International expansion [edit] An AA meeting The World Service Meeting (WSM), established in 1969, is a biennial international forum where AA delegates from around the world exchange ideas and experiences on carrying the message of recovery. Held in various global cities, the WSM focuses on sharing strategies to help alcoholics in different countries and languages.[43] Today, A.A. is present in approximately 180 nations worldwide. By 2018, AA had 2,087,840 members and 120,300 AA groups worldwide.[42] There are AA meetings in Beijing, China.[44] In July 2024, AA launched its first UK-wide advertising campaign with a unique approach—no logos, phone numbers, or links—focusing on subtle messaging like "You Are not Alone" and "Alcohol isn’t the Answer." The campaign, created by The Raised Eyebrow Society, aims to attract people struggling with alcohol without violating AA’s principles of anonymity and non-promotion.[45] AA will celebrate its 100th anniversary meeting in Indianapolis, Indiana in 2035. The international convention is anticipated to attract tens of thousands of attendees to the Indiana Convention Center and Lucas Oil Stadium.[46]

The Alcoholic Foundation [edit] Alcoholics Anonymous material on walls at The Wilson House, 378 Village Street in downtown East Dorset, Vermont. In 1938, Dr. Bob and Bill created The Alcoholic Foundation in New York, bringing in friends of John D. Rockefeller, Jr. as board members. Although they sought to raise significant funds, Rockefeller decided that large contributions might jeopardize the Fellowship. Despite this, the foundation opened a small office in New York to handle inquiries and distribute the Alcoholics Anonymous book, primarily funded by A.A. members. In 1940, Rockefeller organized a dinner to promote A.A., which further increased the number of inquiries.[34] The office became effective. Each request received a personal reply and a pamphlet, enhancing interest in the book. Consequently, many new groups were established, and by the end of 1940, A.A. membership had grown to 2,000.[25] Media coverage leads to expansion [edit] In 1939, media coverage, particularly from The Cleveland Plain Dealer, generated a surge of interest and requests for help.[35] The Cleveland group, although small, successfully assisted many alcoholics, quickly growing from twenty to around 500 members.[25] A subsequent article in Liberty magazine resulted in a flood of requests for assistance, further expanding A.A.'s reach.[36] 1941, AA had 2,000 members in 50 cities and towns. After the article in The Saturday Evening Post on AA, membership tripled over the next year.[37] Interviews on American radio and favorable articles in US magazines led to increased big book sales and membership.[38] As the growing FTellowship faced disputes over structure, purpose, authority, and publicity, Wilson began promoting the Twelve Traditions.[39] Bill W. first introduced his ideas on the Twelve Traditions in an April 1946 article for The Grapevine, titled “Twelve Suggested Points for A.A. Tradition.”[39] Recognizing the need for guidance as A.A. expanded, he aimed to preserve the organization’s unity and purpose. Bill described the input he received as a "welter of exciting and fearsome experience," which greatly influenced the development of the Traditions.[39] From December 1947 to November 1948, The Grapevine published the Traditions individually, and in 1950, the First International Convention in Cleveland officially adopted them.[39] Creation of General Service Conference (GSR) [edit] In 1951, A.A.'s New York office expanded its activities, including public relations, support for new groups, services to hospitals and prisons, and cooperation with agencies in the field of alcoholism. The headquarters also published standard A.A. literature and oversaw translations, while the AA Grapevine gained substantial circulation. Despite these essential services, they were managed by a disconnected board of trustees, primarily linked to Bill and Dr. Bob.[25] Recognizing the need for accountability, delegates from across the U.S. and Canada were convened, leading to the first meeting of the A.A. General Service Conference in 1951.[40] This successful gathering established direct oversight of A.A.'s trusteeship by the Fellowship itself, ensuring the organization’s future governance. At the 1955 conference in St. Louis, Missouri, Wilson relinquished stewardship of AA to the General Service Conference,[41] as AA had grown to millions of members internationally.[42]

The Alcoholic Foundation [edit] Alcoholics Anonymous material on walls at The Wilson House, 378 Village Street in downtown East Dorset, Vermont. In 1938, Dr. Bob and Bill created The Alcoholic Foundation in New York, bringing in friends of John D. Rockefeller, Jr. as board members. Although they sought to raise significant funds, Rockefeller decided that large contributions might jeopardize the Fellowship. Despite this, the foundation opened a small office in New York to handle inquiries and distribute the Alcoholics Anonymous book, primarily funded by A.A. members. In 1940, Rockefeller organized a dinner to promote A.A., which further increased the number of inquiries.[34] The office became effective. Each request received a personal reply and a pamphlet, enhancing interest in the book. Consequently, many new groups were established, and by the end of 1940, A.A. membership had grown to 2,000.[25] Media coverage leads to expansion [edit] In 1939, media coverage, particularly from The Cleveland Plain Dealer, generated a surge of interest and requests for help.[35] The Cleveland group, although small, successfully assisted many alcoholics, quickly growing from twenty to around 500 members.[25] A subsequent article in Liberty magazine resulted in a flood of requests for assistance, further expanding A.A.'s reach.[36] 1941, AA had 2,000 members in 50 cities and towns. After the article in The Saturday Evening Post on AA, membership tripled over the next year.[37] Interviews on American radio and favorable articles in US magazines led to increased big book sales and membership.[38] As the growing Fellowship faced disputes over structure, purpose, authority, and publicity, Wilson began promoting the Twelve Traditions.[39] Bill W. first introduced his ideas on the Twelve Traditions in an April 1946 article for The Grapevine, titled “Twelve Suggested Points for A.A. Tradition.”[39] Recognizing the need for guidance as A.A. expanded, he aimed to preserve the organization’s unity and purpose. Bill described the input he received as a "welter of exciting and fearsome experience," which greatly influenced the development of the Traditions.[39] From December 1947 to November 1948, The Grapevine published the Traditions individually, and in 1950, the First International Convention in Cleveland officially adopted them.[39] Creation of General Service Conference (GSR) [edit] In 1951, A.A.'s New York office expanded its activities, including public relations, support for new groups, services to hospitals and prisons, and cooperation with agencies in the field of alcoholism. The headquarters also published standard A.A. literature and oversaw translations, while the AA Grapevine gained substantial circulation. Despite these essential services, they were managed by a disconnected board of trustees, primarily linked to Bill and Dr. Bob.[25] Recognizing the need for accountability, delegates from across the U.S. and Canada were convened, leading to the first meeting of the A.A. General Service Conference in 1951.[40] This successful gathering established direct oversight of A.A.'s trusteeship by the Fellowship itself, ensuring the organization’s future governance. At the 1955 conference in St. Louis, Missouri, Wilson relinquished stewardship of AA to the General Service Conference,[41] as AA had grown to millions of members internationally.[42]

Founding of AA [edit] Wilson's early efforts and influence of the Oxford Group [edit] Following his hospital discharge, Wilson joined the Oxford Group and tried to recruit other alcoholics to the group. These early efforts to help others kept him sober, but were ineffective in getting anyone else to join the group and get sober. Dr. Silkworth suggested that Wilson place less stress on religion (as required by The Oxford Group) and more on the science of treating alcoholism. Bill W. would later write: "The early AA got its ideas of self-examination, acknowledgment of character defects, restitution for harm done, and working with others straight from the Oxford Group and directly from Sam Shoemaker, their former leader in America, and from nowhere else."[23] According to Mercadante, however, the AA concept of powerlessness over alcohol departs significantly from Oxford Group belief. In AA, alcoholism cannot be cured, and the Oxford Group stressed the possibility of complete victory over sin.[24] Beginnings of AA in Akron, Ohio [edit] Robert Smith's House in Akron In 1935, AA began in Akron, Ohio, as the outcome of a meeting between Bill W., and Dr. Bob, an Akron surgeon. Wilson's first success came during a business trip to Akron, Ohio, where he was introduced to Dr. Robert Smith, a surgeon, who was unable to stay sober.[25] Dr. Bob's participation in the Oxford Group had not been enough to enable him to stop drinking.[25] Bill W. explained that alcoholism affects the mind, emotions, and body, a concept he learned from Dr. Silkworth at Towns Hospital in New York, where he had been a patient multiple times. Convinced by Bill's insights, Dr. Bob soon achieved sobriety and never drank again, marking the inception of A.A., on 10 June 1935.[26] Bill W. and Dr. Bob started working with alcoholics at Akron’s City Hospital.[25] One patient, who soon achieved sobriety, joined them.[25] Together, the three men formed the foundation of what would later become Alcoholics Anonymous, although the name "Alcoholics Anonymous" had not yet been adopted.[25] In late 1935, a new group of alcoholics began forming in New York, followed by another in Cleveland in 1939. Over the course of four years, these three initial groups helped around 100 people achieve sobriety.[25] In early 1939, the Fellowship published its foundational text, Alcoholics Anonymous, which outlined A.A.’s philosophy and introduced the Twelve Steps. This book also included case histories of thirty individuals who had achieved recovery, marking a significant milestone in A.A.'s development.[25] The Twelve Steps were influenced by the Oxford Group's 6 steps and various readings, including William James's The Varieties of Religious Experience.[27][28] The first female member, Florence Rankin, joined AA in March 1937,[29][30] and the first non-Protestant member, a Roman Catholic, joined in 1939.[31] The first black AA group commenced in 1945 in Washington D.C., and was founded by Jim S., an African-American physician from Virginia.[32][33]

Founding of AA [edit] Wilson's early efforts and influence of the Oxford Group [edit] Following his hospital discharge, Wilson joined the Oxford Group and tried to recruit other alcoholics to the group. These early efforts to help others kept him sober, but were ineffective in getting anyone else to join the group and get sober. Dr. Silkworth suggested that Wilson place less stress on religion (as required by The Oxford Group) and more on the science of treating alcoholism. Bill W. would later write: "The early AA got its ideas of self-examination, acknowledgment of character defects, restitution for harm done, and working with others straight from the Oxford Group and directly from Sam Shoemaker, their former leader in America, and from nowhere else."[23] According to Mercadante, however, the AA concept of powerlessness over alcohol departs significantly from Oxford Group belief. In AA, alcoholism cannot be cured, and the Oxford Group stressed the possibility of complete victory over sin.[24] Beginnings of AA in Akron, Ohio [edit] Robert Smith's House in Akron In 1935, AA began in Akron, Ohio, as the outcome of a meeting between Bill W., and Dr. Bob, an Akron surgeon. Wilson's first success came during a business trip to Akron, Ohio, where he was introduced to Dr. Robert Smith, a surgeon, who was unable to stay sober.[25] Dr. Bob's participation in the Oxford Group had not been enough to enable him to stop drinking.[25] Bill W. explained that alcoholism affects the mind, emotions, and body, a concept he learned from Dr. Silkworth at Towns Hospital in New York, where he had been a patient multiple times. Convinced by Bill's insights, Dr. Bob soon achieved sobriety and never drank again, marking the inception of A.A., on 10 June 1935.[26] Bill W. and Dr. Bob started working with alcoholics at Akron’s City Hospital.[25] One patient, who soon achieved sobriety, joined them.[25] Together, the three men formed the foundation of what would later become Alcoholics Anonymous, although the name "Alcoholics Anonymous" had not yet been adopted.[25] In late 1935, a new group of alcoholics began forming in New York, followed by another in Cleveland in 1939. Over the course of four years, these three initial groups helped around 100 people achieve sobriety.[25] In early 1939, the Fellowship published its foundational text, Alcoholics Anonymous, which outlined A.A.’s philosophy and introduced the Twelve Steps. This book also included case histories of thirty individuals who had achieved recovery, marking a significant milestone in A.A.'s development.[25] The Twelve Steps were influenced by the Oxford Group's 6 steps and various readings, including William James's The Varieties of Religious Experience.[27][28] The first female member, Florence Rankin, joined AA in March 1937,[29][30] and the first non-Protestant member, a Roman Catholic, joined in 1939.[31] The first black AA group commenced in 1945 in Washington D.C., and was founded by Jim S., an African-American physician from Virginia.[32][33]

Hazard's search for treatment [edit] Rowland Hazard’s journey from Carl Jung’s psychiatric treatment to spiritual conversion through the Oxford Group played a pivotal role in shaping the foundations of Alcoholics Anonymous, influencing its principles of recovery.[9] In 1926, Hazard went to Zurich, Switzerland, to seek treatment for alcoholism with psychiatrist Carl Jung. When Hazard ended treatment with Jung after about a year, and came back to the US, he soon resumed drinking, and returned to Jung in Zurich for further treatment. Jung told Hazard that his case was nearly hopeless (as with other alcoholics) and that his only hope might be a "spiritual conversion" with a "religious group".[10][11][12][13] Hazard’s spiritual conversion & involvement with Oxford Group [edit] Back in America, Hazard went to the Oxford Group, whose teachings were eventually the source of such AA concepts as "meetings" and "sharing" (public confession), making "restitution", "rigorous honesty" and "surrendering one's will and life to God's care". Hazard underwent a spiritual conversion" with the help of the Group and began to experience the liberation from drink he was seeking. He became converted to a lifetime of sobriety while on a train ride from New York to Detroit after reading For Sinners Only by Oxford Group member AJ Russell.[14][15] Members of the group introduced Hazard to Ebby Thacher. Hazard brought Thacher to the Calvary Rescue Mission, led by Oxford Group leader Sam Shoemaker.[16] Bill W. & his spiritual awakening [edit] In keeping with the Oxford Group teaching that a new convert must win other converts to preserve his own conversion experience, Thacher contacted his old friend Bill Wilson, whom he knew had a drinking problem.[17][18] Thacher approached Wilson saying that he had "got religion", was sober, and that Wilson could do the same if he set aside objections and instead formed a personal idea of God, "another power" or "higher power".[19][20] Sobriety token or "chip", given for specified lengths of sobriety. On the back is the Serenity Prayer. Here green is for six months of sobriety; purple is for nine months. Feeling a "kinship of common suffering", Wilson attended his first group gathering, although he was drunk. Within days, Wilson admitted himself to the Charles B. Towns Hospital after drinking four beers on the way—the last alcohol he ever drank. Under the care of Dr. William Duncan Silkworth (an early benefactor of AA), Wilson's detox included the deliriant belladonna.[21] At the hospital, a despairing Wilson experienced a bright flash of light, which he felt to be God revealing himself.[22]

Hazard's search for treatment [edit] Rowland Hazard’s journey from Carl Jung’s psychiatric treatment to spiritual conversion through the Oxford Group played a pivotal role in shaping the foundations of Alcoholics Anonymous, influencing its principles of recovery.[9] In 1926, Hazard went to Zurich, Switzerland, to seek treatment for alcoholism with psychiatrist Carl Jung. When Hazard ended treatment with Jung after about a year, and came back to the US, he soon resumed drinking, and returned to Jung in Zurich for further treatment. Jung told Hazard that his case was nearly hopeless (as with other alcoholics) and that his only hope might be a "spiritual conversion" with a "religious group".[10][11][12][13] Hazard’s spiritual conversion & involvement with Oxford Group [edit] Back in America, Hazard went to the Oxford Group, whose teachings were eventually the source of such AA concepts as "meetings" and "sharing" (public confession), making "restitution", "rigorous honesty" and "surrendering one's will and life to God's care". Hazard underwent a spiritual conversion" with the help of the Group and began to experience the liberation from drink he was seeking. He became converted to a lifetime of sobriety while on a train ride from New York to Detroit after reading For Sinners Only by Oxford Group member AJ Russell.[14][15] Members of the group introduced Hazard to Ebby Thacher. Hazard brought Thacher to the Calvary Rescue Mission, led by Oxford Group leader Sam Shoemaker.[16] Bill W. & his spiritual awakening [edit] In keeping with the Oxford Group teaching that a new convert must win other converts to preserve his own conversion experience, Thacher contacted his old friend Bill Wilson, whom he knew had a drinking problem.[17][18] Thacher approached Wilson saying that he had "got religion", was sober, and that Wilson could do the same if he set aside objections and instead formed a personal idea of God, "another power" or "higher power".[19][20] Sobriety token or "chip", given for specified lengths of sobriety. On the back is the Serenity Prayer. Here green is for six months of sobriety; purple is for nine months. Feeling a "kinship of common suffering", Wilson attended his first group gathering, although he was drunk. Within days, Wilson admitted himself to the Charles B. Towns Hospital after drinking four beers on the way—the last alcohol he ever drank. Under the care of Dr. William Duncan Silkworth (an early benefactor of AA), Wilson's detox included the deliriant belladonna.[21] At the hospital, a despairing Wilson experienced a bright flash of light, which he felt to be God revealing himself.[22]

Hazard's search for treatment [edit] Rowland Hazard’s journey from Carl Jung’s psychiatric treatment to spiritual conversion through the Oxford Group played a pivotal role in shaping the foundations of Alcoholics Anonymous, influencing its principles of recovery.[9] In 1926, Hazard went to Zurich, Switzerland, to seek treatment for alcoholism with psychiatrist Carl Jung. When Hazard ended treatment with Jung after about a year, and came back to the US, he soon resumed drinking, and returned to Jung in Zurich for further treatment. Jung told Hazard that his case was nearly hopeless (as with other alcoholics) and that his only hope might be a "spiritual conversion" with a "religious group".[10][11][12][13] Hazard’s spiritual conversion & involvement with Oxford Group [edit] Back in America, Hazard went to the Oxford Group, whose teachings were eventually the source of such AA concepts as "meetings" and "sharing" (public confession), making "restitution", "rigorous honesty" and "surrendering one's will and life to God's care". Hazard underwent a spiritual conversion" with the help of the Group and began to experience the liberation from drink he was seeking. He became converted to a lifetime of sobriety while on a train ride from New York to Detroit after reading For Sinners Only by Oxford Group member AJ Russell.[14][15] Members of the group introduced Hazard to Ebby Thacher. Hazard brought Thacher to the Calvary Rescue Mission, led by Oxford Group leader Sam Shoemaker.[16] Bill W. & his spiritual awakening [edit] In keeping with the Oxford Group teaching that a new convert must win other converts to preserve his own conversion experience, Thacher contacted his old friend Bill Wilson, whom he knew had a drinking problem.[17][18] Thacher approached Wilson saying that he had "got religion", was sober, and that Wilson could do the same if he set aside objections and instead formed a personal idea of God, "another power" or "higher power".[19][20] Sobriety token or "chip", given for specified lengths of sobriety. On the back is the Serenity Prayer. Here green is for six months of sobriety; purple is for nine months. Feeling a "kinship of common suffering", Wilson attended his first group gathering, although he was drunk. Within days, Wilson admitted himself to the Charles B. Towns Hospital after drinking four beers on the way—the last alcohol he ever drank. Under the care of Dr. William Duncan Silkworth (an early benefactor of AA), Wilson's detox included the deliriant belladonna.[21] At the hospital, a despairing Wilson experienced a bright flash of light, which he felt to be God revealing himself.[22]

Alcoholics Anonymous (AA) is a global, peer-led mutual-aid fellowship dedicated to abstinence-based recovery from alcoholism through its spiritually inclined twelve-step program.[1] AA’s Twelve Traditions, besides stressing anonymity and the lack of a governing hierarchy, establish AA as free to all, non-promotional, non-professional, unaffiliated, and non-denominational, as well as apolitical.[1][2][3] In 2021 AA reported a presence in approximately 180 countries with nearly two million members—73% in the United States and Canada.[4][5] AA dates its beginning to Bill Wilson's (Bill W.) and Bob Smith's (Dr. Bob) first commiseration alcoholic-to-alcoholic in 1935. Meeting through the Christian revivalist Oxford Group, they and other alcoholics helped each other until forming what became AA. In 1939 the new fellowship published Alcoholics Anonymous: The Story of How More than One Hundred Men Have Recovered from Alcoholism. Debuting AA’s 12 steps, it is Informally known as the “Big Book”. It is also the origin of AA's name. AA’s twelve steps are a “suggested”—but not required—“program of recovery” in which in divining and following the will of a self-defined “God as we understood Him” is one of the most essential suggestions. The steps have individuals acknowledge shortcomings, and engage in structured self-reflection, admission of faults, correction, and personal growth. Its goal is to facilitate a "spiritual awakening" through ethical acts, prayer and meditation. According to the 12th step, they carry AA’s message to other alcoholics through group meetings, one-on-one interactions, and outreach efforts in hospitals, treatment centers, and correctional facilities. AA meetings vary in format, with some focusing on personal stories, readings from the Big Book, or open discussion. Meetings may cater to specific demographics, but they generally welcome anyone who desires to stop drinking. AA is self-supporting, with donations from members covering expenses, and it operates through an "inverted pyramid" structure, where individual groups function autonomously. The organization does not accept outside contributions and relies heavily on literature sales. Many studies and reviews show AA as an effective and cost-efficient method for achieving abstinence in individuals struggling with alcohol addiction. A 2020 Cochrane review found that AA and Twelve-Step Facilitation (TSF) significantly increased rates and durations of abstinence compared to other treatments like cognitive-behavioral therapy, while being more cost-effective.[6][7] AA has faced criticism for various reasons. Critics have questioned its overall success rate, and others have criticized the religious or cult-like aspects of its program. There have also been concerns about "thirteenth-stepping," where older members pursue new members romantically, as well as lawsuits regarding safety and the religious nature of AA in court-mandated treatment. Other addiction recovery fellowships, such as Narcotics Anonymous, Sexual Recovery Anonymous, and Al-Anon—with AA’s permission—have adopted and adapted the twelve steps and traditions.[8]

