Division of Social Psychiatry, Department of Psychiatry, Medical University of Vienna, Vienna, Caritas St Poelten, St Poelten;
Community Mental Health Services, Caritas St Poelten, St Poelten;
Department of Medical Statistics, Medical University of Vienna, Vienna;
Justizanstalt Wien-Mittersteig, Vienna, Austria
Correspondence: Stefan Fruehwald, MD, Community Mental Health Services, Caritas St Poelten, Dr Karl Renner Promenade 12, A-3100 St Poelten, Austria. Tel: +43 699 1063 0808; fax: +43 2742 84139; e-mail: psd.fruehwald{at}stpoelten.caritas.at
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ABSTRACT |
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Aims A casecontrol study was conducted to investigate the relevance of criminal history, psychiatric morbidity and social integration to suicide in prison.
Method For every suicide that occurred in an Austrian correctional institution between 1975 and 1999, two controls matched for correctional institution, gender, nationality, age, custodial status and time of admission were selected. Psychiatric characteristics, previous suicidal behaviour, criminal history and indicators of social integration were compared.
Results Of 250 recorded suicides, 220 personal files were available and matched to 440 controls. The most important predictors for suicide in custody were a history of suicidality (status following attempted suicide and suicide threat), psychiatric diagnosis, psychotropic medication, a highly violent index offence and single- cell accommodation.
Conclusions A significant finding is the importance of suicidal behaviour as an indicator of risk of suicide in correctional institutions, which until now has been a matter of debate. This study demonstrates the need for staff to take suicidal behaviour as seriously in custodial settings as in any other circumstances.
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INTRODUCTION |
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METHOD |
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Controls
For each suicide case that had been identified, two matched controls were
collected to increase the power of the study (this was just manageable with
the available resources). In addition to common matching parameters (age,
gender, nationality), we matched for custodial institution, custodial status
(pre-trial, sentenced, mentally disordered) and time of admission, to control
for environmental factors that might change over time. All 29 correctional
facilities in Austria were visited and the personal files of the matched
controls were collected. We consulted the records of index assessments at each
institution to find the admission of the person who had committed suicide (the
case). We then looked for inmates of the same age, gender, nationality and
custodial status (pre-trial, sentenced, mentally disordered), who had been
admitted at around the time of the admission date of the suicide case. The
personal files of two prisoners whose admission dates were closest to that of
the suicide case were included. If we were unable to find a personal file of
someone who had been admitted to the same custodial institution within 6
months (earlier or later) of the suicide case, or whose age was within 2.5
years of the age of the case individual, or if all personal files of matching
controls had already been destroyed, we took as a control the file of a
prisoner admitted later. All controls were collected by a psychiatrist (P.F.),
and the files of cases and controls were coded by the same researcher
(S.F.).
Variables
The following variables were investigated in the files of cases and
controls.
Personal data
Personal data included gender, age, nationality, marital status, number of
children, religion, degree of professional education, occupational status and
presence of tattoos.
Criminological data
We recorded custodial status (pre-trial, sentenced or not guilty for reason
of insanity); number of previous convictions; number of previous
incarcerations; types of previous offences; and nature of last offence
(property offence, level of violence (low or high), sex offence, drug-related
offence, damage of property, other offence).
Psychiatric characteristics
Psychiatric characteristics noted were psychiatric assessment (contact with
a psychiatrist while incarcerated); psychiatric diagnosis;
psychopharmacological treatment (prescribed while incarcerated); substance
misuse; previous suicide attempt; and suicide threat (coded positive if we
found a remark in the medical record or in the general file).
Information about incarceration
The name of the correctional institution was recorded, together with date
of admission, date of suicide, date of planned release (for sentenced
offenders), visits while in custody, housing while incarcerated, working
status while incarcerated and contact with significant others while
incarcerated.
Statistics
To check for differences between cases and controls, univariate analyses
were performed using Fishers exact tests for categorical variables and
Wilcoxon two-sample tests for continuous variables. This was done for the
whole sample and separately for the three subgroups for custodial status.
