Skip to main content Accessibility help
×
Home
Hostname: page-component-568f69f84b-lkk24 Total loading time: 0.597 Render date: 2021-09-19T02:48:39.322Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "metricsAbstractViews": false, "figures": true, "newCiteModal": false, "newCitedByModal": true, "newEcommerce": true, "newUsageEvents": true }

Ethnic differences in self-harm, rates, characteristics and service provision: three-city cohort study

Published online by Cambridge University Press:  02 January 2018

Jayne Cooper*
Affiliation:
Centre for Suicide Prevention, University of Manchester, Community Based Medicine, Manchester
Elizabeth Murphy
Affiliation:
Centre for Suicide Prevention, University of Manchester, Community Based Medicine, Manchester
Roger Webb
Affiliation:
Centre for Suicide Prevention, University of Manchester, Community Based Medicine, Manchester
Keith Hawton
Affiliation:
Centre for Suicide Research, University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford
Helen Bergen
Affiliation:
Centre for Suicide Research, University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford
Keith Waters
Affiliation:
Derbyshire Mental Health Services NHS Trust Mental Health Liaison Team, Rehabilitation Centre, Royal Derby Hospital, Derby
Navneet Kapur
Affiliation:
Centre for Suicide Prevention, University of Manchester, Community Based Medicine, Manchester
*Corresponding
Jayne Cooper, Centre for Suicide Prevention, University of Manchester, Community Based Medicine, Jean McFarlane Building, Oxford Road, Manchester M13 9PL, UK. Email: jayne.cooper@manchester.ac.uk
Rights & Permissions[Opens in a new window]

Extract

Background

Studies of self-harm in Black and minority ethnic (BME) groups have been restricted to single geographical areas, with few studies of Black people.

Aims

To calculate age- and gender-specific rates of self-harm by ethnic group in three cities and compare characteristics and outcomes.

Method

A population-based self-harm cohort presenting to five emergency departments in three English cities during 2001 to 2006.

Results

A total of 20 574 individuals (16–64 years) presented with self-harm; ethnicity data were available for 75%. Rates of self-harm were highest in young Black females (16–34 years) in all three cities. Risk of self-harm in young South Asian people varied between cities. Black and minority ethnic groups were less likely to receive a psychiatric assessment and to re-present with self-harm.

Conclusions

Despite the increased risk of self-harm in young Black females fewer receive psychiatric care. Our findings have implications for assessment and appropriate management for some BME groups following self-harm.

Type
Paper
Copyright
Copyright © Royal College of Psychiatrists, 2010 

Variation in rates of suicide in Black and minority ethnic (BME) groups have been reported in different countries. Reference McKenzie, Serfaty and Crawford1,Reference Garlow, Purselle and Heninger2 Rates of suicide Reference McKenzie, Bhui, Nanchahal and Blizard3,Reference Bhui and McKenzie4 and self-harm Reference Soni Raleigh5Reference Neeleman, Jones, van Os and Murray7 may be lower in BME groups than White groups overall, but this finding may obscure differences in age- and gender-specific groups. Also, rates of suicide and self-harm within ethnic minority groups may fluctuate according to area, with a decline in relative risk of suicide and self-harm where there is a larger density of minority populations. Reference Neeleman and Wessley8,Reference Neeleman, Wilson-Jones and Wessely9 Previous research on BME groups in the UK has generally been conducted in single geographical areas, Reference Claassen, Ascoli, Berhe and Priebe10 and self-harm studies have been limited by small sample size, with few studies of people of African–Caribbean origin. Reference Bhui, McKenzie and Rasul11 A report on suicide prevention for BME groups in England calls for better information on rates and risk factors for suicide or behaviours that increase the likelihood of suicide. Reference Bhui and McKenzie12 We have conducted a study of self-harm in different minority ethnic groups using a multicentre database of self-harm in three geographical areas in England. Our objectives were to compare ethnic groups (that is, White, South Asian and Black African–Caribbean) with regard to: age- and gender-specific rates of self-harm in different cities; sociodemographic and clinical characteristics; clinical management following self-harm; and risk of repetition of self-harm.

Method

Study design and data collection

We conducted a prospective, multicentre cohort study, identifying all episodes of self-harm presenting to emergency departments in general hospitals in Manchester (three hospitals), Derby (two hospitals) and Oxford (one hospital). The study hospitals were chosen on a pragmatic basis – the centres included were those that had established monitoring systems. The cities of Manchester, Derby and Oxford have different profiles (Table 1), with ethnic groups forming a greater proportion of the general population in Manchester. According to the UK government's Index of Multiple Deprivation, where 353 local authority areas in England were scored on a number of indicators (covering a range of economic, social and health issues) into a single deprivation score, 13 Manchester was ranked fourth (worst), Derby sixty-ninth and Oxford one hundred and fifty-fifth.

