Suicidal thinking, depression, and religiosity in a freedom-deprived population

Objective: to analyze the influence of sociodemographic variables, prison context, religiosity, and symptoms of depression on the presence of suicidal thinking in a population deprived of liberty. Method: a cross-sectional study with a quantitative approach, conducted with 228 participants, based on a sociodemographic questionnaire, on the prison context, and on the presence of suicidal thinking, from the Duke Religiosity Scale and the Depression, Anxiety and Stress Scale (DASS-21). Results: the variables that showed a statistically significant correlation were the following: female gender, not having a partner, working inside the penitentiary, being a primary defendant and using controlled medication, and females are 7.2 times more likely to present suicidal thinking, for each point more in the depression score, increases by 21% in the chances and not having a partner increases the chances of thinking about suicide by three times. Although the scores of religiosity were high, they did not present a statistically significant correlation with the presence of suicidal thinking. Conclusion: the prison context is complex and contains peculiarities that cause the involvement of mental health problems, as well as self-harming thoughts. Considering the relevance of the subject at issue, this work stands out in view of the scarce scientific production on the subject.


Introduction
Freedom-Deprived People (FDP) constitute a risk group for suicide, presenting higher incidences when compared to the general population (1)(2) . In the United States, for example, the occurrence of suicide among FDP is nine times higher when compared to the general population (1) . Incarceration is a traumatic experience, which implies social separation, family separation, limitation of routine activities, discrimination, poor access to the health services, permanence in a stressful environment, with precarious infrastructure and overcrowding, aspects that characterize the greater vulnerability of this population in relation to the presence of suicidal thoughts (3)(4)(5) .
Suicidal ideation is defined as the presence of thoughts in which the individual is the agent of his own death and the greater its magnitude and persistence, the greater the risk of eventual suicide (6)(7)(8) . Although the relationship between suicidal and mental disorders, especially depression and alcohol and drug abuse, are well established, factors such as conflict coping, violence, abuse or loss, isolation, and previous attempts also have a strong association with suicidal behavior (1) .
The approach to suicide is touchy, because it must be understood from the association of social, psychological, cultural, behavioral, and health factors, which act concomitantly and, because these are potentially preventable deaths, the focus should be on early identification of signs and appropriate management, and is an important target for prevention (9)(10)(11)(12) . It is observed that the chances of making new attempts are ten times lower in people who received psychosocial intervention with regular care and due referral to a specialized health service (13) .
Another factor that deserves to be highlighted, regarding prevention, is religiosity, since the evidence has revealed a positive and protective relationship with mental health (14)(15)(16) . Participation in religious meetings attenuates the isolation experienced by the jailed population, provides psychic and spiritual well-being, creates bonds and there are indications that many of those dedicated to religious practices adopt a model of life transformation (16)(17) .
However, few studies to date had investigated the prevalence of suicidal ideation and its correlates in a mixed sample of FDP (1) , being essential to foment new research in the area to identify risk factors as well as of protection, in order to provide instruments for professionals to support the person in the coping process (9)(10)(18)(19) .
In view of the above, this study aimed to analyze the influence of sociodemographic variables, prison context, religiosity and symptoms of depression on the presence of suicidal thinking in freedom-deprived population. The Durel scale was used to survey the religiosity score, a brief and easy to approach instrument, translated, and validated into Portuguese (20)(21)(22) . It has five items that capture three central dimensions of religiosity and that relate to health outcomes, namely:
OR comprises religious behaviors that occur in the context of the religious institution, such as attendance at formal religious activities. NOR, on the other hand, covers private religious behaviors, which occur without fixed locations, and can manifest themselves individually or in small family and informal groups. Finally, IR deals with a subjective dimension, which assesses how much religion can motivate or influence behaviors in the individual's life (20,22) .
The first items on the scale assess OR and NOR and the last three items assess the IR. When analyzing the results, the scores of the three dimensions must be analyzed separately (21) . For both OR and NOR, the score ranges from 1 to 6 points, while IR has a variation of 3 to 15 points. It is noteworthy that the higher the total scores, the greater the religiosity (22) .
For the classification of the scores, low OR scores <3 and high OR scores ≥4 are considered. For NOR, <3 is low and ≥4 is high. Regarding IR, it is considered high when the scores ≥10 and low when the scores <9 (23) .
The survey for the depression symptoms was carried out using the DASS-21 scale, validated and adapted to Portuguese. It is a reduced, selfadministered instrument that contains 21 items that include three subscales which assess the symptoms of depression, anxiety, and stress (24)(25) . The subscale of symptoms of depression is composed of items 3, 5, 10, 13, 16, 17 and 21, the subscale of symptoms of anxiety is composed of items 2, 4, 7, 9, 15, 19 and 20, and the subscale of symptoms of stress is composed of items 1, 6, 8, 11, 12, 14 and 18. Each item is scored from 0 to 3, with Likert-type answers, in which the individual evaluates how much each symptom was applied in the last week (25) .
The four points on the scale are the following: 0 = did not apply at all, 1 = applied to some degree or for a short time; 2 = applied to a considerable degree, or for a good part of the time, and 3 = applied a lot or most of the time. The final result is obtained by the sum of the scores of the items of each subscale, which subsequently must be multiplied by two and the classification is made according to the degree of severity (25) .
Initially, a pilot test was carried out with 10 participants, to verify the applicability of the instruments.

Results
The study population consisted of 228 freedom-        The study with the methodological design closest to this was carried out in Israel, but only with 46 incarcerated women, and found a considerably higher prevalence, since more than 50% of the participants reported a history of suicidal ideation and attempted self-extermination during incarceration (26) .
Other international research studies, with different Based on these data, it can be seen that there are still few studies on this topic, mainly those covering the FDP in Brazil (3) . Even so, it is possible to infer that the prevalence of suicidal thinking among the FDP is higher when compared to the general population (12,(27)(28)(29) .
Thus, it is inferred that incarceration increases the individual's predisposition to the involvement in suicidal ideation, due to factors such as the weakening of the social support system, overcrowding, precarious infrastructure, which require personal adaptive processes in the face of change of reality and favor the onset of symptoms such as anxiety, stress, depression, and self-injurious thoughts (3,(27)(28)(30)(31)(32)(33) .
As for the frequency of suicidal thinking, the majority (64.6%) of the individuals reported having thought about it more than once. As for the psychological care provided by the prison unit, half of the participants who claimed to have thought of suicide requested care at the unit and, of these, 62.5% said they had received it. For this specific information, no data were found in the literature to enable discussion. However, there is evidence that the mental health services in prison units are limited (33) .

Reinforcing these findings, research conducted in
China and the United States, the first two countries with the largest prison population in the world, indicated that psychiatric morbidities, sociodemographic variables, fragile social support, personality traits, and history of attempted suicide are significantly related to suicidal ideation in prison populations (1,30,34) . and incarcerated for less than one year (p=0.001) showed more probability for developing suicidal ideation (3,12,27,(29)(30)(31)35) . Adding to this aspect, the lack of social support and being exposed to the suicidal behavior of fellow inmates increased by two times the chances of experiencing suicidal ideation (12,30) .
In contrast, in Europe, the decrease in the .5% were single, 84.8% were not engaged in any work activity, and 43.2% were facing some degree of depression (3) .
As for the fact that women are more likely to have suicidal thoughts than men, the results corroborate those from other authors, who identified the same relationship both for FDP and among the general population (26,(35)(36) .
Deaths by suicide are approximately three times higher among men than among women. Conversely, suicide attempts are, on average, three times more frequent among women (19) . The trend of men being associated with risky behaviors, higher levels of strength, easier access to more lethal means, and the fact that women are more concerned with health and seek help with less resistance, may explain this circumstance (13,19) .
Regarding marital status, it was verified that living alone increases the risk of suicide, with higher rates among divorced people or individuals who never married (19) . The results of this research ratify those found in the literature, since there was a significant correlation between not having a partner and the presence of suicidal ideation (p=0.004). It is added that another study found the same correlation (p=0.004) and, like other authors, states that having a partner is a protective factor (3,27,(35)(36)(37) .
Although work during incarceration has been associated in other research studies with less suicidal ideation, this study identified an inverse correlation, since labor activity was correlated with an increase in suicidal ideation (p=0.003) (2)(3)12,27) . Participation in work activities guarantees FDP the benefit of the remission of the penalty in the proportion of one day redeemed for every three days worked; however, its inclusion is subject to the multi-professional evaluation of the technical classification committee, which analyzes physical, psychological, behavioral, and safety conditions of the concerned individuals. It is necessary to take into account possible stress factors inherent to these activities, such as a rigorous daily review when leaving and returning from work, the reduced number of vacancies, and the consequent lack of variety of these occupations, which directs them to perform work that is not necessarily the preference or aptitude of the FDP. In addition, there is a severe demand for compliance with disciplinary rules, as any infringement of a medium or severe nature results in the suspension of this benefit (38) .
It is emphasized that this condition should be better explored, in order to understand the representation of work for this population, as no article with a pertinent explanation was found.
Another variable that correlated with the existence of suicidal ideation was the fact that the FDI was a primary defendant, (p=0.010), a data consistent with the fact that a history of previous incarceration was considered a protective factor (p=0.001) (12) .
Regarding to the fact that depression has considerably increased the chances of the FDP to think about suicide, there is a consensus among specialized health groups that the mental illness usually associated with suicide is depression (39) . It is estimated that it was present in at least 50% of the consummated suicides (19,(39)(40) . For both the general population and the FDP, depression is an important risk factor for suicidal ideation, with a positive correlation (10, 26,31,[41][42][43][44][45] .
Regarding controlled drugs, 35.1% of the participants reported using them and a statistically significant correlation was identified with the presence of suicidal ideation; however, for this information, no studies were found that favored any comparison.
With regard to religiosity, even though the evidence indicates that it acts as a protective factor for the presence of suicidal ideation, in this study it was not possible to make such confirmation, since there was no statistically significant correlation (p=0.477/POR=0.941), in accordance with other authors  . There is still no evidence that religiosity significantly reduces suicide in prison, and it is suggested that perhaps this is due to the absence of studies that specifically address the impact of religiosity on the mental health of the FDP (42,47) .
Among the limitations of this study, it is worth highlighting the convenience sampling to the detriment of the probabilistic sampling, since the prison unit

Conclusion
This study identified that 21.1% of the participants declared suicidal ideation after incarceration and, as for the variables analyzed, being female, not having a partner, working within the penitentiary, being a primary defendant, and using controlled medications were those that had some influence on the presence of this thought. It was also verified that being female increases by 7.2 times the chance of having suicidal thoughts, that not having a partner increases it by 3 times and that, for each additional point on the total score of the depression scale, the increase is 21% in the chances of presenting the same thought. It is concluded that the proposed objectives were achieved and that the study contributes to measures that can help in the identification of people at risk, such as the elaboration of new intervention proposals, the prevention of suicidal behavior, and health promotion.