SUICIDE ATTEMPTS AMOMG WOMEN DEPRIVED OF THEIR FREEDOM IN A PRISON UNIT*

Objective: to describe the occurrences and factors associated with attempted suicide among women deprived of their freedom in a prison unit. Method: a cross-sectional study conducted at a detention facility in Paraná - Brazil, with 30 women, with data collected in 2022 using the Columbia-Suicide Severity Rating Scale instrument and another one prepared by the authors and analyzed descriptively and inferentially. Results: during their lifetime, 16 (53.3%) women presented suicidal behavior; 14 (46.7%) made actual suicide attempts; 14 (46.7%) had physical damage; and 10 (33.3%) preparatory acts. An actual suicide attempt was associated with suicidal thoughts before arrest (p<0.01) and with thoughts during arrest (p<0.02). Conclusion: previous history of ideation influenced the suicide attempt. Therefore, it is important to evaluate suicidal behavior in the admission and permanence of women deprived of their freedom. This study contributes to reducing the gap in the Brazilian scientific production on this topic with this population segment. DESCRIPTORS: Nursing; Prison Units; Women; Suicide; Suicide Attempt. HIGHLIGHTS


INTRODUCTION
Suicidal events are considered emergencies in the prison environment, requiring immediate interventions 1 .Therefore, histories of suicide attempts can be associated with suicide records [2][3] .
Suicidal behaviors include actual suicide attempts, interrupted and aborted attempts, and preparatory acts.An effective suicide attempt is understood as an action directed at oneself, non-fatal but with potential harm to life; therefore, it is an action with the intention of death.An interrupted attempt comprises an action directed at oneself, with the intention of killing; however, something or someone interrupts it before the occurrence.An aborted attempt is initiated with the intention of death, with withdrawal before completion.Preparatory acts include organizing and preparing the suicide attempt method, such as gathering medications or writing a letter, among others [2][3] .
Suicide is one of the leading causes of death in the world, the fourth in the age group of 15 to 29 years old.In Brazil, it is the third cause of death in this age group and, among women deprived of their freedom, it is 20 times higher than among women in the general population.In the southern region of the country, of the 41 deaths of imprisoned women in the first half of 2020, two were by suicide 4 .
In the world, approximately 700,000 women are deprived of their freedom, with Brazil ranking fourth 5 , comprising around 45,259 of this population.In Paraná, this number corresponds to 7,264 women, 1,674 of whom are in closed conditions 6 .
A study conducted in Ethiopia with 288 people deprived of their freedom showed that women were 5.14 times more likely to present suicidal behavior when compared to men.These data can be due to women's biological aspects, sociocultural issues and the way of dealing with imprisonment.Furthermore, people with stressful factors were 5.11 times more likely to have suicidal behaviors than those who did not those factors 7 .
Thus, stressful factors in prison environments such as reduced visits, court decisions regarding the crime committed, breakdown of relationships, separation from children, economic issues and lack of knowledge about the prison situation can increase psychological problems such as anxiety, depression, self-aggressive and hetero-aggressive behaviors, and substance abuse 7 .
A study with 186 women deprived of their freedom in a penitentiary from Paraíba showed that 66 of them attempted suicide before imprisonment and 35 during prison time, with symptoms of depression, aggression in prison and sexually transmitted infections as the main factors related to attempts 8 .Another factor was suicidal ideation, understood as thoughts of death, with or without a specific plan, which can predict a suicide attempt 7 .
A study with 288 people deprived of their freedom showed that a quarter of the sample presented suicidal ideation and suicidal ideation with plans followed by actual attempts.Suicidal ideas with a plan and intention to act are close to more serious suicidal behaviors, such as actual attempts 7 .
The prison environment is considered to cause harms to physical and mental health due to overcrowding, cell lighting, adaptation to the closed environment, clothing, food, change in the routine, punishments and isolation within prisons.These factors can lead to psychological distress, mental disorders or an increase in severity of these disorders 5,7,9 .
