Interventions to prevent suicide - Prisons and other custodial settings
Read Overview
Prisoners are a high-risk group for suicide because many are young men, 90% to 95% have mental health problems and/or substance misuse problems and/or personality disorders. They are also incarcerated and cut off from social support (like family and friends). The period of highest risk is the first week, so reception procedures are vital and optimal clinical care should be offered to all prisoners with mental health problems.
Prison provides possible opportunities for prevention of suicide attempts by assessment of inmates to identify those at highest risk, and restricting access to potential ligatures and ligature points.
We found one RCT and one systematic review that included relevant evidence for custodial settings. 1 2
In this section:
Key Messages
- Prisoners are a high-risk group for suicide because many are young men, 90% to 95% have mental health problems and/or substance misuse problems and/or personality disorders, they are incarcerated and cut off from social support (like family and friends)
- Prison provides possible opportunities for prevention of suicide attempts by assessment of inmates to identify those at highest risk, and restricting access to potential ligatures and ligature points
- Hanging is rapidly fatal (case fatality 70%), so once it has been attempted, prompt resuscitation is vital. Of those who attempt suicide by hanging, 80% to 90% of those who reach hospital alive survive.
Population Interventions
Population interventions that work
Our review has not found any unequivocal research evidence of any interventions that work.
Population interventions that may work
Home Office Safer Custody initiative
The Home Office Safer Custody initiative (www.homeoffice.gov.uk/about-us/organisation/directorate-search/noms/hopd/scg/) utilises a number of the promising approaches outlined below. During this initiative, we have seen a steady fall in the number of prison suicides, against a background of a rising prison population, which must be regarded as encouraging.
Promising interventions have included:
• Improving prison health care
Improving prison healthcare for inmates with mental health and or substance misuse problems to ensure access to best current clinical practice for their condition in line with the latest clinical evidence (www.clinicalevidence.com) and guidelines published from time to time by the National Institute for Health and Clinical Excellence (NICE) (www.nice.org.uk/guidance/topic/behavioural).
• Reception screening
It is possible to screen prisoners for suicide risk with a high degree of sensitivity, specificity and predictive value, but this has not as yet been shown to have any effect on the suicide rate itself. 1
• Staff training
Training of police and prison officers in suicide awareness to identify inmates at risk is being implemented and may help.
• Restricting access to means
Restricting access to ligature points by keeping cell hatches closed in police cells 2 and use of safer cells in prisons ( see Factfile: Safer Cells) for those identified as at high risk 2 appears to be a sensible precaution. Also, restricting access to potential ligatures by removal of belts and shoelaces in police cells 2 use of safer bedding and safer clothing in prisons (see Factfile: Safer Clothing and Safer Bedding) for those identified as at high risk. 2
• Prompt cut-down and treatment of those who attempt suicide
It is recommended that prison officers carry personal knives to enable immediate cut-down on finding an inmate attempting suicide by hanging 2 and are trained in resuscitation techniques.
Population interventions that do not work (and may even be harmful)
We have not identified any interventions proven to be ineffective or harmful in custodial settings.
What we don't know
We do not know which, if any, of the interventions applied during the Safer Custody initiative, has been effective, although the overall downward trend has been encouraging.
As with suicide prevention in general, it is difficult to isolate a single factor in a complex and constantly changing environment.
Operational pressures in the prison service, particularly during periods of overcrowding which result in often unplanned transfers, make it exceptionally difficult to conduct high quality research involving tightly controlled trials of interventions in this setting.
References
- Klaus-Peter D, Lohner JC, Konrad N. Suicide prevention in penal institutions: validation and optimization of a screening tool for early identification of high-risk inmates in pretrial detention. International Journal of Forensic Mental Health 2005;4:53-62.
- National Institute for Mental Health in England (NIMHE). National Suicide Prevention Strategy for England Annual Report on Progress 2006. NIMHE. Department of Health; 2007. . External Link
Contributors
Dr Jenny Bywaters
Suicide Prevention
Dr Jenny Bywaters is Senior Public Mental Health Advisor for the National Institute for Mental Health in England (NIMHE) where she directs the national programmes for suicide prevention and mental health promotion/public mental health. She has been seconded to North East Public Health Observatory (NEPHO) two days a week since April 2005 as part of the Public Mental Health Observatory team. She previously worked in the mental health policy branch at the Department of Health, and before that as Senior Commissioning Manager for Mental Health and Learning Disability Services at Birmingham Health Authority. She chairs the joint Faculty of Public Health/NIMHE Working Group on Mental Health.