R E G U L A R

A R T I C L E

Psychiatric Disorders and Suicide in the
Nation’s Largest State Prison System
Jacques Baillargeon, PhD, Joseph V. Penn, MD, Christopher R. Thomas, MD,
Jeff R. Temple, PhD, Gwen Baillargeon, MS, and Owen J. Murray, DO
This study examined the relationship between the overall rate of psychiatric disorders and suicides in the nation’s
largest state prison population. Data from 234,031 Texas Department of Criminal Justice inmates who were
incarcerated for any duration between September 2006 and September 2007 were analyzed by Poisson regression,
to assess the independent associations of major psychiatric disorders and demographic characteristics with suicide.
Across the entire study cohort, 41 inmates (18 per 100,000) were reported to have committed suicide during the
12-month follow-up period; 21 of them had a diagnosis of a serious mental illness. An elevated risk of suicide was
observed among inmates with major depressive disorder (relative risk [RR] ϭ 5.1, 95% confidence interval [CI] ϭ
1.9 –13.8), bipolar disorder (RR ϭ 4.6, CI ϭ 1.3–15.9), and schizophrenia (RR ϭ 7.3, CI ϭ 1.7–15.9). The highest
overall risk was present in those inmates with a nonschizophrenic psychotic disorder (RR ϭ 13.8, CI ϭ 5.8 –32.9).
These findings highlight the importance of maintaining suicide prevention programs in correctional settings, with
particular emphasis on screening and monitoring of patients with severe psychiatric disorders.
J Am Acad Psychiatry Law 37:188 –93, 2009

The widespread deinstitutionalization of mentally ill
patients, coupled with the absence of appropriate
community-based mental health programs, has contributed to an increase in the proportion of persons
with severe mental illness who are incarcerated in
U.S. correctional systems.1,2 Half of the U.S. prison
population, representing over 1 million individuals,
has at least one mental health condition3 and between 15 and 24 percent have a serious mental illness, such as major depressive disorder, bipolar disorder, or schizophrenia.4,5 In view of the sizable
number of mentally ill inmates and the multitude of
psychological stressors they are subjected to in the
correctional setting,5–9 it is not surprising that suicide is one of the leading causes of death in U.S.
Dr. Baillargeon is Associate Professor, Department of Preventive Medicine and Community Health, and Director of Research, Division of
Epidemiology, Correctional Managed Care; Dr. Penn is Director of
Mental Health, Correctional Managed Care; Dr. Thomas is Professor,
Department of Psychiatry; Dr. Temple is Assistant Professor, Department of Obstetrics and Gynecology; Ms. Baillargeon is Biostatistician,
Correctional Managed Care; and Dr. Murray is Assistant Vice President, Correctional Managed Care, University of Texas Medical
Branch, Galveston, TX. The research described herein was coordinated in part by the Texas Department of Criminal Justice (TDCJ)
research agreement (515-MR07). The contents of this manuscript
reflect the views of the authors and not necessarily those of the TDCJ.
Address correspondence to Jacques Baillargeon, PhD, Department of
Preventive Medicine and Community Health, University of Texas
Medical Branch, 301 University Boulevard, Mail Route 1007,
Galveston TX 77555. E-mail: jbaillar@utmb.edu
188

prisons, with rates (18 – 40 per 100,000 inmates)10 –14 substantially exceeding those reported
for the general U.S. population (11 per 100,000).15
Although several studies have been undertaken to
examine the psychiatric profiles of inmates who have
committed suicide,12,16,17 there have been no investigations of the relationship between the overall rates
of psychiatric disorders and suicides in an entire
prison population.
Understanding the extent to which serious psychiatric disorders, such as schizophrenia, bipolar disorder, and major depressive disorder, underlie suicide
risk in prison inmates holds important relevance for
the fields of correctional and community psychiatry.
Consequently, we conducted a study to examine the
association of psychiatric disorders and suicide in the
prison population of the Texas Department of Criminal Justice (TDCJ), the largest state prison system in
the United States.18
Methods
Subjects and Study Design

This was a retrospective cohort study of 234,031
inmates incarcerated in the TDCJ prison system for
any duration between September 1, 2006, and September 1, 2007. The study was reviewed and ap-

The Journal of the American Academy of Psychiatry and the Law

Baillargeon, Penn, Thomas, et al.
Table 1 Prevalence of Psychiatric Disorders in TDCJ Inmates, September 1, 2006 to September 1, 2007

