Suicide in Specific populationS

Suicide in custodyJenny Shaw

pauline turnbull

Suicide trends in the prison population

The number of consciously self-inflicted (CSI) deaths in prison doubled between 1982 and 1988, and the numbers continue to increase.1 While there is a need for caution in converting these raw figures into rates because there has been criticism of the denominator used to calculate rates (the daily average popula-tion of inmates), this rise is larger than would be expected from the increase in prison population figures.2

The report on prison suicides by the Royal College of Psy-chiatrists suggested that the high rate of suicide in prison is not unexpected given the vulnerability of prisoners,3 who as a group have a multitude of risk factors, including:• high rates of substance misuse• mental illness• previous self-harm.4

A recent study attempting to quantify the excess of suicide in male prisoners in England and Wales between 1978 and 2003 in comparison with the general population reported an overall stan-dardized mortality ratio (SMR) of 5.1, indicating a fivefold excess of suicide in the male prison population. This was much higher for males aged between 15 and 17 years, with an SMR of 18. These SMRs increased steadily throughout the sample period.5

The general principles of suicide prevention apply to all cir-cumstances, whether inside or outside prison. The prison service developed its own suicide prevention targets, aiming for a 20% reduction in the rate of suicide from a baseline of 141 per 100,000 in 1999–2000 to a rate of 112.8 by April 2004. Unfortunately, this target was not met, and the rate of suicide in 2004–2005 was 121 per 100,000.

Characteristics of those who commit suicide in custody

Sociodemographic and criminological characteristicsTable 1 illustrates that the majority of suicides in prison in England and Wales are by white males. By far the commonest

Jenny Shaw MBChB PhD MRCPsych is Professor in Forensic Psychiatry

and Consultant Forensic Psychiatrist at Guild Lodge, Preston, UK.

She qualified from Manchester University and trained in general and

forensic psychiatry in Australia and northwest England. Her research

interests include homicide and prison mental health.

Pauline Turnbull MSc is a Research Assistant for the National

Confidential Inquiry into Suicide and Homicide by People with

Mental Illness, Manchester, UK. She qualified from the University

of Manchester. She is currently working on a study into sudden

unexplained death amongst psychiatric in-patients.

pSYcHiatRY 5:8 286

method used was death by asphyxiation, with the commonest ligature being bedclothes attached to cell fittings.9 In the study by this author, 49% of the sample were on remand, although remand prisoners represented only 19% of the overall prison population. In around half the cases, death occurred in the first month of imprisonment.6,9

Prison environmentSeveral researchers have suggested that features of the prison regime itself may be important as risk factors for suicide. A study comparing the characteristics of prisoners who had attempted suicide with those who had not found few socio-economic dif-ferences, but those who attempted suicide perceived themselves to be ‘worse off’ than their peers, spent longer in their cells and experienced more difficulties with other prisoners (e.g. bullying/persecution).11 This study did not examine factors related to mental illness, however. Other authors, although not basing their views on research, have suggested that better prison environ-mental conditions and improved staff training are essential first steps in reducing the prevalence of suicide in custody.12–15 Fur-ther studies are required to examine the importance of the prison environment and regime as risk factors for suicide.

Substance misuseThis author found that 62% of suicides had a history of drug misuse, and 31% a history of alcohol misuse before entering prison.9 Similar findings were reported in a national survey, which found that 58% of male remand prisoners and 63% of male sentenced prisoners had a history of hazardous drinking before entering prison, in comparison to 36% of female remand prisoners and 39% of female sentenced prisoners.4 It was also found that more than half of all prisoners reported illicit drug use in the year before imprisonment. These figures are unlikely to be higher than the rates of alcohol and drug misuse in the prison population as a whole. However, those with a history of drug misuse and those who were dependent on drugs were more likely to die in the first week after reception into prison.9 This potentially has implications for the provision of good assessment and detoxification services within prisons (see below).

Psychiatric historyThe prevalence of mental illness in the prison population is higher than in the community.4 The majority of prisoners interviewed for the national survey had at least one secondary diagnosis, and only one in ten prisoners showed no evidence of any of the disorders surveyed. This author found that 72% of suicides received a psychiatric diagnosis at reception into prison, the most common being drug dependence.9 Thirty-two percent had one or more secondary diagnoses, suggesting complex needs; 30% had previous contact with the mental health services.

Case-control studies into suicide in custodyRecent studies have employed multivariate statistics in order to investigate the unique contribution of risk factors to the outcome of suicide in custody.16,17 A Dutch study reported that a com-bination of being aged over 40, being homeless, having a history of psychiatric care, having a history of drug abuse, having one prior incarceration and having committed a violent offence could correctly classify the majority (82%) of suicides.16 However, this

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Suicide in Specific populationS

Characteristics of suicide victims in prison in England and Wales

Topp, 19796 Dooley, 19907 Dooley, 19918 Shaw et al., 20039 Backett, 198710

Period studied 1958–1971 1972–1987 1972–1987 1999–2000 1970–1982

Sample size (n) 775 346 295 172 33

SociodemographicsMale 775 (100%) 337 (97%) 290 (98%) 159 (92%) 33 (100%)

White 247 (84%) 153 (89%)

History of alcohol misuse 55 (30%) 85 (29%) 46 (31%)

History of drug misuse 21 (11%) 69 (23%) 95 (62%)

Reason for convictionViolent crime 53 (7%) 50 (17%) 41 (26%)

Sexual crime 30 (10%) 15 (9%)

Homicide 56 (19%) 11 (6%)

Method of deathasphyxiation 168 (90%) 302 (87%) 266 (90%) 159 (92%)

Time of deathevening/night 98 (53%) 149 (43%) 147 (47%) 83 (48%)

Within first month of

incarceration

77 (41%) 84 (29%) 88 (51%) 20 (61%)

Penal statusRemand 69 (37%) 153 (45%) 30 (11%) 84 (49%) 19 (58%)

Where no figures appear in columns, the variable was not described in that study.