Table 1 Sociodemographic profile of the three cities: 2001 Census data 18

Characteristic England Manchester Derby Oxford
% of population
    Unemployed, 16–74 years 2 4 3 2
    Lone parents, 16–29 years 5 8 6 3
    No qualifications known, 16–74 years 26 28 28 18
    ‘Non-White’ – all ages 9 19 12 13
    Black – all ages 2 5 2 3
    South Asian – all ages 4 8 8 4
% of all South Asian people
    Indian 51 18 49 40
    Pakistani 35 71 50 45
    Bangladesh 14 11 1 15

Data were collected using established monitoring systems in the three centres, described in full elsewhere. Reference Hawton, Bergen, Casey, Simkin, Palmer and Cooper14,Reference Waters and Stalker15 Self-harm attendances were identified via detailed examination of computerised emergency department records and defined consistently across all three centres as intentional self-poisoning or self-injury, irrespective of motivation and degree of suicidal intent. Reference Hawton and Catalan16 Most participants received a psychosocial assessment from emergency department staff and/or mental health specialists. For assessed participants, clinicians recorded a wide range of sociodemographic and clinical information using research assessment forms. For participants who were not assessed (for example, because they refused or took early discharge), basic information was collected by research clerks from medical records. In Manchester, data were collected for non-assessed individuals from computerised patient record systems from September 2002 onwards. Information on ethnicity was obtained where available and recorded either by the assessing clinician or from the hospital patient records system, using standard UK national 2001 census categories. We combined ethnic groups on a pragmatic basis. Our categories were in line with previous research, Reference Bhugra, Desai and Baldwin17 namely: ‘South Asian’, including all people of Pakistani, Indian, or Bangladeshi origin; ‘Black’, including Black African–Caribbean or Black Other; ‘White’, including White British, Irish or White Other. We chose not to include those of ‘other ethnicity’ because of relatively low numbers and diverse composition of this miscellaneous category. An upper age limit of 64 years was also applied because of low numbers of older people who self-harmed from ethnic minority groups.

Data were analysed for a 6-year study period for Derby and Oxford (1 January 2001 to 31 December 2006). For Manchester, complete data for both assessed and non-assessed individuals were available from the 1 September 2002 and so data were analysed for just over 4 years (ending 31 December 2006).

Statistical analyses

The analyses were carried out using Stata version 10 for Windows. They were based on each individual's first presentation for self-harm during the study period. Two sets of analyses were performed.

First, self-harm rates per 1000 person-years were calculated for individuals aged between 16 and 64 years (this age range ensured consistency with the age bands in the 2001 Census data) 18 and with a postcode within the city catchment area of each of the hospitals in Manchester, Derby and Oxford. Approximate person-years at risk were generated by multiplying the ethnic group, gender and age-specific population estimates for each catchment area by the applicable study period for that centre. Incidence rate ratios (and their 95% confidence intervals) for ethnic groups compared with White groups, city, age and gender were calculated from Poisson regression models, with no significant evidence of overdispersion.

Second, differences between South Asian and Black people compared with White people were explored with respect to characteristics and clinical outcomes following the first episode of self-harm in the study period (index episode) for all individuals aged between 16 and 64 years who attended any of the study hospitals with self-harm, regardless of area of their residence. Statistical significance was assessed using chi-squared tests for method of self-harm, sociodemographic characteristics, precipitating factors and clinical characteristics. Analyses were performed separately for males and females. Analysis of clinical management outcomes (as percentages) following self-harm was conducted using log-binomial regression to estimate risk ratios, with variance estimates corrected for hospital clustering effects. Finally, 12-month rates of repetition of self-harm were calculated based on the proportion of individuals re-presenting within 12 months of index episode (excluding individuals without a full 12-month follow-up period). Log-binomial regression was used to examine differences in the risk of repetition.

Ethical approval

Oxford and Derby both have approval from local health/psychiatric research ethics committees to collect data on self-harm for local monitoring and multicentre projects. Self-harm monitoring in Manchester is part of a clinical audit system, and has been ratified by the local research ethics committee. All monitoring systems are fully compliant with the provisions of the Data Protection Act of 1998. All centres also have approval under Section 251 of the NHS Act 2006 (formerly section 60 of the Health and Social Care Act 2001) regarding the use of patient-identifiable information.

Results

During the study period there was a total of 33 314 episodes of self-harm by 20 574 individuals aged 16 to 64 years. Ethnicity data were available for 15 350 individuals (level of completeness overall 75%: Manchester 79%, Oxford 73% and Derby 69%). Data were analysed for 14 997 individuals, excluding the 353 individuals of ‘other ethnicity’ from the analysis.