Entire cohort (n ϭ 234,031)
Sex
Male (n ϭ 210,501)
Female (n ϭ 23,530)
Race/ethnicity
Non-Hispanic Caucasian (n ϭ 79,106)
African American (n ϭ 85,294)
Hispanic Caucasian (n ϭ 69,001)
Age (years)
16 –29 (n ϭ 74,773)
30 – 49 (n ϭ 128,242)
Ն50 (n ϭ 31,013)

Major Depressive Disorder

Bipolar Disorder

Schizophrenia

Nonschizophrenic
Psychotic Disorder

4.2 (4.1– 4.3)

2.6 (2.5–2.7)

1.4 (1.4 –1.5)

2.4 (2.3–2.5)

3.5 (3.4 –3.6)
10.3 (9.9 –10.7)

2.3 (2.2–2.4)
5.7 (5.4 – 6.0)

1.5 (1.4 –1.5)
0.9 (0.7–1.0)

2.4 (2.3–2.5)
2.2 (2.0 –2.4)

6.3 (6.2– 6.5)
2.6 (2.5–2.7)
3.6 (3.4 –3.7)

5.4 (5.2–5.5)
1.1 (1.0 –1.2)
1.3 (1.2–1.4)

1.0 (0.9 –1.1)
0.8 (0.7– 0.9)
2.3 (2.2–2.4)

2.3 (2.2–2.4)
1.5 (1.4 –1.6)
3.1 (3.0 –3.2)

3.2 (3.1–3.4)
4.7 (4.6 – 4.8)
4.5 (4.2– 4.7)

2.3 (2.2–2.4)
3.0 (2.9 –3.1)
1.9 (1.8 –2.1)

0.7 (0.6 – 0.7)
1.6 (1.5–1.7)
2.3 (2.1–2.4)

1.6 (1.5–1.7)
2.8 (2.7–2.9)
2.7 (2.5–2.9)

Data are expressed as the percentage of the entire group (CI).

proved by the University of Texas Medical Branch
Institutional Review Board. All TDCJ inmates undergo medical and psychiatric examinations during
the intake process. The evaluation lasts approximately 60 minutes and consists of a detailed medical
history, a mental health screening, a comprehensive
physical examination, and laboratory tests that include a rapid plasma reagin and a Mantoux tuberculin skin test. Medical diagnoses are made by physicians, physician assistants, or nurse practitioners at
the time of each inmate’s initial evaluation and/or
subsequent medical encounters and are classified according to the International Classification of Diseases (ICD-10) coding system.
The study was designed to compare the prevalence
of suicide among inmates with any of four types of
major psychiatric illness: major depressive disorder,
bipolar disorder, schizophrenia, and nonschizophrenic psychotic disorders. Nonschizophrenic psychotic disorders included schizoaffective disorders,
delusional disorders, substance-induced psychosis,
and psychotic disorder not otherwise specified. The
mental health screening at the time of the intake
evaluation was conducted in a uniform fashion across
all prison sites by mental health nurses or mental
health paraprofessionals. This screening consists of a
standardized diagnostic interview and includes assessment of the following: displayed symptoms of
psychiatric disease, history of mental health treatment, current suicidal ideation, prior suicidal gestures, display of unusual behavior, affective distress,
and unusual criminal offense. The purpose of the
intake screening is to determine whether an offender
should be referred for a formal mental health evaluation. If a referral is made, the evaluation is con-

ducted by Master’s-level mental health professionals
and follows a standardized structure. A diagnosis of a
psychiatric disorder established during this evaluation is based on Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision
(DSM-IV-TR)19 guidelines and is recorded in the
inmate’s electronic medical record. All inmates who
require psychotropic medication or are currently taking such medication are subsequently referred to a
staff psychiatrist. All medical and demographic data
are maintained in a system-wide electronic medical
record that is routinely updated to ensure that the
information reflects the inmates’ current health status. All suicides were identified by referring to the
TDCJ mortality database (classified using ICD-10
codes) and subsequently confirmed in a separate database maintained by the TDCJ Division of Mental
Health.
Statistical Analysis

All statistical analyses were performed with the
GENMOD procedure in SAS version 8 (SAS Institute, Cary, NC). Poisson regression analysis was used
to examine differences in suicide prevalence across
the subgroups and to calculate adjusted relative risk
(RR) and corresponding 95 percent confidence interval (CI). Poisson regression analyses adjust for
skewed distributions and are thus favored when
studying relatively rare events. After exponentiation,
the regression coefficients were interpreted in terms
of relative rates.
Results
The prevalence of psychiatric disorders varied substantially according to demographic characteristics

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Psychiatric Disorders and Suicide in Prisoners