Considering the scarcity of publications on suicidal behavior in the prison system 10 and the new anti-asylum policy of criminal justice, aiming to promote research on the mental health of people in conflict with the law, the importance of research studies with women deprived of their freedom is reinforced to produce scientific knowledge for health professionals in caring for these people 11 .The objective of this study was to describe the occurrences and factors associated with attempted suicide among women deprived of their freedom in a prison unit.
A cross-sectional study conducted at a prison unit in Paraná -Brazil, with a physical structure comprising nine galleries and the Penitentiary Hospital, which serves men and women deprived of their freedom for clinical and psychiatric treatments.It was crowded with 700 men and 42 women at the time of data collection.
Of the 42 women convicted and/or awaiting trial, 30 participated in this study: five in the pilot test, one refused even after three approaches and six were not approached because they had received a release permit or transfer to other prison units.
Women aged 18 and over, convicted or awaiting trial were included; in turn, those with cognitive impairments recorded in their medical record, with infectious diseases, and those who were not in the unit during the collection period were excluded.
The data were collected from May to August 2022, using the Columbia-Suicide Severity Rating Scale (C-SSRS) instrument by Posner 2 , created to assess the intensity of ideation and the type of suicide attempt in life, and another one prepared by the authors to collect sociodemographic, socioeconomic, clinical and pharmacotherapeutic and additional data on characteristics of suicidal ideation and behaviors.
C-SSRS was submitted by the authors to linguistic validation for different languages and nationalities.In this study, the Brazilian Portuguese version was used, made available and authorized by the authors.Online training was carried out on application of the instrument, linked to granting of use by the authors.
The dependent variable was suicide attempt and the independent variables were sociodemographic (age, race, marital status, children, schooling, occupation and income), clinical conditions (type of physical clinical condition, COVID-19, deprivation of freedom before the pandemic, mental health conditions, mental disorders, tobacco use, alcohol use, substance use and mental health treatment), legal aspects (reason for deprivation, time since deprivation, first deprivation, age at first deprivation, number of deprivation, number of people in the cell, course in the prison system, activity to reduce the sentence and family history of deprivation), and suicidal behaviors (suicidal ideation, active suicidal ideation with a specific plan and intention, suicidal thoughts before and during deprivation of freedom, suicidal behaviors, effective attempts, interrupted attempts, aborted attempts, preparatory acts, attempts during deprivation, method, under the influence of alcohol during the attempt, physical damage and family history of suicide).
The women were invited to participate in the presence of the Criminal Police officer, and those who agreed were handed in an Informed Consent Form.The interviews were carried out by a PhD student, an MSc student and a nurse who are part of the macroproject, in the presence of the Criminal Police officer, with the women handcuffed.
The data were coded and entered into an Excel® spreadsheet, with double entry.Descriptive analyses were carried out using absolute and relative frequencies for the categorical variables, and mean, median and interquartile range for the continuous ones.In the inferential stage, the Prevalence Ratio (PR) was calculated as a measure of effect with a 95% confidence interval (95%CI) of the dependent variable, "effective suicide attempt (yes/no)", in relation to the independent variables, with Poisson Regression, and a p-value < 0.05 was considered significant with the Wald test.

DISCUSSION
Several factors can contribute to the occurrence of suicide attempts in the prison environment, including demographic, socioeconomic, clinical and legal aspects [7][8][9] .The highest number of women in this study were between 30 and 49 years old, an age considered vulnerable for suicidal behaviors, according to the latest Brazilian bulletin on self-inflicted injuries and suicides 12 .The southern region has the highest suicide rate in the country between 20 and 59 years old: 12.9 deaths per 100,000 inhabitants 12 .This age group is considered a reproductive age period, which can generate subsequent consequences in the social and economic spheres, such as the reduction of this population 7,12 .
