Introduction

Suicide is a worldwide public health epidemic. It is intentionally causing one’s own death. There are many reasons a person makes the decision to no longer want to live and to take one’s own life. The Centers for Disease Control and Prevention (CDC) (2018) reports suicide is a result of many risk factors. These risk factors include individual, societal, relationship and community influences. According to the CDC (2018), aggressive tendencies, family history of suicide, mental health, easy access to weapons and drugs, child abuse, drug and/or alcohol abuse, and feelings of hopelessness are just a few of the risk factors associated with suicide.  Suicide is especially prevalent in the prison system. The rates of prison suicide are greater than in the general population. Reports show that the prison suicide rate is 120 deaths per 100,000 people. This is ten times more than the general population. This paper will discuss the tragedy of suicide in prisons, critical issues related to prison suicides, its impact of public health and welfare, and preventative measures.

Suicide in Prison

 Signs have been seen that are good indicators that suicide may be attempted. At times, prior to a suicide attempt, there may be signs of self-harm. This can be in forms of cutting, changes in eating habits, and self-inflicted pain. Another indicator that increases risk is a history of previous suicide attempts. Tolerance increases with previous attempts, making suicide attempts easier and easier. Interestingly, although previous suicide attempts are a risk factor, they still do not account for the majority of suicides in prison. Smith et al. (2016) states, “…over half of those who die by suicide do so in the absence of any history of suicidal behavior”. In fact, Smith et al. (2016) reports, that research has shown risky lifestyles and exposure to things like being in the military during combat, having multiple surgical procedures, intravenous drug users, substance users, being exposed to violence and assault, and even jobs such as veterinarians, who euthanize animals has shown to be more prone to commit suicide.

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 Some may question why the suicide rate is high in prisons. Prisoners have been exposed or have exposed themselves to many life altering experiences. These negative events cause pain and suffering. Additionally, it wears down on an individual psychologically. Once a person is affected psychologically and obtains the thoughts of no longer wanting to live, those thoughts continue to become stronger and stronger as hopelessness sets in. The thoughts of no longer having to suffer becomes an easier avenue than trying to survive.

 Suicide is a leading cause of death in prisons. Research was done in Mississippi on male prison inmates. The goal of this research study was to see if exposure to lifestyles and risky behaviors increased prisoner’s capability of committing suicide. Most participants were African American. The second majority of participants were Caucasian. This left the rest of the participants Native American, Hispanic, and not reported. Common items were the average age of 35 years old. The current time served amongst them was approximately nine years. Also, the majority had not attempted suicide. In fact, out of 399 prisoners, only 51 reported attempted suicide. The prisoners consented to this study and all procedures and materials were approved to be reliable and valid. Life exposure items included aggression, animal abuse, military combat experiences, disordered eating, drug and alcohol abuse, excessive exercise, use of guns, physical and sexual assault, suicidal thoughts and behaviors, thrill seeking and accidental injury. (Smith et. al 2016) The results proved true to assumption. The results showed that life experience and exposures as mentioned above increased prisoners’ capability of committing suicide. Although this study can be limited due to the fact that it incorporated males rather than a mixture of males and females, it still gives insight on the capability of prisoners when it comes to suicide risk.

 Other theorists have argued that suicide rates are increased in prisons due to overcrowding and psychiatric illness. The two were equivalated due to single cells and mental illness however, the research was so limited that this could not be proven. With all of these risk factors and environmental factors potentially influencing suicide, research continues to evaluate the most proper way to screen prisoners in effort to reduce suicide rates in prison. Research was conducted in 12 countries on suicide in prisons. Data was obtained based on eight hundred and sixty-one deaths from suicide across the world. Interestingly enough, eight hundred and ten were male suicides, leaving only fifty-one being female suicides. Although males suicide numbers were extremely higher than females, research showed that suicide in prisons is a national epidemic. Fazal et al. (2010) states, “The results underline the observation that prisoners are a high-risk group for suicide and should therefore be considered part of national suicide prevention strategies”. One fact that made a difference in this study was the difference in psychiatric treatment. Fazal et al. (2010) mentioned, “Previous work has shown that changes to psychiatric services in New Zealand prisons in the 1980’s led to a striking increase in suicide, implying that changes to the provision and delivery of psychiatric care may be important”. This makes one wonder the importance and need for properly trained staff in identifying those at risk for suicide.

 Being around violence and assault has been said to cause an increased risk in suicide attempts in prisons. Fazal et al. (2010) states, “The strongest associations were with being a remand status prisoner, occupying a single cell, and history of violence”. Although these are predispositions, sentencing also seemed to play a role. The research done in a prison in England and Wales exposed more risk factors for prisoners who commit suicide. It was found that those who were unemployed or who were incarcerated for long term also had higher rates of suicide. Additionally, regardless of predisposition, if prisoners did not receive visitors this was also an indicator of suicide risk. History of violence and isolation weighed heavily on prisoners and the decision to commit suicide. Like other studies, mental health problems and previous substance use were high indicators of suicide attempt. The mental health problems usually were an issue prior to incarceration.

