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RESEARCH ARTIC LE Open Access
A cross-sectional survey of prevalence and
correlates of suicidal ideation and suicide
attempts among prisoners in New South Wales,
Australia
Sarah Larney
1,2*
, Libby Topp
3
, Devon Indig
1,4
, Colmán O’Driscoll
5,6
and David Greenberg
5,6
Abstract
Background: We aimed to estimate the prevalence of suicidal ideation and suicide attempt among prisoners in
New South Wales, Australia; and, among prisoners reporting suicidal ideation, to identify factors associated with
suicide attempt.
Methods: A cross-sectional design was used. Participants were a random, stratified sample of 996 inmates who
completed a telephone survey. The estimated population prevalence of suicidal ideation and suicide attempt were
calculated and differences by sex and Aboriginality were tested using c2 tests. Correlates of suicidal ideation and
suicide attempt were tested using logistic regression.
Results: One-third of inmates reported lifetime suicidal ideation and one-fifth had attempted suicide. Women and
Aboriginal participants were significantly more likely than men and non-Aboriginal participants, respectively, to
report attempting suicide. Correlates of suicidal ideation included violent offending, traumatic brain injury,
depression, self-harm, and psychiatric hospitalisation. Univariate correlates of suicide attempt among ideators were
childhood out-of-home care, parental incarceration and psychiatric hospitalization; however, none of these
remained significant in a multivariate model.
Conclusions: Suicidal ideation and attempts are highly prevalent among prisoners compared to the general
community. Assessment of suicide risk is a critical task for mental health clinicians in prisons. Attention should be
given to ensuring assessments are gender- and culturally sensitive. Indicators of mental illness may not be accurate
predictors of suicide attempt. Indicators of childhood trauma appear to be particularly relevant to risk of suicide
attempt among prisoners and should be given attention as part of risk assessments.
Background
Suicide in prison is a major concern, occurring at 3-8
times the rate seen in the general community [1]. Risk
factors for suicide, such as mental illness, substance use
disorders and impulsivity are highly prevalent among pris-
oners [2-4], and inmates import these risk factors into the
correctional setting [5]. The powerlessness and social
exclusion experienced in prison may also contribute to
suicidal behaviour [6,7].
Prison suicides are associated with many of the same
riskfactorsasseeninsuicidesmoregenerally,suchas
prior suicidal ideation and suicide attempts; mental illness;
substance use disorders; and self-harming behaviours
[3,7-12]. Suicide risk factors specific to correctional set-
tings have also been identified, such as unsentenced status
(i.e. on remand) [3,13]; housing in single-occupancy cells
[3]; and conviction for a violent offence [14]. The initial
stages of incarceration are a period of particularly high sui-
cide risk; in the United Kingdom and Australia, one in ten
completed suicides in prison occur within the first twenty-
four hours of imprisonment, and one-third within the first
week [7,12]. The acute intoxication effects of alcohol and
* Correspondence: s.larney@unsw.edu.au
1
Centre for Health Research in Criminal Justice, Justice Health and Forensic
Mental Health Network, Sydney, Australia
Full list of author information is available at the end of the article
Larney et al.BMC Public Health 2012, 12:14
http://www.biomedcentral.com/1471-2458/12/14
© 2011 Larney et al ; licensee BioMed Central Ltd. This is an Open Access art icle distributed under the terms of the Creative Commons
Attribution License (http://creative commons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, pro vided the original work is properly cited.
other drugs, such as reduced inhibitions and increased
impulsivity, may contribute to suicide risk during this time
[7,15].
Of particular concern in the Australian context is sui-
cide among Aboriginal inmates. Aboriginal and Torres
Strait Islander persons make up 2.5% of the Australian
population, but 26% of prisoners, and are incarcerated at
14 times the rate of non-Indigenous persons [16,17]. Indi-
genous Australians have a significantly higher suicide rate
than non-Indigenous persons [18]; however, a previous
study of New South Wales (NSW) prisoners found no
association between Aboriginality and a history of suicidal
ideation or attempts [19]. To our knowledge, no other
studies have examined correlates of suicidality among
Australian prisoners, although a clinical audit found a high
prevalence of established risk factors in completed suicides
(e.g. substance use disorders; histories of self-harm; single
cell accommodation) [12].
