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An increasing body of literature reflects the heightened risk for suicide faced by justice-involved persons, whether they are in jails, in prisons, or in the process of transitioning from a correctional facility back into the community. Suicide and suicide prevention have garnered increased attention, efforts, and resources within correctional facilities. Despite this increased awareness of suicide and heightened efforts to prevent suicide in correctional settings, suicide rates among incarcerated persons in the United States have continued to exceed that of the general population (albeit less so than in previous decades). Pertinent case law clearly creates potential liability for both correctional and health-care staff in the wake of a death by suicide. This research paper will review applicable case law; explore statistical trends, risk factors, and characteristics of suicides in correctional settings; review methods for prevention of suicide supported by the literature; discuss select special populations of incarcerated individuals at risk; and explore the suicide risk surrounding the transition from correctional settings back into the community. This research paper will validate the importance of the issue of suicide in correctional settings and highlight areas where further research and progress are needed.

Case Law History

The potential for legal liability resulting from suicide in correctional settings originates in two seminal cases: Estelle v. Gamble (1976) and Bowring V. Godwin (1976). In the Estelle case, the plaintiff filed suit claiming that the medical director and two correctional officers of a state correctional department violated the Eighth Amendment (cruel and unusual punishment) by not providing appropriate medical care for the inmate’s back pain. Upon appeal, the US Supreme Court established the legal standard of “deliberate indifference” and by using this standard held that the inmate’s medical care did not violate the 8th Amendment. Deliberate indifference requires more than mere negligence. Negligence typically involves the failure to exercise the care toward others which a reasonable or prudent person would do in similar circumstances, with the resulting harm generally being accidental. A reckless culpable mental state typically involves gross negligence, meaning that the individual could foresee the potential for harm, but was heedless of the consequences. The deliberate indifference standard is more akin to recklessness, necessitating that in order to be deemed liable, prison staff must have the subjective knowledge of risk for serious harm and then disregard that risk.

In the Bowring case, an inmate in a state correctional facility claimed Eighth Amendment (cruel and unusual punishment) and Fourteenth Amendment (due process) violations in lower court due to being denied parole, in part as a result of a psychological opinion that he would not be a successful parolee. The plaintiff argued that he was not provided the psychiatric or psychological diagnosis or treatment needed to address the psychological concerns of the parole board. The Fourth Circuit Court of Appeals held that psychiatric illnesses are medical in nature, thereby extending the treatment obligations incumbent upon correctional facilities to mental illness. The combination of these two seminal cases sets the stage for subsequent decisions finding liability in failure to prevent inmate suicide.

Concerning suicide specifically, circuit-level court findings in Partridge v. Two Unknown Police Officers (1986) and Colburn v. Upper Darby Township (1991) establish inmate suicide as a potential source of liability for correctional facilities (Scott 2010). The Partridge Fifth Circuit court determined that psychiatric illnesses potentially resulting in deaths by suicide constitute a “serious medical need.” In Colburn v. Upper Darby Township (1991), the Third Circuit court established that correctional facilities have an obligation to train staff members to identify potentially suicidal inmates and to intervene in an effort to prevent suicide deaths. The court determined that the standard for correctional staff’s competency in identifying potentially suicidal inmates would be comparable to that of a layperson’s and that correctional staff would be held to a standard of “reckless indifference” when legally evaluating efforts to intervene and prevent an inmate death by suicide. The Third Circuit court confirmed the lower court’s analysis, indicating that a plaintiff must prove not only that the deceased inmate had a “particular vulnerability to suicide” but that custody staff knew or should have known about the vulnerability and that the custody staff acted with “reckless indifference” in relation to the individual’s particular vulnerability. Existing case law clearly sets a bar for correctional facilities’ role in suicide prevention, though sets that bar relatively low.

