Let's Break the Silence: Suicide in Prisons- Risk Factors, Epidemiology and Prevention

Psikolojik Araştırma Perspektifleri Dergisi Journal of Psychological Research Perspectives JOPRP 3 (1) https://doi.org/10.5281/zenodo.17506576 Derleme Makale/Review Article Bu makale, araştırma ve yayın etiğine uygun olarak hazırlanmış ve iThenticate ile intihal taramasından geçirilmiştir. The Author(s). This article was prepared in line with research and publication ethics and scanned for plagiarism by using iThenticate. Let’s Break the Silence: Suicide in PrisonsRisk Factors, Epidemiology and Prevention Sessizliği Yıkalım: Cezaevi İntiharları-Epidemiyoloji, Riskler ve Önleme 1. Tuğba Görgülü 1 Abstract Suicide in prisons is a major public health and institutional concern. Incarcerated individuals face a much higher risk of suicide than the general population. This review synthesizes current literature on the epidemiology, psychosocial risk factors, and prevention of suicidal behavior among prisoners. It highlights the interplay between individual vulnerabilities (importation model) such as psychiatric disorders, past trauma, substance use, and social disadvantage and prison-specific stressors (deprivation model), including overcrowding, isolation, limited social contact, and strict disciplinary measures. Studies show that the early period of incarceration, especially the first days and weeks, is a critical window of heightened suicide risk due to adjustment difficulties, acute stress, and loss of social support. Effective prevention requires an integrated approach combining interventions for high-risk individuals, such as mental health screening, psychosocial support, trauma-informed therapy, and anger management, with broader strategies to improve prison conditions, enhance social connections, and foster a supportive environment. Strengthening family ties, promoting positive staff-inmate relationships, and providing educational, vocational, and recreational programs can further enhance resilience and reduce self-harm risk. Comprehensive strategies addressing both individual and environmental factors are essential to mitigate suicide risk. This review emphasizes the need for interdisciplinary, multi-level interventions for sustainable suicide prevention in correctional settings. Keywords: Prison Suicide, Self-harm, Incarcerated, Risk Factors, Suicide Prevention. Özet Cezaevi intiharları hem halk sağlığı hem de kurumsal bir sorundur. Mahkumlar, genel nüfusa kıyasla çok daha yüksek intihar riski altındadır. Bu derleme, mahkumlar arasında intihar davranışının epidemiyolojisi, psikososyal risk faktörleri ve önleme stratejilerine ilişkin güncel literatürü özetlemektedir. Bireysel sorunlar (ithalat/taşıma modeli); psikiyatrik bozukluklar, geçmiş travmalar, madde kullanımı ve sosyal dezavantajlar ile cezaevine özgü stres faktörleri (yoksunluk modeli), örneğin aşırı kalabalık hücreler, izolasyon, sınırlı sosyal temas ve sıkı disiplin önlemleri arasındaki etkileşim vurgulanmaktadır. Araştırmalar, özellikle tutukluluğun ilk günleri ve haftalarının, uyum zorlukları, akut stres ve sosyal destek kaybı nedeniyle intihar riskinin en yüksek olduğu kritik bir dönem olduğunu göstermektedir. Etkili önleme, yüksek riskli bireyler için mental sağlık taramaları, psikososyal destek, travma odaklı terapi ve öfke kontrolü gibi müdahalelerle, cezaevi koşullarının iyileştirilmesi, sosyal bağlantıların güçlendirilmesi ve destekleyici bir ortamın oluşturulmasını birleştiren entegre bir yaklaşım gerektirir. Aile bağlarının güçlendirilmesi, olumlu personel-mahkûm ilişkilerinin teşvik edilmesi ve eğitim, mesleki ve rekreatif programların sunulması psikolojik dayanıklılığı artırabilir ve intihar ile kendine zarar verme riskini azaltabilir. Hem bireysel hem de çevresel faktörleri ele alan kapsamlı stratejiler, intihar riskini azaltmak için esastır. Bu derleme, cezaevlerinde sürdürülebilir intihar önleme için disiplinler arası ve çok düzeyli müdahalelerin önemini vurgulamaktadır. Anahtar Kelimeler: Cezaevi İntiharı, Kendine Zarar Verme, Mahkûm, Risk Faktörleri, İntiharı Önleme. Başvuru/Submitted: 04/09/2025 Kabul/Accepted: 11/10/2025 Yayın/Online Published: 05/11/2025 Atıf/Citation: Görgülü, T. (2025). Let’s break the silence: Suicide in prisonsrisk factors, epidemiology and prevention. Journal of Psychological Research Perspectives, 3(1), https://doi.org/10.5281/zenodo.17506576 1 Doç. Dr. Anadolu Üniversitesi, Edebiyat Fakültesi, Psikoloji Bölümü, Eskişehir, Türkiye, [email protected] Let’s Break the Silence: Suicide in PrisonsRisk Factors, Epidemiology and Prevention Suicidal behavior, defined as an intentional self-directed act that may or may not result in death, has been increasing worldwide, with nearly 800,000 deaths by suicide reported each year. Epidemiological data show that suicide rates have risen by approximately 30% over the past two decades, making suicide the tenth leading cause of death across all age groups. Suicide is the most common cause of death among young people and the second leading cause of death among 15-29-year-olds, after traffic accidents and other unnatural causes (Fleischmann & De Leo, 2014; WHO, 2025). A previous suicide attempt is recognized as one of the strongest predictors of future suicidal behavior. Researches indicate that a significant proportion of individuals who engage in an initial suicide attempt are likely to repeat such behavior within the following year, with some studies reporting recurrence rates approaching 50% (Bostwick et al., 2016; Schmidtke et al., 1996). This highlights the importance of understanding suicidal behavior not merely as an