title: Self-harm and overcrowding among prisoners in Geneva, Switzerland.
abstract: OBJECTIVE
  Prison institutional conditions affect risk for self-harm among detainees. In particular, prison overcrowding may increase the likelihood of self-harm by creating competition for resources, space, and enhancing a "deprivation state." The purpose of this paper is to examine the association between overcrowding and prisoner acts of self-harm.
  
  
  METHODS
  This cross-sectional study took place at Geneva's pre-trial prison (capacity:376) between 2006 and 2014. Outcomes were acts of self-harm that required medical attention, and self-strangulation/hanging events (combined into one group, as these are difficult to differentiate). Dichotomous predictors were overcrowding index- annual mean daily population divided by capacity ( > 200 percent vs < 200 percent), and year group (2006-2009 vs 2011-2014).
  
  
  RESULTS
  Self-harm and self-strangulations/hangings increased in 2011-2014 compared to 2006-2010 (p < 0.001). Overcrowding in excess of 200 percent was associated with self-strangulation/hangings (p < 0.001) but not with all self-harm events. In terms of pertinent demographics that would affect self-harm, there was no prison change in gender, area of origin, foreign residency, religion, or psychiatric treatment.
  
  
  CONCLUSIONS
  The present study is limited by the definition and identification of self-harm. The distinction between self-strangulation and self-hanging, and the precise classification of an intent to die is difficult to make in practice, especially with limited prison data records available. The relevant literature addresses the complexity of the association between non-suicidal and suicidal behavior. Despite this, the combined category self-strangulations/hangings gives some indication of severe self-harm events, especially since the methodology of categorization employed was consistent throughout the entire period of the study. Other limitations include the small sample size and the lack of individual patient data and prison data to help control for confounding factors. Despite these drawbacks, pertinent data (socio-demographics and number of prisoners treated for mental health and drug abuse) remained stable over the years. Thus, there are no apparent changes in the inmate population that could be linked to an increase in self-harm. High-security placements and mean prisoner stay have increased over time, with a decrease in staff to prisoner ratio - and these must be looked into further as contributors. Additionally, qualitative methods such as semi-structured interviews and focus groups could delineate the impact of overcrowding on prisoner well-being and self-harm potential.
  
  
  CONCLUSIONS
  The authors observed a significant increase in self-harm and self-strangulation/hangings over time, and overcrowding was significantly associated with self-strangulation/hangings (but not with all self-harm events). Overcrowding can impose destructive effects on the psychological and behavioral well being of inmates in prison, influencing a myriad of emotional and livelihood factors that predispose to harmful behavior.
  
  
  CONCLUSIONS
  This report should alert public health and prison authorities to this issue, and garner resources to address such an alarming rise. The findings from this short report demonstrate the need for a further examination of the mechanisms affecting self-harm among prisoners in this population, particularly the relationship between self-strangulations/hangings and overcrowding.
authors.affiliation: Division of Correctional Medicine and Psychiatry, Geneva University Hospitals, University of Geneva, Geneva, Switzerland.
authors.forename: Hans
authors.initials: H
authors.lastname: Wolff
authors.forename: Alejandra
authors.initials: A
authors.lastname: Casillas
authors.forename: Thomas
authors.initials: T
authors.lastname: Perneger
authors.forename: Patrick
authors.initials: P
authors.lastname: Heller
authors.forename: Diane
authors.initials: D
authors.lastname: Golay
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Mouton
authors.forename: Patrick
authors.initials: P
authors.lastname: Bodenmann
authors.forename: Laurent
authors.initials: L
authors.lastname: Getaz
mesh_terms: D003430:Cross-Sectional Studies; D003441:Crowding / Q000523:psychology*; D006801:Humans; D008297:Male; D011329:Prisoners / Q000523:psychology*; D011330:Prisons; D012652:Self Mutilation / Q000453:epidemiology*; D013557:Switzerland / Q000453:epidemiology
keywords: Hangings; Health care; Overcrowding; Prison; Self-harm; Self-strangulations