Suicide Rates In Correctional Settings

Historically, suicide rates have been exceedingly high within correctional settings relative to the general population. In 1983, the suicide rate for jails was 129 per 100,000 inmates, and suicide accounted for 56 % of all jail deaths (Noonan 2010). Fortunately, suicide rates in both jails and state prisons have decreased since the 1980s. From 2000 to 2007, the suicide rate within jails decreased by approximately 25 %, from 48 per 100,000 to 36 per 100,000. Despite this relative decline in suicide rates, suicide remained the single leading cause of preventable death in jails. When jail suicide deaths rates from 2000 to 2007 are adjusted for demographic factors such as age, race, and sex, the rates still remain high relative to those observed in the general population in the United States (14 per 100,000). Overall, the adjusted rate for suicide in jail is 59 per 100,000 for males and 27 per 100,000 for females. Comparable rates of suicide in the US general population are 21 per 100,000 for males and 5 per 100,000 for females. It is worth noting that suicide rates within jails may vary substantially depending on the size of (and presumably resources available within) the correctional facility. Large jails had a lower suicide rate (27 per 100,000) relative to small jails (167 per 100,000), with small jails being defined as those housing 50 or fewer inmates. Noonan theorizes that a lack of suicide prevention measures, including appropriate mental health services and more inmate turnover in smaller jails, may account for this difference (2010). State prisons have also demonstrated a fortunate downward trend in suicide rates over the past few decades, though they still exceed that of the general population. The rate of suicide was 34 per 100,000 in 1980 (Mumola 2005) and decreased to a rate of 16 per 100,000 for the years 2000–2007. This rate has held fairly stable since the 1990s (Noonan 2010). Federal prison suicide rates are reported at 10 to 17 per 100,000 (White et al. 2002).

A poignant criticism has been raised regarding the method employed in measuring the rate of suicide in jails. These reported rates are based upon the total national average daily inmate population rather than the number of admissions to the specific incarceration facilities (Hayes 2010). If the rates were calculated based upon the number of admissions rather than the average daily population, calculated suicide rates would be lower. Calculating suicide rates based on the total number of admissions would arguably be more accurate because this method takes into account the high turnover of jails and thus more fully captures the at-risk population. Larger jails release approximately 46 % of inmates within the first 2 days of confinement and release 80 % of their population within an inmate’s first month of incarceration. Calculations based on admissions would thus more fully take into account all the unique individuals incarcerated. Others argue that community suicide rates are not calculated on total “admissions” to the population, and moreover, the majority of admissions are brief incarcerations and thus should not be included in the statistical calculation. But, as will be discussed below, many suicides occur very early after incarceration, illustrating the potential importance of capturing all admissions when calculating rates.

Incarceration within correctional facilities does seem to carry increased risk for suicide. Why has the rate of suicide been high in correctional settings, and furthermore, why has the rate decreased since the early 1990s? Various investigations and expert opinions have proposed several possible explanations.

Prevalence Of Mental Illness In Correctional Settings

One significant risk factor for suicide, applicable to individuals across settings (whether they are in jails, prisons, or the general community), is a diagnosis of mental illness. In one study of individuals who died by suicide in jails between 2005 and 2006, 38 % suffered from mental illness, 20 % had a history of being prescribed psychiatric medications, and 34 % had a history of self-directed violence, including suicide attempts and nonsuicidal self-directed violence (Hayes 2010). Patterson reported that 73 % of the California prison inmates who died by suicide in a 6-year period had a history of mental health treatment and 62 % had a history of suicidal thoughts or behavior (2008). Fazel conducted a systematic review of suicides in prison and found that history of attempted suicide, current psychiatric diagnosis, and current prescription for psychotropic medication were risk factors for suicide in prison (2008).