Alcoholics Anonymous (AA) is a global, peer-led mutual-aid fellowship dedicated to abstinence-based recovery from alcoholism through its spiritually inclined twelve-step program.[1] AA’s Twelve Traditions, besides stressing anonymity and the lack of a governing hierarchy, establish AA as free to all, non-promotional, non-professional, unaffiliated, and non-denominational, as well as apolitical.[1][2][3] In 2021 AA reported a presence in approximately 180 countries with nearly two million members—73% in the United States and Canada.[4][5] AA dates its beginning to Bill Wilson's (Bill W.) and Bob Smith's (Dr. Bob) first commiseration alcoholic-to-alcoholic in 1935. Meeting through the Christian revivalist Oxford Group, they and other alcoholics helped each other until forming what became AA. In 1939 the new fellowship published Alcoholics Anonymous: The Story of How More than One Hundred Men Have Recovered from Alcoholism. Debuting AA’s 12 steps, it is Informally known as the “Big Book”. It is also the origin of AA's name. AA’s twelve steps are a “suggested”—but not required—“program of recovery” in which in divining and following the will of a self-defined “God as we understood Him” is one of the most essential suggestions. The steps have individuals acknowledge shortcomings, and engage in structured self-reflection, admission of faults, correction, and personal growth. Its goal is to facilitate a "spiritual awakening" through ethical acts, prayer and meditation. According to the 12th step, they carry AA’s message to other alcoholics through group meetings, one-on-one interactions, and outreach efforts in hospitals, treatment centers, and correctional facilities. AA meetings vary in format, with some focusing on personal stories, readings from the Big Book, or open discussion. Meetings may cater to specific demographics, but they generally welcome anyone who desires to stop drinking. AA is self-supporting, with donations from members covering expenses, and it operates through an "inverted pyramid" structure, where individual groups function autonomously. The organization does not accept outside contributions and relies heavily on literature sales. Many studies and reviews show AA as an effective and cost-efficient method for achieving abstinence in individuals struggling with alcohol addiction. A 2020 Cochrane review found that AA and Twelve-Step Facilitation (TSF) significantly increased rates and durations of abstinence compared to other treatments like cognitive-behavioral therapy, while being more cost-effective.[6][7] AA has faced criticism for various reasons. Critics have questioned its overall success rate, and others have criticized the religious or cult-like aspects of its program. There have also been concerns about "thirteenth-stepping," where older members pursue new members romantically, as well as lawsuits regarding safety and the religious nature of AA in court-mandated treatment. Other addiction recovery fellowships, such as Narcotics Anonymous, Sexual Recovery Anonymous, and Al-Anon—with AA’s permission—have adopted and adapted the twelve steps and traditions.[8]

Alcoholics Anonymous (AA) is a global, peer-led mutual-aid fellowship dedicated to abstinence-based recovery from alcoholism through its spiritually inclined twelve-step program.[1] AA’s Twelve Traditions, besides stressing anonymity and the lack of a governing hierarchy, establish AA as free to all, non-promotional, non-professional, unaffiliated, and non-denominational, as well as apolitical.[1][2][3] In 2021 AA reported a presence in approximately 180 countries with nearly two million members—73% in the United States and Canada.[4][5] AA dates its beginning to Bill Wilson's (Bill W.) and Bob Smith's (Dr. Bob) first commiseration alcoholic-to-alcoholic in 1935. Meeting through the Christian revivalist Oxford Group, they and other alcoholics helped each other until forming what became AA. In 1939 the new fellowship published Alcoholics Anonymous: The Story of How More than One Hundred Men Have Recovered from Alcoholism. Debuting AA’s 12 steps, it is Informally known as the “Big Book”. It is also the origin of AA's name. AA’s twelve steps are a “suggested”—but not required—“program of recovery” in which in divining and following the will of a self-defined “God as we understood Him” is one of the most essential suggestions. The steps have individuals acknowledge shortcomings, and engage in structured self-reflection, admission of faults, correction, and personal growth. Its goal is to facilitate a "spiritual awakening" through ethical acts, prayer and meditation. According to the 12th step, they carry AA’s message to other alcoholics through group meetings, one-on-one interactions, and outreach efforts in hospitals, treatment centers, and correctional facilities. AA meetings vary in format, with some focusing on personal stories, readings from the Big Book, or open discussion. Meetings may cater to specific demographics, but they generally welcome anyone who desires to stop drinking. AA is self-supporting, with donations from members covering expenses, and it operates through an "inverted pyramid" structure, where individual groups function autonomously. The organization does not accept outside contributions and relies heavily on literature sales. Many studies and reviews show AA as an effective and cost-efficient method for achieving abstinence in individuals struggling with alcohol addiction. A 2020 Cochrane review found that AA and Twelve-Step Facilitation (TSF) significantly increased rates and durations of abstinence compared to other treatments like cognitive-behavioral therapy, while being more cost-effective.[6][7] AA has faced criticism for various reasons. Critics have questioned its overall success rate, and others have criticized the religious or cult-like aspects of its program. There have also been concerns about "thirteenth-stepping," where older members pursue new members romantically, as well as lawsuits regarding safety and the religious nature of AA in court-mandated treatment. Other addiction recovery fellowships, such as Narcotics Anonymous, Sexual Recovery Anonymous, and Al-Anon—with AA’s permission—have adopted and adapted the twelve steps and traditions.[8]

Criminal justice reform seeks to address structural issues in criminal justice systems such as racial profiling, police brutality, overcriminalization, mass incarceration, and recidivism. Criminal justice reform can take place at any point where the criminal justice system intervenes in citizens’ lives, including lawmaking, policing, and sentencing. Police reform [edit] Police reform describes the various proposals to change policing practices. The Brookings Institution organizes police reform into three categories: short-term, medium-term, long-term. Short-term hold Police officers accountable for there actions. The Law Enforcement Bill of Rights protects officers from losing their jobs, having their personal information put out to the world, police officers will be informed when they are being investigated, will be told who they will be interrogated by. Medium-term would shift the financial burden of paying civilian payouts to the police department insurance policy and the police officer their self to pay the sum of money instead of taxpayer dollars. Long-term making policing more about the community then it being the police vs the community, doing research on how to improve law enforcement and the local community.[1] Banning random searches [edit] Some jurisdictions, including the United States and United Kingdom, give their police force the power to stop citizens based on the reasonable grounds (UK) or reasonable suspicion (US) that the person being stopped may be involved in criminal activity.[2][3] Critics of this practice argue that police apply standards of reasonable suspicion to stop citizens unevenly, often targeting individuals based on race.[4] During these stops, police may choose to search the individual for illegal weapons or other items, such as drugs or drug paraphernalia. Frisking members of public without evidence of crime (also known as stop-and-search) was heavily reduced in the United Kingdom as a policing reform.[5] This was done following research, which found that the searches had been a major cause of the 2011 England riots.[6] Alternatives to police [edit] Traffic officers [edit] There have been suggestions for unarmed police or civilian officers to take over some or all traffic policing duties.[7] Relevant duties of a traffic officers would be making sure that goods being transported are safe, checking licensing is up to date, making sure Vehicle operators are not impaired by anything. Qualifications include a law enforcement degree, diploma, certification. There will training in driving commercial Vehicles, pass a fitness test, Pass questionnaires, and a physical exam.[8] Community mediators [edit] There have also been suggestions for police to be replaced by community mediators in minor interpersonal disputers.[7] This is often called violence interruption, and is practiced for example by Cure Violence. Community mediators do not interfere with family issues such as divorce, separation, custody or estates, don't handle issues that involve money. Mobile crisis units [edit] Another suggestion involves sending specially trained social workers to respond to situations caused by mental health or substance abuse problems.[7] An example is the CAHOOTS system in Eugene, Oregon. In the United Kingdom are trying to make a 24/7 in home treatment where a patient would be more comfortable than taking them hospital they would be uncomfortable and could cause them to get worse.[9]   In Canada there are 24/7 crisis units available. The units are available to children, adolescents, adults with a addiction or mental health crisis, or any love ones of the people in distress, can meet with a member of the addiction and mental health team, can get referral to the appropriate services, risk assessment, help getting mental health services.[10] Prison reform [edit] Main article: Prison reform Improving prison conditions [edit] In many countries, prison conditions are such that the health and safety of prisoners cannot be guaranteed. At worst, imprisonment can directly threaten the lives of convicted individuals. Efforts to improve prison conditions are aimed at protecting prisoners and prison employees. Such efforts also attempt to minimize the collateral effects of imprisonment that continue to affect convicted individuals after their sentences have been served. Overcrowding poses a substantial risk to prisoners' health and safety. In spite of the 1955 adoption of the United Nations Standard Minimum Rules for the Treatment of Prisoners,[11] Penal Reform International reports that "the number of prisoners exceeds official prison capacity in at least 115 countries."[12] The World Health Organization recognizes prison overcrowding as a health threat to both prisoners and prison employees. Overcrowded prisons are high-risk environments for the transmission of diseases such as HIV and tuberculosis.[13] Additionally, overcrowding has negative effects on prisoners' mental health. Results from a study conducted at the prison of Champ-Dollon in Geneva, Switzerland indicate that prison overcrowding was associated with an increase in incidents of self-strangulation/hanging.[14] Working in the United States, Huey and McNulty found that "overcrowding is a strong predictor of heightened suicide and may threaten security and safety within prisons more generally by undermining the well-being of inmates."[15] Solitary confinement, or super maximum-security confinement, also poses a threat to the mental health of prison inmates. Studies taking place in the United States, Canada, Denmark, Germany, and South Africa report that those who experience solitary confinement experience "anxiety, fatigue, confusion, paranoia, depression, hallucinations, headaches, and uncontrollable trembling."[16] The World Medical Association notes that, "Negative health effects can occur after only a few days and may in some cases persist when isolation ends."[17] Due to the exacerbation of mental health issues in prisoners who held in solitary confinement, such prisoners may have difficulty adjusting to society once their prison sentences are finished.[18] [19] Based on these issues, organizations such as Penal Reform International and Amnesty International work to raise awareness of the negative effects of solitary confinement and call for an end to the use of solitary confinement.[20][21] Finally, proponents of prison reform argue that healthcare services and sanitary conditions in prisons must be improved. According to Wallace and Papachristos, "A number of studies have shown that incarceration is highly detrimental to health and has lasting, negative health consequences for the ex-prisoner, their immediate social connections, and the larger community."[22] Communicable diseases such as tuberculosis, HIV/AIDS, and syphilis infect prison inmates at a higher rate than they infect the general population.[23] In the United Kingdom, chronic diseases, such as respiratory conditions, heart disease, diabetes, and epilepsy, are often not effectively addressed by prison healthcare staff due to strains on the healthcare system.[24] WHO emphasizes that improving healthcare in prisons ensures the health of the broader communities surrounding prisons because most imprisoned people will eventually be released into their communities, and many of them move between both settings.[25] Justice reinvestment [edit] Justice reinvestment involves redirecting money from prisons to funding the social and physical infrastructure of places with high levels of incarceration.[26] Reductions in incarceration may include risk and need assessments, sentence reductions, intermediate and graduated sanctions to parole and probation violations, treatment of substance addictions, changing sentencing guidelines, post-release supervision, and courts specialized in mental health or substance abuse issues.[27] The money saved through these policies may be invested in addiction treatment, additional probation officers, community sentencing, victims' services, housing support and transitional housing, and behavioral health service.[27] A justice reinvestment project in Bourke, Australia led by Indigenous Australians led to an 18% reduction in the number of major offences reported, 34% reduction in non-domestic violence assaults reported, and an 8% drop in the overall rate of recidivism.[28] Legal reform [edit] Access to legal aid [edit] For accused persons facing trial in a criminal justice system, access to competent legal aid is necessary for guaranteeing that their interaction with the criminal justice system is fair. According to the United Nations, “Legal aid plays a crucial role in enabling people to navigate the justice system, to make informed decisions, as well as to obtain justice remedies. Legal aid makes a critical connection between populations and their justice systems and provides guidance on how to navigate the often difficult-to-understand justice system.”[29] The UN charges member governments with the responsibility of providing legal counsel to citizens, especially the poor, “so as to enable them to assert their rights and where necessary call upon the assistance of lawyers.”[30] In 2016, the UN identified several key issues in ensuring legal aid for citizens of nations that responded to the Global Study on Legal Aid: a lack of specific legislation on legal aid; a need for increased public awareness of the availability of legal aid; overburdened legal aid systems resulting in high caseloads for lawyers or a shortage of qualified lawyers; and limited availability of legal aid for those residing in rural areas or for members of vulnerable populations (e.g. internationally displaced people).[29] These issues result in unequal access to legal aid within individual countries and across the globe. Access to justice initiatives across the globe work to ameliorate these issues an ensure access to legal aid. Plea bargaining [edit] Plea bargaining is the process by which the accused may negotiate with the prosecution for a lesser sentence by admitting partial guilt or by taking full responsibility for the crime committed. This process renders a trial unnecessary, allowing both the defense and the prosecution to move to the sentencing stage. Although plea bargaining was developed in the United States during the 1800s, it “rapidly spread to many other criminal justice systems including civil law countries such as Germany, France and Italy. It has now been used even in international criminal law.”[31] Plea bargaining is useful for both the defense and the prosecution as it spares both from spending the resources needed to conduct a trial. Additionally, defendants may be sentenced with shorter prison terms or lesser fines than they would if they were found guilty at trial. However, critics argue that the process is coercive and that "defendants lose the procedural safeguards of a trial (most of all the presumption of innocence), that victims are not heard, that the public is excluded and that convicted criminals receive too lenient sentences."[31] Additionally, the process has been blamed for increased rates of imprisonment in countries where the majority of incarcerated individuals plead guilty without going to trial.[32] "Cases that are resolved through plea bargaining, scholars estimate that about 90 to 95 percent of both federal and state court."[33] The process of plea bargaining can undercut efforts to conduct a fair trial because the prosecution's case is never tested by the defense's legal representation in court. Moreover, in nations where competent legal aid for defendants is required, cases prepared by public defenders are not evaluated at trial, meaning the adequacy of a given system of public defense is not established.[34] The balance of power tends to be in the prosecution's favor, so the accused may choose to plea bargain in the face of a significant prison sentence rather than risk a guilty verdict at trial. Sentencing reform [edit] Main articles: Sentencing reform and Community sentence Sentencing reform is the effort to change perceived injustices in the lengths of criminal sentences. It is a component of the larger concept of criminal justice reform. In the U.S. criminal justice system, sentencing guidelines are criticized for being both draconian and racially discriminatory. Additionally, they are cited as the main contributor to the growing and excessive prison population known as mass incarceration. One avenue of reform is the concept of the community sentence[35][36] or alternative sentencing or non-custodial sentence is a collective name in criminal justice for all the different ways in which courts can punish a defendant who has been convicted of committing an offence, other than through a custodial sentence (serving a jail or prison term) or capital punishment (death).

