11 Forensic psychiatry11.3 Practising psychiatry in a secure setting
11.3.3 Mental disorder and suicide in prisons
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Written by Resident Doctor Committee · Published
Mental disorder in prison
Prison estimates depend on diagnosis, recording and sample. They mix disadvantage that predates custody with the effects of imprisonment.
Condition | Estimate in prisons in England | Compared with the general population |
|---|---|---|
Depressive disorder | About 13% | Roughly double |
Schizophrenia or bipolar disorder | About 4% | Roughly four times |
Post-traumatic stress disorder, including complex | Up to 1 in 10 | Raised |
Emotionally unstable personality disorder in women | About 1 in 5 | Raised |
Identified substance misuse need | About half | Raised |
Suicide and self-harm: scale and method
Male prisoners die by suicide at roughly three to eight times the rate of age-matched men in the community.
The self-inflicted death rate has stayed around 1 per 1,000 prisoners a year for the past decade.
Hanging or ligature strangulation is by far the commonest method (71 of 79 self-inflicted deaths in 2025), so prevention focuses on ligatures.
Self-harm is far commoner in women than in men: 5,643 against 610 incidents per 1,000 prisoners.
Risk factors for suicide in custody
Factor | What the evidence shows |
|---|---|
Occupying a cell alone, including segregation or solitary confinement | Among the strongest factors, because nobody is present to notice or raise the alarm; outweighs demographic factors |
Remand (unsentenced) status | Raises suicide and suicide attempts compared with sentenced prisoners, peaking early in custody |
History of substance misuse | Outweighs demographic and offence characteristics as a marker of risk |
Repeated self-harm | Well-established individual risk factor internationally |
Overcrowding, staff engagement | Evidence inconsistent or limited |
Drug dependence is the mental disorder most often recorded in prison suicides in England and Wales, because it is common at reception and withdrawal falls in early custody.
High-risk periods
The first days combine loss of freedom and contact, uncertainty, shame, withdrawal and interrupted treatment, while staff do not yet know the person's baseline.
Other peaks are sentencing, bad news from home, transfer between establishments and recall to custody.
After release, just over half of deaths within 14 days occur in the first four days, and 72% are drug-related.
Reduced opioid tolerance, resumed drug use and combining sedatives are important mechanisms of these deaths.
Reception and prevention
NICE recommends a health assessment before cell allocation and a second-stage assessment within seven days.
Staff should continue or start opioid treatment and manage alcohol withdrawal from reception onwards.
The ACCT process is multidisciplinary custodial care planning supported by healthcare.
Step | Requirement |
|---|---|
Opening | Any staff member may open an ACCT |
Immediate action plan | Within one hour |
Assessment by a trained assessor | Within 24 hours |
First case review | Within 25 hours, with healthcare involved |
Risk scales must not be used to predict suicide or decide access to care; staff use a needs-based formulation and safety plan instead.
A ligature-reduced cell does not replace observation with engagement.
Segregating someone on an ACCT needs exceptional justification and is not a treatment for suicidality.
Treatment and transfer to hospital
Dialectical behaviour therapy has the strongest evidence in custody for reducing repeated self-harm and suicidal behaviour; cognitive-behavioural therapy has weaker but real evidence.
Part 4 treatment powers of the Mental Health Act 1983 do not apply in a prison healthcare centre.
The Mental Capacity Act 2005 may authorise best-interests treatment for someone lacking capacity but does not override a capacitous refusal.
Status | Route to hospital |
|---|---|
Sentenced | Section 47, often with section 49 |
Unsentenced | Section 48, often with section 49; urgent treatment criterion applies |
NHS England guidance sets two consecutive 14-day stages, so transfer should take no more than 28 days.
Release
Release plans continue opioid substitution treatment without an automatic taper and provide take-home naloxone, housing and confirmed appointments.