(Table 1). Major depressive disorder, present in 4.2
percent of the entire study population, was more
prevalent among females (10.3%) than males
(3.5%), among non-Hispanic Caucasians (6.3%)
than Hispanic Caucasians (2.6%) and African Americans (3.6%), and among inmates aged 30 to 49 years
(4.7%) and Ն50 years (4.5%) than those aged 16 to
29 years (3.2%). Bipolar disorder, present in 2.6 percent of the study population, was more prevalent
among females (5.7%) than males (2.3%), among
non-Hispanic Caucasians (5.4%) than Hispanic
Caucasians (1.1%) and African Americans (1.3%),
and, among inmates aged 30 to 49 years (3.0%) than
those aged 16 to 29 years (2.3%) and Ն50 years of
age (1.9%). Schizophrenia exhibited an overall prevalence of 1.4 percent in the Texas prison system and
was more prevalent among males (1.5%) than females (0.9%) and among African Americans (2.3%)
than Hispanic Caucasians (0.8%) or non-Hispanic
Caucasians (1.0%). The prevalence of schizophrenia
increased in a stepwise fashion according to age
(16 –29 years: 0.7%; 30 – 49 years: 1.6%; and Ն50
years: 2.3%). Nonschizophrenic psychotic disorders
were present in 2.4 percent of inmates and were more
prevalent among African Americans (3.1%) than
Hispanics (1.5%) or non-Hispanic Caucasians
(2.3%), and among inmates aged 30 to 49 years
(2.8%) and Ն50 years (2.7%) than those aged 16 to
29 years (1.6%).
Among the entire study cohort, 41 inmates (18
per 100,000) were reported to have committed suicide during the 12-month follow-up period. Suicide
prevalence is reported according to demographic
characteristics and presence or absence of the four
major psychiatric disease categories in Table 2. Overall, the prevalence of suicide was higher among males
(19 per 100,000) than females (0 per 100,000),
higher among non-Hispanic Caucasians (21 per
100,000) and Hispanic Caucasians (22 per 100,000)
than African Americans (10 per 100,000), and
higher among inmates aged 30 to 49 years (23 per
100,000) than inmates aged 18 to 29 years (12 per
100,000) or Ն50 years (10 per 100,000). As expected, the prevalence of suicide among inmates in
each of the four psychiatric disorder groups was substantially higher than that in the overall prison population (major depressive disorder: 61 per 100,000;
bipolar disorder: 49 per 100,000; schizophrenia: 91
per 100,000; nonschizophrenic psychotic disorders:
144 per 100,000).
190

Table 2 Prevalence of Suicide Among TDCJ Inmates, September 1,
2006 to September 31, 2007
n/100,000 (CI)
Entire cohort (n ϭ 234,031)
Sex
Male (n ϭ 210,501)
Female (n ϭ 23,530)
Race/ethnicity
Non-Hispanic Caucasian
(n ϭ 79,106)
African American
(n ϭ 85,294)
Hispanic Caucasian
(n ϭ 69,001)
Age (years)
18 –29 (n ϭ 74,773)
30 – 49 (n ϭ 128,242)
Ն50 (n ϭ 31,013)
Major depressive disorder
No (n) ϭ 224,167)
Yes (n ϭ 9,868)
Bipolar disorder
No (n ϭ 227,879)
Yes (n ϭ 6,156)
Schizophrenia
No (n ϭ 230,730)
Yes (n ϭ 3,305)
Nonschizophrenic psychotic
disorders
No (n ϭ 228,476)
Yes (n ϭ 5,559)

18 (13–24)

Adjusted RR (CI)
—

19 (14 –26)
0 (undefined)

(Undefined)
(Undefined)

21 (13–34)

1.0 (referent)

10 (6 –20)

0.4 (0.5– 0.9)

22 (13–36)

0.8 (0.4 –1.7)

12 (6 –23)
23 (16 –32)
10 (3–28)

1.0 (referent)
0.9 (0.5–1.8)
0.5 (0.1–1.7)

16 (11–22)
61 (28 –133)

1.0 (referent)
5.1 (1.9 –13.8)

17 (12–23)
49 (17–143)

1.0 (referent)
4.6 (1.3–15.9)

16 (12–23)
91 (31–267)

1.0 (referent)
7.3 (1.7–31.5)

14 (10 –20)
144 (73–284)

1.0 (referent)
13.8 (5.8 –32.9)

