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Preventing Suicide in Prison:
A Collaborative Responsibility of
Administrative, Custodial, and
Clinical Staff
Anasseril E. Daniel, MD
Suicide is a sentinel event in prison, and preventive efforts reflect the adequacy and comprehensiveness of mental
health, psychiatric, custodial, and administrative services in a correctional system. This article reviews the literature
on suicide in prison during the past three decades and identifies the pattern and occurrence of risk factors. These
risk factors are classified as demographic, institutional, and clinical. Based on this review, the author outlines
specific administrative, custodial, and clinical steps and procedures that form the basis of a comprehensive
suicide-prevention program that can be implemented in small and large systems. The author recognizes the
limitations of staff availability, the budget constraints, and the ineffectiveness of efforts to prevent suicides that
occur without any warning. Ultimately, a prevention program is the collective responsibility of administrative,
custodial, and clinical staff.
J Am Acad Psychiatry Law 34:165–75, 2006

The study of suicide in prisons has increased dramatically since the 1980s. Factors contributing to this
increase include the rising frequency of suicide in
prisons; class action lawsuits related to suicide; deinstitutionalization of the mentally ill; and lack of community-based programs for mentally ill criminals.1– 6
Legal reforms, prison diversionary programs, and regional differences in suicide rates7 have also influenced the research.
Suicide Rate: Problems and Controversies
Suicide is the third leading cause of death in U.S.
prisons and the second in jails.1 The suicide rate in
prisons ranged from 18 to 40 per 100,000 during the
past three decades.8 –11 Populous urban jails such as
those in New York,12 Atlanta,13 and Miami14 have
higher suicide rates than do non-urban jails. A study
Dr. Daniel is Director of Psychiatric Services for the Missouri Department of Corrections by contract, Jefferson City, MO, and Clinical
Professor of Psychiatry, University of Missouri, Columbia, MO. Address correspondence to: Anasseril E. Daniel, MD, Daniel Correctional Psychiatric Services, 33 E. Broadway, Suite 115, Columbia, MO
65203.

of six Midwestern jails from 1966 to 1971 showed a
rate of 58 per 100,000 inmates per year.15 The jail
suicide rate is nine times that of the general population, with a range of 107 to 187.5 per 100,000.16
The rate of 10 to 17 per 100,000 in federal prisons is
slightly lower than the rates in state prisons.3 The
highest rate in a prison is noted among death row
inmates with 146.5 per 100,000.17
The suicide rate in prison is usually compared with
the commonly accepted national general population
rate of 12 per 100,000; however, the comparison is
inaccurate because of the disparity in the distribution
of men and women in prison. When this general
population rate of 12 per 100,000 is broken down by
gender, the rate for men is 18 and 6 for women.
Therefore, a prison rate of 18 to 20 is comparable
with the rate in males in the general population.3
Underreporting of suicide seems to be a problem.
If a suicide victim is found and rushed to the hospital,
only to die there, records may not show that the
victim committed suicide in prison. Also, if the facility chooses to report some deaths as suicides— but

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not others, for fear of litigation—suicide rates could
be inaccurate.5 Prison staff are more likely to report
white inmate suicide, accounting for possible underrepresentation of suicides of black inmates.18 Risk
factors such as drug abuse, unemployment, interpersonal conflicts, and mental illness are common to
both the general public and prison. How different
would the prison rate be if these factors were
controlled?17
The suicide rate is calculated on the basis of average daily population (ADP) in jails and prisons,
which does not factor in the admissions, leading to
miscalculation of the actual rate.1 Furthermore, the
immediate post-release suicides noted among inmates who serve long sentences for violent crimes
(such as homicide) and those who are heavy drug
users before incarceration are generally left
uncounted.19,20
Suicide Attempters Versus
Suicide Completers
Although a suicide attempt in prison is generally
categorized as a type of non-lethal self-injury similar
to self-mutilation, it is fundamentally different.21 All
self-harming acts may be seen on a continuum of
severity, not as distinct problems, since the motivation for self-injurious behavior is the same for both
attempters and completers, and many attempt suicide before they are successful.22 Some inmates attempt suicide with no intention of ever completing
the act, while others persist, using more lethal methods until they are successful. According to Schaller et
al.23 and Green et al.,24 both suicide attempters and
completers are generally younger than 25, have previously attempted suicide, have a history of psychiatric treatment, and are likely to be addicted to opiates
or other substances.23,24 Most suicide attempters
slash their wrists, as opposed to hanging or overdosing on medication, which are common methods used
by completers.25
In general, prior suicide attempts increase the risk
of suicide. From 45 to 63 percent of inmates who
commit suicide have attempted it before.26 –30 Of
those with a history of prior attempts who complete
suicide, two-thirds used lethal methods (i.e., hanging, burning, swallowing a razor blade, strangulation, throat cutting, and drug overdose) during their
prior attempts. Although Durand et al.31 found a
much lower rate of previous attempts (33 percent)
among those who commit suicide, based on the lit166

erature, at least half of the individuals attempt suicide
before completing the act.
Risk Factors

Because suicide research is retrospective, a definitive cause-and-effect relationship between risk factors and suicidal death cannot be established. Usually, what appears to be causative is reported as
associated factors.
Demographic Factors

Generally, more than half of all inmates who commit suicide in prison are between 25 and 34 years of
age.27–29,32 They are often single with no job or family support. Very young prisoners (below age 21) are
especially at risk.22 In fact, the suicide rate among
juvenile offenders placed in adult detention facilities
is almost eight times greater than the rate in juveniles
housed in juvenile detention facilities.33 Although
blacks are overrepresented in prisons, they are underrepresented among suicide completers as well as attempters.11,27,29 Toch34 found that blacks were also
underrepresented in the self-mutilation group,
whereas whites and Hispanics were overrepresented.
Some researchers suggest that the differences among
black, white, and Hispanic suicide rates can be explained by sociocultural factors such as better preparation for prison life by blacks as opposed to that of
whites and Hispanics.35 Haycock5 disputes this theory, indicating that the factors that lead to inmate
suicide are complex and personal and do not simply
depend on sociocultural background.
Upper socioeconomic status and high degree of
social and family integration before incarceration increase the risk of suicide in prison.36 Suicides in
prison fall into two groups: egoistic and fatalistic
(Durkheim typology). Egoistic suicide occurs when
an individual has a low level of integration into society, while fatalistic suicide occurs in a highly regulated, social environment where the individual sees
no possible way to improve his or her life. Accordingly, most suicides in prison are egoistic, whereas
those by death row inmates may be both egoistic and
fatalistic, because they are socially isolated and
heavily regulated, and at the same time, weakly
integrated.17
Clinical Factors

Psychiatric Disorders: Eight to 15 percent of prisoners have a serious and persistent mental illness,12,18 and the proportion is even higher in max-

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Daniel

imum-security prisons.1 Many prisoners have
multiple psychiatric disorders with co-morbid substance abuse.37,38 Using the NIMH Diagnostic Interview Schedule (DIS) III–R, Teplin et al.39 studied
a randomly selected stratified sample of 1272 female arrestees in Cook County and found that 80
percent had one or more lifetime psychiatric disorders. Using similar methodology, Daniel et al.40
found that 90 percent of consecutively admitted
female prisoners had an Axis I disorder and 67
percent had more than one disorder. As far as the
prevalence of psychiatric disorders among suicidal
inmates is concerned, studies show a wide range
from 33 to 95 percent.3,22,28 –30,41,42
Although mood,3,43 psychotic,29 and personality
disorders dominate diagnoses30 among mentally ill
prisoners, depressive disorders are more often linked
to suicide than is any other psychiatric illness.3,43
The onset of the mental disorder may be either before
or during incarceration with most having a preincarceration diagnosis with onset before age 18. Other
commonly found characteristics of suicidal inmates
include a family history of mental illness, substance
abuse, incarceration, suicide, psychiatric care, and
medication treatment, though such factors are not
uncommon among other inmates or the mentally ill
in the community.
Depression, Hopelessness, and Anxiety: Depression and hopelessness seem to be the two most common psychological states at the time of a suicidal
act.44 Although depression and suicide are co-occurring phenomena, hopelessness and suicide have a
stronger correlation than do depression and suicide.
Ivanoff and Jang45 developed a multivariate model to
predict suicide by inmates studying the relationship
between depression, hopelessness, suicidality, social
desirability and other factors. Although age and visitors have no significant effect on suicidality, juvenile
delinquency and violent crime directly increase it, as
does higher education and income levels. Negative
life events and sentence length indirectly impact suicidality by affecting depression. Both violent crime
and previous income level affect hopelessness. Inmates with higher social desirability had lower levels
of depression; thus, they had lower levels of
suicidality.
Anxiety experienced by inmates at various times of
incarceration, particularly on entry into the prison or
just before release, may act as a risk factor. Anxiety

symptoms mixed with agitation, depression, and
hopelessness increase the risk further.
Personality Traits and Disorders: Although antisocial personality disorder is “endemic to correctional settings,”46 the relationship between antisocial
personality disorder and suicide risk seems to be
somewhat complex. Verona et al.47 used the Psychopathy Checklist-Revised (PCL-R) to study 313
male inmates in a federal institution in Florida and
found a positive correlation between antisocial deviance (Factor 2) and suicidal tendencies in male inmates. Borderline Personality Disorder (BPD) increases the risk for suicide attempts and completions
due to poor interpersonal skills, impulsivity, and affective instability. Impulsive suicide attempts under
intoxication are more common among arrestees48
and therefore intoxication is a significant factor in
jails. In prison, impulsivity can be a factor in young
prisoners with personality and depressive disorders
and those who are victims of cluster suicides. Although a direct link between impulsivity and suicide
cannot be established, only a few prepare to attempt
suicide during the days preceding the act.25
Psychosocial Stressors: Institutional stressors such
as undesired unit placement, work assignment, disciplinary confinement, interpersonal conflicts, legal
processes, parole setbacks, and chronic medical conditions may act as precipitators of suicidal behavior.
Nearly 50 percent of those who commit suicide experience acute stressors at the time of the suicide,
whereas most suffer from chronic stressors.3,27 Institutional conflict is seen as the most common acute
stressor, whereas interpersonal conflict and chronic
medical conditions are the most common chronic
stressors.
The severity and type of crime seem to act as risk
factors in certain prisoners, though not universally.
Perhaps the guilt, shame, and stigma associated with
the offenses may be the determining factor. Marital
separation,30 divorce,49 or death of a loved one may
precipitate serious suicide attempts. A prisoner is not
usually able to participate in rituals associated with
the funeral of a loved one. Mourning is difficult to
accomplish50 and expression of grief is likely to be
viewed by others as a sign of weakness and
vulnerability.
Loss or absence of one or both parents for more
than 12 months before the age of 15 is correlated
with attempted suicide.51 Other risk factors include
losing contact with one’s children,27 inability to

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communicate due to language barriers,25,28 or learning disability.22 Mental retardation per se is not correlated with increased risk.
Substance Abuse as a Risk Factor: Being under the
influence of an illegal drug heightens the risk of selfharm.52 Inmates who suffer from Antisocial Personality Disorder, Schizophrenia, or Bipolar Disorder53
are more likely to abuse substances. The risk of suicide is highest among opiate dependents who also
have psychiatric disorders.54 Opiate users are 10
times more likely to die from suicide than are nonusers of the same age and gender.55 Weitzel and
Blount56 did not find any significant difference between the type of drug and risk of suicide, and nonusers were not significantly different from heavy users in the number of suicidal thoughts or attempts.
However, when drug abusers are incarcerated, the
ensuing forced abstinence and not having developed
coping skills due to years of dependency may precipitate suicidal thinking.25
Medical Condition and Its Relation to Suicide:
Salive et al.11 found an increased risk of suicide
among inmates with AIDS due to potential hopelessness, victimization, and threats by other inmates. No
studies have been found that link hepatitis C and
suicide, although interferon treatment is associated
with depression and possible suicidal behavior. If a
medical condition is chronic and causes intractable
pain, it can be a risk factor. Prisoners with epilepsy
are more likely than their non-epileptic peers to have
depression and suicidal ideation.57
Institutional Factors

Stages and Setting of Confinement: In jails, the
high-risk period is the first 24 to 48 hours. While
there is no such period in prison, the first 30 days at
reception centers are generally deemed to be critical
for those with a history of suicide attempts.29,48 Interfacility transfer of mentally disordered offenders
seems to raise suicide risk, which may be related to
the inmate’s adjustment difficulties at the new site.
Findings regarding length of incarceration and suicide risk are contradictory—some indicating a positive correlation,36,58 whereas others indicate none11
after 180 days of incarceration.
With regard to setting, most inmate suicides occur
in maximum-security facilities, in single cells11,28 or
in isolation. Special treatment centers for addiction
and sexually dangerous persons have a lower rate
than in the general community, whereas it is much
168

greater at inpatient hospitals for the “criminally insane”18 and in supermaximum-security facilities.17
Time of the Day, Month, and Season: Contrary to
general belief, suicides are not more likely to occur on
weekends, religious holidays, or during holiday seasons.42 However, the time of day seems to have some
significance, in that most suicides occur between
7:00 p.m. and 7:00 a.m.,27,31 possibly due to lower
staff supervision during the night.25 For unknown
reasons, the most common time of year to commit
suicide is between July and September.22,30,59
Prison Condition and Experience: Almost all departments of corrections in the United States have
recorded an increase of prisoners in recent years, possibly due to the dramatic influx of drug offenders.52
An overcrowded and short-staffed prison is likely to
increase suicide risk due to lack of access to medical
care, increase in assaults, lower staff-offender ratio,
lack of opportunity for activity, lack of food and
clothing, unwanted interactions, and rapidly changing social structures within the prison. As prisons
become more crowded, the number of inmates who
reside in single cells may decrease, a fact often cited as
preventive, since the chance of committing suicide in
multiple-occupant cells is limited.
Understandably, the transition from the outside
world leads to loss of individual autonomy. As a result, inmates often engage in conflict with the prison
staff as well as fellow inmates. Inmates of all ages with
mental disorders and youthful inmates are at greater
risk of abuse and victimization by other inmates.
Threats and attacks may make a younger inmate act
impulsively to take his or her life. A study of sexual
coercion in prison noted that approximately 20 percent of inmates are reportedly pressured or forced
into sexual contact with another person. One third of
the male targets (36 percent of those subjected to
sexual coercion) experience thoughts of suicide.60
Method of Suicide
Over 80 percent of suicides are completed by
hanging. The feet of the hanging victim need not be
off the floor for the attempt to end in fatality. Only 2
kg of pressure has to be applied to the neck to cut off
blood flow to the brain. Hanging can be accomplished while kneeling, sitting, standing, or lying
down. The fastening anchor can be close to the floor,
such as a window bar, window crank, air duct vent,
handrail on the wall, bedrail, cell bar, or lock box, or
higher points such as light fixtures or shower heads.

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Daniel

Death occurs in five to seven minutes, but permanent brain damage takes as little as three minutes.
Bed sheets, shoelaces, jump ropes, belts, socks, elastic
waist bands, and wound bandages can all be used as a
ligature. Asphyxia is the most common cause of
death in hanging.30 Although hanging does not always communicate a serious intent to die, the effectiveness of the method yields a high mortality rate.
Overdose of psychotropic drugs, especially tricyclic antidepressants, is the next most common
method, followed by antihypertensives and over-thecounter pain medications.28,29 Self-immolation is
uncommon, yet it has a mortality rate of 33 percent
in the groups studied. Victims tend to be female and
to have severe psychopathology.61 Other uncommon
methods include hunger strike, swallowing sharp objects, and jumping from a height. Occasionally, homicidal hanging may masquerade as suicide.62
In summary, studies confirm that the most significant risk factors of suicide among prisoners consist
of mental illness—particularly depressive disorder,
psychological states of depression and hopelessness,
prior suicide attempts, a preincarceration history of
psychiatric disorder and substance abuse, and a recent psychosocial stressor acting as a precipitant.
These findings are consistent with those reported recently by Kovasznay et al.63 Other risk factors include being a young white male, placement in a maximum security prison, single-cell living or isolation,
and interfacility transfer. These factors and the methods used should be taken into account in planning
suicide-prevention strategies.
Suicide-Prevention Strategies
Suicide prevention must be the collaborative responsibility of administrative, custodial, and clinical
staff and should be a top administrative and clinical
priority in every prison. A comprehensive mental
health and psychiatric service delivery system64,65
supported by the administration forms the foundation of preventive efforts. A well-designed suicideprevention program incorporates all aspects of identification, assessment, evaluation, treatment,
preventive intervention, and training of all medical,
mental health, and correctional staff.64,65 Comprehensive mental health services in prisons are slowly
being established in departments of corrections,
largely due to successful class-action suits, legislative
actions, and progressive-thinking administrators and
clinicians. Fully trained mental health and correc-

tional staff in prisons are rare because of lack of qualified professional pools, budgetary constraints, National Guard deployment, and the nature of
correctional work. Creation of a specific division of
administration dedicated to offender rehabilitation
that oversees and coordinates medical, mental health,
vocational, and educational services is important to
ensure an adequate staff-patient ratio, a multidisciplinary treatment team approach, timely treatment
planning, staff training, and overall rehabilitative
services.
Administrative Steps
Policy Development and Implementation

Legally sound and defensible policies and procedures that are rigorously and systematically implemented form the basis of appropriate administrative
and clinical practice. Key policies ensuring good
clinical care and suicide prevention include those
covering (1) suicide assessment, observation, and intervention; (2) psychotropic medication use; (3) involuntary/forced medication and involuntary medical treatment; and (4) inpatient hospitalization of the
mentally ill. The policies must be reviewed with all
medical, mental health, and correctional staff.
Implementation of Suicide Risk Rating Program

If properly implemented, a suicide risk rating program can capture high-risk individuals. A commonly
used risk rating instrument is the Multi-Dimensional
Risk Assessment.66 The goal of this program is to
identify suicidal inmates (on their arrival) and to
monitor them as they move through the system. Inmates are given a Suicide Risk Rating score of 1, 2, or
3, indicating the severity of suicide potential. Visible
placement of the SR score in the medical record and
registering the high-risk inmates in chronic care clinics enable systematic tracking of them. An inmate is
registered in a clinic at a specific facility, and the
generated database follows him/her, even when the
inmate is transferred to another facility, making data
available for future mental health and psychiatric
contacts. Many prisons have established a clinical/
administrative-level committee consisting of medical
director, psychiatrist, health services administrator,
and assistant superintendent of administration, to
discuss high-risk inmates.

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Procedures for Administration of
Psychotropic Medication

Policies and procedures covering the length and
quantity of prescriptions, medication renewal, and
nursing practices must address the type and mode of
administration to avoid opportunities for hoarding
of medications with lethal potential. Medications
with non-lethal potential should be preferentially
prescribed, reducing the frequency of overdose with
such medications. The watch-take policy for administration of psychotropic medication instituted in
many correctional systems is an effort to cut back on
the instances of “cheeking” or hoarding. However,
the watch-take practice does not eliminate fatal overdoses of somatic medications—an occurrence that is
not uncommon in prisons. As an alternative, crushing of medications or administration in liquid form
has been implemented. Although crushing medications seems to be a good addition to any psychotropic
medication practice, in reality, this method is full of
pitfalls. For example, some medications are in capsule or time-release form and cannot be crushed before ingestion. Furthermore, there is no guarantee
that every granule of a crushed pill makes it into the
inmate’s mouth, which may alter the dosages.
A structured protocol for dealing with medication
of noncompliant offenders and those who consistently refuse medications is a significant step in preventing suicide. Furthermore, if a suicidal inmate is
incompetent to make a rational decision regarding
medication and if he or she is gravely disabled, involuntary administration of medication may be
implemented.
Administrative Management of Institutions

Four concerns relevant to suicide prevention deal
directly with management of individual institutions
and the correctional system as a whole. These include
(1) segregation monitoring; (2) offender assignment;
(3) out count and interfacility movement; and (4)
cell design.
As a suicide-prevention measure, suicidal inmates
should not be placed in segregation units, because
such placement does not promote improved mental
health. The National Commission of Correctional
Health Care Prison Standards stipulate that suicidal
inmates should not be housed or left alone unless
constant supervision can be maintained.64 If it is necessary to house an inmate alone, provision should be
made for uninterrupted supervision and human con170

tact. In addition, regular rounds in the segregation
area to screen inmates for suicidal intent and mental
illness should be a standard procedure.
Offenders must also be given housing assignments
that are appropriate for the level of threat they present to
themselves and/or others. Careful placement of
younger inmates in appropriate facilities where their
security and mental health needs can be met has the
potential to lower the suicide rate in this group.
Inmates on “out count” for a court hearing may be
temporarily placed in a county jail. The potentially
suicidal inmate may find in the transfer a golden
opportunity for self-harm, because of the laxity of
supervision in jails. Vulnerability to suicide increases
if the court hearing results in an unexpected outcome
such as an additional long sentence. As a preventive
measure, a copy of relevant records must always accompany the inmate with a history of suicidal ideation or attempt when placed on out count. Suicidal
inmates should be treated in county jails just as they
would be treated in prison (i.e., increased monitoring, evaluation by mental health staff, no access to
harmful objects, and a watch-take medication
policy).
A formal procedure to seek input or clearance
from mental health staff before a mentally ill prisoner
is transferred to another facility must be established.
If the system does not have an electronic medical
record system, the inmate’s mental health records
should be transferred promptly to the receiving facility. The transferred prisoner must be seen by a mental health professional within 24 hours and by a psychiatrist within 72 hours and, thereafter, on a regular
basis. Finally, as a precautionary step, no prisoner on
suicide watch should be transferred.
Designing a protrusion-free cell or a cell windowframe in a way that does not permit fastening a ligature band would help decrease suicides, although in
practice such a design would be difficult to achieve.
However, with a little planning the number of obvious anchors can be drastically reduced. Air vents can
be designed with holes too small to permit threading
of a sheet. Use of break-away shower heads and raised
concrete slabs that hold mattresses off the floor are
helpful. Many efforts to create suicide-proof cells
have proven inadequate for the clever inmate seeking
a way to kill himself. While a perfectly designed suicide-proof cell is unlikely, it is important that the
entire interior of each cell be visible from the walkway. Frequent monitoring of inmates in their cells is

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Daniel

more important than any cell design. Nothing can
replace human supervision as a deterrent to suicide.

studied, and anecdotal information questions the
usefulness of these programs.

Training and Education

Handling Inmate Communication of Intent

Training correctional officers and mental health
and medical staff to deal with suicidal inmates is
crucial. If prison staff are given adequate training in
recognizing, dealing with, and understanding the
motivations behind suicidal behavior, they are less
likely to feel that suicidal inmates are being manipulative. Training topics must include (1) identification of high-risk offenders; (2) how to identify signs
and symptoms of mental illness; and (3) how to handle communication of intent. Training must occur
regularly. Any staff can be trained to spot certain
“warning signs” of suicide. Correctional officers and
clinicians may observe slightly different warning
signs, simply because these two groups deal with the
inmate in different situations. With regard to clinicians, the training must also include steps to complete the Multidimensional Risk Assessment Form,
modalities of intervention, and referral to appropriate professionals including the psychiatrist. It is helpful for correctional officers and mental health professionals to be familiar with the general profile of a
suicidal inmate, although there are exceptions to every situation and this “profile” should be used with
discretion. New York State has developed a model
training program for identifying suicidal inmates67
that uses a video, handbook, and tests to teach and
evaluate the correctional officers. Any successful
training program must emphasize good communication between correctional officers and mental health
staff. Individuals from mental health staff and ranking administrative personnel should participate in
the training. Also, having a corrections officer serve
as a trainer makes other correctional officers feel that
the training is worthwhile and applicable to their
jobs.

Approximately 60 percent of inmates may communicate their intent to kill themselves either verbally or nonverbally. Verbal communication is either
spoken or written but nonverbal communication can
be much more ambiguous, such as giving away important possessions, refusing medication or asking
for more medication, and cutting off contact with
family members. An inmate may communicate his or
her intent to a corrections officer, mental health staff,
a friend, family member, judge, or cell-mate. It is
often difficult to learn of communications to outsiders, because the recipient may not report it. If an
inmate commits suicide after such a communication,
the friend or family member usually denies knowing
that the inmate was serious about committing suicide. It is not easy to convince other inmates to report
communications; however, a confidential system for
reporting, preferably in written form, must be established so that inmates do not feel they are putting
themselves in danger when making a report. In view
of the fact that correctional officers and clinicians
have a higher degree of responsibility than do other
recipients, they should make a report of the communication and forward it to a mental health professional, who in turn should confer with prison administration. The report should be added to the inmate’s
file and appropriate steps taken to ensure that the
inmate is not at risk of self-harm.

Peer Groups and Inmate Training

Correctional facilities have attempted to create
peer groups for populations who are often targeted
for victimization, such as child sex offenders. When
inmates are surrounded by those who have had similar experiences, they may be less likely to feel suicidal. Having a trained inmate to work with high-risk
inmates may drastically reduce the likelihood of suicide.29 The effectiveness of peer support groups and
inmate training programs have not been properly

Clinical Procedures
The primary focus up to this point has been administrative and custody staff responsibility. Suicide
prevention must be a clinical priority as well.
Mandatory screening of all inmates for suicidal
intentions has been instituted in almost all reception
centers. Metzner et al.2 proposed three different
types of mental health screenings and evaluations
that include initial screening at reception, mental
health and medical evaluation within 7 days, and
psychiatric evaluation on referral by a mental health
professional. The screening ensures triaging of inmates for proper treatment and placement. Screening, a crucial step in the identification of suicidal
inmates, involves face-to-face contact by intake staff.
The screening tool must be a comprehensive and
standardized measure that is valid and reliable. The

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screening process must capture a complete history of
any suicidal behavior, including all prior suicide attempts and/or periods of suicidal ideation, even if the
inmate is not suicidal at the time of intake. After screening, if an inmate evidences suicidal ideation or behavior,
a Multidimensional Suicide Risk Assessment form,
modified for application in corrections, is completed to
obtain a Suicide Rating (SR) score. Suicide risk assessment is a continual process performed by all mental
health and psychiatric staff and should be performed at
every clinical encounter. Such an assessment will allow
the psychiatrist and other clinicians to take specific intervention steps, which may include placing the patient
on suicide watch, modifying medications, and arranging to have one-to-one sessions, and will also alert correctional officers to keep an eye on the prisoner.
Those who are identified to be at some risk of
suicide, as noted by an SR score, require intensive
clinical monitoring. Since many inmates who commit suicide have contact with mental health staff before the suicide, warning signs and behavioral
changes suggestive of self-harm must translate into
increased watchfulness, careful monitoring, and intervention. Regular contacts by the clinician and systematic counseling can help the inmate with problems that may contribute to suicidal thoughts and/or
attempts. Furthermore, the clinician is able to recognize normal patterns of behavior for that inmate and
will be more closely attuned to any future changes
than other staff members who interact with the inmate only sporadically.
Based on suicide risk assessment, a prisoner may
be placed on suicide watch—a heightened state of
observation where he/she is subjected to frequent
checks by correctional staff. Documentation must
include the reason for the suicide watch, details of
what the prisoner is allowed to have in his or her cell
during suicide watch, frequency of cell checks (for
instance, every 15 minutes), and a procedure for termination of the watch. Records become critical from
a forensic point of view in the event of suicide and
possible litigation. Though video monitoring is an
excellent tool for ensuring uninterrupted observation, it may not be as effective as the direct personal
observation by staff (author’s observation).
Treatment of Psychiatric Disorders and
Substance Abuse

Prisoners with psychiatric problems must be
placed in a proper treatment program.12 Diagnostic
172

specificity and accuracy and clarity of Axis I and II
disorders are critical in determining appropriate psychotropic medications. Psychiatric manpower resources are very limited in corrections, and therefore
reliance on psychotropic drugs as the sole suicideprevention strategy is common.66 Psychiatrists occasionally use suicide-prevention contracts as opposed
to taking time to develop a therapeutic alliance.
These contracts should be used as only a part of a
greater treatment plan and not in lieu of suicide risk
assessment and intervention. Specific procedures
must be in place to facilitate the admission to a psychiatric hospital administered by the State Department of Mental Health of acutely mentally ill offenders, civil commitment of those who are likely to pose
a danger to themselves or others to the Department
of Mental Health on release,68 and transition of
mentally ill prisoners to community-based treatment
programs.
Although detoxification programs are crucial in
jails, a comprehensive substance abuse treatment
program is important in the care of suicidal prisoners
with a history of substance abuse. Most substance
abusers undergo forced abstinence while incarcerated
but on release may relapse due to “rekindling” resulting from exposure to personal triggers. Therefore,
systematic treatment while incarcerated may reduce
immediate post-release suicides.
Information Management System
The administrative and clinical aspects of a sound
suicide-prevention program should be linked by an
effective information-management system. Screening instruments, risk assessment forms, suicide watch
reports, classification files, medical records, mental
health records, psychiatric evaluations and progress
notes, medication entries, the medication administration record, Suicide Risk Rating level 3 (SR 3)
debriefing reports, and suicide debriefing and mortality reports all form essential components of the
program for effective communication. A uniform
system of documentation will assure seamless communication between staff and facilities. Forms provide a simple way to insure that certain pieces of
information are documented every time. Some correctional departments use computerized systems that
provide easy but confidential access to information
from any location. Last but not least is the willingness
of all staff to document observations, decisions, and
actions adequately and thoroughly.

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Psychological Autopsy and
Mortality Review
Suicide prevention is an area that is constantly
evolving. Following a suicide, a complete mental
health debriefing (psychological autopsy) must be
completed. This process involves drawing together
pieces of information from the inmate’s medical and
mental health records, classification files, toxicology
reports, and autopsy. The psychological autopsy
should include basic demographic information, life
history before incarceration (including family, mental health, and medical histories), criminal history,
mental health contacts within the correctional facility, psychotropic drugs used, and pattern of prescriptions and other health concerns while in the facility.
The psychological autopsy should be reviewed to
highlight any patterns or areas of concern for prison
staff. Policy and procedure changes may result from
this process. Unlike the psychological autopsy, which
is written primarily by mental health and correctional representatives, a mortality review is undertaken by a committee consisting of physicians, psychiatrists, and administrators. The committee
discusses the incidents leading up to and including
the suicide. The report includes a brief history of the
inmate’s psychological history, but most of it is focused on the suicidal act itself. The mortality review
reports the last time the inmate was seen alive, the
time that the inmate was found, who found the inmate, efforts that were made to resuscitate the
inmate, when additional help arrived, whether
the inmate was taken to a hospital, heroic measures
taken at the hospital, and time of death. Every person
who was involved in the suicide—from the discovery
of the inmate until the inmate was pronounced
dead—is interviewed so that a complete scene can be
described. The mortality review is often used to evaluate the system’s response to the suicide. Any difficulties that arise with prison staff response can be
addressed so that similar situations are handled more
effectively in the future. A detailed description of
cause of death is completed as well.
Continuous Program Evaluation
It is difficult to determine whether specific suicide-prevention strategies actually decrease the number of suicides.48 Empirical research cannot be conducted on suicide in prison, simply because it would
be unethical to withhold certain preventive strategies

from suicidal individuals for the sake of research.
However, after implementation, the suicide-prevention program must be evaluated continually by standardized auditing, which allows necessary adjustments to be made in a timely manner. Both
administration and service providers must evaluate
individual components as well as the system as a
whole. Therefore, a systematic program evaluation
and quality-assurance plan should be developed and
implemented. Indirectly, lower mental health scores,
fewer incidents of suicidal behavior, or use of less
psychiatric medication may denote improvement in
the program. Of course, it would be necessary to
perform a well-designed study to make sure that the
improvements were not connected with other similarly timed events. Although studies of suicide in
prisons are retrospective, prospective studies using
comparison groups of non-suicidal inmates are
needed. Women who commit suicide in prison
should be studied extensively,69 because data on that
topic are minimal. Another area of research is to determine the effectiveness of timely medical intervention with serious suicide attempters.
Conclusion
When fully operational, the comprehensive suicide-prevention program outlined herein may not
only save lives but also may reflect adequacy and
thoroughness of overall mental health and psychiatric services delivery systems as well as correctional
practices. Nearly 30 percent of inmates who commit
suicide have no psychiatric illness and provide no
warning signs. Mental health and correctional service
providers may fail to identify this population. The
program described is also a roadmap to avoid any
malpractice or deliberate-indifference claims by a
third party.
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