In this study there was predominance of brown skin color predominated, confirming data from the National Survey of Penal Policies, where, in Brazil, brown skin predominates in women deprived of their freedom, with 50.51% 6 .Single marital status prevailed in this study, corroborating the literature in which single women are prone to suicidal behaviors and depression [13][14] .
Incomplete Elementary School predominated in this research.A study conducted with 152 women deprived of their freedom in a penitentiary from São Paulo showed that 60% of the women completed up to fourth grade; 20.6% had Complete High School; and 1.3% were illiterate 15 .
Most of those included in this study were unemployed and earned low incomes.Low schooling is a pattern of vulnerability in this population segment, which can interfere with professional training and employment 15 .
Thyroid endocrine and metabolic changes and dyslipidemia were the main clinical conditions found in this study, similarly to the national study on chronic non-communicable clinical conditions with people deprived of their freedom 16 .
The COVID-19 pandemic resulted in physical and mental consequences, and millions of people died around the world 17 .A number of studies have shown an increase in suicide attempts during the pandemic, both inside and outside the prison system [18][19] .Although most of the women who participated in this study were not deprived of their freedom at the beginning of the pandemic, its consequences may be evident in the short-and longterm on the person's physical and mental health [18][19] .
Among the mental conditions found in this study, the highest frequency corresponded to depression.A study showed that the highest rate of suicide and attempted suicide was related to mental disorders 14,20 , and participants who had depression were five times more susceptible to suicidal behavior than those who were not depressed 20 .
Most of the sample in this study used illicit PAS, alcohol and tobacco.Abuse of these substances is related to suicidal behaviors, according to the literature [19][20][21] .Some prisons allow tobacco use; however, diverse evidence links the increase in this consumption with imprisonment time, generating physical and mental consequences such as respiratory and cardiac problems and increased use of other substances 22 .
In this study, most of the sample received mental health treatments in prison.It is understood that people who were already undergoing treatment may have a history of psychological distress, in addition to consequences acquired due to problems related to the use of alcohol and other substances [20][21] .
Homicide was the most frequent reason for imprisonment, unlike other studies with women in which the predominance of encarcirations was due to drug trafficking 13,15 .
The imprisonment time was less than one year in the largest percentage of the sample.A study conducted at a penitentiary in France showed a suicide rate 6.4 times higher during the first week than in the remaining imprisonment time, in which 11.9% died during the first week and 8.5% in the first month of deprivation 20 , especially at the beginning; the difficulty adapting, the breaking of family ties and the feeling of humiliation can be risk factors 23 .
Having more people in a cell can be a protective factor 9 and, in this study, the number of individuals in the cell was up to three.Having more people in the cell can inhibit or prevent the execution of suicidal behavior; however, overcrowding and unsanitary conditions can be negative factors for a person's mental and physical health 20 .
In this study, a small percentage of women performed work or educational activities to reduce the time spent in prison.A study conducted at a penitentiary in Minas Gerais showed the propensity for suicidal ideation in people who carried out activities to remit their sentence.It should be noted that stressful aspects such as rigorous searches, work schedule routines in the prison environment, few vacancies for activities, and demands for loss of remission due to medium and serious misconduct can generate feelings of concern and demotivation 10 .
The family history of imprisonment in this research was lower than the one found in a study conducted with 152 mothers incarcerated in the inland of São Paulo, which showed 68.4% of this history; they were separated from their parents/caregivers as children because they were imprisoned 15 .
In this study, the number of people who presented more serious ideation equaled the number of effective attempts.A study conducted with people deprived of their freedom in Ethiopia showed that 36 (12.5%) of the participants had suicidal ideation and that 22 (7.6%) planned to attempt suicide.Thoughts before prison can be related to family history and mental disorders 7 .
In this study, an association was observed between actual suicide attempts and suicidal thoughts before and during imprisonment.Presenting suicidal thoughts with a specific plan and intention to carry out the attempt can be a predictor of other suicidal behaviors 20,24 .
