The purposes of this study of incarcerated individuals who died by suicide between 2005 and 2014 were (1) to examine differences in demographic and precipitating/contributing factors between decedents who received any mental health treatment and decedents who did not, (2) to focus on decedents who had a history of or recent suicidal ideation/plans/attempts by examining differences in demographic and precipitating/risk factors between those who did not receive mental health treatment and those who did, and (3) to examine summary coroner/medical examiner and/or law enforcement (CME/LE) reports to better understand mental health problems and other circumstances of suicide among decedents with a reported history of or recent suicidal ideation/plans/attempts. Identification of those who did not receive mental health treatment, despite their reported suicidal ideation/plans/attempts, and understanding the circumstances of death may help increase attention to the plight of many incarcerated individuals and to the need for more effective mental health services to prevent the tragic loss of life in correctional settings.

Ideally, all incarcerated individuals with mental and substance use problems should have access to evidence-based care; however, given limited resources, suicide prevention should have top priority in order to preserve human life. In particular, those who report suicidal ideation and plans or have a history of suicide attempt should receive treatment. Hayes’s (2012) national study found that between 2005 and 2006, 77% of jails, 64% of holding facilities, and 79% of detention facilities surveyed maintained an intake screening process to identify suicide risk when individuals entered the facility. However, only 31% of respondents reported that the intake screening process included verification of whether the arresting and/or transporting officer believed that the new arrival was at risk of suicide, and only 27% reported that the intake screening process included verification as to whether the individual was on suicide precautions during any prior incarceration. Only 37% of decedents had been assessed by a qualified mental health professional prior to their deaths. In terms of suicide prevention, 93% of respondents did report following a suicide precaution protocol, that is, staff observation of suicidal individuals. Observation may help to avert suicides, but it may exacerbate mental conditions, given that it can involve stripping the individual of personal possessions and clothing, isolation from others, and being made to wear garments to prevent hangings ( Tartaro & Lester, 2009 ). Also, observation intervals (every 15 to 30 minutes) tend to be too long to be effective because death from hanging or suffocation, a highly lethal method, takes less than 10 minutes ( Elnour & Harrison, 2008 ; Tartaro & Lester, 2009 ).

In addition to single cell occupancy, prison and jail environments contribute to suicidal behaviors because of fear of the unknown, distrust of authority, perceived or real threats from other inmates, moves within and between facilities (that heighten uncertainty and fear of the unknown), removal from family and other support systems, and lack of or inadequate mental health treatment and suicide prevention services ( Hayes, 2012 ; Jordan, 2011 ; Suto & Arnaut, 2010 ). Studies have also found that suicide is highest near court hearing dates and, in urban settings, within 1 to 4 months after incarceration ( Harrison & Rogers, 2007 ; Hayes, 2012 ). This is likely due to heightened shock, shame, fear, and despair about the situation at the time of and soon after incarceration and lack of appropriate mental health care or social support. Given inadequate, discontinuous, and lack of coordinated care across health, social service, and criminal justice organizations ( Falconer et al., 2014 ), those who do receive mental health services prior to incarceration are unlikely to have continued access to care upon entering jail or prison, a time when they need it most.

Research on suicide in correctional settings points to precipitating or contributing factors that are individual or related to the incarceration environment. Individual factors include mental illness, especially mania and depression, impulsivity, sense of failure and hopelessness, feelings of guilt and/or shame related to crime, relationship issues, and other personal stressors prior to or while incarcerated ( Hayes, 2012 ; Rivlin, Hawton, Marzano, & Fazel, 2013 ; Suto & Arnaut, 2010 ). According to BJS data, 45% of inmates in federal prisons, 56% in state prisons, and 64% in local jails had mental health problems, and 40% of inmates in federal prisons, 49% in state prisons, and 60% in local jails had symptoms of a mental disorder based on Diagnostic and Statistical Manual of Mental Disorders, Fourth ed. ( DSM-IV ) criteria ( James & Glaze, 2006 ). Of those with mental health problems, about three quarters also had a history of substance abuse or dependence, and of those without mental health problems, more than half had a history of substance abuse or dependence, although most who died by suicide were not under the influence of alcohol or other substances at the time of their suicide (possession of such substances is, of course, prohibited while incarcerated; Hayes, 2012 ; James & Glaze, 2006 ). A systematic review of 34 studies (12 based in the United States) found that the factors most strongly associated with suicide among prisoners were recent suicidal ideation, history of attempted suicide, having a current psychiatric diagnosis, and single cell occupancy ( Fazel, Cartwright, Norman-Nott, & Hawton, 2008 ).

