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Cited by 254Suicide and Self-Harm StudiesCriminal Justice and Corrections AnalysisHomicide, Infanticide, and Child Abuse

Risk factors for self-harm in prison: a systematic review and meta-analysis

Open access
Favril, Louis, Yu, Rongqin, Hawton, Keith, Fazel, Seena·2020·The Lancet Psychiatry
DOI 10.1016/s2215-0366(20)30190-5PMC PMC7606912
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Abstract

Background Self-harm is a leading cause of morbidity in prisoners. Although a wide range of risk factors for self-harm in prisoners has been identified, the strength and consistency of effect sizes is uncertain. We aimed to synthesise evidence and assess the risk factors associated with self-harm inside prison. Methods In this systematic review and meta-analysis, we searched four electronic databases (PubMed, Embase, Web of Science, and PsycINFO) for observational studies on risk factors for self-harm in prisoners published from database inception to Oct 31, 2019, supplemented through correspondence with authors of studies. We included primary studies involving adults sampled from general prison populations who self-harmed in prison and a comparison group without self-harm in prison. We excluded studies with qualitative or ecological designs, those that reported on lifetime measures of self-harm or on selected samples of prisoners, and those with a comparison group that was not appropriate or not based on general prison populations. Data were extracted from the articles and requested from study authors. Our primary outcome was the risk of self-harm for risk factors in prisoners. We pooled effect sizes as odds ratios (OR) using random effects models for each risk factor examined in at least three distinct samples. We assessed study quality on the basis of the Newcastle-Ottawa Scale and examined between-study heterogeneity. The study protocol was registered with PROSPERO, CRD42018087915. Findings We identified 35 independent studies from 20 countries comprising a total of 663 735 prisoners, of whom 24 978 (3·8%) had self-harmed in prison. Across the 40 risk factors examined, the strongest associations with self-harm in prison were found for suicide-related antecedents, including current or recent suicidal ideation (OR 13·8, 95% CI 8·6–22·1; I 2 =49%), lifetime history of suicidal ideation (8·9, 6·1–13·0; I 2 =56%), and previous self-harm (6·6, 5·3–8·3; I 2 =55%). Any current psychiatric diagnosis was also strongly associated with self-harm (8·1, 7·0–9·4; I 2 =0%), particularly major depression (9·3, 2·9–29·5; I 2 =91%) and borderline personality disorder (9·2, 3·7–22·5; I 2 =81%). Prison-specific environmental risk factors for self-harm included solitary confinement (5·6, 2·7–11·6; I 2 =98%), disciplinary infractions (3·5, 1·2–9·7; I 2 =99%), and experiencing sexual or physical victimisation while in prison (3·2, 2·1–4·8; I 2 =44%). Sociodemographic (OR range 1·5–2·5) and criminological (1·8–2·3) factors were only modestly associated with self-harm in prison. We did not find clear evidence of publication bias. Interpretation The wide range of risk factors across clinical and custody-related domains underscores the need for a comprehensive, prison-wide approach towards preventing self-harm in prison. This approach should incorporate both population and targeted strategies, with multiagency collaboration between the services for mental health, social care, and criminal justice having a key role. Funding Wellcome Trust.

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review and meta-analysis of 35 studies including 663,735 prisoners found that the strongest risk factors for self-harm in prison were suicide-related antecedents and psychiatric morbidity, with prison-specific environmental factors also strongly associated. The authors conclude that prevention requires a comprehensive, prison-wide approach with multiagency collaboration.

Key findings

  • Across 40 risk factors, the strongest associations were current or recent suicidal ideation (OR 13·8, 95% CI 8·6–22·1; I²=49%), lifetime history of suicidal ideation (8·9, 6·1–13·0; I²=56%), and previous self-harm (6·6, 5·3–8·3; I²=55%).
  • Any current psychiatric diagnosis was strongly associated with self-harm (8·1, 7·0–9·4; I²=0%), particularly major depression (9·3, 2·9–29·5; I²=91%) and borderline personality disorder (9·2, 3·7–22·5; I²=81%).
  • Prison-specific environmental risk factors included solitary confinement (5·6, 2·7–11·6; I²=98%), disciplinary infractions (3·5, 1·2–9·7; I²=99%), and sexual or physical victimisation while in prison (3·2, 2·1–4·8; I²=44%). Sociodemographic (OR range 1·5–2·5) and criminological (1·8–2·3) factors were only modestly associated.
  • The authors did not find clear evidence of publication bias; sensitivity analyses excluding low-quality studies did not materially change risk factor estimates.

