ArticlePDF AvailableLiterature Review

Abstract and Figures

This review will focus on the rates, clinical characteristics, risk factors and methods of self-harm and suicide in different ethnic groups in the United Kingdom, providing an update synthesis of recent literature. Studies that met the inclusion criteria between 2003 and 2013 were reviewed using the following databases: MEDLINE, PsycINFO, EMBASE and CINAHL. The methodological quality of each study was then assessed using a structured scoring system. A total of 2,362 articles were retrieved, 10 of which matched the inclusion criteria were reviewed. Significant differences were found in the rates of self-harm between ethnic groups with Asian males being least likely to self-harm and Black females being most likely to self-harm. Also, Black and South Asian people were less likely to repeat self-harm. Factors that may help protect or predispose individuals to self-harm or attempt suicide (such as religion, mental health and coping styles) also differ between ethnic groups. There are clear ethnic differences in self-harm and suicide, which may be affected by factors such as cultural pressures and prevalence of mental illness. An awareness of these differences is vital to help prevent further attempts of self-harm and suicide. Further research into differences between ethnic and cultural groups and self-harm continues to be important. © The Author(s) 2015.
Content may be subject to copyright.
International Journal of
Social Psychiatry
1 –13
© The Author(s) 2015
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0020764015573085
isp.sagepub.com
E
CAMDEN
SCHIZOPH
Introduction
Self-harm is a common clinical problem that poses a
significant public health concern (Kapur et al., 1998; Perry
et al., 2012) and places a substantial burden on the health
services (Bhui, McKenzie, & Rasul, 2007). It can also be
the most significant risk factor for future self-harm and
completed suicide (Kapur et al., 2005; Owens, Horrocks,
& House, 2002). Self-harm has been defined as any form
of self-destructive behaviour (Lundh, Karim, & Quilisch,
2007) that refers to an individual deliberately hurting or
mutilating their body with or without the intention of
dying, which includes behaviour such as skin carving,
puncturing, scratching, burning, hitting oneself and ingest-
ing harmful substances (Baguelin-Pinaud, Seguy, &
Thibaut, 2009; Lengel & Mullins-Sweatt, 2013). However,
problems arise from classifying self-harm as there is no
clear consensus (Latimer, Meade, & Tennant, 2013) or
clinical agreement regarding what constitutes self-harm
(Husain, Waheed, & Husain, 2006). Therefore, given that
the United Kingdom has one of the highest rates of self-
harm and suicide in Europe (Schmidtke et al., 1996), and
around 14% of individuals in England and Wales are of an
ethnic minority (UK Data Service Census Support, 2011),
it is important to fully understand factors that contribute to
its occurrence.
Geographical variations in the rates of self-harm and
completed suicide have been detected across the world, for
example, annual rates of suicide reported in some South
American countries were low, and high rates were observed
in Russia and some eastern bloc countries (McKenzie,
Serfaty, & Crawford, 2003). Also, some of the highest
rates of suicide and self-harm have been seen in Black and
minority ethnic (BME) groups and South Asian women in
the United Kingdom (Baldwin & Griffiths, 2009; Bhugra,
Desai, & Baldwin, 1999). However, the reasons for the
Self-harm and ethnicity:
A systematic review
Ali Al-Sharifi1, Carl R Krynicki1 and Rachel Upthegrove1,2
Abstract
Aims: This review will focus on the rates, clinical characteristics, risk factors and methods of self-harm and suicide in
different ethnic groups in the United Kingdom, providing an update synthesis of recent literature.
Methods: Studies that met the inclusion criteria between 2003 and 2013 were reviewed using the following databases:
MEDLINE, PsycINFO, EMBASE and CINAHL. The methodological quality of each study was then assessed using a
structured scoring system.
Results: A total of 2,362 articles were retrieved, 10 of which matched the inclusion criteria were reviewed. Significant
differences were found in the rates of self-harm between ethnic groups with Asian males being least likely to self-harm
and Black females being most likely to self-harm. Also, Black and South Asian people were less likely to repeat self-harm.
Factors that may help protect or predispose individuals to self-harm or attempt suicide (such as religion, mental health
and coping styles) also differ between ethnic groups.
Conclusions: There are clear ethnic differences in self-harm and suicide, which may be affected by factors such as
cultural pressures and prevalence of mental illness. An awareness of these differences is vital to help prevent further
attempts of self-harm and suicide. Further research into differences between ethnic and cultural groups and self-harm
continues to be important.
Keywords
Self-harm, suicide, ethnicity, culture
1 Department of Psychiatry, College of Medical and Dental Sciences,
The University of Birmingham, Birmingham, UK
2 Birmingham Early Intervention Service, Birmingham and Solihull Mental
Health Foundation Trust, Birmingham, UK
Corresponding author:
Rachel Upthegrove, Department of Psychiatry, College of Medical and
Dental Sciences, The University of Birmingham, Edgbaston, Birmingham
B15 2TT, UK.
Email: r.upthegrove@bham.ac.uk
573085ISP0010.1177/0020764015573085International Journal of Social PsychiatryAl-Shari et al.
research-article2015
Review Article
at University of Birmingham on March 25, 2015isp.sagepub.comDownloaded from
2 International Journal of Social Psychiatry
cultural differences in self-harm and suicide remain
unclear, thus exemplifying the need for understanding this
association and highlighting the importance of attempting
to address this difference.
Several risk factors pertaining to the prevalence of self-
harm and suicide have been identified. Socioeconomic sta-
tus affects the levels of suicide with those from a lower
socioeconomic background being more likely to attempt
suicide (Aschan et al., 2013). Also, those who are unem-
ployed have been shown to be more at risk of self-harming
as well as those who are single, divorced, separated or
widowed (Aschan et al., 2013; Johnston, Cooper, Webb, &
Kapur, 2006). These factors may differ in minority groups.
Cooper, Spiers et al. (2013) found marital status to be a
prominent factor when predicting self-harm in South Asian
individuals but less so for White individuals, thus exempli-
fying the differences between ethnic groups in rates of
self-harm. Moreover, they identified other risk factors
such as alcohol abuse to be a stronger predictor of self-
harm in South Asian groups. In addition, a history of men-
tal illness has been shown to predict self-harm and suicide
across all ethnic groups (Cooper et al., 2006).
Clinical management of patients who self-harm should
ideally take into account their cultural and ethnic back-
ground. Thus, the relative lack of research into the poten-
tial differences in risk factors for self-harm and suicide
clinicians can call upon is a concern. This article aims to
update and advance previous reviews by reporting the
findings of a systematic review of studies investigating
self-harm and suicide among at least two ethnic groups in
the United Kingdom. We include studies published after
the start date of the last published systematic review in
2007 (K. Bhui et al., 2007). The aim of the review was to
build on previous work and establish recent evidence for
the prevalence, clinical characteristics, risk factors and
methods of self-harm by each of the largest of minority
ethnic groups in the United Kingdom.
Method
Although the aim of this article is to review self-harm,
many studies investigate self-harm and suicide together.
Therefore, our search strategy targeted publications on
both self-harm and suicide.
The full text of studies were retrieved if, following
abstract screening, the study was confirmed to (a) compare
rates or clinical risk factors or methods of self-harm and
suicide, (b) include data on two more ethnic groups living
in the United Kingdom and (c) studies were published in
English between 2003 and the start date of this review,
2013. These abstracts were screened (C.R.K. and A.A.)
and if the abstract was ambiguous, the full text of the study
was examined.
The following databases were searched: MEDLINE,
PsycINFO, EMBASE and CINAHL. The following search
terms were used: (a) SUICIDE or (b) SUICIDAL IDEATION
or (c) SUICIDAL THOUGHTS or (d) SUICIDAL
BEHAVIOUR or (e) SELF-HARM or (f) DELIBERATE
SELF-HARM. This resulted in 71,925 articles being found.
Then, (a) ETHNICITY or (b) ETHNIC or (c) RACE or (d)
CULTURE or (e) CULTURAL was entered into the same
search engines which identified 252,758 articles. The find-
ings were then combined with the previous findings reveal-
ing 2,362 articles, 10 of which matched the strict inclusion
criteria were reviewed (see Figure 1).
Two reviewers (A.A., C.R.K.) independently reviewed
all articles, screened and agreed with the articles included
in the review. An independent reviewer (R.U.) was avail-
able to settle any disagreements that arose. It was not nec-
essary to contact authors of the studies included in the
review for additional information. The methodological
quality of studies was assessed independently using a
standard scoring system adopted by Raine (2000) (see
Table 1). Results were then tabulated into study character-
istics (Table 2) and risk factors and rates of self-harm
across ethnic groups (Table 3).
Data on study characteristics and quality rating are pre-
sented in Table 2. Data on clinical risk factors for self-
harm and suicide, methods of self-harm and suicide and
prevalence or rates of self-harm and suicide were extracted
and are presented in Table 3.
Results
Clinical characteristics and risk factors
Rates of self-harm. The rates of self-harm were considered
by three of the studies reviewed, and all agree that the rates
of self-harm differ in gender and ethnicity. Borrill, Fox,
and Roger (2011) noted that low levels of self-harm was
found in Asian males compared to and all other male
groups. In contrast to this, Klineberg (2010) found that
Asian British males were most likely to self-harm. Cooper
et al. (2010) found that Black females were most likely to
self-harm than Asian and White groups.
