1. SUICIDE AND SUICIDAL BEHAVIOUR IN NEW ZEALAND PRISONS.Assoc Prof Sandy Simpson,Hon Clinical Associate Professor, Department of Psychological Medicine, Faculty of Medicine and Health Sciences, University of AucklandClinical Director and DAMHS, Auckland Regional Forensic Psychiatry ServicePrison inmates have many of the risk factors for suicide. In New Zealandthere have been different patterns and clusters of suicidal behaviour amongstinmates. Suicide rates appear to have been significantly influenced by bothcorrectional and health policy. This paper will describe what we know aboutpatterns of suicidal behaviour in New Zealand prisons, and commonalitieswith international findings.We have seen 2 different patterns in the last 20 years, each of which tells usimportant things about how we should respond to this problem. This assistsus in defining who we need to ensure have access to services. Relevant tothis discussion are the rising rates of imprisonment over the last 20 years,and shifting patterns of bail and sentencing laws.Service responses will be described, including the development of screeningtools for those at risk, the importance of developing sophisticated interventionfor those prisoners who are mentally ill, and the importance of adopting apublic health approach to reducing prison suicide.Please address correspondence to:Assoc Prof Sandy Simpson,Auckland Regional Forensic Psychiatry Service,Private Bag 19986,Avondale,Auckland.New Zealand.Email: sandy.simpson@waitematadhb.govt.nz

2. IntroductionSuicide is one of the leading causes of death in prisons internationally, andhas been a source of major concern in the New Zealand correctionalenvironment for the last 20 years. It is one of the events that correctionalservices regularly monitor a key performance indicator [see the annual reportsof the Chief Executive of the Department of Corrections for example]. Prisonsuicides have resulted in significant public concern that has contributed to twoDepartment of Corrections reports into prison suicide [Department ofCorrections 1995, 1996] and one Ministerial Inquiry [Mason et al, 1988] that,inter alia, addressed this concern.All of this sits in the context of widespread societal concern regardingescalating suicide rates during the 1980s and early 1990s, and a coordinatedattempt to reduce suicide rates, most especially youth and Maori suicide rateswhich were increasing most rapidly. Like societal suicide rates moregenerally, prison suicide rates and related policy and service responses showthat it is possible to both worsen and improve suicide rates by service andpolicy intervention, but to what degree is difficult to define with certainty.Nonetheless, problems with suicide in prison have brought about serviceresponses in the corrections and health sectors which have had positiveimpact. This is a tale of 2 peaks, of vulnerable people, and service responses.The New Zealand Correctional Environment.As a country of 4.1 million people, we currently have a prison muster ofapproximately 7500 prisoners [New Zealand Herald, 26/10/05], or 183inmates per 100,000 population. In comparison, the United States has 680per 100,000 ppn, but all other countries like us have fewer prisoners, Australiahaving 110, England and Wales 125 and most of Western Europe less than120 [Department of Corrections, 2004 a and 2004 b]. Prisoners are onaverage young, with a mean age of just under 30, and half are of Maoriethnicity. 3. We incarcerate with mixed and ill thought through motivations. We at timesargue that we do so as punishment, for punishment, for prevention and forrehabilitation. Correctional policy necessarily must combine aspects of thesemotivations. Whilst many western countries have, like us, had rising prisonmusters in recent decades, not all have done so. Further prison musterscorrelate very poorly with national crime rates. As with suicide of menbetween the ages of 15 and 40, crime rates rose steadily and peaked in theearly 1990s, and have been falling steadily since then. But prison musterscontinue to rise. This implies increasing societal demand for longer retributiveand preventive sentencing is now the major current factor in the increasingprison musters.Whether one agrees with such a policy or not, the result is we incarceratemany people with very high health needs in general, and mental health needsin particular. There is a principle of equivalence in health care for prisoners:that is, ones status as a prisoner should not deny one access to having oneshealth needs met as any other person would. There is also a majoropportunity to intervene because the prevalence of many health problems ishigh amongst prisoners, and screening for many infectious and non infectioushealth problems has a very good chance of detecting problems. Populationhealth specialists can productively target health interventions for thesepeople. If we dont want such people to continue to be alienated from society,we can at least ensure that some aspects of their