The prison abolition movement is a network of groups and activists that seek to reduce or eliminate prisons and the prison system, and replace them with systems of rehabilitation and education that do not focus on punishment and government institutionalization.[1] The prison abolitionist movement is distinct from conventional prison reform, which is intended to improve conditions inside prisons.[2]: 3  Supporters of prison abolitionism are a diverse group with differing ideas as to exactly how prisons should be abolished, and what, if anything, should replace them. Some supporters of decarceration and prison abolition also work to end solitary confinement, the death penalty, and the construction of new prisons through non-reformist reform.[3][4] Others support books-to-prisoner projects and defend prisoners' right to access information and library services. Some organizations, such as the Anarchist Black Cross, seek the total abolishment of the prison system without any intention to replace it with other government-controlled systems. Definition [edit] Scholar Dorothy Roberts takes the prison abolition movement in the United States to endorse three basic theses:[5] 1. "[T]oday’s carceral punishment system can be traced back to slavery and the racial capitalist regime it relied on and sustained." 2. "[T]he expanding criminal punishment system functions to oppress black people and other politically marginalized groups in order to maintain a racial capitalist regime." 3. "[W]e can imagine and build a more humane and democratic society that no longer relies on caging people to meet human needs and solve social problems." Thus, Roberts situates the theory of prison abolition within an intellectual tradition including scholars such as Cedric Robinson, who developed the concept of racial capitalism,[6][7] and characterizes the movement as a response to a long history of oppressive treatment of black people in the United States. In Canada, many abolitionists have called Canada's prisons the "new residential schools", which were designed as a cultural genocide of Indigenous people.[8] Legal scholar Allegra McLeod notes that prison abolition is not merely a negative project of "opening … prison doors", but rather "may be understood instead as a gradual project of decarceration, in which radically different legal and institutional regulatory forms supplant criminal law enforcement."[9] Prison abolition, in McLeod's view, involves a positive agenda that reimagines how societies might deal with social problems in the absence of prisons, using techniques such as decriminalization and improved welfare provision.[9] Like Roberts, McLeod sees the contemporary theory of prison abolition as linked to theories regarding the abolition of slavery. McLeod notes that W. E. B. Du Bois—particularly in his Black Reconstruction in America—saw abolitionism not only as a movement to end the legal institution of property in human beings, but also as a means of bringing about a "different future" wherein former slaves could enjoy full participation in society.[10] (Angela Davis explicitly took inspiration from Du Bois's concept of "abolition democracy" in her book Abolition Democracy: Beyond Empire, Prisons, and Torture.[11]) Similarly, on McLeod's view, prison abolition implies broad changes to social institutions: "[a]n abolitionist framework", she writes, "requires positive forms of social integration and collective security that are not organized around criminal law enforcement, confinement, criminal surveillance, punitive policing, or punishment."[12] The abolition of prisons is not only about the closure of prisons.[13] Abolitionist views is also a way to counter the hegemonic discourse, and gives an alternative ways of thinking.[13] It is a way to reconceptualize basic notions like crime, innocence, punishment etc.[13] Historical development [edit] Anarchism and prison abolition [edit] Many anarchist organizations believe that the best form of justice arises naturally out of social contracts, restorative justice, or transformative justice. Anarchist opposition to incarceration can be found in articles written as early as 1851,[14] and is elucidated by major anarchist thinkers such as Proudhon,[15] Bakunin,[16] Berkman,[15] Goldman,[15] Malatesta,[15] Bonano,[17] and Kropotkin.[15] Personal experiences in prison because of revolutionary activity prompted many anarchists who were “deeply affected by their experiences” to publish their criticisms.[15] In 1886, the trial of eight anarchists following the Haymarket riots brought state repression to public attention. Lucy Parsons, an anarchist and wife of one of the Haymarket eight, embarked on a speaking tour through 17 different states speaking to a total of almost 200,000 people.[18] A single rally in Havana, Cuba, to support the families of the eight accused anarchists raised nearly $1000.[19] Speaking at his trial, in a widely disseminated speech, one of the co-accused, August Spies, stated: It is not likely that the honorable Bonfield and Grinnell can conceive of a social order not held intact by the policeman's club and pistol, nor of a free society without prisons, gallows, and State's attorneys. In such a society they probably fail to find a place for themselves. And is this the reason why Anarchism is such a "pernicious and damnable doctrine?"[20] The Anarchist Red Cross, a prisoner support group and the precursor to the Anarchist Black Cross, was founded roughly in 1906.[21] By that year, groups existed in Kiev, Odessa, Bialystok, and trials of its members, led to its spread across Europe and North America.[21] A 2018 guide to starting an Anarchist Black Cross group states that "we need to destroy all the prisons, and free all the prisoners. Our position is an abolitionist stance against the state and it’s prisons."[22] In 1917, the Anarchist Red Cross would disband and members joined the revolution in Russia.[21] Following the February revolution, political prisoners were released from Russian jails, in a massive wave of amnesties.[21] The Anarchist Red Cross reorganised in 1919 as the Anarchist Black Cross, with some members joining the anarchist insurgent, Nestor Makhno.[21] Makhno, a Ukrainian anarchist who was freed in 1917 from a life sentence in prison, organised a revolutionary insurgent army along anarchist principles that would come to control a territory of seven-and-a-half million people.[23] Upon taking control of a town, Makhnovists would destroy “all remnants and symbols of slavery: prisons, police and gendarmerie posts were blown up with dynamite or put to the torch.”[23] Prisoners in battle who were not officers were typically welcomed into the ranks of Makhnovists or freed.[23] The Makhnovist revolutionary insurgent army adopted a declaration in 1919, stating we are against all rigid judicial and police machinery, against any legislative code prescribed once and for all time, for these involve gross violations of genuine justice and of the real protections of the population. These ought not to be organized but should be instead the living, free and creative act of the community. Which is why all obsolete forms of justice—court administration, revolutionary tribunals, repressive laws, police or militia, Cheka, prisons and all other sterile and useless anachronisms—must disappear of themselves or be abolished from the very first breath of the free life, right from the very first steps of the free and living organization of society and the economy.[23] The Anarchist Black Cross was reconstituted in the aftermath of the Spanish Civil War and Anarchist Revolution. The pressure from the number of anarchist prisoners in need of aid led to the closing of “most of the chapters in the United States and Europe.”[21] Alternative groups, such as the Alexander Berkman Aid Fund and the Society to Aid Anarchist Prisoners in Russia would take their place.[21] Another resurgence was felt in 1967, and, again, in 1979 owing to the efforts of Lorenzo Kom’boa Ervin, whose writings on prison and anarchism are credited as having spread and been foundational to Black anarchism.[21][24] Anarchists agitation against prisons in Canada has included Bulldozer, an anti-prison anarchist project founded in Toronto in 1980.[25] Bulldozer was closed after being raided and charged with sedition. The End the Prison Industrial Complex (Epic) was formed in 2009, and Anarchist Black Cross projects emerged throughout the 2000s. Anarchists and abolitionists within Québec organise yearly noise demonstrations outside of prison facilities on New Year's Eve.[26] A campaign to stop the construction of a migrant prison involved anarchists unloading thousands of crickets into the offices of an architectural firm in 2018.[27] Campaigns to free anarchist prisoners have served as the basis for calling for freedom for all prisoners. June 11, 2011, international solidarity actions for anarchist prisoners Marie Mason and Eric McDavid triggered the start of an international day and week of solidarity with all anarchist prisoners in 2015.[28] 2022's week of solidarity included actions in Poland, Russia, Ukraine, Uruguay, Greece, the UK, and other countries.[29] The 2022-2023 hunger strike of anarchist prisoner Alfredo Cospito led to police skirmishes with protesters in Rome, a Turin cell tower being lit on fire, and a letter with bullets was sent to a newspaper stating "if Alfredo Cospito dies judges will all be targets, two months without food, burn down the prisons."[30] International actions to free Cospito, included the burning of a Strabag excavator in Germany. The Italian placed their embassies on "alert" in response to mobilizations.[30] The Rojavan Revolution, which many have considered illustrative of, and rooted in, anarchist theory,[31] involved the mass liquidation of prisons and freeing of political prisoners and nonviolent offenders.[32] Neighbourhood based "peace committees," composed of elected community members with, largely, no formal legal education, were created to resolve conflicts using a model of consensus and restorative justice.[32] Prison abolition and the New Left [edit] Angela Davis traces the roots of contemporary prison abolition theory at least to Thomas Mathiesen's 1974 book The Politics of Abolition, which had been published in the wake of the Attica Prison uprising and unrest in European prisons around the same time.[33] She also cites activist Fay Honey Knopp's 1976 work Instead of Prisons: A Handbook for Abolitionists as significant in the movement.[33] Eduardo Bautista Duran and Jonathan Simon point out that George Jackson's 1970 text Soledad Brother drew global attention to the conditions of prisons in the United States and made prison abolition a tenet of the New Left.[34] Liz Samuels has observed that, following the Attica Prison uprising, activists began to coalesce around a vision of abolition, whereas previously they had endorsed a program of reform.[35] 1973 Walpole Prison uprising [edit] Main article: Walpole prison strike In 1973, two years after the Attica Prison uprising, the inmates of Walpole prison, in Massachusetts, formed a prisoners' union to protect themselves from guards, end behavioral modification programs, advocate for the prisoner's right for education and healthcare, gain more visitation rights, work assignments, and to be able to send money to their families. The union also created a general truce within the prison and race-related violence sharply declined. During the Kwanzaa celebration, black prisoners were placed under lockdown, angering the whole facility and leading to a general strike. Prisoners refused to work or leave their cells for three months, to which the guards responded by beating prisoners, putting prisoners in solitary confinement, and denying prisoners medical care and food.[36] The strike ended in the prisoners' favour as the superintendent of the prison resigned. The prisoners were granted more visitation rights and work programs. Angered by this, the prison guards went on strike and abandoned the prison, hoping that this would create chaos and violence throughout the prison. But the prisoners were able to create an anarchist community where recidivism dropped dramatically and murders and rapes fell to zero. Prisoners volunteered to cook meals. Vietnam veterans who had been trained as medics took charge of the pharmacy and distribution of medication. Decisions were made in community assemblies. Advocates of prison abolition [edit] Anarchist banner in Melbourne Australia, on 16 June 2017 Angela Davis writes: "Mass incarceration is not a solution to unemployment, nor is it a solution to the vast array of social problems that are hidden away in a rapidly growing network of prisons and jails. However, the great majority of people have been tricked into believing in the efficacy of imprisonment, even though the historical record clearly demonstrates that prisons do not work."[37] In 1997, Angela Davis and Ruth Wilson Gilmore co-founded Critical Resistance, which is an organization working to "build an international movement to end the Prison Industrial Complex by challenging the belief that caging and controlling people makes us safe."[38][39] Other similarly motivated groups such as the Prison Activist Resource Center (PARC), a group "committed to exposing and challenging all forms of institutionalized racism, sexism, able-ism, heterosexism, and classism, specifically within the Prison Industrial Complex,"[40] and Black & Pink, an abolitionist organization that focuses around LGBTQ rights, all broadly advocate for prison abolition.[41] Furthermore, the Human Rights Coalition, a 2001 group based in the city of Philadelphia that aims to abolish prisons,[42][43] with their mission stating "to empower prisoners' families to be leaders in prison organizing and to teach them how to advocate on behalf of their loved ones in prison and expose the inhumane practices of the Department of Corrections."[44] In addition, the California Coalition for Women Prisoners, a grassroots organization dedicated to dismantling the PIC,[45] can all be added to the long list of organizations that desire a different form of justice system.[46] Project NIA, an organization founded in 2009 by Mariame Kaba, helps to end the incarceration of youth, as well as victims of violence "through community-based alternatives to the criminal legal process."[47] Since 1983,[48] the International Conference on Penal Abolition (ICOPA) gathers activists, academics, journalists, and "others from across the world who are working towards the abolition of imprisonment, the penal system, carceral controls and the prison industrial complex (PIC),"[49] to discuss three important questions surrounding the reality of prison abolition ICOPA was one of the first penal abolitionist conference movements, similar to Critical Resistance in America, but "with an explicitly international scope and agenda-setting ambition."[50] Anarchists wish to eliminate all forms of state control, of which imprisonment is seen as one of the more obvious examples. Anarchists also oppose prisons given that statistics show incarceration rates affect mainly poor people and ethnic minorities, and do not generally rehabilitate criminals, in many cases making them worse.[51] In October 2015, members at a plenary session of the National Lawyers Guild (NLG) released and adopted a resolution in favor of prison abolition.[52][53] In Canada, a number of organizations support prison abolition, which includes the Saskatchewan Manitoba Alberta Abolition Organization (SMAAC) or the Toronto Prisoners’ Rights Project.[54][55] These organizations collaborate and organize on issues of prison abolition and work towards prison abolition. Disability, mental illness and prison [edit] Further information: Mentally ill people in United States jails and prisons Prison abolitionists such as Amanda Pustilnik take issue with the fact that prisons are used as a "default asylum" for many individuals with mental illness:[56] Why do governmental units choose to spend billions of dollars a year to concentrate people with serious illnesses in a system designed to punish intentional lawbreaking, when doing so matches neither the putative purposes of that system nor most effectively addresses the issues posed by that population? In the United States, there are more people with mental illness in prisons than in psychiatric hospitals.[56] In Canada, mental health issues are 2 to 3 times more prevalent in prisons than in the general population.[57] Prison abolitionists contend that prisons violate the Constitutional rights (5th and 6th Amendment rights) of mentally ill prisoners on the grounds that these individuals will not be receiving the same potential for rehabilitation as the non-mentally ill prison population. This injustice is sufficient grounds to argue for the abolishment of prisons.[56][58][59] Prisons were not designed to be used to house the mentally ill, and prison practices like solitary confinement are damaging to mental health. Additionally, individuals with mental illnesses have a much higher chance of committing suicide while in prison.[60] In response to the fear that prisons are needed for the most serious cases of mentally ill, Liat Ben-Mosh describe prison abolitionist's' view on the issue: "Many prison abolitionists advocate for transformative justice and healing practices in which no one will be restrained or segregated, while some, like PREAP, believe that there will always be a small percentage of those whose behavior is so unacceptable or harmful that they will need to be incapacitated, socially exiled, or restrained and that this should be done humanely, temporarily, and not in a carceral or punitive manner."[61] Another point raised is that the current focus in criminal justice reform on nonviolent, nonserious and nonsexual offences shrinks the borders and understandings of innocence and guilt.[62] Aging in prison [edit] The prison abolition movement and prison abolitionists like Liat Ben-Moshe have taken issue with the treatment of the aging population in prisons.[63] Prolonged sentencing policies have resulted in an increased aging population in prisons as well as the harsh conditions of imprisonment.[63] A number of reasons can contribute to older adult's risk for illness while in prison.[64] Prisons are not intended to be used as nursing homes, hospice or long-term care facilities for the aging prison population.[65] Despite this, prison hospice does exist.[66][67] In Canada, individuals 50 years of age and older in federal custody account for 25% of the federal prison population.[65] Investigations into the Canadian federal penitentiary have found that there is a general failure of the Correctional Service of Canada to meet safe and humane custody and assisting in the rehabilitation and reintegration of offenders into the community.[65] The conditions of confinement of older individuals jeopardize the protection of their human rights.[65] The conditions of the aging population in Canada has been denounced by persons who are incarcerated.[68] Proposed reforms and alternatives [edit] 2022 Spanish-language graffiti in Vallcarca i els Penitents (Barcelona) advocating for the freeing of prisoners 2022 Catalan-language graffiti in Vallcarca i els Penitents (Barcelona) deeming prisons as torture Proposals for prison reform and alternatives to prisons differ significantly depending on the political beliefs behind them. Often they fall in one of three categories from the "Attrition Model", a model proposed by the Prison Research Education Action Project in 1976: moratorium, decarceration, and excarceration.[69][70] Proposals and tactics often include:[70] • Penal system reforms: • Substituting, for incarceration, supervised release, probation, restitution to victims, and/or community work. • Decreasing terms of imprisonment by abolishing mandatory minimum sentencing • Decreasing ethnic disparity in prison populations • Prison condition reforms • Crime prevention rather than punishment • Abolition of specific programs which increase prison population, such as the prohibition of drugs (e.g., the American War on Drugs) and prohibition of prostitution. • Education programs to inform people who have never been in prison about its problems • Fighting individual cases of wrongful conviction The United Nations Office on Drugs and Crime published a series of handbooks on criminal justice. Among them is Alternatives to Imprisonment which identifies how the overuse of imprisonment impacts fundamental human rights, especially those convicted for lesser crimes. Social justice and advocacy organizations such as Students Against Mass Incarceration (SAMI) at the University of California, San Diego often look to Scandinavian countries Sweden and Norway for guidance in regard to successful prison reform because both countries have an emphasis on rehabilitation rather than punishment.[71] According to Sweden's former Prison and Probation Service Director-General, Nils Öberg, this emphasis is popular among the Swedish because the act of imprisonment is considered punishment enough.[72] This focus on rehabilitation includes an emphasis on promoting normalcy for inmates, a charge led by experienced criminologists and psychologists.[73] In Norway a focus on preparation for societal re-entry has yielded "one of the lowest recidivism rates in the world at 20%, [while] the US has one of the highest: 76.6% of [American] prisoners are re-arrested within five years".[74] The Swedish incarceration rate decreased by 6% between 2011 and 2012.[75] Abolitionist views [edit] Many prison reform organizations and abolitionists in the United States advocate community accountability practices, such as community-controlled courts, councils, or assemblies as an alternative to the criminal justice system.[76] Abolitionists like Angela Davis recommend four measures as a way to deal with violent and other serious crimes: (1) make mental health care available to all (2) everyone should have access to affordable treatment for substance use disorders (3) make a stronger effort to rehabilitate those who commit criminal offences and (4) employ reparative or restorative justice measures as an accountability tool to reconcile offenders with their victims and undo or compensate the harm done.[77] Organizations such as INCITE! and Sista II Sista that support women of color who are survivors of interpersonal violence argue that the criminal justice system does not protect marginalized people who are victims in relationships. Instead, victims, especially those who are poor, minorities, transgender or gender non-conforming can experience additional violence at the hands of the state.[78] Instead of relying on the criminal justice system, these organizations work to implement community accountability practices, which often involve collectively-run processes of intervention initiated by a survivor of violence to try to hold the person who committed violence accountable by working to meet a set of demands.[79] For organizations outside the United States see, e.g. Justice Action, Australia. Some anarchists and socialists contend that a large part of the problem is the way the judicial system deals with prisoners, people, and capital. According to Marxists, in capitalist economies incentives are in place to expand the prison system and increase the prison population. This is evidenced by the creation of private prisons in America and corporations like CoreCivic, formerly known as Correction Corporation of America (CCA).[80] Its shareholders benefit from the expansion of prisons and tougher laws on crime. More prisoners is seen as beneficial for business. Some anarchists contend that with the destruction of capitalism, and the development of social structures that would allow for the self-management of communities, property crimes would largely vanish. There would be fewer prisoners, they assert, if society treated people more fairly, regardless of gender, color, ethnic background, sexual orientation, education, etc. The demand for prison abolition is a feature of anarchist criminology, which argues that prisons encourage recidivism and should be replaced by efforts to rehabilitate offenders and reintegrate them into communities.[81] “Nine perspectives for prison abolitionists” [edit] Instead of prisons: a handbook for abolitionists, republished by Critical Resistance in 2005, outlines what the organization identifies as the nine main perspectives for prison abolitionists:[82] • Perspective 1 The imprisonment of a human being is inherently immoral, and while total abolition of the current prison system is not an easy task, it is possible. The first step towards abolition is admitting that prisons cannot be reformed, as a carceral system is founded on brutality and contempt for those imprisoned. Additionally, the current system works to disproportionally imprison poor and working-class people, so its abolition would ensure progress towards equality. Abolitionists see many similarities between today's carceral system and the slavery establishment of the past, and would in fact say that the current system is simply reformed enslavement which perpetuates the same oppressive and discriminatory patterns. But just as superficial reforms could not alter the brutality of the slave system, reforms cannot change a system rooted in racism. • Perspective 2 The abolitionist message requires changing our language and definitions of punishment “treatment” and “inmates”. In order to break away from the prison system, we must use honest language and take back the power of our vocabulary. • Perspective 3 Imprisonment is not a proper response to deviance. Abolitionists promote reconciliation rather than punishment, a perspective seeking to restore both the criminal and the victim while limiting the disruption of their lives in the process. • Perspective 4 Abolitionists advocate for changes beneficial to the prisoner but do so while remaining a non-member of the system. In a similar fashion, abolitionists respect the personhood of system managers but oppose their role in the perpetuation of an oppressive system. • Perspective 5 The abolitionist message extends farther than the traditional helping relationship; Abolitionists identify themselves as allies of the imprisoned, respecting their perspectives as well as the requirements for abolition. • Perspective 6 The empowerment of prisoners and ex-prisoners is crucial to the abolitionist movement. Programs and resources dedicated to reinstating that which has been stripped from them by the prison system are fundamental in putting power back in their own hands. • Perspective 7 Abolitionists believe that citizens are the true source of institutional power which can lead to the abolition of the prison system. Giving or limiting support from certain policies and practices will enable the progression of the abolitionist movement. • Perspective 8 Abolitionists believe that crime is a consequence of a broken society, and resources must be used towards social programs instead of the funding of prisons. They advocate for public solutions to public problems, producing effects which will benefit everyone in society. • Perspective 9 An emphasis is placed on the correction of society rather than the correction of an individual. It is only in a corrected or caring community that individual redemption and rehabilitation can be achieved. Thus, abolitionists see that the only adequate alternative to the prison system is building a kind of society which has no need for prisons.