Repeated attempts and completed suicide. Two studies
reviewed focused on repeated attempts of self-harm. Bor-
rill et al. (2011) identified the highest rates of repeated
attempts of self-harm among White individuals with no
religious affiliation. They found that Hindus and Sikhs
were less likely to repeat self-harm, but Christian females
displayed high levels of repeated self-harm defined as
being more than five incidents. Repeating self-harm was
found in 11.7% of female Christians and 13.2% non-reli-
gious females. Cooper, Steeg et al. (2013) also reviewed
differences between ethnic groups and repeated attempts
of self-harm. They found that, compared to White indi-
viduals, Black and South Asian individuals were less likely
to repeat self-harm when matched on clinical and social
characteristics.
at University of Birmingham on March 25, 2015isp.sagepub.comDownloaded from
Al-Sharifi et al. 3
2362 articles screened by
AA
25 full text articles read by
AA and CK
2337 articles excluded after
title and abstract reviewed
title
8articles regarding self-
harm:
Bhogal et al. (2006)
Batsleer et al. (2003)
Borrill et al.(2011)
Cooper et al. (2013)
Cooper et al. (2010)
Harrissand Hawton
(2011)
Klineberg(2010)
Woolgar& Tranah
(2010)
2 articles regarding self-harm
and suicide:
Baldwinand Grifiths
(2009)
Bhui and McKenzie
(2008)
15 articles were excluded
from this review because they
were either repeat
publications or were on the
subject of suicide only.
Figure 1. Flow chart of the selection process.
Table 1. Study quality scoring criteria.
Criteria Range of points awarded
1 Size of the study population of relevance 0–1
2 Power calculation carried out or not 0–1
3 Confounding factors adjusted 0 – none
1 – age or gender
2 – age or gender and
socioeconomic indicators
4 Explicit and accurate hypothesis-based
ethnicity definition
0 – none
1 – a definition
2 – self-assigned
3 – rated on the basis of self-
identification and parental origin
5 Deliberate self-harm: attempts to be
made to establish whether it was self-
harm
0 – none
1 – self-report
2 – some attempt at measurement
3 – well defined and measured
at University of Birmingham on March 25, 2015isp.sagepub.comDownloaded from
4 International Journal of Social Psychiatry
Table 2. Study characteristics in self-harm and ethnic groups.
Author Ethnicity Population Sample size DSH or suicide
rating scale?
Data sources Quality
rating
Cross-sectional:
Baldwin and
Griffiths (2009)
No definition given;
recorded by health
visitor (Bangladeshi,
Indian, Pakistani,
Bhutanese, White,
Black Africans,
Turkish, Black
British, Black
Caribbean, Eastern
European, Mixed
Race). We have
condensed these
down into Asian,
Black, White and
Mixed race
Mothers
attended by
health visitors
working within
one London
NHS PCT
2 samples;
‘South Asian’
sample: 61
Asian Paired
with ‘control’
sample: 26
White; 21
Black; 8 Asian; 4
Mixed Race
None Interviews, case
notes
2
Qualitative:
Batsleer etal.
(2003)
South Asian Staff in the
mental health
services in
Manchester,
survivors of self-
harm or suicide
attempt
7 South Asian;
18 undisclosed
ethnicity (staff
members)
None Interviews 2
Retrospective
case note:
Bhogal,
Baldwin,
Hartland, and
Nair (2006)
No definition
given. Ethnicity
was recorded by
researchers via
several methods;
most common was
what was recorded
in case notes and
patients’ self-
reported ethnicity
on Trust forms
Inpatients
admitted
following DSH
between May
2000 and
October 2003
234 White; 34
Asian; 4 Other;
14 unknown
Indicators of suicide
intent: planning,
precautions against
being found, suicide
note, anyone
present nearby,
expected to die,
action taken to gain
help
Clinical notes and
letters
4
Retrospective
case note: Bhui
and McKenzie
(2008)
Reported by lead
clinician who
completed NCI
form using Office for
National Statistics
categories. The
researchers used the
main groups: Black
Caribbean, Black
African, South Asian
and White
People who
had completed
suicides who
had also been
in contact with
mental health
services in
England and
Wales during
their last
12 months
7,698 White;
166 South
Asian; 168 Black
None National
Confidential
Inquiry into
Suicide and
Homicide. Data
were for the
period from 1
January 1996 to 31
December 2001
5
Cross-sectional:
Borrill, Fox, and
Roger (2011)
Self-reported;
White = people
from White British,
White European and
Turkish backgrounds;
Asian = from families
who originated in
and/or migrated
from the Indian
sub-continent
(India, Pakistan and
Bangladesh)
London
university
students
241 White;
153 Asian; 116
Black; 43 Mixed
Ethnicity; 49
Other
Frequency of self-
harm: at least once,
5 or more incidents
of self-harm
Questionnaires 5
Method of self-
harm: cutting,
scratching or biting
skin, overdose,
swallowing objects,
burning, self-
poisoning, other
at University of Birmingham on March 25, 2015isp.sagepub.comDownloaded from
Al-Sharifi et al. 5
Author Ethnicity Population Sample size DSH or suicide
rating scale?
Data sources Quality
rating
Cohort:
Cooper etal.
(2010)
Recorded by
attending clinician
and then grouped
by researchers
into ‘South
Asian’ = people of
Pakistani, Indian or
Bangladeshi origin;
‘Black’ = Black
African–Caribbean
or Black Other;
‘White’ = White
British, Irish or
White Other
DSA
attendances to
6 hospitals: 3 in
Manchester, 1
in Oxford, 2 in
Derby
7,938 White;
459 South
Asian; 288 Black
Self-harm
repetition:
repetition within
12 months of index
episode based on
all individuals with
at least 12 months
of follow-up data
within study period
Hospital records 3
Cohort:
Cooper, Steeg
etal. (2013)
Recorded by
attending clinician
and then grouped
by researchers into
‘White’; ‘South
Asian (including
Indian, Pakistani and
Bangladeshi)’; ‘Black
(including Black
African–Caribbean,
Black Other)’
DSA
attendances to
6 hospitals: 3 in
Manchester, 1
in Oxford, 2 in
Derby
705 White; 751
South Asian;
486 Black
Frequency of
self-harm: no self-
harm in the past
year, self-harm in
the past year, no
previous self-harm,
self-harm > 1 year
ago
Hospital records 3
Circumstances of
act: self-poisoning,
self-cutting or
stabbing, alcohol
use
Retrospective
comparative:
Harriss and
Hawton (2011)
Recorded by
attending clinician
and then grouped
by researchers into
‘White’, ‘Black,
Asian, Mixed, Other’
DSA
attendances to
John Radcliffe
Hospital
2,029 White;
197 Black,
Asian, Mixed,
Other
Method of DSH:
poisoning, injury,
both poisoning and
injury
Oxford
Monitoring System
for Attempted
Suicide which
draws on hospital
records
3
Alcohol at the time
of DSH (yes or no)
Previous DSH
episodes (yes or
no)
Suicide intent score
(low or high)
Cross-sectional:
Klineberg
(2010)
Self-reported
according to 2001
census with minor
modifications:
White, Bangladeshi,
Black, Asian Indian,
Pakistani, Asian
British, Other
Students from
27 secondary
schools in East
London
237 White;
199 Black; 400
Asian; 103
Other
Self-harm (yes or
no), self-harm in the
past 12 months (yes
or no)
Questionnaires 7
Methods of self-
harm: self-cutting,
overdose, burning,
self-battery,
recreational use of
opiates or heroin,
drowning
Qualitative:
Klineberg
(2010)
Self-reported
according to 2001
census which has
been grouped into
broad ethnic groups:
White, Black and
Asian
Students from
27 secondary
schools in East
London
8 White; 10
Black; 14 Asian
None Interviews 7
Table 2. (Continued)
(Continued)
at University of Birmingham on March 25, 2015isp.sagepub.comDownloaded from
6 International Journal of Social Psychiatry
Author Ethnicity Population Sample size DSH or suicide
rating scale?
Data sources Quality
rating
Cross-sectional:
Woolgar and
Tranah (2010)
No definition given;
self-reported (White,
Black, Dual Heritage,
Asian)
Young people
serving custodial
sentences at a
Secure Training
Centre
22 White; 11
Black; 3 Dual
Heritage; 2
Asian
None Questionnaires,
case notes
3
Young people
serving custodial
sentences and/
or detained
on welfare
grounds at
Local Authority
Secure Care
Homes
DSH: deliberate self-harm.
Table 2. (Continued)
A broad definition of suicide was adopted whereby
cases in which the coroner recorded a verdict of death by
suicide were employed by K. S. Bhui and McKenzie
(2008). This is following the guidelines by Linsley,
Schapira, and Kelly (2001). They found that of those who
died by suicide within 12 months of last clinical contact,
the rate of self-harm was significantly higher in Black
African individuals. They also found that those of Black
African decent experienced suicidal ideas (5%), emotional
distress (20%) and hostility (6%) than Black Caribbean,
South Asian and White individuals. Hopelessness (17%)
and depression (30%) were more common in South Asian
individuals. Delusions and hallucinations were also more
common among the Black African (14%), Black Caribbean
(19%) and South Asian (12%) communities.