Rates of self-harm

Analysis of rates of self-harm was conducted for individuals of White, Black or South Asian ethnicity (n = 8401) resident within defined city population areas of each of the centres' catchment areas (Table 2). Rates of self-harm in young Black females were highest in all three cities. The pooled rate ratio for Black females aged 16–34 years compared with White females of the same age group was 1.70 (95% CI 1.46–1.98). When we conducted a conservative sensitivity analysis, ascribing all missing ethnicity data as relating to White persons, the rate ratio (RR) was attenuated but remained significantly elevated (RR = 1.21, 95% CI 1.04–1.40). Combining data across the cities, there was no difference in risk of self-harm in South Asian females aged 16–34 years compared with White females of the same age (RR = 0.99, 95% CI 0.87–1.11).

Table 2 Numbers, person-years denominators and self-harm rates per 1000 × city, gender, age and ethnic groupa

White South Asian Black
Self-harm (n = 7564) Person years Rate/1000 Self-harm (n = 499) Person-years Rate/1000 Self-harm (n = 338) Person-years Rate/1000
Manchester
Males
    16–34 years 955 224 263 4.3 64 28 409 2.3 52 11 938 4.4
    35–64 years 778 227 972 3.4 19 16 553 1.1 21 12 216 1.7
Females
    16–34 years 1526 231 361 6.6 193 28 929 6.7 134 13 030 10.3
    35–64 years 939 229 445 4.1 31 16 493 1.9 35 13 312 2.6
Derby
Males
    16–34 years 504 148 362 3.4 35 18 828 1.9 12 3 102 3.9
    35–64 years 374 215 448 1.7 9 14 514 0.6 9 5 148 1.7
Females
    16–34 years 674 151 464 4.4 58 19 356 3.0 21 3 054 6.9
    35–64 years 450 216 690 2.1 13 14 574 0.9 8 5 184 1.5
Oxford
Males
    16–34 years 317 139 074 2.3 24 7 584 3.2 13 3 534 3.7
    35–64 years 236 111 294 2.1 3 4 284 0.7 3 3 690 0.8
Females
    16–34 years 544 136 530 4.0 41 7 776 5.3 25 3 948 6.3
    35–64 years 267 110 496 2.4 9 4 536 2.0 5 3 624 1.4

We tested for differences in age/gender-specific rates between cities using a Wald chi-squared test for heterogeneity. Compared with White people, the rate ratios in South Asian and in Black people varied significantly by centre in young people aged 16–34 years (in males: χ2 = 17.9, P = 0.001; females: χ2 = 11.10, P = 0.03), that is, ethnicity did not have the same risk or protective effects in all cities. However, there was no evidence of heterogeneity in older people aged 35–64 years of either gender (males: χ2 = 3.6, P = 0.46; females: χ2 = 2.9, P = 0.57).

In comparison with White groups, there were significantly higher rate ratios for young Black females in all three cities (Table 3). In contrast, rate ratios in young Black males did not differ materially from those of young White males. There were lower rate ratios in older Black people of both genders compared with White people (Table 3), a difference that reached significance in Manchester. There was variation in relative risk in South Asian groups relative to White people, with significantly lower rate ratios in young people of both genders in Derby, a lower relative risk in males in Manchester, but no difference in either gender in Oxford. For older South Asian people relative rates were lower than in White people in both genders in all three cities, the differences being significant in Manchester and Derby.

Table 3 Age-specific rate ratios (RRs) for minority ethnic groups v. White people: by city

South Asian Black
RRa (95% CI) RRa (95% CI)
Manchester
Males
    16–34 years 0.53 (0.41–0.68) 1.02 (0.77–1.35)
    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)
    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)
    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)
    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)
    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)
    35–64 years 0.82 (0.42–1.60) 0.57 (0.24–1.38)

Characteristics

Analyses of sociodemographics, precipitating factors and clinical characteristics were conducted for individuals of White, Black or South Asian ethnicity×gender regardless of area of residence (online Tables DS1 and DS2). In both genders, ethnic minority groups (Black and South Asian) were younger than the White groups, and less likely to have clinical characteristics known to increase risk of further suicidal behaviour compared with their White peers (that is, alcohol use within 6 h of the self-harm episode, previous self-harm, history of psychiatric treatment).

Females

There were some differences between ethnic groups in females. White females were more likely to present with self-injury (mostly cutting) as a method of harm, compared with South Asian and Black females, who were more likely to self-poison using non-ingestible substances (mostly cleaning fluids). South Asian females were more likely to be married and live with their partner/husband or relatives and Black females were more likely to be single than White females. Differences in employment status were observed with South Asian females more likely to be classified under household duties; Black females were more likely to be unemployed; and females in both ethnic minority groups were more likely to be students compared with White females. Although problems in relationships with partner was the most common precipitant in all groups, South Asian females were significantly more likely to cite relationship problems with their partner/husband and family than White females. South Asian females and Black females were significantly less likely to report a number of other precipitating problems than White females, apart from housing problems, which were more common in Black females.

