The British Journal of Psychiatry (2010) 197, 313–319. doi: 10.1192/bjp.bp.110.077883 Psychiatric disorders in male prisoners who made near-lethal suicide attempts: case–control study Adrienne Rivlin, Keith Hawton, Lisa Marzano and Seena Fazel Background Although male prisoners are five times more likely to die by with near-lethal suicide attempts, including major depression suicide than men of a similar age in the general population, (odds ratio (OR) = 42.0, 95% CI 5.8–305), psychosis (OR = 15.0, the contribution of psychiatric disorders is not known. 95% CI 2.0–113), anxiety disorders (OR = 6.0, 95% CI 2.3–15.5) and drug misuse (OR = 2.9, 95% CI 1.3–6.4). Lifetime Aims psychiatric disorders associated with near-lethal attempts To investigate the association of psychiatric disorders with included recurrent depression and psychoses. Although near-lethal suicide attempts in male prisoners. cases were more likely than controls to meet criteria for antisocial personality disorder, the difference was not Method statistically significant. Comorbidity was also significantly A matched case–control study of 60 male prisoners who more common among cases than controls for both current made near-lethal suicide attempts (cases) and 60 prisoners and lifetime disorders. who had never carried out near-lethal suicide attempts in prison (controls) was conducted. Psychiatric disorders were identified with the Mini International Neuropsychiatric Conclusions In male prisoners, psychiatric disorders, especially Interview (MINI), and information on sociodemographic characteristics and criminal history was gathered using a depression, psychosis, anxiety and drug misuse, are semi-structured interview. associated with near-lethal suicide attempts, and hence probably with suicide. Results Psychiatric disorders were present in all cases and 62% of Declaration of interest controls. Most current psychiatric disorders were associated None. Reducing the incidence of suicide by prisoners is part of national prisoners, there was no control group and psychiatric morbidity strategies for suicide prevention in the USA,1 UK,2 Ireland3 and was not investigated. other countries,4 and is highlighted in a recent World Health 5 Organization statement on mental health in prisons. Relative to Method age-adjusted rates in the general population, suicide rates in male prisoners are five times higher in England and Wales,6 and large Participating prisons 7 proportionate excesses have been found in the USA and some We requested information from the Ministry of Justice Safer mainland European countries.8 Potentially modifiable factors have 9,10 Custody and Offender Policy Group on prisons within 100 miles been the focus of suicide prevention guidelines in prisons, of Oxford that had relatively high rates of serious suicide attempts although there has been little attention to specific psychiatric and completed suicides. Nineteen prisons were identified, including disorders. A recent systematic review showed that clinical factors three young offenders’ institutes (prisoners aged 18–21), three have strong associations with suicide in prison, but which 11 Category A (maximum security) prisons, 12 Category B prisons diagnoses and their relative contributions were uncertain. Part (establishments for those who do not require maximum security of the reason for this is that investigating risk factors for prison but for whom escape must be made difficult) and one Category suicide has principally been based on examination of official C prison (for prisoners who cannot be housed in open conditions records, or use of the psychological autopsy approach, which aims but who are unlikely to try to escape). to build a retrospective picture of the deceased’s mental state at the time of death in order to develop a profile of the prisoner.12 As this method relies primarily on medical records for information Participant identification on clinical factors, it is limited by the quality of these.13–15 Near-lethal suicide attempts were defined as acts that could have In this study, we addressed this limitation by assessing been lethal had it not been for intervention or chance, and/or psychiatric disorders in male prisoners who made near-lethal involved methods that are associated with a reasonably high suicide attempts and comparing them with those of a matched chance of death.21 Detailed criteria were developed to aid prison control group of prisoners who had never made a similar attempt officers refer suitable cases to the study (Appendix). The criteria in prison.16 The validity of the near-lethal method is supported by are based on the physical danger and consequences of the two pieces of evidence. First, survivors of medically serious suicide act, an approach that is in line with that used in previous attempts are epidemiologically similar to individuals who die by investigations of near-lethal suicide attempts in the community.21 suicide.17,18 Second, individuals who have made a medically They intentionally do not include suicidal intent. This is because