U.S. Bureau of Justice Statistics (BJS) data show that between 2001 and 2014, 4% of federal prison inmate deaths (10 per 100,000 federal prisoners) and 6% of state prison inmate deaths (16 per 100,000 state prisoners) were by suicide, and that between 2000 and 2014, 31% of all local jail inmate deaths (42 per 100,000 prisoners) were by suicide ( Noonan, 2016a , 2016b ). Suicide is the leading cause of death in local jails. BJS data also show that from 2013 to 2014, the number of suicides in state prisons increased by 30%, and the number of suicides in local jails increased 13%, reaching 50 suicides per 100,000 jail population in 2014 ( Noonan, 2016a , 2016b ). In a national study of jail suicides between 2005 and 2006, 93% of decedents were male, their average age was 35 years, and 67% were non-Hispanic White ( Hayes, 2012 ).

We used χ 2 and t tests to examine Research Question 1 (differences in demographic and precipitating/contributing factors by mental health treatment status among all incarcerated decedents). We examined Research Question 2 (differences in sociodemographic and precipitating/contributing factors by mental health treatment status among decedents with a history of or recent suicidal ideation/plans/attempts) with χ 2 and t tests and logistic regression analysis. In the logistic regression models, nonreceipt versus receipt of current mental health treatment was the dependent variable, precipitating/contributing factors were the independent variables, and sociodemographic characteristics and incident year were the control variables. Logistic regression results are reported as adjusted odds ratios ( AOR ) with 95% confidence intervals (CI). Variance inflation factor diagnostics, using a cutoff of 2.50 ( Allison, 2012 ), indicated that multicollinearity among covariates was not a concern. Research Question 3 (circumstances of suicide) was examined by reviewing summary CME/LE reports for all suicide decedents. We purposely selected 12 CME/LE reports that describe decedents’ mental health problems and circumstances of their death in some detail and summarized some of them for brevity. Given the higher suicide rates in jails than in prisons, a majority of our reports are about decedents, primarily young people, who were jailed at the time of their injury to highlight the tragic loss of lives that could have been saved with effective mental health and suicide prevention services.

Other precipitating/contributing factors ( presence = 1; absence/unknown = 0) were (1) mental illness (any disorder or syndrome listed in the DSM-IV , except alcohol and other substance use disorders, or other unspecified mental health problems identified [e.g., by self, family, or other entity] that was being treated or required treatment); (2) recent (at the time of injury) depressed mood; (3) alcohol problem; (4) other substance use problem; (5) relationship problem (e.g., with spouse/partner/family, other inmates, prison staff); (6) physical health problem; (7) death or suicide of family/friend that appears to have contributed to the death; and (8) recent (within the past month) serious crime (e.g., robbery, sexual assault), perpetration of violence, or experience of violence. In the absence of a length of stay variable, we used this latter variable as a proxy for recency of incarceration (e.g., jail/prison entry or reentry).

NVDRS links data from death certificates and includes summaries of CME/LE reports from the death scene, ongoing investigations, or family/friend accounts, and, when available, abstracts from crime lab and toxicology reports. In addition, the NVDRS includes variables on the circumstances of death that were “calculated” (yes/present or no/not present/unknown) from these multiple original data sources ( CDC, 2016a ). Some of these variables (e.g., relationship and physical health problems) are coded yes only when they were believed or appeared to have caused or led to death (i.e., were precipitating factors), while others (e.g., suicidal ideation, attempt, and intent disclosure; mental illness; depressed mood; alcohol/substance problem) are coded yes whether or not there is any indication that they directly contributed to the death (i.e., were precipitating or contributing factors; CDC, 2016b ).

