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Limited resources often result in prison staff conducting mental health assessments quickly and individuals self-reporting to staff who are not mental health specialists. This non-clinical type of assessment can miss important context and risk, protective, and precipitating factors. As a result, the process may not identify individuals who are at higher risk for self-harm or suicide, leading to missed opportunities to provide appropriate support and care.
During his talk at the International Forensic Psychiatry Lecture Series, Professor Seena Fazel discussed suicide risk assessment and prevention for people in prison settings. He discussed concerns about how mental health is defined and diagnosed in prison, distinguishing between mental illness and “adjustment” and short-term problems. He also noted that better collaboration is needed between prison services and clinical researchers to better identify suicide risk when people first enter prison.
Defining and Diagnosing Mental Illness
In many prison settings, prison officers assess individuals on entering prison and complete a generic checklist to assess their health. In others, it is the primary health care staff. Those assessments then determine who gets additional attention. While this approach can uncover some types of common mental problems in a broad sense, it does not capture the specificity and severity of mental illness. It also fails to consider context, individual histories, or other underlying factors that a trained mental health specialist would consider. As a result, the process can miss people with serious mental illness, including those who are at higher risk for self-harm or suicide. This makes it difficult to provide effective support.
When considering how to address self-harm and suicide risk, the key is to recognize and focus on individuals with clinically diagnosed serious mental disorders, particularly major depression, schizophrenia spectrum disorders, and bipolar disorder. But these individuals are often not recognized with the non-clinical approach to screening. For example, general mental health assessments done by prison officers and other non-health professionals find that seven out of 10 people (70 per cent) in prison suffer from depression. However, the scores from psychiatrist-led diagnostic testing show that major clinical depression affects a much smaller portion of the prison population; about one in eight people (10 to 14 per cent).
Better Identification and Prevention
Researchers have conducted many studies to determine how many people in prison have mental health needs. Instead of conducting more research studies to confirm that these problems are prevalent, Dr. Fazel explained why it might be more useful to focus on finding effective ways to treat underlying conditions and prevent adverse outcomes associated with them, particularly with respect to suicide risk.
Developing useful tools to support more careful evaluation would make it easier to screen out people at lower self-harm and suicide risk and target limited resources on individuals who need the most help. It would also support better clinical decision-making, which in turn would help establish more effective treatment.
For treatment to be more personalized and effective, the assessor needs to assess risk in a structured and evidence-based way rather than simply administering a generic checklist assessment (which has usually been developed for other purposes, such as symptom scores). The current assessment tools for self-harm and suicide do not:
- consider risk factors that are specifically associated with suicidal outcomes,
- provide a consistent and transparent evidence-based approach to weighing these factors,
- allow for effective communication of risk between professionals and services, and
- lead to more collaborative approaches to managing risk, including involving people in prison and other services.
One particular challenge is how to prevent repeated self-harm, which is common in prisons and often lacks a structured way for assessment and decision-making about further monitoring, care, and health care involvement.
Well-resourced, multi-disciplinary research is needed to develop more effective assessment tools and services to help people in prison with severe mental illness. Dr. Fazel also pointed out that important environmental factors should not be overlooked. Particularly in older prisons, many fixtures, furniture, and other elements allow an individual to attach a cord, rope, or cloth to hang or strangle themselves. Removing these ligature points is an important system-based step in prevention.
Tools and Targets
Mental health screens on entering prison typically have a simple yes/no question about current suicide risk. This is not a prognostic tool but is screening what is already present (i.e., identifying current ideation). The lack of a structured approach is more acute when someone has already self-harmed, as these individuals in prison represent a high-risk population with substantially higher rates of repeating and suicide mortality inside and on release.
The Risk Assessment for People in Prison for Self-harm and Suicide (RAPSS) was recently developed at the universities of Oxford and Manchester to identify people who have already self-harmed and to inform decisions about what to do next. It is not intended as a screen on admission to prison but at the end of a risk management plan for someone who has self-harmed.
Such a tool could be particularly useful for mental health specialists when they are considering management for people who have self-harmed in prison as it provides an evidence-based, transparent, and scalable approach to supporting clinical decision-making about future monitoring (including considering unmet needs after a set period of time, such as a week or two), liaison with other services, and the allocation of limited psychosocial interventions.
Conclusion
Addressing the problem of suicide in prison will require approaches targeted at individuals and systems. Some approaches will help, but they are interrelated. The approach of predict and prevent, which has been so effective in the rest of medicine, should be applied in prison mental health. The prediction part will involve improving assessment and drawing on data to personalize and anchor decision-making in evidence about risk factors.
New tools, such as RAPSS, targeted intervention and treatment approaches, and population-wide measures should be part of any prison-based suicide prevention strategy. Improving and implementing them further requires better collaboration between the prison system and researchers.
For more details, watch the recording of the November 28, 2025, lecture, “New Research on Mental Health and Suicide Prevention of People in Prison” on our website.
Approved by Dr. Seena Fazel.