Poisson regression was used to calculate adjusted
odds ratios, to assess whether these associations persisted after simultaneous adjustment for all of the
study covariates. Of the demographic factors examined, several associations emerged. African Americans had a reduced risk of suicide (RR ϭ 0.4, CI ϭ
0.5– 0.9) in comparison to the reference group (nonHispanic Caucasians). None of the three age groups
exhibited a statistically significant association with
the risk of suicide, and sex was undefined. (No female inmates committed suicide during the study
period.) Inmates in each of the four psychiatric disorder subgroups exhibited elevated risks of suicide.
Although statistically significant elevated risk ratios
were observed among inmates with major depressive
disorder (RR ϭ 5.1, CI ϭ 1.9 –13.8), bipolar disorder (RR ϭ 4.6, CI ϭ 1.3–15.9), and schizophrenia
(RR ϭ 7.3, CI ϭ 1.7–31.5), the highest overall risk
of suicide was found among inmates with a nonschizophrenic psychotic disorder (RR ϭ 13.8, CI ϭ
5.8 –32.9).

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Baillargeon, Penn, Thomas, et al.

Discussion
The overall prevalence of suicide in our cohort of
Texas prisoners (18 per 100,000) was higher than that
reported for the general U.S. population (11 per
100,000),15 and was consistent with the low end of the
range reported in previous studies of prison populations
(18 – 40 per 100,000 inmates).10 –14 In terms of demographic factors, the prevalence of suicide in the TDCJ
population was reduced among African Americans and
elevated among males. Both of these findings are consistent with studies of the general U.S. population15,20
and other prison populations.16,17,21 The factors underlying racial and ethnic differences in suicide risk are
unknown.20 Some investigators have speculated that
the elevated rate of suicide among males, persistent
across multiple geographic locations and cultures, may
be related to males’ comparatively higher rates of aggressive behavior and alcoholism, both of which are independent risk factors for suicide.20,22
Our finding that inmates with diagnoses of each
of the four types of psychiatric disorders exhibited
a strikingly elevated risk of suicide is generally consistent with other studies that have reported elevated rates of mental health problems among inmates who commit suicide.12,16,17 However,
because these earlier studies focused exclusively on
numerator data (i.e., inmates who committed suicide), it was not possible for investigators to determine whether the rate of psychiatric disorders
among inmates who commit suicide exceeds the
rate among the entire inmate population. To the
best of our knowledge, this is the first study to
examine the association of psychiatric disorders
and completed suicide in an entire state prison
population.
In a study of 25 suicides that occurred in the Texas
prison system in 1996 to 1997, He et al.16 reported
that 44 percent of the suicide victims had a psychotic
disorder diagnosed while they were incarcerated, and
64 percent had a mood disorder; 24 percent had no
history of a psychiatric disorder. In our study of the
41 Texas inmates who committed suicide within a
one-year period, 22 percent had a psychotic disorder,
23 percent had a mood disorder, and 49 percent had
no major psychiatric disorder. Comparing the results
of these two studies is problematic, however, because
of differences in study design and methods. Our investigation, which focused on population-based
rates, was restricted to an analysis of four major cat-

egories of serious mental illness. In contrast, the previous study,16 which focused exclusively on the characteristics of the inmates who committed suicide,
included a description of a much broader range of
psychiatric disorders (e.g., anxiety, impulse control,
and personality disorders).
It is unclear why inmates with nonschizophrenic
psychotic disorders had a higher risk of suicide than
inmates in any of the other three subgroups, particularly those with mood disorders. General population-based studies have consistently reported that
persons with major depressive disorder and bipolar
disorders have a considerably higher risk of suicide
than do persons with other psychiatric disorders.22,23
It is possible that inmates classified as having nonschizophrenic psychotic disorders were misdiagnosed and possibly were suffering from depressive
disorder not otherwise specified or major depressive
disorder with psychotic features (i.e., psychotic depression), both of which are associated with an increased risk of suicide.24,25 It is also possible, albeit
unlikely, that the prison staff were more aware of the
increased suicide risk associated with depression and
schizophrenia and thus were more proactive in initiating suicide prevention measures for inmates with
these disorders.
It is noteworthy that 20 (49%) of the 41 inmates
who committed suicide did not have a diagnosis of any
of the four classes of severe psychiatric disorders under
study. There is a broad consensus within the psychiatric
community that suicide is a complication of psychiatric
illness. Three studies have reported that approximately
90 percent of suicide victims had a psychiatric disorder
at the time of the suicide.20,26,27 While the Texas prison
system provides rigorous mental health screening, it is
possible that some inmates who committed suicide had
a psychiatric disorder that was not diagnosed. It is important that future investigations examine whether this
finding persists in populations in other states.
A major objective of this study was to describe the
distribution of psychiatric disorders that contribute
to suicide among prison inmates. Our findings indicate that Texas prison inmates have rates of psychiatric disorders that are higher than those in the general U.S. population, but comparable to those in
other prison populations. The Epidemiologic Catchment Area study,28 conducted in the 1980s, estimated the prevalence of psychiatric disorders in the
general U.S. population. Compared with these estimates (major depressive disorder, 2.7%; bipolar dis-