Males

Significant differences in method of harm were observed between Black and White males. They were more likely to self-injure other than by cutting (using more violent methods of harm such as hanging and self-asphyxiation) and self-poison using non-ingestible substances. South Asian males were more likely to live with a partner or relative and cite relationship problems with their family than White males. Ethnic minority males were more likely to be students than White males.

Clinical management and outcome

Analyses of clinical management following self-harm showed that young Black females were less likely to receive a specialist psychiatric assessment compared with White females (Table 4). Ethnic minority groups of both genders were less likely to present to the emergency departments within the study hospitals with further self-harm (Tables 4 and 5). We fitted extra models adjusting for age in both genders but estimates were materially unaltered.

Table 4 Clinical management and repetition following self-harm: Black and South Asian v. White females aged 16–64 yearsa

White (n = 7938) South Asian (n = 459) Black (n = 288)
Clinical management outcome n % n % RR 95% CI n % RR 95% CI
Assessmentb
    Specialist psychiatric assessment 5756 73 289 63 0.9 0.7–1.03 186 65 0.9 0.8–0.98
Clinical managementb,c
    Psychiatric referral 2651 33 81 18 0.5 0.5–0.6 60 21 0.6 0.5–0.8
    Alcohol or drug services referral/told to see 344 4 2 0.4 0.1 0.1–0.2 10 3 0.8 0.3–2.1
    Other services referral/told to see 1893 24 97 21 0.9 0.6–1.3 59 20 0.9 0.6–1.2
    General practitioner referral 4710 59 262 57 1.0 0.8–1.1 154 53 0.9 0.9–0.98
    No formal follow-up 1555 20 142 31 1.6 0.98–2.5 97 34 1.7 1.00–2.9
Self-harm repetitiond 1646 24 49 13 0.5 0.4–0.7 31 13 0.6 0.4–0.8

Table 5 Clinical management and repetition following self-harm: Black and South Asian v. White males aged 16–64 yearsa

White (n = 5949) South Asian (n = 218) Black (n = 145)
Clinical management outcome n % n % RR 95% CI n % RR 95% CI
Assessmentb
    Specialist psychiatric assessment 4292 72 147 67 0.9 0.8–1.1 99 68 0.9 0.9–1.01
Clinical managementb,c
    Psychiatric referral 1862 31 58 27 0.9 0.7–1.1 42 29 0.9 0.7–1.3
    Alcohol or drug services referral/told to see 530 9 13 6 0.7 0.3–1.5 8 6 0.6 0.2–1.7
    Other services referral/told to see 1324 22 38 17 0.8 0.5–1.2 33 23 1.0 0.6–1.7
    General practitioner referral 3301 55 119 55 1.0 0.8–1.2 68 47 0.8 0.8–0.9
    No formal follow-up 1232 21 61 28 1.4 1.02–1.8 39 27 1.3 0.9–1.8
Self-harm repetitiond 1223 23 29 16 0.7 0.5–0.97 19 15 0.7 0.4–0.99

Females

Females in both ethnic minority groups were considerably less likely to be referred for psychiatric out-patient or in-patient care following self-harm compared with White females. Black females were also less likely to be referred to their general practitioner (GP) or receive formal follow-up arrangements.

Males

Compared with White men, following self-harm, Black males were less likely to be referred to their GP and South Asian males were less likely to be referred to any other service.

Discussion

Main findings

Our main result was that across all three cities young Black females were at increased risk of self-harm. We also found differences in clinical management, with BME groups being less likely to receive a specialist psychiatric assessment and psychiatric follow-up services than the White population. In addition both minority ethnic groups in the older age range had a lower risk in all cities, and there was a variation in rates between cities among young South Asian males and females.

To our knowledge this is the first study to show significantly higher rates of self-harm in young Black females across a number of cities using large population based databases. A previous study in the UK over 20 years ago did suggest that there may be an elevated risk of self-harm in this group, Reference Merrill and Owens19 although these findings were limited by small sample size and data confined to one hospital. A more contemporary study among people with recent previous contact with psychiatric services showed a higher standardised mortality ratio for suicide in Black African and Caribbean females aged 25–39 compared with their White peers. Reference Bhui and McKenzie4 Our finding of lower rates of self-harm in older males and females in both ethnic minority groups are consistent with previous studies. Reference Cooper, Husain, Webb, Waheed, Kapur and Guthrie6,Reference Bhui, McKenzie and Rasul11 We did not find the high rates of self-harm previously reported in young South Asian females Reference Bhui, McKenzie and Rasul11 across the centres in our study.