Psychiatric disorder and management. Two studies fell into
this category; these were Cooper et al. (2010) and Cooper,
spiers et al. (2013). Both studies assessed psychiatric dis-
order using clinical diagnosis rather than any assessment
scales. They focused on psychiatric disorders and man-
agement and self-harm. Cooper, Speirs et al. (2013)
found that Black individuals who self-harm and experi-
ence a psychiatric condition were more likely to self-
harm than the White individuals who self-harm. They
also found that South Asian participants were more likely
to self-harm than White participants if they abused alco-
hol and did not have a partner. Also, Cooper, spiers et al.
(2013) noted that the risk of repeated self-harm was
linked with alcohol misuse, particularly in BME groups.
Cooper et al. (2010) found that BME groups were also
less likely to receive a psychiatric assessment and fol-
low-up care than White individuals. However, Cooper,
spiers et al. (2013) speculate that this may be due to BME
groups being disillusioned by the mental health-care
services when previously seeking treatment or as a result
of not possessing the characteristics that are known to
increase the risk of self-harm.
Location. Urban or rural differences in mental health spe-
cifically suicide and self-harm, suggested by Harriss and
Hawton (2011), highlight the potential effect of location on
mental health. Harriss and Hawton (2011) found that self-
harm in urban areas was more likely to occur in those who
are non-White, unemployed, living alone, who have a crim-
inal record and those who experience housing problems.
Methods of self-harm. Only one study addressed the meth-
ods used when self-harming. Borrill et al. (2011) reported
scratching as the most common form of self-harm among
White individuals, and Black males were the least likely to
employ this method of self-harm.
Coping styles. Coping styles have been found to be vital in
self-harming behaviour. Poor coping mechanisms have
also been linked with distress and poor skills in managing
emotions (Borrill et al., 2011). Borrill et al. (2011) explored
coping styles in self-harming behaviour and found that
Black students adopted a rational style of coping compared
to White and Asian students. Furthermore, Asian students
possessed an avoidance coping style and scored highly on
emotional inhibition scales compared to White students.
Methodological quality
Using the quality assessment set out by Raine (2000), six
studies obtained a low score (3 or less) (Baldwin &
Griffiths, 2009; Batsleer, Chantler, & Burman, 2003; J.
Cooper et al., 2010; Cooper, Steeg et al., 2013; Harriss &
Hawton, 2011; Woolgar & Tranah, 2010), three studies
at University of Birmingham on March 25, 2015isp.sagepub.comDownloaded from
Al-Sharifi et al. 7
Table 3. Risk factors and rates of self-harm across ethnic groups.
Author Units of
rates
Population Results as reported by article Summary of main findings
Baldwin
etal. (2009)
Adults (new
mothers)
South Asian (n = 60),
n, %
Comparison group
(n = 60), n, %
Difference (%), two-
sided p-value
Specialist Community Public Health
Nurses (SCPHNs) assessed general
risk factors for postnatal depression
and some culture-specific factors,
but there were significant differences
in the documentation of risk factors
between South Asian mothers
and mothers from other ethnic
backgrounds
History of self-harm
or suicide
2, 3.3 4, 6.7 3.4, .69
Bhui and
McKenzie
(2008)
Adults who
completed suicide
within 12 months of
contact with mental
health services
Variable
Black
African,
n, %
Black
Caribbean,
n, %
South Asian,
n, %
White, n, %
p-value
Out of those who went on to
complete suicide within 12 months
of last clinical contact, self-harm
was significantly commoner in Black
Africans. Suicidal ideas, emotional
distress and hostility were less
common among Black Africans,
Black Caribbean and South Asians.
Hopelessness and depression were
more common among South Asian.
Delusions and hallucinations more
common among Black Africans,
Black Caribbean and South Asian
Self-harm 5, 8 9, 10 8, 5 772, 9 .38
Suicidal ideas 3, 5 5, 5 11, 7 1,584, 21 <.001
Hopelessness 3, 5 6, 7 27, 7 1,560, 21 <.001
Hostility 4, 6 10, 11 7, 4 805, 11 .05
Depressive illness 5, 8 12, 12 48, 30 2,123, 28 <.001
Deterioration of
physical illness
0, 0 4, 4 12, 8 1,155, 15 <.001
Delusions and
hallucinations
9, 14 18, 19 20, 12 255, 3 <.001
Emotional distress 12, 20 27, 29 49, 31 3,528, 46 <.001
Immediate suicide risk (clinical assessment)
None 24, 37 34, 37 74, 47 1,906, 25
Low to high 41, 63 59, 63 85, 54 5,602, 75
Preventable 13, 21 26, 31 26, 18 1,566, 23 .31
Borrill etal.
(2011)
Frequency Adults Any self-harm (%) Repeated
self-harm (%)
Cutting (%) Overdose
(%)
White participants and participants
with no religious affiliation were
more likely to report repeated
incidents of self-harm, mainly
scratching and cutting skin. Hindu
religion was associated with lower
levels of repeated self-harm. Asian
males less likely to report self-harm
than both Asian females and other
males. Black students were less likely
to report cutting and scored highest
on rational coping style
White female 30.9 14.9 16.7 9.4
White male 33.3 12.5 12.5 2.1
Black female 23.9 6.9 5.7 12.5
Black male 21.4 7.4 0 0
Asian female 29.4 5.9 16.2 11
Asian male 11.4 2.9 8.6 0
Mixed female 32.3 9.7 12.9 9.7
Mixed male 25 25 18.2 0
(Continued)
at University of Birmingham on March 25, 2015isp.sagepub.comDownloaded from
8 International Journal of Social Psychiatry
Author Units of
rates
Population Results as reported by article Summary of main findings
Cooper
etal. (2010)
Adolescents and
adults
South Asian (n = 499) versus White
(n = 7,564), RR, 95% CI
Black (n = 338) versus White, RR,
95% CI
Rates of self-harm were highest in
young Black females (16–34 years)
in all three cities. Black and minority
ethnic groups were less likely to
receive a psychiatric assessment
when re-presenting with self-harm
Manchester
Males 16–34 years 0.53, 0.41–0.68 1.02, 0.77–1.35
Males 35–64 years 0.34, 0.21–0.53 0.50, 0.33–0.78
Females 16–34 years 1.01, 0.87–1.17 1.56, 1.31–1.86
Females 35–64 years 0.46, 0.32–0.66 0.64, 0.46–0.90
Derby
Males 16–34 years 0.55, 0.39–0.77 1.14, 0.64–2.02
Males 35–64 years 0.36, 0.18–0.69 1.01, 0.52–1.95
Females 16–34 years 0.67, 0.51–0.88 1.55, 1.00–2.39
Females 35–64 years 0.43, 0.25–0.75 0.74, 0.37–1.50
Oxford
Males 16–34 years 1.39, 0.92–2.10 1.61, 0.93–2.81
Males 35–64 years 0.33, 0.11–1.03 0.38, 0.12–1.20
Females 16–34 years 1.32, 0.96–1.82 1.59, 1.06–2.37
Females 35–64 years 0.82, 0.42–1.60 0.57, 0.24–1.38
Cooper,
Steeg etal.
(2013)
Percentage Adults Variable White, Black and
South Asian
South Asian Black Risk ratio for repetition of self-harm
in South Asian and Black sample
were less than for White sample.
Risk factors for repetition were
similar for all ethnicities, although
excess risk versus Whites seen in
Black people with mental health
symptoms and alcohol misuse, and
South Asian people reporting alcohol
misuse and not having a partner
Repeaters
(%)
Hazard
ratio
Repeaters
(%)
Hazard
ratio
Repeaters
(%)
Hazard
ratio
Total 25.9 14.2 16.9
No partner 26.4 1.2,
1.1–1.3
19.2 2.4, 1.4–3.9
Problem alcohol use 29.5 1.2,
1.1–1.3
33.3 2.9, 1.4–5.8
Mental health
symptoms
29.9 1.2,
1.1–1.3
28.6 2.1,
1.2–3.6
Self-harm in past year 36.3 1.9,
1.8–2.0
26.6 2.9, 1.9–4.6
In current treatment 33.2 1.7,
1.6–1.8
25.5 2.7, 1.7–4.1
Self-poisoning involved 25.2 0.8,
0.7–0.9
12.9 0.5, 0.3–0.8
Self-cutting or stabbing
involved
31.2 1.3,
1.2–1.5
25.6 2.3, 1.4–3.7
Alcohol used in the
act
27.2 1.2,
1.1–1.3
25.6 2.7, 1.7–4.2
Table 3. (Continued)
at University of Birmingham on March 25, 2015isp.sagepub.comDownloaded from
Al-Sharifi et al. 9
Author Units of
rates
Population Results as reported by article Summary of main findings
Harriss and
Hawton
(2011)
Adults Urban (%) Rural (%) Chi-square pUrban DSH patients were more
likely to be younger, non-White in
ethnic origin, unemployed, living
alone, to have a criminal record, to
have previously engaged in DSH and
to report problems with housing
White 91 94 5.9 <.02
Black, Asian, Mixed,
Other
9 6
Klineberg
(2010)
Adolescents Life-time self-harm (n = 905) Self-harm in last 12 months
(n = 939)
Asian British group more likely
to have self-harmed in the last
12 months compared with the White
group
nOR, 95% CI nOR, 95% CI
White 26 1 20 1
Bangladeshi 15 0.65, 0.33–1.27 10 0.57, 0.26–1.24
Black 16 0.72, 0.38–1.39 11 0.64, 0.30–1.36
Asian Indian 8 1.06, 0.46–2.47 8 1.45, 0.61–3.45
Pakistani 4 0.50. 0.17–1.48 5 0.84, 0.30–2.31
Asian British 11 1.96, 0.90–4.27 11 2.44, 1.10–5.41
Other 8 0.68, 0.30–1.56 3 0.33, 0.10–1.12
Woolgar
and Tranah
(2010)
Adolescents White Ethnic minority Mood induction tasks examining
latent negative self-schemas
revealed that young people from
ethnic minority backgrounds were
particularly susceptible, suggesting a
higher latent cognitive vulnerability
to depression
Neutral condition 24 22
Negative condition 26 27
RR: relative risk; OR: odds ratio; CI: confidence interval; DSH: deliberate self-harm; NHS: National Health Service; PCT: primary care trust.
