By David H. Cloud; Brie Williams; Regine Haardörfer, et al

Question What is the association between exposures to extreme heat and suicide-watch incidents in a state prison system without air-conditioned living units?

Findings This case series of 6576 facility-incarceration days found that extreme heat was significantly associated with a 30% increase in the incident rate of daily suicide-watch incidents.

Meaning These findings suggest that extreme heat may increase vulnerabilities to situations that lead to suicide-watch placements for incarcerated people, bolstering calls for heat mitigation and decarceral interventions to assuage heat-induced harms among incarcerated populations.

Importance Extreme heat poses a distinct risk to the 2.1 million incarcerated people in the United States, who have disparately high rates of behavioral health conditions. Suicide is a leading cause of death among people in prisons.

Objective To examine associations of extreme heat, solitary confinement, and an indicator of suicidal behaviors among incarcerated men in a Deep South US prison system.

Design, Setting, and Participants This longitudinal case series panel study included adult men in prisons in Louisiana, a state with one of the largest prison systems in the United States that has been engaged in litigation due to lack of air conditioning and extreme heat. The unit of analysis was prison facility-days. A facility-level data set was created by merging administrative data files, which included demographic characteristics, health classification, housing location and movement, disciplinary records, and involvement in suicide-watch incidents for all incarcerated men in Louisiana during the observation period. Individual-level variables were aggregated to facility-days to merge in daily maximum heat index data from the US Local Climatological Data, which were linked to the zip codes of prisons. The observation period was January 1, 2015, to December 31, 2017. Data set construction occurred from August 2020 to September 2022, and analysis was conducted from December 2022 to February 2023.

Exposure The focal exposure was extreme heat days. Daily maximum heat index data were categorized into 6 bins (<30 °F, 30-39 °F, 40-49 °F, 50-59 °F, 70-79 °F, and ≥80 °F) and as an indicator for any facility-day where the maximum heat index exceeded the 90th percentile of heat indices for total days in observation period. Conditional fixed-effects negative binomial regression models were used to calculate incident rate ratios to test associations between extreme heat and suicide watch incidents, while controlling for covariates.

Main Outcomes and Measures The focal outcome was daily count of suicide watch incidents that were recorded in a carceral system database. Covariates included daily percentages of incarcerated persons at each prison with serious mental illness diagnosis, daily rate of solitary confinement, and total facility population.

Results The sample of 6 state-operated prisons provided 6576 facility-days for the analysis. Results suggest a dose-responsive association between extreme heat and daily counts of suicide-watch incidents; compared with days with temperatures between 60 and 69 °F, the rate of daily suicide incidents increased by 29% when the heat index reached the level of caution (ie, 80-89 °F) and by 36% when reaching extreme caution (90-103 °F) (80-89 °F: incidence rate ratio [IRR], 1.29; 95% CI, 1.17-1.43; P < .001; 90-103 °F: IRR, 1.36; 95% CI, 1.15-1.61; P  95% CI, 1.18-1.45; P < .001).

Conclusions and Relevance Findings suggest an association between extreme heat and an indicator of suicidality among an incarcerated sample, contribute to an emerging literature exploring linkages between climatological events and health outcomes in prisons, and may have implications for legal interventions and advocacy seeking to abate heat-induced morbidity and mortality in carceral contexts.

JAMA Netw Open. 2023 Aug; 6(8): e2328380.

Edited by Janet Weston and Virginia Berridge

This Witness Seminar, held at the London School of Hygiene and Tropical Medicine in May 2017, brings together some of those involved in influencing and implementing prison policy decisions surrounding HIV and AIDS in the 1980s and 1990s. AIDS first appeared in Europe in the early 1980s, and prisons were soon identified as sites that would face particular challenges. Injecting drug use was one of the primary modes of HIV transmission, and the large numbers of drug users passing through prisons meant that the prevalence of HIV was feared to be high. Added to this were suspicions about the frequency of risky sexual activity and injecting drug use within prisons. Prisoners were not only thought to be at a higher risk of already having HIV or AIDS, but prisons themselves were seen as an ideal environment for the spread of infection amongst inmates, potentially also from inmates to staff, and ultimately from released prisoners to the wider population. Urgent decisions had to be made about how to minimise disruptions prompted by diagnoses or fears of HIV and AIDS, how to reduce the risks of HIV transmission, and how to look after prisoners already affected. The emergence of HIV and AIDS highlighted many of the existing tensions and problems surrounding healthcare for prisoners. Witnesses described the reluctance of the prison service to acknowledge and tackle difficult issues, but also observed that there did not seem to have been an HIV or AIDS epidemic within prisons in England and Wales. What also emerged was a sense of some of the ongoing difficulties facing the prison service, in terms of lost gains in healthcare services, mounting overcrowding, and a failure to learn the lessons of the past.

London: London School of Hygiene & Tropical Medicine, 2017. 67p.

By Coral Sirdifield, Charlie Brooker, Rebecca Marples

A narrative systematic review was undertaken of the literature concerning the health of people on probation. In this paper, we provide an up-to-date summary of what is known about the most effective ways of providing mental healthcare for people on probation, and what is known about the relationship between different systems and processes of mental healthcare provision, and good mental health outcomes for this population. A total of 5125 papers were identified in the initial electronic searches but after careful double-blind review only four papers related to mental health that met our criteria, although a further 24 background papers and 13 items of grey literature were identified which are reported. None of the included studies was a randomized controlled trial although one was quasi-experimental. Two of the other papers described mental health disorders in approved premises and the other described the impact and learning from an Offender Personality Disorder project. We conclude that the literature is bereft of evidence on how to effectively provide mental healthcare for people on probation.

Forensic Science International: Mind and Law Volume 1, (2020) 100003

By Coral Sirdifield, Charlie Brooker, Rebecca Marples

A narrative systematic review was undertaken of the literature concerning the health of people on probation. In this paper, we provide an up-to-date summary of what is known about suicide and suicidal ideation and probation. This includes estimates of prevalence and possible predictors of suicide and suicidal ideation. Searches were conducted on nine databases from January 2000 to May 2017, key journals from 2000 to September 2017, and the grey literature. A total of 5125 papers were identified in the initial electronic searches but after careful double-blind review only one research paper related to this topic met our criteria, although a further 12 background papers were identified which are reported. We conclude that people on probation are a very high risk group for completed suicide, and factors associated with this include drug overdose, mental health problems, and poor physical health. There is a clear need for high quality partnership working between probation and mental health services, and investment in services, to support appropriate responses to suicide risk.

Forensic Science International: Mind and Law, Volume 1, November 2020,