Preventing Suicide in Forensic
Settings: Assessment and
Intervention for Inmates
With Serious Mental Illness
Journal of Correctional Health Care
2017, Vol. 23(4) 383-397
ª The Author(s) 2017
Reprints and permission:
Georgia M. Winters, MA1,2, Emily Greene-Colozzi, MA2,
and Elizabeth L. Jeglic, PhD2
Suicide is one of the leading causes of inmate deaths in correctional settings. Furthermore, there is
heightened risk for suicide among individuals diagnosed with serious mental illness (SMI) who
present in jails and prisons. In the present article, the authors review suicide risk factors associated
with SMI, with emphasis on incarcerated individuals, and discuss the best practices in assessing risk
for suicide. The authors review interventions designed to prevent suicide among individuals with SMI
in forensic settings. The article also points to the need for continued research to inform the
development of assessment tools and intervention strategies for this population.
suicide assessment, suicide intervention, serious mental illness, forensic settings, inmates
Each year in the United States, there are 34,000 suicides and more than 376,000 emergency department visits resulting from self-inflicted injuries (Centers for Disease Control and Prevention, 2015).
While the national suicide rate has drawn significant public concern, with increased attention being
focused on the high suicide rates among returning veterans (Wiederhold, 2008), the importance of
addressing suicide in forensic settings should not be overlooked. The suicide rate in jails and prisons
has decreased drastically since the 1980s (Mumola, 2005); however, it still remains nine times
higher than that of the general population and is among the top three causes of inmate deaths in
local jails and state and federal prisons (Daniel, 2006). Therefore, continued efforts directed at
preventing suicide in forensic settings are warranted.
The Graduate Center, City University of New York, New York, NY, USA
Psychology Department, John Jay College of Criminal Justice, New York, NY, USA
Georgia Winters, MA, Psychology Department, John Jay College of Criminal Justice, 524 West 59th Street, New York,
NY 10019, USA.
Journal of Correctional Health Care 23(4)
While general jail and prison suicide prevention and intervention efforts have increased in recent
years, it is imperative to note that inmates diagnosed with a serious mental illness (SMI), such as
schizophrenia, schizoaffective disorder, bipolar disorder, posttraumatic stress disorder, severe major
depression, panic disorder, or obsessive–compulsive disorder, may be at particularly high risk for
suicide in this environment (Insel, 2013). Since the deinstitutionalization movement in the 1970s,
prison populations have increased by 216%, with much of this increase attributed to correctional
facilities housing displaced psychiatric patients (Bureau of Justice Statistics [BJS], 1995; Kim, 2016;
Palermo, Smith, & Liska, 1991). It is estimated that between 6% and 15% of individuals in jails and
10% to 15% of individuals in prisons have an SMI. A 2002 investigation into the prevalence of SMI
among suicidal inmates found that almost 80% of inmates committing a serious suicide attempt had
been diagnosed with a chronic psychiatric illness (Gross, Peterson, Smith, Kalb, & Brodey, 2002).
Furthermore, a national survey of 696 prison suicides estimated that approximately 38% of victims
had a history of SMI and 20% had been previously prescribed psychotropic medication (National
Institute of Corrections, 2010), suggesting that inmates with SMI are at heightened risk for suicidality. Consequently, it has been argued that those with SMI, whose long-term treatment requires
ongoing therapeutic care and individual intervention, are not well served in correctional environments and that these environments may exacerbate existing symptoms possibly increasing their risk
for suicide (Lamb & Bachrach, 2001).
While many agree that alternatives to incarceration need to be further developed to divert those
with SMI from the criminal justice system, the reality remains that high numbers of those with SMI
end up under correctional supervision at some point in their lives, and thus it is imperative to ensure
that proper assessment and treatment protocols are in place for suicide prevention to meet the unique
needs of this high-risk group (Dicataldo, Greer, & Profit, 1995; James & Glaze, 2006). This article
will review suicide risk factors for individuals with SMI, with an emphasis on those who present in
prisons and jails. We will also discuss the best practices in assessing suicide and providing effective
interventions for individuals with SMI in correctional settings.
Suicide Risk Factors
In forensic settings, suicide risk assessment and treatment are the responsibility of experienced
clinicians who consider all risk and protective factors, thereby establishing the person’s ultimate
level of risk (Goodwin & Jamison, 2007). This can be especially challenging in overcrowded jails,
where understaffed mental health services are responsible for a diverse and fluid inmate population.
