Prior to the introduction of ventilation systems and the use of portable air supplies by coal miners, canaries were used as an early warning system. As long as the canary kept singing, the miners knew they could continue working safely, but when the music died, they knew that levels of carbon monoxide, methane, and other lethal gases were rising and that it was time to abandon the mine.
A recent research report explored the criminal justice histories of all adult suicides in the country of Denmark between 1981 and 2006. The findings are of interest to the readership of this blog.
First, they confirmed that men were more likely to die by suicide than women – a finding that has been replicated over and over again. Having a criminal justice history of any kind raised the risk for suicide substantially, and this effect was more pronounced for women. Thus, while the risk for suicide doubled for men with a criminal justice history, it more than tripled for women with a criminal justice history.
Drilling down further, the findings were even more interesting. It was not just convictions that raised the risk, but even arrests that did not lead to convictions raised the risk – often significantly more than did a conviction. Thus, fore example, men who were acquitted were 3.8 times as likely to die by suicide, and women who were acquitted were 5.5 times as likely to die by suicide, when compared to those without a criminal justice history. But the most powerful risk factor was an outcome of “sentenced to psychiatric treatment” – this outcome raised the risk by over 13 times for men, and over 25 times for women!
What does this mean? Don't we believe that mandated treatment is good for people who otherwise do not engage in treatment voluntarily?
First, it is important to understand the methodology of the study. This research was retrospective, and therefore it is impossible to draw firm cause/effect conclusions. Thus, readers should not walk away from this column concluding that contact with the criminal justice system CAUSES suicide. What this sort of epidemiologic work is very good for is generating hypotheses about how factors may interrelate, leading to further research to better understand causes and effects. In that vein, lets talk about some hypotheses:
One conclusion to be drawn from this research, which I believe is supported by the rates of suicide based on the various outcomes, is that contact with the criminal justice system is a sort of systemic “canary in the coal mine.” People who come into contact with the law may demonstrate gaps or flaws in our mental health and social services systems. For those with mental illnesses, an arrest represents a failure of our system of care. Why is it that a “sentence to psychiatric treatment” is the most powerful risk factor for later suicide? It is not that the “sentence to psychiatric treatment” CAUSES the later suicide. Rather, the contact with the CJ system is a “proxy” or “mediating factor” or “warning,” as follows:
- the person has mental illness;
- that mental illness is inadequately treated, leading to contact with the law;
- the justice system recognizes the untreated illness and sentences the person to treatment;
- some percentage of such people later commit suicide due to the mental illness; and
- that percentage is higher than for those without criminal justice contact – perhaps in part because they were not mentally ill or if they were, had more successful treatment.
It's not the arrest or sentence that caused the suicide; rather, it is the mental illness that the person comes with, and which we know itself to be a risk factor for, and often a cause of, suicide. We should view the arrest as the “canary in the coal mine” and act accordingly.
Perhaps the most sobering message is that this research was conducted in a country with a comprehensive public health care system. Unlike in the US, nobody is “uninsured” in Denmark, so any citizen or other legal resident has coverage. Despite this, people manage to find their way into the criminal justice system, at least in part related to untreated mental illnesses. These illnesses claim lives, despite an action on the part of the court that would seem appropriate – a mandate to engage in treatment. The takeaway message is that simply sending folks to treatment, which seems satisfying and may end a current prosecution, does not by itself constitute a full response to the dead canary in the coal mine.
Erik Roskes is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes' employers or consultees, including the Maryland Department of Health and Mental Hygiene. He can be found a http://mysite.verizon.net/eroskes.