People with mental illnesses are over-represented in jail and prison populations in the United States relative to the general population.[1][2][3] There are three times as many mentally ill people in jails and prisons than in hospitals in the United States.[1] Mentally ill people are subjected to solitary confinement at disproportionate rates compared to the general prison population.[4][5][6] There are a number of reasons for this over-representation of mentally ill people in jails and prisons, including the deinstitutionalization of mentally ill individuals in the mid-twentieth century, inadequate community treatment resources, and the criminalization of mental illness itself. Research has shown that that mentally ill offenders have comparable rates of recidivism to non-mentally ill offenders.[7] The United States Supreme Court has upheld the right of inmates to mental health treatment.[8][9] The majority of prisons in the United States attempt to employ a mental health providers,[10] however, there is a severe shortage of staff to fill these vacancies and it is difficult to retain employees.[11] Prevalence [edit] There is a broad scholarly consensus that mentally ill individuals are over-represented within the jail and prison populations of the United States.[1][3][12] In a 2010 study, researchers concluded that, based on statistics from sources including the Bureau of Justice Statistics and the U.S. Department of Health and Human Services, there are currently three times more seriously mentally ill people in jails and prisons than in hospitals in the United States, with the ratio being nearly ten to one in Arizona and Nevada.[1] "Serious mental illness" is defined here as schizophrenia, bipolar disorder, or major depression.[13] Further, they found that 16% of the jail and prison population in the U.S. has a serious mental illness (compared to 6.4% in 1983),[1] although this statistic does not reflect differences among individual states.[14] For example, in North Dakota, they found that a person with a serious mental illness is equally likely to be in prison or jail versus a hospital. In contrast, in states such as Arizona, Nevada, and Texas, the imbalance is much more severe.[15] Finally, they noted that a 1991 survey by the National Alliance for the Mentally Ill concluded that jail and/or prison are part of the life experiences of forty percent of these mentally ill individuals.[15] In addition to mood and anxiety disorders, other psychopathologies have also been found in the US prison System. Antisocial personality disorder is found in less than 6% of the general American population,[16] but seems to be found in anywhere between 12% and 64% of prison samples.[17] Estimates of borderline personality disorder seem to make up around 1% to 2% of the general public, compared to 12% to 30% within prisons.[18] Personality disorders, especially in the inmate population, are often found to be comorbid with other disorders.[16] A separate research study, The Prevalence of Mental Illness among Inmates in a Rural State, noted that national statistics like those previously mentioned primarily pull data from urban jails and prisons.[19] To investigate possible differences in rural areas, researchers interviewed a random sample of inmates in both jails and prisons in a rural northeastern state.[20] They found that in this rural setting, there was little evidence of high rates of mental illness within jails, "suggesting the criminalization of mental illness may not be as evident in rural settings as urban areas." However, high rates of serious mental illness were found among rural prison inmates. [2] 2015 studies [edit] In 2015, lawyer and activist Bryan Stevenson claimed in his book Just Mercy that over 50% of inmates in jails and prisons in the United States had been diagnosed with a mental illness and that one in five jail inmates had had a serious mental illness.[21] As for the gender, age, and racial demographics of mentally ill offenders, the 2017 Bureau of Justice Statistics report found that female inmates, when compared to male inmates, had statistically significantly higher rates of serious psychological distress (20.5% of female prisoners and 32.3% of female jail inmates had serious psychological distress, versus 14% of male prisoners and 25.5% of male jail inmates) and a history of a mental health problem (65.8% of female prisoners and 67.9% of female jail inmates compared to 34.8% of male prisoners and 40.8% of male jail inmates). Significant differences between race and ethnicity were also observed. White prisoners and jail inmates were more likely to have serious psychological distress or a history of mental health problems than black or Hispanic inmates. For example, in local jails, 31% of white inmates had serious psychological distress compared to 22.3% of black inmates and 23.2% of Hispanic inmates. Finally, regarding age, there were virtually no statistical differences between age groups and the percentage of those with serious psychological distress or a history of a mental health problem.[22] 2017 studies [edit] A 2017 report issued by the Bureau of Justice Statistics used self-reported survey data from inmates to assess the prevalence of mental health problems among prisoners and jail inmates. They found that 14% of prisoners and 25% of jail inmates had experienced serious psychological distress in the past 30 days, compared to 5% of the general population. In addition, 37% of prisoners and 44% of jail inmates had a history of mental health problems. [3] Potential reasons for the high number of incarcerated people diagnosed with mental illnesses [edit] Deinstitutionalization [edit] Researchers commonly cite deinstitutionalization, or the emptying of state mental hospitals in the mid-twentieth century, as a direct cause of the rise of mentally ill people in prisons.[1][23][24] In the 2010 study "More mentally ill persons are in jails and prisons than hospitals: a survey of the states," researchers noted that, at least in part due to deinstitutionalization, it is increasingly difficult to find beds for mentally ill people who need hospitalization. Using data collected by the Department of Health and Human Services, they determined there was one psychiatric bed for every 3,000 Americans, compared to one for every 300 Americans in 1955.[1] They also noted increased percentages of mentally ill people in prisons throughout the 1970s and 1980s and found a strong correlation between the number of mentally ill people in a state's jails and prisons and how much money the state spends on mental health services.[15] In the book Criminalizing the Seriously Mentally Ill: The Abuse of Jails as Mental Hospitals, researchers note that while deinstitutionalization was carried out with good intentions, it was not accompanied by alternate avenues for mental health treatment for those with serious mental illnesses. According to the authors, Community Mental Health Centers focused their limited resources on individuals with less serious mental illnesses; federal training funds for mental health professionals resulted in lots more psychiatrists in wealthy areas but not in low-income areas; and a policy that made individuals eligible for federal programs and benefits only after they'd been discharged from state mental hospitals unintentionally incentivized discharging patients without follow-up.[25] In the article Assessing the Contribution of the Deinstitutionalization of the Mentally Ill to Growth in the U.S. Incarceration Rate, researchers Steven Raphael and Michael A. Stoll discuss trans institutionalization, or how many patients released from mental hospitals in the mid-twentieth century ended up in jail or prison. Using U.S. census data collected between 1950 and 2000, they concluded that "those most likely to be incarcerated as of the 2000 census experienced pronounced increases in overall institutionalization between 1950 and 2000 (with particularly large increases for black males). Thus, the impression created by aggregate trends is somewhat misleading, as the 1950 demographic composition of the mental hospital population differs considerably from the 2000 demographic composition of prison and jail inmates." However, when estimating (using a panel data set) how many individuals incarcerated between 1980 and 2000 would have been institutionalized in years past, they found significant trans institutionalization rates for all men and women, with the largest rate for white men. [26] Accessibility [edit] A main contributing factor to the US's steady increase in those who are mentally ill within the prison system could be the lack of accessibility in various communities. Specifically, those who come from a lower-income background face these issues, in which there are few to no readily available resources for those experiencing ongoing difficulty with their mental health. The AMA Journal of Ethics discusses more specific factors contributing to the consistently high arrest rates of those with severe mental illness within certain communities, stating that the arrests of drug offenders, a lack of affordable housing, and a significant lack of funding for community treatments are the main contributors.[27] With the introduction of Medicaid, many state-run mental health facilities closed due to a shared responsibility for funding with the federal government. Eventually, states would close a good portion of their facilities so that mentally ill patients could be treated at hospitals where they would be partially covered by Medicaid and the government.[27] The National Council for Behavioral Health conducted a study in October 2018 that included survey results that confirmed "nearly six in 10 (56%) Americans [are] seeking or wanting to seek mental health services either for themselves or for a loved one..." These individuals are skewing younger and are more likely to be of lower income and military background”.[28] Criminalization [edit] A related cause of the disproportionate number of mentally ill people in prisons is the criminalization of mental illness itself. In the 1984 study Criminalizing mental disorder: The comparative arrest rate of the mentally ill, researcher L. A. Taplin notes that in addition to a decline in federal support for mental illness resulting in more people being denied treatment, mentally ill people are often stereotyped as dangerous, making fear a factor in action taken against them. Bureaucratic and legal impediments to initiating mental health referrals mean arrest can be easier, and in Taplin's words, "Due to the lack of exclusionary criteria, the criminal justice system may have become the institution that cannot say no."[23] Mentally ill people do indeed experience higher arrest rates than those without mental illness,[29] but to investigate whether or not this was due to the criminalization of mental illness, researchers observed police officers over a period of time. As a result, they concluded that "within similar situations, persons exhibiting signs of mental disorder have a higher probability of being arrested than those who do not show such signs."[30] The authors of the book Criminalizing the Seriously Mentally Ill: The Abuse of Jails as Mental Hospitals claim that nationwide, 29% of jails will hold mentally ill individuals with no charges brought against them, sometimes as a means of 'holding' them when psychiatric hospitals are very far away. This practice occurs even in states where it is explicitly forbidden.[31] Beyond that, the vast majority of people with mental illnesses in jails and prisons are held on minor charges like theft, disorderly conduct, alcohol or drug-related charges, and trespassing. These are sometimes "mercy bookings" intended to get the homeless mentally ill off the street, a warm meal, etc. Family members have reported being encouraged by mental health professionals or the police to get their loved ones arrested to get them treatment.[32] Finally, some mentally ill people are in jails and prisons on serious charges, such as murder. Many such crimes would likely not have been committed had the individuals been receiving proper care.[33] Malingering [edit] Some inmates feign psychiatric symptoms for secondary gain. For example, an inmate may hope to receive a transfer to a more desirable setting or psychotropic medication.[34][35][36][37] Exacerbation of mental illness in a prison setting [edit] Another proposed reason for the high number of people incarcerated with mental illness is the way a prison setting can worsen mental health. Individuals with pre-existing mental health conditions can worsen, or new mental health problems may arise.[38] A few reasons are listed as to how prisons can worsen the mental health of the incarcerated: • Separation from loved ones • Lack of movement or isolation[39] • Overcrowded prisons[40] • Witnessing violence in the prison setting[41] Mental health care in prisons and jails [edit] Psychologists report that one in every eight prisoners was receiving some mental health therapy or counseling services by mid-2000. Inmates are generally screened at admission, and depending on the severity of the mental illness, they are placed in either general confinement or specialized facilities. Inmates can self-report mental illness if they feel it is necessary. In mid-2000, inmates self-reported that state prisons held 191,000 mentally ill inmates.[42] A 2011 survey of 230 correctional mental health service providers from 165 state correctional facilities found that 83% of facilities employed at least one psychologist and 81% employed at least one psychiatrist. The study also found that 52% of mentally ill offenders voluntarily received mental health services, 24% were referred by staff, and 11% were mandated by a court to receive services.[43] Although 64% of providers of mental health services reported feeling supported by prison administration and 71% were involved in continuity of care after release from prison, 65% reported being dissatisfied with funding.[44] Only 16% of participants reported offering vocational training,[45] and the researchers noted that although risk/need/responsiveness theory has been shown to reduce the risk of recidivism (or committing another crime after being released), it is unknown whether it is incorporated into mental health services in prisons and jails.[46] A 2005 article by researcher Terry A. Kuper's noted that male prisoners tend to under report emotional problems and don't request help until a crisis,[47] and that prison fosters an environment of toxic masculinity, which increases resistance to psychotherapy.[48] A 2017 report from the Bureau of Justice Statistics noted that 54.3% of prisoners and 35% of jail inmates who had experienced serious psychological distress in the past 30 days have received mental health treatment since admission to the current facility, and 63% of prisoners and 44.5% of jail inmates with a history of a mental health problem said they had received mental health treatment since admission. [49] Finally, the book Criminalizing the Seriously Mentally Ill: The Abuse of Jails as Mental Hospitals points out that 20% of jails have no mental health resources. In addition, small jails are less likely to have access to mental health resources and are more likely to hold individuals with mental illnesses without charges brought against them. Jails in richer areas are more likely to have access to mental health resources, and jails with more access to mental health resources also deal with fewer medication refusals.[50] Recidivism [edit] Research shows that rates of recidivism, or re-entry into prison, are not significantly higher for mentally ill offenders. A 2004 study found that although 77% of mentally ill offenders studied were arrested or charged with a new crime within the 27–55-month follow-up period, when compared with the general population, "our mentally ill inmates were neither more likely nor more serious recidivists than general population inmates."[7] In contrast, a 2009 study that examined the incarceration history of those in Texas Department of Criminal Justice facilities found that "Texas prison inmates with major psychiatric disorders were far more likely to have had previous incarcerations compared with inmates without a serious mental illness." In the discussion, the researchers noted that their study's results differed from most research on this subject and hypothesized that this novelty could be due to specific conditions within the state of Texas.[51] A 1991 study by L. Feder noted that although mentally ill offenders were significantly less likely to receive support from family and friends upon release from prison,[52] they were actually less likely to be revoked on parole. However, mentally ill offenders were less likely to have the charges dropped for nuisance arrests, although they were more likely to have charges dropped for drug arrests. In both cases, mentally ill offenders were more likely to be tracked into mental health care. Finally, there were no significant differences in charges for violent arrests.[53] Tools for effective mental healthcare [edit] A research paper published in 2020 by M. Georgiou remarked that having a well-defined consultation process for mental health services will allow for effective care. This is called the Care Programmer Approach. It lists six steps to effective care of the prisoner:[54] 1. Identify the health and care needs of the prisoner. 2. Written and clear plans. 3. Having key persons supervise the program. 4. Regular assessments of the program. 5. Inter-professional involvement. 6. Career involvement. Solitary confinement [edit] A broad range of scholarly research maintains that mentally ill offenders are disproportionately represented in solitary confinement[4][5][6] and are more vulnerable to the adverse psychological effects of solitary confinement.[55][5][6][56] Due to differing schemes of classification, empirical data on the makeup of inmates in segregated housing units can be difficult to obtain,[57] and estimates of the percentage of inmates in solitary confinement who are mentally ill range from nearly a third,[58] to 11% (with a "major mental disorder"),[59] to 30% (from a study conducted in Washington), to "over half" (from a study conducted in Indiana),[57] depending on how mental illness is determined, where the study is conducted, and other differences in methodology. Researchers J. Metzner and J. Fellner note that mentally ill offenders in solitary confinement "all too frequently" require crisis care or psychiatric hospitalization and that "many simply won't get better as long as they are isolated."[4] Researchers T. L. Hafemeister and J. George note that mentally ill offenders in isolation are at higher risk for psychiatric injury, self-harm, and suicide.[60] A 2014 study that analyzed data from medical records in the New York City jail system[61] found that while self-harm was significantly correlated with having a serious mental illness regardless of whether or not an inmate was in solitary confinement, inmates with serious mental illness in solitary confinement under 18 years of age accounted for the majority of acts of self-harm studied.[62] When brought before federal courts, judges have prohibited or curtailed this practice,[4] and many organizations that deal with human rights, including the United Nations, have condemned it.[4][63] In addition, scholars argue that the conditions of solitary confinement make it much more difficult to deliver proper psychiatric care.[4][64][6] According to researchers J. Metzner and J. Fellner, "Mental health services in segregation units are typically limited to psychotropic medication, a health care clinician stopping at the cell front to ask how the prisoner is doing (i.e., mental health rounds), and occasional meetings in private with a clinician."[4] One study in the American Journal of Public Health claimed that health care professionals must "frequently" conduct consultations through a slit in a cell door or an open tier that provides no privacy.[64] However, some researchers disagree with the scope of claims surrounding the psychological effects of solitary confinement. For example, in 2006, researchers G. D. Glancy and E. L. Murray conducted a literature review in which they claimed that many frequently-cited studies have methodological concerns, including researcher bias, the use of "volunteer Non prisoners, naturalistic experiments, or case reports, case series, and anecdotes", and concluded "there is little evidence to suggest the majority...kept in SC...experience negative mental health effects."[65] However, they did support claims that inmates with preexisting mental illnesses are more vulnerable and do suffer adverse effects. In their conclusion, they claim, "we should therefore be concerned about those with pre-existing mental illness who are housed in segregation because there is nowhere else to put them within the correctional system."[56] Community standpoint and outcome [edit] Social stigma regarding this issue is significant due to the public's outlook and perception of mental health; some may not recognize it as a health factor that must be addressed. For this reason, some may avoid or deny the assistance offered to them, thus further suppressing feelings and experiences that eventually need to be dealt with. The NCBH notes that about one-third (or 38%) of Americans worry about their peers and family judging them if they seek mental help.[28] Without the presence of these facilities within communities, mentally ill individuals would carry on with no preventative treatment or care to keep the severity of their condition at a healthy level. About 2 million of these individuals go to jail each year; moreover, data shows that 15% of men and 30% of women who are taken to prison have a serious mental health condition.[66] The National Alliance on Mental Illness further looked into the results of decreased mental health services, and they found that for many, individuals do ultimately become homeless or find themselves in emergency rooms as a result of the inaccessibility of mental health services and support groups. Statistics show that about 83% of jail inmates did not have access to needed treatment within their community before their incarceration, and so some people end up getting re-arrested as a way to return to some form of assistance.[66] The Marshall Project has gathered data regarding those being treated in jail, and what they found was that the Federal Bureau of Prisons implicated a new policy to be initiated that was meant to improve the care for inmates with mental health issues. It ultimately led to a decrease in the number of inmates who were categorized as needing higher care levels by more than 35%.[11] After this policy change, the Marshall Project noted the steady decline since May 2014 of inmates receiving treatment for a mental illness. Research shows that in recent years, those with “serious psychotic disorders, especially when untreated, can be more likely to commit a violent crime”.[11] It is said that an institutional shift would be more effective in reducing the number of incarcerated people through the collaboration of multiple agencies, especially regarding the criminal justice system and the community.[54] This collaboration between agencies deviates from the "self-perpetuating" system meant to incarcerate and process individuals administratively; therefore, it focuses closely on people with severe mental illness and ensures ongoing care within and out of prison to reduce recidivism.[54][67] Legal aspects [edit] Current laws [edit] The Federal Bureau of Prisons has claimed to have made policy changes, but those changes only apply to the rules within the system, and they did not fund resources to carry out those new implementations.[11] It should also be noted that within the prison system, states have laws and responsibilities to ensure as well, one of which is the Eighth amendment, which requires prisoners' medical needs to be consistently met. The Prison Litigation Reform Act upholds this right in federal court cases.[68] As of late December 2018, the First Step Act (S 756) was signed into law as a way to reduce recidivism and provide overall improvements to the conditions faced within federal prisons, as well as working to reduce the mandatory sentences given.[69] Although this Act primarily applies to about 225.000, or 10%, of individuals in federal prisons and jails, this reform may not be applied to those in state prisons and jails.[69] Some of the provisions resulting from this act include staff training on how to identify and assist those suffering from a mental illness and providing improved, accessible treatment regarding drug abuse with programs like medication-assisted treatment. The implementation of significantly more Certified Community Behavioral Health Clinics has also been discussed as a solution to the mental health issue in the prison system. Its primary goal is to cater to the needs of its specific communities and expand access to mental health treatment for everyone. An organization like this claims to reduce criminal justice costs, hospital re-admissions, and, once again, recidivism.[69] They strive to treat individuals with mental illness early on rather than allowing them to carry on without professional care and general support. Emergency detention [edit] One major area of legal concern is the emergency detention of the non-criminal mentally ill in jails while waiting for formal procedures for involuntary hospitalization. Twenty-five states and the District of Columbia have laws specifically addressing this practice; eight of these states and D.C. explicitly forbid it. Seventeen states, on the other hand, explicitly allow it. Within this set, the criteria and circumstances necessary differ by state. Most states limit the detention periods in jails to one to three days.[70] One distinguishing factor of this practice is that it is often initiated by a non-medical professional, such as a police officer.[71] In many states, especially those in which a non-public official such as a medical health professional or concerned citizen can initiate the detention, a judge or magistrate is required to approve it before or soon after the initiation.[72] When emergency detention in jails has been brought to court, judges generally agree that the practice is not unconstitutional.[70][73] One notable exception was Lynch v. Baxley;[73] however, later cases, particularly Boston v. Lafayette County, Mississippi, have connected the ruling of unconstitutionality in that case with the conditions of the jails themselves rather than the fact that they were jails.[74] That being said, the Supreme Court of Illinois has stated that this practice is unconstitutional if the person being detained doesn't pose an imminent threat to himself or others.[75] Supreme court cases [edit] Several landmark Supreme Court cases, notably Estelle v. Gamble, have established the constitutional right of prison inmates to mental health treatment.[8][9] Estelle v. Gamble determined that "deliberate indifference to serious medical needs" of prisoners was a violation of the Eighth Amendment to the U.S. Constitution. This case was the first time the phrase "deliberate indifference" was used; it is now legal. To determine "serious medical need" later cases would use tests such as the treatment mandated by a physician or an obvious need to a layman. On the other hand, other cases, notably McGuckin v. Smith, used much stricter terms, and in 1993 researchers Henry J. Steadman and Joseph J. Cocozza commented that "serious medical need" had little definitional clarity.[76] Langley v. Coughlin involved a prisoner "regularly isolated without proper screening or care" and clarified that a single, distinctive act is not necessary to constitute deliberate indifference but rather "if seriously ill inmates are consistently made to wait for care while their condition deteriorates, or if diagnoses are haphazard and records minimally adequate then, over time, the mental state of deliberate indifference may be attributed to those in charge."[77] The landmark case Washington v. Harper determined that although inmates do have an interest in and the right to refuse treatment, this can be overridden without judicial process even if the inmate is competent, provided there this act is "reasonably related to legitimate penological interest".[78][79] Washington's internal process for determining this need was seen as affording due process.[80] In contrast, in Breads v. Moehrle, the forcible injection of drugs in jail was not upheld because sufficient procedures were not taken to ensure "substantive determination of need".[81] Court cases [edit] George Daniel, a mentally ill man on Alabama's death row was arrested and charged with capital murder. In jail, George became acutely psychotic and couldn't speak in complete sentences. Daniel had been on death row until several years later, Lawyer Bryan Stevenson uncovered the truth about the doctor who lied about examining Daniels's mental illness. Daniel's trial was then overturned and he has been in a mental institution since.[82] Another mentally ill man, Avery Jenkins, was convicted of murder and sentenced to death. Throughout Jenkins's childhood, he had been in and out of foster homes and developed a serious mental illness. Jenkins erratic behavior didn't change, so his foster mother decided to get rid of him by tying him to a tree and leaving him there. Around the age of sixteen, he was left homeless and started to experience psychotic episodes. At age twenty, Jenkins had wandered into a strange house and stabbed a man to death as he perceived him to be a demon. He was then sentenced to death and spent several years in prison as if he had been sane and responsible for his actions. Jenkins then got off death row and was put into a mental institution.[83] In the past, overall living and treatment conditions within US prisons were not up to par, which can be seen through the details and points made by the Coleman v. Brown case that went to trial in 1995. In this case, The district court judge ultimately recognized the system's systemic failure to properly care for and provide resources to mentally ill inmates.[68] These individuals were not receiving treatment prior to prison, and were sent there with expectations from others that they would be receiving treatment there, but that expectation was not fulfilled. In Coleman v. Brown, a special court, including three judges that can make final decisions on whether or not a problem is significant enough to enact change, concluded that overcrowding was in fact a reason for poor conditions in prisons, therefore they called for a reduction in the prison population to partially relieve said issue. Justice Alito at this time questioned whether the reduction solution was helpful when they could be looking into constructing additional prison medical and mental health facilities.[68] Although, the decision did not take care of the living conditions that were problematic before and even after the case. It has been noted that psychotic prisoners were often held in small, narrow essentially restricted areas where standing on their secretions was common. Regarding actual mental health treatment conditions, the waiting time to even receive care could take up to a year, and when they finally reached that date, the screenings for such lacked privacy for those being evaluated as several physicians often shared the spaces at a time.[68] Other cases that have been discussed is John Rudd, who was being a federal prison in West Virginia as of 2017. Rudd had a history of mental health disorders consisting of post traumatic stress disorder, as well as schizophrenia.[11] He was evaluated and diagnosed by a doctor as early as 1992. In 2017, he stopped taking his psychiatric medication, then informed staff of his intentions to take his own life. Staff put him in a suicide watch cell, where he would physically and violently hurt himself. Staff injected him with haloperidol, an anti-psychotic drug, to treat him, but after some time they concluded that Rudd was not ill enough to receive proper, regular treatment and continued to categorize him as a level one inmate, meaning no significant mental health needs.[11] Although they were aware of his pre-existing conditions, the prison staff claimed those were resolved and adjusted it to Rudd having an antisocial personality disorder. On December 7, 2020, Thomas Lee Rutledge died of hyperthermia at the home of William E. Donaldson in Bessemer. According to a lawsuit filed by his sister, Rutledge had a core temperature of 109 degrees when he was found unconscious in his psychiatric cell. Listed as defendants were the prison staff, guards, and contractors.[84] A more recent case is that a mentally ill man froze to death at an Alabama jail as of 2023, according to a lawsuit filed by the man’s family who say he was kept naked in a concrete cell and believe he was also placed in a freezer or other frigid environment. According to the lawsuit, Anthony Don Mitchell, 33, arrived at the hospital's emergency room with a body temperature of 72 degrees (22 degrees Fahrenheit) and was pronounced dead hours later. He was rushed to the hospital on January 26 from the Walker County Jail, where he had been held for two weeks. The paramedic who tried unsuccessfully to resuscitate Mitchell writes, "I believe hypothermia was the ultimate cause of death," according to a lawsuit filed by Mitchell's mother in federal court Monday. Mitchell, who had a history of substance abuse, was arrested on January 12, 2023, after a cousin asked authorities to check on his well-being for wandering through portals to heaven and hell at his home and suffering a nervous breakdown. According to the lawsuit, prison video shows Mitchell being held naked in a solitary cell with a concrete floor. The lawsuit speculates that Mitchell was also taken to the prison kitchen "freezer" or similar freezing environment and left there for hours "because his body temperature was so low."[85][84] Prison staff in general, have also been experiencing issues for various years now. Previously in the 1990s, just about one-third of positions went unfilled for mental health staff, and it became increasingly impactful on inmates when the vacancy rates for psychiatrists reached 50% and up.[11] Staffing shortage is still seen today in which some counselors can be pulled and asked to serve as corrections officers for the time being. This situation had worsened due to the Trump administration and the hiring freeze that was meant to reduce costs.[11] Rudd, now out of prison and receiving counselling and taking medication, speaks on triggers within the prison environment that are not in any way healthy for those who are mentally ill.[11]

