Tedium vitae, death wishes, suicidal ideation and attempts in Kenya-prevalence and risk factors

Prevalence of suicide attempts across the African continent: A systematic review and meta-analysis

BACKGROUND

Over 700,000 people worldwide lose their lives through suicide every year. The prevalence of suicide has increased, especially in low- and middle-income countries such as many African countries. For every fatal suicidal attempt, there are approximately 20 other non-fatal suicide attempts within the population. The purpose of this study is to investigate the prevalence of attempts of suicides in the African continent through a systematic review and meta-analysis.

METHODS

To identify relevant sources, the PubMed, Scopus, Web of Science, Embase, ScienceDirect and Google Scholar repositories and databases were systematically searched without a lower time limit and until July 2023. The heterogeneity of the studies was checked with the I2 index, and accordingly random effects model was adopted to perform the analysis. Data analysis was conducted within the Comprehensive Meta-Analysis software (v.2).

RESULTS

In the review of 48 studies with a sample size of 244,701 people, the prevalence of suicide attempts in Africa was found to be 9.9% (95%CI: 8.5%-11.6%). With the increase in the year of study, the prevalence of suicide attempt in the African continent increases. Also, with the increase in the sample size, the prevalence of suicide attempts in Africa decreases. The suicide attempt prevalence among African men and woman slightly differed with 7.6% and 8.2%, respectively.

CONCLUSION

Suicide attempt is an important public health concern in Africa. The findings of this study are important not only for African health policy making, but also to contribute to the accuracy of global estimates with respect to suicide attempts.

Prevalence and associated determinants of suicidal ideation and attempt among people with severe mental disorders in Addis Ababa, Ethiopia a cross-sectional study

Suicidal ideation and attempts are much more common in people with severe mental disorders than in the general population. As a result, the goal of this study was to look at suicidal ideation and attempts in people with severe mental disorders in Addis Ababa, Ethiopia, in 2022. Using a simple random sample technique, a facility-based cross-sectional study involving 423 patients with severe mental disorders was conducted. The factors associated with suicidal thoughts and attempts were identified using a bivariate and multivariate logistic regression analysis model. Significant factors were determined using a p-value of less than 0.05. The prevalence of suicidal ideation and attempt was 26.4% (95% CI: 22.3-30.99%) and 18.6% (95% CI: 15.2-22.7%), respectively. Moreover, suicidal thoughts were linked with being single (AOR = 2.1.1, 95% CI: 1.01, 4.72), having poor social support (AOR = 3.1, 95% CI: 1.05, 9.422), and having comorbid depression (AOR = 2.72, 95% CI: 1.62, 4.54). Suicidal attempt was also associated with secondary education (AOR = 4.06, 95% CI: 1.50, 10.98), illness duration (AOR = 2.48, 95% CI: 1.15, 5.35), hopelessness (AOR = 3.415, 95% CI: 2.114, 15.516), and the absence of positive symptoms (AOR = 0.37, 95% CI: 0.209, 0.683). A significant proportion of patients with severe mental disorders have contemplated or actually attempted suicide. Poor psychosocial support, a higher level of education, and comorbid depression were all linked to these issues. Therefore, controllable risk factors such as education, hopelessness, and psychosocial support should be prioritized and given particular emphasis.

Risk of suicidality in mental and neurological disorders in low and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Both fatal and nonfatal suicidal behaviours are important complications of mental, neurological, and substance use disorders (MNSDs) worldwide. We aimed at quantifying the association of suicidal behaviour with MNSDs in Low and Middle Income Countries (LMICs) where varying environmental and socio-cultural factors may impact outcome.

METHODS

We conducted a systematic review and meta-analysis to report the associations between MNSDs and suicidality in LMICs and the study-level factors of these associations. We searched the following electronic databases: PUBMED, PsycINFO, MEDLINE, CINAHL, World Cat, and Cochrane library for studies on suicide risk in MNSDs, with a comparison/control group of persons without MNSDs, published from January 1, 1995 to September 3, 2020. Median estimates were calculated for relative risks for suicide behaviour and MNSDs, and when appropriate, these were pooled using random effects metanalytic model. This study was registered with PROSPERO, CRD42020178772.

