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Self harm – a culture-bound syndrome? Ghana and UK experience

  • Eric Doe Avevor (a1)
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Abstract
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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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EFERAKEYA, A. E. (1984) Drugs and suicide attempts in Benin City, Nigeria. British Journal of Psychiatry, 145, 7073.
ODEJIDE, A. O., WILLIAMS, A. O., OHAERI, J. U., et al (1986) The epidemiology of deliberate self-harm. The Ibadan experience. British Journal of Psychiatry, 149, 734737.
SCHMIDTKE, A., BILLE-BRAHE, U., DELEO, D., et al (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, 327338.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Self harm – a culture-bound syndrome? Ghana and UK experience

  • Eric Doe Avevor (a1)
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Self-harm: a culture-bound syndrome? Ghana and UK experience. A response.

Emmanuel N. B. Quarshie, Doctoral Research Student, School of Psychology, University of Leeds, Leeds, UK.
09 July 2016

Dr Avevor (1) provides very interesting experiential comparative reflections on the incidence of the phenomenon of self-harm or parasuicide between Ghana and the UK. However, his reflections reveal two key factual inaccuracies about the subject matter with regard to Ghana.

First, the author mentions ‘I am not aware of any publications from Ghana on the subject’ and goes on to cite two extant studies conducted in neighbouring Nigeria to support his argument (2, 3). However, the fact is that there are at least two studies from Ghana (4, 5) on the subject of self-harm published within the same period as those from Nigeria cited by the author. These two studies from Ghana were published in the Ghana Medical Journal – arguably the most authoritative medical (and health science) journal in Ghana. The paradox is that the first study published on self-harm and attempted suicide in Ghana (4) was a retrospective chart review/analysis conducted in the Korle-Bu Teaching Hospital – the largest teaching hospital in Ghana where the author claims he “never saw or head [sic] of a single case of self-harm” throughout his training and work with the hospital as a medical student and a house officer.

Second, according to the author “Ghana does not have a free national health service; a so-called cash and carry system operates whereby patients pay for services”. This is factually inaccurate in that Ghana has replaced the ‘cash and carry system’ with a fully-operational National Health Insurance Scheme (NHIS) since 2003 (6), approximately 4 years prior to the publication of the correspondence by the author. So far, the evidence shows that the NHIS has “a positive effect on health seeking behaviour and utilization of health care services by removing significant financial barriers to access” (7).

Thus, although the experiential correspondence by the author fairly represents the status of the subject matter of self-harm in Ghana, it lacks key reflective contextual facts, as identified in this response.

References

1. Avevor ED. Self harm - a culture-bound syndrome? Ghana and UK experience. The Psychiatrist 2007 (correspondence); 31: 357.

2. Eferakeya AE. Drugs and suicide attempts in Benin City, Nigeria. Br J Psychiatry 1984; 145: 70-3.

3. Odejide AO, Williams AO, Ohaeri JU, Ikuesan BA. The epidemiology of deliberate self-harm. The Ibadan experience. Br J Psychiatry 1986; 149: 734-7.

4. Adomakoh CC. A preliminary report on attempted suicides seen in a general hospital in Ghana. Ghana Med J 1975; 14: 323-236.

5. Roberts MA, Nkum, BC. Deliberate self-harm in Ghana. Ghana Med J 1989; 23: 81-7.

6. Blanchet NJ, Fink G, Osei-Akoto I. The effect of Ghana’s National Health Insurance Scheme on health care utilisation. Ghana Med J 2012; 46: 76-84.

7. Gobah FF, Liang Z. The National Health Insurance Scheme in Ghana: prospects and challenges: a cross-sectional evidence. Global Journal of Health Science 2011; 3: 90.

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Conflict of interest: None Declared

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Self harm : Can socio-economic structure explain the difference?

Ankush Singhal, Psychiatrist
25 September 2007

I read with interest, Dr Avevor’s views on self harm and the possibility of this being a culture bound syndrome (Avevor, 2007). I agreewith him partially.

I qualified in India and did my post-graduation in psychiatry there. I have 3 years of experience of working in psychiatry in both countries. I had a very similar experience as Dr Avevor, that there was hardly any mention of deliberate self harm in the medical curriculum of psychiatry in India. I don’t remember having seen such cases even while doing psychiatry on-calls in India. Here in UK, there appears to be hardlya day when an A & E does not see such cases. ABC of psychiatry in UK, appears to revolve around assessment and management of such cases. Though,not all such cases are due to mental disorder, I think a very significant proportion of mental health resources is consumed by this particular patient group. No doubt, they have added to the current scenario of psychiatry driven by risk management.

Free NHS and social services, different kinds of allowances and benefits and too much emphasis on risk resulting in ‘defensive medicine’, have surely not helped in reduction of such cases. I sincerely believe that even excellent social services can not be an alternative for family support.

I think in India (and probably in other south-east Asian developing countries), stronger family ties (so, lesser need of ‘cry for help’) and lack of good psychiatry, community and social services are probably responsible to some extent, for relative scarcity of such cases. On the other hand, I also believe that many such cases go undiagnosed or under-reported.

Culture bound syndrome is a relatively vague concept and mental health presentation is highly influenced by pathoplastic effect of culture, so its very difficult to put a particular symptom group into thiscategory unless it is relatively unique to that culture. I think deliberate self harm partially meets the criteria, just as anorexia nervosa does.

Reference : Eric Doe Avevor. Self harm - a culture-bound syndrome? Ghana and UK experience. Psychiatr Bull 2007; 31: 357-a
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