Harris & Barraclough1showed that opioid users’ deaths from sui-
cide were 10 times the number expected for their age and gender
(95% CI for standardised mortality ratio 7.8–12.6). I subsequently
proposed2that estimating the expected number of suicides in
prison should at least take account of inmates’ high prevalence
of opioid dependency, and I derived suicide alert thresholds for
UK prison services accordingly. I suggested that investigation
was warranted if the observed number of prison suicides in
any year exceeded the alert threshold. Liebling,3on the other
hand, has questioned whether statistical science has much to
offer in the understanding, monitoring and reducing of prison
Self-inflicted male deaths in Scottish prisons in each year from
1994 to 1998 numbered 12, 8, 12, 13, and 12 (with 7 deaths not
classified as to suicide status). My original alert threshold of 12
approached in every calendar year in 1994–98 except 1995, and
breached in 1997.
In Scotland as a whole, average male death rates from self-
harm at younger ages (15–24, 25–34 and 35–44 years) increased
markedly between 1989–93 and 1999–2003 (15–24 years, up from
17.9 to 21.7; 25–34 years, up from 25.2 to 33.4; 35–44 years, up
from 23.9 to 31.3 years),4but with most of the increase having
occurred by 1994–98.
For England and Wales, Fazel et al5documented both
increased numbers of suicides in male prisoners during 1978–
2003 and an overall standardised mortality ratio for suicide of
5, although for boys aged 15–17 years the ratio was much higher,
at 18 (95% CI 13–26). Fazel et al did not adjust for opioid
dependency but they did highlight the high prevalence of other
serious mental disorders in surveys of prisoners. The excess
suicide risk of those for whom prisons have a duty of care was
clearly evidenced by Pratt et al.6Suicide rate ratios (95% CI 12–
15) for recently released adult prisoners in England and Wales
in 2000–02 were double the rate ratio during other times at liberty,
or while incarcerated.5
Prison populations have not only increased since 1994–98, but
they have also aged. Longer sentences by courts and late detection
of sexual offences have contributed to a marked increase in the
number of male inmates aged 55+ years in UK prisons.7Males
aged 45–54 in Scottish prison custody on 30 June 1997 numbered
371 (v. 433 on 30 June 2003, a 17% increase) and those aged 55+
numbered 170 (v. 249 on 30 June 2003, a 46% increase).
By the mid-1990s,3,9–14there was recognition that remand
prisoners were over-represented among those who die by suicide
and that the immediate post-reception period was high risk.
Suicide risk was particularly high for Scottish prisoners with a past
history of addictions, and there was concern about prisons’
detoxification regime.14,15Inspectorial reports intensified up to
2000.16–19Other recognised risk factors were history of psychiatric
treatment and self-injury,20and being remanded or convicted for
serious, violent or sexual crimes which attract long sentences.
Some such suicides occur many years after reception into prison
and at older ages, as for Dr Harold Shipman,21who took his
own life in the fourth year of his sentence and on the day before
his 58th birthday. Thus, drivers for prison suicides are known to
differ at the extremes of prisoner age, and may be differentially
responsive to prisons’ several interventions to reduce suicides in
prison. In this paper, I have investigated male suicides in Scottish
prisons during the period 1994 to 2003.
I made two methodological improvements on my previous work.2
First, I introduced separate age distributions for prisoners with
and without opioid dependency. Second, for specific age groups
(15–24, 25–34, 35–44, 45–54, 55–64, 65–74 years), I applied the
Changes in male suicides in Scottish prisons:
Sheila M. Bird
In 1999 I estimated the expected number of UK prison
suicides, taking into account that opioid users’ deaths from
suicide were 10 times the number expected for their age
and gender. Changes have since taken place in Scottish
To estimate the expected number of male suicides in
Scottish prisons in 1994–2003, having taken age and opioid
dependency into account; and to consider the extremes of
The effective number that prisons safeguard in terms of
suicide risk was approximated as 10 times the number of
opioid-dependent inmates plus other inmates. By applying
age-appropriate suicide rates for Scottish males to these
effective numbers, expectations for male suicides in Scottish
prisons were calculated.
