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Modifiable risk factors for external cause mortality after release from prison: a nested case–control study

  • M. J. Spittal (a1), S. Forsyth (a2), R. Borschmann (a1) (a3) (a4), J. T. Young (a1) (a5) (a6) and S. A. Kinner (a1) (a3) (a7) (a8) (a9)...



People released from prison are at higher risk of mortality from potentially preventable causes than their peers in the general population. Because most studies of this phenomenon are reliant on registry data, there is little health and behavioural information available on those at risk, hampering the development of targeted, evidence-based preventive responses. Our aim was to identify modifiable risk and protective factors for external cause and cause-specific mortality after release from prison.


We undertook a nested case–control study using data from a larger retrospective cohort study of mortality after release from prison in Queensland, Australia between 1994 and 2007. Cases were 286 individuals who had died from external causes (drug overdose, suicide, transport accidents, or violence) matched with 286 controls on sex, Indigenous status, and release date. We extracted data from detention, case-management, and prison medical records.


Factors associated with increased risk of external cause mortality included use of heroin and other opioids in the community [odds ratio (OR) = 2.20, 95% CI 1.41–3.43, p < 0.001], a prescription for antidepressants during the current prison sentence (OR = 1.94, 95% CI 1.02–3.67, p = 0.042), a history of problematic alcohol use in the community (OR = 1.54, 95% CI 1.05–2.26, p = 0.028), and having ever served two or more custodial sentences (OR = 1.51, 95% CI 1.01–2.25, p = 0.045). Being married (OR = 0.45, 95% CI 0.29–0.70, p < 0.001) was protective. Fewer predictors were associated with cause-specific mortality.


We identified several behavioural, psychosocial, and clinical markers associated with mortality from preventable causes in people released from prison. Emerging evidence points to interventions that could be targeted at those at increased risk of external cause mortality. These include treatment and harm reduction programmes (for substance use), improving transitional support programmes and continuity of care (for mental health), diversion and drug reform (for repeat incarceration) and nurturing stable relationships during incarceration. The period of imprisonment and shortly after release provides a unique opportunity to improve the long-term health of ex-prisoners and overcome the disadvantage associated with imprisonment.


Corresponding author

*Address for correspondence: M. J. Spittal, Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria 3010, Australia. (Email:


