Social Psychiatry and Psychiatric Epidemiology

, Volume 52, Issue 10, pp 1295–1305 | Cite as

Ambulance attendances resulting from self-harm after release from prison: a prospective data linkage study

  • Rohan BorschmannEmail author
  • Jesse T. Young
  • Paul Moran
  • Matthew J. Spittal
  • Ed Heffernan
  • Katherine Mok
  • Stuart A. Kinner
Original Paper



Incarcerated adults are at high risk of self-harm and suicide and remain so after release into the community. The aims of this study were to estimate the number of ambulance attendances due to self-harm in adults following release from prison, and to identify factors predictive of such attendances.


Baseline surveys with 1309 adults within 6 weeks of expected release from prison between 2008 and 2010 were linked prospectively with state-wide correctional, ambulance, emergency department, hospital and death records in Queensland, Australia. Associations between baseline demographic, criminal justice and mental health-related factors, and subsequent ambulance attendances resulting from self-harm, were investigated using negative binomial regression.


During 4691 person-years of follow-up (median 3.86 years per participant), there were 2892 ambulance attendances in the community, of which 120 (3.9%) were due to self-harm. In multivariable analyses, being Indigenous [incidence rate ratio (IRR): 2.10 (95% CI 1.14–3.86)], having previously been hospitalised for psychiatric treatment [IRR: 2.65 (95% CI 1.44–4.87)], being identified by prison staff as being at risk of self-harm whilst incarcerated [IRR: 2.12 (95% CI 1.11–4.06)] and having a prior ambulance attendance due to self-harm [IRR: 3.16 (95% CI 1.31–7.61)] were associated with self-harm attendances.


Ambulance attendances resulting from self-harm following release from prison are common and represent an opportunity for tertiary intervention for self-harm. The high prevalence of such attendances, in conjunction with the strong association with prior psychiatric problems, reinforces the importance of providing appropriate ambulance staff training in the assessment and management of self-harm, and mental health problems more broadly, in this vulnerable population.


Self-injurious behaviour Prisons Emergency service Ambulance Data linkage 



The authors wish to thank Queensland Corrective Services for assistance with data collection and Passports study participants for sharing their experiences. The views expressed herein are solely those of the authors, and in no way reflect the views or policies of Queensland Corrective Services.

Compliance with ethical standards


The Passports study was funded through an Australian National Health and Medical Research Council (NMHRC) Strategic Award (#409966) and Project Grant (#1002463). RB is supported by an NHMRC Early Career Fellowship (#1104644). SK is supported by an NHMRC Senior Research Fellowship (#1078168).

Conflict of interest

The authors declare that they have no competing interests.