Methods

  • Systematic review and meta-analysis following PRISMA, registered with PROSPERO (CRD42018087915). Searched PubMed, Embase, Web of Science, and PsycINFO from database inception to Oct 31, 2019, with no language restrictions, supplemented by hand-searching and author correspondence.
  • Included 35 independent studies from 20 countries comprising 663,735 prisoners, of whom 24,978 (3·8%) had self-harmed in prison. Median sample size was 785 (IQR 142–2119); 9·6% of the pooled sample were women.
  • Pooled odds ratios using random-effects models for risk factors examined in at least three distinct samples; heterogeneity assessed with I²; study quality assessed with the Newcastle-Ottawa Scale; meta-regression examined sample size and outcome definition; publication bias assessed via funnel plots and Egger’s test.

Limitations

  • Paper-stated limitations include lack of adjustment for confounding and non-independence of risk factors; possible reverse causality; no consideration of chronicity or frequency of self-harm; reliance on retrospective self-report in most cross-sectional studies, which may inflate estimates; high heterogeneity among some estimates; inability to investigate institutional variables such as prison size, mental health care availability, and overcrowding; no studies from low-income and middle-income countries; and limited sex-stratified analysis because 13 studies combined sexes.
  • Evident from the text: most included studies were case-control (k=17) or cross-sectional (k=12), with only six cohorts and only two prospective studies; the three largest retrospective studies accounted for 609,366 (91·8%) of the pooled sample, and several key pooled estimates had very high heterogeneity (e.g., solitary confinement I²=98%, disciplinary infractions I²=99%).

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/s2215-0366(20)30190-5

Cites

84 of 84 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 39 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    The systematic review identified 35 independent studies from 20 countries comprising a total of 663,735 prisoners.

    “We identified 35 independent studies from 20 countries comprising a total of 663 735 prisoners”
    • Also stated in: § Results · plain
      “We included 35 studies reported in 38 articles in the meta-analysis (appendix pp 4–5), comprising a total of 663 735 prisoners”
    Quote in the paperSubstantial claim
  • Findingown data

    Major depression is associated with increased odds of self-harm in prison (OR 9.3, 95% CI 2.9-29.5; I2=91%).

    “particularly major depression (9·3, 2·9–29·5; I2=91%)”
    • Also stated in: § Results · plain
      “Major depression | 4 | 3908 | 9·3 (2·9–29·5) | 3·8 | <0·0001 | 91%”
    Quote in the paperSubstantial claim
  • Findingown data

    Solitary confinement is associated with increased odds of self-harm in prison (OR 5.6, 95% CI 2.7-11.6; I2=98%).

    “solitary confinement (5·6, 2·7–11·6; I2=98%)”
    • Also stated in: § Results · plain
      “Solitary confinement | 11 | 410 314 | 5·6 (2·7–11·6) | 4·6 | <0·0001 | 98%”
    Quote in the paperSubstantial claim
  • Findingown data

    Current or recent suicidal ideation is associated with increased odds of self-harm in prison (OR 13.8, 95% CI 8.6-22.1; I2=49%).

    “current or recent suicidal ideation (OR 13·8, 95% CI 8·6–22·1; I2=49%)”
    • Also stated in: § Results · plain
      “Current or recent | 6 | 7256 | 13·8 (8·6–22·1) | 10·9 | <0·0001 | 49%”
    Quote in the paperSubstantial claim
  • Findingown data

    Of the 663,735 prisoners included, 24,978 (3.8%) had self-harmed in prison.

    “of whom 24 978 (3·8%) had self-harmed in prison”
    • Also stated in: § Results · plain
      “Of all 663 735 prisoners included, 24 978 (3·8%) had self-harmed in prison.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 21
  • The quote only partly states this claim. 4
  • Classified as probably not a substantial claim. 18

  • May combine two claims.

    Findingown data

    Overall, strong effects were found for modifiable clinical and custodial variables, moderate effects for historical variables, and smaller effects for sociodemographic and criminological variables.

    “Overall, we found strong effects for modifiable clinical and custodial variables, moderate effects for historical variables, and smaller effects for sociodemographic and criminological variables.”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Findingown data

    Childhood emotional abuse is associated with increased odds of self-harm (OR 3.0, 95% CI 1.9-4.9; I2=71%).

    “Emotional | 4 | 3453 | 3·0 (1·9–4·9) | 4·5 | <0·0001 | 71%”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Outcome definition was a moderator only for the relationship between major depression and self-harm (B=-2·1; p=0·031), with a stronger effect observed for major depression in studies examining suicide attempt compared with non-suicidal self-injury.