isolated psychological crisis, but as a complex phenomenon emerging from the interaction of multiple personal, social, and environmental risk factors. Suicide rates in prisons are considerably higher than in the general population. Life in prisons is shaped by various social, psychological, and environmental factors that create significant risks to inmates’ mental health. Researches indicate that suicide behavior among male inmates is three to eight times higher than in general population, while among female inmates it is ten times higher (Fazel et al., 2017). Approximately 80 % of prisoners are reported to be at significant risk of suicide (Görgülü & Tutarel-Kişlak, 2014). This risk is particularly elevated during the initial days of incarceration. Considering the psychosocial risks within prisons, it is estimated that approximately 10% of inmates engage in at least one self-harming behavior during their incarceration (Favril et al., 2022). This phenomenon can be linked to individual-level psychiatric and social factors such as depression, anxiety, substance use, past trauma, limited social support, and loneliness (Angelakis et al., 2020b; Görgülü & Tutarel-Kişlak, 2014). At the institutional level, Görgülü environmental conditions including single-cell confinement, restricted visitation opportunities, lack of meaningful activities, and absence of privacy also contribute to the occurrence of such behaviors (Huey & McNulty, 2005; Larney & Farrell, 2017). The existing literature indicates that the phenomenon of suicide in prisons has been predominantly studied in high-income countries. In contrast, systematic and comparable data from lowand middle-income regions remain scarce (Fazel et al., 2011; Mundt & Baggio, 2024). This gap hinders the development of effective suicide prevention strategies at both national and global levels. Effective interventions should not be limited to individual psychological support and treatment. They should also include staff training, risk assessment systems, improvements in prison conditions, and the strengthening of social support networks. Limited access to mental health services and structural challenges in many countries, including Turkiye, pose additional obstacles to these initiatives. Therefore, preventing suicide in prisons should be approached as a multidimensional process requiring interdisciplinary collaboration and comprehensive institutional interventions. Within this context, the present study examines the definition of suicidal behavior, epidemiological findings, and key suicide risk factors in prisons, while offering recommendations for effective and sustainable prison suicide prevention policies. Suicide Risk Factors in Prisons Prison suicide is one of the most significant mental health challenges faced by correctional systems worldwide. International data indicate that the risk of suicide among inmates is 5-10 times higher than in the general population (Bachmann, 2018). The initial days of detention are particularly critical, representing the period of the highest risk (Radeloff et al., 2021). Two main approaches have been proposed to understand this risk. Those are the Importation Model and Deprivation Model. These models represent two fundamental theoretical perspectives on the patterns of response to imprisonment (Schwartz, 1971; Thomas & Foster, 1973). The Importation Model focuses on individual characteristics and psychiatric factors from a psychological and public health perspective, while the Deprivation Model Let’s Break the Silence: Suicide in PrisonsRisk Factors, Epidemiology and Prevention emphasizes the negative conditions created by the prison environment from a sociological and criminological perspective. The psychological perspective identifies factors such as depression, anxiety, substance use, trauma history, and genetic vulnerability as key contributors to suicide risk. In contrast, the sociological approach highlights that inmates often come from disadvantaged social backgrounds. Adverse prison conditions, such as overcrowded cells, social isolation, limited communication, and strict disciplinary measures, increase psychological pressure and can trigger suicidal behavior. The two principal theoretical approaches explaining suicide in prisons are examined in the following sections. Importation Model: Psychological and Public Health Perspective Within the framework of the Importation Model, inmates already possess certain risk factors before entering prison. Suicidal behavior, in this context, is largely independent of the prison environment and is primarily associated with pre-existing psychological conditions and social disadvantages. In other words, these individuals represent a high-risk and socially disadvantaged population. Considering the widespread prevalence of mental disorders and various psychosocial difficulties among prisoners, the Importation Model emphasizes the importance of identifying and addressing these vulnerabilities early in the incarceration process (Molina-Coloma et al., 2021). The Importation Model offers a compelling and coherent explanatory framework for understanding suicide in correctional settings. In this context, the risk factors emphasized by this model are as follows: Suicide ideation, self-harm and suicide attempts Among the strongest predictors of suicidal behavior are suicidal ideation, a history of self-harm, and previous suicide attempts (Liu et al., 2022). Suicidal thoughts that involve planning and concrete preparations represent the most critical risk factors for suicidal behavior, particularly when accompanied by feelings of hopelessness and