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      Suicide in prisons: an international study of prevalence and contributory factors

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        , MD, , MSc , FMedSci
      The lancet. Psychiatry

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          Summary

          Background

          Prison suicide rates, rate ratios, and associations with prison-related factors need clarification and updating. We examined prison suicide rates in countries where reliable information was available, associations with a range of prison-service and health-service related factors, how these rates compared with the general population, and changes over the past decade.

          Methods

          We collected data for prison suicides in 24 high-income countries in Europe, Australasia, and North America from their prison administrations for 2011–14 to calculate suicide rates and rate ratios compared with the general population. We used meta-regression to test associations with general population suicide rates, incarceration rates, and prison-related factors (overcrowding, ratio of prisoners to prison officers or health-care staff or education staff, daily spend, turnover, and imprisonment duration). We also examined temporal trends.

          Findings

          3906 prison suicides occurred during 2011–14 in the 24 high-income countries we studied. Where there was breakdown by sex (n=2810), 2607 (93%) were in men and 203 (7%) were in women. Nordic countries had the highest prison suicide rates of more than 100 suicides per 100 000 prisoners apart from Denmark (where it was 91 per 100 000), followed by western Europe where prison suicide rates in France and Belgium were more than 100 per 100 000 prisoners. Australasian and North American countries had rates ranging from 23 to 67 suicides per 100 000 prisoners. Rate ratios, or rates compared with those in the general population of the same sex and similar age, were typically higher than 3 in men and 9 in women. Higher incarceration rates were associated with lower prison suicide rates (b = –0·504, p = 0·014), which was attenuated when adjusting for prison-level variables. There were no associations between rates of prison suicide and general population suicide, any other tested prison-related factors, or differing criteria for defining suicide deaths. Changes in prison suicide rates over the past decade vary widely between countries.

          Interpretation

          Many countries in northern and western Europe have prison suicide rates of more than 100 per 100 000 prisoners per year. Individual-level information about prisoner health is required to understand the substantial variations reported and changes over time.

          Funding

          Wellcome Trust and the UK National Institute for Health Research (NIHR).

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          Most cited references21

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          Prison suicide in 12 countries: an ecological study of 861 suicides during 2003-2007.

          Although suicide rates among prisoners are high and vary between countries, it is uncertain whether this reflects the importation of risk from the general population or is associated with incarceration rates.
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            Suicide in prisoners: a systematic review of risk factors.

            To examine factors associated with suicide in prisoners. Studies were identified through electronic searches of MEDLINE (1950-February 2007), PsycINFO (1806-February 2007), EMBASE (1974-February 2007), and CINAHL (1982-February 2007) without language restriction using the search terms prison, jail, felon, detainee, penal, and custody combined with suicide. Included studies were investigations that reported on prisoners dying by suicide who were compared with prisoners in control groups (which were randomly selected or matched, or consisted of the total or average prison population). Subgroup analysis and meta-regression were used to explore sources of heterogeneity. Thirty-four studies (comprising 4780 cases of prison suicide) were identified for inclusion in the review, of which 12 were based in the United States. Demographic factors associated with suicide included white race/ethnicity (OR = 1.9, 95% CI = 1.7 to 2.2), being male (OR = 1.9, 95% CI = 1.4 to 2.5), and being married (OR = 1.5, 95% CI = 1.3 to 1.7). Criminological factors included occupation of a single cell (OR = 9.1, 95% CI = 6.1 to 13.5), detainee/remand status (OR = 4.1, 95% CI = 3.5 to 4.8), and serving a life sentence (OR = 3.9, 95% CI = 1.1 to 13.3). Clinical factors were recent suicidal ideation (OR = 15.2, 95% CI = 8.5 to 27.2), history of attempted suicide (OR = 8.4, 95% CI =6.2 to 11.4), having a current psychiatric diagnosis (OR = 5.9, 95% CI = 2.3 to 15.4), receiving psychotropic medication (OR = 4.2, 95% CI = 2.9 to 6.0), and having a history of alcohol use problems (OR = 3.0, 95% CI = 1.9 to 4.6). Black race/ethnicity was inversely associated with suicide (OR = 0.4, 95% CI = 0.3 to 0.4). Few differences were found in risk estimates when compared by study design or publication type. Several demographic, criminological, and clinical factors were found to be associated with suicide in prisoners, the most important being occupation of a single cell, recent suicidal ideation, a history of attempted suicide, and having a psychiatric diagnosis or history of alcohol use problems. As some of these associations included potentially modifiable environmental and clinical factors, there is scope for targeting these factors in suicide prevention strategies for individuals in custody. Copyright 2008 Physicians Postgraduate Press, Inc.
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              Are suicide deaths under-reported? Nationwide re-evaluations of 1800 deaths in Scandinavia

              Objective Valid mortality statistics are important for healthcare planning and research. Suicides and accidents often present a challenge in the classification of the manner of death. The aim of this study was to analyse the reliability of the national suicide statistics by comparing the classification of suicide in the Scandinavian cause of death registers with a reclassification by 8 persons with different medical expertise (psychiatry, forensic pathology and public health) from each of the 3 Scandinavian countries. Methods The cause of death registers in Norway, Sweden and Denmark retrieved available information on a sample of 600 deaths in 2008 from each country. 200 were classified in the registers as suicides, 200 as accidents or undetermined and 200 as natural deaths. The reclassification comprised an assessment of the manner and cause of death as well as the level of certainty. Results In total, 81%, 88% and 90% of deaths registered as suicide in the official mortality statistics were confirmed by experts using the Swedish, Norwegian and Danish data sets, respectively. About 3% of deaths classified as accidents or natural deaths in the cause of death registers were reclassified as suicides. However, after a second reclassification based on additional information, 9% of the natural deaths and accidents were reclassified as suicides in the Norwegian data set, and 21% of the undetermined deaths were reclassified as suicides in the Swedish data set. In total, the levels of certainty of the experts were 87% of suicides in the Norwegian data set, 77% in the Swedish data set and 92% in Danish data set; the uncertainty was highest in poisoning suicides. Conclusions A high percentage of reported suicides were confirmed as being suicides. Few accidents and natural deaths were reclassified as suicides. Hence, reclassification did not increase the overall official suicide statistics of the 3 Scandinavian countries.
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                Author and article information

                Contributors
                Journal
                101638123
                42935
                Lancet Psychiatry
                Lancet Psychiatry
                The lancet. Psychiatry
                2215-0366
                2215-0374
                25 July 2018
                December 2017
                30 July 2018
                : 4
                : 12
                : 946-952
                Affiliations
                Department of Psychiatry, University of Oxford, Oxford, UK
                Centre for Suicide Research, University of Oxford, Oxford, UK
                Author notes
                Correspondence to: Prof Seena Fazel, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK seena.fazel@ 123456psych.ox.ac.uk
                Article
                EMS78777
                10.1016/S2215-0366(17)30430-3
                6066090
                29179937
                b06dd186-3207-46be-8b2b-4cd1b65562b4

                This is an Open Access article under the CC BY 4.0 license ( http://creativecommons.org/licenses/by-nc-nd/4.0/).

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