Prevention

 Clearly, suicide in prisons needs to be addressed. Staffing should be equipped and trained to assess, identify, evaluate and maintain continuity of care for long term prevention. Nurses work autonomously and must be equipped with the right training in order to react and respond immediately to many different health care situations. Trusting relationships must be built not only with colleagues but also with the prisoners. Collaborative care is needed. A wide range of experience is needed especially in the medical/psychiatric field for prevention of suicide. Danahy (2017) stated, “…one thing is certain, a nurse must be seasoned and experienced, because one shift you will pull from your experience in many different clinical areas, from primary care, urgent care, chronic disease management, mental health, or others”.

Suicide rates in prisons would be reduced tremendously if the proper screening was done and prisons had the resources to provide escorts for those at risk for harm. By law, prisoners of the United States are to be treated with the same quality of care as the general population.

 Continuity of care is important when it comes to prisoner suicide prevention. Finn (2009) states, “…failure to hand over information about a prisoner’s serious condition properly can result in inadequate treatment being provided, an emergency situation arising, and the need for custodial staff to get involved escorting the prisoner to hospital”. Another limitation is having the resources to provide medical care especially in the form of psychiatric care and suicide prevention to this growing population in prison. As the number of prisoners goes up, so does the demand for health care. Biczo (2017) states, “Many prisoners arrive quite unwell and with multiple health concerns because they may not have had the money, resources or ability to pay for health care in the community”.

 One article recommended individualizing prisoners care instead of grouping care. (Perry et al. 2010) Once prisoners are screened and results show high risk for suicide, a plan needs to be put in place. Specific knowledge and skills are required. These prisoners come from different backgrounds, have many medical and mental illnesses, and may come from poverty. All the more reason to assess these risk factors and provide the necessary means for these prisoners to survive and not be successful with suicide.

It takes selflessness in order to treat prisoners and advocate for the same medical and mental resources deserved as the general population acquires. Suicide rates should not be increased in prisons due to lack of resources and care. Standard policies are put into place the moment prisoners enter the facility. The officers are responsible to ensuring safety, identity, reasons for incarceration, and identifying the needs of the offender based on protection needs. The medical team have the responsibility of assessing background for risks of suicide, addressing special needs such as physical or mental disability, identifying risks for self-harm, identifying health care needs, and evaluating documentation pertaining to medical or mental health needs of the prisoner.

 It is recommended that health assessments should be done within the first week of the prisoner arriving. Research showed that most suicides happen within the first week. Therefore, early and proper assessment is key. Prisoners that are high risk should be monitored closely and immediately be seen by psychiatry to have an individualized plan of care devised and implemented. Perry et al. (2010) states, “Such offenders may be placed under constant or intermittent observation, depending on the degree of risk, which will be reviewed and reassessed regularly”.  Most importantly, suicide prevention is a collaborative approach. Once the medical team identifies a prisoner at risk, all of the staff members should be made aware for the safety of the prisoner. All colleagues working together can reduce suicide in prisons.

Conclusion

 It is clear the epidemic of suicide in prisons is a public health issue that needs to be addressed. Although it may be a challenging task, services need to be put into place to collaborate care, educate prison staff, and advocate for the prisoners. With more awareness to the increased suicides in prisons, collaborative care, and increased staffing and resources, the number of suicide rates in prisons will decrease.

References

Biczo, R. (2017). A career dedicated to prison nursing. Kai Tiaki Nursing New Zealand, 23(8), 15. Retrieved from https://ezproxy.monmouth.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=125308770&site=ehost-live&scope=site

CDC. (2018, September 6) Suicide Risk and Prevention Factors. Retrieved by. https://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html

Danahy, L. (2017). Nursing Behind Bars: The Differences Between Jail and Prison. Journal of Legal Nurse Consulting, 28(1), 22–25. Retrieved from https://ezproxy.monmouth.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=122075778&site=ehost-live&scope=site

Finn E. (2009). Workshops to support prison nurses… (Kai Tiaki Nursing New Zealand, September, p20-22). Kai Tiaki Nursing New Zealand, 15(10), 3–4. Retrieved from https://ezproxy.monmouth.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=105252663&site=ehost-live&scope=site

Perry AE, Gilbody S, Perry, A. E., & Gilbody, S. (2009). Detecting and predicting self-harm behavior in prisoners: a prospective psychometric analysis of three instruments. Social Psychiatry & Psychiatric Epidemiology, 44(10), 853–861. https://doi.org/10.1007/s00127-009-0007-7

Perry J, Bennett C, & Lapworth T. (2010). Nursing in prisons: developing the specialty of offender health care. Nursing Standard, 24(39), 35–40. Retrieved from https://ezproxy.monmouth.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=105030285&site=ehost-live&scope=site

Smith E. (2010). Care versus custody: nursing in the Prison Service. Practice Nurse, 40(7), 33–35. Retrieved from https://ezproxy.monmouth.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=104949995&site=ehost-live&scope=site