Rates of suicide in correctional settings are almost certainly related to the prevalence of mental illness. For jails and prisons, the number of admitted individuals suffering mental illness has increased over the last half of the twentieth century. Since the 1960s, the number of long-term care mental health institutions (such as state mental health hospitals) has decreased under the deinstitutionalization movement (Lamb and Weinberger 2005). Deinstitutionalization evolved from legal and ethical concepts favoring treatment of mentally ill individuals in the least restrictive environment possible. Under this theory, individuals would be released from highly restrictive psychiatric facilities and would instead be treated and supported in community-based mental health centers. Unfortunately, many experts agree that the deinstitutionalization movement has largely failed due to the inadequate creation and funding of needed community mental health centers, such that many severely, chronically mentally ill individuals are not receiving the treatment and support needed to sustain tenure in the community (Scott 2010). In the absence of such support, many of these mentally ill persons go on to engage in behaviors that eventually lead to incarceration. Hence, the failed deinstitutionalization movement has, over time, resulted in a shift in location for the severely mentally ill, from mental health facilities to correctional settings. In 1955, there were 559,000 psychiatric hospital beds for a total United States population of 165 million, compared to 59,403 psychiatric hospital beds for a total United States population of 273 million in 2000 (Lamb and Weinberger 2005). The notion that individuals suffering from a mental illness have shifted institutional settings, from mental health hospitals to correctional facilities, has been termed the criminalization of the mentally ill (Scott 2010). Other proffered explanations for this shift include lack of resources for community mental health care, peace officers assuming the role of triaging individuals to hospitals versus jail, and more restrictive involuntary psychiatric hospitalization laws (Lamb and Weinberger 2005).

Simultaneous to the deinstitutionalization of the mentally ill, the United States began its incarceration binge which has resulted in an increased rate and prevalence of incarceration. The total number of inmates in the United States in 1980 was 501,886, compared to over 2.2 million in 2009 (Glaze 2010). As a result, the total number of mentally ill incarcerated individuals increased with the incarceration binge. A study by Bradley Engen supports this additional explanation (2010). The study reported the change in the total number of individuals admitted to Washington State prisons from 1998 to 2006 and the relative proportion of inmates diagnosed with serious mental illness and co-occurring substance use at time of admission. The results of the study suggest that the increase in the diagnosis of serious mental illnesses and co-occurring substance use disorders is related to the increase in total admissions to prisons during the study time period and is not due to an increase in the percentage of admissions involving serious mental illness. In other words, this study suggests that at least some of the increase of the total number of incarcerated mentally ill is a result of the overall higher number of individuals being incarcerated. Collectively, it seems that an unfortunate combination of factors, chiefly involving the failed deinstitutionalization movement and a criminal justice system featuring a strong predilection toward incarceration, has resulted in growing populations of mentally ill persons behind bars in the United States.

Estimates vary for prevalence rates of mental illness in jails and prisons depending on the method of the study. The Bureau of Justice Statistics reported that 56 % of state prisoners, 45 % of federal prisoners, and 64 % of jail inmates suffered from some type of mental health problem (James et al. 2006). Bradley-Engen reported that past studies suggest that the prevalence of serious mental illness in prisons ranges from 16 % to 24 %, compared to 5–7 % in the general community (2010). A recent study suggests that the rate of serious mental illness in jail is 14.5 % for men and 31.0 % for women (Steadman et al. 2009).

Risk Factors For Suicide Pertinent To Correctional Settings

Besides housing an influx of many individuals that might have otherwise been institutionalized in mental health facilities during an earlier era, the correctional setting tends to contain populations with high rates of other important risk factors for suicide. Many of the risk factors associated with inmates’ suicide deaths match risk factors associated with suicide deaths in the community: male gender, Caucasian race, substance abuse, psychiatric treatment history, and prior suicide attempts (Anasseril 2006; Patterson and Hughes 2008; Hayes 2010). Fazel reported that being a male and being Caucasian were risk factors for suicide in prison; he also found that being African American was inversely related to suicide (2008). Noonan reported that the suicide rate for African Americans was lower compared to Hispanic and Caucasian inmates (2010). However, it is vital to appreciate that demographic risk factors of this kind are of very limited utility in determining risk at the single inmate level, keeping in mind that favorable demographic factors identified via population-based research do not keep individuals safe; inmates of any race or gender may of course present at heightened risk for suicide.