The high prevalence of suicide risk factors among pris-
oner populations means that these factors are of limited
use in discriminating individuals at risk of suicide attempt
[13,20]. As such, the clinical task of predicting and conse-
quently preventing suicide attempts in prison remains pro-
blematic [20,21]. Given the close relationship between
suicidal ideation and completed suicide among prisoners
[3], understanding suicide risk in prison requires a greater
understanding of the prevalence of suicide attempts in
relation to suicidal ideation, and risk factors for suicide
attempt in the presence of ideation. Therefore, this study
aimed to:
1. Estimate the 12-month and lifetime population pre-
valence of suicidal ideation and attempt among prisoners
in NSW;
2. Identify factors associated with lifetime suicidal
ideation; and
3. Identify factors associated with lifetime suicide
attempt among prisoners reporting lifetime suicidal
ideation.
Methods
Reporting of this study is in accordance with the
Strengthening the Reporting of Observations Studies in
Epidemiology (STROBE) statement [22].
Data were sourced from the 2009 Inmate Health Survey
(IHS), a cross-sectional survey of the health and wellbeing
of prisoners in NSW, Australia. NSW is Australia’smost
populous correctional jurisdiction, housing 37% of the
country’s prisoners [16]. Full methodological details for
the IHS are provided elsewhere [23]. Briefly, between May
2008 and March 2009 a random sample of inmates strati-
fied by age, gender and Aboriginal status was recruited
from 30 adult correctional centres. Women and Aborigi-
nal inmates were oversampled to allow credible estimates
of low-prevalence conditions in these sub-populations.
Inmates were excluded from participation if they did not
speak sufficient English or had an intellectual disability or
mental illness that prevented them from providing
informed consent, or were aged under 18 years.
The survey instrument was administered via telephone,
with interviewers entering inmate responses directly into a
computer database. Participants were reimbursed AU$10
for their involvement. Approvals for the IHS were granted
by the Justice Health Human Research Ethics Committee,
the Corrective Services NSW Research Ethics Committee
and the Aboriginal Health and Medical Research Council
Ethics Committee.
Measures
Suicidal ideation was assessed by asking participants “have
you ever thought about suicide?”. Participants who
reported suicidal ideation were asked “When did you last
think about suicide?”. Suicide attempts were assessed by
asking participants “have you ever thought about suicide?”,
with participants who responded yes asked “Thinking
about your last suicide attempt, how long ago did this
occur?”. Participants did not need to endorse suicidal idea-
tion to be asked if they had attempted suicide.
Variables explored for their relationship to suicidality
were measured using standardised measures and stand-
alone questions specific to this survey [23]. Aboriginal sta-
tus was based on self-reported identification. Self-harm
was defined as deliberately harming or injuring oneself,
excluding suicide attempts. ‘Regular illicit drug use’was
defined as using illicit drugs on a daily or almost daily
basis in the 12 months prior to incarceration. Traumatic
brain injury (TBI) was defined as a head injury resulting in
unconsciousness [24]. Participants scoring 17 or greater
on the Beck Depression Inventory [25] were classified as
having moderate/severe depression. The Alcohol Use Dis-
orders Identification Test [26] was modified so as to refer
to alcohol consumption in the 12 months prior to the cur-
rent incarceration, with a score of 8 or more indicative of
harmful alcohol use during this period.
Statistical analysis
Statistical analyses were undertaken in SAS 9.2 [27].
Survey analysis procedures were used to adjust for the
sample design. Sample weights were calculated as the
inverse of the probability of being selected to participate
in the survey and adjusted for non-response. The cor-
rectional centre in which the inmate was incarcerated
was incorporated into analyses as a cluster variable to
account for potential similarities between inmates
housed in the same centre.
Weighted prevalence estimates of 12-month and life-
time suicidal ideation and suicide attempt were calcu-
lated for the total prison population and by gender and
Aboriginality. Differences between groups were tested
Larney et al.BMC Public Health 2012, 12:14
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using c
2
tests. Correlates of lifetime suicidal ideation
were tested at the univariate level using logistic regres-
sion, with all variables significant at the p≤.05 level
entered into a multivariate logistic regression model.
Thesamemodellingstrategywasusedtoexaminecor-
relates of lifetime suicide attempt among participants
reporting lifetime suicidal ideation.
Results
Of 1166 inmates randomly approached to participate,
996 agreed, yielding a response rate of 85.4%. Women
comprised 20% (n = 199) of participants, and 31% (n =
312) of participants self-identified as Aboriginal.
Prevalence of suicidal ideation and suicide attempts
The lifetime prevalence of suicidal ideation among NSW
inmates was 33.7%, and of suicide attempt was 20.5%
(Table 1). There was no gender difference in terms of
prevalence of suicidal ideation; however, women were
significantly more likely than men to report a lifetime
suicide attempt (28.7% vs. 19.9%, p= .03). Similarly, there
was no difference in suicidal ideation between Aboriginal
and non-Aboriginal inmates; however, Aboriginal
inmates were significantly more likely than non-Aborigi-
nals to report a lifetime suicide attempt (26.9% vs. 18.7%,
p= .01), and were more than twice as likely to have
attempted suicide in the previous 12 months (4.4% vs.
2.1%, p= .03).
As expected, there was a strong association between
suicidal ideation and suicide attempt. More than half
(57.5%; 95% CI 51.0%-64.0%) of participants reporting
lifetime suicidal ideation reported a lifetime suicide
attempt. Almost all participants (94.8%; 95% CI 91.6%-
97.9%) reporting a lifetime suicide attempt also reported
lifetime suicidal ideation.
Correlates of lifetime suicidal ideation
In univariate analyses, lower education levels, childhood
experiences of out-of-home care, harmful alcohol use
and regular illicit drug use in the 12 months prior to
incarceration were significantly associated with increased
odds of lifetime suicidal ideation. None of these variables
retained significance in the multivariate model. In the
multivariate model, older age, having a violent offence as
one’s most serious offence, a history of TBI, BDI scores
indicative of moderate to severe depression, and self-
harm without suicidal intent were all associated with sig-
nificantly increased odds of lifetime suicidal ideation
(Table 2).
Correlates of suicide attempt among participants
reporting suicidal ideation
As shown in Table 3, in univariate analyses, a history of
out-of-home care, parental incarceration, TBI, and mod-
erate/severe depression were associated with suicide
attempt among participants who reported suicidal idea-
tion. In the multivariate analysis, none of these variables
retained statistical significance.
Discussion
Population prevalence estimates
Suicidal ideation and suicide attempts are common among
people in NSW prisons. An estimated 33.7% of prisoners
in NSW have had suicidal thoughts during their lifetime,
while 20.5% report suicide attempts. In comparison, 13.3%
of Australian adults in the 2007 National Survey of Mental
Health and Wellbeing reported lifetime suicidal ideation,
and 3.2% reported a suicide attempt [28]. As in the general
population, a greater proportion of women than men had
attempted suicide; however, prevalence was greatly ele-
vated above that seen in the general population for both
women (28.7% vs. 4.4%) and men (19.9% vs. 2.1%) [28].
The finding that women prisoners in particular are vulner-
able to suicide attempts highlights the need for gender-
specific suicide prevention interventions. Women in
prison frequently have extensive trauma histories and mul-
tiple psychiatric co-morbidities [29-31]; addressing the
range of traumas experienced by women in prison is likely
an important component of effective suicide prevention
for this group [24,30,31].
A significantly greater proportion of Aboriginal than
non-Aboriginal inmates had attempted suicide. Although
this is in line with general population data demonstrating
higher rates of completed suicide among Aboriginal than
Table 1 12-month and lifetime prevalence of suicidal ideation and suicide attempts among NSW inmates
% (95% confidence interval)
Men Women Non-Aboriginal Aboriginal All persons
Suicidal ideation
12-month 9.1 (6.6-11.7) 10.8 (5.6-16.1) 8.7 (5.8-11.5) 11.3 (7.8-14.8) 9.3 (6.9-11.6)
Lifetime 33.4 (28.9-37.8) 38.7 (33.3-44.1) 32.8 (27.8-37.8) 37.0 (30.8-43.3) 33.7 (29.5-37.9)
Suicide attempt
12-month 2.5 (1.5-3.5) 3.8 (1.3-6.2) 2.1 (1.1-3.1) 4.4 (2.0-6.9)
#
2.6 (1.6-3.6)
Lifetime 19.9 (16.0-23.7) 28.7 (20.8-36.7)* 18.7 (14.4-23.0) 26.9 (21.7-32.0)
#
20.5 (16.8-24.1)
*Statistically significant (p< .05) difference between men and women.
#
Statistically significant (p< .05) difference between non-Aboriginal and Aboriginal persons
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non-Aboriginal Australians [18], this result nevertheless
contrasts with the findings of a previous study in the
same prison system that found no relationship between
Aboriginality and suicide attempts [19]. There are several
potential explanations for this discrepant finding. There
may have been genuine changes over time in the preva-
lence of suicidality among Aboriginal and/or non-
Aboriginal inmates. Alternatively, the use of a telephone
interview in the current study, as opposed to a face-to-
face interview in the earlier study, may have influenced
responding. Finally, the earlier study derived its sample
by combining a subset of a random sample with new
receptions to prison [19]. This sampling strategy may
have obscured differences in suicidality between Aborigi-
nal and non-Aboriginal inmates that became apparent
when using a more strictly selected sample.
Suicide among Australian Aboriginal people is a com-
plex phenomenon, influenced by individual and commu-
nity-level psychological distress, inter-generational trauma
and social marginalisation [32,33]. Although research is
limited, there are suggestions that compared to non-
Aboriginal persons, mental illness has less influence, and
situational factors more influence, on Aboriginal suicide
[32,34]. Culturally appropriate suicide risk assessments
Table 2 Correlates of lifetime suicidal ideation in NSW prisoners
Univariate Multivariate
OR (95% CI) pAOR (95% CI) p
Female 1.26 (0.93-1.70) .13
Aboriginal 1.20 (0.85-1.70) .29
Age > 33 years 1.55 (1.13-2.14) .007 2.20 (1.56-3.12) < .0001
Year 10 education or above 0.64 (0.47-0.89) .007 0.89 (0.60-1.33) .57
Out-of-home care aged < 16 1.78 (1.33-2.39) < .0001 1.23 (0.91-1.66) .18
Juvenile detention history 1.34 (0.96-1.87) .08
Parental incarceration 0.93 (0.57-1.52) .77
Remand inmate 1.10 (0.66-1.82) .73
Violent offender 1.62 (1.17-2.25) .004 1.62 (1.13-2.32) .008
Harmful alcohol use 1.65 (1.21-2.23) .001 1.26 (0.84-1.88) .27
Regular illicit drug use 1.39 (1.08-1.79) .01 1.26 (0.92-1.71) .15
Traumatic brain injury 2.00 (1.34-3.00) .0007 1.67 (1.08-2.58) .02
Moderate/severe depression 3.36 (2.59-4.35) < .0001 3.06 (2.25-4.17) < .0001
Self-harm without suicidal intent 10.93 (6.85-17.47) < .0001 9.81 (5.58-17.23) < .0001
OR = Odds ratio. AOR = Adjusted odds ratio (adjusted for all other factors in the multivariate model).
Table 3 Correlates of lifetime suicide attempt among NSW inmates reporting lifetime suicidal ideation
Univariate Multivariate
OR (95% CI) pAOR (95% CI) p
Female 1.59 (0.72-3.52) .25
Aboriginal 1.60 (0.96-2.66) .07
Age > 33 years 0.78 (0.45-1.33) .36
Year 10 education or above 0.87 (0.54-1.39) .55
Out-of-home care aged < 16 2.20 (1.29-3.74) .004 1.82 (0.98-3.36) .06
Juvenile detention history 1.72 (0.92-3.21) .09
Parental incarceration 2.38 (1.24-4.58) .009 2.05 (0.99-4.21) .05
Remand inmate 1.36 (0.85-2.17) .20
Violent offender 1.12 (0.68-1.86) .67
Harmful alcohol use 0.93 (0.50-1.73) .82
Regular illicit drug use 1.15 (0.63-2.09) .67
Traumatic brain injury 1.76 (0.99-3.08) .05 1.55 (0.88-2.73) .13
Moderate/severe depression 1.58 (0.99-2.48) .05 1.38 (0.85-2.26) .20
Self-harm without suicidal intent 1.46 (0.87-2.45) .16
OR = Odds ratio. AOR = Adjusted odds ratio (adjusted for all other factors in the multivariate model).
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and interventions are therefore needed, as generic
approaches may not identify Aboriginal prisoners at risk,
or address their specific risk factors.
Correlates of suicidal ideation
Despite the greater prevalence of suicide attempts among
women and Aboriginal inmates, gender and Aboriginality
were not in themselves risk factors for suicidal ideation.
Rather, psychiatric factors - depression and self-harm
without suicidal intent - were the strongest correlates of
suicidal ideation, highlighting the importance of providing
adequate mental health services in prison.
A history of TBI was associated with increased odds of
suicidal ideation. An association between TBI and suicidal-
ity has previously been reported in general population
samples [35]. As with other factors associated with suicidal
ideation, the prevalence of TBI is elevated in prisoner
populations [24]. It is thought that TBI increases the risk
of suicide via two pathways; the injury itself may act as a
stressor, precipitating suicidal ideation, and increased
impulsivity as a result of the injury may increase the ten-
dency to act on suicidal thoughts [36]. Impulsivity may
also underlie the observed association between suicidal
ideation and violent offending [15].
Although problematic substance use has been associated
with suicidal ideation in general population samples [37],
in this prisoner sample neither hazardous alcohol use nor
regular pre-incarceration illicit drug use were associated
with suicidal ideation in the multivariate analysis. At least
one other study of suicidal ideation in prisoners has
reported a lack of association with alcohol and drug use
[13]. The high prevalence of problematic substance use
among prisoners may mean that it is not a useful predictor
of suicidality in this population.
Suicide attempts among ideators
Over half of participants who reported suicidal ideation
also reported a suicide attempt, confirming the importance
of suicidal ideation in identifying prisoners most at risk of
suicide attempt. Suicide attempt in the absence of suicidal
ideation was rare. It could be argued that a suicide attempt
cannot occur in the absence of suicidal ideation [38]; how-
ever, it is possible that some participants perceive their
suicide attempt/s as impulsive acts that occurred in the
absence of formal thoughts about suicide.
The analysis reported in Table 3 was aimed at identify-
ing factors that may be clinically useful in identifying
who, of the large number of people in prison reporting
suicidal ideation, may be more likely to attempt suicide.
Inthemultivariateanalysis,noneoftheassessedfactors
were statistically significant; however, the odds ratios
associated with parental incarceration and out-of-home
care as a child neared significance. These factors may be
indicators of childhood trauma, which itself is strongly
associated with suicide attempts [39]. Parental incarcera-
tion and out-of-home care may be clinically relevant
indicators of risk of suicide attempt, but a more direct
measurement of childhood trauma would allow for better
understanding of this relationship.
Research on general population samples has noted that
although mental illness is highly prevalent among people
reporting suicidal ideation, a mental illness diagnosis is of
limited utility in predicting who, of people with suicidal
ideation, will go on to attempt suicide [40]. Our results
confirm that this is also the case among prisoners. Moder-
ate/severe depression was significantly associated with
increased risk of suicidal ideation, but of participants
reporting suicidal ideation, moderate/severe depression
was not associated with suicide attempt when other factors
were controlled. Similarly, although strongly associated
with suicidal ideation, a history of self-harm without suici-
dal intent was not associated with having attempted sui-
cide. This was surprising, as self-harm is generally
associated with an increase in subsequent suicide attempts
and completed suicide [41]. However, a general population
survey in the United Kingdom reported some separation
between self-harm without suicidal intent and suicidal
attempts [38]; our results suggest that among prisoner
populations, self-harm and suicide attempts may indeed
be distinct behaviours, and that self-harm may not be indi-
cative of risk of suicide attempt. That said, self-harm
remains a behaviour of serious concern to mental health
clinicians in prisons, as self-inflicted injuries can be fatal
even in the absence of suicidal intent. These results sug-
gest that self-harm without suicidal intent, and suicidal
ideation and attempt, are at least in part separate issues
and may therefore require discrete risk assessment and
intervention strategies.
Limitations
The retrospective, cross-sectional nature of the survey
prevented us from examining the ordering of onset of
suicide risk factors (e.g. psychiatric disorders), suicidal
ideation and suicide attempts. Understanding of the tem-
poral relationships between these factors may assist in
more clearly delineating which prisoners who experience
suicidal ideation will go on to attempt suicide. Large pro-
spective studies would be most suitable for obtaining
such data; in their absence, future cross-sectional studies
of prison suicide should attempt to obtain data regarding
onset of risk factors, suicidal ideation and suicide
attempts.
It is important to bear in mind the potential for bias
as a result of stigma and sensitivity around suicide, and
the self-report nature of the data. It is not possible to
determine the extent to which this may have affected
the results; under-reporting of suicidal behaviours would
contribute to more conservative findings.
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Conclusions
Thehighprevalenceofsuicideriskfactorsamongpris-
oner populations complicates the task of identifying
which prisoners are most at risk of attempting suicide.
We found that among prisoners expressing suicidal idea-
tion, parental incarceration was associated with having
made a suicide attempt, but depressive symptoms and
self-harm were not. Further work is required to deter-
mine particular patterns of risk factors that heighten the
likelihood of a suicide attempt. Prospective studies
encompassing entire prisoner populations would assist in
more clearly delineating associations between risk factors
for suicide, and suicide attempt, among prisoners.
Acknowledgements
Thank you to the IHS Clinical Co-ordinator, Shalin Kumar; Belinda Border of
Hunter New England Population Health; the IHS investigator team; and
Corrective Services NSW for supporting the conduct of the IHS. The IHS was
originally developed by Professor Tony Butler. Funding for the IHS was
provided by NSW Health and Justice Health. The funding bodies had no role
in the collection, analysis and interpretation of data; in the writing of the
manuscript; or in the decision to submit the manuscript for publication.
Author details
1
Centre for Health Research in Criminal Justice, Justice Health and Forensic
Mental Health Network, Sydney, Australia.
2
National Drug and Alcohol
Research Centre, University of New South Wales, Sydney, Australia.
3
The
Kirby Institute (formerly the National Centre in HIV Epidemiology and Clinical
Research), University of New South Wales, Sydney, Australia.
4
School of
Public Health and Community Medicine, University of New South Wales,
Sydney, Australia.
5
Statewide Forensic Mental Health, Justice Health and
Forensic Mental Health Network, Sydney, Australia.
6
School of Psychiatry,
University of New South Wales, Sydney, Australia.
Authors’contributions
SL conceived of the research questions, conducted the statistical analysis
and drafted the manuscript. LT helped conduct the Inmate Health Survey
and helped to draft the manuscript. DI led the conduct of the Inmate
Health Survey and helped to draft the manuscript. CO helped to draft the
manuscript. DG helped conduct the Inmate Health Survey and helped to
draft the manuscript. All authors read and approved the final manuscript.
Competing interests
SL, DI and DG are current employees, and LT and CO are past employees, of
Justice Health, which funded the Inmate Health Survey.
Received: 18 October 2011 Accepted: 6 January 2012
Published: 6 January 2012
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Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2458/12/14/prepub
doi:10.1186/1471-2458-12-14
Cite this article as: Larney et al.: A cross-sectional survey of prevalence
and correlates of suicidal ideation and suicide attempts among
prisoners in New South Wales, Australia. BMC Public Health 2012 12:14.
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