In 1994–98, there were at least 57 male suicides, significantly
exceeding the age- and opioid-adjusted expectation of 41. In
1999–2003, the 51 male suicides in prison were consistent
with expectation (upper 95% limit: at least 54). During the
decade 1994–2003, observed and expected suicides were
mismatched at both extremes of age: 40 males aged 15–24
years died by suicide v. 24 expected, and 13 males aged 45+
v. 2 expected. Against 4.5 prison suicides expected for males
aged 15–24 years during a 2-year period, actual suicides
were 3 in 2002 + 2003 and 4 in 2004 + 2005.
Scotland has redressed an excess of male suicides,
especially by its youngest prisoners.
Declaration of interest
None. Funding from Medical Research Council WBS no.
The British Journal of Psychiatry (2008)
192, 446–449. doi: 10.1192/bjp.bp.107.038679
more robust average death rate from self-harm (per 100000 males
in the general population) for the quinquennium of interest, as
supplied by the Registrar General’s Office for Scotland.
The Seventh Prison Survey, in 2004 (overall response rate:
77%),22was the sole contemporary source of information on
Scottish prisoners’ opioid dependency in 1999–2003. It asked
about respondents’ use of specific drugs in the 12 months before
incarceration. I requested ad hoc cross-tabulations from the
Seventh Prison Survey, which gave the age distribution in 2004
of male respondents according to their reported use (or not) of
heroin/other opiates/methadone in the 12 months before
incarceration. The data are shown as the final column of online
Table DS1. Because only 60% of eligible prisoners responded to
questions about specific drug use, the final column of online Table
DS2 allows for the possibility of under-reporting, whereby 90%
only of those who were opioid dependent had reported this in
Table DS1. A third option was to assume that opioid dependency
by age group for prisoners in 1999–2003 followed the same
pattern as in 1994–98.
From 1992–96 Willing Anonymous Salivary HIV (WASH)
surveillance studies23,24in Scottish Prison Service establishments,
I deduced an approximate age distribution for adult male injectors
in 1994–98 (Table DS1, col. 4), which was assumed to apply for
opioid dependency. In Table DS2, opioid dependency was taken
to be 1.5 times the corresponding injector prevalence, and there-
fore 27% among male young offenders and overall 50% for male
adult prisoners – a multiplier which aligned well with results from
random mandatory drugs testing of Scottish prisoners.25(And
likewise in England and Wales in 2001: of 2266 surveyed prisoners,
29% reported using heroin and 18% reported injecting it in the
month before incarceration).26Proportionate redistribution of in-
jectors from the original WASH age groups to Registrar General’s
Office for Scotland age groups had to be carried out, as shown in
According to Scottish Prison Service Annual Reports (follow
link from Library to Keydocs at www.sps.gov.uk), the average
numbers of male prisoners held by the Scottish Prison Service
in the financial years 1999/2000 to 2003/04 were 5764, 5676,
5929, 6193, 6306 (mean for males=5974). In Table DS2, the age
distribution for male prisoners in custody on 30 June 2001 (as
given in Prison Statistics Scotland, 2001)27was applied to the
quinquennial mean prison population of 5974 male inmates.
The corresponding analysis for 1994–98 had to adopt the age
distribution for male prisoners in custody on 30 June 1997
(because age distribution was not available for 30 June 1996).
The average numbers of prisoners held by the Scottish Prison
Service in the financial years 1995/96 to 1998/99 (not available
for 1994/95) were 5632, 5992, 6059, 6029 and so the mean for
both genders was 5928. Gender breakdown was not available
but, at 30 June 1997, 5936/6121 inmates were male, and so the
1994–98 mean male prison population was taken as 5936/
612165928=5749 male inmates. Having approximated, for each
age group, its average number of opioid-dependent and other
(that is: non-opioid dependent) male prisoners by quinquennium,
the former were given a weight of 10,1as in my previous study,2
when computing the expected quinquennial number of male
suicides in prison (Table 1).
The Scottish Prison Service maintains separate databases on
fatal accident inquiries into prisoner deaths and on prisoner
suicides. There is a small risk that suicides in prison in
2004+2005 are undercounted owing to late-reporting fatal
accident inquiries. However, since the majority of suicides in
prison are by hanging, they are starkly evident.