Interpretation of findings

Several of our findings require further explanation. High rates in some BME groups may be explained by characteristics that confer greater vulnerability. Poor outcome may be influenced by complex socioeconomic factors Reference Stronks and Kunst20 or may be culturally specific with differences between age and gender groups. We lacked the necessary explanatory variables to test these hypotheses. However, young Black females who self-harm may be experiencing greater social adversity, as in our cohort they were more likely to be unemployed and report housing problems compared with White women. We found that people from ethnic minority groups were more likely to be students than their White counterparts. Academic pressure may also have contributed to increased rates of self-harm, especially in women. Reference Garlow, Rosenberg, Moore, Haas, Koestner and Hendin21,Reference Verger, Combes, Kovess-Masfety, Choquet, Guagliardo and Rouillon22 Previous studies examining high rates of psychosis in BME groups, particularly in young Black–Caribbeans, suggest that socioeconomic factors contribute part of the explanation. Reference Karlsen and Nazroo23,Reference Kirkbride, Barker, Cowden, Stamps, Yang and Jones24

The lower rates of self-harm in young Black males across centres deserves further investigation. Previous studies have found increased risk of mental illness and higher rates of completed suicide in this group compared with the White reference group. Reference Bhui and McKenzie4,Reference Sharpley, Hutchinson, Murray and McKenzie25 Contemporary mainstream hip-hop epitomises ‘Black’ youth culture and places emphasis on strength, aggression and virility. However, stereotypical ‘manly’ behaviour may mean that young Black males do not seek help for emotional problems. A recent community study of suicidal behaviour in the UK provides some support for this interpretation of our results. Reference Crawford, Nur, McKenzie and Tyrer26 These researchers found limited evidence of higher levels of suicidal ideation in second-generation immigrants and that ethnic minority groups were half as likely to seek medical attention following self-harm compared with White groups.

In our cohort older ethnic minority people of both genders had lower rates of self-harm than their White counterparts in all three cities (although only significantly so in Manchester and Derby). One explanation is that they have lower rates per se. Another is that older BME groups may be more reluctant to present to statutory services. In an American study, African Americans were less likely to access specialist mental health services compared with non-Hispanic White people. Reference Garland, Lau, Yeh, McCabe, Hough and Lansverk27 Suggested reasons for a resistance to presentation to hospital following self-harm have included that seeking help for mental distress is considered stigmatising and socially unacceptable, and that services were not accessible or considered relevant. Reference Crawford, Nur, McKenzie and Tyrer26,Reference Ahmed, Mohan and Bhugra28

Clinical management is guided by knowledge of risk factors from epidemiological studies in the context of an individual patient presentation. An explanation of the less frequent specialist psychiatric assessment received by BME groups could relate to their ‘low risk’ clinical characteristics; for example, they were less likely to live alone, use alcohol with the self-harm attempt and have a previous psychiatric history or history of self-harm. Some BME groups were slightly less likely to be subsequently referred for formal follow-up. In addition to having apparent low-risk social and clinical characteristics, a further explanation for low-risk management might be related to how individuals from different ethnic groups communicate distress. In a recent UK study on response to childbirth, Black females had lower depression scores than White women, despite experiencing greater social adversity. Reference Edge and Rogers29 The ‘discourse of strength’ (a perceived ability to deal effectively with a range of problems) attributed to young Black females may be part of their sense of identity, and admitting to depression therefore a sign of weakness. Reference Edge30 They may still actually experience psychological distress and resort to self-harming behaviour at a time of crisis, but this attitude of being strong may mean that these young females do not subsequently communicate risk to clinical staff.

The rate ratio for repetition of self-harm was significantly lower in all ethnic minority groups compared with White groups. This may be a result of reduced risk as they were much less likely to have those characteristics known to increase risk of suicidal behaviour. Reference Kapur, Cooper, King-Hele, Webb, Lawlor and Rodway31 However, it may also be explained in terms of disillusionment with statutory services. Black and minority ethnic groups are generally perceived to have poor experiences of mental health services. 32 It is possible that on initial presentation some ethnic minority groups may not have received appropriate help, which may have affected their willingness to re-present. Reference Raleigh, Irons, Hawe, Scobie, Cook and Reeves33,Reference Taylor, Hawton, Fortune and Kapur34