Table 1

combination of risk factors did not have the same high predic-tive value when applied to different national populations, suggest-ing that further case-control studies are required. Recent Austrian research found that the factors showing the strongest positive asso-ciations with suicide in custody were a history of suicidality, psy-chiatric diagnosis, prescription of psychotropic medication, violent index offence and single-cell accommodation.17 These findings are an important consideration of suicide prevention in prisons.

Prison service monitoring and management of self-harm risk

The current prison service policy for preventing deaths in custody originated from the Review of Suicide and Self-harm in Custody by Her Majesty’s Chief Inspector of Prisons (HMCIP) in 1990.18 A subsequent review of the behaviour and characteristics of female prisoners who attempted suicide or self-harm,19 and the recommen-dations derived from this study, led to the final policy in 1994.

The pivotal features of the policy were to encourage devel-opment of a prison-wide responsibility for caring for suicidal prisoners, with less reliance on healthcare staff, and with sui-cide prevention being multidisciplinary. The aim was to identify and target resources for those most at risk, and to monitor risk and plan care, and to document this in the ‘Self-Harm At-Risk’ F2052SH form. This form can be ‘opened’ by any member of staff within the prison and all members reviewing the prisoner write in the document. The HMCIP Thematic Review criticized the policy for failing to give sufficient attention to particular at-risk groups, such as women, young prisoners and those in overcrowded local prisons (local prisons serve the courts in a particular locality and take prisoners on remand and those serving short sentences only; they characteristically have a high turnover of prisoners).2

pSYcHiatRY 5:8 28

It was noted that the F2052SH form did not necessarily lead to an effective care plan being developed for the at-risk prisoner.

A comprehensive audit of the efficacy of the F2052SH system found that, while the process targeted an at-risk group of prisoners with levels of mental health pathology similar to that found in gen-eral mental health services (as measured on the Brief Psychiatric Rating Scale (BPRS)), there were also high levels of ‘unmet need’ (i.e. undetected cases with similar needs who were not on an F2052SH). The care planning elements of the F2052SH document were criticized, with 50% of the care plan actions not assigned either to an individual or department. The review recommended a radical overhaul of the current system of screening, monitoring and care of prisoners at risk of suicide or self-harm.20

Following this study the Assessment, Care in Custody, Team-work (ACCT) Plan was piloted at five custodial establishments in 2004.21 As with the F2052SH form, an ACCT plan can be opened by any member of staff who has recognized that an individual is at risk. The at-risk individual is then interviewed by a trained asses-sor and a care and management plan (CAREMAP) is drawn up within 24 hours of the concern being raised. All staff are required to read the CAREMAP of at-risk prisoners, and to record events, conversations and observations in the ongoing record. A case man-ager is assigned to ensure that all care plan actions are completed and reviews attended by the prisoner are arranged proportional to need. The efficacy of the ACCT approach is currently being evalu-ated and ACCT will shortly replace the F2052SH systems.

How can the target of 20% reduction be achieved?

Changes to the prison regime as a whole have been recommended, including the removal of potential ligatures and ligature points,

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Suicide in Specific populationS

and specific recommendations about the mental health assess-ment and care of prisoners.9,22 Comprehensive screening for mental health problems at reception into custody has been called for, with detailed psychosocial assessment for ‘screen positives’ within 24 hours and a subsequent multidisciplinary care plan, which hopefully will be achieved with ACCT.9,20 Recommenda-tions have been made about improving mental health informa-tion exchange between community mental health services and prison healthcare services and the development of dual diagnosis services. More radical recommendations have also been put for-ward, which argue that fewer people should be held in prison, particularly on remand.23

The Royal College of Psychiatrists recommended that each prison should have a clear suicide prevention programme.3 Their report highlighted training needs for the assessment of mental health problems and for the assessment and provision of compre-hensive substance misuse services. The report made a final radi-cal recommendation that all trainee psychiatrists should undergo training attachments in a prison; currently, few training schemes have placements in prison.

Evaluating the recommendationsIt is evident that researchers and influential bodies such as the Royal College of Psychiatrists agree on the policies required to reach the target of a 20% reduction in suicide rates in custody. It is reasonable to ask, however, whether there is any evidence for the efficacy of the proposed measures, bearing in mind that the recommendations stem from descriptive studies and a review of practice. Following the introduction of an integrated system of mental health referral, evaluation and care in New York prisons in 1985, the suicide rate fell.24 Closer to home, anti-suicide strategy introduced in 1997 at the Cornton Vale Scottish Women’s Prison was successful in raising staff morale, with ‘problem ownership’ helping to secure staff involvement ‘from the bottom up’.25

The recommendations for radical change in screening, assess-ment and care planning for those with mental health problems and those at risk of suicide/self-harm in English prisons have some face validity. The plan is to introduce these changes ini-tially in pilot prisons and to evaluate outcomes and efficacy. If successful, they will then be implemented across the whole prison estate. ◆

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