Most of the sample presented suicidal behaviors, including actual, interrupted and aborted attempts and preparatory acts.Both ideation and interrupted and aborted attempts can predict actual suicide attempts in the general population.In a study with 137 people who were undergoing treatment at a Psychosocial Care Center for Alcohol and Other Drugs, where the C-SSRS instrument was used, 27 individuals had an interrupted attempt and an effective attempt 24 .However, in the population deprived of their freedom, it is not common for studies to evaluate these predictors of attempted suicide 10 .
The suicide attempts outside prison found in this study are similar to those found in the literature 10,15,20 .Brazilian studies showed that more than 30% of the women deprived of their freedom attempted suicide outside prison 15 and another study identified that attempts outside prison were more frequent than in the prison environment 8 .
In this study, four people committed attempts inside prison.An international study with a population deprived of their freedom showed that 24.6% attempted suicide in prison 20 .In the national literature, 36.1% of the women attempted suicide in this environment 15 .Of the four suicide attempts in prison, three were for the first time.The literature points out some aspects that can be related, such as memories of the crime, family rejection, loss of social ties and the new environment in which they are living 23 .
Exogenous drug intoxication was the main method used by the participants throughout their lives, as was the case in a national study 24 .Some studies show that in the prison environment the main method was hanging, followed by poisoning, which may be due to the resources available inside the cells 7,20,23 .
In this study, four people reported being under the influence of alcohol during suicide attempts.It is considered that the effect of a substance such as alcohol on the body can generate behavioral changes and impulsively increase suicidal behavior 24 .
For the participants who attempted suicide in this study, the methods used caused physical harms and had the possibility of lethality.The literature shows that men present a higher mortality rate due to suicide; on the other hand, women have a higher frequency of attempts.Male lethality can be associated with higher levels of strength and accessibility to the means for more lethal attempts 10 .
Preparation of suicide attempts was found in this study.International scientific evidence shows these actions in prison, which include gathering objects that will be used during the attempt, waiting for the Criminal Police to change shifts or waiting to be alone in the cell [20][21] .
The family history of attempted suicide exceeded 20% in this study; however, in an international study with 235 people deprived of their freedom with suicidal behaviors, 7.0% had a family history of suicidal behaviors 20 .
In this study, the main factors associated with suicide attempts were suicidal thoughts before and during imprisonment.However, other studies with the population deprived of their freedom presented several factors associated with suicide attempts in the prison system, mainly mental, socioeconomic and family clinical history.
The sample size limited the possibilities for inferential analysis and, as this was a crosssectional study, there may have been bias in the participants' memory.However, there were advantages considering the scarcity of studies on this topic in prison units due to restrictions on access to these places, given that they are considered maximum-security units.
Another limitation is the need for Police monitoring during the interviews, which can influence the correct and complete information provided by the participants; as well as closure of the local health sector during the data collection period, which interrupted new admissions to the unit.
In this study, suicide attempts were associated with suicidal thoughts before and during imprisonment.Therefore, knowing these factors, identifying them and devising strategies such as appropriate therapeutic monitoring in advance can prevent the occurrence of suicidal behaviors.
This study contributes to reducing the gap in the scientific production about suicidal ideation and behaviors, exclusively in women deprived of their freedom in Brazil.By uniquely characterizing the researched population, stigmatized and constantly growing, describing this environment, understanding the profile of this population segment and the factors associated with attempted suicide contributes to planning future intervention actions, as well as to promotion and prevention of suicide among women deprived of their freedom.
No. 5,259,143.The Coronavirus prevention measures of the Paraná Penal Police Department were respected.
The software used was Stata version 12 (StataCorp, College Station, United States).The Research Ethics Committee-UFPR approved this study under opinion METHOD

Table 1 -
Characterization of the health conditions of women deprived of their liberty.Pinhais, PR, Brazil, 2022 Source: The authors (2023).

Table 4 -
Univariate analysis of the Prevalence Ratio (PR) of women deprived of liberty associated with actual suicide attempts (SA).Pinhais, PR, Brazil, 2022 Source: The authors (2023).