Article
Seena Fazel, Lisa Gunnarsson & Howard Ryland
Self-harm is a leading cause of morbidity among incarcerated individuals globally¹ and a risk factor for completed suicide in prison.² The global pooled prevalence of suicide attempts during incarceration is estimated to be around 10% – in other words, one in ten incarcerated individuals has attempted suicide at some point during their current period of imprisonment.¹ Severe incidents often require the involvement of external medical services³, placing additional demands on already limited resources and potentially disrupting the rehabilitative functions of prisons.⁴ Addressing high rates of self-harm and suicide should be a central priority for prisons, yet people in prison at risk of these outcomes are often missed. Achieving good mental health for prisoners and reducing rates of self-harm are important in their own right but would also enable individuals in correctional settings to better access and engage in rehabilitative activities.
In many high-income countries, standard practice involves initiating a suicide risk management plan for incarcerated individuals deemed at high risk.⁵ In England and Wales, this safety management approach is called the Assessment, Care in Custody and Teamwork (ACCT) pathway. Individuals on this safety plan are subject to additional observations which can be continuous, including overnight observations which disrupt sleep, and restrictions that limit access to reintegration-focused activities, including work and education. While these measures aim to ensure safety, prolonged time spent on a risk management plan can limit access to activities that promote good mental health and rehabilitation.
Currently, no structured, evidence-based approach is routinely used for assessing the risk of suicidality and self-harm in prison settings. Decision making usually relies on the subjective judgment of correctional staff, who may close a safety plan, such as the ACCT, if they deem the risk to be sufficiently low. Similarly, assessment of the individual’s psychosocial needs after the closure of a plan is usually based on an unstructured review by a prison officer, and there is no evidence that this assessment is accurate, unbiased across subgroups, or effective in improving outcomes.⁴ Standardized and scalable approaches to stratify the risk of further suicidality could therefore improve the consistency of assessments⁶ and result in a more efficient use of resources.⁷
A new tool, the Risk Assessment for People in Prison at Risk of Self-harm and Suicide (RAPSS), offers a structured approach to assess the risk of repeat self-harm. Used at or towards the end of an ACCT or suicide risk management plan, RAPSS produces a percentage likelihood of another ACCT being opened within 90 days. The model was developed and validated using data from 1,144 individuals across 13 UK prisons, uses nine routinely collected variables, such as age and self-harm history, and is available via a free online calculator.⁸
RAPSS can identify those at higher risk of repeat suicidal acts and inform decisions around post-ACCT care. Directed support could be provided to meet identified psychosocial needs, such as referrals to mental health, pastoral/spiritual care, and peer programs. This could help to reduce future self-harm and other risky behaviors, avoid unnecessarily long periods of people on observations and restricting their activities, and improve mental health.
Innovative approaches to create more personalized rehabilitation pathways require structured, transparent ways of identifying needs and targeting support. Tools like RAPSS could offer an evidence-based approach to stratify risk and inform decisions about care – ensuring individuals receive the right support at the right time.
References
¹ Favril L, Shaw J, Fazel S. Prevalence and risk factors for suicide attempts in prison. Clin Psychol Rev 2022;97:102190.
² Hawton K, Linsell L, Adeniji T, Sariaslan A, Fazel S. Self-harm in prisons in England and Wales: an
epidemiological study of prevalence, risk factors, clustering, and subsequent suicide. Lancet. 2014;383:1147–1154.
³ Tsiachristas A, McDaid D, Casey D, et al. General hospital costs in England of medical and psychiatric care for patients who self-harm: a retrospective analysis. Lancet Psychiatry 2017;4:759–67.
⁴ Fazel S, Heathcote L, Farouki L, Senior J, Perry A, Fanshawe TR, Shaw J. Bridging assessment and
treatment for repeat suicidality in prisons: development and validation of a risk model. BMJ Ment Health. 2024;27:e301280.
⁵ Humber N, Hayes A, Senior J, et al. Identifying, monitoring and managing prisoners at risk of self-harm/
suicide in England and Wales. J Forens Psychiatry Psychol 2011;22:22–51.
⁶ Fazel S, Vazquez-Montes M, Molero Y, et al. Risk of death by suicide following self-harm presentations
to healthcare: development and validation of a multivariable clinical prediction rule (OxSATS). BMJ Ment
Health 2023;26:e300673.
⁷ Berman AL, Canning RD. Proximal risk for suicide in correctional settings: A call for priority research.
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Seena Fazel, MD, FRCPsych is Professor of Forensic Psychiatry at the University of Oxford and Director of the Centre for Suicide Research. His work focuses on the links between mental illness and outcomes such as violence, suicide, and reoffending, particularly in prison populations. He leads research on risk assessment tools (e.g. OxMIS, OxRec, RAPSS) and has contributed to national and international guidelines. He serves on the UK’s Independent Advisory Panel on Deaths in Custody.
Lisa Gunnarsson is an MRes student in the Department of Psychiatry at the University of Oxford. Affiliated with Karolinska Institutet in Sweden, she has published work on open science and on physicians’ experiences of assessing and supporting fatigued patients in primary care.
Howard Ryland, DPhil, FRCPsych is a Consultant Forensic Psychiatrist with Oxford Health NHS Foundation Trust and Honorary Senior Clinical Research Fellow at the University of Oxford. His research focuses on forensic mental health outcomes, and he developed the FORUM tool during his DPhil. He is an NIHR Researcher with the Oxford Health BRC, Editor of RCPsych CPD eLearning, and organizer of the Oxford Postgraduate Psychiatry Course. He previously held a policy fellowship at the UK Parliament.
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