Studying survivors of near-lethal suicide attempts as a proxy for completed suicide in prisons

Abstract

Suicides in prisons are common. There is a pressing need to understand more about the causes and prevention of prisoner suicides. A particularly informative approach is through studying survivors of near-lethal suicide attempts. However, the extent to which this approach is a good proxy for completed suicide requires verification. In this article we aimed to assess (1) the extent to which male and female prisoners who made near-lethal suicide attempts in prison are similar to prisoners who die by suicide; (2) the suicidal intent of those making near-lethal suicide attempts; and (3) the applicability of the Suicide Intent Scale in prisons. Survivors of near-lethal suicide attempts and prisoners who died by suicide were compared on sociodemographic and criminological characteristics. The suicidal intent of prisoners engaging in near-lethal self-harm was assessed using Beck's Suicide Intent Scale. There were no significant differences when the sociodemographic and criminological profiles of prisoners who made near-lethal suicide attempts and those who died by suicide were compared, except that male prisoners who made near-lethal suicide attempts were somewhat younger. Most prisoners carrying out near-lethal acts had high suicidal intent. However, some questions in the Suicide Intent Scale were inappropriate for assessing intent in prisoners. Prisoners who survive near-lethal self-harm would appear to be a valid proxy for those who die by suicide in prison. The Suicide Intent Scale requires some modifications for use in prisons.

Introduction

Rates of suicide in prisons are disproportionately higher than in the general population, including in the USA [1], England and Wales [2], [3], Finland [4] and other countries [5]. In addition, suicide attempts and acts of deliberate self-harm without suicidal intent are very common [6]. Research has shown that the socio-demographic and criminological profile of those dying by suicide in prison is different from the general prison population [7].

In order to identify risk factors for suicide in prisoners, researchers have largely conducted psychological autopsy studies [8], [9]. This approach aims to build a retrospective picture of the deceased's mental state at the time of death and involves examining official records and interviewing key informants such as family members. Whilst providing some instructive information on factors associated with suicide, this method has several limitations [10]. For example, data found in prison and medical records or coroners’ reports is usually incomplete. Also, such records contain information that was gathered for a different purpose than research so that variables that can be included in the study are limited. Furthermore, supplementing official data with the testimony of key informants assumes that they actually have access to relevant information, which may often not be the case, particularly for prisoners, and may provide biased or distorted information.

An alternative, and increasingly popular, research methodology for investigating causes of suicide, both in prisons [11] and in the community [12], is to interview survivors of near-lethal suicide attempts. These are acts which were very nearly fatal had it not been for “rapid and effective pre-hospital care or other emergency treatment” or, in some cases, chance [13: 175]. As a concept, lethality refers to the seriousness, deadliness or severity of an act [14]. In other words, it is the likelihood that an act will result in death. It does not include an assessment of suicidal intent. This approach is predicated on the assumption that near-lethal suicide attempts are a close proxy for completed suicide. However, to date, little evidence has been presented assessing this claim.

In this paper we had three aims to assess (1) the extent to which male and female prisoners who make near-lethal suicide attempts in prison are similar to prisoners who died by suicide; (2) the suicidal intent of those making near-lethal suicide attempts; and (3) the applicability of the Suicide Intent Scale in prisons.