Previous studies have found an increased risk of self-harm in young South Asian females compared with White women. Reference Bhui, McKenzie and Rasul11 We did not find this. There are a number of possible interpretations for the difference in results in young South Asian groups compared with previous findings and between centres. First, previous studies were carried out in Birmingham and London Reference Bhugra, Desai and Baldwin17,Reference Merrill and Owens35 and not all South Asian populations are the same. For example within our three centres the proportions of the population that were of Indian, Pakistani and Bangladeshi origin varied considerably (Table 1). Our results might therefore reflect the particular mix of South Asian populations in the three centres. Second, comparative studies took place over 10–25 years ago and the young British South Asian population is likely to have changed over time. Reference Platt, Simpson and Akinwale36 Third, since these findings, considerable attention has been drawn to this problem, with consequent improvement of services. 37,38

The higher rate ratios observed in young South Asian people compared with young White people in Oxford in relation to the other cities might be a result of differences in the relative socioeconomic profiles between ethnic groups in different cities. Differences in the relative density of ethnic groups between cities may also explain this variation in rates. Oxford has the lowest proportion of South Asian people within its population compared with the other cities, although it had higher rates of self-harm in South Asian young males and females compared with their White counterparts. This could reflect the cultural incongruence and ecological-effect modification suggested in previous research – a negative correlation between the incidence of psychological distress and the size of an ethnic group relative to the total population. Reference Neeleman and Wessley8,Reference Bhugra and Arya39 Unfortunately, we had no measure of these contextual variables to enable examination of their potential effects.

Strengths and limitations

The strength of this study is that we used large, contemporary population-based databases from three separate centres and examined the three main ethnic groups living in the UK. The data were collected principally from urban populations and this might limit the generalisability of the findings, although the populations covered by the three centres had different socioeconomic characteristics. Reference Hawton, Bergen, Casey, Simkin, Palmer and Cooper14 The ethnic minority categories we applied were broad and did not take account of cultural identity. Reference Bhui40 However, it enabled estimation of precise rates and relative risks stratified by age and gender and allowed direct comparison with previous research on ethnic groups in the UK. This may have concealed differences between ethnic groups within the categories we used. All three centres may have overassigned people to ethnic minority groups compared with Office for National Statistics ascertainment procedures. Ethnicity was recorded by healthcare staff who may or may not have asked the individual to categorise themselves. Ethnicity was recorded for 75% of individuals. Ethnicity is not recorded comprehensively in hospital settings, although our capture rate was significantly higher than a recent survey of users of community mental health services in England. Reference Raleigh, Irons, Hawe, Scobie, Cook and Reeves33 Even so, there is the potential for selection bias. However, when we conducted a conservative sensitivity analysis on rates of self-harm on White versus Black females aged 16 to 34 years ascribing all missing data to the White groups the conclusion was essentially unchanged.

Implications for services and further research

Those designing services for people who self-harm need to be aware of the different levels of risk of self-harm and the variations in risk characteristics in different ethnic groups. Services also should be able to respond to the varied needs within these groups. It may be that a failure of professionals to recognise cultural factors at play, and an ignorance of available services, contribute to the lack of recognition of mental health problems and subsequent failure to offer (and for ethnic minority patients to engage in) further services. The challenge is to make services more culturally sensitive. There is some evidence for effectiveness of cultural competency training in demonstrating a change in skills and attitudes of clinicians. Reference Bhui, Warfa, Edonya, McKenzie and Bhugra41 Future culturally sensitive studies might help us achieve a greater understanding of the suicidal process in ethnic minority groups.

Funding

We acknowledge financial support from the Department of Health under the NHS R&D Programme.

Acknowledgements

The authors would like to thank the staff at each centre for data collection and clinical staff for completion of assessment forms.

Footnotes

Declaration of interest

N.K. is Chair of the NICE Guidelines Development Group for the new self-harm guidelines.