RESULTS

The search identified 73 eligible studies: 28 were used for quantitative synthesis of estimates and 45 for description of risk factors. Studies included came from low and upper middle-income countries with a majority of these from Asia and South America and none from a low-income country. The sample size was 13,759 for MNSD cases and 11,792 hospital or community controls without MNSD. The most common MNSD exposure for suicidal behaviour was depressive disorders (47 studies (64%)), followed by schizophrenia spectrum, and other psychotic disorders (28 studies (38%)). Pooled estimates from the meta-analysis were statistically significant for suicidal behaviour with any MNSDs (odds ratios (OR) = 1∙98 (95%CI = 1∙80-2∙16))) and depressive disorder (OR = 3∙26 (95%CI = 2∙88-3∙63))), with both remaining significant after inclusion of high-quality studies only. Meta-regression identified only hospital-based studies (ratio of OR = 2∙85, CI:1∙24-6∙55) and sample size (OR = 1∙00, CI:0∙99-1∙00) as possible sources of variability in estimates. Risk for suicidal behaviour in MNSDs was increased by demographic factors (e.g., male sex, and unemployment), family history, psychosocial context and physical illness.

INTERPRETATION

There is an association between suicidal behaviour and MNSDs in LMICs, the association is greater for depressive disorder in LMICs than what has been reported in High Income Countries (HICs). There is urgent need to improve access for MNSDs care in LMICs.

FUNDING

None.

Sociocultural perspectives on suicidal behaviour at the Coast Region of Kenya: an exploratory qualitative study

OBJECTIVES

To explore perceived sociocultural factors that may influence suicidality from key informants residing in coastal Kenya.

DESIGN

We used an exploratory qualitative study design.

SETTING

Mombasa and Kilifi Counties of Coastal Kenya.

PARTICIPANTS

25 key informants including community leaders, professionals and community members directly and indirectly affected by suicidality.

METHODS

We conducted in-depth interviews with purposively selected key informants to collect data on sociocultural perspectives of suicide. Thematic analysis was used to identify key themes using both inductive and deductive processes.

RESULTS

Four key themes were identified from the inductive content analysis of 25 in-depth interviews as being important for understanding cultural perspectives related to suicidality: (1) the stigma of suicidal behaviour, with suicidal victims perceived as weak or crazy, and suicidal act as evil and illegal; (2) the attribution of supernatural causality to suicide, for example, due to sorcery or inherited curses; (3) the convoluted pathway to care, specifically, delayed access to biomedical care and preference for informal healers; and (4) gender and age differences influencing suicide motivation, method of suicide and care seeking behaviour for suicidality.

CONCLUSIONS

This study provides an in depth understanding of cultural factors attributed to suicide in this rural community that may engender stigma, discrimination and poor access to mental healthcare in this community. We recommend multipronged and multilevel suicide prevention interventions targeted at changing stigmatising attitudes, beliefs and behaviours, and improving access to mental healthcare in the community.

Community suicide rates and related factors within a surveillance platform in Western Kenya

BACKGROUND

Suicide is an important contributor to the burden of mental health disorders, but community-based suicide data are scarce in many low- and middle-income countries (LMIC) including Kenya. Available data on suicide underestimates the true burden due to underreporting related to stigma and legal restrictions, and under-representation of those not utilizing health facilities.

METHODS

We estimated the cumulative incidence of suicide via verbal autopsies from the Health and Demographic Surveillance System (HDSS) in Kisumu County, Kenya. We then used content analysis of open history forms among deaths coded as accidents to identify those who likely died by suicide but were not coded as suicide deaths. We finally conducted a case-control study of suicides (both verbal autopsy confirmed and likely suicides) compared to accident-caused deaths to assess factors associated with suicide in this HDSS.

RESULTS

A total of 33 out of 4306 verbal autopsies confirmed suicide as the cause of death. Content analysis of a further 228 deaths originally attributed to accidents identified 39 additional likely suicides. The best estimate of suicide-specific mortality rate was 14.7 per 100,000 population per year (credibility window = 11.3 - 18.0). The most common reported method of death was self-poisoning (54%). From the case-control study interpersonal difficulties and stressful life events were associated with increased odds of suicide in both confirmed suicides and confirmed combined with suspected suicides. Other pertinent factors such as age and being male differed depending upon which outcome was used.

CONCLUSION

Suicide is common in this area, and interventions are needed to address drivers. The twofold increase in the suicide-specific mortality rate following incorporation of misattributed suicide deaths exemplify underreporting and misclassification of suicide cases at community level. Further, verbal autopsies may underreport suicide specifically among older and female populations.

Experiences of Violence and Mental Health Concerns Among Sexual and Gender Minority Adults in Western Kenya

