Zero Suicide, an approach to be considered in criminal justice systems?

Professor Siobhan O'Neill, Professor of Mental Health Sciences, Ulster University

Suicidal behaviour is common among prisoners, and among people in contact with the criminal justice system generally. Figures from the Ministry of Justice showed that a record number of people killed themselves in prisons in England and Wales in 2016. In that year there were 119 deaths by suicide, this was an increase of 29 on the previous year and was the highest number ever recorded in a single year (Ministry of Justice 2016). In the same year there were 37,784 incidents of self-harm. In the same year there were 6 recorded suicides in NI prisons in 2016, compared with 3 the year before. When we examine the factors associated with suicide; mental illness, adverse life events associated with shame and humiliation, and the fragmentation of key social relationships, these figures are perhaps unsurprising. However, if we consider that suicide is preventable, then it may be considered striking, and unacceptable that so many suicides can happen in group of individuals who are under close supervision. There is much discussion of Zero Suicide, and how it is being used within health care systems, and the question may be asked about its applicability to other systems where there is ongoing contact with individuals who are at risk, such as the criminal justice system.

The belief that suicide is preventable is a key tenet of the Zero Suicide movement. Whilst the factors associated with mental illness, and life crises are difficult to address, every suicide death results from an action or behaviour and, there is growing recognition that the action or behaviour that leads to the death can be prevented. The proponents argue that we should not set targets for preventable deaths in the same way that we do not set targets for plane crashes. They point to the reduction in suicide deaths in the Henry Ford Health Care system in the US, following the introduction of a series of strategies with the goal of producing “perfect depression care”. The argument is, that if a target for suicide is to be set, then it should surely be zero (Suicide Prevention Resource Centre, 2018a).

The preventability of suicide deaths is evidenced by the fact that suicidal thoughts and plans are common, that death by suicide is by no means inevitable among those who are suicidal and most who survive a suicide attempt who do not go on to die by suicide. In NI 10.6% of women and 7% of men in NI have seriously considered suicide, and 4.3% of women and 2.3% of men have attempted suicide (O’Neill et al., 2014). There now exist strategies and treatments which directly address suicidal thoughts and behaviours, which are based on an improved theoretical understanding of suicidal behaviour. In other words, there is much that we can do to provide hope for people in crisis, and help them manage suicidal thoughts to keep themselves safe.

Zero suicide is therefore a mindset, a conviction that suicides are preventable and that suicide prevention should be a goal of health care systems. It is also a series of strategies and techniques. The components can be described as a direct approach of identifying and treating suicidal thoughts and behaviour, using quality and safety improvements to provide highly accessible, reliable, and continuous care processes and routines; and the development of a broader organisational culture, with strong leadership and a commitment to the goal of zero. A zero suicide toolkit has been developed by the US National Alliance for Suicide Prevention and the Suicide Prevention Resource Center, comprising  seven fundamental principles or goals, and gives examples of techniques and strategies that may be used to achieve that goal (Suicide Prevention Resource Centre, 2018b). Whilst it was designed for implementation in a health care context, it is clear that many of these principles could be applied to other sectors where large numbers of clients may be at risk of suicide. The toolkit for example recommends the training of all staff in recognising and responding to individuals who may be at risk, the systematic screening for suicidal thoughts and behaviours, and followup with interventions focusing on suicide prevention. Finally, it recommends the ongoing use of data driven system changes to reduce risk, including the rapid investigation of all deaths that are suspected to be suicides.

A key debate surrounds the extent to which the use of these approaches will actually lead to a reduction in suicide rates, and the quality of evidence surrounding the efficacy of the techniques that are recommended. The evidence base for suicide specific treatments and strategies is evolving and we currently do not have evidence from robust randomised controlled trials demonstrating the efficacy of suicide prevention treatments that are common is other health care contexts (Coyne, 2016). This is a significant problem, and it is noteworthy that a recent review of the evidence for suicide risk assessment techniques concluded that “Risk scales following self-harm have limited clinical utility and may waste valuable resources” (Quinlivan et al., 2017). Nonetheless there is emerging evidence that techniques such as safety planning (Bryan et al., 2017; Stanley & Brown, 2012) and CAMS-CARE (Jobes, 2012) are showing promise in reducing suicidal thoughts and behaviours.

A recent review of the evidence by Mokkenstrom et al. (2017) concluded that the core components of Zero Suicide are rational, however there are many unresolved question, and that the evidence base needs to be strengthened. Critics question whether suicide can and should be prevented and there appears to be particular difficulty with the use of the term “zero” itself. Some have argued that there are circumstances and cases whereby people may well make a rational choice to end their lives, and indeed the notion that many suicides are not preventable can provide consolation to the bereaved and their health care providers. Commentators have also cautioned against the use of the term Zero Suicide, without a systems wide implementation of all the components. In particular, a focus on the eradication of suicide deaths without leadership and culture change would risk placing individual clinicians at risk of being blamed for deaths. This in turn could lead to the covering up of deaths and the adoption of inappropriate treatment strategies, including restraint, which would narrow the focus from promoting recovery to simply preventing death by suicide. This would undoubtedly be detrimental to patient care and recovery (Hawton, 2016;  Smith et al., 2015). Staff must be empowered in a genuinely blame free environment for any Zero Suicide initiative to be effective and engaging.