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Psychiatric Disorders and Suicide in Prisoners

order, 0.7%; schizophrenia, 1.0%), most of the psychiatric disorders in our study cohort were
substantially elevated, even after adjustment for the
high proportion of males in the prison population.
The rates of schizophrenia (1.4%) and major depressive disorder (4.2%) observed in our cohort were
within the range of estimates reported in other incarcerated populations (schizophrenia, 0.8%–3.0%;
major depressive disorder, 3.5%–9.2%), but the rate
of bipolar disorder (2.6%) was somewhat higher than
that reported in previous prison studies
(0.7%–2.1%).4,5,7,29 However, it is difficult to draw
direct comparisons from study to study because previous studies may have evaluated populations with
different distributions of sex, race, and substance
abuse and may have employed different assessment
methods.
Several limitations of the present study should be
noted. First, as with all prison studies, comparisons
to population-based samples should be interpreted
cautiously, given that prison populations are not representative of the general population (e.g., disproportionate representation of males, younger individuals,
and racial/ethnic minorities). Second, because relatively less severe psychiatric disorders such as anxiety
disorders and Axis II disorders are not rigorously
evaluated in the TDCJ, either at the inmate’s initial
screening or during subsequent medical encounters,
we restricted our study to four broad categories of
severe psychiatric disorders. In addition, information
about a prisoner’s history of substance abuse is maintained in a separate, confidential TDCJ database that
was not available for analysis. Consequently, our
ability to assess the extent to which either less severe
psychiatric conditions or substance use disorders
contributed, either independently or comorbidly, to
suicides was limited. Third, our findings are highly
dependent on the reliability and validity of the
screening measures, the diagnoses of mental health
professionals, and the accuracy of data entry into the
electronic medical record. Although TDCJ has standardized mental health screening policies that are
universally applied during the intake process, as well
standardized and validated data entry procedures, it
is likely that some inmates were misclassified or misdiagnosed and that some data were entered incorrectly. Fourth, it is possible that the high rate of
incarceration in Texas30 relative to that in other
states, limits the generalizability of our findings to
other prison systems.
192

It should also be noted that a direct comparison of
our investigation’s findings with study results focusing on other populations, such as jails or noncorrectional settings, may be limited due to variability in
the underlying person-time structure of each population. The TDCJ, like all U.S. prison systems, is
characterized by a high degree of population turnover. Therefore, the most precise way to account for
such instability would be to measure the amount of
time each inmate was observed during the study period. Unfortunately, we were unable to calculate a
person-time denominator because the dates of diagnosis of mental illness, suicide, incarceration, and
release were unavailable for a substantial proportion
of our study population. In a comparison of the results of investigations that are unable to account for
the person-time contribution of each subject, the stability of each cohort must be considered. For example, relative to the present investigation, a study of
jail detainees may have a higher degree of population
movement, whereas a population-based study would
be likely to have considerably less.
Despite these limitations, this study is the first to
examine variation in the rate of suicide according to
psychiatric diagnosis within an entire state prison
population. Because this investigation was carried
out in the nation’s largest state prison system, these
findings have a high degree of statistical power. The
high prevalence of psychiatric disorders and suicide
holds important implications for both correctional
and community psychiatry. In particular, these results highlight the need to explore the development
of alternative facilities for inmates with severe psychiatric disorders. Ideally, such facilities would provide
a more appropriate clinical environment for inmates
suffering from severe mental illness, including expanded opportunities for treatment, and monitoring.14,31 Given that the number of inmates who
commit suicide represents an exceedingly small proportion of the overall prison population, it is difficult, particularly in the short term, to determine
whether such interventions would effectively reduce
the number of prison suicides. Nevertheless, because
most prison inmates are incarcerated for less than
three years,32 long-term effects of such programs
would extend far beyond prison walls and yield more
directly observable outcomes. Most notably, inmates
with psychiatric disorders who are appropriately
screened and managed during incarceration will be
more likely to seek treatment and adhere to clinical

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Baillargeon, Penn, Thomas, et al.

regimens after their release from prison. It is possible
that such enhanced correctional mental health programs would result in reduced criminal activity, substance abuse, and recidivism and would ultimately
increase the likelihood of the released inmates’ successful reintegration into their home communities.
Acknowledgments
The authors thank Leonard Pechacek for assistance with writing
and editing the article and DeeAnn Novakosky for conducting the
data management for the project.

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