Studying survivors of near-lethal suicide attempts as a proxy for completed suicide 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.
Section snippets
Participating prisons
Nineteen male prisons and 10 female prisons in England and Wales participated in the study of near-lethal suicide attempts. The men's prisons included three Young Offenders’ Institutes (prisoners aged 18–21), three Category ‘A’ (maximum security) prisons, 12 Category B prisons (establishments for those who do not require maximum security but for whom escape must be made difficult) and one Category C prison (for prisoners who cannot be housed in open conditions but who are unlikely to try to
Males
Two-thirds (n = 40, 67%) of the near-lethal self-harm incidents were by hanging or ligaturing. Severe cutting accounted for 20% (n = 12) of incidents, self-asphyxiation for five per cent (n = 3), and overdoses for five per cent (n = 3). There was also one (2%) ingestion of foreign objects (plastic knives) and one (2%) self-immolation.
Females
Most near-lethal incidents were by hanging (28, 47%) or ligaturing (15, 25%). There were also nine (15%) severe cuttings, seven (12%) overdoses, and one (2%) self-induced
Discussion
We have assessed the extent to which interviewing survivors of near-lethal suicide attempts can be considered a proxy for investigating completed suicide in prison. We found that the sociodemographic and criminological profiles of those who made near-lethal suicide attempts and those who die by suicide are similar, except for male suicides being somewhat older. One possible explanation for this age difference is that prisoners in this older age category are more likely to die as opposed to make
Acknowledgements
The study was funded by the NHS Forensic Mental Health R&D Programme. KH is also supported by Oxfordshire and Buckinghamshire Mental Health NHS Foundation Trust and is a National Institute for Health Research Senior Investigator. The funders had no role in the design and conduct of the study, collection, management, analysis and interpretation of data, or preparation, review and approval of the manuscript.
We are grateful to Tunde Adeniji, Debra Baldwin, Pat Baskerville and Jenny Rees, of the
References (50)
- et al.
Suicides in male prisoners in England and Wales, 1978–2003
Lancet
(2005) Prison suicide in Finland, 1969–1992
Forensic Sci. Int.
(1997)- et al.
Interviewing survivors of near-lethal self-harm: a novel approach for investigating suicide amongst prisoners
J. Forensic Leg. Med.
(2009) - et al.
‘Near-fatal’ deliberate self-harm: characteristics, prevention and implications for the prevention of suicide
J. Affect. Disord.
(2004) - et al.
Emergency airway management in hanging victims
Ann. Emerg. Med.
(1994) - et al.
The epidemiology of case fatality rates for suicide in the northeast
Ann. Emerg. Med.
(2004) - et al.
Deliberate self-harm and suicide attempts in custody: distinguishing features in male inmates’ self-injurious behavior
Int. J. Law Psychiatry
(2006) - et al.
Psychosocial influences on prisoner suicide: a case–control study of near-lethal self-harm in women prisoners
Soc. Sci. Med.
(2011) - et al.
Mortality among habitually violent offenders
Forensic Sci. Int.
(1999) - et al.
Psychiatric disorders and suicide in the nation's largest state prison system
J. Am. Acad. Psychiatry Law
(2009)
Suicides in female prisoners in England and Wales, 1978–2004
Br. J. Psychiatry
Prison suicide in 12 countries: an ecological study of 861 suicides during 2003–2007
Soc. Psychiatry Psychiatr. Epidemiol.
Psychiatric and social aspects of suicidal behaviour in prisons
Psychol. Med.
Suicide in prisoners: a systematic review of risk factors
J. Clin. Psychiatry
Suicide by prisoners
Br. J. Psychiatry
Suicide in custody: case–control study
Br. J. Psychiatry
The psychological autopsy approach to studying suicide: a review of methodological issues
J. Affect. Disord.
Identification of nearly fatal suicide attempts: self-inflicted injury severity form
Suicide Life Threat. Behav.
Prison inmate characteristics and suicide attempt lethality: an exploratory study
Psychol. Serv.
An unmatched case-control study of nearly lethal suicide attempts in Houston, Texas: research methods and measurements
Suicide Life Threat. Behav.
The epidemiology and prevention of suicide by hanging: a systematic review
Int. J. Epidemiol.
Suicides and attempted suicides by hanging
Ann. Med. Psychol. (Paris)
Correlation of circumstances with pathological findings in asphyxial deaths by hanging: a prospective study of 61 cases from Seattle, WA
J. Forensic Sci.
Suicide by hanging: multicentre study based on coroners’ records in England
Br. J. Psychiatry
A study of attempted suicides in prisons
Med. Sci. Law
Cited by (30)
Risk factors for suicide in prisons: a systematic review and meta-analysis
2021, The Lancet Public HealthCitation Excerpt :All authors had full access to all the data in the study and had final responsibility for the decision to submit for publication. We identified 8033 relevant studies in the database search and eight additional records through other sources, of which 43 new studies, not indentified in the 2007 systematic review,4 met eligibility criteria (figure 1).1,11–52 The total number of identified publications for the meta-analysis was 77, of which 34 were from the original review53–86 (see appendix pp 7–13 for characteristics of studies).
Mental health of prisoners: prevalence, adverse outcomes, and interventions
2016, The Lancet PsychiatryCitation Excerpt :Table 2 summarises risk factors for suicide, near-lethal self-harm, and self-harm. Near-lethal self-harm is a valid proxy for completed suicide in prisons, and has advantages over psychological autopsy approaches because it allows for a broader and deeper range of risk factors to be evaluated.28 Many interventions for the management of suicide and self-harm in prison have been reviewed,29 ranging from screening on reception, staff training, treatment, appropriate supervision of at-risk prisoners, and improvements to the safety of the physical environment and social support.
Environmental and Psychological Correlates of Self-Injurious Thoughts and Behaviors among Jail Detainees
2024, Corrections: Policy, Practice, and ResearchSuicide in prisons: describing trends and staff knowledge and preparedness to address suicide
2023, International Journal of Prisoner HealthPsychosocial factors in prisoner suicide in European prisons: A systematic review and meta-Analysis
2023, Anuario de Psicologia Juridica