Mental health courts link offenders who would ordinarily be prison-bound to long-term community-based treatment. They rely on mental health assessments, individualized treatment plans, and ongoing judicial monitoring to address both the mental health needs of offenders and public safety concerns of communities. Like other problem-solving courts such as drug courts, domestic violence courts, and community courts, mental health courts seek to address the underlying problems that contribute to criminal behavior.[1] Mental health courts share characteristics with crisis intervention teams, jail diversion programs, specialized probation and parole caseloads, and a host of other collaborative initiatives intended to address the significant overrepresentation of people with mental illness in the criminal justice system.[2] History [edit] In the United States in the early 1980s, Judge Evan Dee Goodman helped establish a court exclusively to deal with mental health matters at Wishard Memorial Hospital. The mentally ill were frequently arrested and had charges pending when the treatment providers sought a civil commitment to send their patient for long-term psychiatric treatment. Goodman's court at Wishard Hospital could serve both purposes. The probate part of the mental health court would handle the civil commitment. The criminal docket of the mental health court could handled the arrest charges. The criminal charges could be put on diversion, or hold, allowing the patient's release from jail custody. The civil commitment would then become effective and the patient could be sent to a state hospital for treatment. Goodman would schedule periodic hearings to learn of the patient's progress. If warranted, the criminal charges were dismissed, but the patient still had obligations to the civil commitment. In addition to arranging inpatient treatment, Goodman often put defendants on diversion, or on an outpatient commitment, and ordered them into outpatient treatment. Goodman would have periodic hearings to determine the patient's compliance with the treatment plan. Patients who did not follow the treatment plan faced sanctions, a modification of the plan, or if they were on diversion their original charge could be set for trial. Goodman's concept and the original mental health court were dissolved in the early 1990s. In 1995, Goodman was reprimanded for nepotism.[3] In the mid-1990s, many of the professional mental health workers who had worked with Goodman sought to re-establish a mental health court in Indianapolis. Representatives of the county's mental health service providers and other stake holders began meeting weekly. The group decided to accept the name of the PAIR Program (PAIR stood for Psychiatric Assertive Identification and Referral). After, a couple years of lobbying the local authorities in Marion County, Indiana, the mental health court began as a formal program in 1996. Many consider this to be the nation's first mental health court in this second wave of mental health court initiatives.[citation needed] Since the PAIR Program did not operate with any new funds, there was not much scholarly research and therefore the accomplishments of Goodman and the PAIR Program are frequently overlooked. The current PAIR Program is a comprehensive pretrial, post-booking diversion system for mentally ill offenders.[4] A program launched in Broward County, Florida was the first court, to be recognized and published as a specialized mental health court. Overseen by Judge Ginger Lerner-Wren, the Broward County Mental Health Court was launched in 1997, partially in response to a series of suicides of people with mental illness in the county jail. The Broward court and three other early mental health courts, in Anchorage, Alaska, San Bernardino, California, and King County, Washington, were examined in a 2000 Bureau of Justice Assistance monograph, which was the first major study of this emerging judicial strategy.[5] Shortly after the establishment of the Broward County Mental Health Court, other mental health courts began to open in jurisdictions around the U.S., launched by practitioners who believed that standard punishments were ineffective when applied to the mentally ill.[6] In Alaska, for example, the state's first mental health court (established in Anchorage in 1998) was spearheaded by Judge Stephanie Rhoades, who felt probation alone was inadequate. "I started seeing a lot of people in criminal misdemeanors who were cycling through the system and who simply did not understand their probation conditions or what they were doing in jail. I saw police arresting people in order to get them help. I felt there had to be a better solution," she explained in an interview.[7] Mental health courts were also inspired by the movement to develop other problem-solving courts, such as drug courts, domestic violence courts, community courts and parole reentry courts. The overarching motivation behind the development of these courts was rising caseloads and increasing frustration—both among the public and among system players—with the standard approach to case processing and case outcomes in state courts.[8] In February 2001, the first juvenile mental health court opened in Santa Clara, California. Since 2000, the number of mental health courts has expanded rapidly. There are an estimated 150 courts in the U.S. and dozens more are being planned.[9] An ongoing survey conducted by several organizations identified more than 120 mental health courts across the country as of 2006.[10] The proliferation of courts was spurred in large part by the federal Mental Health Courts Program[11] administered by the Bureau of Justice Assistance, which provided funding to 37 courts in 2002 and 2003. In England, UK, two pilot mental health courts was launched in 2009 in response to a review of people with mental health problems in the criminal justice system. They were considered a success which met needs that would have otherwise gone unmet; however they required financial support and wider changes to the system, and it is not clear whether they will be more broadly implemented.[12] Definition [edit] Mental health courts vary from jurisdiction to jurisdiction, but most share a number of characteristics. The Council of State Governments Justice Center has defined the "essential elements"[13] of mental health courts. The CSG Justice Center, in a publication detailing the essential elements, notes that the majority of mental health courts share the following characteristics: • A specialized court docket, which employs a problem-solving approach to court processing in lieu of more traditional court procedures for certain defendants with mental illness. • Judicially supervised, community-based treatment plans for each defendant participating in the court, which a team of court staff and mental health professionals design and implement. • Regular status hearings at which treatment plans and other conditions are periodically reviewed for appropriateness, incentives are offered to reward adherence to court conditions, and sanctions are imposed on participants who do not adhere to the conditions of participation. • Criteria defining a participant's completion of (sometimes called graduation from) the program. Court process [edit] Potential participants in a mental health court are usually screened early on in the criminal process, either at the jail or by court staff such as pretrial services officers or social workers in the public defender's office. Most courts have criteria related to what kind of charges, criminal histories, and diagnoses will be accepted. For example, a court may accept only defendants charged with misdemeanors, who have no history of violent crimes, and who have an Axis I diagnoses as defined by the DSM-IV. Defendants who fit the criteria based on the initial screening are usually given a more comprehensive assessment to determine their interest in participating and their community treatment needs. Defendants who agree to participate receive a treatment plan and other community supervision conditions. For those who adhere to their treatment plan for the agreed upon time, usually between six months and two years, their cases are either dismissed or the sentence is greatly reduced. If the defendant does not comply with the conditions of the court, or decides to leave the program, their case returns to the original criminal calendar where the prosecution proceeds as normal. As a rule, most mental health courts use a variety of intermediate sanctions in response to noncompliance before ending a defendant's participation. An essential component of mental health court programs for protection of the public is a dynamic risk management process that involves court supervised case management with interactive court review and assessment. As in other problem-solving courts, the judge in a mental health court plays a larger role than a judge in a conventional court. Problem-solving courts rely upon the active use of judicial authority to solve problems and to change the behavior of litigants. For instance, in a problem-solving court, the same judge presides at every hearing.[8] The rationale behind this is not only to ensure that the presiding judge is trained in pertinent concepts, such as mental illness, drug addiction, or domestic violence, but also to foster an ongoing relationship between the judge and participants.[14] Although the judge has final say over a case, mental health courts also take a team approach in which the defense counsel, prosecutor, case managers, treatment professionals, and community supervision personnel (for example, probation) work collaboratively to, for example, craft systems of sanctions and rewards for offenders in drug treatment. Many mental health courts also employ a full-time coordinator who manages the docket and facilitates communication between the different team members. Criticisms [edit] Some have criticized mental health courts for deepening, as opposed to lessening, the involvement of people with mental illness in the criminal justice system. They argued that this was particularly true in mental health courts that focus on misdemeanor offenders who would have received short jail sentences or probation if not for the mental health court. These critics urged mental health courts to accept defendants charged with felonies, which many of the more recent courts, such as the Brooklyn Mental Health Court,[15] have started to do.[16] Critics have also raised concerns about the use of mental health courts to coerce people into treatment, the requirement in some courts that defendants enter a guilty plea prior to entering the court, and about infringement on the privacy of treatment information. Furthermore, many have noted that the rise of mental health courts is, in large part, the result of an underfunded and ineffective community mental health system, and without attention to the deficiencies in community treatment resources, mental health courts can only have a limited impact.[17] Finally, it has been noted that when scarce mental health services are redirected to those who have come in contact with the criminal justice system, it creates a perversion in the system were a person's best bet for obtaining services is to get arrested.[18] Outcomes [edit] Several studies of the Broward County court were released in 2002 and 2003 and found that participation in the court led to a greater connection to services. A 2004 study of the Santa Barbara County, California, Mental Health Court found that participants had reduced criminal activity during their participation. An evaluation of the Brooklyn Mental Health Court[15] documented improvements in several outcome measures, including substance abuse, psychiatric hospitalizations, homelessness and recidivism.[19] In a 2011 meta-analysis of literature on the effectiveness of mental health courts in the United States, it was found that mental health courts reduced recidivism by an overall effect size of −0.54.[20] In 2012, an Urban Institute evaluation found that participants in two New York City mental health courts were significantly less likely to re-offend than similar offenders whose cases are handled in the traditional court system.[21] A review published in 2019 concerned with drug-using offenders with co-occurring mental health problems found that mental health courts may help people reduce future drug use and criminal activity.[22] Mental health service as an intensive monitoring service [edit] A study conducted in Washington state in 2019 had found that timely mental health services is associated with the risk of incarceration.[23] It was shown in this finding that timely mental health services can be a catalyst for deeper involvement in the criminal justice system since the mental health service can act as a form of monitoring, resulting in higher technical violations in relation to higher supervision. Other studies show that more involvement of mental health services, or more supervision of the individual receiving treatment, is positively correlated with higher levels of recidivism.[24][25][26][27]

Risk factors [edit] Signs that a prisoner may be at risk of suicide include giving away valued possessions, speaking as if they are not going to be around much longer even though they are not scheduled for release, withdrawing, becoming acutely intoxicated, having a recent history of severe addiction, being threatened or assaulted by other prisoners, having a history of psychiatric hospitalizations or suicide attempts, talking about death, having recently been arrested for an offense punishable by a long sentence or actually sentenced to a lengthy term, or having impulse-control problems. Prisoners who have recently received bad news from home or are demonstrating an inability to adapt to the institutional environment may also be at higher risk. Prisoners with illnesses are at higher risk of suicide. Prisoners with AIDS have a suicide rate between 16 and 36 times higher than that of the general population.[1] Objective tests such as the Beck Depression Inventory are of limited usefulness because a malingerer may fake signs of being suicidal, while a prisoner who does not want to be stopped from committing suicide may hide signs of being suicidal. Incidence [edit] Suicides in prison compared to the general population (Council of Europe members, average 2011–15)[2]   Suicide rate in the general population, per 100,000 people per year   Suicide rate in prison, per 100,000 inmates per year In some European countries such as France, Belgium and Norway, the suicide rate among prisoners is ten times as high as among the general population,[2] but it is unknown whether this is because of the prison environment or because persons with marked suicidal tendencies are more liable to be imprisoned for crime. The apparent motivations for prison suicide are most commonly fear of other inmates, of the consequences of one's crime, or imprisonment, and the loss of a significant relationship.[3] Suicides occur most commonly in isolation cells. The most common time for suicides to occur is in the early morning hours.[4] Suicidal inmates are sometimes put on suicide watch and/or placed in special cells with no furniture or objects with which they could harm themselves.[5] A study in New York found that 41% of prison suicides involved inmates who had recently received mental health services,[6] although only one-third of prison suicides are found to have a psychiatric history, as opposed to 80–90 percent of suicides in the general community.[3] Pretrial detainees tend to have higher rates of suicide than other inmates, with about a third of all prison suicides occurring within the first week of custody.[3] Custodial suicide is the leading cause of death among detainees housed in jails.[7] According to data by the Council of Europe, in the Balkans the suicide rate in prisons is lower than in the rest of Europe: between 2011 and 2015 there were on average 53 cases of suicide each year for every 100,000 prisoners in the Balkans, and 87 in the rest of Europe. This may be explained by the fact that in Balkan countries the incarceration rate is relatively high – so the prisons are not populated by people that are particularly vulnerable – and the use of preventive detention is rather low.[2] The World Health Organization (WHO) has criticised the fact that the rate of suicide in Norwegian prisons is one of the highest in Europe.[8] Liability [edit] In the United States, liability can arise under 42 U.S.C. § 1983 and the Eighth Amendment to the United States Constitution if jail and prison officials demonstrate deliberate indifference toward a prisoner's suicidal tendencies, as suicidal inmates are regarded as being in need of medical care.[9][10] In Farmer v. Brennan, deliberate indifference was established as a standard between negligence and acting with purpose or intent, thus amounting basically to recklessness. The Farmer decision has created difficulties for plaintiffs in proving suicide liability as a violation of constitutionally established civil rights.[11] The burden of proof appears to be higher than in malpractice cases.[12] Case law provides that liability only exists if prison officials had subjective knowledge of (or at least willful blindness to) an inmate's serious medical need. I.e., they cannot be held liable if they merely should have known, but did not actually know.[13] Mere negligence is not enough for there to be a constitutional violation. The federal courts seldom allow recovery based on section 1983 absent extreme instances of deliberate indifference to a suicidal prisoner or a clear pattern of general indifference to suicidal inmates. There has to have been a strong likelihood rather than a mere possibility that a suicide would occur. Courts have also found that there is no duty to screen every prisoner for suicide potential, unless it is obvious that an inmate has such tendencies or propensities. Further, even if prison officials are aware of the inmate's suicidal tendencies and he does commit suicide, they are not liable if they took reasonable actions to prevent the suicide. In determining deliberate indifference, the practical limitations on jailers in preventing inmate suicides must be taken into account. Examples of failures that can give rise to claims related to suicide in correctional settings include inadequate mental health and psychiatric examination,[14] failure to consider obvious and substantial risk factors in assessing potential for suicide,[15] failure to place an inmate on suicide precautions upon recognizing the obvious and substantial risk, failure to communicate the action taken to other providers[16] or to custody and jail staff, failure to adequately monitor an inmate on suicide watch and maintain an appropriate observation log, discontinuation of suicide watch despite prior knowledge of suicidal behavior of the inmate and potential continued risk, failure to follow policies and procedures related to suicide risk assessment, intervention, and prevention, failure to provide training to correctional staff, abrupt discontinuation of psychotropics in an inmate who is known to have made a serious suicide attempt in the recent past, and grossly inadequate treatment by professional standards or the lack of treatment plans, policies, procedures, or staff, creating a grossly inadequate mental health care system, and repeated examples of delayed or denied medical treatment. One criticism of the current case law is that prison officials are incentivized to avoid screening inmates for suicidal tendencies, because if the screening is ineffective, or the jail fails to deter the suicidal attempt of a prisoner it knows is suicidal, the governmental entity and the jailer may be at greater risk of being held liable than if they had conducted no screening. Nonetheless, some jails screen anyway, since jail suicides are difficult on staff and on the municipality and often lead to legal action, and because some states mandate screening procedures and impose tort liability for failure to follow them. Elected officials may face political ramifications if they become the scapegoat for a prisoner suicide.[17] Another factor that has led to more screening of inmates for suicide is that research has shown that suicide tends to be the result of a plan rather than impulsive, which makes the suicide potentially more foreseeable if proper screening is done.[18]

Substance-induced psychosis (commonly known as toxic psychosis or drug-induced psychosis) is a form of psychosis that is attributed to substance intoxication. It is a psychosis that results from the effects of various substances, such as medicinal and nonmedicinal substances, legal and illegal drugs, chemicals, and plants. Various psychoactive substances have been implicated in causing or worsening psychosis in users.[1] Signs and symptoms [edit] Main article: Psychosis Psychosis manifests as disorientation, visual hallucinations and/or haptic hallucinations.[2] It is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the capacity to deal with life's demands.[3] While there are many types of psychosis, the cause of substance-induced psychosis can be pinpointed to intake of specific chemicals. To properly diagnose Substance-Induced Psychotic Disorder, one must conclude that exhibited hallucinations or delusions began during intoxication, withdrawal, or within a month after use of the substance and the symptoms are not related to a non-substance-induced psychotic disorder.[4] Treatment [edit] Because substance-induced psychosis results from the consumption of a substance or combination of substances, treatment practices heavily rely on detoxification and discontinuation of the substance(s). [1] Detox and addiction treatment centers may often provide rehabilitation programs, including inpatient and outpatient treatment options, support groups, and extended treatment plans. Substance-induced psychosis may persist for hours, days, or weeks, but typically resolves within a month of sobriety. [1] Treating psychosis involves a very thorough evaluation, including medical history, family background, symptoms, and other potential causes.[5] Treatment prioritizes emergent symptoms, evaluates for underlying mental illnesses, and focuses on behavioral and preventative measures against substance use.[1] Substance use and schizophrenia [edit] Rates of drug use amongst people with schizophrenia are higher than the general population; 50% of those diagnosed with schizophrenia use substances over their life.[6]: 495, 496  There is a model that suggests this arises because those with schizophrenia self-medicate with psychoactive drugs.[6]: 500  Transition to schizophrenia [edit] A 2019 systematic review and meta-analysis found that the 25% (18–38%) of people diagnosed with substance-induced psychosis went on to be diagnosed with schizophrenia, compared with 36% (30–43%) for brief, atypical and not otherwise specified psychoses.[7] The substance present was the primary predictor of transition from drug-induced psychosis to schizophrenia, with highest rates associated with cannabis (34% (25–46%)), hallucinogens (26% (14–43%)) and amphetamines (22% (14–34%)). Lower rates were reported for opioid– (12% (8–18%)), alcohol– (9% (6–15%)) and sedative– (10% (7–15%)) induced psychoses. Transition rates were slightly lower in older cohorts but were not affected by sex, country of the study, hospital or community location, urban or rural setting, diagnostic methods, or duration of follow-up.[7] Substances [edit] Psychotic states may occur after using a variety of legal and illegal substances. Substances whose use or withdrawal is implicated in psychosis include the following: International Classification of Diseases [edit] Psychoactive substance-induced psychotic disorders outlined within the ICD-10 codes F10.5—F19.5: • F10.5 alcohol:[8][9][10] Alcohol is a common cause of psychotic disorders or episodes, which may occur through acute intoxication, chronic alcoholism, withdrawal, exacerbation of existing disorders, or acute idiosyncratic reactions.[8] Research has shown that excessive alcohol use causes an 8-fold increased risk of psychotic disorders in men and a 3 fold increased risk of psychotic disorders in women.[11][12] While the vast majority of cases are acute and resolve fairly quickly upon treatment and/or abstinence, they can occasionally become chronic and persistent.[8] Alcoholic psychosis is sometimes misdiagnosed as another mental illness such as schizophrenia.[13] • F11.5 opioid: Studies show stronger opioids such as fentanyl are more likely to cause psychosis and hallucinations[14] • F12.5 cannabinoid: Some studies indicate that cannabis may trigger full-blown psychosis.[15] Recent studies have found an increase in risk for psychosis in cannabis users.[16] • F13.5 sedatives/hypnotics (barbiturates;[17][18] benzodiazepines):[19][20][21] It is also important to this topic to understand the paradoxical effects of some sedative drugs.[22] Serious complications can occur in conjunction with the use of sedatives creating the opposite effect as to that intended. Malcolm Lader at the Institute of Psychiatry in London estimates the incidence of these adverse reactions at about 5%, even in short-term use of the drugs.[23] The paradoxical reactions may consist of depression, with or without suicidal tendencies, phobias, aggressiveness, violent behavior and symptoms sometimes misdiagnosed as psychosis.[24][25] However, psychosis is more commonly related to the benzodiazepine withdrawal syndrome.[26] • F14.5 cocaine[27] • F15.5 other stimulants: amphetamines,[28][pages needed] methamphetamine,[28] and methylphenidate,[28] among others (see also Stimulant psychosis). • F16.5 hallucinogens (LSD and others) • F18.5 volatile solvents (volatile inhalants);[29] • Toluene,[30][31] found in glue, paint, thinner, etc. (see also Toluene toxicity). • Butane[32] • Gasoline (petrol)[33] F17.5 is reserved for tobacco-induced psychosis, but is traditionally not associated with the induction of psychosis. The code F15.5 also includes caffeine-induced psychosis, despite not being specifically listed in the DSM-IV. However, there is evidence that caffeine, in extreme acute doses or when taken in excess for long periods of time, may induce psychosis.[34][35] Medication [edit] • Fluoroquinolone drugs: Fluoroquinolone use has been linked to serious cases of toxic psychosis (see Quinolone antibiotic § Adverse effects).[36][37][38][39][40][41][42][43][excessive citations] The related quinoline derivative mefloquine (Lariam) has also been associated with psychosis.[44][45] • some over-the-counter drugs, including: • Dextromethorphan (DXM) at high doses.[46][47] • Certain antihistamines at high doses.[48][49][50][51] • Cold Medications[52] (i.e. containing phenylpropanolamine, or PPA) • prescription drugs: • Prednisone and other corticosteroids[53] • Isotretinoin[54] • Anticholinergic drugs • atropine[55][56] • scopolamine[57] • antidepressants[58] • L-dopa[59] • antiepileptics[60] • antipsychotics, in an idiosyncratic or paradoxical reaction • antimalarials • mepacrine[61] Other drugs illicit in America [edit] Other drugs illegal in America (not listed above), including: • MDMA (ecstasy)[62] • Phencyclidine (PCP)[63][64] • Ketamine[65] • Synthetic research chemicals used recreationally, including: • JWH-018 and some other synthetic cannabinoids, or mixtures containing them (e.g. "Spice", "Kronic", "MNG" or "Mr. Nice Guy", "Relaxinol", etc.).[66] Various "JWH-..." compounds in "Spice" or "Incense" have also been found and have been found to cause psychosis in some people.[67][68][69] • Mephedrone and related amphetamine-like drugs sold as "bath salts" or "plant food".[70] Plants [edit] Plants: • Hawaiian baby woodrose (contains ergine) • Morning glory seeds (contains ergine) • Datura[71] (Jimsonweed, devil's trumpet, thorn apple) • Belladonna (deadly nightshade) • Salvia divinorum[72] Nonmedicinal substances [edit] See also: Particulates § Cognitive hazards and mental health Substances chiefly nonmedicinal as to source: • Carbon monoxide (T58),[73] carbon dioxide (T59.7),[73] carbon disulfide (T65.4); • heavy metals; • organophosphate insecticides (T60.0);[73] • sarin and other nerve gases;[73] • tetraethyllead (T56.0); • aniline (T65.3); • acetone and other ketones (T52.4); • antifreeze – a mixture of ethylene glycol and other glycols (T51.8); • arsenic and its compounds (T57.0).