personal needs can be metand attended to whilst in custody. Further, so many problems in health andoffending are 2 sides of the same problem. Victims and victimisers; theproducts of neglect and the self neglectful. Positive intervention in their livesand a sense of self worth can assist with the establishment of reasons for notcontinuing to behave in a criminal manner.Suicide, mental illness and imprisonment.It is self evident that many of the risk factors for suicide are to be found in thelives of inmates. Being young, male, of unstable personal background,substance abusing, impulsive and antisocial are risk factors for both 4. imprisonment and suicidality. Add to that the experience of imprisonment andthe reasons for it, often involving major stress, withdrawal from drugs, entryinto a new and at times intimidating environment, and it makes the presenceof suicidality in inmates very likely.If one adds to that the increased rate of mental illness amongst prisoners thenthe co occurrence becomes unsurprising. There are multiple reasons whyinmates suffer more mental illness [Ogloff, 2002]. For instance, the causesand precipitants of offending and mental illness overlap, for instance the roleof substance misuse in both. Second, mental illness may lessen peoplescapacity to cope, resulting in minor disability related offending such asdisorderly behaviour and minor property crime, in people who are otherwisehomeless. Third, mentally ill people might be more easily caught, resulting inan apparently greater incidence of offending, when it is more about detection.Finally, policies or competencies of state agencies such as police, courts ormental health services may favour people with mental illness beingincarcerated.Whatever of these processes apply, increased prevalence of all the majormental disorders amongst prisoners, but most particularly substance misuse,major depression, post traumatic stress disorder, schizophrenia andpersonality disorders is very well documented internationally [Fazel andDanesh, 2002; Ogloff, 2002]. We performed a study of psychiatric morbidity inNZ prisons in New Zealand in the late 1990s, and found very similar findings[Simpson et al, 1999; Brinded et al, 2001; Simpson et al, 2003].Suicide in New Zealand PrisonsPrior to 1980, I cannot find record that any more that 2 people died by suicidein NZ prisons in any one year. Since then, there have only been 4 years whenthere have been 2 or fewer [see figure 1]. Two discernable peaks in thenumber of suicides can be seen, the first being in 1984 and 1985, and thesecond in 1994 and 1995. In between these peaks, suicide numbers have notsustainedly fallen to their pre 1980 levels, although population suicide rates 5. have fallen back to levels more typical of the early 1980s [Ministry of Health,2005]]. Expressed a ratio of the prison muster, however, it appears that therate as a percentage of the average daily muster is static or falling asmusters have risen [Figure 2]. Why then have we had these 2 apparentpeaks, and what gave rise to them? Why have suicide rates not droppedsince back to the 1980 levels?Over the time period 1986-1992, the rate of suicide by inmates was 2.5 -5.2times that of the general population. This degree of increase is similar to othernations internationally [Department of Corrections, 1995]. There appearedhowever to be particular issues in relation to these 2 peaks. For instance,Skegg and Cox [1991, 1993] found that there were particular clusters in spaceand time of the suicides that occurred prior to 1990. It appeared that a suicideincreased the risk that others could suicide, suggesting that prisonersrepresented a population at risk. One event might spark another.Davey [2000] studied these 2 peaks and found significant differences betweenthe suicides in the 2 groups. Those who killed themselves prior to 1990 weresignificantly older, were almost all sentenced prisoners, most had a history ofself harm and a history of mental illness. After 1990 they were much younger,only about 1/3 had prior mental health involvement, most were on remand anddid not have a prior history of self harm. The majority were of Maori ethnicityregardless of the time period. Why should the 2 groups of suicides beotherwise so different?The answers lie in public policy. In 1984 the Auckland Hospital Board stoppedadmitting mentally ill prisoners from Auckland and Mt Eden Prisons. Thesewere sentenced prisoners with serious mental illness. As the Mason Inquirydocumented, 12 died by suicide in the period that followed [Mason et al,1988]. They were older sentenced prisoners with a history of serious mentalillness who died because of a policy change by an agency of government. Allwere Maori. These tragedies led to the establishment of the network offorensic psychiatry services that exist around the country today. We have not 6. seen a similar peak of suicides of people with serious mental illness sincethose services were established.In the early 1990s, coinciding with