Self-harm and suicide in custodial settings in low- and middle-income countries: a systematic review and meta-analysis of prevalence and risk factors

Background: Suicidal behavior and self-harm are common in custodial settings, however research from low- and middle-income countries (LMICs) is underrepresented. We aimed to document the prevalence of self-harm, suicide and suicidal behavior (suicide attempts and suicidal ideation) among incarcerated persons in LMICs, and to report determinants for these behaviors. Methods: We searched five databases and five search engines from inception to November 25th, 2024, without restrictions. We calculated pooled prevalence and adjusted odds ratio (aOR) for risk factors and analyzed qualitative data independently. We assessed risk of bias and assessed publication bias. Results: We identified 137 studies from 36 countries. The pooled proportion of all custodial deaths by suicide was 10 % (95 % CI: 7–12 %); suicide attempts during incarceration was 7 % (3–10 %); suicidal ideation was 19 % (11–27 %) and self-harm acts was 30 % (25–36 %). The strongest association with suicide attempt was sex (aOR: 2.55 (95 % CI: 1.80–3.61)) and recidivism (2.23, 1.43–3.49); with suicide ideation it was recidivism (2.96, 1.04–8.40) and family history of mental illness (2.82, 1.97–4.04). Conclusion: The prevalence of suicidal behaviour in LMIC custodial settings appears to be lower than in high-income countries, while the prevalence of self-harm acts is higher. In LMIC custodial settings, suicidal behavior and self-harm are associated with a range of risk factors. Context-specific prevention programs should be established and existing programs strengthened. There is a need for more research in LMIC custodial settings on suicide and self-harm that takes the complex individual, ecological, and systematic dynamics into consideration.