Self-harm and ethnicity: A systematic review

Abstract

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.

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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
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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.
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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
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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
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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)
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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
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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)
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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)
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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)
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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
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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