In prisons, suicide is the leading cause of mortality (estimated at 3-5 times the general population). Mental health disorders are known to increase the risk.

Generally, suffering from a bipolar disorder increases the risk of attempted or completed suicide when compared to the general population. So it would be expected that prisoners with bipolar disorder would have similar elevated risks to other psychiatric diagnoses.

Methods

The authors (an expert team) conducted a systematic review of the literature, although this is an update on a paper previously published in 2008, so only includes observational studies published in the last 6 years. The search used a variety of keywords in Medline, with an additional grey literature and non-English publications search included, although details are lacking.

The authors used two main inclusion criteria:

1. Suicide cases where controls were available
2. Suicide where bipolar disorder could be extracted from the data.

Both meta-analyses and regression were applied to the dataset.  Five observational studies were included in the review.

Results

• A total sample of 237,654 prisoners, of which 6,285 had a bipolar disorder, was identified
• The researchers calculated the odd ratios for risk of suicide in different conditions:
  • Bipolar disorder: 2.4 (95% confidence interval: 1.6 – 3.7; I² = 0%)
  • Major depression: 4.36 (CI: 2.1 – 11.5)
  • Schizophrenia: 5.2 (CI: 2.5 – 10.8)
  • Any diagnosis 4.46 (CI: 2.3 – 8.65) in the included sample
  • So, the risk of suicide was lower in bipolar disorder than other disorders (e.g. schizophrenia or depression), although the risk estimates were not significantly lower in the meta-regression (p=0.11)

Conclusions

The reviewers concluded:

Although bipolar disorder is associated with suicide and non-fatal suicidal behavior in prisoners, further research is necessary to confirm any associations and mediating mechanisms.

This paper suggests that in prisons the risk of suicide for those with bipolar disorder did not seem to be as high as other disorders (psychosis or depression). However, the risk remains higher than the general prison population. There appeared to be no explanation of why this might occur, although a number of theories were suggested:

• Does the routine and structure of prison life make a relapse less likely?
• How does the availability of medicines in prisons or the abrupt discontinuation of medicines on admission influence outcomes, or does this affect other disorders more?
• Are bipolar disorders less prevalent in prisons?

Despite the reasonable sample size, there were only a few papers that contributed to this review, with 98.5% of the sample from one US study. Of potential unexplored interest were the differences in diagnostic criteria in the countries where the research was conducted (USA compared to the UK/Sweden). The focus of some of the papers might also have affected the reliability of the findings, with one study focusing on women only, another on a non-white adolescent population; these are known areas of diagnostic uncertainty.  Clearly more research is needed in this area.

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.

Link

Fazel S, Wolf A, Geddes JR. Suicide in prisoners with bipolar disorder and other psychiatric disorders: a systematic review. Bipolar Disord. 2013 Feb 26. doi: 10.1111/bdi.12053. [PubMed abstract]