AT THE ANNUAL AAS CONFERENCE

ATLANTA (FRONTLINE MEDICAL NEWS) – One-third of a large sample of male state prison inmates reported some level of suicidal ideation in the first-ever study to examine the applicability of Joiner’s interpersonal theory of suicide in a correctional setting.

That’s a high rate, especially since the study participants hadn’t been red-flagged by prison officials for any indication of increased suicidality. By comparison, studies conducted in the general population outside of a prison setting have placed the prevalence of suicidal ideation at 2%-10%, Jon Mandracchia, Ph.D., noted at the annual conference of the American Association of Suicidology.

His study earned the Young Investigator of the Year Award from the American Foundation for Suicide Prevention.

Suicide is a serious problem in correctional settings. According to the Bureau of Justice Statistics, suicide is the number-one cause of death in jails, accounting for 29% of all mortality in that setting. In prisons, suicide accounts for 6.2% of all deaths, making it the fourth most common cause of mortality, said Dr. Mandracchia of the University of Southern Mississippi, Hattiesburg.

Prison officials realize suicide is a major problem. Guards, nurses, and other staff have been trained to be on the lookout for suicidality and are quick to ask inmates if they’ve been thinking about harming themselves, but the answer is virtually always no.

“Prison is a harsh place. You can’t live in prison if you’re seen as a potential victim or target by other inmates,” Dr. Mandracchia said. “You’re not going to admit to anything that might possibly be perceived as weakness, whether it’s true or just in your mind.”

The interpersonal theory of suicide , introduced by Thomas Joiner, Ph.D., a decade ago, has generated enormous interest among suicide researchers because of its simplicity and ready testability. Indeed, much of this year’s AAS conference was devoted to studies examining the theory’s validity in various populations.

The theory holds that, for suicide attempts to occur, three elements are necessary. In Dr. Joiner’s terminology, an individual must simultaneously experience thwarted belongingness and perceived burdensomeness, which together generate suicidal ideation. To move from ideation to action, however, a third component must be present: acquired capability, the ability to overcome the powerful, innate urge to survive. Acquired capability is often achieved through desensitization to trauma or pain.

Prison is an environment rife with thwarted belongingness and perceived burdensomeness. Prisoners are removed from their family and friends, hence the thwarted belongingness. They also often feel that they’ve become a burden to their family because they’re not providing income and often ask their families for money to buy snacks. Moreover, they are constantly reminded that they are a burden on society. Dr. Mandracchia hypothesized that, if the interpersonal theory of suicide is valid in a prison population, then prisoners who score high on measures of thwarted belongingness and perceived burdensomeness should have the highest levels of suicidal ideation.

That’s exactly what he found in his study of 399 male inmates in Mississippi state prisons. For his measurement tools, he used the Beck Scale for Suicide Ideation and the Interpersonal Needs Questionnaire, which features separate scales to look at perceived burdensomeness and thwarted belongingness. In addition, he employed the Center for Epidemiological Studies Depression Scale and the hopelessness scale from the Depression Hopelessness Suicide Screening Form, a tool developed specifically for use in criminal offenders. He measured inmates’ levels of depression and hopelessness to be able to control for those two factors in his analysis, since they are traditionally viewed as risk factors for suicide but aren’t central to the Joiner model.

Dr. Mandracchia found a strong dose-response effect between thwarted belongingness and perceived burdensomeness and suicidal ideation among the inmates, all of whom participated in the study voluntarily. Inmates who scored in the top tertiles for both thwarted belongingness and perceived burdensomeness had the greatest amount of suicidal ideation, while those in the middle tertiles had mid-range levels of suicidal ideation on the Beck scale.

Dr. Mandracchia highlighted several practical implications of the study findings in terms of suicidality assessment and management in prison populations. For example, instead of asking inmates, “How are you feeling?” and “Are you thinking of hurting yourself?” as prison staff routinely do now, they should instead be on the lookout for inmates who complain that they are a burden to their family or feel particularly isolated. This ought to reduce the traditionally extremely high false-positive and false-negative rates for detection of suicidality in correctional institutions, he said.

In terms of implications for management, Dr. Mandracchia said that he is trying to convince prison officials to limit their use of suicide watch.

“They don’t know what else to do, so when they’re concerned about someone they remove them and lock them in isolation until they’re safe. That’s often counterproductive. It takes the inmates away from their support system,” he said.

Mental health professionals working in prison settings also could try to boost inmates’ sense of belongingness, perhaps by encouraging them to join one of the prosocial groups that exist in prisons. Staying in touch with friends and family by writing letters is another means of increasing belongingness. Perceived burdensomeness can be addressed through cognitive behavioral therapy aimed at helping inmates gain a more accurate picture of how much of a burden they are to others, Dr. Mandracchia added.

He is planning a longitudinal study to identify measures that predict actual future suicidal behavior among prison inmates, but acknowledged there are challenges to doing this work.

“When you start doing mental health research in prisons, you quickly realize that no one wants you there. Not the staff, not the inmates,” he said.

Dr. Mandracchia reported having no financial conflicts regarding this study, which was conducted free of commercial support.

bjancin@frontlinemedcom.com

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