  1. 1.
    Hawton K, Linsell L, Adeniji T, Sariaslan A, Fazel S (2014) Self-harm in prisons in England and Wales: an epidemiological study of prevalence, risk factors, clustering, and subsequent suicide. Lancet 383(9923):1147–1154CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Fazel S, Grann M, Kling B, Hawton K (2011) Prison suicide in 12 countries: an ecological study of 861 suicides during 2003–2007. Soc Psychiatry Psychiatr Epidemiol 46:191–195CrossRefPubMedGoogle Scholar
  3. 3.
    Fazel S, Benning R, Danesh J (2005) Suicides in male prisoners in England and Wales, 1978–2003. Lancet 366(9493):1301–1302CrossRefPubMedGoogle Scholar
  4. 4.
    Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG et al (2007) Release from prison—a high risk of death for former inmates. N Engl J Med 356(2):157–165CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Spittal MJ, Forsyth S, Pirkis J, Alati R, Kinner SA (2014) Suicide in adults released from prison in Queensland, Australia: a cohort study. J Epidemiol Community Health 68(10):993–998CrossRefPubMedGoogle Scholar
  6. 6.
    Haglund A, Tidemalm D, Jokinen J, Långström N, Lichtenstein P, Fazel S et al (2014) Suicide after release from prison: a population-based cohort study from Sweden. J Clin Psychiatry 75(10):1047CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Pratt D, Piper M, Appleby L, Webb R, Shaw J (2006) Suicide in recently released prisoners: a population-based cohort study. Lancet 368(9530):119–123CrossRefPubMedGoogle Scholar
  8. 8.
    Kariminia A, Law MG, Butler TG, Levy MH, Corben SP, Kaldor JM et al (2007) Suicide risk among recently released prisoners in New South Wales, Australia. Med J Aust 187(7):387PubMedGoogle Scholar
  9. 9.
    Hawton K, Zahl D, Weatherall R (2003) Suicide following deliberate self harm: long term follow up of patients who presented to a general hospital. Br J Psychiatry 182:537–542CrossRefPubMedGoogle Scholar
  10. 10.
    Owens D, Horrocks J, House A (2002) Fatal and non-fatal repetition of self-harm. Systematic review. Br J Psychiatry 181:193–199CrossRefPubMedGoogle Scholar
  11. 11.
    Skegg K (2005) Self-harm. Lancet 366:1471–1483CrossRefPubMedGoogle Scholar
  12. 12.
    NICE (2011) Self-harm: longer-term management. National Clinical Guideline 133. National Institute for Health and Clinical Excellence, LondonGoogle Scholar
  13. 13.
    Lloyd B, Gao CX, Heilbronn C, Lubman DI (2015) Self-harm and mental health-related ambulance attendances in Australia: 2013 data. Turning Point, FitzroyGoogle Scholar
  14. 14.
    Sterud T, Ekeberg Ø, Hem E (2006) Health status in the ambulance services: a systematic review. BMC Health Serv Res 6(1):1CrossRefGoogle Scholar
  15. 15.
    Druss BG, Silke A, Compton MT, Rask KJ, Zhao L, Parker RM (2010) A randomized trial of medical care management for community mental health settings: the Primary Care Access, Referral, and Evaluation (PCARE) study. Am J Psychiatry 167(2):151–159CrossRefPubMedGoogle Scholar
  16. 16.
    Rees N, Rapport F, Thomas G, John A, Snooks H (2014) Perceptions of paramedic and emergency care workers of those who self harm: a systematic review of the quantitative literature. J Psychosom Res 77(6):449–456CrossRefPubMedGoogle Scholar
  17. 17.
    Rees N, Rapport F, Snooks H (2015) Perceptions of paramedics and emergency staff about the care they provide to people who self-harm: constructivist metasynthesis of the qualitative literature. J Psychosom Res 78(6):529–535CrossRefPubMedGoogle Scholar
  18. 18.
    Williams B, Boyle M, Fielder C (2015) Empathetic attitudes of undergraduate paramedic and nursing students towards four medical conditions: a three-year longitudinal study. Nurse Educ Today 35(2):e14–e18CrossRefPubMedGoogle Scholar
  19. 19.
    Snooks H, Evans A, Wells B, Peconi J, Thomas M (2012) What are the highest priorities for research in pre-hospital care? Results of a review and Delphi consultation exercise. Australas J Paramed 6(4):2–4Google Scholar
  20. 20.