Purpose: Sexual and gender minority (SGM) populations throughout Kenya as well as other sub-Saharan African countries face systemic discrimination and substantial human rights violations, yet scant literature documents the potentially harmful mental health effects of these experiences. This study sought to understand the relationship among experiences of violence, social support, and mental health among SGM adults in Kenya. Methods: Members of a local LGBT community-based organization collected survey data in Western Kenya from October 2017 to April 2018, recruiting 527 SGM participants through an array of community outreach methods. Respondents in this cross-sectional study completed a survey regarding their mental health and other psychosocial factors. Multiple linear regression analyses were conducted to assess associations between experiences of violence (SGM violence and intimate partner violence [IPV]) and mental health outcomes (depressive symptoms and post-traumatic stress symptoms [PTSSs]) and to examine the potential moderating effect of social support on these relationships. Results: Relative to those who had never faced violence, participants who experienced IPV and/or violence based on their sexual orientation, gender identity, or gender expression (SGM violence) reported significantly higher levels of depressive symptoms and PTSSs. Emotional support was associated with lower levels of PTSSs. Social support did not moderate the relationship between SGM violence and mental health symptoms. Conclusions: These findings suggest that there may be a relationship between experiences of violence and poor mental health among SGM Kenyans. More studies are needed to better understand SGM-specific risk factors for poor mental well-being among SGM people in Kenya and the types of interventions that may help mitigate these challenges.

Reframing Non-Communicable Diseases and Injuries for Equity in the Era of Universal Health Coverage: Findings and Recommendations from the Kenya NCDI Poverty Commission

Background

Kenya has implemented a robust response to non-communicable diseases and injuries (NCDIs); however, key gaps in health services for NCDIs still exist in the attainment of Universal Health Coverage (UHC). The Kenya Non-Communicable Diseases and Injury (NCDI) Poverty Commission was established to estimate the burden of NCDIs, determine the availability and coverage of health services, prioritize an expanded set of NCDI conditions, and propose cost-effective and equity-promoting interventions to avert the health and economic consequences of NCDIs in Kenya.

Methods

Burden of NCDIs in Kenya was determined using desk review of published literature, estimates from the Global Burden of Disease Study, and secondary analysis of local health surveillance data. Secondary analysis of nationally representative surveys was conducted to estimate current availability and coverage of services by socioeconomic status. The Commission then conducted a structured priority setting process to determine priority NCDI conditions and health sector interventions based on published evidence.

Findings

There is a large and diverse burden of NCDIs in Kenya, with the majority of disability-adjusted life-years occurring before age of 40. The poorest wealth quintiles experience a substantially higher deaths rate from NCDIs, lower coverage of diagnosis and treatment for NCDIs, and lower availability of NCDI-related health services. The Commission prioritized 14 NCDIs and selected 34 accompanying interventions for recommendation to achieve UHC. These interventions were estimated to cost $11.76 USD per capita annually, which represents 15% of current total health expenditure. This investment could potentially avert 9,322 premature deaths per year by 2030.

Conclusions and Recommendations

An expanded set of priority NCDI conditions and health sector interventions are required in Kenya to achieve UHC, particularly for disadvantaged socioeconomic groups. We provided recommendations for integration of services within existing health services platforms and financing mechanisms and coordination of whole-of-government approaches for the prevention and treatment of NCDIs.

Intimate Partnerships, Suicidal Ideation and Suicide-Related Hospitalization Among Young Kenyan Men

The first study focused on a three-month chart review containing information on suicide attempts (n = 34) admitted to a local mission hospital in Meru County, Kenya. The second study utilized a cross-sectional survey administered to men 18-34 years old (n = 532) residing in rural Kenya. Data posit intimate partnership discord as salient to suicide ideation and behavior. Men who reported their partner status was "divorced" had four-times the odds of reporting suicide ideation than other partnership states, an association significantly mediated by loneliness. Violent conflict tactics predicted suicidal ideation, mediated by loneliness and decreased marital satisfaction.

Suicide behaviour among adolescents in a high HIV prevalence region of western Kenya: A mixed-methods study

The study purpose was to determine the prevalence and determinants of suicidal thoughts and behaviours in a rural community sample of 15-19-year-old Kenyan adolescents in a region with high HIV burden. Data were from an observational study examining ethical issues in adolescent HIV research (N=4084). Participants reporting suicidal ideation were assessed for suicide risk. Directed content analyses were conducted using assessment reports. Logistic regression was used to identify factors associated with suicide outcomes. Prevalence of suicidal ideation was 16%. Of these, 38% were low risk and 12% were moderate/high-risk. Females and sexually active adolescents had higher odds of suicidal ideation and being categorised as moderate/high-risk. Adolescents with higher depression scores had higher odds of reporting ideation. Pregnancy was protective for females while impregnating a partner was a risk factor for males. Abuse from a family member, financial stress and health concerns were the most frequently mentioned precipitants of ideation. However, only abuse increased odds of suicide behaviour. Effective programmes to identify and support sexually active, pregnant, and distressed adolescents at risk for suicide are needed. Approaches involving families, schools, health facilities, and community gatekeepers may have the most promise in sub-Saharan African rural areas with limited mental health services.

Terminology and assessment tools of psychosis: A systematic narrative review

AIM

Phenomena within the psychosis continuum that varies in frequency/duration/intensity have been increasingly identified. