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Suicide risk assessment difficult in jails, prisons.

SCOTTSDALE, ARIZ. -- Sometimes the importance of suicide risk assessment in correctional facilities can be brought home in very poignant ways, Michael Champion, M.D., said at the annual meeting of the American Academy of Psychiatry and the Law.

"A few weeks ago, we had a prisoner commit suicide in New Hampshire," said Dr. Champion of Dartmouth University, Hanover, N.H.

"The inmate was known to us. He had been an inpatient previously and had been discharged to the [correctional] community. He was getting ongoing suicide risk assessment and follow-up. He received some difficult news and jumped off a three-story balcony."

Dr. Champion noted that suicide is the third-leading cause of death in prison, after natural causes and AIDS-related complications. Generally, prison inmates are one and a half times more likely to commit suicide than the general population, he noted.

"It's important for clinicians to address" the issue in an effort to decrease morbidity and mortality, he said. The risk is even higher in shorter-term facilities: The suicide rate in jail is nine times higher than the general population, and in lock-up--the sheriff's holding facility for people on their way to jail--it's 250 times higher.

Several factors make the suicide risk higher in jails and prisons, Dr. Champion explained. The criminalization of the mentally ill means there is a higher percentage of mentally ill patients who are incarcerated. And then there are the stressors of the correctional environment itself. "The environment is primitive by design," he said, showing a picture of one correctional facility in Pennsylvania to illustrate how prisoners are "walled off" from the rest of society. "The person is separated from family and friends, and that's going to lead to radically increased stress. It's not designed to lift your spirits in any way."

Another problem frequently found in correctional facilities is the "handoff problem," he continued. "There is a lack of communication about critical risk factors [for suicide], and the ball ends up getting dropped." For instance, one shift might neglect to tell another that "'Joe Smith found out today that his wife is leaving him; we need to keep a watch on him.' It's important to pass that on from shift to shift." Communication between facilities--from the lock-up to the jail and the jail to the prison--is even more difficult, he said.

Suicide risk factors for jail inmates are similar but not quite the same as those for prison inmates. Jail inmates with the highest suicide risk are young males who are intoxicated upon arrest. Psychiatric history, prior suicide attempts, and recent negative life events, such as losing a child or being cut off from family, are also risk factors for jail inmates.

Suicide risk factors for prison inmates include history of psychiatric problems, placement in a segregated area with its own cell, prior attempts at suicide and self-harm, a lengthy sentence, and having committed a violent felony, Dr. Champion said.

If a particular inmate seems at high risk of suicide, there are practical strategies that people who work with prisoners can take to lessen the risk, said James Knoll, M.D., also of Dartmouth. "A large impact can be made by addressing modifiable factors."

For instance, prisoners can be dressed in a "safety smock" made of a material that is very difficult to rip. "This is especially important in facilities where resources are limited," Dr. Knoll said, noting that the same manufacturer makes pillows and blankets out of the same material. "Cloth that can be ripped and torn is a big problem." He cited the case of one prisoner who made a noose out of strips of hard canvas from a pair of tennis shoes. If an attempt does occur, staff members must know the exact location of the "Wyoming knife," a tool used to cut down a noose.

In working with a prisoner who may become suicidal, don't rely on "no harm" suicide contracts, said forensic consultant Fred Cohen of Tucson, Ariz. "If an inmate fails to keep his or her word, the contract is worthless."

Television monitors are another tool that can be overrelied on. "The main thing TV monitors do is record a suicide, not prevent it," he said.

When it comes to inmates who malinger, don't worry about being fooled. "Tell the staff to plan on taking [even] a phony threat seriously, just on general principle," Mr. Cohen said.

BY JOYCE FRIEDEN

Associate Editor, Practice Trends
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Title Annotation:Forensic Psychiatry
Author:Frieden, Joyce
Publication:Clinical Psychiatry News
Geographic Code:1U8AZ
Date:Jan 1, 2005
Words:733
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