The largest ever study of self-harm in prisons: prevalence, risk, clustering and subsequent suicide

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New research published today in the Lancet shows that up to one in four women prisoners in England and Wales self-harm every year. The largest study of self-harm in prisons also reports that female prisoners are four times more likely to self-harm than male inmates.

Previous systematic reviews have investigated self-harm in prisons (Lohner, 2007 and Dixon-Gordon, 2012) and also the risk factors for suicide in prisoners (Fazel, 2008). The prevalence of self-harm in custody is estimated to be 5-24% (Dixon-Gordon, 2012).

Individual studies have explored the risk factors for suicide in European prisoners and associations have been reported with violent offences (Rabe, 2012), increased cell occupancy (Opitz-Welke, 2013) and self-harm (Humber, 2013). However, individual studies to date have included no more than 500 prisoners who self-harmed, so a more complete study is long overdue.

Methods

20-24% of female prisoners self-harmed each year

20-24% of female prisoners self-harmed each year

The research team (mostly from the University of Oxford) carried out a case-control study of all prisoners in England and Wales (from Jan 2004 to Dec 2009) to ascertain the prevalence of self-harm in this population, associated risk factors, clustering effects, and risk of subsequent suicide after self-harm.

They employed Bayesian techniques to look at how the people who self-harmed were clustered.

Those who self-harmed and subsequently died by suicide in prison were compared with other inmates who self-harmed.

Results

Rates of self-harm

  • 139,195 incidents of self-harm (involving 26,510 inmates) were recorded between 2004 and 2009
Women in prison

Women in prison are 4 times more likely to self-harm than men in prison

  • Despite reductions in suicide rates over the 6-year study period, incidents of self-harm in custody did not decrease, and ranged from about 20,000-25,000 each year
    • Women accounted for roughly half of these self-harm incidents, despite the fact that they only made up 5% of the prison population
  • Incidents of self-harm were 10 times higher in female prisoners compared with male prisoners
    • 20-24% of female prisoners self-harmed each year
    • 5-6% of male inmates self-harmed each year
  • Incidents of self-harm were 30 times higher in female prisoners compared with the general population of the UK (0.6%)

Repetition rates

  • Repetition rates were striking:
    • Female prisoners who self-harmed, on average went on to self-harm eight times each year
    • 102 women (and two male) inmates self-harmed more than 100 times each year

Risk factors for self-harm

  • Women who had committed a violent crime were at increased of self-harm

    Women who had committed a violent crime were at increased of self-harm

    The following factors increased the risk of self-harm in both sexes:

    • Younger age (<20 years)
    • Being white
    • Being unsentenced
    • Having a life sentence
  • In female prisoners, having committed a violent offence was also a risk factor for self-harm

Methods of self-harm

  • Common methods of self-harm were:
    • Cutting and scratching (most common in both sexes)
    • Poisoning
    • Overdose
    • Swallowing objects not intended for ingestion (among men and teenage boys)
    • Self-strangulation (in women and adolescent girls)

Suicide

The study found a strong link between self-harm and the risk of subsequent suicide

The study found a strong link between self-harm and the risk of subsequent suicide in male prisoners

  • Importantly, self-harm in prison was also found to be a strong risk factor for suicide in prison, particularly among male inmates:
    • The annual suicide rate among male prisoners who self-harmed was 334 per 100,000
    • That’s over four times that of the general male prison population (79 per 100,000)

Conclusions

Lead researcher Dr Seena Fazel said:

While self-harm is a substantial problem across the board, it is a particularly serious issue for women in prison who make up only 5% of the prison population but account for half of all self-harm incidents. Moreover, now we know the extent to which the risk of subsequent suicide in prisoners who self-harm is greater than the general prison population, suicide prevention initiatives should be changed to include a focus on prisoners who are self-harming, especially repeatedly.

This is a well conducted and very nicely reported study, which adds significantly to our knowledge in this area. It tells us that the burden of self-harm in the prison population is high and that this burden is largely borne by a subgroup of women who self-harm repeatedly. There is evidence of clustering of self-harm episodes, which suggests that the contagion effect may be contributing to higher rates.

These results show that prevention of suicide in prisons should focus on inmates who are self-harming and there should be a special focus on women who repeatedly self-harm.

If you need help

If you need help and support now and you live in the UK or the Republic of Ireland, please call the Samaritans on 116 123.

If you live elsewhere, we recommend finding a local Crisis Centre on the IASP website.

We also highly recommend that you visit the Connecting with People: Staying Safe resource.

Links

Hawton K, Linsell L, Adeniji T, Sariaslan A, Fazel S. Self-harm in prisons in England and Wales: an epidemiological study of prevalence, risk factors, clustering, and subsequent suicide. The Lancet, published online 16th Dec 2013. dx.doi.org/10.1016/S0140-6736(13)62118-2 [Abstract]

Dixon-Gordon K, Harrison N, Roesch R. Non-suicidal self-injury within offender populations: a systematic review. Int J Forensic Ment Health 2012; 11: 33–50. DOI:10.1080/ 14999013.2012.667513.

Fazel S, Cartwright J, Norman-Nott A, Hawton K. Suicide in prisoners: a systematic review of risk factors. J Clin Psychiatry 2008; 69: 1721–31. [PubMed abstract]

Humber N, Webb R, Piper M, Appleby L, Shaw J. A national case-control study of risk factors for suicide among prisoners in England and Wales. Soc Psychiatry Psychiatr Epidemiol 2013; 48: 1177–85. [PubMed abstract]

Lohner J, Konrad N. Risk factors for self-injurious behaviour in custody: problems of definition and prediction. Int J Prison Health 2007; 3: 135–61. DOI:10.1080/17449200701321654. [Abstract]

Opitz-Welke A, Bennefeld-Kersten K, Konrad N, Welke J. Prison suicides in Germany from 2000 to 2011. Int J Law Psychiatry 2013; published online July 11. DOI:10.1016/j.ijlp.2013.06.018. [PubMed abstract]

Rabe K. Prison structure, inmate mortality and suicide risk in Europe. Int J Law Psychiatry 2012; 35: 222–30. [PubMed abstract]

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