What is the standard of care for evaluating inmates with a history of suicide for suicide watch in jail or prison?

Standard of Care for Evaluating Inmates with Suicidal History for Suicide Watch

A comprehensive suicide risk assessment must be conducted for all inmates with a history of suicide attempts, including evaluation of current suicidal ideation, plan, intent, access to means, and mental state, with immediate placement on suicide watch for those expressing persistent wish to die or demonstrating abnormal mental states. 1

Initial Screening Protocol

Immediate Assessment (Upon Intake)

• Screen all inmates immediately upon arrival for:
  • Current suicidal thoughts, plans, or intent
  • History of previous suicide attempts
  • Current mental state (depression, mania, psychosis, anxiety)
  • Recent significant losses or stressors 1, 2

Risk Factors to Document

1. Demographic factors:

   • Male gender (higher completion risk)
   • Living alone prior to incarceration 1

2. Mental health indicators:

   • Mood disorders (depression, bipolar disorder)
   • Substance use disorders (particularly during withdrawal)
   • Psychotic symptoms (delusions, hallucinations)
   • Severe anxiety
   • Agitation or irritability 1

3. Historical factors:

   • Prior suicide attempts (method, lethality, intent)
   • Previous psychiatric hospitalizations
   • Family history of suicide 1, 2

4. Current presentation:

   • Hopelessness
   • Persistent wish to die
   • Specific suicide plan
   • Access to means 1

Comprehensive Evaluation Protocol

Mental Status Examination

• Assess for:
  • Signs of clinical depression (depressed mood, anhedonia, sleep/appetite disturbance, worthlessness, hopelessness)
  • Signs of mania/hypomania (elevated mood, decreased need for sleep, racing thoughts, grandiosity)
  • Psychotic symptoms
  • Substance intoxication or withdrawal 1

Timing Considerations

• Complete comprehensive mental health assessment within 7-14 days of intake 1
• Conduct more urgent evaluation if initial screening reveals acute risk 2
• Pay particular attention to high-risk periods:
  • First 30 days of incarceration (42% of jail suicides occur during this period)
  • Within 3 days of court appearances (50% of suicides) 3
  • Between 3 PM and midnight (60% of suicides) 1

Risk Stratification and Management

High Risk (Immediate Suicide Watch)

Place on suicide watch if ANY of the following are present:

• Current suicidal ideation with plan and intent
• Persistent wish to die
• Clearly abnormal mental state (psychosis, severe depression, mania)
• Recent suicide attempt
• Agitation, irritability with threats of violence
• Acute substance withdrawal 1, 2

Moderate Risk (Close Observation)

• Current suicidal ideation without specific plan/intent
• History of suicide attempts but no current ideation
• Mental illness with stabilized symptoms
• Substance use disorder without acute intoxication/withdrawal 2

Lower Risk (Routine Monitoring)

• No current suicidal ideation
• Remote history of suicidal behavior
• Stable mental health status
• Good social support 2

Suicide Watch Implementation

Environmental Safety Measures

• Remove access to potential suicide methods:
  • House in suicide-resistant cells
  • Remove shoelaces, belts, sheets, and other potential ligatures
  • Never house potentially suicidal inmates alone in cells (91% of suicides occur in single-occupancy cells) 3
  • Conduct regular safety checks (15-30 minute intervals) 1

Clinical Management

• Continue suicide watch until mental state and suicidality have stabilized 1
• Obtain collateral information from third parties regardless of apparent mildness of suicidal behavior 1
• Provide appropriate psychiatric medication management 1
• Document all assessments and observations thoroughly 2

Common Pitfalls to Avoid

1. Underestimating risk:

   • 70% of inmates who died by suicide had been assessed by mental health professionals (half within previous 6 days)
   • 70% had history of suicidal ideation
   • Nearly 50% had previous suicide attempts 1

2. Overreliance on "no-harm" contracts:

   • No-suicide contracts have limited value and should not replace vigilant monitoring 1

3. Inadequate follow-up:

   • Ensure clear communication between shifts and departments
   • Schedule follow-up evaluations at regular intervals 1, 4

4. Failing to identify precipitating factors:

   • Fear of transfer or placement
   • Recent death of family member
   • Failure in rehabilitation program
   • Recent suicide in facility
   • Parental failure or threats not to visit 1

By implementing this systematic approach to suicide risk assessment and management, correctional facilities can significantly reduce the risk of inmate suicide while meeting the standard of care for this vulnerable population.