Self-Harm in Low- And Middle-Income Country Prisons: The Example of Morocco

Abstract

Suicidal behavior and self-harm are common in custodial settings, however research from low- and middle-income countries (LMICs) is underrepresented. We conducted a systematic review and meta-analysis on self-harm and suicidal behavior among incarcerated persons in LMICs, and a national retrospective case-control study with frequency matching based on original data to describe self-harm over a one-year period and to establish its determinants in Moroccan prisons.

We searched five databases and five search engines from inception to November 25th, 2024, without restrictions. We calculated pooled prevalence and adjusted odds ratio for risk factors and analyzed qualitative data independently and assessed risk of bias for independent studies and tested for publication bias. A total of 137 studies from 36 countries were identified. The pooled proportion of all custodial deaths by suicide was 10% (95% CI: 7 - 12%) per annum; suicide attempts during incarceration was 7% (3-10%); suicide ideation was 19% (11 - 27%) and self-harm acts was 30% (25 - 36%). The strongest risk factor association with suicide attempt was sex (pooled aOR: 2.55, 95% CI: 1.80 - 3.61) and recidivism (2.23, 1.43 - 3.49); with suicide ideation was recidivism (2.96, 1.04 - 8.40) and family history of mental illness (2.82, 1.97 - 4.04).

In the case-control study, we successfully matched on prison, sex and remand status employing 1:2 matching ratio. The self-harm rate in Moroccan prisons is 728.67 per 100,000 or 0.73%, substantially lower than the rate for LMICs and HICs with higher rates for women (750) and for youth (6,550). People mostly self-harmed during the daytime (71%) by cutting (62%) though methods demonstrated a gendered prevalence (higher rates of overdose and banging heads among women compared to men (26% versus 2% and 26% versus 13%, respectively). We conducted multivariable logistic regression adjusting for clustering. Receiving visits is a protective factor with people who receive irregular visits having 64% lower odds compared to those who do not receive any visits (aOR 0.359, 95% CI: 0.155 - 0.785). The odds of self-harm in Moroccan prisons are higher for people receiving psychotropic medication (12.33, 6.491 - 23.425), people who take drugs (6.10, 3.15 – 11.80) especially ‘hallucinatory pills’ (38.141, 20.64 - 70.48) and hasheesh or alcohol (3.735, 1.999 - 6.976) and those who had previously been to prison (1.826, 1.172 - 2.844). Unemployment and precarious job sectors are also a risk factor (3.533, 2.272 - 5.494 for unemployment, 3.048, 1.577 - 5.891 for the agricultural sector and 4.66, 2.811 - 7.785 for day laborers compared to working in the retail and services sector). Receiving both regular and irregular phone calls increased the odds of self-harm though only irregular calls were statistically significant in the adjusted model (2.299, 1.202 - 4.397).

Self-harm is a serious problem in LMIC prisons, including Morocco. There is a need for support to prevention and management programs that promote interaction with the outside world and mental health. Programs should focus on youth, women and the socio-economically disadvantaged while linking to the community given the high mobility of people in prison. Collaboration with LMIC prison services should be encouraged to conduct both quantitative and qualitative epidemiologic research that adopts a holistic approach to understand the role played by individual, ecologic and systems variables in shaping self-harm and suicidal behavior in prisons.