    Emond K, Furness S, Deacon-Crouch M (2015) Undergraduate paramedic students’ perception of mental health using a pre and post questionnaire. Australas J Paramed 12(5):1–5Google Scholar
  21. 21.
    Lloyd B, Gao C, Heilbronn C, Lubman D (2015) Self-harm and mental health-related ambulance attendances in Australia: 2013 data. Turning Point, FitzroyGoogle Scholar
  22. 22.
    Borschmann R, Thomas E, Moran P, Carroll M, Heffernan E, Spittal MJ et al (2016) Self-harm following release from prison: a prospective data linkage study. Aust N Z J Psychiatry. 51(3):1–10. doi: 10.1177/0004867416640090 Google Scholar
  23. 23.
    Kinner SA, Lennox N, Williams GM, Carroll M, Quinn B, Boyle FM et al (2013) Randomised controlled trial of a service brokerage intervention for ex-prisoners in Australia. Contemp Clin Trials 36(1):198–206CrossRefPubMedGoogle Scholar
  24. 24.
    Holman CAJ, Bass AJ, Rouse IL, Hobbs MS (1999) Population-based linkage of health records in Western Australia: development of a health services research linked database. Aust N Z J Public Health 23(5):453–459CrossRefPubMedGoogle Scholar
  25. 25.
    Moran P, Coffey C, Romaniuk H, Olsson C, Borschmann R, Carlin JB et al (2012) The natural history of self-harm during adolescence and young adulthood: population-based cohort study. Lancet 379(9812):236–243CrossRefPubMedGoogle Scholar
  26. 26.
    OESR (2008) Australian standard offence classification (Queensland extension). Brisbane, Australia: Office of Economic and Statistical Research, Queensland GovernmentGoogle Scholar
  27. 27.
    ABS (2008) National Health Survey: summary of results, 2007–2008. Australian Bureau of StatisticsGoogle Scholar
  28. 28.
    Madge N, Hewitt A, Hawton K, De Wilde EJ, Corcoran P, Fekete S et al (2008) Deliberate self-harm within an international community sample of young people: comparative findings from the Child & Adolescent Self-harm in Europe (CASE) Study. J Child Psychol Psychiatry 49(6):667–677CrossRefPubMedGoogle Scholar
  29. 29.
    Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness: a practical scale. Lancet 304(7872):81–84CrossRefGoogle Scholar
  30. 30.
    Lawless JF (1987) Negative binomial and mixed Poisson regression. Can J Stat 15(3):209–225CrossRefGoogle Scholar
  31. 31.
    Stata (2013) Stata Release 13.0. Stata Corporation. 13.0 ed. Texas, USAGoogle Scholar
  32. 32.
    Darke S (2003) Polydrug use and overdose: overthrowing old myths. Addiction 98(6):711CrossRefPubMedGoogle Scholar
  33. 33.
    Andrews JY, Kinner SA (2012) Understanding drug-related mortality in released prisoners: a review of national coronial records. BMC Public Health 12(1):270CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Fazel S, Baillargeon J (2011) The health of prisoners. Lancet 377(9769):956–965CrossRefPubMedGoogle Scholar
  35. 35.
    Sinclair J, Green J (2005) Understanding resolution of deliberate self harm: qualitative interview study of patients’ experiences. BMJ 330(7500):1112CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Avery A, Kinner SA (2015) A robust estimate of the number and characteristics of persons released from prison in Australia. Aust N Z J Public Health 39(4):315–318CrossRefPubMedGoogle Scholar
  37. 37.
    Platt S, Hawton K, Kreitman N, Fagg J, Foster J (1988) Recent clinical and epidemiological trends in parasuicide in Edinburgh and Oxford: a tale of two cities. Psychol Med 18:405–418CrossRefPubMedGoogle Scholar
  38. 38.
    Guthrie E, Kapur N, Mackway-Jones K, Chew-Graham C, Moorey J, Mendel E et al (2001) Randomised controlled trial of a brief psychological intervention after deliberate self poisoning. BMJ 323:165–169CrossRefGoogle Scholar
  39. 39.
    Milloy M-JS, Buxton J, Wood E, Li K, Montaner JSG, Kerr T (2009) Elevated HIV risk behaviour among recently incarcerated injection drug users in a Canadian setting: a longitudinal analysis. BMC Public Health 9(1):156CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Fazel S, Danesh J (2002) Serious mental disorder in 23 000 prisoners: a systematic review of 62 surveys. Lancet 359(9306):545–550CrossRefPubMedGoogle Scholar
  41. 41.
    Cutcher Z, Degenhardt L, Alati R, Kinner SA (2014) Poor health and social outcomes for ex-prisoners with a history of mental disorder: a longitudinal study. Aust N Z J Public Health 38(5):424–429CrossRefPubMedGoogle Scholar
  42. 42.
    Kouyoumdjian FG, McIsaac KE, Liauw J, Green S, Karachiwalla F, Siu W et al (2015) A systematic review of randomized controlled trials of interventions to improve the health of persons during imprisonment and in the year after release. Am J Public Health 105(4):e13–e33CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Kinner S, Burford B, van Dooren K, Gill C, Gallagher C (2013) Service brokerage interventions to improve health outcomes in ex-prisoners (protocol). Cochrane Database Syst Rev 36(1):198–206Google Scholar
  44. 44.
    Wakeman SE, Bowman SE, McKenzie M, Jeronimo A, Rich JD (2009) Preventing death among the recently incarcerated: an argument for naloxone prescription before release. J Addict Dis 28(2):124–129CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Lenton S, Dietze P, Olsen A, Wiggins N, McDonald D, Fowlie C (2015) Working together: expanding the availability of naloxone for peer administration to prevent opioid overdose deaths in the Australian Capital Territory and beyond. Drug Alcohol Rev 34(4):404–411CrossRefPubMedGoogle Scholar
  46. 46.
    Strang J, Bird SM, Parmar MK (2013) Take-home emergency naloxone to prevent heroin overdose deaths after prison release: rationale and practicalities for the N-ALIVE randomized trial. J Urban Health. 90(5):983–996CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Winter R, Stoove M, Degenhardt L, Hellard M, Spelman T, Jenkinson R et al (2015) Incidence and predictors of non-fatal drug overdose after release from prison among people who inject drugs in Queensland, Australia. Drug Alcohol Depend 153:43–49CrossRefPubMedGoogle Scholar
  48. 48.
    Dietze P, Jolley MD, Cvetkovski MS (2003) Patterns and characteristics of ambulance attendance at heroin overdose at a local-area level in Melbourne, Australia: implications for service provision. J Urban Health 80(2):248–260CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Kelly A-M, Kerr D, Dietze P, Patrick I, Walker T, Koutsogiannis Z (2005) Randomised trial of intranasal versus intramuscular naloxone in prehospital treatment for suspected opioid overdose. Med J Aust 182(1):24–27PubMedGoogle Scholar
  50. 50.
    Kinner SA, Milloy M, Wood E, Qi J, Zhang R, Kerr T (2012) Incidence and risk factors for non-fatal overdose among a cohort of recently incarcerated illicit drug users. Addict Behav 37(6):691–696CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Spilsbury K, Rosman D, Alan J, Boyd JH, Ferrante AM, Semmens JB (2015) Cross-border hospital use: analysis using data linkage across four Australian states. Med J Aust 202(11):582–585CrossRefPubMedGoogle Scholar
  52. 52.
    Nada-Raja S, Morrison D, Skegg K (2003) A population-based study of help-seeking for self-harm in young adults. Aust N Z J Psychiatry 37:600–605CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  1. 1.Centre for Adolescent Health, Murdoch Childrens Research InstituteRoyal Children’s HospitalMelbourneAustralia
  2. 2.Melbourne School of Population and Global HealthThe University of MelbourneVictoriaAustralia
  3. 3.Centre for Health Services Research, School of Population HealthThe University of Western AustraliaPerthAustralia
  4. 4.National Drug Research InstituteCurtin UniversityPerthAustralia
  5. 5.Centre for Academic Mental Health, School of Social and Community MedicineUniversity of BristolBristolUK
  6. 6.Queensland Forensic Mental Health ServiceBrisbaneAustralia
  7. 7.Mater Research InstituteUniversity of QueenslandBrisbaneAustralia
  8. 8.Griffith Criminology InstituteGriffith UniversityBrisbaneAustralia
  9. 9.School of Public Health and Preventive MedicineMonash UniversityMelbourneAustralia
  10. 10.The Black Dog InstituteRandwickAustralia

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