It has been found that a majority of jail suicides occur within the first week of incarceration before
institutional mental health professionals (MHPs) have had the opportunity to engage at-risk inmates
in meaningful assessment and counseling (Mumola, 2005). Furthermore, inmates identified as
suicidal still may not receive sufficient intervention due to staffing limitations (Blasko, Jeglic, &
Malkin, 2008). Fortunately, research over the past two decades has uncovered some of the more
common risk factors associated with inmate suicide, including demographic and institutional factors,
as well as psychiatric diagnoses, which has contributed to increased success at preventing suicide in
this setting (Daniel, 2006). Since early interventions and treatment are essential in preventing suicide
among individuals with SMI, familiarity with these risk factors is necessary for performing adequate
evaluation of suicide risk. We will present a review of risk factors for suicide among those with SMI
and then highlight particular risk factors for those with SMI in the correctional milieu.
Suicide Risk Factors For Individuals with SMI
Studies have revealed a lifetime suicide rate of approximately 4% to 8% for individuals with SMI,
compared to the general population rate of 1% (Bostwick & Pankratz, 2000; Harris & Barraclough,
Winters et al.
1997). Additionally, retrospective studies of completed suicides found that 90% of people who
committed suicide suffered from a psychiatric and/or substance use disorder, which demonstrates
that SMI significantly increases the risk for completed suicide (Maris, Canetto, McIntosh, & Silverman, 2000). Aside from general demographic-based suicide risk factors (e.g., age, gender, race/
ethnicity), clinicians working with forensic populations should consider SMI-specific factors in
assessing suicide risk. Short-term risk factors for those with SMI include the presence of hopelessness, impulsivity, instability, panic or anxiety, relational conflict, aggression, substance use, and
insomnia (Fawcett et al., 1990; R. C. Hall, Platt, & Hall, 1999). Rudd (2006) also identified longterm risk factors for those with SMI, such as persistent psychiatric symptoms, low thresholds of
activation of suicidality, inadequate coping skills, and comorbid Axis II personality disorders.
Researchers have not only highlighted the importance of risk factors for individuals with SMI but
also investigated disorder-specific risk factors.
Mood disorders. Mood disorders (e.g., major depressive disorder, bipolar disorder) pose the most
significant risk across all psychiatric disorders in regard to risk of suicide and suicide attempts
(Goodwin & Jamison, 2007; Kessler, Borges, & Walter, 1999). The lifetime suicide risk for individuals with mood disorders may be as high as 14% to 15% (Guze & Robins, 1970), although more
recent studies estimate around 4% for patients hospitalized for a mood disorder and 2% for those
never hospitalized (Bostwick & Pankratz, 2000). It should also be noted that age may exacerbate risk
for suicide among those with mood disorders, as 74% of all attempted or completed suicides
occurring among those aged 55 or older were related to mood disorders (Beautrais, 2002).
It has been found that the lifetime suicide risk for males with major depression is 7%, while the
risk for females lies around 1% (Blair-West, Cantor, Mellsop, & Eyeson-Annan, 1999). Suicide in
individuals with major depression has been associated with past suicide attempts, family history of
mental illness, more severe depressive symptoms, and comorbid disorder (e.g., anxiety, substance
abuse; Hawton, Casañas, Comabella, Haw, & Saunders, 2013). Furthermore, a meta-analysis examining suicide risk for those with major depressive disorder found the five most significant risk factors
were hopelessness, family history of suicide, negative life events, delusions, and self-accusation (Liu
& Bai, 2014).
Bipolar disorder is one of the SMIs most highly associated with suicide. Between 25% and 50%
of individuals with bipolar disorder will attempt suicide in their lifetime, with 8% to 19% completing
suicide (Latalova, Kamaradova, & Prasko, 2014). Increased risk has been associated with earlier age
of illness onset, past suicidal behaviors, family history of suicide, feelings of hopelessness, and
comorbid disorders (i.e., borderline personality disorder, substance use). Notably, women with
bipolar disorder have suicide mortality rates equal to those of men (Weeke, 1979), whereas in the
general population, women are more likely to attempt suicide, but men are 4 times more likely to die
from suicide (Goldsmith, Pellmar, Kleinman, & Bunney, 2002). Given the difficulties of distinguishing between states of depression from manic symptoms, it remains largely unclear whether
depressive or manic episodes pose a higher risk for suicidality in those with bipolar-related disorders
(Goodwin & Jamison, 2007).