helplessness (Bauer et al., 2022; Görgülü, 2020). In prison populations, this risk is significantly higher compared to the general population. Approximately 33% of prisoners report suicidal ideation, while 9% have made at least one attempt during incarceration. Suicide attempt rates are 12.2% among Görgülü men and 8.6% among women in prisons (Favril et al., 2020; Favril et al., 2022). Furthermore, 19-22% of incarcerated individuals have attempted suicide at some point in their lives which is a high risk for suicide. The risk is particularly elevated in the initial weeks of imprisonment due to acute stress and adjustment difficulties (Radeloff et al., 2021), with suicide rates reaching nearly 10 times higher than those of the population. Psychiatric disorders Psychiatric disorders are among the most significant determinants of high-risk behaviors, with mood disorders representing particularly strong predictors. Major depression and bipolar disorder are frequently linked to an increased risk of suicide, with approximately 15% of individuals with depression exhibiting related high-risk behaviors, and 50-60% of those who died by suicide having a history of major depressive disorder (Angst et al., 1999; Jeon, 2011). In Canadian correctional facilities, the lifetime prevalence of depression among prisoners ranges from 21.5% to 29.8% (Boothby & Durham, 1999). Substance use disorders further amplify this risk, particularly when co-occurring with depressive symptoms. Nearly half of the individuals who died by suicide were reported to have a history of substance use (Schneider, 2009). Among inmates, substance use is highly prevalent, with tobacco use reported in 72%, alcohol use in 26-39%, and illicit drug use in 64% of individuals (Butler et al., 2003). Borderline Personality Disorder, characterized by emotional dysregulation, impulsivity, and fear of abandonment, is also a significant risk factor, with 9-33% of affected individuals having engaged in high-risk behaviors at least once in their lifetime. In prison populations, the prevalence of psychiatric disorders is markedly higher than in the general population. Conditions such as depression, bipolar disorder, substance use disorders, and borderline personality disorder occur several times more frequently among inmates (Armoon et al., 2021; Mundt & Baggio, 2024). The high prevalence of these psychiatric and substancerelated conditions contributes substantially to the elevated incidence of high-risk behaviors within correctional settings. Let’s Break the Silence: Suicide in PrisonsRisk Factors, Epidemiology and Prevention Neglect and abuse A considerable proportion of offenders have experienced such adversities during childhood and adolescence, which are widely recognized as major contributors to long-term psychosocial difficulties (Angelakis et al., 2020b; Capuzzi et al., 2021). Empirical evidence consistently demonstrates that early traumatic experiences, particularly recurrent abuse, undermine self-concept and foster feelings of worthlessness, guilt, and helplessness, thereby increasing vulnerability to both criminal and self-destructive behaviors (Angelakis et al., 2020a; Kaplan et al., 1997). Emotional and behavioral problems commonly observed among trauma survivors, such as anger, impulsivity, and aggression, may further facilitate criminal involvement and elevate the risk of self-harm. The prison environment intensifies this vulnerability, as isolation, punitive conditions, and limited social ties often reactivate earlier feelings of insecurity and helplessness (Armour, 2012). For inmates without adequate family or social support, these conditions may erode coping capacities and increase susceptibility to self-injurious or suicidal behaviors, positioning childhood trauma as a critical determinant of both offending and suicide risk. Physical and mental health problems Chronic illnesses and infectious diseases, such as HIV and hepatitis C, occur at rates of 5-10% among prisoners, substantially higher than in the general population (Weyant et al., 2023). Psychiatric disorders and substance use are also widespread among inmates, and the prevalence of these problems is significantly higher than in the general population. The combination of social disadvantage and health problems makes prisoners more psychologically vulnerable and less able to cope with stress. This underscores the urgent need for comprehensive interventions at multiple levels, including improvements in education, social support, healthcare access, and living conditions within prisons. Social factors and health problems One of the risk factors for the Importation Model is social factors and health problems among prisoners. Prisons predominantly house socioeconomically disadvantaged and Görgülü vulnerable individuals. Around 60% of inmates have not completed high school (Harlow, 2003), while in the United Kingdom, over 30% enter prison living at or near the poverty line, and nearly 20% of prisoners in several countries lack stable housing prior to incarceration (Greenberg & Rosenheck, 2008). These negative factors represent key structural vulnerabilities for inmates. Deprivation Model: Structural and Institutional Risk Factors The elevated risk of suicide among incarcerated individuals is shaped not only by preexisting psychopathological vulnerabilities or adverse life experiences prior to imprisonment but also by the structural and social conditions within correctional facilities. Empirical research highlights that suicide in prisons is a multidimensional phenomenon, arising from the dynamic interplay between individual susceptibilities and