the highest rates of societal offending,suicide and unemployment, bail laws were tightened and there was a suddenrise in the number of remand prisoners. And a new group of people becamepredominant amongst the suicides in custody. They were young men onremand, generally with no history of mental health contact or prior suicidality,who found themselves in custody. These people comprised the early to mid1990s peak in suicides in custody. The recognition of this group with newneeds led to a review of the policies and procedures of the Department ofCorrections [1995, 1996], the effect of which has been to hold, or perhapsreduce, the rate of suicide amongst inmates.Thus the lessons of these 2 peaks has been that both inmates with seriousmental illness and the young men with offending histories going through theupheaval of imprisonment are at risk.How Common is Suicidality amongst inmates?In order to understand this better, we asked about suicidality in the NationalStudy on Psychiatric Morbidity in NZ Prisons [Simpson et al, 1999]. Weasked:Since you have been in prison, have you at any time thought a lot aboutdeath?Since you have been in prison, have you at any time felt so low you thought alot about committing suicide?Did you tell the prison nurse or doctor about feeling suicidal?Did you make a plan as to how you might do it?Since you have been in prison have you attempted suicide?The answers we received are shown on Table 1. In short, about one fifth ofprisoners reported thinking significantly about suicide at some stage of their 7. imprisonment, confirming the finding of Skegg and Cox that this populationwere at risk of suicide, and the cluster effects they found make sense in thiscontext. Interestingly, there was no difference in the prevalence of suicidalideation on the basis of age, gender or remand and sentenced status of theinmate. However, Maori were less frequently responded that they thought alot about suicide [see Table 2]. Given that Maori are more likely to be thevictims of successful suicide in prison [Department of Corrections, 1996;Davey, 2000] this suggests that the presence of suicidal thoughts maybemore lethal amongst Maori than non-Maori inmates, and should be respondedto with greater concern [Simpson et al, 2003].Service responsesGiven that we have a history of experience that tells us that making rapidchanges in policy has very negative impact on offenders with a risk of suicide,what lessons have been learned and still need to be learned? First, a publichealth approach must be taken. The work of Skegg and Cox, and our work onthe prevalence of suicidal ideation, tells us that it is not discrete individualswho are at risk of suicide, but a group of people, similarly at risk, who if theyhave the availability of others modelling the behaviour, or the means andopportunity to kill themselves, may take it. Thus processes like removinghanging points and constructing prisons with few opportunities to kill oneselfare very important. Second, all prison staff need education and training in howto assess and look for people at risk. Third, new prisoners should be screenedfor suicidal feelings and referred for intervention from primary health staff ifthought to be at risk. All these steps have been taken by the Department ofCorrections [see Department of Corrections 1995, 2004b], and have almostcertainly contributed to the holding of the absolute number and proportionatedecline in suicide rates since 1995.The other major service development is that of regional forensic servicesproviding secondary level CMHC like care to prison populations, includingtransfer to inpatient facilities if needed. These services were commenced in1989 after the Mason Inquiry and have developed since with a clear mandate 8. for the care of people with serious mentally illness within the correctionalsystem [Simpson and Chaplow, 2001; Ministry of Health, 2001]. In the mainsuccessful, these services have the brief to provide multidisciplinary careincluding acute assessment, follow up clinics, transfer to inpatient facilities ifneeded and to arrange hand over of care upon release to the community.They are looking to further develop the standard to care for some prisoners tobe closer to an assertive community treatment model. It is estimated thatbetween 10 and 15% of all inmates should be receiving assessment ortreatment from mental heath services [Brinded et al, 2001]. If one adds to thisthe rising prison musters, it is clear that mental health services to prisonsneed to be expanded in parallel.We know from our prior work that only inmates with current bipolar disorderregularly contact mental health services in prison, whilst fewer than 40% ofthose with schizophrenia or major depression receive treatment in prison[Simpson et al, 1999]. This suggests that the means we use to detect thoseinmates with serious mental illness is missing many inmates. The currentprocess of screening new inmates for mental illness hasnt been validated andyet there are