In 1994–98, the Scottish Prison Service recorded 100 male deaths
in legal custody, for eight of whom cause of death was not detailed
on its databases: six deaths at ages 23, 39, 51, 43 (remand), 20 and
34 years in 1994; one death at 53 years in 1995; one death in
hospital from ‘natural causes’ at 30 years in 1998. Fifty-seven
deaths were known suicides (33 on remand; and 12, 8, 12, 13
and 12 by calendar year; Tables 1 and 2). Three of the 100
deaths in 1994–98 were of prisoners aged 65 years or older.
In 1999–2003, the Scottish Prison Service recorded 92 male
deaths in legal custody. Table 2 shows that 51 were suicides (33
on remand; and 13, 14, 9, 9, and 6 by calendar year). Ten of the
Male suicides in Scottish Prisons
dependency by assigning opioid-dependent inmates 10 times the suicide risk for their age group
Expected numbers of male suicides in Scottish prisons, 1994–98 and 1999–2003, after allowance for prisoners’ opioid
mean number of male prisoners=5748
mean number of male prisoners=5974
per 100 000
cides for male
age groups, 90%
15–2419.8 1142511.3121.7 89619.721148112.46974410.57
45–5422.53590.40 22.49261.04 3860.43 9891.11
65–7414.946 0.0313.11170.0872 0.05 1260.08
(95% CI 28–54)
(95% CI 29–54)
(95% CI 31–58)
(95% CI 32–58)
a. In 1994–98, eight deaths were described as ‘formal findings only’ (six in 1994, one in 1995) or from ‘natural causes’ (one in 1998).
b. Calculated using age distributions for opioid-dependent adult male prisoners, as derived from age distribution for adult injectors in 1992–96 Willing Anonymous Salivary HIV
(WASH) surveillance studies (see online Table DS1 for further details).
c. Calculated using age distributions for opioid-dependent adult male prisoners, as derived from age distribution for adult injectors in Seventh Prison Survey, 2004 (see Table DS1 for
d. Calculated using opioid dependency (or not) by age group applied to 1999–2003 if only 90% of dependency was reported in Seventh Prison Survey 2004 (see Table DS2 for further
92 deaths in 1999–2003 occurred in prisoners aged 65 years or
older. Table 1 gives, by age group, Scotland’s average death rates
from self-inflicted harm per 100 000 males for 1994–98 and
1999–2003. Male suicide rates were highest at 25–34 years and
35–44 years of age.
To take opioid-dependent prisoners’ 10 times greater suicide
risk1into account, in Table 1, I have multiplied by X, where
X=(number of opioid-dependent male prisoners)610+number
of non-opioid-dependent male prisoners), Scotland’s age-specific
suicide rates per 100000 males to work out, for each age group,
the expected numbers of male suicides in Scottish prisons in
1999–2003 and in 1994–98. For 1994–98, Table 1 shows an esti-
mated 268 (27%) out of 268+725=993 young offenders as opioid
dependent, but 770 out of 1090 inmates aged 21–24 years. Taking
their opioid dependency into account, these 2083 male prisoners
aged 15–24 years had a weighted suicide risk equivalent to
11425 males of the same age in the Scottish population.
Table 1 shows summarily that, whereas 57 male suicides (at
least) in 1994–98 significantly exceeded the age- and opioid-
adjusted expectation of 41.1 for 1994–1998 (upper 95% limit
54), the 51 male suicides in 1999–2003 were in line with the
expectation of 41 to 45 (upper 95% limit at least 54).
Even having made allowance for opioid dependency, the actual
age distribution of known suicides was at odds with the age dis-
tribution expected for suicides in 1994–2003. The total number
of suicides by 15- to 24-year-old male prisoners was nearly twice
the expected number (21+19=40 v. 11.3+12.5=23.8). Also, at the
other extreme of prisoner age, there were 13 known suicides by
male prisoners aged 45+ years v. 2 expected.
Eighty per cent of suicides by male prisoners aged 15–24 years
in Scotland for the decade 1994–2003 were among young men on
remand or who were untried ((17+15)/(21+19) =32/40; 95% CI
68–92%). Those on remand or untried accounted for around half
only of the self-inflicted deaths by prisoners aged 25–34 years with
known remand/convicted status (20/39; 95% CI 35–67%), or by
older men (14/28; 95% CI 31–69%).
