Risk factors for self-harm in prison: a systematic review and meta-analysis

Abstract

Background Self-harm is a leading cause of morbidity in prisoners. Although a wide range of risk factors for self-harm in prisoners has been identified, the strength and consistency of effect sizes is uncertain. We aimed to synthesise evidence and assess the risk factors associated with self-harm inside prison.Methods In this systematic review and meta-analysis, we searched four electronic databases (PubMed, Embase, Web of Science, and PsycINFO) for observational studies on risk factors for self-harm in prisoners published from database inception to Oct 31, 2019, supplemented through correspondence with authors of studies. We included primary studies involving adults sampled from general prison populations who self-harmed in prison and a comparison group without self-harm in prison. We excluded studies with qualitative or ecological designs, those that reported on lifetime measures of self-harm or on selected samples of prisoners, and those with a comparison group that was not appropriate or not based on general prison populations. Data were extracted from the articles and requested from study authors. Our primary outcome was the risk of self-harm for risk factors in prisoners. We pooled effect sizes as odds ratios (OR) using random effects models for each risk factor examined in at least three distinct samples. We assessed study quality on the basis of the Newcastle-Ottawa Scale and examined between-study heterogeneity. The study protocol was registered with PROSPERO, CRD42018087915. FindingsWe identified 35 independent studies from 20 countries comprising a total of 663 735 prisoners, of whom 24 978 (3•8%) had self-harmed in prison. Across the 40 risk factors examined, the strongest associations with self-harm in prison were found for suicide-related antecedents, including current or recent suicidal ideation (OR 13•8, 95% CI 8•6-22•1; I²=49%), lifetime history of suicidal ideation (8•9, 6•1-13•0; I²=56%), and previous self-harm (6•6, 5•3-8•3; I²=55%). Any current psychiatric diagnosis was also strongly associated with self-harm (8•1, 7•0-9•4; I²=0%), particularly major depression (9•3, 2•9-29•5; I²=91%) and borderline personality disorder (9•2, 3•7-22•5; I²=81%). Prison-specific environmental risk factors for self-harm included solitary confinement (5•6, 2•7-11•6; I²=98%), disciplinary infractions (3•5, 1•2-9•7; I²=99%), and experiencing sexual or physical victimisation while in prison (3•2, 2•1-4•8; I²=44%). Sociodemographic (OR range 1•5-2•5) and criminological (1•8-2•3) factors were only modestly associated with selfharm in prison. We did not find clear evidence of publication bias.Interpretation The wide range of risk factors across clinical and custody-related domains underscores the need for a comprehensive, prison-wide approach towards preventing self-harm in prison. This approach should incorporate both population and targeted strategies, with multiagency collaboration between the services for mental health, social care, and criminal justice having a key role.Funding Wellcome Trust.

Predicting self-harm within six months after initial presentation to youth mental health services: A machine learning study

“…Although factors such as suicidal thoughts, depression and alcohol misuse are consistently associated with future self-harm [12,13], there is still significant doubt about the actual clinical utility of these factors for individual risk predictions [3,14]. The problem extends to other biological [15] or clinical [16,17] risk factors which have similarly weak predictive value.…”

<p>Dissociative Symptoms and Self-Reported Childhood and Current Trauma in Male Incarcerated People with Borderline Personality Disorder – Results from a Small Cross-Sectional Study in Iran</p>

“…Fourth, by nature, not all psychological and psychophysiological dimensions were assessed; it follows that further latent and unassessed psychological factors might have biased the present pattern of results. This holds particularly true, as both Favril et al 10 and Verdolini et al 11 showed that BPD, along with misuse of multiple substances and major depressive disorders, was highly associated with self-harming behavior. Given this, future studies should consider self-harming behavior as an important behavior-moderating factor.…”

“…Last, as regards suicidal behavior, Marzano et al 8 and Valizadeh et al 9 reported strong associations between psychiatric disorders and suicidal behavior among incarcerated people; specifically, psychiatric morbidity and comorbidities, and trauma, along with social isolation, increased the risk of suicidal behavior. 8 Likewise, most recently, Favril et al 10 showed in their SR and MA of 35 studies from 20 countries including 663ʹ735 participants, that 3.8% of them reported self-harm-related behavior. Among other factors, current psychiatric diagnoses, particularly major depressive disorders and borderline personality disorder (BPD), and experiencing sexual or physical victimization were important predictors of self-harm.…”

Uncovering social-contextual and individual mental health factors associated with violence via computational inference

“… 9 , 18 The study of the determinants of violence has mainly been conducted through epidemiological methods and has focused on one set of determinants, either individual mental health or sociocontextual, with few studies analyzing both of these factors simultaneously. 9 , 19 , 20 , 21 , 22 , 23 …”

“… 46 Previous meta-analyses have shown limited statistical robustness of studies using assessments of violence based on a small subset of risk factors. 9 , 20 , 22 , 23 Machine learning procedures can complement studies using structured assessment, including multiple interactions between a comprehensive group of potential risk factors. Recent studies in psychiatry and in communities exposed to violence have started to navigate in this direction.…”