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Binswanger, IA, Stern, MF, Deyo, RA, Heagerty, PJ, Cheadle, A, Elmore, JG, Koepsell, TD (2007). Release from prison – a high risk of death for former inmates. New England Journal of Medicine 356, 157165.
Binswanger, IA, Blatchford, PJ, Lindsay, RG, Stern, MF (2011). Risk factors for all-cause, overdose and early deaths after release from prison in Washington state. Drug and Alcohol Dependence 117, 16.
Binswanger, IA, Stern, MF, Yamashita, TE, Mueller, SR, Baggett, TP, Blatchford, PJ (2016). Clinical risk factors for death after release from prison in Washington state: a nested case-control study. Addiction 111, 499510.
Braithwaite, RL, Stephens, TT, Treadwell, HM, Braithwaite, K, Conerly, R (2005). Short-term impact of an HIV risk reduction intervention for soon-to-be released inmates in Georgia. Journal of Health Care for the Poor and Underserved 16, 130139.
Carroll, M, Kinner, SA, Heffernan, EB (2014). Medication use and knowledge in a sample of indigenous and non-indigenous prisoners. Australian and New Zealand Journal of Public Health 38, 142146.
Chang, Z, Fazel, S, Lichtenstein, P, Larsson, H, Fazel, S, Chang, Z, Lichtenstein, P, Larsson, H (2015). Substance use disorders, psychiatric disorders, and mortality after release from prison: a nationwide longitudinal cohort study. The Lancet Psychiatry 2, 422430.
Clarke, JG, Stein, LAR, Martin, RA, Martin, SA, Parker, D, Lopes, CE, McGovern, AR, Simon, R, Roberts, M, Friedman, P, Bock, B (2013). Forced smoking abstinence: not enough for smoking cessation. JAMA Internal Medicine 173, 789794.
Degenhardt, L, Larney, S, Kimber, J, Gisev, N, Farrell, M, Dobbins, T, Weatherburn, DJ, Gibson, A, Mattick, R, Butler, T, Burns, L (2014). The impact of opioid substitution therapy on mortality post-release from prison: retrospective data linkage study. Addiction 109, 13061317.
Douglas, N, Plugge, E, Fitzpatrick, R (2009). The impact of imprisonment on health: what do women prisoners say? Journal of Epidemiology and Community Health 63, 749754.
Fazel, S, Bains, P, Doll, H (2006). Substance abuse and dependence in prisoners: a systematic review. Addiction 101, 181191.
Forsyth, SJ, Alati, R, Ober, C, Williams, GM, Kinner, SA (2014). Striking subgroup differences in substance-related mortality after release from prison. Addiction 109, 16761683.
Freudenberg, N, Ramaswamy, M, Daniels, J, Crum, M, Ompad, DC, Vlahov, D (2010). Reducing drug use, human immunodeficiency virus risk, and recidivism among young men leaving jail: evaluation of the REAL MEN re-entry program. The Journal of Adolescent Health 47, 448455.
Gordon, MS, Kinlock, TW, Schwartz, RP, O'Grady, KE (2008). A randomized clinical trial of methadone maintenance for prisoners: findings at 6 months post-release. Addiction 103, 13331342.
Graham, L, Fischbacher, CM, Stockton, D, Fraser, A, Fleming, M, Greig, K (2015). Understanding extreme mortality among prisoners: a national cohort study in scotland using data linkage. European Journal of Public Health 25, 879885.
Haglund, A, Tidemalm, D, Jokinen, J, Långström, N, Lichtenstein, P, Fazel, S, Runeson, B (2014). Suicide after release from prison: a population-based cohort study from Sweden. The Journal of Clinical Psychiatry 75, 10471053.
Hosmer, DW, Lemeshow, S, May, S (2008). Applied Logistic Regression. Wiley-Interscience: Hoboken, NJ.
Jarrett, M, Thornicroft, G, Forrester, A, Harty, M, Senior, J, King, C, Huckle, S, Parrott, J, Dunn, G, Shaw, J (2012). Continuity of care for recently released prisoners with mental illness: a pilot randomised controlled trial testing the feasibility of a Critical Time Intervention. Epidemiology and Psychiatric Sciences 21, 187193.
Jorm, AF, Kitchener, BA (2011). Noting a landmark achievement: Mental Health First Aid training reaches 1% of Australian adults. Australian and New Zealand Journal of Psychiatry 45, 808813.
Kariminia, A, Law, MG, Butler, TG, Levy, MH, Corben, SP, Kaldor, JM, Grant, L (2007). Suicide risk among recently released prisoners in New South Wales, Australia. Medical Journal of Australia 187, 387390.
Kinner, SA, Binswanger, IA (2014). Mortality after release from prison. In Encyclopedia of Criminology and Criminal Justice (ed. Bruinsma, G and Weisburd, D), pp. 31573167. Springer: New York, NY.
Kinner, SA, Wang, EA (2014). The case for improving the health of ex-prisoners. American Journal of Public Health 104, 13521355.
Kinner, SA, Forsyth, S, Williams, G (2013). Systematic review of record linkage studies of mortality in ex-prisoners: why (good) methods matter. Addiction 108, 3849.
Kinner, SA, Alati, R, Longo, M, Spittal, MJ, Boyle, FM, Williams, GM, Lennox, NG (2016). Low-intensity case management increases contact with primary care in recently released prisoners: a single-blinded, multisite, randomised controlled trial. Journal of Epidemiology and Community Health, jech-2015-206565.
Kouyoumdjian, FG, McIsaac, KE, Liauw, J, Green, S, Karachiwalla, F, Siu, W, Burkholder, K, Binswanger, I, Kiefer, L, Kinner, SA, Korchinski, M, Matheson, FI, Young, P, Hwang, SW (2015). A systematic review of randomized controlled trials of interventions to improve the health of persons during imprisonment and in the year after release. American Journal of Public Health 105, e13e33.
Lim, S, Seligson, AL, Parvez, FM, Luther, CW, Mavinkurve, MP, Binswanger, IA, Kerker, BD (2012). Risks of drug-related death, suicide, and homicide during the immediate post-release period among people released from New York City jails, 2001–2005. American Journal of Epidemiology 175, 519526.
Merrall, ELC, Kariminia, A, Binswanger, IA, Hobbs, MS, Farrell, M, Marsden, J, Hutchinson, SJ, Bird, SM (2010). Meta-analysis of drug-related deaths soon after release from prison. Addiction 105, 15451554.
Moloney, M, MacKenzie, K, Hunt, G, Joe-Laidler, K (2009). The path and promise of fatherhood for gang members. British Journal of Criminology 49, 305325.
Parmar, MKB, Strang, J, Choo, L, Meade, AM, Bird, SM (2017). Randomized controlled pilot trial of naloxone-on-release to prevent post-prison opioid overdose deaths. Addiction 112, 502515.
Petridou, E, Moustaki, M (2000). Human factors in the causation of road traffic crashese. European Journal of Epidemiology 16, 819826.
Pratt, D, Appleby, L, Piper, M, Webb, R, Shaw, J (2010). Suicide in recently released prisoners: a case-control study. Psychological Medicine 40, 827835.
Randall, D, Roxburgh, A, Gibson, A, Degenhardt, L (2009). Mortality among People who use Illicit Drugs: A Toolkit for Classifying Major Causes of Death (NDARC Technical Report No. 301). National Drug and Alcohol Research Centre: Sydney.
Rosen, DL, Schoenbach, VJ, Wohl, DA (2008). All-cause and cause-specific mortality among men released from state prison, 1980–2005. American Journal of Public Health 98, 22782284.
Sacks, JY, McKendrick, K, Hamilton, Z (2012). A randomized clinical trial of a therapeutic community treatment for female inmates: outcomes at 6 and 12 months after prison release. Journal of Addictive Diseases 31, 258269.
Shaw, J, Hunt, IM, Flynn, S, Amos, T, Meehan, J, Robinson, J, Bickley, H, Parsons, R, McCann, K, Burns, J, Kapur, N, Appleby, L (2006). The role of alcohol and drugs in homicides in England and Wales. Addiction 101, 11171124.
Singleton, N, Pendry, E, Taylor, C, Farrell, M, Marsden, J (2003). Drug-related Mortality among Newly Released Offenders. Findings. UK Home Office: London, UK.
Spittal, MJ, Forsyth, S, Pirkis, J, Alati, R, Kinner, SA (2014). Suicide in adults released from prison in Queensland, Australia: a cohort study. Journal of Epidemiology and Community Health 68, 993998.
StataCorp (2013). Stata: Release 13.1. StataCorp LP: College Station, TX.
Stein, LAR, Clair, M, Lebeau, R, Colby, SM, Barnett, NP, Golembeske, C, Monti, PM (2011 a). Motivational interviewing to reduce substance-related consequences: effects for incarcerated adolescents with depressed mood. Drug and Alcohol Dependence 118, 475478.
Stein, LAR, Lebeau, R, Colby, SM, Barnett, NP, Golembeske, C, Monti, PM (2011 b). Motivational interviewing for incarcerated adolescents: effects of depressive symptoms on reducing alcohol and marijuana use after release. Journal of Studies on Alcohol and Drugs 72, 497506.
Sullivan, CJ, McKendrick, K, Sacks, S, Banks, S (2007). Modified therapeutic community treatment for offenders with MICA disorders: substance use outcomes. The American Journal of Drug and Alcohol Abuse 33, 823832.
Thomas, EG, Spittal, MJ, Heffernan, EB, Taxman, FS, Alati, R, Kinner, SA (2016). Trajectories of psychological distress after prison release: implications for mental health service need in ex-prisoners. Psychological Medicine 46, 611621.
van Dooren, K, Kinner, SA, Forsyth, S (2013). Risk of death for young ex-prisoners in the year following release from adult prison. Australian and New Zealand Journal of Public Health 37, 377382.
Villagra Lanza, P, Gonzalez Menendez, A (2013). Acceptance and commitment therapy for drug abuse in incarcerated women. Psicothema 25, 307312.
Visher, C, Knight, CR, Chalfin, A, Roman, JK (2009). The Impact of Marital and Relationship Status on Social Outcomes for Returning Prisioners. The Urban Institute: Washington, DC.
Young, JT, Arnold-Reed, D, Preen, D, Bulsara, M, Lennox, N, Kinner, SA (2015). Early primary care physician contact and health service utilisation in a large sample of recently released ex-prisoners in Australia: prospective cohort study. BMJ Open 5.
Zlodre, J, Fazel, S (2012). All-cause and external mortality in released prisoners: systematic review and meta-analysis. American Journal of Public Health 102.



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