environmental stressors inherent in institutional contexts (Mazher & Arai, 2025). The Deprivation Model has been widely used to explain these institutional influences, emphasizing that solitary confinement, restricted social support, high-security environments, and the intake process significantly increase suicide risk (Thomas, 1977). According to this model, the loss of autonomy combined with deprivation of fundamental human needs, such as freedom, safety, privacy, and meaningful social interaction, can produce profound and enduring psychological consequences (Hayes, 1995). Newly admitted inmates are particularly vulnerable, as they are often separated from family, lose prior social supports, and experience abrupt disruptions to their daily routines. These deprivations undermine social identity, belonging, and self-worth, and research indicates that such restrictions are strongly associated with heightened depressive affect and increased susceptibility to suicidal behavior (Miller, 1994). Environmental stressors commonly observed in prisons, such as overcrowded cells, excessive noise, lack of privacy, and limited physical space, further strain psychological resilience and intensify mental health difficulties. In addition, the absence of meaningful activities and restricted opportunities for social engagement can exacerbate feelings of boredom, helplessness, and despair. Chronic stress, adaptation challenges, and emotional Let’s Break the Silence: Suicide in PrisonsRisk Factors, Epidemiology and Prevention exhaustion within the prison context are consistently identified as some of the most significant institutional determinants of suicide (Huey & McNulty, 2005). High-security facilities are particularly concerning, as the combination of strict routines, continuous surveillance, and reduced autonomy amplifies social isolation and psychological strain. Moreover, the prison intake process itself constitutes a critical period of vulnerability. During the initial days and weeks of incarceration, inmates frequently experience shock, anxiety, uncertainty, and disorientation (D'Orta et al., 2022; Reinhardt & Rogers, 1998). These conditions can precipitate acute psychological distress, especially for individuals with pre-existing mental health issues or prior trauma exposure. Limited access to social support during this period can further compromise coping capacity, increasing the likelihood of selfharm or suicidal behavior (Radeloff et al., 2021). Prison intake process and maladjustment The initial period of incarceration constitutes a critical high-risk phase for inmates and is frequently associated with elevated suicide risk. Newly admitted individuals experience not only the loss of personal freedom but also heightened uncertainty, fear, and anxiety regarding their immediate and future circumstances. During this period, intense emotional reactions such as shock, anger, helplessness, and acute distress are common and may increase susceptibility to self-harming behaviors (Hayes, 1995). Adjustment challenges are compounded by unfamiliarity with institutional rules, procedures, and social dynamics, as well as the need to navigate a novel and often stressful environment. These factors contribute to heightened psychological vulnerability, with the first weeks of incarceration representing a particularly high-risk for suicide ideation and suicidal behavior (Radeloff et al., 2021). Given these risks, the implementation of structured psychosocial support programs for newly admitted inmates is essential (Calear et al., 2016). Such programs should provide orientation to institutional routines, deliver emotional and social support, and facilitate the development of adaptive coping strategies. Interventions may include mentorship schemes, group therapy sessions, and regular psychological counseling, Görgülü all designed to enhance resilience and reduce vulnerability. A robust intake support framework enables early identification of high-risk individuals, facilitates adaptation to the prison environment, and ensures rapid intervention in crisis situations. Accordingly, targeted measures during the intake process play a pivotal role in mitigating suicide risk at both the individual and institutional levels. Lack of social support and effect of social isolation One of the most critical predictors of suicidal behavior is the weakness of social support mechanisms. Social support not only fulfills individuals’ emotional needs but also strengthens their capacity to cope with stress, thereby serving as a protective buffer against adverse life events (Hou et al., 2022). Within prison settings, the weakening of ties with family members and social networks often intensifies feelings of loneliness and helplessness. In particular, inmates who lack support systems or who have fragile family relationships are at greater risk for suicide (Marzano et al., 2016). In correctional environments, social support extends beyond family and peer relationships. Interactions with prison staff also constitute an essential component of this process. Experiencing acceptance and fair treatment from staff can enhance inmates’ sense of self-worth. Conversely, being subjected to exclusion, belittlement, arbitrary disciplinary practices, or hostile attitudes can foster feelings of worthlessness and hopelessness, thereby elevating suicide risk. Research indicates that supportive staff attitudes mitigate loneliness, enhance self-esteem, and contribute to the development of psychological resilience among inmates (Marzano et al., 2016; Pratt & Foster, 2020). 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