Identifying inmates that will actually die by suicide

Abstract

WHAT IS ALREADY KNOWN ON THIS TOPIC?Suicide rates among prisoners are higher than in the general population. 1 It has also been shown that specific risk factors, such as violent behaviour in prison, psychiatric diagnosis, substance abuse and previous suicide attempts are associated with self-harm in prison.2 Fifty per cent of prisoners who die by suicide have a history of self-harm 3 and longitudinal studies are needed to understand which prisoners with self-harm are more likely to complete suicide.WHAT THIS PAPER ADDS ▸ For the first time, a study reports a very large clustering effect of self-harm in prisoners (ICC=0.15). ▸ The longitudinal observation provides an opportunity to identify risk factors associated with prisoners to be targeted by more intensive preventive programmes. Older age, a previous self-harm incident of moderate or high lethality for males, and a life sentence or more than five self-harm incidents in the previous year for females, are significantly associated with completed suicide among prisoners who self-harmed. ▸ Self-harm repetition rates, stratified by gender, offer valuable information for health professionals who work in prison. Female prisoners who self-harm will have an average of eight self-harm incidents per year and therefore require increased preventive efforts. LIMITATIONS▸ The risk factors that have been identified as associated with suicide have low predictive power and are not readily translatable into the clinical practice. Clinicians need screening tools with increased specificity in order to be able to identify those patients who are likely not to complete suicide. ▸ No information was available about completed suicides after release from jail/prison, which is a critical time with increased risk. 4 The reported suicide rates only refer to suicide in prison and are therefore likely to underestimate the number of prisoners who self-harm in jail and subsequently die by suicide. WHAT NEXT IN RESEARCH?It is necessary to identify more risk factors that might be associated with suicide with higher specificity, such as personality characteristics and psychiatric diagnoses. This can be achieved through prospective cohort studies that specifically evaluate a large number of risk and protective factors at baseline and observe suicides after long-term follow-up. An alternative but powerful approach is to look at near-lethal deaths (rather than completed suicides); it has the advantage of not needing such large numbers.5 Such studies would require a major effort in terms of resources to be allocated but represent the only means for the development of tools that would be useful to clinicians who work with suicidal inmates. Such prospective studies should also consider biological predictors of suicide, such as genetic vulnerability factors. 6 DO THESE RESULTS CHANGE YOUR PRACTICES AND WHY?The results of the study do affect clinical practice in prison. Specifically, the reported large clustering effects suggest that any intervention to prevent self-harm should involve not only the indi...