Suicide is the act of intentionally causing one's own death.[9] Mental disorders (including depression, bipolar disorder, schizophrenia, personality disorders, anxiety disorders, attention deficit hyperactivity disorder, and cognitive disengagement syndrome), physical disorders (such as chronic fatigue syndrome), and substance abuse (including alcoholism and benzodiazepine use and withdrawal) are risk factors.[2][3][5][10] Some suicides are impulsive acts due to stress (such as from financial or academic difficulties), relationship problems (such as breakups or divorces), or harassment and bullying.[2][11][12] Those who have previously attempted suicide are at a higher risk for future attempts.[2] Effective suicide prevention efforts include limiting access to methods of suicide such as firearms, drugs, and poisons; treating mental disorders and substance abuse; careful media reporting about suicide; improving economic conditions;[2][13] and dialectical behaviour therapy (DBT).[14] Although crisis hotlines, like 988, are common resources, their effectiveness has not been well studied.[15][16] Suicides resulted in 828,000 deaths globally in 2015, an increase from 712,000 deaths in 1990.[17][18][inconsistent] This makes suicide the 10th leading cause of death worldwide.[3][6] Approximately 1.5% of all deaths worldwide are by suicide.[8] In a given year, this is roughly 12 per 100,000 people.[6] Rates of suicide are generally higher among men than women, ranging from 1.5 times higher in the developing world to 3.5 times higher in the developed world.[1] Suicide is generally most common among those over the age of 70; however, in certain countries, those aged between 15 and 30 are at the highest risk.[1] Europe had the highest rates of suicide by region in 2015.[19] There are an estimated 10 to 20 million non-fatal attempted suicides every year.[20] Non-fatal suicide attempts may lead to injury and long-term disabilities.[21] In the Western world, attempts are more common among young people and women.[21] The most commonly adopted method of suicide varies from country to country and is partly related to the availability of effective means.[22] Views on suicide have been influenced by broad existential themes such as religion, honor, and the meaning of life.[23][24] The Abrahamic religions traditionally consider suicide as an offense towards God due to belief in the sanctity of life.[25] During the samurai era in Japan, a form of suicide known as seppuku (腹切り, harakiri) was respected as a means of making up for failure or as a form of protest.[26] Similarly, a ritual fast unto death, known as Vatakkiruttal (Tamil: வடக்கிருத்தல், Vaṭakkiruttal, 'fasting facing north'), was a Tamil ritual suicide in ancient India during the Sangam age.[27] Suicide and attempted suicide, while previously illegal, are no longer so in most Western countries.[28] It remains a criminal offense in some countries.[29] In the 20th and 21st centuries, suicide has been used on rare occasions as a form of protest; or as both a military and terrorist tactic while or after murdering others.[30] Suicide is often seen as a major catastrophe causing significant grief to the deceased's relatives, friends and community members, and it is viewed negatively almost everywhere around the world.[31][32][33] Definitions Main article: Suicide terminology Suicide, derived from Latin suicidium, is "the act of taking one's own life".[9][34] Attempted suicide or non-fatal suicidal behavior amounts to self-injury with at least some desire to end one's life that does not result in death.[35][36] Assisted suicide occurs when one individual helps another bring about their own death indirectly via providing either advice or the means to the end.[37] This is in contrast to euthanasia, where another person takes a more active role in bringing about a person's death.[37] Suicidal ideation is thoughts of ending one's life but not taking any active efforts to do so.[35] It may or may not involve exact planning or intent.[36] Suicidality is defined as "the risk of suicide, usually indicated by suicidal ideation or intent, especially as evident in the presence of a well-elaborated suicidal plan."[38] In a murder–suicide (or homicide–suicide), the individual aims at taking the lives of others at the same time. A special case of this is extended suicide, where the murder is motivated by seeing the murdered persons as an extension of their self.[39] Suicide in which the reason is that the person feels that they are not part of society is known as egoistic suicide.[40] The Centre for Suicide Prevention in Canada found that the normal verb in scholarly research and journalism for the act of suicide was commit, and argued for destigmatizing terminology related to suicide; in 2011, they published an article calling for changing the language used around suicide entitled "Suicide and language: Why we shouldn't use the 'C' word".[41][42] The American Psychological Association lists "committed suicide" as a term to avoid because it "frame[s] suicide as a crime."[43] Some advocacy groups recommend using the terms took his/her own life, died by suicide, or killed him/herself instead of committed suicide.[44][45][46] The Associated Press Stylebook recommends avoiding "committed suicide" except in direct quotes from authorities.[47] The Guardian and Observer style guides deprecate the use of "committed",[48] as does CNN.[49] Opponents of commit argue that it implies that suicide is criminal, sinful, or morally wrong.[50] Pathophysiology BDNF - Brain-derived neurotrophic factor (violet) and NT-4 heterodimer (blue). There is no known unifying underlying pathophysiology for suicide;[21] it is believed to result from an interplay of behavioral, socio-economic and psychological factors.[22] Low levels of brain-derived neurotrophic factor (BDNF) are both directly associated with suicide[51] and indirectly associated through its role in major depression, post-traumatic stress disorder, schizophrenia and obsessive–compulsive disorder.[52] Post-mortem studies have found reduced levels of BDNF in the hippocampus and prefrontal cortex, in those with and without psychiatric conditions.[53] Serotonin, a brain neurotransmitter, is believed to be low in those who die by suicide.[54] This is partly based on evidence of increased levels of 5-HT2A receptors found after death.[55] Other evidence includes reduced levels of a breakdown product of serotonin, 5-hydroxyindoleacetic acid, in the cerebral spinal fluid.[56] However, direct evidence is hard to obtain.[55] Epigenetics, the study of changes in genetic expression in response to environmental factors which do not alter the underlying DNA, is also believed to play a role in determining suicide risk.[57] Risk factors Factors that affect the risk of suicide include mental disorders, drug misuse, psychological states, cultural, family and social situations, genetics, experiences of trauma or loss, and nihilism.[59][60][16] Mental disorders and substance misuse frequently co-exist.[61] Other risk factors include having previously attempted suicide,[21] the ready availability of a means to take one's life, a family history of suicide, or the presence of traumatic brain injury.[62] For example, suicide rates have been found to be greater in households with firearms than those without them.[63] Socio-economic problems such as unemployment, poverty, homelessness, and discrimination may trigger suicidal thoughts.[64][65] Suicide might be rarer in societies with high social cohesion and moral objections against suicide.[36] Genetics appears to account for between 38% and 55% of suicidal behaviors.[66] Suicides may also occur as a local cluster of cases.[67] Most research does not distinguish between risk factors that lead to thinking about suicide and risk factors that lead to suicide attempts.[68][69] Risks for suicide attempt, rather than just thoughts of suicide, include a high pain tolerance and a reduced fear of death.[70] Previous attempts A previous history of suicide attempts is the most accurate predictor of death by suicide.[21] Approximately 20% of suicides have had a previous attempt. Of those who have attempted suicide, 1% die by suicide within a year[21] and more than 5% die by suicide within 10 years.[71] Mental illness See also: Brain health and pollution Mental illness is present at the time of suicide 27% to more than 90% of the time.[72][21][73][74] Of those who have been hospitalized for suicidal behavior, the lifetime risk of suicide is 8.6%.[21][75] Comparatively, non-suicidal people hospitalized for affective disorders have a 4% lifetime risk of suicide.[75] Half of all people who die by suicide may have major depressive disorder; having this or one of the other mood disorders such as bipolar disorder increases the risk of suicide 20-fold.[76] Other conditions implicated include schizophrenia (14%), personality disorders (8%),[77][78] obsessive–compulsive disorder,[79] and post-traumatic stress disorder.[21] Those with autism also attempt and consider suicide more frequently.[80] Others estimate that about half of people who die by suicide could be diagnosed with a personality disorder, with borderline personality disorder being the most common.[81] About 5% of people with schizophrenia die of suicide.[82] Eating disorders are another high risk condition.[71] Around 22% to 50% of people with gender dysphoria have attempted suicide, however this greatly varies by region.[83][84][85][86][87] Among approximately 80% of suicides, the individual has seen a physician within the year before their death,[88] including 45% within the prior month.[89] Approximately 25–40% of those who died by suicide had contact with mental health services in the prior year.[72][88] Antidepressants of the SSRI class appear to increase the frequency of suicide among children and young persons.[90] An unwillingness to get help for mental health problems also increases the risk.[67] Substance misuse See also: Substance-induced psychosis "The Drunkard's Progress", 1846 demonstrating how alcoholism can lead to poverty, crime, and eventually suicide Substance misuse is the second most common risk factor for suicide after major depression and bipolar disorder.[91] Both chronic substance misuse as well as acute intoxication are associated.[61][92] When combined with personal grief, such as bereavement, the risk is further increased.[92] Substance misuse is also associated with mental health disorders.[61] Most people are under the influence of sedative-hypnotic drugs (such as alcohol or benzodiazepines) when they die by suicide,[93] with alcoholism present in between 15% and 61% of cases.[61] Use of prescribed benzodiazepines is associated with an increased rate of suicide and attempted suicide. The pro-suicidal effects of benzodiazepines are suspected to be due to a psychiatric disturbance caused by side effects, such as disinhibition, or withdrawal symptoms.[10] Countries that have higher rates of alcohol use and a greater density of bars generally also have higher rates of suicide.[94] About 2.2–3.4% of those who have been treated for alcoholism at some point in their life die by suicide.[94] Alcoholics who attempt suicide are usually male, older, and have tried to take their own lives in the past.[61] Between 3 and 35% of deaths among those who use heroin are due to suicide (approximately fourteenfold greater than those who do not use).[95] In adolescents who misuse alcohol, neurological and psychological dysfunctions may contribute to the increased risk of suicide.[96] The misuse of cocaine and methamphetamine has a high correlation with suicide.[61][97] In those who use cocaine, the risk is greatest during the withdrawal phase.[98] Those who used inhalants are also at significant risk with around 20% attempting suicide at some point and more than 65% considering it.[61] Smoking cigarettes is associated with risk of suicide.[99] There is little evidence as to why this association exists; however, it has been hypothesized that those who are predisposed to smoking are also predisposed to suicide, that smoking causes health problems which subsequently make people want to end their life, and that smoking affects brain chemistry causing a propensity for suicide.[99] Cannabis, however, does not appear to independently increase the risk.[61] Self-harm Non-suicidal self-harm is common with 18% of people engaging in self-harm over the course of their life.[100]: 1  Acts of self-harm are not usually suicide attempts and most who self-harm are not at high risk of suicide.[101] Some who self-harm, however, do still end their life by suicide, and risk for self-harm and suicide may overlap.[101] Individuals who have been identified as self-harming after being admitted to hospital are 68% (38–105%) more likely to die by suicide.[102]: 279  Medical conditions There is an association between suicidality and physical health problems such as[71] chronic pain,[103] traumatic brain injury,[104] cancer,[105] chronic fatigue syndrome,[106] kidney failure (requiring hemodialysis), HIV, and systemic lupus erythematosus.[71] The diagnosis of cancer approximately doubles the subsequent frequency of suicide.[105] The prevalence of increased suicidality persisted after adjusting for depressive illness and alcohol abuse. Among people with more than one medical condition the frequency was particularly high. In Japan, health problems are listed as the primary justification for suicide.[107] Sleep disturbances, such as insomnia[108] and sleep apnea, are risk factors for depression and suicide. In some instances, the sleep disturbances may be a risk factor independent of depression.[109] A number of other medical conditions may present with symptoms similar to mood disorders, including hypothyroidism, Alzheimer's, brain tumors, systemic lupus erythematosus, and adverse effects from a number of medications (such as beta blockers and steroids).[21] Psychosocial factors A number of psychological factors increase the risk of suicide including: hopelessness, loss of pleasure in life, depression, anxiousness, agitation, rigid thinking, rumination, thought suppression, and poor coping skills.[76][110][111] A poor ability to solve problems, the loss of abilities one used to have, and poor impulse control also play a role.[76][112] In older adults, the perception of being a burden to others is important.[113] Those who have never married are also at greater risk.[21] Recent life stresses, such as a loss of a family member or friend or the loss of a job, might be a contributing factor.[76][67] Certain personality factors, especially high levels of neuroticism and introvertedness, have been associated with suicide. This might lead to people who are isolated and sensitive to distress to be more likely to attempt suicide.[110] On the other hand, optimism has been shown to have a protective effect.[110] Other psychological risk factors include having few reasons for living and feeling trapped in a stressful situation.[110] Changes to the stress response system in the brain might be altered during suicidal states.[36] Specifically, changes in the polyamine system[114] and hypothalamic–pituitary–adrenal axis.[115] Social isolation and the lack of social support has been associated with an increased risk of suicide.[110] Poverty is also a factor,[116] with heightened relative poverty compared to those around a person increasing suicide risk.[117] Over 200,000 farmers in India have died by suicide since 1997, partly due to issues of debt.[118] In China, suicide is three times as likely in rural regions as urban ones, partly, it is believed, due to financial difficulties in this area of the country.[119] Being religious may reduce one's risk of suicide while beliefs that suicide is noble may increase it.[120][67][121] This has been attributed to the negative stance many religions take against suicide and to the greater connectedness religion may give.[120] Muslims, among religious people, appear to have a lower rate of suicide; however, the data supporting this is not strong.[29] There does not appear to be a difference in rates of attempted suicide.[29] Young women in the Middle East may have higher rates.[122] Occupational factors See also: Suicide in the military Certain occupations carry an elevated risk of self-harm and suicide, such as military careers. Research in several countries has found that the rate of suicide among former armed forces personnel in particular,[123][124][125][126] and young veterans especially,[127][128][123] is markedly higher than that found in the general population. War veterans have a higher risk of suicide due in part to higher rates of mental illness, such as post-traumatic stress disorder, and physical health problems related to war.[129] Media See also: Copycat suicide and Social media and suicide In Goethe's The Sorrows of Young Werther, the title character kills himself due to a love triangle involving Charlotte (pictured at his grave). Some admirers of the story were triggered into copycat suicide, known as the "Werther effect". The media, including the Internet, plays an important role.[59][110] Certain depictions of suicide may increase its occurrence, with high-volume, prominent, repetitive coverage glorifying or romanticizing suicide having the most impact.[130] For example, about 15–40% of people leave a suicide note,[131] and media are discouraged from reporting the contents of that message. When detailed descriptions of how to kill oneself by a specific means are portrayed, this method of suicide can be imitated in vulnerable people.[22] This phenomenon has been observed in several cases after press coverage.[132][133] In a bid to reduce the adverse effect of media portrayals concerning suicide report, one of the effective methods is to educate journalists on how to report suicide news in a manner that might reduce that possibility of imitation and encourage those at risk to seek for help. When journalists follow certain reporting guidelines the risk of suicides can be decreased.[130] Getting buy-in from the media industry, however, can be difficult, especially in the long term.[130] This trigger of suicide contagion or copycat suicide is known as the "Werther effect", named after the protagonist in Goethe's The Sorrows of Young Werther who killed himself and then was emulated by many admirers of the book.[134] This risk is greater in adolescents who may romanticize death.[135] It appears that while news media has a significant effect, that of the entertainment media is equivocal.[136][137] It is unclear if searching for information about suicide on the Internet relates to the risk of suicide.[138] The opposite of the Werther effect is the proposed "Papageno effect", in which coverage of effective coping mechanisms may have a protective effect. The term is based upon a character in Mozart's opera The Magic Flute—fearing the loss of a loved one, he had planned to kill himself until his friends helped him out.[134] As a consequence, fictional portrayals of suicide, showing alternative consequences or negative consequences, might have a preventive effect,[139] for instance fiction might normalize mental health problems and encourage help-seeking.[140] Environmental exposures Some environmental exposures, including air pollution, intense sunlight, sunlight duration, hot weather, and high altitude, are associated with suicide.[141] There is a possible association between short-term PM10 exposure and suicide.[142][143] These factors might affect certain high-risk individuals more than others.[141] The time of year may also affect suicide rates. There appears to be a decrease around Christmas,[144] but an increase in rates during spring and summer, which might be related to exposure to sunshine.[36] Another study found that the risk may be greater for males on their birthday.[145] Genetics might influence rates of suicide. A family history of suicide, especially in the mother, affects children more than adolescents or adults.[110] Adoption studies have shown that this is the case for biological relatives, but not adopted relatives. This makes familial risk factors unlikely to be due to imitation.[36] Once mental disorders are accounted for, the estimated heritability rate is 36% for suicidal ideation and 17% for suicide attempts.[36] An evolutionary explanation for suicide is that it may improve inclusive fitness. This may occur if the person dying by suicide cannot have more children and takes resources away from relatives by staying alive. An objection to this explanation is that deaths by healthy adolescents likely do not increase inclusive fitness. Adaptation to a very different ancestral environment may be maladaptive in the current one.[112][146] Other factors Trauma is a risk factor for suicidality in both children[147] and adults.[110] Some may take their own lives to escape bullying or prejudice.[148] A history of childhood sexual abuse[149] and time spent in foster care are also risk factors.[150] Sexual abuse is believed to contribute to approximately 20% of the overall risk.[66] Significant adversity early in life has a negative effect on problem-solving skills and memory, both of which are implicated in suicidality.[36] According to a 2022 study, adverse childhood experiences maybe "associated with a two-fold higher odds" of anxiety disorders, depression and suicidality."[151] Problem gambling is associated with increased suicidal ideation and attempts compared to the general population.[152] Between 12 and 24% of pathological gamblers attempt suicide.[153] The rate of suicide among their spouses is three times greater than that of the general population.[153] Other factors that increase the risk in problem gamblers include concomitant mental illness, alcohol, and drug misuse.[154] Infection by the parasite Toxoplasma gondii, more commonly known as toxoplasmosis, has been linked with suicide risk. One explanation states that this is caused by altered neurotransmitter activity due to the immunological response.[36] Rational Teenage recruits for Japanese Kamikaze suicide pilots in May 1945 Rational suicide is the reasoned taking of one's own life.[155] However, some consider suicide as never being rational.[155] Euthanasia and assisted suicide are accepted practices in a number of countries among those who have a poor quality of life without the possibility of getting better.[156][157] They are supported by the legal arguments for a right to die.[157] The act of taking one's life for the benefit of others is known as altruistic suicide.[158] An example of this is an elder ending his or her life to leave greater amounts of food for the younger people in the community.[158] Suicide in some Inuit cultures has been seen as an act of respect, courage, or wisdom.[159] A suicide attack is a political or religious action where an attacker carries out violence against others which they understand will result in their own death.[160] Some suicide bombers are motivated by a desire to obtain martyrdoms or are religiously motivated.[129] Kamikaze missions were carried out as a duty to a higher cause or moral obligation.[159] Murder–suicide is an act of homicide followed within a week by suicide of the person who carried out the act.[161] Mass suicides are often performed under social pressure where members give up autonomy to a leader (see Notable cases below).[162] Mass suicides can take place with as few as two people, often referred to as a suicide pact.[163] In extenuating situations where continuing to live would be intolerable, some people use suicide as a means of escape.[164][165] Some inmates in Nazi concentration camps are known to have killed themselves during the Holocaust by deliberately touching the electrified fences.[166] Prevention Main article: Suicide prevention As a suicide prevention initiative, these signs on the Golden Gate Bridge promote a special telephone that connects to a crisis hotline, as well as a 24/7 crisis text line. Suicide prevention is a term used for the collective efforts to reduce the incidence of suicide through preventive measures. Protective factors for suicide include support, and access to therapy.[60] About 60% of people with suicidal thoughts do not seek help.[167] Reasons for not doing so include low perceived need, and wanting to deal with the problem alone.[167] Despite these high rates, there are few established treatments available for suicidal behavior.[110] Reducing access to certain methods, such as access to firearms or toxins such as opioids and pesticides, can reduce risk of suicide by that method.[22][168][16][36] Reducing access to easily-accessible methods of suicide may make impulsive attempts less likely to succeed.[169] Other measures include reducing access to charcoal (for burning) and adding barriers on bridges and subway platforms.[22][170][16] Treatment of drug and alcohol addiction, depression, and those who have attempted suicide in the past, may also be effective.[168][16] Some have proposed reducing access to alcohol as a preventive strategy (such as reducing the number of bars).[61] A suicide prevention fence on a bridge In young adults who have recently thought about suicide, cognitive behavioral therapy appears to improve outcomes.[171][110] School-based programs that increase mental health literacy and train staff have shown mixed results on suicide rates.[16] Economic development through its ability to reduce poverty may be able to decrease suicide rates.[116] Efforts to increase social connection, especially in elderly males, may be effective.[172] In people who have attempted suicide, following up on them might prevent repeat attempts.[173] Although crisis hotlines are common, there is little evidence to support or refute their effectiveness.[15][16] Preventing childhood trauma provides an opportunity for suicide prevention.[147] The World Suicide Prevention Day is observed annually on 10 September with the support of the International Association for Suicide Prevention and the World Health Organization.[174] Diet About 50% of people who die of suicide have a mood disorder such as major depression.[175][176] Sleep and diet may play a role in depression (major depressive disorder), and interventions in these areas may be an effective add-on to conventional methods.[177] Vitamin B2, B6 and B12 deficiency may cause depression in females.[178] Risk of depression may be reduced with a healthy diet "high in fruits, vegetables, nuts, and legumes; moderate amounts of poultry, eggs, and dairy products; and only occasional red meat".[179][180] A balanced diet and the consumption of lots of water is essential for mental health. Consuming oily fish may also help as they contain omega-3 fats. Consuming too much refined carbohydrates (e.g., snack foods) may increase the risk of depression symptoms. The mechanism on how diet improves or worsens mental health is still not fully understood. Blood glucose levels alterations, inflammation, or effects on the gut microbiome have been suggested.[179] Examples of balanced diets, proven essential for maintaining mental health.[179] Screening IS PATH WARM [...] is an acronym [...] to assess [...] a potentially suicidal individual, (i.e., ideation, substance abuse, purposelessness, anger, feeling trapped, hopelessness, withdrawal, anxiety, recklessness, and mood).[181] — American Association of Suicidology (2019) There is little data on the effects of screening the general population on the ultimate rate of suicide.[182][183] Screening those who come to the emergency departments with injuries from self-harm have been shown to help identify suicide ideation and suicide intention. Psychometric tests such as the Beck Depression Inventory or the Geriatric Depression Scale for older people are being used.[184] As there is a high rate of people who test positive via these tools that are not at risk of suicide, there are concerns that screening may significantly increase mental health care resource utilization.[185] Assessing those at high risk, though, is recommended for.[21] Asking about suicidality does not appear to increase the risk.[21] Treatment of mental illness See also: Antidepressants and suicide risk and Group psychotherapy In those with mental health problems, a number of treatments may reduce the risk of suicide. Those who are actively suicidal may be admitted to psychiatric care either voluntarily or involuntarily.[21] Possessions that may be used to harm oneself are typically removed.[71] Some clinicians get patients to sign suicide prevention contracts where they agree to not harm themselves if released.[21] However, evidence does not support a significant effect from this practice.[21] If a person is at low risk, outpatient mental health treatment may be arranged.[71] Short-term hospitalization has not been found to be more effective than community care for improving outcomes in those with borderline personality disorder who are chronically suicidal.[186][187] There is tentative evidence that psychotherapy, specifically dialectical behaviour therapy, reduces suicidality in adolescents[188] as well as in those with borderline personality disorder.[189] It may also be useful in decreasing suicide attempts in adults at high risk.[190] There is controversy around the benefit-versus-harm of antidepressants.[59] In young persons, some antidepressants, such as SSRIs, appear to increase the risk of suicidality from 25 per 1000 to 40 per 1000.[191] In older persons, however, they may decrease the risk.[21] Lithium appears effective at lowering the risk in those with bipolar disorder and major depression to nearly the same levels as that of the general population.[192][193] Clozapine may decrease the thoughts of suicide in some people with schizophrenia.[194] Ketamine, which is a dissociative anaesthetic, seems to lower the rate of suicidal ideation.[195] In the United States, health professionals are legally required to take reasonable steps to try to prevent suicide.[196][197] Caring letters Main article: Caring letters A caring letter sent by Jerome Motto to his patient The "Caring Letters" model of suicide prevention[198][199] involved mailing short letters that expressed the researchers' interest in the recipients without pressuring them to take any action. The intervention reduced deaths by suicide, as proven through a randomized controlled trial.[200] The technique involves letters sent from a researcher who had spoken at length with the recipient during a suicidal crisis.[199] The typewritten form letters were brief – sometimes as short as two sentences – personally signed by the researcher, and expressed interest in the recipient without making any demands.[199] They were initially sent monthly, eventually decreasing in frequency to quarterly letters; if the recipient wrote back, then an additional personal letter was mailed.[199] Caring letters are inexpensive and either the only,[199] or one of very few,[198] approaches to suicide prevention that has been scientifically proven to work during the first years after a suicide attempt that resulted in hospitalization. Methods Deaths by gun-related suicide versus non-gun-related suicide rates per 100,000 in high-income countries in 2010[201] Main article: Suicide methods The leading method of suicide varies among countries. The leading methods in different regions include hanging, pesticide poisoning, and firearms.[202] These differences are believed to be in part due to availability of the different methods.[22] A review of 56 countries found that hanging was the most common method in most of the countries,[202] accounting for 53% of male suicides and 39% of female suicides.[203] Worldwide, 30% of suicides are estimated to occur from pesticide poisoning, most of which occur in the developing world.[2] The use of this method varies markedly from 4% in Europe to more than 50% in the Pacific region.[204] It is also common in Latin America due to the ease of access within the farming populations.[22] In many countries, drug overdoses account for approximately 60% of suicides among women and 30% among men.[205] Many are unplanned and occur during an acute period of ambivalence.[22] The death rate varies by method: firearms 80–90%, drowning 65–80%, hanging 60–85%, jumping 35–60%, charcoal burning 40–50%, pesticides 60–75%, and medication overdose 1.5–4.0%.[22] The most common attempted methods of suicide differ from the most common methods of completion; up to 85% of attempts are via drug overdose in the developed world.[71] In China, the consumption of pesticides is the most common method.[206] In Japan, self-disembowelment known as seppuku (harakiri) still occurs;[206] however, hanging and jumping are the most common.[207] Jumping to one's death is common in both Hong Kong and Singapore at 50% and 80% respectively.[22] In Switzerland, firearms are the most frequent suicide method in young males, although this method has decreased since guns have become less common.[208][209] In the United States, 50% of suicides involve the use of firearms, with this method being somewhat more common in men (56%) than women (31%).[210] The next most common cause was hanging in males (28%) and self-poisoning in females (31%).[210] Together, hanging and poisoning constituted about 42% of U.S. suicides (as of 2017).[210] Epidemiology Main articles: Epidemiology of suicide and List of countries by suicide rate See also: Seasonal effects on suicide rates The US has had the largest number of gun-related suicides in the world every year from 1990 through at least 2019.[211] With 4% of the world's population, the US had 44% of global gun suicides in 2019, and the highest rate per capita.[211] Approximately 1.4% of people die by suicide, a mortality rate of 11.6 per 100,000 persons per year.[6][21] Suicide resulted in 842,000 deaths in 2013 up from 712,000 deaths in 1990.[18] Rates of suicide have increased by 60% from the 1960s to 2012, with these increases seen primarily in the developing world.[3] Globally, as of 2008/2009, suicide is the tenth leading cause of death.[3] For every suicide that results in death there are between 10 and 40 attempted suicides.[21] Suicide rates differ significantly between countries and over time.[6] As a percentage of deaths in 2008 it was: Africa 0.5%, South-East Asia 1.9%, Americas 1.2% and Europe 1.4%.[6] Rates per 100,000 were: Australia 8.6, Canada 11.1, China 12.7, India 23.2, United Kingdom 7.6, United States 11.4 and South Korea 28.9.[212][213] It was ranked as the 10th leading cause of death in the United States in 2016 with about 45,000 cases that year.[214] Rates have increased in the United States in the last few years,[214] with about 49,500 people dying by suicide in 2022, the highest number ever recorded.[215] In the United States, about 650,000 people are seen in emergency departments yearly due to attempting suicide.[21] The United States rate among men in their 50s rose by nearly half in the decade 1999–2010.[216] Greenland, Lithuania, Japan, and Hungary have the highest rates of suicide.[6] Around 75% of suicides occur in the developing world.[2] The countries with the greatest absolute numbers of suicides are China and India, partly due to their large population size, accounting for over half the total.[6] In China, suicide is the 5th leading cause of death.[217] • Death rate from suicide per 100,000 as of 2017[218] • Share of deaths from suicide, 2017[219] An unofficial report estimated 5,000 suicides in Iran in 2022.[220] Sex and gender Main article: Gender differences in suicide Suicide rates per 100,000 males (left) and females (right). Globally as of 2012, death by suicide occurs about 1.8 times more often in males than females.[6][221] In the Western world, males die three to four times more often by means of suicide than do females.[6] This difference is even more pronounced in those over the age of 65, with tenfold more males than females dying by suicide.[222] Suicide attempts and self-harm are between two and four times more frequent among females.[21][223][224] Researchers have attributed the difference between suicide and attempted suicide among the sexes to males using more lethal means to end their lives.[222][225][226] However, separating intentional suicide attempts from non-suicidal self-harm is not currently done in places like the United States when gathering statistics at the national level.[227] China has one of the highest female suicide rates in the world and is the only country where it is higher than that of men (ratio of 0.9).[6][217] In the Eastern Mediterranean, suicide rates are nearly equivalent between males and females.[6] The highest rate of female suicide is found in South Korea at 22 per 100,000, with high rates in South-East Asia and the Western Pacific generally.[6] A number of reviews have found an increased risk of suicide among lesbian, gay, bisexual, and transgender people.[228][229] Among transgender persons, rates of attempted suicide are about 40% compared to a general population rate of 5%.[230][231] This is believed to in part be due to social stigmatisation.[232] Age Suicide rates by age[233] In many countries, the rate of suicide is highest in the middle-aged[234] or elderly.[22] The absolute number of suicides, however, is greatest in those between 15 and 29 years old, due to the number of people in this age group.[6] Worldwide, the average age of suicide is between age 30 and 49 for both men and women.[235] Suicidality is rare in children, but increases during the transition to adolescence.[236] In the United States, the suicide death rate is greatest in Caucasian men older than 80 years, even though younger people more frequently attempt suicide.[21] It is the second most common cause of death in adolescents[59] and in young males is second only to accidental death.[234] In young males in the developed world, it is the cause of nearly 30% of mortality.[234] In the developing world rates are similar, but it makes up a smaller proportion of overall deaths due to higher rates of death from other types of trauma.[234] In South-East Asia, in contrast to other areas of the world, deaths from suicide occur at a greater rate in young females than elderly females.[6] History Main article: History of suicide The Ludovisi Gaul killing himself and his wife, Roman copy after the Hellenistic original, Palazzo Massimo alle Terme In ancient Athens, a person who died by suicide without the approval of the state was denied the honors of a normal burial. The person would be buried alone, on the outskirts of the city, without a headstone or marker.[237] It was also common for the hand to be cut off the body and buried separately[238] - the hand (and the instrument used) being considered the perpetrator.[239] However, it was deemed to be an acceptable method to deal with military defeat.[240] In Ancient Rome, while suicide was initially permitted, it was later deemed a crime against the state due to its economic costs.[241] Aristotle condemned all forms of suicide while Plato was ambivalent.[242] In Rome, some reasons for suicide included volunteering death in a gladiator combat, guilt over murdering someone, to save the life of another, as a result of mourning, from shame from being raped, and as an escape from intolerable situations like physical suffering, military defeat, or criminal pursuit.[242] The Death of Seneca (1684), painting by Luca Giordano, depicting the suicide of Seneca the Younger in Ancient Rome Suicide came to be regarded as a sin in Christian Europe and was condemned at the Council of Arles (452) as the work of the Devil. In the Middle Ages, the Church had drawn-out discussions as to when the desire for martyrdom was suicidal, as in the case of martyrs of Córdoba. Despite these disputes and occasional official rulings, Catholic doctrine was not entirely settled on the subject of suicide until the later 17th century. A criminal ordinance issued by Louis XIV of France in 1670 was extremely severe, even for the times: the dead person's body was drawn through the streets, face down, and then hung or thrown on a garbage heap. Additionally, all of the person's property was confiscated.[243][244] Attitudes towards suicide slowly began to shift during the Renaissance. John Donne's work Biathanatos contained one of the first modern defences of suicide, bringing proof from the conduct of Biblical figures, such as Jesus, Samson and Saul, and presenting arguments on grounds of reason and nature to sanction suicide in certain circumstances.[245] The secularization of society that began during the Enlightenment questioned traditional religious attitudes (such as Christian views on suicide) toward suicide and brought a more modern perspective to the issue. David Hume denied that suicide was a crime as it affected no one and was potentially to the advantage of the individual. In his 1777 Essays on Suicide and the Immortality of the Soul he rhetorically asked, "Why should I prolong a miserable existence, because of some frivolous advantage which the public may perhaps receive from me?"[245] Hume's analysis was criticized by philosopher Philip Reed as being "uncharacteristically (for him) bad", since Hume took an unusually narrow conception of duty and his conclusion depended upon the suicide producing no harm to others – including causing no grief, feelings of guilt, or emotional pain to any surviving friends and family – which is almost never the case.[246] A shift in public opinion at large can also be discerned; The Times in 1786 initiated a spirited debate on the motion "Is suicide an act of courage?".[247] By the 19th century, the act of suicide had shifted from being viewed as caused by sin to being caused by insanity in Europe.[244] Although suicide remained illegal during this period, it increasingly became the target of satirical comments, such as the Gilbert and Sullivan comic opera The Mikado, which satirized the idea of executing someone who had already killed himself. By 1879, English law began to distinguish between suicide and homicide, although suicide still resulted in forfeiture of estate.[248] In 1882, the deceased were permitted daylight burial in England[249] and by the middle of the 20th century, suicide had become legal in much of the Western world. The term suicide first emerged shortly before 1700 to replace expressions on self-death which were often characterized as a form of self-murder in the West.[242] Social and culture Legislation Main article: Suicide legislation A tantō knife prepared for seppuku (abdomen-cutting) Samurai about to perform seppuku Suicide is a crime in some parts of the world.[250] No country in Europe currently considers suicide or attempted suicide to be a crime.[251] It was, however, in most Western European countries from the Middle Ages until at least the 19th century.[248] The Netherlands was the first country to legalize both physician-assisted suicide and euthanasia, which took effect in 2002, although only doctors are allowed to assist in either of them, and have to follow a protocol prescribed by Dutch law.[252] If such protocol is not followed, it is an offence punishable by law. In Germany, active euthanasia is illegal and anyone present during suicide may be prosecuted for failure to render aid in an emergency.[253] Switzerland has taken steps to legalize assisted suicide for the chronically mentally ill. The high court in Lausanne, Switzerland, in a 2006 ruling, granted an anonymous individual with longstanding psychiatric difficulties the right to end his own life.[254] England and Wales decriminalized suicide via the Suicide Act 1961 and the Republic of Ireland in 1993.[251] The word "commit" was used in reference to its being illegal, but many organisations have stopped it because of the negative connotation.[255][256] In the United States, suicide is not illegal, but may be associated with penalties for those who attempt it.[251] Physician-assisted suicide is legal in the state of Washington for people with terminal diseases.[257] In Oregon, people with terminal diseases may request medications to help end their life.[258] Canadians who have attempted suicide may be barred from entering the United States. U.S. laws allow border guards to deny access to people who have a mental illness, including those with previous suicide attempts.[259][260] In Australia, suicide is not a crime.[261] However, it is a crime to counsel, incite, or aid and abet another in attempting to die by suicide, and the law explicitly allows any person to use "such force as may reasonably be necessary" to prevent another from taking their own life.[262] The Northern Territory of Australia briefly had legal physician-assisted suicide from 1996 to 1997.[263] In India, suicide was illegal until 2014, and surviving family members used to face legal difficulties.[264][265] It remains a criminal offense in most Muslim-majority nations.[29] In Malaysia, suicide per se is not a crime; however, attempted suicide is. Under Section 309 of the Penal Code, a person convicted of attempting suicide can be punished with imprisonment of up to one year, fined, or both. There are ongoing efforts to decriminalise attempted suicide, although rights groups and non-governmental organisations such as the local chapter of Befrienders say that progress has been slow.[266][267] Proponents of decriminalisation argue that suicide legislation may deter people from seeking help, and may even strengthen the resolve of would-be suicides to end their lives to avoid prosecution.[268] The first reading of a bill to repeal Section 309 of the Penal Code was tabled in Parliament in April 2023, bringing Malaysia one step closer towards decriminalising attempted suicide.[269] Suicide became a trending crisis in North Korea in 2023; a secret order criminalized suicide as treason against the socialist state.[270] Religious views Main article: Religious views on suicide Christianity Main article: Christian views on suicide Most forms of Christianity consider suicide sinful, based mainly on the writings of influential Christian thinkers of the Middle Ages, such as St. Augustine and St. Thomas Aquinas, but suicide was not considered a sin under the Byzantine Christian code of Justinian, for instance.[271][272] In Catholic and Orthodox doctrine, suicide is considered to be murder, violating the commandment "Thou shalt not kill," and historically neither church would even hold a burial service for a member that died by suicide, deeming it an act that condemned the person to hell, since they died in a state of mortal sin.[273] The basic idea being that life is a gift given by God which should not be spurned, and that suicide is against the "natural order" and thus interferes with God's master plan for the world.[274] However, it is believed that mental illness or grave fear of suffering diminishes the responsibility of the one completing suicide.[275] Judaism Main article: Jewish views on suicide Judaism focuses on the importance of valuing this life, and as such, suicide is tantamount to denying God's goodness in the world. Despite this, under extreme circumstances when there has seemed no choice but to either be killed or forced to betray their religion, there are several accounts of Jews having died by suicide, either individually or in groups (see Holocaust, Masada, First French persecution of the Jews and York Castle for examples), and as a grim reminder there is even a prayer in the Jewish liturgy for "when the knife is at the throat", for those dying "to sanctify God's Name" (see Martyrdom). These acts have received mixed responses by Jewish authorities, regarded by some as examples of heroic martyrdom, while others state that it was wrong for them to take their own lives in anticipation of martyrdom.[276] Islam Islamic religious views are against suicide.[29] Suiciding is Haram in Islam. The Quran forbids it by stating "do not kill or destroy yourself".[277][278] The hadiths also state individual suicide to be unlawful and a sin.[29] Stigma is often associated with suicide in Islamic countries.[278] One who suicides and succeeds, he\she shall never enter Paradise. Hinduism and Jainism A Hindu widow burning herself with her husband's corpse, 1820s In Hinduism, suicide is generally disdained and is considered equally sinful as murdering another in contemporary Hindu society. Hindu Scriptures state that one who dies by suicide will become part of the spirit world, wandering earth until the time one would have otherwise died, had one not taken one's own life.[279] However, Hinduism accepts a man's right to end one's life through the non-violent practice of fasting to death, termed Prayopavesa;[280] but Prayopavesa is strictly restricted to people who have no desire or ambition left, and no responsibilities remaining in this life.[280] Jainism has a similar practice named Santhara. Sati, or self-immolation by widows, is a rare and illegal practice in Hindu society.[281] Ainu Within the Ainu religion, someone who dies by suicide is believed to become a ghost (tukap) who would haunt the living,[282] to come to fulfillment from which they were excluded during life.[283] Also, someone who insults another so they kill themselves is regarded as co-responsible for their death.[284] According to Norbert Richard Adami, this ethic exists due to the case that solidarity within the community is much more important to Ainu culture than it is to the Western world.[284] Philosophy Main article: Philosophy of suicide A number of questions are raised within the philosophy of suicide, including what constitutes suicide, whether or not suicide can be a rational choice, and the moral permissibility of suicide.[285] Arguments as to acceptability of suicide in moral or social terms range from the position that the act is inherently immoral and unacceptable under any circumstances, to a regard for suicide as a sacrosanct right of anyone who believes they have rationally and conscientiously come to the decision to end their own lives, even if they are young and healthy. Opponents to suicide include philosophers such as Augustine of Hippo, Thomas Aquinas,[285] Immanuel Kant[286] and, arguably, John Stuart Mill – Mill's focus on the importance of liberty and autonomy meant that he rejected choices which would prevent a person from making future autonomous decisions.[287] Others view suicide as a legitimate matter of personal choice. Supporters of this position maintain that no one should be forced to suffer against their will, particularly from conditions such as incurable disease, mental illness, and old age, with no possibility of improvement. They reject the belief that suicide is always irrational, arguing instead that it can be a valid last resort for those enduring major pain or trauma.[288] A stronger stance would argue that people should be allowed to autonomously choose to die regardless of whether they are suffering. Notable supporters of this school of thought include Scottish empiricist David Hume,[285] who accepted suicide so long as it did not harm or violate a duty to God, other people, or the self,[246] and American bioethicist Jacob Appel.[254][289] Advocacy See also: Advocacy of suicide In this painting by Alexandre-Gabriel Decamps, the palette, pistol, and note lying on the floor suggest that the event has just taken place; an artist has taken his own life.[290] Advocacy of suicide has occurred in many cultures and subcultures. The Japanese military during World War II encouraged and glorified kamikaze attacks, which were suicide attacks by military aviators from the Empire of Japan against Allied naval vessels in the closing stages of the Pacific Theater of World War II. Japanese society as a whole has been described as "suicide-tolerant"[291] (see Suicide in Japan). Internet searches for information on suicide return webpages that, in a 2008 study, about 50% of the time provide information on suicide methods. A similar study found that 11% of sites encouraged suicide attempts.[292] There is some concern that such sites may push those predisposed over the edge. Some people form suicide pacts online, either with pre-existing friends or people they have recently encountered in chat rooms or message boards. The Internet, however, may also help prevent suicide by providing a social group for those who are isolated.[293] Locations See also: List of suicide sites and Suicides at the Golden Gate Bridge Some landmarks have become known for high levels of suicide attempts.[294] These include China's Nanjing Yangtze River Bridge,[295] San Francisco's Golden Gate Bridge, Japan's Aokigahara Forest,[296] England's Beachy Head,[294] and Toronto's Bloor Street Viaduct.[297] As of 2010, the Golden Gate Bridge has had more than 1,300 suicides by jumping since its construction in 1937.[298] Many locations where suicide is common have constructed barriers to prevent it;[299] this includes the Luminous Veil in Toronto,[297] the Eiffel Tower in Paris, the West Gate Bridge in Melbourne, and Empire State Building in New York City.[299] They generally appear to be effective.[300] Notable cases Main article: List of suicides An example of mass suicide is the 1978 Jonestown mass murder/suicide in which 909 members of the Peoples Temple, an American new religious movement led by Jim Jones, ended their lives by drinking grape Flavor Aid laced with cyanide and various prescription drugs.[301][302][303] Thousands of Japanese civilians took their own lives in the last days of the Battle of Saipan in 1944, some jumping from "Suicide Cliff" and "Banzai Cliff".[304] The 1981 Irish hunger strikes, led by Bobby Sands, resulted in 10 deaths. The cause of death was recorded by the coroner as "starvation, self-imposed" rather than suicide; this was modified to simply "starvation" on the death certificates after protest from the dead strikers' families.[305] During World War II, Erwin Rommel was found to have foreknowledge of the 20 July plot on Hitler's life; he was threatened with public trial, execution, and reprisals on his family unless he killed himself.[306] Other species Main article: Animal suicide As suicide requires a willful attempt to die, some feel it therefore cannot be said to occur in non-human animals.[240] Suicidal behavior has been observed in Salmonella seeking to overcome competing bacteria by triggering an immune system response against them.[307] Suicidal defenses by workers are also seen in the Brazilian ant Forelius pusillus, where a small group of ants leaves the security of the nest after sealing the entrance from the outside each evening.[308] Pea aphids, when threatened by a ladybug, can explode themselves, scattering and protecting their brethren and sometimes even killing the ladybug; this form of suicidal altruism is known as autothysis.[309] Some species of termites (for example Globitermes sulphureus)[310] have soldiers that explode, covering their enemies with sticky goo.[311][310] There have been anecdotal reports of dogs, horses, and dolphins killing themselves,[312] but little scientific study of animal suicide.[313] Animal suicide is usually put down to romantic human interpretation and is not generally thought to be intentional. Some of the reasons animals are thought to unintentionally kill themselves include: psychological stress, infection by certain parasites or fungi, or disruption of a long-held social tie, such as the ending of a long association with an owner and thus not accepting food from another individual.[314]