Table 3. (Continued)
at University of Birmingham on March 25, 2015isp.sagepub.comDownloaded from
10 International Journal of Social Psychiatry
obtained a medium score (between 4 and 6) (Bhogal,
Baldwin, Hartland, & Nair, 2006; K. S. Bhui & McKenzie,
2008; Borrill et al., 2011) and two studies scored highly (7
and over) which were both carried out by Klineberg
(2010). Four studies incorporated adolescents into their
sample and scored between 3 and 7 (Borrill et al., 2011;
Klineberg, 2010; Woolgar & Tranah, 2010). This review
includes three qualitative studies which used the format of
semi-structured interviews, namely, Klineberg (2010),
Batsleer et al. (2003) and Baldwin and Griffiths (2009).
Two components of the quality assessment (power calcu-
lation and degree of adjustment for obvious confounders)
could not be applied to the qualitative studies.
Three studies employed a questionnaires design (Borrill
et al., 2011; Klineberg, 2010; Woolgar & Tranah, 2010).
Clinical case notes were used by four studies, namely,
Bhogal et al. (2006), Bhui et al. (2008), Cooper, Steeg
et al. (2013) and Cooper et al. (2010). Bhui et al. (2008)
used national statistics derived from the National
Confidential Inquiry which records suicides among people
in contact with services in the preceding 12 months. Harriss
and Hawton (2011) employed a retrospective comparative
study design.
Four studies adopted a cross-sectional design; Woolgar
and Tranah (2010), Baldwin and Griffiths (2009), Borrill
et al. (2011) and one study by Klineberg (2010). Structural
content analysis of semi-structured mixed method inter-
views carried out on 60 matched pairs Specialist
Community Public Health Nurses (SCPHN) records
(Baldwin & Griffiths, 2009). Klineberg (2010) and Borrill
et al. (2011) employed a cross-sectional, questionnaire
design. Woolgar and Tranah (2010) also used a cross-sec-
tional design whereby participants were randomly assigned
to one of four conditions following mood induction.
Participants completed a questionnaire and then an intel-
lectual assessment exercise. After each exercise, mood
checks were administered. Bhogal et al. (2006) used retro-
spective case note study.
Discussion
General findings
This review supports the clear finding of an ethnic differ-
ence in self-harm presentation in the United Kingdom,
with much of the research supporting the assumption that
Asian males are least likely to self-harm and Black females
are most likely to self-harm (Borrill et al., 2011; J. Cooper
et al., 2010). Moreover, the research reviewed also sug-
gests that there are differences in repeated attempts of self-
harm with Black and South Asian individuals being less
likely to repeat self-harm. Protective and predisposing fac-
tors of self-harm have also been identified such as religion
(Borrill et al., 2011) and coping styles (Borrill et al., 2011;
Woolgar & Tranah, 2010). An individual’s location seems
to be an important factor in the rates of self-harm and sui-
cide as identified by McKenzie et al. (2003) and has also
been supported by Harriss and Hawton (2011). The pres-
ence of a psychiatric disorder and its management seems
to affect levels of self-harm and suicide (Cooper et al.,
2006) which differs between ethnic groups (Cooper, Spiers
et al., 2013).
Considering the existence of an ethnic difference in
self-harm and risk of suicide is vital for the clinical man-
agement of patients; thus, our findings will have clinical
relevance to front-line mental health and emergency teams.
Differences in rates of self-harm between ethnic groups
may be a result of BME groups being left disillusioned by
the health-care services after treatment (Cooper, Spiers
et al., 2013) or because of differences in help-seeking
behaviour. Therefore, our evidence supports the view that
ethnic background must be taken into consideration when
treating individuals. The research reviewed identified dif-
ferences between ethnic groups in the methods of self-
harm with White males being most likely to report
scratching unlike Black males (Baguelin-Pinaud et al.,
2009; Lengel & Mullins-Sweatt, 2013). These findings
suggest that there are differences in the rate, contributing
factors and the methods used by different ethnicities and
contribute to the knowledge base for factors that lead an
individual to self-harm or attempt suicide.
It has previously been asserted that clinical services
need to widen access and better reflect the population
they serve (Fernando, 2005). Common mental health
conditions, such as depression, personality disorder and
psychosis, often include self-harm and suicidal ideation.
Thus, services targeting self-harm need to be in the con-
text of better mental health services for people from
minority groups. The use of community settings without
stigma (Lamb, Bower, Rogers, Dowrick, & Gask, 2012),
such as those integrated to mosques, churches and bar-
bershops, has been suggested, but it is clear that further
evidence is still required (Lamb et al., 2012). However,
it has been shown that primary care physicians need to
be alert to patients from minority ethnic groups with
mental illness presenting with somatisation (Cooper,
Spiers et al., 2013).
Limitations
Several factors prevented a meta-analysis from being
conducted including the methods used by the studies
reviewed, the samples of these studies and distinct out-
comes. The samples from which the studies were drawn
from were different. This has been exemplified by some
studies looking at the levels of re-attendance of emer-
gency departments (Harriss & Hawton, 2011), whereas
other studies looked at methods of deliberate self-harm
(DSH) (Borrill et al., 2011; Klineberg, 2010). Also, vari-
ous samples were used such as young people serving
at University of Birmingham on March 25, 2015isp.sagepub.comDownloaded from
Al-Sharifi et al. 11
custodial sentences (Woolgar & Tranah, 2010), univer-
sity students (Borrill et al., 2011) and hospital patients
(Cooper, Spiers et al., 2013; Harriss & Hawton, 2011).
Classification of ethnic groups differed between each
study, for example, some studies categorised an ethnic
group called ‘Black’ (Cooper Spiers et al., 2013; Harriss
& Hawton, 2011), whereas other studies adopted a more
precise category definition such as ‘Black Somali’ or
‘Black British’ (Klineberg, 2010). The use of broad defi-
nitions to define ethnicity may have been used to over-
come small numbers or because of coding used to
categorise ethnic groups by medical staff, such as in
Cooper, Steeg et al. (2013). However, clustering together
potentially diverse ethnic groups does not account for
cultural differences between ethnicities, thus limiting
conclusions.
Future research
To improve on the previous research, a precise definition
of ethnic groups would allow more focused conclusions
and confident inferences to be drawn from the data. An
unclear definition of ethnic groups restricts the ability to
carry out appropriate and definitive statistical testing nec-
essary for meta-analyses and clouds the true nature of eth-
nic differences in self-harm and suicide. Also, given the
rise in Eastern European immigrants to the United
Kingdom, it seems crucial to explore rates of self-harm
and suicide in these groups and to compare this to other
ethnic groups, which may be important when devising
appropriate treatment plans and managing self-harm
patients. As noted, there is no consistency in terms used
when defining ethnic groups. Future research must use
more informative and meaningful terms when defining
ethnic groups and take into account what generation
migrant they are. Learning which generation of migrant
would be useful in understanding the stability of cultural
identity over different generations and how this may influ-
ence rates of self-harm which is particularly important
given the increasing levels of migration. Various interven-
tional studies have been used to help tackle levels of self-
harm and suicide (Hawton, Saunders, & O’Connor, 2012).
Interventions based on psychological principles initially
showed promise (Wood, Trainor, Rothwell, Moore, &
Harrington, 2001), but this was failed to be replicated
(Hazell et al., 2009). The usefulness of anti-depressants in
treating individuals who are self-harming or at risk of sui-
cide remains unclear (Wheeler, Gunnell, Metcalfe,
Stephens, & Martin, 2008). Psychological interventions
promoting social inclusion and help-seeking behaviour
may be of particular benefit to individuals of BME groups
who are at risk of suicide or who self-harm. This indicates
a clear gap in our knowledge and demonstrates that future
research is needed to explore ethnicity and suicide, and the
role of self-harm therein.
Conclusion
We have shown that there is a potential ethnic difference in
self-harm in the United Kingdom, and it is thus important
that the clinical management of patients who have self-
harmed or attempted suicide be informed by knowledge of
this difference. Also, factoring the patients’ ethnic back-
ground into the clinical management of this patient groups
may help develop appropriate treatment options and thus
prevent further attempts of self-harm (Cooper, Stieg et al.,
2013). Last but not least, several other factors associated
with self-harm such as socioeconomic grouping, marital
status and premorbid mental illness (Cooper, Spiers et al.,
2013) have also been implicated in the different rates of
the prevalence of self-harm and should be controlled for in
future larger studies.
Acknowledgements
R.U., A.A. and C.R.K. contributed to the development of the
review including design and drafting of this article. C.R.K. and
A.A. screened and reviewed the articles and R.U. was available
to resolve any disagreements and approved the articles reviewed
in the review. R.U., A.A. and C.R.K. contributed to the develop-
ment of this article. All authors read and approved this article.