    “Outcome definition was a moderator only for the relationship between major depression and self-harm (B=–2·1; p=0·031), with a stronger effect observed for major depression in studies examining suicide attempt compared with non-suicidal self-injury.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Childhood physical abuse is associated with increased odds of self-harm (OR 3.2, 95% CI 1.4-7.0; I2=75%).

    “Physical | 3 | 1183 | 3·2 (1·4–7·0) | 2·9 | 0·0044 | 75%”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Egger's test was not significant for violent offending (p=0·68), single marital status (p=0·14), and previous self-harm (p=0·53).

    “Similarly, Egger's test was not significant for violent offending (p=0·68), single marital status (p=0·14), and previous self-harm (p=0·53).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The leading risk factors from each of the five domains were homelessness, being sentenced for 5 years or more, current suicidal ideation, solitary confinement, and childhood sexual abuse.

    “The leading risk factors from each of the five domains were homelessness, being sentenced for 5 years or more, current suicidal ideation, solitary confinement, and childhood sexual abuse (figure 4).”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Findingown data

    Any childhood abuse is associated with increased odds of self-harm (OR 2.1, 95% CI 1.8-2.5; I2=0%).

    “Any abuse | 6 | 9481 | 2·1 (1·8–2·5) | 8·9 | <0·0001 | 0%”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Screening of funnel plots suggests no clear publication bias for violent offending (k=24), single marital status (k=20), and previous self-harm (k=19).

    “Screening of funnel plots (appendix pp 13–15) suggests that there was no clear publication bias for violent offending (k=24), single marital status (k=20), and previous self-harm (k=19).”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Childhood sexual abuse is associated with increased odds of self-harm (OR 3.9, 95% CI 2.0-7.5; I2=57%).

    “Sexual | 4 | 1325 | 3·9 (2·0–7·5) | 4·0 | <0·0001 | 57%”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    There were no clear associations between self-harm and single cell occupancy or remand status.

    “we found no clear associations between self-harm and single cell occupancy or remand status.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Environmental factors specific to prison, including solitary confinement, disciplinary infractions, victimisation during imprisonment, and poor social support, were clearly associated with self-harm.

    “In addition, we found that environmental factors specific to prison, including solitary confinement, disciplinary infractions, victimisation during imprisonment, and poor social support, were clearly associated with self-harm.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    There was an increased risk of self-harm in female prisoners, although this was not statistically significant.

    “There was an increased risk of self-harm in female prisoners, although this was not statistically significant.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Potential publication bias was assessed by funnel plot asymmetry and Egger's test for the top three risk factors with the most information.

    “The presence of potential publication bias was assessed by examination of asymmetry in funnel plots48 and by applying Egger's test49 for the top three risk factors that had the most information.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [48] Duval, 2000, Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis, Biometrics source

      Not checked in the free run.

    • cites [49] Egger, 1997, Bias in meta-analysis detected by a simple, graphical test, BMJ source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    Overall, 18 (51%) of the 35 included studies were judged to be of high quality and four (11%) were categorised as being of low methodological quality.

    “Overall, 18 (51%) of the 35 studies included were judged to be of high quality and four (11%) were categorised as being of low methodological quality (appendix pp 4–5).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The systematic review and meta-analysis followed the PRISMA guidelines.

    “We did a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines19 (known as PRISMA; appendix pp 1–3)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [19] Moher, 2009, Preferred Reporting Items for Systematic reviews and Meta-analyses: the PRISMA statement, PLoS Med source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The median modified Newcastle-Ottawa Scale score for cross-sectional studies was 6 (IQR 5-6).

    “the median score for the cross-sectional studies was 6 (5–6)”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    Random effects models were generated for all analyses to account for anticipated high heterogeneity between studies.

    “For all analyses, we generated random effects models that accounted for the anticipated high heterogeneity between studies resulting from differences in samples, measures, and design.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The annual prevalence of self-harm in prison has been estimated to be 5-6% in men and 20-24% in women.

    “the annual prevalence of self-harm in prison has been estimated to be 5–6% in men and 20–24% in women,5”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [5] Hawton, 2014, Self-harm in prisons in England and Wales: an epidemiological study of prevalence, risk factors, clustering, and subsequent suicide, Lancet source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Data were independently extracted by two researchers.

    “Data were independently extracted by two researchers (LF and Isabel Yoon).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The funder had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

    “The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The study protocol was registered with PROSPERO (CRD42018087915).

    “The study protocol was registered with PROSPERO, CRD42018087915.”
    • Also stated in: § Search strategy and selection criteria · plain
      “The research protocol was registered on PROSPERO (CRD42018087915) before the systematic review was done.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    All studies were assessed for risk of bias using the Newcastle-Ottawa Scale for cohort and case-control studies.