serious suicide attempt are twice as likely as other people who basing the criteria only on the lethality of the act includes in the have attempted suicide to subsequently complete suicide.19 study both those with high suicidal intent and those whose actions Furthermore, the near-lethal method has been piloted in may have very nearly caused death but may not have been prisons.20 However, the pilot study only included 15 male motivated by suicidal intentions. Such cases would be recognised 313 Downloaded from https://www.cambridge.org/core. 24 Sep 2021 at 23:31:13, subject to the Cambridge Core terms of use. Rivlin et al by most researchers as being within a broad conceptualisation of used in prisons.31–33 However, previous research in prisoners33 suicide. and our pilot work suggested that the MINI may overdiagnose Cases were interviewed within 4 weeks of the suicide attempt. certain disorders. We therefore made the following modifications: Controls were prisoners who had not made a near-lethal suicide a diagnosis of mania (current or lifetime) was only made when attempt while in prison. They were matched with cases by age prisoners met criteria for elation/expansiveness (i.e. irritable (5 years older or younger) and by type/category of prison. mood alone was insufficient to reach a diagnosis); and a diagnosis Identification of controls was done randomly from the Ministry of obsessive–compulsive disorder was dependent on meeting of Justice’s daily list of prisoners using these two matching criteria. criteria for both obsessions and compulsions. All participants were aged 18 years and over. Prisoners making a near-lethal suicide attempt were excluded Ethical approval from the study if they declined to take part (15 individuals), could not speak English (8), were considered too dangerous (4) or too The study had ethical approval from the Central Office for seriously mentally ill (1), or because staff shortages or absences Research Ethics Committees (Ethics number 06/MRE12/83), and meant that the 4-week time limit within which an interview had the Prison Service (Reference PG 2006 063). to be conducted had been missed (6). A further eight prisoners were released from prison or transferred to a non-participating Statistical analyses prison before an interview could be arranged. Those included in All analyses were conducted using the Statistical Package for the the case group were significantly more likely than those excluded Social Sciences (SPSS, Version 15.0 for Windows) and STATA to be White (52/60 (87%) v. 25/42 (60%), odds ratio (OR) = 4.4, (Version 9.0 for Windows). A 95% (P50.05) significance level 95% CI 1.7–11.6) and to be on a life sentence (13/39 (33%) v. 2/23 was adopted. In the results, unless otherwise specified, denominators (9%) OR = 5.1, 95% CI 1.0–24.9). Other recorded socio- for both cases and controls are 60. Odds ratios, 95% confidence demographic and criminological characteristics did not differ intervals and associated P-values for analyses of categorical factors significantly between the included and excluded prisoners. were calculated using McNemar’s test to account for matching of cases and controls. For continuous data, paired sample t-tests and Interviews Wilcoxon signed ranks tests (for non-normally distributed data) Following training in use of the instruments and questionnaires were used. employed in the research, and piloting at a large adult male Possible confounders (ethnicity, marital status, prior local prison, one of the authors (A.R.) conducted semi-structured employment, educational qualifications, index offence, remand face-to-face interviews with 60 cases and 60 controls. A total status, previous prison spells, and sentence length greater than sample size of 120 was calculated to provide sufficient power to 18 months) were assessed using conditional logistic regression. determine important differences in psychiatric characteristics. We examined whether confounders were each independently After participants’ written consent had been obtained, the associated with having made a near-lethal attempt in prison and interviews took place in private in the prison and lasted for with specific psychiatric disorders. Confounders were then 90–120 min. Participants were offered support both before and introduced and left in the model if they altered the odds ratio after the interviews from a prison officer, chaplain, Samaritan, by more that 10%.34,35 No confounder fulfilled both these criteria. Listener (trained peer support) or psychologist. We looked at risk of near-lethal suicide attempts according to Sociodemographic and criminal history information was diagnostic subgroups using conditional logistic regression (as the gathered using an adapted version of a structured questionnaire data were matched on age and prison type/category). Where the 22 used in the Oxford Monitoring System for Attempted Suicide. number of discordant pairs of cases and controls was less than The following information regarding a participant’s medical 10, we do not report odds ratios.