Review of completed suicides in the California Department of Corrections and Rehabilitation, 1999 to 2004

Psychiatr Serv. 2008 Jun;59(6):676-82. doi: 10.1176/ps.2008.59.6.676.


Objective: The purpose of this extended review is to assist health care managers, clinicians, prison administrators, and custody staff in identifying and responding effectively to prisoners who present a substantial risk of suicide in the foreseeable future.

Methods: The California Department of Corrections and Rehabilitation (CDCR) is the largest state-operated prison system in the country, with a census range of 155,365 to 163,346 prisoners between 1999 and 2004. The authors conducted a review of all 154 suicides that occurred in CDCR during this period and examined several factors related to the suicide, including demographic characteristics of the inmate, health care information, suicide method, custody information, and emergency response.

Results: The analysis of trends in this six-year review reveals that prisoners who completed suicide were similar to those who took their lives in the community in age distribution and mental health factors. The analysis also found that this group of prisoners who committed suicide had other characteristics or commonalities related specifically to their incarceration. In this review 60% of the suicides were judged to have been foreseeable, preventable, or both.

Conclusions: Although suicide is not predictable, the terms "foreseeable" and "preventable" are used to indicate cases in which the risk of suicide was elevated or events occurred that should have triggered clinical or custodial reactions that would have reduced the likelihood of completed suicide. This review provides clues to recognize inmates at elevated risk and identifies some of the health care practices and conditions of confinement to consider for provision of an adequate suicide prevention program.

MeSH terms

  • California
  • Humans
  • Mental Health
  • Prisons*
  • Risk Assessment
  • Suicide / trends*