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency
in the public, commercial or not-for-profit sectors.
References
Aschan, L., Goodwin, L., Cross, S., Moran, P., Hotopf, M., &
Hatch, S. L. (2013). Suicidal behaviours in South East
London: Prevalence, risk factors and the role of socio-eco-
nomic status. Journal of Affective Disorders, 150, 441–449.
doi:10.1016/j.jad.2013.04.037
Baguelin-Pinaud, A., Seguy, C., & Thibaut, F. (2009). [Self-
mutilating behaviour: A study on 30 inpatients]. Encephale,
35, 538–543. doi:10.1016/j.encep.2008.08.005
Baldwin, S., & Griffiths, P. (2009). Do specialist community
public health nurses assess risk factors for depression, sui-
cide, and self-harm among South Asian mothers living in
London? Public Health Nursing, 26, 277–289.
Batsleer, J., Chantler, K., & Burman, E. (2003). Responses of
health and social care staff to South Asian women who
attempt suicide and/or self-harm. Journal of Social Work
Practice, 17, 103–114.
Bhogal, K., Baldwin, D., Hartland, L., & Nair, R. (2006). Brief
communication: Differences between ethnic groups in demo-
graphic and clinical features of patients admitted and assessed
after deliberate self-harm: A retrospective case-note study.
International Journal of Social Psychiatry, 52, 483–486.
Bhugra, D., Desai, M., & Baldwin, D. S. (1999). Attempted sui-
cide in west London, I. Rates across ethnic communities.
Psychological Medicine, 29, 1125–1130.
at University of Birmingham on March 25, 2015isp.sagepub.comDownloaded from
12 International Journal of Social Psychiatry
Bhui, K., McKenzie, K., & Rasul, F. (2007). Rates, risk factors
& methods of self harm among minority ethnic groups in
the UK: A systematic review. BMC Public Health, 7, 336.
doi:10.1186/1471-2458-7-336
Bhui, K. S., & McKenzie, K. (2008). Rates and risk factors
by ethnic group for suicides within a year of contact with
mental health services in England and Wales. Psychiatric
Services, 59, 414–420. doi:10.1176/appi.ps.59.4.414
Borrill, J., Fox, P., & Roger, D. (2011). Religion, ethnicity, cop-
ing style, and self-reported self-harm in a diverse non-clini-
cal UK population. Mental Health, Religion & Culture, 14,
259–269. doi:10.1080/13674670903485629
Cooper, J., Husain, N., Webb, R., Waheed, W., Kapur, N.,
Guthrie, E., & Appleby, L. (2006). Self-harm in the UK:
Differences between South Asians and Whites in rates,
characteristics, provision of service and repetition. Social
Psychiatry and Psychiatric Epidemiology, 41, 782–788.
doi:10.1007/s00127-006-0099-2
Cooper, J., Murphy, E., Webb, R., Hawton, K., Bergen, H.,
Waters, K., & Kapur, N. (2010). Ethnic differences in self-
harm, rates, characteristics and service provision: Three-
city cohort study. The British Journal of Psychiatry, 197,
212–218. doi:10.1192/bjp.bp.109.072637
Cooper, J., Spiers, N., Livingston, G., Jenkins, R., Meltzer, H.,
Brugha, T., … Bebbington, P. (2013). Ethnic inequalities in
the use of health services for common mental disorders in
England. Social Psychiatry and Psychiatric Epidemiology,
48, 685–692. doi:10.1007/s00127-012-0565-y
Cooper, J., Steeg, S., Webb, R., Stewart, S. L., Applegate, E.,
Hawton, K., … Kapur, N. (2013). Risk factors associ-
ated with repetition of self-harm in black and minor-
ity ethnic (BME) groups: A multi-centre cohort study.
Journal of Affective Disorders, 148, 435–439. doi:10.1016/
j.jad.2012.11.018
Fernando, S. (2005). Multicultural mental health services:
Projects for minority ethnic communities in England.
Transcultural Psychiatry, 42, 420–436.
Harriss, L., & Hawton, K. (2011). Deliberate self-harm in rural
and urban regions: A comparative study of prevalence and
patient characteristics. Social Science & Medicine, 73, 274–
281. doi:10.1016/j.socscimed.2011.05.011
Hawton, K., Saunders, K. E. A., & O’Connor, R. C. (2012). Self-
harm and suicide in adolescents. The Lancet, 379, 2373–
2382. doi:10.1016/S0140-6736(12)60322-5
Hazell, P. L., Martin, G., McGill, K., Kay, T., Wood, A., Trainor,
G., & Harrington, R. (2009). Group therapy for repeated
deliberate self-harm in adolescents: Failure of replication
of a randomized trial. Journal of the American Academy of
Child & Adolescent Psychiatry, 48, 662–670. doi:10.1097/
CHI.0b013e3181aOacec
Husain, M. I., Waheed, W., & Husain, N. (2006). Self-harm in
British South Asian women: Psychosocial correlates and
strategies for prevention. Annals of General Psychiatry, 5,
7. doi:10.1186/1744-859x-5-7
Johnston, A., Cooper, J., Webb, R., & Kapur, N. (2006).
Individual- and area-level predictors of self-harm rep-
etition. The British Journal of Psychiatry, 189, 416–421.
doi:10.1192/bjp.bp.105.018085
Kapur, N., Cooper, J., Rodway, C., Kelly, J., Guthrie, E., &
Mackway-Jones, K. (2005). Predicting the risk of repetition
after self harm: Cohort study. British Medical Journal, 330,
394–395. doi:10.1136/bmj.38337.584225.82
Kapur, N., House, A., Creed, F., Feldman, E., Friedman, T., &
Guthrie, E. (1998). Management of deliberate self poison-
ing in adults in four teaching hospitals: Descriptive study.
British Medical Journal, 316, 831–832.
Klineberg, E. (2010). Self-harm in East London adolescents
(Doctoral thesis). Queen Mary’s School of Medicine and
Dentistry, University of London, London, England.
Lamb, J. D., Bower, P., Rogers, A., Dowrick, C., & Gask, L.
(2012). Access to mental health in primary care: A qualita-
tive meta-synthesis of evidence from the experience of peo-
ple from ‘hard to reach’ groups. Health, 16, 76–104.
Latimer, S., Meade, T., & Tennant, A. (2013). Measuring engage-
ment in deliberate self-harm behaviours: Psychometric
evaluation of six scales. BMC Psychiatry, 13, 4.
doi:10.1186/1471-244x-13-4
Lengel, G. J., & Mullins-Sweatt, S. N. (2013). Nonsuicidal self-
injury disorder: Clinician and expert ratings. Psychiatry
Research, 210, 940–944. doi:10.1016/j.psychres.
2013.08.047
Linsley, K. R., Schapira, K., & Kelly, T. P. (2001). Open ver-
dict v. suicide – Importance to research. British Journal of
Psychiatry, 178, 465–468.
Lundh, L. G., Karim, J., & Quilisch, E. (2007). Deliberate
self-harm in 15-year-old adolescents: A pilot study
with a modified version of the Deliberate Self-Harm
Inventory. Scandinavian Journal of Psychology, 48, 33–41.
doi:10.1111/j.1467-9450.2007.00567.x
McKenzie, K., Serfaty, M., & Crawford, M. (2003). Suicide in
ethnic minority groups. The British Journal of Psychiatry,
183, 100–101. doi:10.1192/bjp.02.667
Owens, D., Horrocks, J., & House, A. (2002). Fatal and non-
fatal repetition of self-harm. Systematic review. The British
Journal of Psychiatry, 181, 193–199.
Perry, I. J., Corcoran, P., Fitzgerald, A. P., Keeley, H. S.,
Reulbach, U., & Arensman, E. (2012). The incidence and
repetition of hospital-treated deliberate self harm: Findings
from the world’s first national registry. PLoS One, 7(2),
e31663. doi:10.1371/journal.pone.0031663
Raine, R. (2000). Does gender bias exist in the use of specialist
health care? Journal of Health Services Research & Policy,
5, 237–249. doi:10.1177/135581960000500409
Schmidtke, A., Bille-Brahe, U., Deleo, D., Kerkhof, A., Bjerke,
T., Crepef, P., … Sampaio-Faria, J. G. (1996). Attempted
suicide in Europe: Rates, trends and sociodemographic
characteristics of suicide attempters during the period 1989–
1992. Results of the WHO/EURO Multicentre Study on
Parasuicide. Acta Psychiatrica Scandinavica, 93, 327–338.
doi:10.1111/j.1600-0447.1996.tb10656.x
UK Data Service Census Support. (2011). Census: Aggregate
data (England and Wales). Retrieved from http://www.
nationalarchives.gov.uk/doc/open-government-licence/ver-
sion/2
Wheeler, B. W., Gunnell, D., Metcalfe, C., Stephens, P., & Martin,
R. M. (2008). The population impact on incidence of sui-
cide and non-fatal self harm of regulatory action against the
use of selective serotonin reuptake inhibitors in under 18s
in the United Kingdom: Ecological study. British Medical
Journal, 336, 542–545. doi:10.1136/bmj.39462.375613.BE
at University of Birmingham on March 25, 2015isp.sagepub.comDownloaded from
Al-Sharifi et al. 13
Wood, A., Trainor, G., Rothwell, J., Moore, A., & Harrington,
R. (2001). Randomized trial of group therapy for repeated
deliberate self-harm in adolescents. Journal of the American
Academy of Child & Adolescent Psychiatry, 40, 1246–1253.
doi:10.1097/00004583-200111000-00003
Woolgar, M., & Tranah, T. (2010). Cognitive vulnerability
to depression in young people in secure accommoda-
tion: The influence of ethnicity and current suicidal idea-
tion. Journal of Adolescence, 33, 653–661. doi:10.1016/
j.adolescence.2009.11.005
at University of Birmingham on March 25, 2015isp.sagepub.comDownloaded from
... Previous evidence suggests that for certain ethnic minority groups, self-harm (regardless of suicidal intent) is more likely than majority groups. 4,5 Individuals from ethnic minority groups are more likely to experience language barriers, acculturative stress, and discrimination which influence suicide risk. 6−8 However, research regarding suicide risk and ethnic minority status is mixed, with some evidence suggesting higher rates of suicide in ethnic minority groups, whilst other studies point to an opposite effect. ...
