Screening for suicide risk in prison. Seena Fazel and Achim Wolf, Department of Psychiatry, University of Oxford

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1 Screening for suicide risk in prison Seena Fazel and Achim Wolf, Department of Psychiatry, University of Oxford

2 Overview Epidemiology of suicide in prison Development of a screening tool External validation of the tool (results not published here) Management of suicide risk

3 Suicide in male prisoners Country Croatia Northern Ireland USA Scotland Czech Republic Ireland Belgium New Zealand Finland Spain Iceland England and Wales Denmark Germany Sweden Netherlands France Portugal Italy Norway RR (95% CI) 0.5 (0.0, 7.3) 0.5 (0.0, 23.8) 1.6 (1.4, 1.8) 1.7 (0.7, 4.1) 1.9 (1.0, 3.5) 2.0 (0.5, 8.2) 2.0 (1.1, 4.0) 3.4 (1.5, 8.1) 3.5 (1.2, 10.5) 3.7 (2.4, 5.6) 3.7 (0.1, 191.9) 3.9 (3.1, 5.0) 4.2 (1.4, 12.7) 4.2 (3.2, 5.6) 5.4 (2.4, 11.9) 5.6 (3.0, 10.3) 5.7 (4.7, 6.9) 6.5 (3.7, 11.2) 7.7 (5.8, 10.2) 10.2 (4.6, 22.7) Fazel, Lancet Psychiatry 2017,

4 Suicide in female prisoners Country RR (95% CI) USA New Zealand Czech Republic Sweden Spain England and Wales Netherlands Germany Belgium Norway Scotland Italy Denmark Portugal France Northern Ireland 3.7 (2.6, 5.4) 6.6 (0.1, 338.2) 7.2 (0.4, 116.3) 8.3 (0.2, 421.5) 8.7 (1.5, 50.3) 8.9 (2.2, 35.6) 10.6 (0.7, 169.4) 11.9 (4.0, 35.5) 12.2 (1.3, 117.9) 16.7 (0.3, 848.3) 17.4 (2.4, 124.7) 20.5 (4.1, 101.9) 30.3 (0.6, ) 33.6 (5.7, 196.7) 41.3 (20.6, 82.8) (16.3, )

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6 Fazel, J Clin Psychiatry 2008

7 Methods Two studies of near-lethal attempts MALES: 60 cases and 60 controls FEMALES: 60 cases and 60 controls Aged 18 years and over Within a month of the act

8 Methods information collected Before imprisonment Family history Early and previous life events Criminal history Psychiatric history In prison Psychiatric disorder Psychological and personality factors Social and environmental factors See papers by Rivlin and Marzano,

9 Suicide screen 11 items categorical Different items for men and women Simple, scalable model Draws on evidence from systematic review and research on nearlethal self harm in prison Based on discovery sample (near-lethal self harm studies), cut off of 5 had highest combination of sensitivity and specificity Tested in external validation (for outcome of any self harm within 6 months) in new project funded by NHS Innovations

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11 Methods Population and data sources DATA HMP Wormwood Scrubs HMP Woodhill Prisoners screened between November and May 2016 SCREENING 11-item screening tool based on systematic review FOLLOW UP Incident of self-harm within 6 months of screening All analyses prespecified

12 Methods Samples & Analyses SAMPLE 542 prisoners Median follow-up of 53 days (IQR ) OUTCOMES 17 individuals with incident of self-harm within 6 months VALIDATION Low / High 5+ Sensitivity/Specificity PPV/NPV AUC Brier score

13 Results (not published yet)

14 Conclusions This tool has utilty to screen out people Screening for suicide risk is possible but good methods matter Good methods prespecified protocol, testing individual factors, weighting them, externally validating on large enough sample Focus on high risk population e.g. those at the end of an ACCT

15 Population approaches Reducing access to means of self-harm and suicide Improving training for prison officers Prisons should become more research-friendly environments

16 Targeted approaches Repetitive self-harmers (especially women) Ensuring mental health input into high risk prisoners Improving detection and treatment of mental illness (especially depression, PTSD, comorbidity) Psychological treatments for those with histories of severe trauma and abuse Prison-specific treatment guidelines

17 Other stages of the pathway Before prison screening, sentencing policy After prison improving links with community mental health services

18 Prevention of suicidal behaviour in prisoners Pre-reception Reception Incarceration Release Ongoing monitoring of risk Pre-release screening Diversion of offenders with severe mental illness Screening for suicide risk First Night Centres Targeted strategies Treatment of psychiatric disorders and psychosocial problems Pharmacological and/or therapeutic interventions Population strategies Improvements to the regime and built environment Targeted strategies Referral to community or psychiatric inpatient services Population strategies Resettlement and after care Specialist support Information materials Peer support (e.g. Listeners) Reducing access to means of suicide Social support Anti-bullying interventions Staff training and support Evidence-based practice and learning from previous incidents Information flow and multi-agency working Marzano, Crisis 2016

19 Acknowledgements Achim Wolf, Tristan McGeorge, Charlotte Gould (screening study) Taanvi Ramesh (epidemiological study) Adrienne Rivlin, Lisa Marzano (near-lethal study) Keith Hawton (for all of

20 Some references Fazel. S, Ramesh T, Hawton K. Suicide in prisons: an international study of prevalence and contributory factors. Lancet Psychiatry (in press; December 2017 issue) Fazel S, Hayes A, Bartellas K, Trestman R. Mental health of prisoners: prevalence, adverse outcomes, and interventions. Lancet Psychiatry 2016; 3: Marzano L, Hawton K, Rivlin A, Smith EN, Piper M, Fazel S. Prevention of suicidal behaviour in prisons. Crisis 2016; 37: Rivlin A, Hawton K, Marzano L, Fazel S Psychosocial characteristics and social networks of suicidal prisoners: towards a model of suicidal behaviour in detention. PLoS ONE 2103; 8(7): e doi: /journal.pone Fazel S, Grann M, Kling B, Hawton K. Prison suicide in 12 countries: an ecological study of 861 suicides during Social Psychiatry and Psychiatric Epidemiology, 2011 Fazel S, Cartwright J, Nott-Norman A, Hawton K Suicide in prisoners: a systematic review of risk factors. Journal of Clinical Psychiatry, 69: 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. Lancet 2014; 383: doi: /s (13)