Led by Dr Seena Fazel and Professor Keith Hawton from the University of Oxford in the UK, the study examined the prevalence of self-harm in all prisoners in England and Wales between 2004 and 2009—a total of 139 195 incidents of self-harm, involving 26 510 inmates. Risk factors for self-harm were assessed and compared with those of the general prison population, and associations with suicide examined.
Despite reductions in suicide rates over the 6-year study period, incidents of self-harm in custody did not decrease, and ranged from about 20 000 to 25 000 per year, with women accounting for roughly half of these incidents.
Incidents of self-harm were 10 times higher in female than in male prisoners—with 20–24% of female prisoners and 5–6% of male inmates self-harming every year—and around 30 times that of the general population of the UK (0.6%).
"Repetition rates were striking—if a female prisoner self-harmed, she would self-harm eight times per year, and there were 102 women (and two male) inmates who self-harmed more than 100 times per year", explains Dr Fazel, a Wellcome Trust Senior Research Fellow.
The researchers found that several factors increased the risk of self-harm in both sexes, including: younger age (<20 years), being white, and being unsentenced or having a life sentence. Among female prisoners, having committed a violent offence was also a factor.
Cutting and scratching were the most common methods of self-harm in both sexes, followed by poisoning, overdose, or swallowing objects not intended for ingestion among men and teenage boys (9%), and self-strangulation in women and adolescent girls (31%).
Importantly, self-harm in prison was also found to be a strong risk factor for suicide in prison, particularly among male inmates—with an annual suicide rate among male prisoners who self-harm (334 per 100 000) around four times that of the general male prison population (79 per 100 000).
According to Dr Fazel, "While self-harm is a substantial problem across the board, it is a particularly serious issue for women in prison who make up only 5% of the prison population but account for half of all self-harm incidents. Moreover, now we know the extent to which the risk of subsequent suicide in prisoners who self-harm is greater than the general prison population, suicide prevention initiatives should be changed to include a focus on prisoners who are self-harming, especially repeatedly."
Writing in a linked Comment, Dr Andrew Forrester from Kings College London, London, UK and Dr Karen Slade from Nottingham Trent University, Nottingham, UK call for more research to address the questions of 'why' and 'what works' to reduce the stagnating self-harm rate in prisons, writing that, "Despite clear gains in the care of prisoners and prevention of self-harm and suicide in prisons in England and Wales, much work remains to be done…[the] available evidence indicates a key role for multi-agency collaboration, in which "suicide is everyone's concern", rather than being the sole preserve of health-care staff… We need to invest in the wide inclusion of all people who, on the ground, can listen to prisoners who are experiencing distress, mobilise concern, and help to deliver joined-up care."
More information: www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62118-2/abstract