Other factors besides age and opioid dependency clearly matter
for the mitigation of male suicides in prison. They include mental
health comorbidity,5remand status,13,18,19time since reception
and the seriousness or violence of the prisoner’s indictment
offence. None of these other factors is adequately addressed by
an analysis which adjusts solely for age and opioid dependency.
However, going further would require ethically approved access
to prisoner information systems which hold medical or
Male prisoners’ suicides significantly exceeded age- and
opioid-dependency adjusted expected suicides in 1994–98 (at least
57 observed v. 41 expected) but exceeded the annual alert
threshold of 12 only once.20,28Suicides by male prisoners were
consistent with expectation in 1999–2003 (51 observed v. 41–45
expected), despite worryingly high numbers2
In the decade 1994–2003, there were nearly twice as many
suicides by 15- to 24-year-old male prisoners (40) as expected
(24) after accounting for opioid dependency. Also, at the other
extreme of prisoner age, there were 13 known suicides at age
45+ years v. 2 expected.
Mismatch of the age distributions of observed v. opioid-
adjusted expected suicides emphasised the vulnerability of male
prisoners aged 15–24 years: 80% of suicides in this age group were
by young men on remand or who were untried. Their vulnerabil-
ity was addressed by the Scottish Prison Service’s changes in how
addictions and the identifying of suicide risk15are dealt with on
reception into prison, and by remedying deficiencies in younger
prisoners’ induction and their lack of activities or occupation
UK’s prison inspectorates were influential in tackling prison
suicides.10,13,16–19Mental health nurses now conduct the suicide
risk assessment on reception into prison, and the number of them
in post featured regularly in Scotland’s prison inspection reports
in 1994–2003. In-cell television to reduce suicides by remand
prisoners was first suggested in the 1995–96 report by Her
Majesty’s Chief Inspector of Prisons for Scotland13and again in
Women Offenders – A Safer Way.16Initially, the suggestion
received a stony ministerial hearing until in-cell electricity
facilitated in-cell television from 2000.
Punishment First, Verdict Later19reviewed conditions for
remand prisoners in Scotland at the end of the 20th century. It
relationships, which require an understanding of the particular
pressures and problems encountered by remand prisoners so that
their needs might be better met and rights safeguarded. ‘Because
of the numbers’ was staff’s explanation of why so many remand
prisoners had so little time out of their cells, so few programmes
were available to them, why there was limited access to telephones,
showers and possessions, and why they were sometimes housed
with convicted prisoners. In Scotland no operating standards dealt
specifically with remand prisoners, whose legal status should have
entitled them, in the inspectorate’s view, to a continuance of
(community-) prescribed medication14and equitable delivery of
other services. Dependency on others, even for access to money
during their period of remand, ‘compounded feelings of helpless-
ness and hopelessness, with sometimes tragic consequences’.
Healthcare standards introduced in May 1998 required
Scottish prisons to provide detoxification regimes, but not until
Health Care Standard 10 in 2001 was continuation, or provision
in prison, of substitution therapy14given equal prominence. The
proportion of (around 7000) prisoners testing positive for
methadone in random mandatory drugs tests increased from
1% in the financial year 2002/03 to 9% in 2003/04 and 14% in
of 13+14 in
and poor prisoner–staff
Observed suicides of males in Scottish prisons 1994–98 and 1999–2003 (those on remand/untried and total numbers)
Prison suicides 1994–98, n
Prison suicides 1999–2003, n
Age group, yearsPrisoner on remand/untried TotalPrisoner on remand/untried Total
15–2415 19 17
Total for all ages 33 57 3351
a. Status undetermined for one prisoner, eight known to be convicted.
Male suicides in Scottish Prisons
2004/05,29as the Scottish Prison Service’s new methadone policy
Against the progressive backdrop of the Scottish Prison
Service’s revised suicide risk and drugs strategies, mental health
nurses at reception assessments, in-cell television and improved
induction for remand prisoners, male suicides by 15- to 24-
year-olds were 3+0 in 2002+2003 and 2+2 in 2004+2005, against
a 2-year expectation of 4.5. The exceptional vulnerability to
suicide of the youngest age group of prisoners may thus have been
redressed in Scotland.
International prison comparators, or intervention studies,
would be needed to decipher how much credit to ascribe to the
different components of the Scottish Prison Service’s successful
approach for its youngest prisoners, or to assess their relative
The Scottish Prison Service’s attention should now turn to its
older male prisoners7(aged 45+ years), whose excess suicides have
different precursors: there were six such suicides in around 2400
prisoner-years during 2002 to 2005.
