For prison psychiatrists, the best suicide-prevention strategies
incorporate knowledge of risk factors that extend beyond those found in the
general population and the use of specialized tools designed for inmates who
pose an imminent suicide risk.
Inmates who receive "Dear John" letters, are detained in secure
housing units, or receive a lengthy sentence are among those at increased risk
Two forensic psychiatrists, Michael Champion, M.D., and James Knoll IV,
M.D., talked about these risk factors and offered suicide-prevention
strategies at the annual meeting of the American Academy of Psychiatry and the
Law in October.
Champion, who is associate director of forensic psychiatry and an assistant
professor of psychiatry at Dartmouth Medical School, noted that suicide is the
third-leading cause of death in the correctional environment, behind natural
causes and AIDS-related complications. Champion is also the administrative and
medical director of the Secure Psychiatric Unit at the New Hampshire
Department of Corrections.FIG1
Prison psychiatrist James Knoll IV, M.D., discusses suicide-prevention
tools used in correctional settings, such as the "strong cloth safety
smock" and the cutdown tool, which can tear through makeshift nooses
He noted that suicide rates differ depending on the type of facility in
which inmates are housed. Among prison inmates, the suicide rate is about 1.5
times that of the general population, or 14 per 100,000 inmates. Among jail
inmates, Champion said, that rate rises to about nine times that of the
general population. People who are newly arrested and brought to lockups,
which are holding cells in city or county police or sheriffs' offices, have
the highest suicide rate—about 250 times that of the general
Knoll explained that prison inmates typically have the lowest suicide rate
because, for the most part, "prisons usually have better mental health
resources and monitoring ability" than jails.
In addition, he said, people who are sent to prison "have usually
been off the streets, and thus off of substances for a long period."
Jails, which have slightly higher suicide rates, have a transient
population, which makes it difficult to follow and monitor people
consistently, Knoll said. Often, jails have few mental health resources, and
inmates may undergo withdrawal from drugs when first incarcerated.
Suicide rates at lockup facilities are so high, Knoll said, because these
facilities "are generally entirely unequipped for suicide monitoring or
mental health screening."
"People admitted to a lockup are fresh off the street," Knoll
continued. Many are intoxicated or withdrawing from substances, he observed,
and "experiencing the initial shock and humiliation of arrest and
One of the reasons suicide may be higher among inmates than the general
population is the "unending supply of factors that increase stress
levels" of inmates, he noted.
Prisons are designed to isolate offenders from society and even from one
another. "Separation from family, friends, and other support networks
radically increases stress," Champion said.
Perhaps the most isolative place in prisons is the maximum-security housing
unit (SHU), a cell used by prison staff as a disciplinary sanction for inmates
who act out in some way.
Inmates typically stay in these environments for 23 hours a day; the
remaining hour is for "recreation," spent in another enclosed
space. A number of studies have associated SHU placement with suicide attempts
and completed suicides, Champion said.
"This level of isolation can often either generate or exacerbate
existing psychiatric symptoms, thus raising suicide risk," he
Champion cited data from a 2004 study by Jenny Shaw, M.D., which was
published in the March British Journal of Psychiatry. The study found
that of 172 suicides committed in British prisons, a third occurred during the
first week of incarceration. Half of the suicides occurred upon remand, or
being re-sentenced for a parole violation, after release. Seventy-two inmates
had a history of mental disorder.
Although suicide risk factors for jail inmates often overlap with those of
prison inmates—common risk factors include prior suicide attempts and
having a history of a psychiatric disorder—some risk factors are unique
to each type of correctional facility.
For instance, Champion noted that suicide risk for jail inmates increases
if the inmate is intoxicated upon arrest, experiences recent negative life
events such as a spouse's instigating a divorce, other family members'
indicating they want no further contact with the prisoner, or receiving new
charges while in jail.
Risk factors associated with prison inmates include being housed in an SHU,
receiving a long sentence, or being convicted of a violent crime, he said.
Being bullied may also be associated with an elevated risk of suicide for
inmates in correctional settings, according to Knoll, director of forensic
psychiatry at the New Hampshire department of corrections and an assistant
professor of psychiatry at Dartmouth Medical School.
A 2001 study by Eric Blaauw, Ph.D., found that among 95 inmates who
committed suicide in Dutch jails between 1987 and 1998, over one-third had
been bullied while incarcerated, and 22 percent had reported "serious
bullying" by other inmates.
"The authors believe bullying may be a precursor to suicide"
for those inmates, he said.
Knoll said he has interviewed a number of suicidal inmates who told him
other inmates "held court" on them. In this scenario, an
aggressive, "alpha" inmate rounds up other inmates to try"
convicting" a more vulnerable inmate of a real or perceived
offense. They then "mete out a punishment" for the inmate, which
may include anything from "taking things away from the prisoner to
serious physical assault."
Certain tools—quite literally—are crucial to suicide prevention
in correctional settings, Knoll pointed out.
One is the "strong cloth safety smock," which can be used for
inmates who are acutely suicidal.
Anywhere from 80 percent to 90 percent of inmates commit suicide by hanging
themselves with bed clothes or sheets, Knoll observed. The smock cannot be
torn or ripped to form a noose. Bedding can be made with the same material, he
Another lifesaving resource is a "cutdown" tool, which is a
specialized knife built to hook on to cloth and used by prison staff to cut
through fibers very quickly to prevent death by suicide but which can't be
used by inmates as a weapon.
Knoll noted that "true suicide prevention begins at the point of
arrest" and that "police play a critical role in observing and
communicating important information about the arrestee's behavior to staff
working at lockup facilities, where the risk of suicide is especially
high," he said.
It is also crucial for corrections staff to communicate certain information
about inmates to the next shift, he noted, such as a sudden loss of support
outside the facility or another negative life event. ▪