References

1 McKenzie, K, Serfaty, M, Crawford, M. Suicide in ethnic minority groups. Br J Psychiatry 2003; 183: 100–1.CrossRefGoogle ScholarPubMed
2 Garlow, S, Purselle, D, Heninger, M. Ethnic differences in patterns of suicide across the life cycle. Am J Psychiatry 2005; 162: 319–23.CrossRefGoogle ScholarPubMed
3 McKenzie, K, Bhui, K, Nanchahal, K, Blizard, B. Suicide rates in people of South Asian origin in England and Wales: 1993–2003. Br J Psychiatry 2008; 193: 406–9.CrossRefGoogle ScholarPubMed
4 Bhui, K, McKenzie, K. Rates and risk factors by ethnic group for suicides within a year of contact with mental health services in England and Wales. Psychiatr Serv 2008; 59: 414–20.CrossRefGoogle ScholarPubMed
5 Soni Raleigh, V. Suicide patterns and trends in people of Indian Subcontinent and Caribbean origin in England and Wales. Ethn Health 1996; 1: 5563.CrossRefGoogle Scholar
6 Cooper, J, Husain, N, Webb, R, Waheed, W, Kapur, N, Guthrie, E, et al. Self-harm in the UK: differences between South Asians and Whites in rates, characteristics, provision of service and repetition. Soc Psychiatry Psychiatr Epidemiol 2006; 41: 782–8CrossRefGoogle ScholarPubMed
7 Neeleman, J, Jones, P, van Os, J, Murray, RM. Parasuicide in Camberwell: ethnic differences. Soc Psychiatry Psychiatr Epidemiol 1996; 31: 284–7.CrossRefGoogle ScholarPubMed
8 Neeleman, J, Wessley, S. Ethnic minority suicide: a small area geographical study in south London. Psychol Med 1999; 29: 429–36.CrossRefGoogle ScholarPubMed
9 Neeleman, J, Wilson-Jones, C, Wessely, S. Ethnic density and deliberate self harm; a small area study in south east London. J Epidemiol Community Health 2001; 55: 8590 CrossRefGoogle ScholarPubMed
10 Claassen, D, Ascoli, M, Berhe, T, Priebe, S. Research on mental disorders and their care in immigrant populations: a review of publications from Germany, Italy and the UK. Euro Psychiatry 2005; 20: 540–9.CrossRefGoogle ScholarPubMed
11 Bhui, K, McKenzie, K, Rasul, F. Rates, risk factors & methods of self harm among minority ethnic groups in the UK: a systematic review. BMC Public Health 2007; 7: 336.CrossRefGoogle ScholarPubMed
12 Bhui, K, McKenzie, K. Final Report: Suicide Prevention for BME Groups in England. Report from the BME Suicide Prevention Project. Centre for Health Improvement and Minority Ethnic Services (CHIMES), 2006.Google Scholar
13 Department for Communities and Local Government. Index of Multiple Deprivation. Department for Communities and Local Government, 2007 (http://www.communities.gov.uk/communities/neighbourhoodrenewal/deprivation/deprivation07).Google Scholar
14 Hawton, K, Bergen, H, Casey, D, Simkin, S, Palmer, B, Cooper, J, et al. Self-harm in England: a tale of three cities. Multicentre study of self-harm. Soc Psychiatry Psychiatr Epidemiol 2007; 42: 513–21.CrossRefGoogle ScholarPubMed
15 Waters, K, Stalker, C. MHLT (Derby) 2007 Annual Report of Both Reported Self Harm and Mental Health Presentation, Presenting to the Derby Acute Hospitals. Derbyshire Mental Health Services Trust, 2008.Google Scholar
16 Hawton, K, Catalan, J. Attempted Suicide: A Practical Guide to its Nature and Management. Oxford University Press, 1987.Google Scholar
17 Bhugra, D, Desai, M, Baldwin, DS. Attempted suicide in west London, I. Rates across ethnic communities. Psychol Med 1999; 29, 1125–30.CrossRefGoogle ScholarPubMed
18 National Statistics. United Kingdom National Census, 2001. Office for National Statistics, 2001 (http://www.statistics.gov.uk/census2001/default.asp).Google Scholar
19 Merrill, J, Owens, J. Ethnic differences in self poisoning. A comparison of West Indian and White groups. Br J Psychiatry 1987; 150: 765–8.CrossRefGoogle ScholarPubMed
20 Stronks, K, Kunst, AE. The complex interrelationship between ethnic and socio-economic inequalities in health. J Public Health; 31: 324–5.Google Scholar
21 Garlow, S, Rosenberg, , Moore, JD, Haas, A, Koestner, B, Hendin, H, et al. Depression, desperation, and suicidal ideation in college students: results from the American Foundation for Suicide Prevention College Screening Project at Emory University. Depress Anxiety 2007; 25: 482–8.Google Scholar
22 Verger, P, Combes, JB, Kovess-Masfety, V, Choquet, M, Guagliardo, V, Rouillon, F, et al. Psychological distress in first year university students: socioeconomic and academic stressors, mastery and social support in young males and females. Soc Psychiatry Psychiatr Epidemiol 2009; 44: 643–50.CrossRefGoogle Scholar
23 Karlsen, S, Nazroo, J. The relationship between racism, social class and physical and mental health among different ethnic groups in England. Ethn Health 2004; 9: S467.Google Scholar
24 Kirkbride, JB, Barker, D, Cowden, F, Stamps, R, Yang, M, Jones, PB, et al. Psychoses, ethnicity and socio-economic status. Br J Psychiatry 2008; 193: 1824.CrossRefGoogle ScholarPubMed