Complicating risk assessment in correctional settings is the fact that so many of the identified risk factors for suicide occur at a very high prevalence, higher than the prevalence in the general community. For example, inmates in correctional settings are predominately male (Glaze 2010). The male gender is dramatically overrepresented in correctional settings, is overrepresented in suicide deaths in the general community, and also represents approximately 93 % of jail suicides (based on figures from 2005 to 2006) (Hayes 2010). In federal prisons, despite having a 7 % female population, from 1993 to 1997, 100 % of suicides were completed by males (White et al. 2002). Noonan reports that white males in jail have a rate of suicide 5.7 times greater than white males in the general population (2010).

Substance use disorders also have a high prevalence in correctional settings. As a conservative estimate, 50 % of incarcerated individuals have substance use disorders, with jail inmates having a higher prevalence rate than prison inmates (Scott 2010). Hayes found that of the individuals that died by suicide in jail between 2005 and 2006, 47 % had a history of substance abuse; 20 % were intoxicated at the time of the suicide (2010). In New York state prisons between 1993 and 2001, 95 % of inmates who died by suicide had a history of substance abuse (Way et al. 2005).

Many incarcerated individuals have experienced violent trauma during their lifetime (Wolff et al. 2010). As cited by Wolff, at least 50 % of incarcerated women have reported victimization in their lifetime. Additional profile characteristics for individuals that committed suicide in prisons are low education level and limited social supports in the community (White et al. 2002; Anasseril 2006). The frequency of trauma, victimization, and limited support among correctional populations seems particularly relevant to suicide risk when one considers the interpersonal-psychological theory of suicide risk offered by Thomas Joiner (2005). Under this model, the convergence of acquired ability (relating to habituation to pain and suffering along with perceived burdensomeness and/or a sense of failed belongingness results in a heightened risk for death by suicide). The above-referenced research indicates that inmates are frequently themselves victims of trauma, potentially contributing to habituation to pain and suffering, and thus acquired ability to engage in suicidal behaviors. Additionally, limited psychosocial support and the impact incarceration has on families likely engender feelings of burdensomeness and failed belonging. It would seem that the convergence described by Joiner is probably a common occurrence among inmates and may in part explain the observed elevation in suicide rates.

The high rates of violent perpetration and aggression among correctional populations are a consideration when thinking about suicide risk and suicide rates. Violent offenders have been found to face increased suicide rates across a number of studies, with the Bureau of Justice statistics reporting a suicide rate nearly three times that of nonviolent offenders in jail, and violent offenders in prison being more than twice as likely to die by suicide. Hayes reported that 43 % of inmates that died of suicide had been arrested on personal and/or violent charges, including murder, negligent manslaughter, armed robbery, rape, sexual assault, indecent assault, child abuse, domestic violence, assault, battery, aggravated assault, and kidnapping (2010). Noonan also found that violent offenders had the highest suicide rate, with public-order offenders having the second highest rate of suicide, compared to individuals with property and drug offenses (2010). Inmates incarcerated for the alleged offenses of homicide, kidnapping, and rape had the highest rate of suicide (Noonan 2010). Notably, aggression features prominently in a theoretical model for suicide risk offered by Kerr et al. (2007). Under that model, aggression may lead to suicide attempts via various routes: aggression may lead to depression and then to suicidal ideation; aggressive acts may yield negative consequences leading to worsening depression and suicidal ideation; or aggression may more directly be turned inwardly resulting in self-directed violence and suicide attempts.

The incarcerated individual’s coping styles, changing emotional states, or emotional traits have also been associated with suicide risk. Individuals that have a maladaptive style of interacting with the environment and coping with stress have increased risk for suicide and self-directed violence. Specifically, rigidity and dichotomous thinking, poor problem-solving ability, avoidant behavior, and poor positive reinterpretation are personality styles that lend themselves to suicidal behavior (Polluck and Williams 2006). Emotional states or traits involving anxiety, depression, aggression/agitation, hostility, fear, and impulsivity are characteristic of individuals who have suicidal behavior (Polluck and Williams 2006; Anasseril 2006; Way et al. 2005). An individual’s self-report of feeling hopeless is arguably a highly significant risk factor for suicide in most if not all populations, including incarcerated populations (Anasseril 2006). Recent “behavior changes” of incarcerated individuals from baseline observations also has been noted as a characteristic profile of individuals who are at risk for suicide in prison (Way et al. 2005). For example, prior to some suicide deaths, staff members report that the inmate had not been acting in his or her usual manner.

Psychosocial stressors unique to incarceration and the criminal justice process may also contribute to increased suicide risk. For example, many jail and prison suicides occur during the initial incarceration phase or after transfer to a new facility (Anasseril 2006; Hayes 2010). After arrest and initial incarceration in jail, an individual has gone from living in a free society to living in isolation, or possibly in a cell under 23 h lockdown where freedoms are severely curtailed and most aspects of daily life kept under strict control (Patterson and Hughes 2008; Hayes 2010). Many recent detainees are unclear of the specific consequences of their legal charges or have not spoken with an attorney, are intoxicated or experiencing withdrawal from drugs or alcohol, and/or have not yet communicated with their primary supports in the community. Some detainees are experiencing guilt or shame concerning their charge and/or have just experienced a personal/family crisis that is related to their charge (Hayes 2010). Although the abovedescribed stressors are challenging for all inmates, individuals from higher social economic backgrounds incarcerated for the first time seem to be particularly susceptible to such stressors and at higher risk for suicide (Anasseril 2006).

For longer stays in jail or prisons, stressors from both within the correctional setting or crises occurring outside the correctional setting can contribute to suicide risk. Specifically, death of a loved one, relationship problems/losses, financial losses, new charges or setbacks in court, gang problems, victimization, bullying, recent experience or risk of sexual assault, and recent institutional disciplinary action are often antecedents of inmate deaths by suicide (Way et al. 2005; Anasseril 2006). A life sentence is considered a risk factor for suicide in prisons (Fazel et al. 2008). Death row inmates have the highest suicide risk (Anasseril 2006). Although counterintuitive to some, marriage was found to be a risk factor for suicide in prisons and during periods of longer incarceration in jails (Fazel et al. 2008; Hayes 2010). It is interesting to note that jail and prison suicides were not associated with certain holidays but evenly distributed through the year (White et al. 2002; Anasseril 2006; Hayes 2010).

Despite curtails in freedom and relatively limited access to means (compared to life in the community), the correctional environment does offer sufficient opportunity for inmates that are having suicidal thoughts to engage in lethal acts of self-directed violence (Hayes 2010). A oneperson cell, time spent alone in a cell, and access to lethal means (such as anchor points for hanging) provide the necessary means for an inmate to die by suicide (Patterson and Hughes 2008; Hayes 2010). Fazel found that single-cell occupation is a risk factor for suicide (2008). The most common method of suicide in both jails and prisons is hanging, featuring in over 80 % of suicides (Patterson and Hughes 2008; Hayes 2010). Other methods employed include overdose, self-inflicted laceration resulting in exsanguination, self-strangulation, swallowing objects, electrocution, poisoning, self-immolation, self-inflicted gunshot wound, and intentional fall (Felthous 2011). All these techniques are more easily accomplished when an inmate is isolated.

Suicide Prevention Programming

The primary method to mitigate suicide risk and implement protective factors is to create an effective comprehensive suicide prevention program in individual correctional facilities (Hayes 2010). Effective suicide prevention programs have been credited with reduction of suicides in correctional settings. National organizations and credentialing bodies such as the American Psychiatric Association, the National Commission on Correctional Health Care, and the American Correctional Association all recommend that correctional facilities have suicide prevention programs and articulate specific standards for these programs. Hayes recommends the following eight essential components for a comprehensive suicide prevention program: staff training, intake screening/ assessment, communication, housing, levels of observation, intervention, reporting, and follow-up and morbidity-mortality review (Hayes 2010). A brief summary highlighting the major aspects of Hayes’ recommendations for a comprehensive suicide prevention program follows.

Hayes states that all custody, mental health, and medical staff should initially have 8 h of training and 2 h of training annually (Hayes 2010). Training custody staff is crucial due to the large amount of time they spend with inmates, resulting in their significant role in identifying potentially suicidal inmates. Hayes asserts that staff training should include, at a minimum, “reasons why correctional environments are conducive to suicidal behavior, staff attitudes about suicide, potential predisposing factors to suicide, high-risk suicide periods, warning signs and symptoms, identification of suicide risk despite the denial of risk, liability issues, critical incident stress debriefing, [review of] recent suicides and/or serious suicide attempts within the facility or agency, and components of the facility’s or agency’s suicide prevention policy” (Hayes 2010).

Hayes recommends that individuals receive screening and assessment for suicide risk upon intake to a correctional facility (Hayes 2010). Hayes asserts that screening should include questions concerning suicidal thoughts/plans (including such thoughts during past incarcerations), past suicidal attempts, history of mental health treatment, recent stressors and losses, suicide behavior by family or close friends, and reports from arresting officers concerning suicide risk (Hayes 2010). As in other settings, suicide risk assessment is a process, not an event; suicide screening does not end after intake, but continues throughout the individual’s incarceration. Inmates’ self-reporting should be considered in concert with behavioral observations and other collateral information in determining the level of suicide risk.

Communication between arresting officer, correctional staff, mental health staff, and medical staff is essential to reduce suicide risk (Hayes 2010). Protocols for appropriate suicide precautions should be in place to enable staff to take appropriate action if an inmate is considered to be at risk for suicide in order to keep the inmate safe. Hayes suggests that custody staff should not be underestimated in their importance in identifying potentially suicidal inmates and communicating this concern to mental health staff (2010). In additions, barriers need to be reduced in order for inmates to obtain mental health care.

Appropriate housing of inmates with significant suicide risk is an important component of a proper suicide prevention program (Hayes 2010). Inmates with clinically determined differing levels of suicide risk should be housed in the least restrictive environment needed to provide the appropriate level of safety, such as medical/ mental health units or general population housing where staff can readily interact with them. Only individuals with the highest acuity of suicide risk should be housed in a locked-down environment, and only when the appropriate suicide precautions are provided. Although segregation may be the safest option for individuals at imminent suicide risk, isolation may also be detrimental to the inmate’s emotional well-being and seldom addresses the factors driving the crisis. Careful consideration regarding the risks and benefits of segregation is warranted. Cells used for individuals at acute risk for suicide should be free of methods which might be employed to act upon suicidal thoughts, such as anchors or hanging devices in the cell or on the inmate. Level of observation of a suicidal inmate in a particular housing setting depends on the particulars of the individual’s suicide risk (Hayes 2010). Observation should be, at a minimum, staggered in 15-min intervals and, at least for inmates judged to be at imminent risk, should consist of continuous in-person observation. Cameras in cells can help monitor inmates at acute risk for suicide but do not replace the need for continuous in-person observation. Inmates flagged for suicide precautions should be closely followed for evaluation and treatment by mental health staff.

All staff with regular contact with inmates should be provided with first aid, cardiopulmonary resuscitation, and automated external defibrillator training to be prepared to intervene after a suicide attempt (Hayes 2010). Staff should be prepared to quickly triage the emergency situation, contact appropriate medical staff, and initiate the appropriate above treatment(s). Staff should not assume that the individual is deceased. If a serious suicide attempt or completed suicide has occurred, family and appropriate authorities should be notified immediately. Morbidity-mortality reviews and psychological autopsies are recommended. Within 24–72 h, Hayes recommends that staff involved in the incident be offered critical incident stress debriefing by a trained professional (Hayes 2010).

Correctional facility culture and environment seem to be related to suicide risk. Liebling argues that inmates that are already vulnerable to suicide and self-directed violence face even higher suicide risk if the institution creates feelings of lack of safety, lack of respect/fairness, alienation, and frustration (2006). In fact, she argues that institutions that provide individual support create a protective factor. She recommends that institutions focus on improving both correctional custody and healthcare staff culture, specifically avoiding environments that use excessive authority, have a lack of personalization of the individual inmate, and avoid addressing or listening to inmate complaints. An international study analyzed possible interventions or factors that reduced the incidence of suicide in prisons. “Purposeful activity” (as defined as classes or activities for inmates, such as education, substance abuse treatment, work, and family visits) was significantly associated with lower suicide rates (Leese et al. 2006). In a study conducted in one jail, protective factors included reasons for living and social connectedness.

Special Populations

Special populations mandate specific considerations when evaluating the risk for suicide and self-directed violence within correctional settings. A few examples follow.

Adolescents

In the United States general population, suicide is one of the leading causes of death for adolescents. Suicide is the fourth leading cause of death of individuals between the ages of 10 and 14, while suicide is the third leading cause of death for teenagers between the ages of 15 and 24. The Centers for Disease Control and Prevention reported that the suicide rate in 2007 for adolescents between the ages of 15 and 19 is 6.8 per 100,000. According to Roberts, a leading cause of death in juvenile correctional settings is suicide, with incarcerated juveniles having a risk for suicide approximately four times greater than juveniles in the general population (2006). As with incarcerated adults, confined juveniles have a high rate of mental illness compared to the general population. Hayes cited multiple studies which indicate prevalence rates of mental illness in the confined juvenile population to be well above 50 %, with many of the juveniles having multiple psychiatric diagnoses, including substance use disorders, conduct disorder, and history of childhood abuse (2009). Penn reported that 12.4 % of 289 adolescents recently admitted to a New England correctional facility had a previous history of attempting suicide (2003).

Characteristics of juveniles who have died by suicide while in confinement are similar to characteristics of adult victims of suicide in correctional settings. A review by Hayes of 79 juvenile suicides between 1995 and 1999 documented many characteristics similar to adult suicide victims in correctional settings, as well as some demographics unique to this population (2009). For example, juvenile suicide victims were 68 % white and 79.7 % male. Also similar to incarcerated adults, 73.4 % had a history of substance abuse, 74.3 % had a history of mental illness, and 69.6 % had history of prior suicidal behavior. The method of suicide, similar for adult suicide deaths, was hanging by 98.7 %. As with adult correctional facilities, the physical plant characteristics provided opportunities for suicide behavior with 50 % being in room confinement and 74.7 % housed in single-occupancy rooms. In addition, the data provided specifics for juvenile suicide victims, including a mean age of 15.7 with 70 % between ages of 15 and 17, 69.6 % confined for nonviolent offenses, and 78.5 % with history of previous offenses. Approximately 40 % of juvenile suicide victims confined in detention centers had died by suicide during the first 72 h of confinement. Other confinement settings including training school/secure facility, reception/diagnostic center, and residential treatment center had more diverse time frames of juvenile suicide deaths. Hayes argued that although adolescent suicide has gained national attention, suicide of juveniles in confinement has gained much less consideration. He recommended more research into investigating the possible precipitating factors of juvenile suicide in confinement (Hayes 2009).

Women

The total percentage of incarcerated women in the United States has increased by 14 % from 1990 to 2009 (Glaze 2010). Steadman estimated that the rate of serious mental illness for female jail inmates is 31 % (2009). The Bureau of Justice Statistics reported that the rate of suicide for female inmates in both jails and prisons between 2000 and 2002 (32 per 100,000 and 10 per 100,000, respectively) is lower than that for males (Mumola 2005). Recent rates using data from 2000 to 2007 reflect a decrease in the rate of suicide deaths for female jail inmates (28 per 100,000) (Noonan 2010). However, the suicide rate still remains five times higher than the general population when these rates are demographically adjusted (Noonan 2010). Noonan also reports that incarcerated Hispanic females have a rate of suicide 10.5 times greater than the rate of suicide for Hispanic women in the general population (2010). Incarceration does appear to substantially increase the risk for suicide among women. Research on incarcerated female suicides has been sparse. Clements-Nolle reported that one risk factor for suicide attempts in prison is childhood trauma (2009). Marzano found that in English and Welsh prisons, there was a higher prevalence of current depression, two or more psychiatric diagnoses, history of inpatient psychiatric hospitalization, and history of suicide attempt in women with near-lethal self-directed violence compared to a control group (2010). Fazel hypothesized that substance use disorder and loss of contact with dependent children may contribute to incarcerated female suicide risk (2009).