Data for this study came from the 2005 to 2014 National Violent Death Reporting System (NVDRS; Blair, Fowler, Jack, & Crosby, 2016 ; Centers for Disease Control and Prevention [CDC], 2017 ). In 2005 through 2014, 16 states (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin) provided data; Ohio joined in 2011 and Michigan in 2014 ( CDC, 2016a ). We focus on suicide decedents who were in custody (inclusive of police lockups, other holding/detention facilities, jails, and prisons) at the time of their self-inflicted injury that resulted in death ( N = 1,727). Decedents incarcerated at the time of their suicide were 1.5% of all NVDRS suicide decedents between 2005 and 2014. Although 7 and 13 states, respectively, participated in the NVDRS in 2003 and 2004, we excluded data from 2003 and 2004 to minimize potential state by time confounding effects.

CME/LE reports also show that decedents were experiencing multiple life stressors that likely contributed to their suicide: for example, divorce papers served, strained relationships and/or lack of contact with family members, shame and guilt about being incarcerated, fear of other inmates and violence in prison, and hopelessness about the future. Those who had been incarcerated before often let others know that they would rather die than return to jail/prison. Some Hispanic decedents were also fearful about the prospect of being deported. Some decedents had a family history of suicide and were grieving a parent or other relative’s passing.

Table 4 provides a summary of CME/LE reports of 12 decedents (11 were jail inmates and 1 [Decedent 12] was in prison at the time of suicide). Decedent 12 was seeing a psychologist for depression and schizophrenia and prescribed medication by a psychiatrist, while CME/LE reports for most decedents who were in jail noted no mental health or substance abuse treatment at the time of injury. For example, in the case of Decedent 1, a newcomer to the correctional system, his mother and public defender had asked the court for mental health evaluation for his depression, but it was not done. Decedent 3 had expressed concerns about his suicidal behaviors and tried to keep busy and stay away from potential means (e.g., bedsheets), and Decedent 9 had been eating little due to his depression. However, CME/LE reports give no indication that they received any treatment or support to help alleviate their suicidal ruminations or behaviors. Decedent 8 had reportedly received prescription medication for depression, schizophrenia, and bipolar disorder prior to his incarceration, but his family reported that he had not been provided his medication in jail. Toxicology test results confirmed that he had not been taking any medication at the time of his injury. Decedent 10 was depressed but did not receive any medication. It appears that some jails followed a suicide precaution protocol that was mainly observation of suicidal inmates. Decedent 7 was on suicide watch after his previous suicide attempts, “but he was not on watch at the time of the incident.” Many decedents engaged in fatal injury almost immediately following their incarceration. For example, Decedent 4 was found hanging “approximately 40 minutes after being placed in a jail cell.”

Table 3 shows that among decedents with a history of or recent suicidal ideation/plans/attempts, controlling for sociodemographic and geographic distributions, those with mental illness ( AOR = 0.004, 95% CI [0.001, 0.013]) and recent depressed mood ( AOR = 0.418, 95% CI [0.204, 0.857]) had lower odds of not having received treatment. However, those with an alcohol problem ( AOR = 2.346, 95% CI [1.026, 5.364]) and those with past-month crime/violence ( AOR = 2.601, 95% CI [1.025, 6.601]) had higher odds of not having received treatment. Those with relationship problems also had marginally higher odds of not receiving treatment ( AOR = 1.963, 95% CI [0.986, 3.907], p = .055). Demographic and geographic variables, other substance use problem, and physical health problem were not significant. Incident year (2005 through 2014) was also not significant, suggesting no change in mental health service access during the study period.

Table 2 shows that of decedents with a history of or recent suicidal ideation/plans/attempts, 36.2% had received treatment at the time or shortly before their injury, and 63.8% had not received treatment. Two groups did not differ on demographic/geographic distributions. Additional analysis showed that lower proportions of treatment non receivers than receivers had mental illness, depressed mood, relationship problems, and past-month crime/violence, but the two groups did not differ on other precipitating/contributing factors. Table 2 also shows that among those with mental illness, 70.9% received treatment; among those with recent depressed mood, 45.7% received treatment; among those with relationship problems, 28.0% received treatment; and among those with past-month crime/violence, 22.9% received treatment.

Of all decedents, 21.6% were receiving mental health treatment at the time of or shortly before their suicide. Of those who received treatment, 50.4% had recent/prior suicidal ideation/plans/attempts, 97.6% had a mental illness (in the NVDRS, those who received treatment were noted as having a mental illness), 30.0% had depressed mood, 12.9% had an alcohol problem, and 26.0% had another substance use problem. These proportions were significantly higher compared to those who had not received treatment. Treatment receivers and nonreceivers did not differ on relationship problems, suicide or death of family/friend, and past-month crime/violence, or on demographic or geographic distributions.

Decedents ranged in age from 14 to 82 years, with an average age of 36.1 ( SD = 11.3; Table 1 ); 91.5% were male; and 66.9% were non-Hispanic White, 16.6% Black, 10.2% Hispanic, and 2.8% American Indian/Alaska Native. Of all, 30.1% had a history of or recent suicidal ideation, plans, or attempts; 29.9% had a diagnosed mental illness or other mental health problem; 16.6% had depressed mood at the time of injury; 9.3% had an alcohol problem; 18.3% had another substance use problem; 19.0% had a relationship problem identified as having precipitated/contributed to suicide; 4.8% had a physical health problem identified as having precipitated/contributed to suicide; 3.6% had experienced a death or suicide of a family member or friend that appeared to have contributed to the suicide; and 11.9% had been involved in crime/violence in the past month. Most (92.2%) died by hanging/suffocation using bedsheets, towels, or piece of clothes in cells where they were placed in isolation or when cellmates were not present.

Discussion

In the face of increasing suicide rates among incarcerated individuals, this study focused on decedents who were reported to have had recent or prior suicidal ideation/plans/attempts (30% of all decedents) and examined whether or not they received mental health treatment services following their incarceration. The findings show that only a little over one fifth of all suicide decedents had received mental health treatment while incarcerated. Although those with a history of or recent suicidal ideation/plans/attempts comprised one half of treatment receivers, only 36% of all those with a history of or recent suicidal ideation/plans/attempts received mental health treatment. In the majority of cases, treatment appears to have been prescription medication, although medication adherence was unknown. In any case, any treatment received appears to have been ineffective at preventing suicide among these individuals.

We assume that decedents involved in past-month crime/violence were likely to have been incarcerated recently. Although they may have been more susceptible to suicide due in part to the shock of incarceration, they were highly unlikely to have received treatment despite their reported suicidal ideation/plans/attempts. CME/LE reports generally described suicide as happening immediately or soon after jail entry/reentry and that these decedents had mental health and substance abuse problems and other life stressors and felt hopelessness about the future. Fear of the jail environment and other inmates also appears to have contributed to their despair. What is especially concerning is the tragic loss of these young lives. Many may have been able to overcome adversity had they received appropriate help, but they appeared to have been overwhelmed and despondent that their lives had taken such a turn. The losses are all the more tragic, given that many of these newcomers to correctional settings were being detained while awaiting bail arrangements, trial, or sentencing. Many are held in jail because they cannot afford bond (Aiken, 2017). The likelihood is that many would not be convicted and would be released, as only about one third of the 720,000 people in jail on a given day have been convicted and typically would be sentenced to less than a year in jail if convicted (Minton & Zeng, 2016). Studies have also shown that although most people with serious mental illness enter jail charged with minor, nonviolent crimes, they end up staying in jail for longer periods of time (Subramanian, Delaney, Roberts, Fishman, & McGarry, 2015).

