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• W3044207477 abstract "Research has consistently shown that the prevalence of poor mental health among prisoners is considerably higher than that in the community. Mental health services in prisons cite several other vulnerabilities, such as substance misuse problems and poor physical health, and report high rates of self-harm behaviour.1WHONational suicide prevention strategies: progress, examples and indicators.https://www.who.int/mental_health/suicide-prevention/national_strategies_2019/en/Date: 2018Date accessed: June 19, 2020Google Scholar In prisons, little is known about the underlying mechanisms for self-harm behaviour and research on this topic is crucial to understand more about how the problem can be addressed. Louis Favril and colleagues2Favril L Yu R Hawton K Fazel S Risk factors for self-harm in prison: a systematic review and meta-analysis.Lancet Psychiatry. 2020; 7: 682-691Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar reported on the results of a systematic review and meta-analysis of four databases with the aim of identifying risk factors for self-harm in prison. The research identified 35 independent studies from 20 countries comprising a total of 663 735 prisoners. Favril and colleagues2Favril L Yu R Hawton K Fazel S Risk factors for self-harm in prison: a systematic review and meta-analysis.Lancet Psychiatry. 2020; 7: 682-691Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar grouped risk factors into five categories: sociodemographic, criminological, custodial, clinical, and historical. Across the 40 risk factors examined, the strongest associations with self-harm in prison were found for suicide-related antecedents, including current or recent suicidal ideation (odds ratio 13·8, 95% CI 8·6–22·1), lifetime history of suicidal ideation (8·9, 6·1–13·0), and previous self-harm (6·6, 5·3–8·3). Other strong associations included current psychiatric diagnosis and prison-specific environmental risk factors. Sociodemographic and criminological factors were only modestly associated with self-harm in prison. Many of the identified risk factors are similar to those found for self-harm in the general population.3Turecki G Brent DA Gunnell D et al.Suicide and suicide risk.Nat Rev Dis Primers. 2019; 5: 74Crossref PubMed Scopus (83) Google Scholar The majority of studies included in the article were case-control studies comparing someone with an incidence of self-harm (a case) to someone with no known history of self-harm behaviour (a control). Only two of the 35 studies were prospective in design. This paucity of prospective studies means that we have sparse research knowledge about how repeat self-harm behaviour in prison is affected by future life events, and how the risk of self-harm can change with the life course of an individual who might pass in and out of prison on many different occasions. Contrary to many other research studies, Favril and colleagues2Favril L Yu R Hawton K Fazel S Risk factors for self-harm in prison: a systematic review and meta-analysis.Lancet Psychiatry. 2020; 7: 682-691Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar did not find a statistical difference in self-harm behaviour between male and female prisoners, although women did have an increased risk of self-harm.4Hawton 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: 1147-1154Summary Full Text Full Text PDF PubMed Scopus (154) Google Scholar Unlike self-harm behaviour in the community, the culture of the prison environment provides exposure to experiences that are unique to being in prison. Some examples of these experiences might include solitary confinement, disciplinary infractions, victimisation, and poor social support. These findings from Favril and colleagues support other research that has focused on the general impact of the prison environment and the effect of this environment on mental health, although the quality of the published evidence in general is variable.5Walker J Illingworth C Canning A et al.Changes in mental state associated with prison environments: a systematic review.Acta Psychiatr Scand. 2014; 129: 427-436Crossref PubMed Scopus (36) Google Scholar Interventions to target self-harm and improve co-occurring mental health problems (eg, major depression and borderline personality disorder) in prison should look wider than a medicalised perspective and should involve a holistic approach. Innovative, targeted interventions to support and improve the culture, attitudes, and relationships between staff and prisoners would fit well with the current strategy in UK prisons, of which aims to support a rehabilitative culture that seeks change through procedural opportunities, such as the prisons process for behavioural punishments.6Howard FF Investigating disciplinary adjudications as potential rehabilitative opportunities.https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/661909/investigating-disciplinary-adjudications.pdfDate: 2017Date accessed: June 19, 2020Google Scholar Despite the article by Favril and colleagues2Favril L Yu R Hawton K Fazel S Risk factors for self-harm in prison: a systematic review and meta-analysis.Lancet Psychiatry. 2020; 7: 682-691Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar having many merits, the study noted several limitations. The strength of the risk estimates was likely to be overestimated because the study did not account for confounding factors, and risk factors were only linked to first-episode self-harm behaviour and repetition of self-harm behaviour might present at differing levels of risk factors. This limitation is particularly important because repetition of self-harm behaviour is known to increase the risk of eventual suicide.7Fazel S Grann M Kling B Hawton K Prison suicide in 12 countries: an ecological study of 861 suicides during 2003-2007.Soc Psychiatry Psychiatr Epidemiol. 2011; 46: 191-195Crossref PubMed Scopus (168) Google Scholar Studies from low-income and middle-income countries were absent from this article. More global research is needed to understand this topic and enable an examination of self-harm behaviour relating to the cultural and environmental differences across prison systems worldwide.8Baranyi G Scholl C Fazel S Patel V Priebe S Mundt AP Severe mental illness and substance use disorders in prisoners in low-income and middle-income countries: a systematic review and meta-analysis of prevalence studies.Lancet Glob Health. 2019; 7: e461-e471Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar Further research could examine cultural and environmental risk factors in relation to people who either go on to experience suicidal ideation in prison or self-harm in the community. This modelling might untangle how tailored interventions can help to support people who self-harm while in prison in the future.9Borschmann R Thomas E Moran P et al.Self-harm following release from prison: a prospective data linkage study.Aust N Z J Psychiatry. 2017; 51: 250-259Crossref PubMed Scopus (24) Google Scholar I declare no competing interests. Risk factors for self-harm in prison: a systematic review and meta-analysisThe wide range of risk factors across clinical and custody-related domains underscores the need for a comprehensive, prison-wide approach towards preventing self-harm in prison. This approach should incorporate both population and targeted strategies, with multiagency collaboration between the services for mental health, social care, and criminal justice having a key role. Full-Text PDF Open Access" @default.
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• W3044207477 title "Self-harm in prisons: what do we know and how can we move forwards?" @default.
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