... Another possible explanation may be due to the way in which ethnic minority groups are defined. Some studies define ethnic minority status based on presumed/self-reported ethnicity 5 while others determine by migrant status 8 or indigenous. 10,11 The presumption of ethnicity is problematic as it has been shown to misclassify individuals and is often based on skin colour. ...
Article
Full-text available
Background Existing evidence suggests that some individuals from ethnic minority backgrounds are at increased risk of suicide compared to their majority ethnic counterparts, whereas others are at decreased risk. We aimed to estimate the absolute and relative risk of suicide in individuals from ethnic minority backgrounds globally. Methods Databases (Medline, Embase, and PsycInfo) were searched for epidemiological studies between 01/01/2000 and 3/07/2020, which provided data on absolute and relative rates of suicide amongst ethnic minority groups. Studies reporting on clinical or specific populations were excluded. Pairs of reviewers independently screened titles, abstracts, and full texts. We used random effects meta-analysis to estimate overall, sex, location, migrant status, and ancestral origin, stratified pooled estimates for absolute and rate ratios. PROSPERO registration: CRD42020197940. Findings A total of 128 studies were included with 6,026,103 suicide deaths in individuals from an ethnic minority background across 31 countries. Using data from 42 moderate-high quality studies, we estimated a pooled suicide rate of 12·1 per 100,000 (95% CIs 8·4–17·6) in people from ethnic minority backgrounds with a broad range of estimates (1·2–139·7 per 100,000). There was weak statistical evidence from 51 moderate-high quality studies that individuals from ethnic minority groups were more likely to die by suicide (RR 1·3 95% CIs 0·9–1·7) with again a broad range amongst studies (RR 0·2–18·5). In our sub-group analysis we only found evidence of elevated risk for indigenous populations (RR: 2·8 95% CIs 1·9–4·0; pooled rate: 23·2 per 100,000 95% CIs 14·7–36·6). There was very substantial heterogeneity (I² > 98%) between studies for all pooled estimates. Interpretation The homogeneous grouping of individuals from ethnic minority backgrounds is inappropriate. To support suicide prevention in marginalised groups, further exploration of important contextual differences in risk is required. It is possible that some ethnic minority groups (for example those from indigenous backgrounds) have higher rates of suicide than majority populations. Funding No specific funding was provided to conduct this research. DK is funded by Wellcome Trust and Elizabeth Blackwell Institute Bristol. Matthew Spittal is a recipient of an Australian Research Council Future Fellowship (project number FT180100075) funded by the Australian Government. Rebecca Musgrove is funded by the NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC-2016-003).
... Such disparities have frequently been correlated to socioeconomic deprivation [6,7], or discrepancies between the management of self-harm between hospitals [8,9]. When comparing rates between ethnic groups, research indicates that black females are the most at-risk group [10,11], though the data is generally limited in this area. ...
Article
Full-text available
Background and aims This systematic review sought to identify, explain and interpret the prominent or recurring themes relating to the barriers and facilitators of reporting and recording of self-harm in young people across different settings, such as the healthcare setting, schools and the criminal justice setting. Methods A search strategy was developed to ensure all relevant literature around the reporting and recording of self-harm in young people was obtained. Literature searches were conducted in six databases and a grey literature search of policy documents and relevant material was also conducted. Due to the range of available literature, both quantitative and qualitative methodologies were considered for inclusion. Results Following the completion of the literature searches and sifting, nineteen papers were eligible for inclusion. Facilitators to reporting self-harm across the different settings were found to be recognising self-harm behaviours, using passive screening, training and experience, positive communication, and safe, private information sharing. Barriers to reporting self-harm included confidentiality concerns, negative perceptions of young people, communication difficulties, stigma, staff lacking knowledge around self-harm, and a lack of time, money and resources. Facilitators to recording self-harm across the different settings included being open to discussing what is recorded, services working together and co-ordinated help. Barriers to recording self-harm were mainly around stigma, the information being recorded and the ability of staff being able to do so, and their length of professional experience. Conclusion Following the review of the current evidence, it was apparent that there was still progress to be made to improve the reporting and recording of self-harm in young people, across the different settings. Future work should concentrate on better understanding the facilitators, whilst aiming to ameliorate the barriers.
... Other authors have suggested that across the lifespan, ethnic differences in self-harming within the UK are evidenced, suggesting black females are most likely to self-harm and Asian males least likely (Al-Sharifi et al., 2015). However the real picture is likely to be more complicated. ...
Article
Background: In recent years, the rates of young people presenting with self-harming have increased dramatically, with self-harm being a predictor of suicide. Despite evidence suggesting that self-harm is common in young people and that hospital admissions are increasing, research exploring the reasons behind young people’s motivations is not easily accessed. Systematic reviews have explored this from a range of perspectives, but none have drawn all this literature together. Methods: A systematic review of systematic reviews was conducted in accordance with PRISMA guidelines. Seven databases were searched using a peer reviewed search strategy, with a focus on the factors of child and adolescent self-harming. All English language articles, published between 2008 and 2021, were considered, and screened against inclusion criteria. References of included articles were also searched for eligible articles. Results: Twenty-two systematic reviews were included after screening against eligibility criteria. Narrative synthesis identified eight themes for motivation or reasons for self-harming: identity and subcultures, peer influences, educational stressors, mental ill health, cognitive and neuropsychological factors, trauma and attachment, internet influences and social media. Conclusion: Reasons for self-harming in adolescents are complex and multifactorial. Many studies focus on single causes or associations with self-harm rather than open-mindedly exploring a range of factors or the interactions between them. This leaves gaps in the research where hypothetical reasons for self-harm have not been systematically explored. The themes identified here could help in the clinical assessment process and guide future research in this area, including the development of potential differentiated prevention and treatment approaches.
... A binomial regression model was performed in order to investigate whether the outcomes of self-harm and suicide-related ideation where substances played a contributing role were predicted by the different time points. Demographics characteristics, such as gender, age and ethnicity were also added in the binomial model, as literature suggests that they differentiate the risk of suicidal outcomes (Al-Sharifi et al. 2015;O'Connor and Nock 2014). Odds ratios (OR) and 95% CIs are presented. ...
Article
Introduction: Given the evidence that drinking patterns and self-harm hospital presentations have changed during COVID-19, this study aimed to examine any change in self-harm and suicide-related ideation presentations, together with any possible contribution made by alcohol or substance misuse, to Irish Emergency Departments in 2020, compared with 2018 and 2019. Methods: A population-based cohort with self-harm and suicide-related ideation presenting to Irish hospitals derived from the National Clinical Programme for Self-Harm was analysed. Descriptive analyses were conducted based on sociodemographic variables and types of presentation for the period January to August 2020 and compared with the same period in 2018 and 2019. Binomial regression analyses were performed to investigate the independent effect of demographic characteristics and pre/during COVID-19 periods on the use of substances as contributory factors in the self-harm and suicide-related ideation presentations. Results: 12,075 presentations due to self-harm and suicide-related ideation were recorded for the periods January–August 2018–2020 across nine emergency departments. The COVID-19 year was significantly associated with substances contributing to self-harm and suicide-related ideation ED presentations (OR = 1.183; 95% CI, 1.075–1.301, p < 0.001). No changes in the demographic characteristics were found for those with self-harm or suicide-related ideation across the years. Suicide-related ideation seemed to be increased after May 2020 compared with previous years. In terms of self-harm episodes with comorbid drug and alcohol overdose and poisoning, these were significantly increased in January–August 2020, compared with previous timepoints (χ2 = 42.424, df = 6, p < 0.001). Conclusion: An increase in suicide-related ideation and substance-related self-harm presentations may indicate longer term effects of the pandemic and its relevant restrictions. Future studies might explore whether those presenting with ideation will develop a risk of suicide in post-pandemic periods.
... Other authors have suggested that across the lifespan, ethnic differences in self-harming within the UK are evidenced, suggesting black females are most likely to self-harm and Asian males least likely (Al-Sharifi et al., 2015). However the real picture is likely to be more complicated. ...