Suicidal ideation, or suicidal thoughts, is the thought process of having ideas, or ruminations about the possibility of completing suicide.[1] It is not a diagnosis but is a symptom of some mental disorders, use of certain psychoactive drugs, and can also occur in response to adverse life events without the presence of a mental disorder.[2] On suicide risk scales, the range of suicidal ideation varies from fleeting thoughts to detailed planning. Passive suicidal ideation is thinking about not wanting to live or imagining being dead.[3][4] Active suicidal ideation involves preparation to kill oneself or forming a plan to do so.[3][4] Most people who have suicidal thoughts do not go on to make suicide attempts, but suicidal thoughts are considered a risk factor.[5] During 2008–09, an estimated 8.3 million adults aged 18 and over in the United States, or 3.7% of the adult U.S. population, reported having suicidal thoughts in the previous year, while an estimated 2.2 million reported having made suicide plans in the previous year.[6] In 2019, 12 million U.S. adults seriously thought about suicide, 3.5 million planned a suicide attempt, 1.4 million attempted suicide, and more than 47,500 died by suicide.[7][8] Suicidal thoughts are also common among teenagers.[9] Suicidal ideation is associated with depression and other mood disorders; however, many other mental disorders, life events and family events can increase the risk of suicidal ideation. Mental health researchers indicate that healthcare systems should provide treatment for individuals with suicidal ideation, regardless of diagnosis, because of the risk for suicidal acts and repeated problems associated with suicidal thoughts.[10][11] There are a number of treatment options for people who experience suicidal ideation. Definitions [edit] The ICD-11 describes suicidal ideation as "thoughts, ideas, or ruminations about the possibility of ending one's life, ranging from thinking that one would be better off dead to formulation of elaborate plans".[1] The DSM-5 defines it as "thoughts about self-harm, with deliberate consideration or planning of possible techniques of causing one's own death".[12] The U.S. Centers for Disease Control and Prevention defines suicidal ideation "as thinking about, considering, or planning suicide".[13] Terminology [edit] Another term for suicidal ideation is suicidal thoughts.[5] When someone who has not shown a history of suicidal ideation experiences a sudden and pronounced thought of performing an act which would necessarily lead to their own death, psychologists call this an intrusive thought. A commonly experienced example of this is the high place phenomenon,[14] also referred to as the call of the void, the sudden urge to jump when in a high place.[15] Euphemisms related to mortal contemplation include internal struggle,[16] voluntary death,[17] and eating one's gun.[18] Risk factors [edit] See also: Suicide § Risk factors The risk factors for suicidal ideation can be divided into three categories: psychiatric disorders, life events, and family history. Psychiatric disorders [edit] Suicidal ideation is a symptom of many mental disorders and can occur in response to adverse life events without the presence of a mental disorder.[2] There are several psychiatric disorders that appear to be comorbid with suicidal ideation or considerably increase the risk of suicidal ideation.[19] For example, many individuals with borderline personality disorder exhibit recurrent suicidal behavior and suicidal thoughts. One study found that 73% of patients with borderline personality disorder have attempted suicide, with the average patient having 3.4 attempts.[20] The following list includes the disorders that have been shown to be the strongest predictors of suicidal ideation. These are not the only disorders that can increase the risk of suicidal ideation. The disorders in which risk is increased the greatest include:[21] • Anxiety disorders • Autism spectrum disorder[22] • Major depressive disorder[23]: 162  • Dysthymia • Bipolar disorder • Attention deficit hyperactivity disorder (ADHD) • Premenstrual dysphoric disorder (PMDD) • Post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (C-PTSD)[23]: 278  • Personality disorders • Psychosis (detachment from reality) • Paranoia • Schizophrenia[23]: 104  • Substance use disorders,[24][25] inhalant use disorder[23]: 538  • Body dysmorphic disorder[23]: 245  • Nightmare disorder[23]: 405  • Gender dysphoria[23]: 454  • Conduct disorder[23]: 473  • Specific learning disorder[23]: 70  • Obsessive compulsive disorder • Eating disorders, such as Anorexia, Binge eating disorder, and Bulimia Medication side effects [edit] Antidepressant medications are commonly used to decrease the symptoms in patients with moderate to severe clinical depression, and some studies indicate a connection between suicidal thoughts and tendencies and taking antidepressants,[26] increasing the risk of suicidal thoughts in some patients.[27] Some medications, such as selective serotonin reuptake inhibitors (SSRIs), can have suicidal ideation as a side effect. Moreover, these drugs' intended effects, can themselves have the unintended consequence of increased individual risk and collective rate of suicidal behavior: Among the set of persons taking the medication, a subset feel bad enough to want to attempt suicide (or to desire the perceived results of suicide) but are inhibited by depression-induced symptoms, such as lack of energy and motivation, from following through with an attempt. Among this subset, a "sub-subset" may find that the medication alleviates their physiological symptoms (such as lack of energy) and secondary psychological symptoms (e.g., lack of motivation) before or at lower doses than it alleviates their primary psychological symptom of depressed mood. Among this group of persons, the desire for suicide or its effects persists even as major obstacles to suicidal action are removed, with the effect that the incidences of suicide and suicide attempts increase.[28] In 2003, the U.S. Food and Drug Administration (FDA) issued the agency's strictest warning for manufacturers of all antidepressants (including tricyclic antidepressants [TCAs] and monoamine oxidase inhibitors)[29] due to their association with suicidal thoughts and behaviors.[30] Further studies disagree with the warning, especially when prescribed for adults, claiming more recent studies are inconclusive in the connection between the drugs and suicidal ideation.[30] Individuals with anxiety disorders who self-medicate with drugs or alcohol may also have an increased likelihood of suicidal ideation.[31] Most people are under the influence of sedative-hypnotic drugs (such as alcohol or benzodiazepines) when they die by suicide,[32] with alcoholism present in between 15% and 61% of cases.[33] Use of prescribed benzodiazepines is associated with an increased rate of suicide and attempted suicide. The pro-suicidal effects of benzodiazepines are suspected to be due to a psychiatric disturbance caused by side effects, such as disinhibition, or withdrawal symptoms.[34] Life events [edit] Life events are strong predictors of increased risk for suicidal ideation. Furthermore, life events can also lead to or be comorbid with the previously listed psychiatric disorders and predict suicidal ideation through those means. Life events that adults and children face can be dissimilar and for this reason, the list of events that increase risk can vary in adults and children. The life events that have been shown to increase risk most significantly are:[35] • Alcohol use disorder • Studies have shown that individuals who binge drink, rather than drink socially, tend to have higher rates of suicidal ideation[36] • Certain studies associate those who experience suicidal ideation with higher alcohol consumption[37] • Not only do some studies show that solitary binge drinking can increase suicidal ideation, but there is a positive feedback relationship causing those who have more suicidal ideation to have more drinks per day in a solitary environment[36] • Minoritized gender expression and/or sexuality[38] • Unemployment[37] • Chronic illness or pain[39] • Death of family members or friends • End of a relationship or being rejected by a romantic interest • Major change in life standard (e.g. relocation abroad) • Other studies have found that tobacco use is correlated with depression and suicidal ideation[40] • Social isolation • Unplanned pregnancy • Bullying, including cyberbullying[41][42] and workplace bullying[43] • Previous suicide attempts • Having previously attempted suicide is one of the strongest indicators of future suicidal ideation or suicide attempts[36] • Military experience • Military personnel who show symptoms of PTSD, major depressive disorder, alcohol use disorder, and generalized anxiety disorder show higher levels of suicidal ideation[44] • Community violence[45] • Undesired changes in body weight[46] • Women: increased BMI increases chance of suicidal ideation • Men: severe decrease in BMI increases chance of suicidal ideation • In general, the obese population has increased odds of suicidal ideation in relation to individuals that are of average-weight • Exposure and attention to suicide related images or words[47] Family history [edit] • Parents with a history of depression • Valenstein et al. studied 340 adults whose parents had experienced depression. They found that 7% of the offspring had suicidal ideation in the previous month alone[48] • Abuse[45] • Childhood: physical, emotional and sexual abuse[49] • Adolescence: physical, emotional and sexual abuse • Family violence • Childhood residential instability • Certain studies associate those who experience suicidal ideation with family disruption.[37] Relationships with parents [edit] According to a study conducted by Ruth X. Liu of San Diego State University, a significant connection was found between the parent–child relationships of adolescents in early, middle and late adolescence and their likelihood of suicidal ideation. The study consisted of measuring relationships between mothers and daughters, fathers and sons, mothers and sons, and fathers and daughters. The relationships between fathers and sons during early and middle adolescence show an inverse relationship to suicidal ideation. Closeness with the father in late adolescence is "significantly related to suicidal ideation".[50] Liu goes on to explain the relationship found between closeness with the opposite sex parent and the child's risk of suicidal thoughts. It was found that boys are better protected from suicidal ideation if they are close to their mothers through early and late adolescence; whereas girls are better protected by having a close relationship with their father during middle adolescence. An article published in 2010 by Zappulla and Pace found that suicidal ideation in adolescent boys is exacerbated by detachment from the parents when depression is already present in the child. Lifetime prevalence estimates of suicidal ideation among nonclinical populations of adolescents generally range from 60% to 75% and in many cases its severity increases the risk of suicide.[51] Parents who are unaccepting of their child's expressed LGBT sexuality, especially in a predominantly Christian culture as exists in South Korea, creates a hotbed for suicidal ideation (see under LGBT youth below). Prevention [edit] See also: Suicide prevention As a suicide prevention initiative, these signs on the Golden Gate Bridge promote a special telephone that connects to a crisis hotline, as well as a 24/7 crisis text line. Crisis hotlines, such as the National Suicide Prevention Lifeline, enable people to get immediate emergency telephone counselling. A caring letter written by hand Early detection and treatment are the best ways to prevent suicidal ideation and suicide attempts.[52][citation needed] If signs, symptoms, or risk factors are detected early then the individual might seek treatment and help before attempting to take their own life. In a study of individuals who did die by suicide, 91% of them likely had one or more mental illnesses. However, only 35% of those individuals were treated or being treated for a mental illness.[53] This emphasizes the importance of early detection; if a mental illness is detected, it can be treated and controlled to help prevent suicide attempts. Another study investigated strictly suicidal ideation in adolescents. This study found that depression symptoms in adolescents as early as 9th grade is a predictor of suicidal ideation. Most people with long-term suicidal ideation do not seek professional help.[citation needed] The previously mentioned studies point out the difficulty that mental health professionals have in motivating individuals to seek and continue treatment. Ways to increase the number of individuals who seek treatment may include: • Increasing the availability of therapy treatment in early stage • Increasing the public's knowledge of when psychiatric help may be beneficial to them • Those who have adverse life conditions seem to have just as much risk of suicide as those with mental illness[53] A study conducted by researchers in Australia set out to determine a course of early detection for suicidal ideation in teens stating that "risks associated with suicidality require an immediate focus on diminishing self-harming cognitions so as to ensure safety before attending to the underlying etiology of the behavior". A Psychological Distress scale known as the K10 was administered monthly to a random sample of individuals. According to the results among the 9.9% of individuals who reported "psychological distress (all categories)" 5.1% of the same participants reported suicidal ideation. Participants who scored "very high" on the Psychological Distress scale "were 77 times more likely to report suicidal ideation than those in the low category".[54] In a one-year study conducted in Finland, 41% of the patients who later died by suicide saw a healthcare professional, most seeing a psychiatrist. Of those, only 22% discussed suicidal intent on their last office visit. In most of the cases, the office visit took place within a week of the suicide, and most of the victims had a diagnosed depressive disorder.[55] There are many centers where one can receive aid in the fight against suicidal ideation and suicide. Hemelrijk et al. (2012) found evidence that assisting people with suicidal ideation via the internet versus more direct forms such as phone conversations has a greater effect. In a 2021 research study, Nguyen et al. (2021) propose that maybe the premise that suicidal ideation is a kind of illness has been an obstacle to dealing with suicidal ideation.[56] They use a Bayesian statistical investigation, in conjunction with the mindsponge theory,[57] to explore the processes where mental disorders have played a very minor role and conclude that there are many cases where the suicidal ideation represents a type of cost-benefit analysis for a life/death consideration, and these people may not be called "patients". Assessment [edit] See also: Evidence-based assessment Assessment seeks to understand an individual by integrating information from multiple sources such as clinical interviews; medical exams and physiological measures; standardized psychometric tests and questionnaires; structured diagnostic interviews; review of records; and collateral interviews.[58] Interviews [edit] Psychologists, psychiatrists, and other mental health professionals conduct clinical interviews to ascertain the nature of a patient or client's difficulties, including any signs or symptoms of illness the person might exhibit. Clinical interviews are "unstructured" in the sense that each clinician develops a particular approach to asking questions, without necessarily following a predefined format. Structured (or semi-structured) interviews prescribe the questions, their order of presentation, "probes" (queries) if a patient's response is not clear or specific enough, and a method to rate the frequency and intensity of symptoms.[59] Standardized psychometric measures [edit] See also: Assessment of suicide risk § In practice • Beck Scale for Suicide Ideation • Nurses' Global Assessment of Suicide Risk • Suicidal Affect–Behavior–Cognition Scale (SABCS)[60] • Columbia Suicide Severity Rating Scale Management [edit] Treatment of suicidal ideation can be problematic due to the fact that several medications have actually been linked to increasing or causing suicidal ideation in patients. Therefore, several alternative means of treating suicidal ideation are often used. The main treatments include: therapy, hospitalization, outpatient treatment, and medication or other modalities.[5] Diet [edit] There are no specific diets that can treat suicidal ideation. Therapy [edit] In psychotherapy a person explores the issues that make them feel suicidal and learns skills to help manage emotions more effectively.[5][61] Hospitalization [edit] Hospitalization allows the patient to be in a secure, supervised environment to prevent suicidal ideation from turning into suicide attempts. In most cases, individuals have the freedom to choose which treatment they see fit for themselves. However, there are several circumstances in which individuals can be hospitalized involuntarily. These circumstances are: • If an individual poses a danger to self or others • If an individual is unable to care for oneself Hospitalization may also be a treatment option if an individual: • Does not have social support or people to supervise them • Has a suicide plan • Has symptoms of a psychiatric disorder (e.g., psychosis, mania, etc.) Outpatient treatment [edit] Outpatient treatment allows individuals to remain at their place of residence and receive treatment when needed or on a scheduled basis. Being at home may improve quality of life for some patients, because they will have access to their personal belongings, and be able to come and go freely. Before allowing patients the freedom that comes with outpatient treatment, physicians evaluate several factors of the patient. These factors include the patient's level of social support, impulse control and quality of judgment. After the patient passes the evaluation, they are often asked to consent to a "no-harm contract". This is a contract formulated by the physician and the family of the patient. Within the contract, the patient agrees not to harm themself, to continue their visits with the physician, and to contact the physician in times of need.[5] There is some debate as to whether "no-harm" contracts are effective. These patients are then checked on routinely to assure they are maintaining their contract and avoiding dangerous activities (drinking alcohol, driving fast and not wearing a seat belt, etc.). Medication [edit] Prescribing medication to treat suicidal ideation can be difficult. One reason for this is that many medications lift patients' energy levels before lifting their moods. This puts them at greater risk of following through with attempting suicide. Additionally, if a person has a comorbid psychiatric disorder, it may be difficult to find a medication that addresses both the psychiatric disorder and suicidal ideation. Antidepressants may be effective.[5] Often, SSRIs are used instead of TCAs as the latter typically have greater harm in overdose.[5] Antidepressants have been shown to be a very effective means of treating suicidal ideation. One correlational study compared mortality rates due to suicide to the use of SSRI antidepressants in certain counties. The counties which had higher SSRI use had a significantly lower number of deaths caused by suicide.[62] Additionally, an experimental study followed depressed patients for one year. During the first six months of that year, the patients were examined for suicidal behavior including suicidal ideation. The patients were then prescribed antidepressants for the six months following the first six observatory months. During the six months of treatment, experimenters found suicidal ideation reduced from 47% of patients down to 14% of patients.[63] Thus, it appears from current research that antidepressants have a helpful effect on the reduction of suicidal ideation. Although research is largely in favor of the use of antidepressants for the treatment of suicidal ideation, in some cases antidepressants are claimed to be the cause of suicidal ideation. Upon the start of using antidepressants, many clinicians will note that sometimes the sudden onset of suicidal ideation may accompany treatment. This has caused the Food and Drug Administration (FDA) to issue a warning stating that sometimes the use of antidepressants may actually increase suicidal ideation.[62] Medical studies have found antidepressants help treat cases of suicidal ideation and work especially well with psychological therapy.[64] Lithium reduces the risk of suicide in people with mood disorders.[65] Tentative evidence finds clozapine in people with schizophrenia reduces the risk of suicide.[66] Others [edit] Dialectical behavior therapy [edit] Transcranial magnetic stimulation [edit] LGBT youth [edit] Main article: Suicide among LGBT youth Suicidal ideation rates among lesbian, gay, bisexual, transgender (LGBT) youth are significantly higher than among the general population.[67] Suicidal ideation, which has a higher prevalence among LGBT teenagers compared to their cisgender and heterosexual peers, has been attributed to minority stress, bullying, and parental disapproval.[68][69] South Korea [edit] Main article: Suicidal ideation in South Korean LGBT youth South Korea has the 12th highest rate of suicide in the world and the second in the OECD. Within these rates, suicide is the primary cause of death for South Korean youth, ages 10–19.[70] While these rates are elevated, suicidal ideation additionally increases with the introduction of LGBT identity.[71]

A suicide crisis, suicidal crisis or potential suicide is a situation in which a person is attempting to kill themselves or is seriously contemplating or planning to do so. It is considered by public safety authorities, medical practice, and emergency services to be a medical emergency, requiring immediate suicide intervention and emergency medical treatment. Suicidal presentations occur when an individual faces an emotional, physical, or social problem they feel they cannot overcome and considers suicide to be a solution. Clinicians usually attempt to re-frame suicidal crises, point out that suicide is not a solution and help the individual identify and solve or tolerate the problems.[1] Nature [edit] Most cases of potential suicide have warning signs.[2][3] Attempting to kill oneself, talking about or planning suicide, writing a suicide note, talking or thinking frequently about death, exhibiting a death wish by expressing it verbally or by taking potentially deadly risks, or taking steps towards attempting suicide (e.g., obtaining rope and tying it to a ligature point to attempt a hanging or stockpiling pills for an attempted overdose) are all indicators of a suicide crisis. More subtle clues include preparing for death for no apparent reason (such as putting affairs in order, changing a will, etc.), writing goodbye letters, and visiting or calling family members or friends to say farewell. The person may also start giving away previously valued items (because they "no longer need them"). In other cases, the person who seemed depressed and suicidal may become normal or filled with energy or calmness again; these people particularly need to be watched because the return to normalcy could be because they have come to terms with whatever act is next (e.g., a plan to attempt suicide and "escape" from their problems). Depression is a major causative factor of suicide, and individuals with depression are considered a high-risk group for suicidal behavior. However, suicidal behaviour is not just restricted to patients diagnosed with some form of depression.[4] More than 90% of all suicides are related to a mood disorder, such as bipolar disorder, depression, addiction, PTSD, or other psychiatric illnesses, such as schizophrenia.[5] The deeper the depression, the greater the risk,[6] often manifested in feelings or expressions of apathy, helplessness, hopelessness, or worthlessness.[7] Suicide is often committed in response to a cause of depression, such as the cessation of a romantic relationship, serious illness or injury (like the loss of a limb or blindness), the death of a loved one, financial problems or poverty, guilt or fear of getting caught for something the person did, drug abuse, old age, concerns with gender identity, among others.[8] In 2006, WHO conducted a study on suicide around the world. The results in Canada showed that 80-90% of suicide attempts (an estimation, due to the complications of predicting attempted suicide). 90% of attempted suicides investigated led to hospitalizations. 12% of attempts were in hospitals.[citation needed] Treatments [edit] Crisis hotlines, such as the 988 Suicide & Crisis Lifeline, enable people to get immediate emergency telephone counselling Ketamine has been tested for treatment-resistant bipolar depression, major depressive disorder, and people in a suicidal crisis in emergency rooms, and is being used this way off-label.[9][10] The drug is given by a single intravenous infusion at doses less than those used in anesthesia, and preliminary data have indicated it produces a rapid (within 2 hours) and relatively sustained (about 1–2 weeks long) significant reduction in symptoms in some patients.[11] Initial studies with ketamine have sparked scientific and clinical interest due to its rapid onset,[12] and because it appears to work by blocking NMDA receptors for glutamate, a different mechanism from most modern antidepressants that operate on other targets.[9][13] Some studies have shown that lithium medication can reduce suicidal ideation within 48 hours of administration. Intervention [edit] Intervention is important to stop someone in a suicidal crisis from harming or killing themselves. Every sign of suicide should be taken seriously. Steps to take in order to help defuse the situation or get the person in crisis to safety include:[14] • Stay with the person so they are not alone. • Call 988 (if in the U.S.) or another suicide hotline, or take the person to the nearest hospital facility. • Reach out to a family member or friend about what is going on. If a friend or loved one is talking about suicide but is not yet in crisis, the following steps should be taken to help them get professional help and feel supported:[14] • Call a suicide hotline number; the U.S. numbers are 988 or 800-273-8255. • Remove dangerous objects, such as guns and knives, from the home. • Offer reassurance and support. • Help the person to seek medical treatment.