25 Sharpley, MS, Hutchinson, G, Murray, RM, McKenzie, K. Understanding the excess of psychosis among the African–Caribbean population in England: review of current hypotheses. Br J Psychiatry 2001; 178: s608.CrossRefGoogle Scholar
26 Crawford, M, Nur, U, McKenzie, K, Tyrer, P. Suicidal ideation and suicide attempts among ethnic minority groups in England: results of a national household survey. Psychol Med 2005; 35: 1369–77.CrossRefGoogle ScholarPubMed
27 Garland, A, Lau, A, Yeh, M, McCabe, K, Hough, R, Lansverk, J. Racial and ethnic differences in utilization of mental health services among high-risk youths. Am J Psychiatry 2005; 162: 1336–43.CrossRefGoogle ScholarPubMed
28 Ahmed, K, Mohan, R, Bhugra, D. Self-harm in South Asian women: a literature review informed approach to assessment and formulation. Am J Psychother 2007; 61; 7181.Google ScholarPubMed
29 Edge, D, Rogers, A. Dealing with it: Black Caribbean women's response to adversity and psychological distress associated with pregnancy, childbirth, and early motherhood. Soc Sci Med 2005; 61: 1525.CrossRefGoogle ScholarPubMed
30 Edge, D. Ethnicity, psychosocial risk, and perinatal depression – a comparative study among inner-city females in the United Kingdom. J Psychosom Res 2007; 63: 291–5.CrossRefGoogle ScholarPubMed
31 Kapur, N, Cooper, J, King-Hele, S, Webb, R, Lawlor, M, Rodway, C, et al. The repetition of suicidal behavior: a multicenter cohort study. J Clin Psychiatry 2006; 67: 1599–609.CrossRefGoogle ScholarPubMed
32 Commission for Healthcare Audit and Inspection. Variations in the Experiences of Patients using the NHS Services in England. Analysis of the Healthcare Commission's 2004/2005 Surveys of Patients. Commission for Healthcare Audit and Inspection, 2006.Google Scholar
33 Raleigh, VS, Irons, R, Hawe, E, Scobie, S, Cook, A, Reeves, R, et al. Ethnic variations in the experiences of mental health service users in England. Results of a national patient survey programme. Br J of Psychiatry 2007; 191: 304–12.CrossRefGoogle ScholarPubMed
34 Taylor, TL, Hawton, K, Fortune, S, Kapur, N. Attitudes towards clinical services among people who self-harm: systematic review. Br J of Psychiatry 2009; 194: 104–10.CrossRefGoogle ScholarPubMed
35 Merrill, J, Owens, J. Ethnic differences in self poisoning: a comparison of Asian and White groups. Br J Psychiatry 1986; 148: 708–12.CrossRefGoogle ScholarPubMed
36 Platt, L, Simpson, L, Akinwale, B. Stability and change in ethnic groups in England and Wales. Popul Trends 2005; 121: 3546.Google Scholar
37 National Institute for Mental Health in England. Inside Outside: Improving Mental Health Services for Black and Minority Ethnic Communities in England. Department of Health, 2003.Google Scholar
38 Department of Health. Delivering Race Equality in Mental Health Care: A Summary. TSO (The Stationery Office), 2005.Google Scholar
39 Bhugra, D, Arya, P. Ethnic density, cultural congruity and mental illness in migrants. Int Rev Psychiatry 2005; 17: 133–7.Google ScholarPubMed
40 Bhui, K. The new science of cultural epidemiology to tackle ethnic health inequalities. J Public Health 2009; 31: 322–3.CrossRefGoogle ScholarPubMed
41 Bhui, K, Warfa, N, Edonya, P, McKenzie, K, Bhugra, D. Cultural competence in mental health care: a review of model evaluations. BMC Health Serv Res 2007; 7: 15.Google ScholarPubMed
Figure 0

Table 1 Sociodemographic profile of the three cities: 2001 Census data18

Figure 1

Table 2 Numbers, person-years denominators and self-harm rates per 1000 × city, gender, age and ethnic groupa

Figure 2

Table 3 Age-specific rate ratios (RRs) for minority ethnic groups v. White people: by city

Figure 3

Table 4 Clinical management and repetition following self-harm: Black and South Asian v. White females aged 16–64 yearsa

Figure 4

Table 5 Clinical management and repetition following self-harm: Black and South Asian v. White males aged 16–64 yearsa

Supplementary material: PDF

Cooper et al. supplementary material

Supplementary Table S1-S2

Download Cooper et al. supplementary material(PDF)
PDF 45 KB
Submit a response

eLetters

No eLetters have been published for this article.
You have Access
47
Cited by

Send article to Kindle

To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Ethnic differences in self-harm, rates, characteristics and service provision: three-city cohort study
Available formats
×

Send article to Dropbox

To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

Ethnic differences in self-harm, rates, characteristics and service provision: three-city cohort study
Available formats
×

Send article to Google Drive

To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

Ethnic differences in self-harm, rates, characteristics and service provision: three-city cohort study
Available formats
×
×

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *