Prevention of suicide behind bars: first Italian results

About 10 suicides per 10,000 inmates, and about 150 attempted suicides for 10,000 inmates occur every year In Italy (Frangione et al., 2016). The reduction of suicides in jails and prisons is an international priority (WHO, 2014) and a lot of countries have national standards and guidelines for suicide prevention in custodial settings (Daigle et al., 2007). Suicide is a complex phenomenon (Troiano et al., 2017) and is one of the most common causes of death in custody worldwide, with rates substantially higher than in the general population (Fazel et al., 2008). As previous studies demonstrated, several clinical, demographic, criminological factors are associated with suicide in prisoners, the most important being occupation of a single cell, recent suicidal ideation, a history of attempted suicide, and having a psychiatric diagnosis or history of alcohol use problems (Fazel et al., 2008).

Studies in Germany (Opitz-Welke et al., 2013), Italy (Marzano et al., 2016), and other countries in the European Union (Rabe, 2012) as well as Australia (Kariminia et al., 2007) and the US (Baillargeon et al., 2009) suggested that current suicide prevention strategies need to be improved in order to better meet the complex needs of this population (Marzano et al., 2016). Successful intervention programs, designed to identify individuals particularly at risk and to assist them through intervention, confirm that prisoners are a group especially at risk for suicide (Felthous, 2011; Gore, 1999). More than 50% of U.S. jail suicide victims were men, white, unmarried, under 28 years, charged with minor or drug-related offenses, and intoxicated with drugs or alcohol. Suicides significantly occurred in isolation. Psychiatric diagnosis, alcohol abuse, taking psychotropic medication, and suicidal ideation were also positively correlated (Felthous, 2011; Mercurio et al., 2016a; Mercurio et al., 2016b; Stefania Milione et al., 2016; Gambaro et al., 2014a; Gambaro et al., 2014b; Katia Guerrini et al., 2013; Roda et al., 2013; Mercurio et al., 2017). Psychosis, depression, and substance abuse are factors frequently found among inmates (Fazel et al., 2011), and that could increase the suicide risk. The commonest method of suicide is by hanging (Shaw et al., 2004).

In 2013 the National Bioethics Committee for Health in Prison published a report and established the absolute necessity to create specific protocols to prevent suicide risk. The Regional Council of Tuscany (Italy) affirmed the necessity of a synergic work between health personnel and operators of prisons to adopt this kind of measures: this led to the creation of a new biphasic protocol (Frangione et al., 2016). The aim of our study was, therefore, to show the preliminary results after the introduction of this protocol in the Penitentiary of Pistoia (Italy).

We conducted an ecological pilot study from April to December 2016 in the Penitentiary of Pistoia. The multidisciplinary staff, created according to the protocol (2014), had to identify the needs of new inmates in order to prepare specific measures to prevent the discomfort and self harm, as well as to manage and monitor the risk of suicide. The multidisciplinary team was composed by the director of the Penitentiary, the Director of the Local Health Unit (or his delegate), a psychiatrist, a psychologist, by educators and by the Head of the Penitentiary Police (or his delegate). If necessary, other professionals such as operators of the Service for Drug Addiction (SerT), nurses, social workers and cultural mediators were included in the staff. The multidisciplinary staff met weekly and prepared a special report containing information about the prisoners and the measures / actions that should be done or revoked. If necessary, the staff met “in emergency” with the operators available at that time.

For all the new prisoners were collected: socio-demographic information (age, citizenship, residence, job) and clinical information (the presence of psychiatric disorders, the use of substances and / or alcohol, the suicidal risk) and were ordered, if necessary, specific interventions for their best management: great surveillance, prescription of psychotropic medication, psychological support, psychiatric treatment.

The data were collected in a computerized medical record and analyzed in a totally anonymous way.

All new prisoners were screened for the suicide risk through the administration of the “Arboleda-Florez Check List” (Arboleda-Florez & Holley, 1989). In all cases of first detention the Great Surveillance was activated; in cases of drug abuse the Service for Drug Addiciton (SerT) was contacted.

The doctor on duty visited the prisoners and collected urine samples for the research of the most common substances of abuse in order to prescribe the most appropriate pharmacological treatment. The specialist established the frequency of medical visits and, if necessary, established additional therapeutic-rehabilitative interventions with the involvement of a psychologist.

Self-injurious behavior involving deliberate self-harm and suicide attempts by inmates while under custodial authority is a major problem for prisons and jails (prevalence, legal obligation for suicide prevention, and stress for officers) (Lohner & Konrad, 2006). So, in penal settings it is important to be able to quickly discriminate which kinds of self-destructive behaviors carry a larger suicide potential and which inmates present a greater suicide risk. The Suicide Checklist by Arboleda-Florez, was designed for use by the nursing staff of the Penitentiaries to provide a screening process which would be: (a) reliable; (b) valid (within the broad constraints and difficulties inherent in any attempt to predict dangerousness to self); (c) standardized; (d) quick and feasible to implement; and (e) a combination of clinical and past history variables (Arboleda-Florez & Holley, 1988).

In 2004 Shaw et al., conducted a study on prisoners judged to have died by suicide. But their findings had important limitations. Clinicians and other prison personnel completing questionnaires may have been biased by their awareness of outcome, and this may have affected, in particular, their reporting of estimates of risk at last contact. Suicide rates were not standardized by age and were not strictly comparable with the general population (Shaw et al., 2004).

In 2004 in Canada, was performed a similar study: however, the data collected for the research from volunteers, correctional staff, general inmate population, and professional staff were too low and the statistical analyses were not practical (Hall & Gabor, 2004).

In Italy, Preti et al., monitored the attempted suicides and other self-harming behaviours that occurred in Italian prisons from 1990 to 2002. They showed in their study that the suicide rates in Italian prisons were constantly about ten times higher than among the general population, but over time they did not increase significantly despite nearly a doubling in the absolute number of inmates. Moreover, the rate of completed suicides in overcrowded prisons was about ten times higher than in non-overcrowded ones. Foreigners (non-EU citizens mostly) were twice at risk to self-harm than residents. The authors highlighted that a better identification of the people suffering from mental disorders and a reduction in prison overcrowding are two key issues that need to be implemented to reduce the impact of suicide and self-harming behaviours among convicts (Preti & Cascio, 2006).

Several prison suicide prevention strategies in the US, UK, and Australia, have been developed partly in response to what is known about the epidemiology of suicide in prisoners and in-depth analyses of the prison and clinical records of inmates thought to have taken their own lives (Konrad et al., 2007) .

Our choice to use this tool could be debatable. However, a recent review showed that the effectiveness of suicide screening tools and checklists is not strong (O'Connor et al., 2013), with high false-positive and false-negative rates (Marzano et al., 2016). But their use is generally considered to be an important component of any comprehensive prison suicide prevention policy because it can help identify high-risk groups and may reduce suicide risk (Konrad et al., 2007).

The evaluation made at the Penitentiary of Pistoia identified 67 prisoners at risk (so it was disposed the great surveillance) and 3 at elevated risk (so it was disposed the greatest surveillance). A number of studies have found that prisoners making nearlethal attempts in prison are more likely than other prisoners to have a history of prior self-harm and suicide attempts (both in prison and outside), and to have received psychiatric hospital inpatient and outpatient treatment (Marzano et al., 2010; Rivlin et al., 2012). Other historical factors relate to adverse life events (Marzano et al., 2016; Levorato et al., 2017), including a family history of suicide (Marzano et al., 2016; Marzano et al., 2010).

Studying survivors of near-lethal suicide attempts (Rivlin et al., 2012), the mental health problems, both current and historical, were specifically identified as factors associated with, and potentially precipitating, near-lethal suicide attempts in prisoners. In previously published studies male prisoners were disproportionately affected by major depressive symptoms (Lohner & Konrad, 2006) psychosis, anxiety (including posttraumatic stress disorder [PTSD]) and drug misuse disorders. In both men and women inmates, comorbidity of disorders was common and significantly associated with near-lethal attempts (Marzano et al., 2010). There were high levels of self-reported aggression, impulsivity, hostility, childhood trauma, and hopelessness (the latter also being a significant risk factor in other research (23)), and lower levels of social support and self-esteem (Marzano et al., 2016).

This is the reason why, a psychological support was provided to 23 prisoners who didn’t need the prescription of psychotropic medication, but only a emotional support, and a symptomatic therapy for mild anxiety and insomnia was prescribed in 29 cases. 13 inmates needed a specific pharmacological treatment prescribed by the psychiatrist.

Preventing suicide is difficult, especially in a prison setting. While certain aspects of prison life should make suicide more easily preventable than in the community (e.g., by allowing greater monitoring of those at risk, and limiting access to means of suicide), others (e.g., bullying, social isolation, and lack of purposeful activity) may increase risk in an already high-risk population by virtue of their elevated levels of psychiatric morbidity, substance abuse, trauma, and social isolation. However, a previous research has shown that comprehensive multifactored suicide prevention programs and peer-focused suicide prevention initiatives can reduce the number of suicides and suicide attempts in prisons by tackling potentially modifiable environmental, clinical, and psychosocial factors (Barker et al., 2014).

The most important limits of our study are represented by the small sample size that could not totally represent the population of inmates and by the tool used to identify subjects at risk. However the use of the Arboleda Florez Checklist, although with its limits, let us identify suicide behaviors and prevent suicidal behaviors and self injuries among our sample.

In conclusion, our study showed that the protocol introduced in 2014 was able to manage in a good way the suicide risk in the Penitentiary of Santa Caterina, in fact no suicide occurred in the examined period of time. However, studies covering longer periods of time and with the application of the protocol to other realities could furnish more reliable results about its efficacy and we hope to continue monitoring the efficacy of the protocol with further ecological investigations. Although we sometimes lack the ability to accurately predict if and when an inmate will attempt or commit suicide, prison officials and correctional, health care, and mental health personnel are in the best position to identify, assess, and treat potentially suicidal behaviour. Even though not all inmate suicides are preventable, many are, and a systematic reduction of these deaths can occur if comprehensive suicide prevention programmes are implemented in correctional facilities throughout the world.