Veterans

Another special population is veterans. Estimates suggest that nearly 10 % of incarcerated persons are veterans, although such estimates were derived from data that probably fails to fully reflect the impact of current conflicts in the Middle East. Clinical experience among those familiar with the population of returning veterans suggests that such numbers may be on the rise (Mumola 2000; Noonan 2004). The Veterans Administration now officially recognizes that veterans are arrested for a variety of offenses, some of which may be related to extended periods of battle readiness and combat exposure during multiple deployments and to maladaptive coping with the return to civilian life. The VA’s Uniform Mental Health Services Package now calls not only for assistance for veterans reentering the community from state and federal prisons but also for outreach efforts to veterans who are interfacing with jails, courts, and law enforcement and for education to these agencies regarding mental health problems relevant to veteran populations, such as posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI). Unfortunately, relatively little is known about the subpopulation of incarcerated veterans, including their suicide rates. It has been argued that suicide risk factors faced by the general veteran population may interact with risk factors specific to incarceration or justice involvement, potentially placing the incarcerated veteran at especially high risk for suicide. Additional research is needed to better characterize this potentially high-risk population to determine rates and opportunities for intervention (Wortzel et al. 2009).

Risk After Release

The suicide risk associated with incarceration unfortunately does not end upon release. Rather, research suggests that the time of release represents yet another difficult transition period that carries increased risk for mortality in general and increased risk for suicide specifically. A study by Pratt examined suicide following prison incarceration in England and Wales (2006). Compared to the rate of suicide of 18 per 100,000 in the general population, the rate for recently released inmates was 348 per 100,000, with 21 % of the suicides occurring within 28 days of release. Suicide risk was also found to be high for individuals after release from New South Wales, Australia, prisons (Kariminia et al. 2007). The suicide rate for individuals within 2 weeks of release from prison was found to be 3.87 times higher when compared with the suicide rate for individuals 6 months after release. Binswanger conducted a retrospective cohort study of inmates released from the Washington State Department of Corrections (DOC) and reported an adjusted risk of death among former inmates 3.5 times higher than that faced by other state residents (2007). More specifically, former inmates had a 3.4 relative risk for suicide, a 10.4 relative risk for homicide, and a 12.2 relative risk for accidental overdose. Meaningful efforts to mitigate suicide risk among recently incarcerated individuals will necessarily involve linkage to appropriate resources in the community.

Conclusions

The ongoing high risk of suicide death in correctional settings compared to the general population has resulted in more attention by the academic community, the courts, and correctional settings. This attention has led to a better understanding of the risks that exist in these settings and pragmatic solutions to decrease suicide risks. More recent studies have suggested that the rate of suicide in correctional settings has decreased over time. However, the decreased rates continue to remain higher than the general population rates, suggesting that efforts need to continue to find solutions to further reduce correctional suicide rates. The academic examination of suicide death and self-directed violence in correctional settings involving adolescents, women, and veterans is relatively new and is an area requiring further study. The high suicide risk/rate of recently released inmates from correctional settings is an area that is ripe for further study. Future studies could help provide direction in formulating a plan to target and reduce the high suicide risk/rate in this subpopulation. Finally, this research paper demonstrates the responsibility that correctional institutions have in further developing policies and procedures that aim to reduce the risks of inmate suicide.

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