To explain suicide in prison, stepwise unmatched logistic regression was used because of the large number of missing values. In all multivariate analyses the matching variables were kept fixed in the models. In a first analysis (model 1) all variables that had a P value less than 0.01 in at least one of the four univariate comparisons cases v. controls were considered as independent variables to model the odds for suicide in custody. The significance level for entering the stepwise logistic model was set to P=0.05. In the stepwise logistic regression all individuals with missing values in at least one of the influence factors were dropped. So in a further non-stepwise final analysis, only the variables selected by model 1 and the matching variables were used as independent variables, to reduce the number of missing cases (model 2). For the final analysis, odds ratios and corresponding 95% confidence intervals were calculated. We also performed matched conditional logistic regression analyses (SAS procedure PHREG with a STRATA variable), which essentially confirmed the results when convergence of the model could be achieved. We used the SAS statistical software system (version 8.1, SAS Institute Inc., Cary, NC, USA) for the calculations.
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RESULTS |
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Overall analysis for the whole sample
Performing the stepwise logistic regression for the whole sample, 265 (out
of 660) observations were deleted because of missing values for explanatory
variables. In model 1 the seven explanatory variables entered were
known suicide attempt, single-cell accommodation,
psychiatric diagnosis, last offence: high level of
violence, psychiatric medication, last offence
against property and suicide threat. However, before
interpreting these significant results, it has to be mentioned that the
matching variables custodial institution (P=0.029), age
(P=0.03) and time of admission (P=0.036) also contributed to
the risk of suicide. Applying model 2 to the reduced set of influence
variables selected by model 1, custodial institution (P=0.0086) and
time of admission (P=0.01) still remained as significant predictors.
This points to an imbalance of missing values against the values of the
matching variables. In fact, a systematic loss of data for the control group
had to be considered: pre-trial prisoners personal files were destroyed
after a defined period, but this was not done for pre-trial prisoners who had
died by suicide. The casecontrol ratio for this subgroup in the final
model was as low as 1:1.01, whereas for sentenced prisoners the ratio was
practically 1:2 in all the analyses. The reason why the factor
custodial institution shows up in the statistical analyses is
that the majority of custodial institutions had occupants of only one
custodial status. Ignoring the custodial institution in the multivariate
analysis, the most influential matching variable remaining was custodial
status. As a consequence of these imbalances for the pre-trial group, we
performed separate multivariate analyses for pre-trial and sentenced
prisoners. The number of mentally disordered prisoners was too small for this
type of multivariate analysis.
Pre-trial prisoners
Following the stepwise selection procedure, the final model using 181
observations (casecontrol ratio 95:86) confirmed the significant
influence of the selected variables single-cell accommodation
(OR=19.9), last offence: high level of violence (OR=11.9),
psychiatric medication (OR=26.9) and known suicide
attempt (OR=17.9). Values of P, odds ratio estimates and
corresponding 95% confidence intervals for this final model are reported in
Table 2. The matching variable
time of admission became significant. This was to be expected,
because for pre-trial controls with an early date of admission the personal
files were destroyed after a defined period.
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Sentenced prisoners
In the final model a total of 252 observations (cases, 84; controls, 168)
were used. The significant influence of the chosen factors psychiatric
diagnosis (OR=17.4), single-cell accommodation (OR=16.9),
suicide threat (OR=53.2), last offence: high level of
violence (OR=4.3) and psychiatric medication (OR=5.8)
could be reproduced (Table 3).
None of the matching variables yielded a significant result. A further model
was performed using length of sentence as an additional variable. For this
model the variables psychiatric diagnosis, single-cell
accommodation, suicide threat and length of
sentence were selected as independent variables. The final model
validated their significant influence, and none of the matching variables
yielded significant results. The new variable length of sentence
covers that of last offence: high level of violence and
psychiatric medication; people whose current offence involved
high levels of violence are usually sentenced to long-term imprisonment.