    “LF assessed all studies for risk of bias using the Newcastle-Ottawa Scale for cohort and case-control studies, with 9 points indicating high quality and low risk of bias.35”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [35] Wells

      Not checked in the free run.

  • May combine two claims.

    Premiseown data

    One meta-analysis published in 2020 examined the association between childhood maltreatment and suicide attempt in a population in contact with the criminal justice system, but it included non-prisoners, juvenile offenders, and community outcomes.

    “We found one meta-analysis published in 2020 that examined the association between childhood maltreatment and suicide attempt in a population who has been in contact with the criminal justice system, but this meta-analysis included non-prisoners, juvenile offenders, and outcomes in the community.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Evidence on the clustering of self-harm and suicide in custody suggests that interventions after suicidal behaviour should extend beyond the individual prisoner to others in the same wing or prison who could be at risk.

    “This recommendation is supported by evidence on the clustering of self-harm5 and suicide78 in custody, which suggests that interventions after suicidal behaviour should extend beyond the individual prisoner to others in the same wing or prison who could be at risk.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [5] Hawton, 2014, Self-harm in prisons in England and Wales: an epidemiological study of prevalence, risk factors, clustering, and subsequent suicide, Lancet source

      Not checked in the free run.

    • cites [78] McKenzie, 2007, Contribution of imitative suicide to the suicide rate in prisons, Suicide Life Threat Behav source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    Some variables associated with self-harm showed high heterogeneity among risk estimates, so the pooled estimates should be interpreted with caution, and ranges should be considered.

    “some variables associated with self-harm showed high heterogeneity among risk estimates, so the pooled estimates should be interpreted with caution, and ranges should be also considered.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    The strength of the risk estimates is likely to be overestimated because the meta-analysis did not account for confounding, and risk factors are unlikely to be independent of each other.

    “the strength of our risk estimates is likely to be overestimated because we did not account for confounding, and risk factors are unlikely to be independent of each other (eg, psychiatric comorbidity).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Risk factors for self-harm are unlikely to be independent of each other.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Study design and conductnone given

    Adding bibliographical indexes for criminal justice and global health might have identified additional work.

    “adding bibliographical indexes for criminal justice and global health might have identified additional work.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Female prisoners are more likely to experience additional stressors around separation from family and children, higher rates of background abusive histories, and bereavement.

    “Female prisoners are more likely to experience additional stressors around separation from family and children, higher rates of background abusive histories, and bereavement43 that might require interventions to be further tailored.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [43] Marzano, 2011, Psychosocial influences on prisoner suicide: a case-control study of near-lethal self-harm in women prisoners, Soc Sci Med source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    Heterogeneity might be due to national differences in prison regimes and sentencing policies, and diversity in the ethnic compositions of prison populations worldwide.

    “Heterogeneity might be due to national differences in prison regimes and sentencing policies, and diversity in the ethnic compositions of prison populations worldwide.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation

    Most of the included cross-sectional studies relied on retrospective self-report of self-harm, which might underestimate the prevalence of self-harm in custody.

    “most of the included cross-sectional studies relied on retrospective self-report of self-harm, which might underestimate the prevalence of self-harm in custody.79”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [79] Borschmann, 2017, Accuracy and predictive value of incarcerated adults' accounts of their self-harm histories: findings from an Australian prospective data linkage study, CMAJ Open source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    The non-significance of female sex as a risk factor in this meta-analysis contrasts with findings in the general population, where female sex as a risk factor for self-harm is stronger, and with one high-quality population study of UK prisoners that reported that the odds of self-harm was four times higher in women than in men.

    “This non-significance contrasts with findings in the general population,74 in which female sex as a risk factor for self-harm is stronger, and one high-quality population study of UK prisoners5 that reported that the odds of self-harm was four times higher in women than in men.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [74] Fox, 2018, Examining the role of sex in self-injurious thoughts and behaviors, Clin Psychol Rev source

      Not checked in the free run.

    • cites [5] Hawton, 2014, Self-harm in prisons in England and Wales: an epidemiological study of prevalence, risk factors, clustering, and subsequent suicide, Lancet source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The authors are not aware of any studies that have assessed prison size or the availability of mental health care.

    “We are not aware of any studies that have assessed prison size or the availability of mental health care.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Antisocial personality disorder is strongly associated with self-harm in the community.

    “Antisocial personality disorder, despite being strongly associated with self-harm in the community,73”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [73] Olfson, 2017, National trends in suicide attempts among adults in the United States, JAMA Psychiatry source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    Reported associations could be due to reverse causality, and prospective studies are necessary to explore whether these risk factors predict self-harm during imprisonment.

    “reported associations could be due to reverse causality (eg, solitary confinement as a consequence of self-harm) and prospective studies are necessary to explore whether these risk factors predict self-harm during the course of imprisonment.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Ecological studies have identified a positive association between overcrowding and self-harm.

    “Ecological studies looking at such variables have identified a positive association between overcrowding and self-harm.80, 81”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [80] Baggio, 2018, Association of overcrowding and turnover with self-harm in a Swiss pre-trial prison, Int J Environ Res Public Health source

      Not checked in the free run.

    • cites [81] Wolff, 2016, Self-harm and overcrowding among prisoners in Geneva, Switzerland, Int J Prison Health source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

    Interpretationcitation

    Because prisoners are generally a population at high risk of self-harm, the identification of those at elevated risk of self-harm is a complex task and will probably require high-quality methods and external validation.

    “Because prisoners are generally a population at high risk of self-harm, the identification of those at elevated risk of self-harm is a complex task,16 and will probably require high-quality methods and external validation.82”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [16] Lohner, 2007, Risk factors for self-injurious behaviour in custody: problems of definition and prediction, Int J Prison Health source

      Not checked in the free run.

    • cites [82] Ryland, 2020, Predicting self-harm in prisoners: risk factors and a prognostic model in a cohort of 542 prison entrants, Eur Psychiatry source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Strengths of this investigation include a quantitative synthesis, large population numbers, and the inclusion of previously unavailable data.

    “Strengths of this investigation include a quantitative synthesis, large population numbers, and the inclusion of previously unavailable data.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Prisoners might import a vulnerability for self-harm into prison (characterised by social disadvantage, trauma, violence, and poor health) that might interact with custody-specific stressors (eg, isolation, victimisation, and long sentences) and thereby increase the likelihood of self-harming in prison.

    “the leading risk factors from each domain suggest that prisoners might import a vulnerability for self-harm into prison (characterised by social disadvantage, trauma, violence, and poor health) that might interact with custody-specific stressors (eg, isolation, victimisation, and long sentences) and thereby increase the likelihood of self-harming in prison.”
    Quote in the paperSubstantial claim
38 of 38

  • The paper relies on this without support.

    Risk factors for self-harm are unlikely to be independent of each other.

    “risk factors are unlikely to be independent of each other (eg, psychiatric comorbidity).”
1 of 1

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Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Five-year sentence threshold is stated inconsistently

    Minor

    One passage defines the risk factor as a sentence longer than 5 years, while another includes sentences of exactly 5 years.

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Related

Authors
Favril, L., Yu, R., Hawton, K., & Fazel, S.
Affiliations
  • Ghent University (BE)
  • Warneford Hospital (GB)
Corresponding author
Fazel, Seena
ORCID
Venue
The Lancet Psychiatry
Publisher
Elsevier BV
Published
2020-08
Volume
7
Issue
8
Pages
682-691
ISSN
2215-0366 (ISSN-L)
DOI
10.1016/s2215-0366(20)30190-5
PMC
PMC7606912
OpenAlex
W3044322306
Semantic Scholar
8f73675fc1f3a997e3dbd54a79efabc5521b0308
Cited by
254
References
84
Citations by year
2026: 22 · 2025: 45 · 2024: 63 · 2023: 38 · 2022: 53 · 2021: 28 · 2020: 5
FWCI
2.46
Type
journal article
Language
en
Open access
Licence
Locations
  • The Lancet Psychiatry (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Ghent University Academic Bibliography (Ghent University) (submittedVersion, cc-by)
Funders
  • Universität Ulm
  • Università degli Studi di Milano-Bicocca
  • University of Ottawa
  • Nottingham Trent University
  • St George's University Hospitals NHS Foundation Trust
  • Universitat de Barcelona
  • University of Queensland
Topics
  • Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
  • Social Sciences › Sociology and Political Science › Criminal Justice and Corrections Analysis
  • Social Sciences › Sociology and Political Science › Homicide, Infanticide, and Child Abuse
Keywords
self-harm, prisoners, risk factors, suicidal ideation, mental illness, major depressive disorder, borderline personality disorder, substance use disorders, self-harm history, suicide prevention programs, suicide prevention funding
MeSH terms
Mental Disorders, Borderline Personality Disorder, Criminal Law, Major Depressive Disorder, Evaluation Studies as Topic, Female, Humans, Male, Mental Health, Prisoners, Risk Factors, Suicide, Attempted, Case-Control Studies, Self-Injurious Behavior, Crime Victims, Suicidal Ideation, Observational Studies as Topic

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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