Psychiatric disorders in women prisoners who have engaged in near-lethal self-harm: case-control study

Female prisoners are 20 times more likely to die by suicide than women of the same age in the general population. However, risk factors and indicators of vulnerability for suicide in this group are not well-known.

We investigated prevalence of psychiatric disorders in women prisoners who had recently engaged in near-lethal self-harm (cases) and others who had never carried out near-lethal attempts in prison (controls).

We interviewed 60 cases and 60 controls from all closed female prison establishments in England and Wales. In addition to gathering details of sociodemographic, criminological and clinical history, we assessed participants' current and lifetime disorders using the Mini-International Neuropsychiatric Interview. Associations between near-lethal self-harm and psychiatric disorders were adjusted for age, educational qualifications (any v. none) and remand status (sentenced v. unsentenced).

At the time of their near-lethal self-harm, 53 cases (88%) were on ACCT (Assessment, Care in Custody and Teamwork), the system for the care of prisoners at risk of suicide and self-harm in England and Wales. Cases had significantly greater levels of psychiatric morbidity than controls, and more comorbidity. The strongest associations with near-lethal self-harm were with current depression (age-adjusted odds ratio (OR) = 23.7, 95% CI 9.0-62.3), the presence of two or more diagnoses (age-adjusted OR = 18.3, 95% CI 5.9-56.9), a history of psychiatric in-patient treatment (OR = 25.4, 95% CI 5.7-113.5) and previous attempted suicide, especially in prison (OR = 129, 95% CI 27-611). The only tested diagnoses not associated with near-lethal self-harm were antisocial personality disorder, substance use and eating disorders. Adjusting for sociodemographic and criminological variables did not significantly alter any of these findings.

This research underlines the importance of psychiatric risk factors for suicide in custody and in particular comorbidity. The finding that a formal care plan was in place for most cases at the time of their near-lethal act is indicative of good risk detection, but also suggests high levels of unmet need. Given the potential complexity of their mental health needs, interventions incorporating pharmacological and psychological treatments should be considered for at-risk prisoners.