This preventable loss of lives underscores the importance of suicide risk screening at or shortly after incarceration and providing necessary treatment and support. While three fourths of jails surveyed in 2005 to 2006 reported that they had suicide risk screening in place (Hayes, 2012), others found that jails lacked evidence-based suicide screening for those with mental illness (Scheyett et al., 2009). Along with evidence-based screening, prompt provision of appropriate mental health services for those at suicide risk would likely have helped these young individuals weather crises and refrain from taking their own lives. CME/LE reports also show that observation of those at suicide risk, which has been identified as the main suicide precaution protocol in jails (Hayes, 2012), was ineffective for these decedents, perhaps because they were not properly or closely monitored. Perceptions of how those who report suicidal ideation are treated may also hamper incarcerated individuals from revealing suicidal thoughts.

The study has some limitations due to NVDRS data constraints: (1) Rates of suicidal ideation/plans/attempts are likely underestimated, as unknown/unavailable information was treated as absence of the conditions. (2) Information obtained from family, staff, or other incarcerated individuals may also have been influenced by their perceptions and biases. (3) While the NVDRS contains the richest data on the largest numbers of suicide decedents in the United States, the short summary CME/LE reports often contain little information on the circumstances of suicide and are not always clear about whether the decedent was incarcerated in prison or jail. (4) Although no regional differences were found in mental health treatment rates, since less than half of the U.S. states participated during the study period, the findings may not be generalizable to all U.S. suicide decedents.

Despite these limitations, the study is consistent with previous studies that show a high suicide rate in the early stage of incarceration. Our findings underscore the urgent need for more effective suicide prevention efforts. In addition to the continued access to medications for depression and other mental disorders, psychological and other support services are needed to help these individuals process the shock, shame, and fear of incarceration and remain hopeful in the face of adversity. Second, staff need better training to screen for suicide risk/crisis and detect depressive symptoms, identify changes in behaviors (e.g., eating little, being frightened, isolating oneself), monitor those in suicidal crisis more effectively, and provide support, especially for those who are new to correctional settings. As shown in the case of Decedent 1, other inmates may be recruited and trained to help alleviate new arrivals’ sense of panic, isolation, and vulnerability due to the crisis of incarceration. Those at risk of suicide, especially those experiencing suicidal crisis that may have been triggered or exacerbated by incarceration-related or other life stressors, should also be placed with a sympathetic cellmate rather than alone in cells. Specially trained inmate “buddies” have been used in some facilities and found effective (Barker, Kõlves, & De Leo, 2014; Pompili et al., 2009). Monitoring is also particularly important during night shifts (when staffing is low) and should be constant (without lapses) for those at high suicide risk (Pompili et al., 2009) while also preserving what dignity those incarcerated have.

Third, staff should pay attention to what family members say about the incarcerated individual’s mental health and need for psychiatric evaluation and medication continuation as family members have more knowledge about their loved ones’ need. A study of individuals with suicidal ideation incarcerated in state prison also found that they wanted more contact with family and staff (although not necessarily about their suicidal ideation) as their preferred prevention approach (Way, Kaufman, Knoll, & Chlebowski, 2013). A study of prisoners who overcame suicidality found that sense of self, presence of meaning, connectedness, shift of perspective, and reestablishing control were common themes (Reading & Bowen, 2014). Fourth, the high proportion of inmates with substance abuse problems requires special attention to withdrawal symptoms that may contribute to suicidal behaviors, as CME/LE reports also indicate.

Other studies and investigations of suicides in correctional settings have pointed out the importance of linkage and collaboration with community-based mental health (and health) services and using licensed mental health professionals to conduct intake screening and provide suicide prevention services, as it is unlikely that correctional facilities have sufficient resources now or will in the future (Pompili et al., 2009; Subramanian et al., 2015; University of Texas, 2016). Community mental health agencies are also overtaxed, but collaboration with them is likely to minimize jail use and facilitate successful community reentry for detainees with severe mental illness (Sayers, Domino, Cuddeback, Barrett, & Morrissey, 2017). A review of telepsychiatry services for incarcerated individuals found that it improved their access to mental health services and at a lower cost (Deslich, Thistlethwaite, & Coustasse, 2013). Furthermore, diversion programs where nonviolent arrestees who need mental health treatment are placed in community-based mental health treatment facilities rather than jail should be implemented (Marks & Turner, 2014; Tartaro & Lester, 2009; University of Texas, 2016).