Schizophrenia. For individuals with schizophrenia, suicide is the leading cause of death, with the
lifetime risk for dying by suicide being approximately 6% (Palmer, Pankratz, & Bostwick, 2005).
Individuals with schizophrenia are at 8.5 times higher risk for suicide compared to the general
population and that risk is particularly heightened within the first 10 years following symptom
presentation (Harris & Barraclough, 1997). Hawton, Sutton, Haw, Sinclair, and Deeks (2005)
conducted a systematic analysis of risk factors for suicide risk among those with schizophrenia and
found that increased risk is attributed less to psychotic symptoms and more to secondary factors such
as affective symptoms (e.g., worthlessness, hopelessness, and agitation), understanding the impact
Journal of Correctional Health Care 23(4)
schizophrenia has on cognitive functioning, living alone or not with family, recent loss, prior suicide
attempts, drug abuse, fear of disintegration, and treatment nonadherence. History of depression and
the presence of depressive symptoms have been associated with mortality from suicide for those
diagnosed with schizophrenia (Kohler & Lallart, 2005). Postpsychotic depression, the occurrence of
major depression following remission from a psychotic episode, has also been related to increased
risk for death by suicide in individuals with schizophrenia, and this risk is further elevated when
symptoms of anxiety are also present (Kohler & Lallart, 2005).
For inmates diagnosed with schizophrenia, many of these aforementioned factors are likely
exacerbated by correctional settings, such as separation from social supports or psychological
distress. Although little research has clarified the relationship between symptom onset and contact
with the criminal justice system, a 2003 Danish study reported that at least 71% of male inmates
diagnosed with schizophrenia had committed a crime prior to their initial contact with a psychiatric
hospital system and subsequent diagnosis (Munkner, Haastrup, Joergensen, & Kramp, 2003). This
study also found that 18.5% of individuals with schizophrenia who committed crimes prior to
diagnosis were imprisoned in correctional institutions rather than psychiatric institutions. Given
that the 10 years following diagnosis are a high-risk period, individuals with schizophrenia may
come in contact with the criminal justice system during this time, which emphasizes the importance
of MHP in forensic settings recognizing undiagnosed individuals or those exhibiting prodromal
symptoms in an effort toward preventing suicide.
Anxiety disorders. Historically, anxiety disorders such as phobias, obsessive–compulsive disorder,
post-traumatic stress disorder (PTSD), and panic disorder have been overlooked as risk factors in the
suicide literature (Litts, Radke, & Silverman, 2008). However, more recent research has found that
anxiety disorders pose an independent risk factor (not comorbid with other disorders) for predicting
suicide attempts (Bolton et al., 2008). In fact, the onset of anxiety disorders nearly doubles an
individual’s risk for attempting suicide. Often studies aggregate less severe anxiety disorders
(e.g., simple phobia) with those that meet criteria for SMI (e.g., PTSD, obsessive-compulsive
disorder, and panic disorder), making it difficult to parse out disorder-specific suicide risk. One
meta-analysis revealed a positive association between PTSD and suicidality, especially among those
with comorbid depression (Panagioti, Gooding, & Tarrier, 2012). For individuals experiencing
symptoms of PTSD, there is a potential for further traumatization within the correctional setting,
which emphasizes the importance of continuous monitoring of these symptoms, given the increased
risk for suicidality.
Suicide Risk Factors for Inmates With SMI
Among inmates with SMI, the nature and severity of SMI is an important factor in predicting suicide.
For example, inmates with bipolar disorder, major depression, schizophrenia, and personality disorders
are overrepresented in prison suicide data, according to a study of New York State prisons (Way,
Miraglia, Sawyer, Beer, & Eddy, 2005). Similarly, Baillargeon et al. (2009) found that 23% of suicide
victims in a Texas prison had a diagnosed mood disorder and 22% had a diagnosed psychotic disorder.
