Rates, risk factors & methods of self harm among minority ethnic groups in the UK: a systematic review.(Research article)(United Kingdom)

Authors: Kamaldeep Bhui (corresponding author) [1,2]; Kwame McKenzie [3,4]; Farhat Rasul [1]

Background

Non-fatal self harm (SH) is common [1]. It places significant burden on care services. The degree of suicidal intent is often difficult to assess, but SH is the most important risk factor for later completed suicide [2, 3] and future self-harm [4]. Mental distress and illness are both risk factors for suicide and self harm. Though there are many studies that show ethnic variations in prevalence of mental illness, and access to care and treatment [5], few have considered the cultural epidemiology of self harm.

Cross cultural investigations of self harm and suicide are necessary to inform future preventive initiatives if these are to be effective across diverse ethnic groups [6, 7]. Cultural influences are proposed to explain some of the ethnic variations in rates and methods of self harm within any one country and across countries [8, 9, 10]. In addition, factors known to increase the risk of mental distress, social exclusion, unemployment, and financial strain are more common in some ethnic groups and may increase the risk of self harm among these ethnic groups [11, 12].

Clinical assessment and preventive policies rarely take into consideration potentially distinct needs of specific ethnic groups. This partly reflects that the evidence base is not accessible or synthesised to guide practitioners or policy makers to consider ethnic differences in rates and risk factors. This paper reports the findings of a systematic review of UK studies investigating self harm amongst at least two minority ethnic groups. The aim of the review was to establish whether there were ethnic differences in prevalence rates, clinical presentations including risk factors, and methods of self harm across the largest minority ethnic groups in the UK. We hypothesised that prevalence, risk and methods of self harm would differ between South Asian, Black Caribbean, and White British people.

Methods

The literature review is part of a larger mixed-methods study investigating suicide and self harm in minority ethnic groups commissioned by the National Institute of Mental Health England and the Department of Health's 'Delivering Race Equality' strategy. The paper presents a review of self harm only, but because many studies investigate self harm and suicide, our search strategy targetted both publications on suicide and self harm. Specifically, we searched for publications that included data on a) self harm or suicide, b) in at least two ethnic groups living in the UK, and c) that were published in English. Titles and abstracts of these studies were screened (FR, KB, KM). Full text papers were obtained if from the abstracts the studies were confirmed to a) compare rates or clinical risk factors or methods of self harm or suicide; b) include data on 2 or more ethnic groups living in the UK; c) studies were published in English between 1960 and the start date of the project, 2004. Where there was uncertainty, the full text paper was retrieved. The following databases: MEDLINE, PSYCHINFO, EMBASE and CINAHL. The search strategy used the following search terms: SUICIDE or SUICIDAL IDEATION, or SUICIDAL THOUGHTS, or SUICIDE BEHAVIOUR or SELF-HARM or DELIBERATE SELF-HARM. The strategy was devised with the assistance of a librarian familiar with the databases and MESH terms needed to optimise the search. The findings from this search were combined with a search on ETHNICITY or ETHNIC or RACE. There were 1765 hits. In this paper we review the 25 studies that met our inclusion criteria (see Figure 1).

Figure 1: Flow chart of identified papers. [figure omitted]

Two reviewers (KB KM) independently assessed the methodological quality of the studies using a scoring scheme adapted from previous reviews (adapted from [5]; Table 1). Data were extracted and tabulated independently by the two reviewers who tabulated study characteristics (Table 2), clinical risk factors for self harm and methods of self harm (Additional file 1) and prevalence or rates of self harm (Table 3). Adolescent studies were separately reported given the distinct risk of mental health problems, service use and developmental challenges for adolescents.

Table 1 caption: Paper quality scoring system on five criteria: [table omitted]Table 2 caption: Characteristics of studies on self harm in ethnic groups in the UK [table omitted]Table 3 caption: Rates of Self Harm across Ethnic groups in the UK [table omitted]Additional file 1: additional file y. Clinical Risk Factors & Methods for Self Harm in Ethnic Groups in the UK.

The largest ethnic minority groups living in the UK are migrants and their descendents from the Indian sub-continent, often called South Asians in the UK. Other migrants and their descendents are from the Caribbean and Africa; these ethnic groups are often called Black Caribbean or African Caribbean if of Caribbean origin and Black African if of African origin. These categories are those used in the 2001 census in the UK. As much as possible we have tried to group different studies together by ethnic …