validated screening tools available internationally for thispurpose. But we dont know whether they will work for in a New Zealandcontext. A project is currently being planned to develop a validated tool forNew Zealand, as it is agreed between the Ministry of Health and theDepartment of Corrections that screening all prisoners for mental illness andsuicidal risk is an important priority.ConclusionsAs can be seen, health and correctional policies have evolved dramaticallyover the last 20 years, at times without thought for the mental well being andrisk of suicide of inmates. There is evidence that policy can get it wrong andget it right in terms of developing services for these people, but there is needfor active and continual collaboration between the sectors if this group ofpeople at risk of self harm are not to manifest that risk. Current initiatives forbuilding prisons which incorporate architectural safety, providing awareness of 9. suicide risk to correctional staff, screening for suicidality and mental illness ofall inmates and providing primary and secondary mental health servicesextensively to inmates each provide a piece of the right response. We need toremain vigilant, though, that new problems may emerge that we haventunderstood or envisaged, that may mean a new peak occurs. We are, afterall, trying to help a group of people who, not infrequently, feel there is nothingleft for them. 10. ReferencesBrinded PJ, Simpson AIF, Laidlaw TM, Fairley N, Malcolm F. Prevalence ofpsychiatric disorders in New Zealand prisons: a national study. Australian andNew Zealand Journal of Psychiatry 2001; 35: 166-183.Cox B, and Skegg K. Contagious suicide in prisons and police cells. JEpidemiol Community Health. 47(l): 69-72, 1993.Davey N. A retrospective study of completed suicide in New Zealand Prisons.Unpublished thesis, University of Auckland, 2000.Department of Corrections. Report of the Maori Suicide Working Group.Wellington, Department of Corrections and Te Puni Kokiri, 1996.Department of Corrections. Report of the Suicide Prevention Working Group.Wellington, Department of Corrections, 1995.Department of Corrections. About Time. Wellington, Department ofCorrections, 2004 a.Department of Corrections. Annual Report of the Chief Executive. Wellington,Department of Corrections, 2004 b.Fazel S, Danesh, J. Serious mental disorder in 23,000 prisoners: a systematicreview of 62 surveys. The Lancet 2002; 359: 545-50. 11. Mason K, Bennett H and Ryan A. Report of the Committee of Inquiry intoprocedures in certain psychiatric hospitals in relation to admission, dischargeor release on leave of certain classes of patients. Wellington, GovernmentPrinter, 1988.Ministry of Health. Services for People with Mental Illness in the JusticeSystem. Review Findings. Wellington, Ministry of Health, 2001.Ministry of Health. Suicide Facts: Provisional 2002 All-Ages Statistics. Ministryof Health, Wellington, 2005.New Zealand Herald. Vans ruled out as jail cell crisis deepens.www.nzherald.co.nz, 26/10/05.Ogloff JRP. Identifying and accommodating the needs of mentally ill people injails and prisons. Psychiatry Psychology and Law 2002; 9: 1-33.Simpson AIF, Brinded PMJ, Laidlaw TL, Fairley N, and Malcolm F. NationalStudy of Psychiatric Morbidity in New Zealand Prisons. Wellington,Department of Corrections, 1999.Simpson A I F, Brinded P J, Laidlaw T M, Fairley N and Malcolm F. Doesethnicity effect need or service access for treatment of mental disorders inNew Zealand prisoners? Australian and New Zealand Journal of Psychiatry,37: 728-734, 2003. 12. Simpson AIF and Chaplow DG. New Zealand model for the provision offorensic psychiatry services. Psychiatric Services, 52:973-974, 2001.Skegg K, Cox B. Suicide in custody: occurrence in Maori and non Maori NewZealanders. New Zealand Medical Journal 1993; 106: 1-3.Figure 1.Prison Suicides and Average Daily Muster 7000 12 6000 10 5000 8 4000 Average Muster6 3000 Number of Suicides 2000 4 1000 20 019801981198219841986198719891991199219941996199920002001198319851988199019931995199719982002 Year[Data derived from Department of Corrections, 1995, 2004b] 13. Figure 2. Prison Suicide by Average Daily Muster 7000 0.35 6000 0.3 5000 0.25 % Suicides 4000 0.2MusterAverage Muster 3000 0.15% of average Muster 2000 0.1 1000 0.05 0019801981198219851986198919901991199219941995199619971998199920002001200219831984198719881993Year[Data derived from Department of Corrections, 1995, 2004b] 14. Table 1. Self Report of Suicidal Ideation or Behaviour since being in Prison[n=1159; Simpson et al, 1999] PresentNot PresentPercentage PresentThoughts of death32383627.9Thoughts of23892120.5suicideReported thoughts80 1079 6.9to doctor or nurseSuicidal plans 52 1107 4.5Suicidal attempts30 1129 2.6 15. Table 2. Self report of Suicidal Ideation by Ethnic Group [n=1159, Simpson etal, 1999]A lot ofPakeha Maori Pacific OwnTotalthoughts ofPeoples specificatioSuiciden or otherNo279462 72108921Yes 86 902339 238Percentage23.6%16.3% 24.2% 26.5 20.5%suicidal