Suicide in Prisons is the Royal College of Psychiatrists' response to a thematic review on this subject produced by HM Chief Inspector of Prisons for England and Wales (Home Office, 1999), called Suicide is Everyone's Concern.

The College takes a clinical approach to the prevention of suicide and the treatment of suicidal thinking. It is emphasised throughout that to carry out the recommendations, new resources will be required. More beds and more staff are required in the NHS. More and differently trained staff are required in the prison service. Unless services are resourced they are not services at all.

The commonest method of suicide in prison is asphyxiation, usually at night. The high-risk factors for suicide among prisoners are similar to those among other citizens: youth, male gender, depression, alcoholism and loss of a relative, friend or partner.

The thematic review implies that suicide rates are higher in prison than might be expected. The College accepts that suicide rates in prison are very high — too high — but they are not necessarily higher than can be expected given the vulnerable nature of the individuals, at high-risk of suicide, who are sent to prison.

The College emphasises the importance of making accurate diagnoses, if applicable, in all prisoners, and noting the significance of multiple diagnoses. Every prison should have a comprehensive primary care service with a secondary care community mental health team operating within the prison. It recommends that community drug teams should have access to prisoners and that all prison doctors should receive specific training in psychiatric and in drug misuse medicine.

Like the Chief Inspector, the College does not believe that prisons are suitable environments for people under the age of 18 years. Offenders below this age should be admitted to specialised institutions. The College also recommends that antibullying programmes should be mandatory in all prisons.

The Chief Inspector draws favourable attention to prisoner participation observation schemes for suicide prevention. The College agrees and suggests that several schemes be considered.

The thematic review concludes with a chapter on healthy prisons, which is strongly endorsed by the College. The Chief Inspector's key constituents for healthy prison are a safe environment, treating people with respect, a full constructive and purposeful regime and resettlement training to prevent re-offending.

Overall, the College welcomes the thematic review, but stresses further points:

1. • too many mentally disordered people are being sent to prison

2. • there is a need for a more appropriate model of mental healthcare delivery within prisons

3. • there is a need for better screening for suicidal ideas and propensities at reception and for further assessment and treatment

4. • there are inadequate treatment facilities for mentally disordered offenders (MDOs) outside of prison, and mental health services in the community need to be amplified so they can play a bigger role in the care of MDOs

5. • NHS authorities need to provide more beds for acute psychiatric care, to make court diversion schemes a practical possibility

6. • there needs to be a greater provision of secure beds in the NHS

7. • there needs to be more and better liaison between the prison health care service and the NHS.

As an aside, the College draws attention to the fact that the whole of the criminal justice system, not just the prisons, is implicated in the mental health problems seen in prisons and that judges and other lawyers should learn more about psychiatry, psychology and criminology.

The College concludes by emphasising the mental hygiene issue of socialisation, which is so difficult in prisons, and the importance of ensuring that mentally distressed people are not kept in isolation. Special attention is drawn to the need for all suicidal prisoners to be in close contact with other people.