Article
Background In recent years the rates of young people presenting with self-harming have increased dramatically, with self-harm being a predictor of suicide. Despite evidence suggesting that self-harm is common in young people and that hospital admissions are increasing, research exploring the reasons behind young people’s motivations is not easily accessed. Systematic reviews have explored this from a range of perspectives, but none have drawn all this literature together. Methods A systematic review of systematic reviews was conducted in accordance with PRISMA guidelines. Seven databases were searched using a peer reviewed search strategy, with a focus on the factors of child and adolescent self-harming. All English language articles, published between 2008 and 2021, were considered, and screened against inclusion criteria. References of included articles were also searched for eligible articles. Results Twenty-two systematic reviews were included after screening against eligibility criteria. Narrative synthesis identified eight themes for motivation or reasons for self-harming: identity and subcultures, peer influences, educational stressors, mental ill health, cognitive and neuropsychological factors, trauma and attachment, internet influences and social media. Conclusion Reasons for self-harming in adolescents are complex and multifactorial. Many studies focus on single causes or associations with self-harm rather than open-mindedly exploring a range of factors or the interactions between them. This leaves gaps in the research where hypothetical reasons for self-harm have not been systematically explored. The themes identified here could help in the clinical assessment process and guide future research in this area including the development of potential differentiated prevention and treatment approaches.
... Migrants may be at a higher risk of suicidal ideation, suicide attempts, self-harm, and death by suicide compared to the general population [18][19][20]. Suicide risk may vary among ethnic minorities, and they may experience different risk factors for suicidal behaviour compared to the native population of a country [21][22][23]. Some evidence indicates that acculturation, a process by which individuals acquire the attitudes, values, customs, beliefs, and behaviours of a different culture, may in fact increase the risk of suicidal behaviour among some migrants [24]. ...
Article
Full-text available
Young people experience high rates of suicidal ideation, self-harm, suicide attempt and death due to suicide. As a result of increasing globalisation, young people are increasingly mobile and can migrate from one country to another seeking educational and employment opportunities. With a growing number of young migrants, it is important to understand the prevalence of suicidal behaviour among this population group. We systematically searched Medline, Embase, and PsycINFO from inception until 31 March 2022. Eligible studies were those providing data on suicidal ideation, self-harm, suicide attempt, and death due to suicide. Seventeen studies were included in the review, some of which provided data on multiple outcomes of interest. Twelve studies provided data on suicidal ideation, five provided data on self-harm, eight provided data on suicide attempt, and one study had data on suicide death among young migrants. The quality of the included studies was varied and limited. The studies included in this review commonly reported that young migrants experience higher rates of self-harm and suicide attempt, but no major differences in suicidal ideation and suicide death compared to non-migrant young people. However, the limited number of studies focused on suicidal behaviour among young migrants highlights the need for further high-quality studies to capture accurate information. This will enable the development of policies and interventions that reduce the risk of suicidal behaviour among young migrants.
... Firstly, there is an apparent lack of research looking at this behaviour in university aged populations (Forrester et al., 2017). In addition, awareness of cultural differences in terms of self-harming remains limited (Sharifi et al., 2015). Furthermore, there is a lack of research exploring the impact of insecure attachments and poor parenting on self-harm (Glazebrook et al., 2016). ...
Article
Full-text available
Self-harm is the intentional destruction of the body tissue with or without a suicidal purpose. Self-harm is the second leading cause of death across the world and it is most prevalent among young people. Although parenting style and parental attachment have shown to have a direct impact on chronic self-harm, surprisingly there is very limited research exploring the complex interplay between these factors and cultural differences. Therefore, this study aimed to explore whether parenting style (using the Parental Authority Questionnaire) and the quality of parent-child attachment (using the Inventory of Parents and Peer Attachments) has an impact on self-harming in young people from the UK (n = 100) and Sri Lanka (n = 100), using a questionnaire-based quantitative design. Results indicated that Sri Lankan students currently self-harm more compared to the British students, although a substantial difference in the parenting style was not found between the two cultures. Irrespective of the cultural background, participants from both countries were more likely to self-harm in the absence of strong, secure attachments with parents. Authoritarian parenting style also had a direct impact on self-harm. Clinical implications highlighted the importance of awareness of the pivotal role of parenting when managing a young person who is self-harming. Furthermore, clinicians would benefit from incorporating culturally relevant treatment methods when working in multicultural settings.
... Considering the lack of Irish evidence on the risk of self-harm for ethnic groups, our results of the lowest risk of selfharm for Asian patients could only be compared with UK ndings, highlighting that Asian people, speci cally males, are least likely to present with self-harm or repeated self-harm compared to other ethnicities [29]. ...
Preprint
Full-text available
Purpose Previous research has examined the suicide risk of the Irish Traveller population, but less is known about the prevalence of suicidal behaviours and thoughts of this ethnic minority group recorded at hospital level. The aim of the current study was to compare the incidence of hospital-presenting self-harm and suicide-related ideation of Travellers to non-Traveller patients and describe any ethnic disparities in the aftercare of their presentation. Methods A population-based study was conducted for the years 2018–2019. Data were obtained from the service improvement dataset of an Irish dedicated national programme for the assessment of those presenting to emergency departments (EDs) due to self-harm and suicide-related ideation. Results 24,473 presentations were recorded with 3% of the presentations made by Irish Travellers. Female Traveller patients had 3·04 (95% CI 2·51 − 3·68) higher risk for suicide-related ideation and 3·85 (95% CI 3·37 − 4·41) for self-harm, compared to White Irish female patients. Male Traveller patients had 4·46 (95% CI 3·86 − 5·16) higher risk for suicide-related ideation and 5·43 (95% CI 4·75 − 6·21) higher rates for self-harm presentations. The highest rate ratios for self-harm were observed among older Traveller patients [male: 9·23 (95% CI 5·93 − 14·39); female: 6·79 (95% CI 4·37 − 10·57)]. A higher proportion of Traveller patients requested no next of kin involvement, compared to other ethnicities. Conclusion Given that Irish Travellers are at higher risk of suicide-related hospital presentations, compared to other ethnic groups in Ireland, EDs should be viewed as an important suicide intervention point.
... Additionally, those who self-harm demonstrate diminished help-seeking (Nearchou et al., 2018). This behaviour is conceptualised as engagement in destructive behaviour with the deliberate intention of hurting one's body (Al-Sharifi et al., 2015). This may be done with or without the intention of suicide and most often relates to the mutilation of one's body through actions such as cutting, scratching, burning, hitting, puncturing, bone-breaking, abnormal or disturbed eating habits, or self-poisoning (Mullins-Sweatt et al., 2013). ...
Article
Full-text available
Mental illness within evangelical Christian communities is frequently stigmatised, with many attributing it exclusively to demonic possession, lack of faith, personal sin, or other negative spiritual influences. This study explores perceptions of self-harm in the context of evangelical Christian faith communities using the novel qualitative story completion task. A convenience sample of 101 UK-based evangelical Christians completed a third-person fictional story stem featuring a devout female Christian who self-harms. A contextualist informed thematic analysis was carried out focusing on perceptions of cause, cure, and treatment. Most stories positioned spiritual causes of mental illness (that is, demonic possession or personal sin) as harmful to the individual by rendering individuals as stigmatised objects or as socially displaced. The stories also provided insight into negative perceptions of females experiencing mental illness within evangelical communities. The stories suggested that these views often led to stigma and shame, which ultimately exacerbated illness and led to reduced help-seeking. Conversely, stories depicting the integration of relational care alongside spiritual resources frequently led to recovery. That the stories represented the need for relational support, within a spiritually syntonic framework, for recovery from mental illness highlights the limitations of a dichotomised approach to pastoral care. Meth-odologically, the study demonstrates the usefulness of a seldom-used tool within the pastoral psychology context-the story completion task-for accessing sociocultural discourses and wider representations surrounding stigmatised topics or populations.
Article
The present study aimed to advance the literature with a qualitative exploration of self-harm amongst UK university students, providing novel insight into support provisions and help-seeking, as well as key triggers and maintenance factors of self-harm within a university context. Sixteen semi-structured interviews (81% female) were carried out with individuals who had engaged in self-harm during their time at university and were analysed using inductive thematic analysis. Three overarching themes were identified: 1) Understanding Self-Harm; 2) A New Identity – The impact of University on Self-Harm; and 3) Professional Help-Seeking at University – “A vague and confusing process”. Participants shared that whilst the function of self-harm as a means of coping remained relatively consistent, academic and social stressors were influential in either maintaining or reducing engagement in self-harm during university. Increased understanding of self-harm amongst university personnel and peers has the potential to encourage disclosure and reduce stigma. These findings have important implications for universities and their support services, specifically in relation to advertisement and awareness of services during university transitions, and the ways in which support is offered and delivered for students who self-harm. Greater recognition of views and definitions of self-harm from the perspective of those with lived experience is needed. This study highlights that the presence of university support services is not enough and that key factors including session numbers, referral pathways, and communication from services are crucial in determining a positive or negative experience of help-seeking amongst university students who self-harm.
Article
Full-text available
Samenvatting Automutilatie of zelfverwonding is het moedwillig direct beschadigen van lichaamsweefsel, zonder bewust uit te zijn op zelfdoding. Beschadiging van het lichaamsweefsel wordt door de cliënt bij zichzelf toegebracht door bijvoorbeeld snijden, branden of door bij zichzelf botbreuken te veroorzaken door van grote hoogtes te springen. Ook kan zelfbeschadiging bestaan uit zelfvergiftiging of zelfwurging. Hoewel vele tips en behandelsuggesties in omloop zijn2), is er over de juiste behandeling van cliënten die zichzelf verwonden, nog weinig bekend1).
Article
Full-text available
Background Engagement in Deliberate Self-Harm (DSH) is commonly measured by behavioural scales comprised of specific methods of self-harm. However, there is a scarcity of information about the degree to which the methods relate to the same DSH construct although such scales are routinely used to provide a DSH total score. This study addresses the shortfall by evaluating the dimensionality of six commonly used behavioural measures of DSH. Methods The DSH measures were Self-Injury Questionnaire Treatment Related (SIQTR), Self-Injurious Thoughts and Behaviors Interview (SITBI), Deliberate Self-Harm Inventory (DSHI), Inventory of Statements About Self-Injury (ISAS), Self-Harm Information Form (SHIF) and Self-Harm Inventory (SHI). The behavioural scales contained in each measure were administered to 568 young Australians aged 18 to 30 years (62% university students, 21% mental health patients, and 17% community members). Scale quality was examined against the stringent standards for unidimensional measurement provided by the Rasch model. Results According to the stringent post-hoc tests provided by the Rasch measurement model, there is support for the unidimensionality of the items contained within each of the scales. All six scales contained items with differential item functioning, four scales contained items with local response dependency, and one item was grossly misfitting (due to a lack of discrimination). Conclusions This study supports the use of behavioural scales to measure a DSH construct, justifies the summing of items to form a total DSH score, informs the hierarchy of DSH methods in each scale, and extends the previous evidence for reliability and external validity (as provided by test developers) to a more complete account of scale quality. Given the overall adequacy of all six scales, clinicians and researchers are recommended to select the scale that best matches their adopted definition of DSH.
Article
Full-text available
Previous studies of ethnic and cultural differences in self-harm have focussed on overdose and suicide attempts by South Asian women. Research comparing ethnic groups has rarely examined religion or nationality. To achieve a more balanced approach this study examined self-harm methods and self-injury across gender, religion and ethnic group in a non-clinical population. Six hundred and seventeen university students completed a questionnaire asking whether they had ever harmed themselves, and the frequency and method of any self-harm. White participants and participants with no religious affiliation were more likely to report repeated incidents of self-harm, mainly scratching and cutting skin. Hindu religion was associated with lower levels of repeated self-harm. Asian males were less likely to report self-harm than both Asian females and other males. Black students were less likely to report cutting and scored highest on Rational coping style. The results raise questions about differential disclosure of self-harm across gender and culture.
Article
Full-text available
Purpose: The purpose of this study is to investigate whether minority ethnic people were less likely to receive treatment for mental health problems than the white population were, controlling for symptom severity. Method: We analysed data from 23,917 participants in the 1993, 2000 and 2007 National Psychiatric Morbidity Surveys. Survey response rates were 79, 69 and 57 %, respectively. The revised Clinical Interview Schedule was used to adjust for symptom severity. Results: Black people were less likely to be taking antidepressants than their white counterparts were (Odds ratio 0.4; 95 % confidence interval 0.2-0.9) after controlling for symptom severity. After controlling for symptom severity and socioeconomic status, people from black (0.7; 0.5-0.97) and South Asian (0.5; 0.3-0.8) ethnic groups were less likely to have contacted a GP about their mental health in the last year. Conclusions: Interventions to reduce these inequalities are needed to ensure that NHS health care is delivered fairly according to need to all ethnic groups.
Article
Full-text available
Self-harm and suicide are major public health problems in adolescents, with rates of self-harm being high in the teenage years and suicide being the second most common cause of death in young people worldwide. Important contributors to self-harm and suicide include genetic vulnerability and psychiatric, psychological, familial, social, and cultural factors. The effects of media and contagion are also important, with the internet having an important contemporary role. Prevention of self-harm and suicide needs both universal measures aimed at young people in general and targeted initiatives focused on high-risk groups. There is little evidence of effectiveness of either psychosocial or pharmacological treatment, with particular controversy surrounding the usefulness of antidepressants. Restriction of access to means for suicide is important. Major challenges include the development of greater understanding of the factors that contribute to self-harm and suicide in young people, especially mechanisms underlying contagion and the effect of new media. The identification of successful prevention initiatives aimed at young people and those at especially high risk, and the establishment of effective treatments for those who self-harm, are paramount needs.
Article
Nonsuicidal self-injury (NSSI) is a growing clinical and public health problem that affects individuals from all age groups, most prominently young adults. NSSI involves numerous methods and functions. NSSI has long been associated with borderline personality disorder (BPD), and in fact, it is only referenced among the diagnostic criteria of BPD in the DSM-IV-TR. However, recent studies have provided strong evidence that NSSI occurs outside of BPD. For these reasons, a diagnosis of nonsuicidal self-injury is included in DSM-5 Section-III as a condition that requires further study. The primary purpose of the present study was to identify whether the proposed DSM-5 NSSI criteria adequately reflect the symptoms of a prototypic individual who engages in self-injury. Clinicians in private practice and expert NSSI researchers (n=119) were asked to describe their familiarity and agreement with the proposed DSM-5 NSSI criteria, as well as the degree to which each proposed criterion is a prototypic symptom. Overall, most participants reported that the proposed DSM-5 criteria for NSSI accurately captured the behavior of the prototypic self-injurer. The results of this study provide incremental support for the proposed DSM-5 NSSI diagnostic criteria.
Article
Background: Little information is available to inform clinical assessments on risk of self-harm repetition in ethnic minority groups. Methods: In a prospective cohort study, using data collected from six hospitals in England for self-harm presentations occurring between 2000 and 2007, we investigated risk factors for repeat self-harm in South Asian and Black people in comparison to Whites. Results: During the study period, 751 South Asian, 468 Black and 15,705 White people presented with self-harm in the study centres. Repeat self-harm occurred in 4379 individuals, which included 229 suicides (with eight of these fatalities being in the ethnic minority groups). The risk ratios for repetition in the South Asian and Black groups compared to the White group were 0.6, 95% CI 0.5-0.7 and 0.7, 95% CI 0.5-0.8, respectively. Risk factors for repetition were similar across all three groups, although excess risk versus Whites was seen in Black people presenting with mental health symptoms, and South Asian people reporting alcohol use and not having a partner. Additional modelling of repeat self-harm count data showed that alcohol misuse was especially strongly linked with multiple repetitions in both BME groups. Limitations: Ethnicity was not recorded in a third of cases which may introduce selection bias. Differences may exist due to cultural diversity within the broad ethnic groups. Conclusion: Known social and psychological features that infer risk were present in South Asian and Black people who repeated self-harm. Clinical assessment in these ethnic groups should ensure recognition and treatment of mental illness and alcohol misuse.
Article
This paper draws on a ten month British study completed in April 2001 investigating service responses to women of South Asian background who had attempted suicide or who self-harmed. The scope of the study is briefly outlined and an analysis of perspectives documented in the study is presented, drawing on research interviews with 18 staff from a variety of health and social care disciplines and with seven survivors of attempted suicide/self-harm. The implications of this analysis for improving practice are considered. Attitudes surrounding attempted suicide and self-harm are discussed. The issue of 'race anxiety' is also discussed. The factors seen by workers as contributing to South Asian women's attempted suicide are considered, with a particular focus on the difficulties caused in the delivery of services by common-sense accounts of cultural issues. Current approaches to the delivery of services to South Asian women are identified and analysed, showing how their current organisation can lead to circularity in referral systems and consequent non-intentional neglect of the needs of this client group. It is urged that proper consideration be given to the support and professional supervision of staff in this complex area of work.
Article
Les automutilations recouvrent plusieurs types de conduites, de la simple excoriation cutanée à l’autocastration. Il est actuellement difficile d’obtenir une définition consensuelle de ce type de troubles. Pour certains auteurs, les blessures auto-infligées sont un symptôme pathognomonique de la personnalité « borderline » ; pour d’autres, il s’agit au contraire d’une entité diagnostique à part entière, amenant ainsi à définir de nouveaux syndromes. Ces comportements d’automutilation sont particulièrement fréquents chez les adolescents, avec une prépondérance féminine et chez les patients présentant une pathologie psychiatrique. La plupart des sujets utilisent plusieurs méthodes pour s’automutiler et privilégient différentes localisations pour les automutilations, celles-ci sont souvent associées à des comorbidités psychiatriques. Cette étude décrit une cohorte de 30 patients hospitalisés s’automutilant et compare les données recueillies (sociodémographiques, antécédents, comorbidités et type d’automutilation) à celles de la littérature. Le groupe se compose majoritairement de filles et l’âge moyen est de 18 ans. Trente pour cent des patients disent avoir subi des maltraitances durant l’enfance, 60 % sont suivis sur le plan psychiatrique et 73 % ont un antécédent de tentative d’autolyse. Tous les patients se sont infligés des blessures à au moins deux reprises et plusieurs moyens sont associés dans la plupart des cas (incision des avant-bras le plus souvent). Les conduites addictives telles que l’abus de substance (tabac 46,7 % ; alcool 23,3 % ; toxique 16,7 %) et les troubles des conduites alimentaires (33,3 %) sont fréquemment associés aux automutilations. Enfin, trois diagnostics sont principalement retrouvés dans notre cohorte (syndrome dépressif 36,7 % ; trouble de personnalité 20 % ; trouble psychotique 10 % ; association d’un syndrome dépressif et d’un trouble de personnalité 33,3 %).