval scale estimates failed to show predictive value when applied within AUC analysis (0.491–0.566) or adjusted Cox proportional hazards models. However, good predictive values were shown for gender-specific sets of items, thus providing easily applied screening indexes.ConclusionsWhile four out of five potential screening instruments were found to have acceptable psychometric properties within this setting, their predictive validity of all instruments was poor under AUC analysis. Gender-specific item sets were put together to form two screening indexes with formative indicators which gave reasonable AUC values, particularly so for females. The indexes provide identification of low–medium–high risk of self-harm, and so may help to inform potential care pathways and decisions to sign prisoners off from the ACCT. Future work should concentrate on refining a set of predictive screening items among different offender populations and investigating the time point at which this set of items should be administered. Future work may also look at the different magnitudes of risk as indicators for care pathways.FundingThe National Institute for Health Research Health Technology Assessment programme.

Predictors for self‐directed aggression in Italian prisoners include externalizing behaviors, childhood trauma and the serotonin transporter gene polymorphism 5‐HTTLPR

“…This study sought to identify independent predictors of self-directed aggression (suicidal behavior and/or self-mutilation), in a large sample of incarcerated Italian men. Both suicidal behavior and self-mutilation are more common in prisoners than the general population and these behaviors are frequently comorbid (Carli et al 2011a;Fazel & Danesh 2002;Horton et al 2014;Jenkins et al 2005;Stanley et al 2001). Indeed, one third of our sample with self-directed aggression had a lifetime history of both suicidal behavior and self-mutilation.…”

“…Another study has shown that 77% of US prisoners who attempted suicide had psychiatric disorders compared with 15% in the general prison population (Goss et al , 2002). A few studies have shown that self-mutilation is also common in prisoners (Carli et al , 2011a, Horton et al , 2014). …”

Prisoner suicide: a multilevel problem

“…Nowhere are the problems more apparent than in the criminal justice system where Aboriginal and Torres Strait Islander Australians are grossly overrepresented, accounting for about 30% of adult prisoners in Australia although they make up only 2% of the Australian population. 2,3 Many Aboriginal and Torres Strait Islander Australians cycle between prison and the community with their needs unmet. The high rates of short-term repeated incarceration have a multitude of negative health effects for Aboriginal families, communities, and wider society.…”

“…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. 2,3 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.…”

Self-harm in the prison system

“…There are conflicting data about the possibility of a predictive score for self-harm / suicide. Thus, while authors from the UK use a psychometric instrument (SCOPE) designed to distinguish between those at risk and those with no risk of self-harm [7], other authors refute this possibility [6,8].…”