Despite the criticisms Zero Suicide appears to be gaining momentum and elements are being adopted in health care settings across the UK and internationally. It is clear that many of the approaches and techniques could be applied to other settings, including criminal justice settings, and this is surely something that should be explored.


Bryan, C. J., Mintz, J., Clemans, T. A., Leeson, B., Burch, T. S., Williams, S. R., et al. (2017). Effect of crisis response planning vs. contracts for safety on suicide risk in US Army soldiers: A randomized clinical trial. Journal of Affective Disorders, 212, 64–72.

Coyne, J. (2016). An open-minded, skeptical look at the success of “zero suicides”: Any evidence beyond the rhetoric? Retrieved November 15, 2016, from http://blogs.plos.org/mindthebrain/2016/10/28/an-open-minded-skeptical-look-at-the-success-of-zero-suicides-any-evidence-beyond-the-rhetoric/

Hawton, K. (2016). Submission to the U.K. Parliament suicide inquiry. from http://data.parliament.uk/WrittenEvidence/CommitteeEvidence.svc/EvidenceDocument/Health/Suicide%20Prevention/written/36847.html

Jobes, D. A. (2012). The Collaborative Assessment and Management of Suicidality (CAMS): An evolving evidence-based clinical approach to suicidal risk. Suicide and Life-Threatening Behavior, 42, 640–653.

Ministry of Justice (2017). Safety in Custody Statistics Bulletin, England and Wales, Deaths in prison custody to December 2016, Assaults and Self-Harm to September 2016. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/595797/safety-in-custody-quarterly-bulletin.pdf

Mokkenstorm, J.K., Kerkhof, J.F.M., Smit, J.H., Beekman, A.T.F. (2017). Is It Rational to Pursue Zero Suicides Among Patients in Health Care? Suicide and life threatening behaviour, First published: 26 October 2017. doi: 10.1111/sltb.12396. [Epub ahead of print]

O’Neill, S., Ferry, F., Murphy, S.D., Corry, C., Bolton, D., Devine, B., Ennis, E., Bunting, B.P. (2014). Patterns of Suicidal Ideation and Behavior in Northern Ireland and Associations with Conflict Related Trauma. PlosOne. Mar 19;9(3):e91532. doi: 10.1371/journal.pone.0091532. eCollection  2014.

Smith et al 2015Smith, M. J., Bouch, J., Bradstreet, S., Lakey, T., Nightingale, A., & O'Connor, R. C. (2015). Health services, suicide, and self-harm: Patient distress and system anxiety. The Lancet Psychiatry, 2, 275280.

Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264.

Suicide Prevention Resource Centre (2018a) Zero Suicide in Health and Behavioural Health Care. https://zerosuicide.sprc.org

Suicide Prevention Resource Centre (2018b) Zero Suicide Toolkit, https://zerosuicide.sprc.org/toolkit

Quinlivan, L., Cooper, J.m, Meehan, D., Longson, D., Potokar, J., Hulme, T., Marsden, J., Brand, F., Lange, K., Riseborough, E., Page, L., Metcalfe, C., Davies, L., O’Connor, R., Hawton, K., Gunnell, D., Kapur, N..L (2017). Predictive accuracy of risk scales following self-harm: multicentre, prospective cohort study. Br J Psychiatry. 2017 Jun;210(6):429-436. doi: 10.1192/bjp.bp.116.189993. Epub 2017 Mar 16.

Siobhan O’Neill is a Professor of Mental Health Sciences at Ulster University. Her current research programmes focus on trauma and suicidal behaviour in Northern Ireland (NI) and novel interventions for mental health and suicidal behaviour. Siobhan has expertise in qualitative and quantitative (epidemiology and survey) research methods.

Prior to joining Ulster University in 2000, she completed a degree in psychology at the Queen's University of Belfast and a masters in health psychology at NUI Galway. She also worked as a Public Health Researcher, conducting evaluations of health services and users’ experience of care.

Between 2005 and 2008 Siobhan coordinated the largest ever study of mental health in Northern Ireland, the NI Research and Development Office funded, NI Study of Health and Stress. This study revealed the high proportions of the NI population who had unmet mental health needs and the extent of mental health disorders associated with the NI conflict.
She is also a coordinator of the NI suicide study, a study of the characteristics of completed suicides and undetermined deaths. She is responsible for the dissemination of the research findings on trauma and suicide to policy makers and stakeholders in NI.

Siobhan is a member of the World Mental Health Survey Consortium, a Director of the Irish Association of Suicidology and Youthlife, and an advisor to several organisations who provide services and interventions for mental health and suicide prevention and sits on several national and international research committees.

She has over 70 publications in peer-reviewed journals, including several ground breaking studies of mental health and suicidal behaviour in Northern Ireland. She is part of the World Mental Health Gender and Mental-Physical Comorbidity workgroups and led the world mental health paper linking mental illness with the subsequent development of cancer.