Elevated suicide risk among formerly incarcerated

CONTENT WARNING: This article references suicide. Please take caution when reading. If you need mental health support, please consult this page for resources.

By Rachel Crumpler

Brian Scott visited Craven Correctional Institution in eastern North Carolina a couple of months ago to speak to a group of men who were all within a year of their release dates from prison.

Scott, who was released from prison in February 2021 after 20 years behind bars, said he told the group how wonderful freedom is — from getting in a car and driving anywhere, to walking into a grocery store and being surrounded by endless food options, like “50 kinds of Pop-Tarts.” 

Scott said one of the men raised his hand and offered a comment: “Freedom is great, but you gotta get there first.” 

“I understood exactly what he meant,” Scott said. “He wasn’t talking about getting out of prison. He was talking about those weeks and those months after release when freedom is overwhelming.

“For some people, it’s more overwhelming than it is for others because they don’t have a place to live. They don’t have basic transportation. They don’t have community or family support.”

For most people, Scott said, the path to rebuilding a life in the community after incarceration is filled with a variety of obstacles — ones that can be distressing and difficult to overcome.

A recent study published in the American Journal of Epidemiology reveals new insight into the period after incarceration, offering the most in-depth look at suicide rates among formerly incarcerated North Carolinians.

Researchers from UNC Chapel Hill and the N.C. Department of Health and Human Services found that, on average, people who have been incarcerated are at twice the risk of death by suicide — even years after their release — compared to those never imprisoned.

“We might think, ‘Well, they’re getting out, that’s a joyous moment, our loved one is returning to the community,’ said lead author Kate Vinita Fitch, an epidemiology doctoral student at the UNC Gillings School of Global Public Health. “We don’t think about suicide necessarily, especially several years out.” 

“Families might be concerned about opioid overdoses especially right after release because we know that risk is really, really high,” said Fitch who also works with the UNC Injury Prevention Research Center. “But then, a year out, are you still thinking about whether your loved one is at high risk of suicide?”

The study is the first since 2007 to evaluate the suicide risk of people released from North Carolina prisons. It is also the most in-depth look at the subject, analyzing data over nearly two decades. 

“This is a population that often gets disregarded in the conversation about suicide prevention,” Fitch said. “It’s not a population that’s at the forefront of people’s minds, but incarceration is a very common experience… so it’s a really important predictor to look at.”

Identifying suicide risk

Fitch and colleagues analyzed data from 2000 to 2020 from the N.C. Department of Adult Correction and death records from the Vital Records Unit of the North Carolina Division of Public Health to identify patterns in suicide rates among formerly incarcerated people. During this span, 266,400 people ages 18 to 69 were released from the state’s prisons. 

Of the releases, 21,231, or 4.5 percent of the people, died before the end of the study period. Among those deaths, 889, or 4.2 percent of that number, died by suicide.

In particular, the highest rate of suicide mortality occurred in the two-week period after release — at a rate of 37 per 100,000 people. The suicide mortality rates reached another peak at 33.5 per 100,000 people three years after release, Fitch said. 

“It’s the sustained long-term elevation in risk that’s really concerning because that indicates that there are more of these structural upstream factors that are contributing to that suicide risk,” Fitch said.

In contrast to patterns in the general population in which over half of suicide deaths involved a firearm, formerly incarcerated people were more likely to use other methods, such as hanging, suffocation and intentional overdose. Fitch said this finding makes sense because criminal histories often prohibit firearm ownership. Fitch also noted that use of these methods that are less often fatal means there are likely unseen suicide attempts among this population that are not captured in this data.

The analysis revealed that white and Hispanic people had more elevated suicide mortality rates after incarceration compared to Black people, according to Fitch. Suicide deaths among formerly incarcerated white people were nine times higher than those of formerly incarcerated Black people, the study found, even though there were fewer white than Black people in that total population.

While Fitch said their research could not test the reasons for this, she said existing literature offers some potential explanations. For example, white people may be experiencing a greater perceived loss of economic and social status, whereas Black people may have already experienced the burden of structural racism before incarceration so there’s less of a compounding effect on post-release health compared to other groups.

Fitch also said the rate of suicide death among formerly incarcerated people generally decreased with age. Initially, she expected the reverse might be true — that older people would have higher rates of suicide because they’ve often been incarcerated longer and might find reentry particularly jarring as society could be completely different.

However, Fitch said adults ages 18 to 21 who are reentering the community had particularly elevated suicide mortality rates — three times more than their general population peers. Fitch said this may be due to the interruption in social network and identity development that generally occurs during this period.

Suicide mortality for adults ages 22 to 49 years was approximately twice that of their general population peers. 

There are many factors that could contribute to the findings of elevated suicide risk among formerly incarcerated people, Fitch explained. First, incarcerated people have a high rate of mental illness and substance use disorder that could contribute to increased risk. Second, the experience of incarceration itself and living in a prison environment can often lead to mental health problems. Barriers to jobs, housing and health care after release might also contribute to psychological distress and suicidality.

Reality of reentry

Patrice Funderburg, executive director at the Center for Community Transitions in Charlotte, a nonprofit providing support to people rebuilding their lives in society after incarceration, said she’s not surprised by the findings.

Underlying — sometimes even surpassing — the joy a person feels upon being released from prison are feelings of anxiety and fear about what path lies ahead, Funderburg said. There also are questions of if and how one will be able to navigate challenges.

Scott, who was released from prison in 2021, said he felt all those feelings. 

“I was eager to take this next chapter of my life, but I was also scared in a way that I don’t think most people can really understand,” Scott said. “Prison does something to your soul. One of the things it does is it takes away your self-confidence and your belief in yourself. You don’t show that in prison. You can never show that you don’t have that confidence, but the closer you get to your release date, the more it’s like, ‘Wow, this is gonna be really challenging.’” 

In working with this population, Funderburg said she repeatedly sees how a person’s criminal conviction history — or as she says, the “scarlet F of felon” — affects job prospects, housing options, relationships and more.

“The barriers that [formerly incarcerated] people face and the biases that people are so anchored to in our society are certainly conditions ripe for someone to not only consider but attempt extreme measures of dealing with that, including suicide,” Funderburg said.

While Funderburg said she has not worked with a formerly incarcerated person who has died by suicide, she said she has witnessed many people face repeated challenges that can be emotionally distressing and hard to overcome. 

At some point, formerly incarcerated people hope to reach a place of stability with their needs met, Funderburg said. But when that day takes longer than anticipated — or never comes — she said she could see how someone could get to a place where they just don’t want to do it anymore.

“When you think about three years out, how many job applications have been rejected? Funderburg said. “How many times have you not been able to get the services that you need around medical care management or other things? How many family relationships have not been restored? What is your economic situation?”

During the reentry process, failures are magnified, Scott said. They can certainly lead to frustration, depression and even suicide.

For example, Scott described a low he faced when his dad took him to the DMV after his release to get a driver’s license. Since it was the height of the COVID pandemic, the DMV wasn’t offering road tests and he was told he would have to get a learner’s permit. Scott said that felt like a huge blow to regaining his autonomy. He didn’t know how he would be able to rebuild his life or get a job.

“I kind of dwelt in that co-space of anger and depression for a while. Everybody goes through that sometimes on a much more extreme level than I did,” he recalled. “It made me mad enough that it compelled me to action and so I wrote a letter to the head of the DMV, to the head of the Department of Transportation and then also to Governor Cooper and said just like, ‘How do you expect me to rebuild my life? You talk about second chances.’”

About a week later, Scott said he heard back from a DMV official and got a driver’s license. Overcoming that obstacle was euphoric, Scott said. But not all obstacles go away like this, he added.

Need to increase support

Fitch said she hopes the study’s findings can be used to direct more targeted suicide prevention efforts, particularly toward vulnerable segments of this population. Given the long-term sustained risk of suicide years after release, Fitch emphasized that post-release suicide prevention efforts must go beyond prisons and community supervision.

“I think that’s a tempting place to say, ‘Oh, we can deliver suicide prevention services while they’re still being supervised by the criminal legal system.’ But I think it’s apparent due to the fact that suicide risk is sustained for such a long period of time that we have to think about more higher level structural issues and address the root causes of why formerly incarcerated people are so disadvantaged in society.”

Fitch said next steps to address systemic issues include housing, education and employment support, improved access to health care through Medicaid expansion and post-release enrollment programs, along with preventing a return to incarceration. 

Funderburg agrees that it will take changes in society to create an environment that allows formerly incarcerated people to move forward in their lives, and she’s encouraged to see increased momentum around reentry support. Gov. Roy Cooper issued a January executive order initiating a whole-of-government approach to improving reentry support. 

“We live in a society where the general consensus and the bias around a person with a criminal background is that you’re othered,” Funderburg said. “You’re over there. Go figure it out. 

“I think it only contributes to options that a person might explore that sort of bends in some cases toward ending it all.”