Inmates with SMI are further disadvantaged by a lack of protective factors that are available to those
with SMI who are not incarcerated, such as positive social supports (i.e., strong therapeutic relationship, attachment to family or therapist, supportive living environment), having responsibilities to
others (e.g., pregnancy, children living in the home), life satisfaction (e.g., hope for the future, selfefficacy), ability to reality test, adaptive coping skills, and fear of suicide or social disapproval (Centre
for Applied Research, 2007; CRICO/Risk Management Foundation, 2015; Jacobs, 2007).
The conditions of prison life also introduce risk factors that are unique to forensic settings.
Administrative and disciplinary segregation, which involve separating an inmate from the general
Winters et al.
population for a period of time, have been shown to exacerbate the risk of suicide among inmates,
yet these practices remain part of the penal system (Coid et al., 2003; Fazel, Cartwright, NormanNott, & Hawton, 2008; Metzner & Fellner, 2010; Stuart, 2003). Inmates can be segregated from the
general population for a number of reasons, including disciplinary measures (e.g., short-term punishment for fighting with other inmates, talking back to a guard, getting caught with contraband) and
safety concerns (e.g., indefinite administrative segregation to protect vulnerable inmates and officers) which, for those with SMI, may be behaviors related to the disorder (Weir, 2012). Typically,
those placed in segregation will be locked in a small cell for 23 to 24 hours each day, which limits
both movement and social contact, and can lead to adverse psychological effects (e.g., anxiety,
depression, paranoia, psychosis) in healthy and mentally disordered individuals (Smith, 2006). The
negative effects caused by segregation may greatly impact those with SMI, as this could exacerbate
current symptoms or induce symptom recurrence (Ambramsky & Fellner, 2003). While administrative segregation units are thought to increase safety by providing a more structured setting with
increased supervision, these environments may actually cause decompensation among those with
SMI. Not surprisingly, it has been found that suicides occur more often in solitary segregated
environments than other locations in the prison (Hayes, 1995; Patterson & Hughes, 2008; White,
Schimmel, & Frickey, 2002). Mental health services in segregation units typically focus on psychotropic medication management, brief visits from an MHP during mental health rounds, and possibly
an occasional meeting with a clinician (Smith, 2006). However, other services (e.g., individual and
group therapy, educational and recreation activities) are not commonly available due to limited
resources and rules requiring inmates to remain in their cells (Metzner & Dvoskin, 2006). Therefore,
should the use of segregation be deemed necessary for an individual with SMI, staff must be acutely
aware of the potentially adverse psychological impact and heightened risk for suicidality. Increased
monitoring and provision of services should be implemented for those with SMI in segregation,
including continued assessment for risk of suicide.
Overall, one of the greatest risk factors associated with incarceration and suicidality is inadequate
assessments and follow-up for inmates identified as having mental health problems or suicidal
ideation upon admission (Blasko et al., 2008; Goldsmith et al., 2002). Despite mandatory mental
health screening upon forensic admission, follow-up care is not always available. A national study of
correctional suicide in England and Wales conducted over 4 years found that 50% of inmates who
completed suicide had been identified upon admission as experiencing mental problems. A high
percentage of those had a history of suicidal ideation, self-harm, or previous suicide attempts
(Forrester & Slade, 2014; Hawton, Linsell, Adeniji, Sariaslan, & Fazel, 2014; Humber, Webb, Piper,
Appleby, & Shaw, 2013). Another study showed that of the 76 suicides that occurred in New York
State correctional institutions between 1993 and 2001, 84% of victims had seen an MHP during their
incarceration and 41% had contacted an MHP within 3 days of the suicide attempt (Way et al.,
2005). This suggests that inadequately assessing inmates for risk is a significant obstacle to preventing suicide in forensic settings.
Suicide Risk Assessment
Suicide risk assessment is the first step in identifying individuals with SMI who may be at higher risk
for self-harm. In principle, suicide risk assessment should be done with every inmate upon admission
to a correctional setting; however, due to limited resources, this is not always possible. Therefore,
targeted suicide risk assessments should be conducted for clients who exhibit suicidal thoughts or
behaviors during initial assessment upon admission or if there is significant change in clinical
presentation (e.g., increased depression, self-harm behavior, or substance use; Centre for Addiction
and Mental Health, 2010).
Journal of Correctional Health Care 23(4)
When conducting a suicide risk assessment with inmates in general, and specifically with those
with SMI, there are several broad areas that should be assessed: (1) present suicidal ideation and
intent; this may or may not include ...
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