Sheila M. Bird, MA, PhD, CStat, FFPH, Department of Statistics and Modelling
Science, University of Strathclyde, and Medical Research Council, Biostatistics Unit,
Cambridge CB2 2SR, UK. Email: firstname.lastname@example.org
First received 3 Apr 2007, final revision 31 Jan 2008, accepted 2 Feb 2008
Graham Jackson, Registrar General’s Office for Scotland, for average death rates (per
100 000 males by age group) by cause (intentional self-harm or ischaemic heart disease)
in 1994–1998 and 1999–2003; Dr Roisin Ash, Dr James Carnie and Dr Ed Wozniak, Seventh
Prison Survey analyst team, for ad hoc cross-tabulations; Dr Andrew Fraser, medical
advisor to the Scottish Prison Service, for formative discussions; Peter Wilson, healthcare
team at the Scottish Prison Service, and Sharron di Chiacca, legal team at the Scottish
Prison Service, for database access; Colonel Clive B. Fairweather, formerly Her Majesty’s
Chief Inspector of Prisons for Scotland, who encouraged me to revisit the analysis for
1994–1998 because he sensed that suicides had been mitigated in 1999–2003 by a range
of initiatives within the Scottish Prison Service.
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1998; 173: 11–53.
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prisoners: a population-based cohort study. Lancet 2006; 368: 119–23.
Owers A. ‘No problems – Old and Quiet’: Older Prisoners in England and
Wales. HM Chief Inspectorate of Prisons for England and Wales, 2004.
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England and Wales of Suicide and Self-Harm in Prison Service Establishments
in England and Wales. HMSO, 1990.
11 Green C, Kendall K, Andre G, Looman T, Polvi N. A study of 133 suicides
among Canadian federal prisoners. Med Sci Law 1993; 33: 121–7.
12 Bogue J, Power K. Suicide in Scottish prisons, 1976-1993. J Forensic
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13 HM Inspectorate of Prisons for Scotland. Annual Report 1995–1996:
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– A Safer Way. Review of Community Disposals and the Use of Custody for
Women Offenders in Scotland, 1998. TSO (The Stationery Office), London,
17 Ramsbotham D. Suicide is Everyone’s Concern: A Thematic Review. HM
Inspectorate of Prisons for England and Wales, Home Office, 1999.
18 HM Inspector of Prisons for Scotland. Report for 1999–2000 (Cm4824 Annex
3: Suicide). TSO (The Stationery Office), Edinburgh, 2000.
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Remand Prisoners in Scotland at the End of the 20th Century. HM Chief
Inspectorate of Prisons for Scotland, 2000.
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injector data. J Epidemiol Biostat 2001; 6: 243–65.
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The British Journal of Psychiatry (2008)
192, 446–449. doi: 10.1192/bjp.bp.107.038679
1992–96 Willing Anonymous Salivary HIV (WASH) surveillance studies23,24or from 2004 Seventh Prison Survey22
Age distributions for opioid-dependent adult male prisoners, as derived from age distribution for adult injectors in
7th Prison Survey
Adult male injectors
(as per 1994–98;
and applied also
to 1999–03), n
Adult male injectors,
proportionately revised from
WASH to RGOS age groups, n
Opioid usersain year before
incarceration, % (n/N)
21–25 26321–24 21015–24 40.2 (446/1110)
26–3022925–29183+53=23625–29 55.4 (380/686)
31–35 11230–3490+46=13630–34 53.4 (286/536)
36+44 35–4444+22=6635–39 44.6 (200/448)
Adult male injectors64864840–44
RGOS, Registrar General Office Scotland.
a. Only 60% of eligible prisoners responded to questions about heroin/other opiates/methadone use.
Opioid dependency by age group applied to 1999–2003 mean male prison population of 5974 inmates
7th Prison Survey
from WASH age groups
If only 90% of opioid dependency
reported 7th Prison Survey
Total5974 253334412566 25642816 3158
WASH, 1992–96 Willing Anonymous Salivary HIV surveillance studies.23,24
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Sheila M. Bird
Changes in male suicides in Scottish prisons: 10-year study
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