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DISCUSSION |
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According to the logistic regression models, the most important predictors for suicide in custody were a history of suicidality (status following attempted suicide and suicide threat), a psychiatric diagnosis, psychotropic medication, a highly violent index offence and single-cell accommodation. Most of these indicators of risk have been previously identified in the scientific literature, but history of suicidality has been the subject of contradictory reports. Suicidal behaviour (suicide attempts, suicide threats, self-harm) is considered to be an important risk factor for suicidality in general (Ringel, 1969). In previous prison suicide studies, a high percentage (4362%) of suicides were found to be of people with a history of suicidality (Backett, 1987; Dooley, 1990; Marcus & Alcabes, 1993; Bogue & Power, 1995; Laishes, 1997; Fruehwald et al, 2003). Suicide attempts, suicide threats and self-harm were considered typical of the total prison population, thus having little relevance for intervention (Dooley, 1990). On the other hand, it was argued that a not predictable majority of inmate suicides was committed by inmates who seemingly made a rational decision not to go on living, as they did not communicate their decision to anyone. The remaining minority, which was identified to be suicidal, managed to succeed in spite of appropriate monitoring and intervention (Laishes, 1997). More recently, it was stated that most prisoners who injure themselves many repeatedly do not go on to kill themselves (HM Chief Inspector of Prisons for England and Wales, 1999). We think that this study demonstrates the necessity for all correctional staff to take suicidal behaviour as seriously in custodial settings as in any other circumstances. Suicidal behaviour might be an important opportunity to refer people in prison to adequate psychiatric care and to take further steps to prevent suicides.
The relevance of psychiatric morbidity as one of the main risk factors for suicide in custody is strongly confirmed by this study, as is the relevance of single-cell accommodation (Frottier et al, 2002a,b), which has to be seen as a facilitating factor rather than in any way directly causative. There were a number of further significant differences between cases and controls that have not yet been identified as risk indicators, which are covered by other factors in the multivariate analyses. Professional education and working status before and during incarceration were significantly different between cases and controls, as were some details concerning criminological history. We think that further analyses and replication in other studies are necessary to prove the relevance of social parameters for suicide in custody parameters that have also been mentioned in reviews by HM Chief Inspector of Prisons for England and Wales (1999) and the Scottish Prison Service (2003). Indicators of social integration could be easily used for suicide prevention purposes if asked about during admission proceedings; questions concerning working status before incarceration or professional education would be far less stigmatising than questions about psychiatric history and previous suicidal behaviour. However, such questions are not currently part of prison intake procedures in Austria.
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The major strength of our study is its epidemiological approach, including two controls for each case of suicide over a quarter of a century. There are some limitations: we were unable to obtain all 250 personal files, as 30 files had already been destroyed. We do not think that selection bias occurred, as we obtained more than half of all files pertaining to the first few years of the period studied, over 25 years ago. A more relevant problem was that the personal files of controls tended not to contain as much valuable information as the case files. In particular, if the duration of incarceration of the people chosen as control had been short and from the viewpoint of the institution without complications, only limited amounts of information could be found in their files. Therefore, we faced a number of missing values when adhering to the matching criterion admission to the same institution closest to the case. However, for sentenced prisoners the main results are based on a model in which only 60 observations were dropped, resulting in a perfect casecontrol ratio (i.e. 1:2).
Implications of the study
In this casecontrol study of 220 cases of prison suicide and 440
controls, we found that the most important predictors of suicide of pre-trial
prisoners were single-cell accommodation, known previous suicide attempt,
psychiatric medication prescribed while in custody, and last offence of a
highly violent nature. For sentenced offenders, the most important predictors
were psychiatric diagnosis, single-cell accommodation, known previous suicide
attempt, last offence of a highly violent nature and psychiatric medication
prescribed while in custody. Our study confirms the relevance of psychiatric
diagnoses, single-cell accommodation (as a facilitating issue) and highly
violent index offences to suicide in prison. It highlights the importance of
suicidal behaviour for suicides in correctional institutions, for which
evidence has been conflicting until now.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication November 6, 2003. Revision received June 1, 2004. Accepted for publication June 26, 2004.
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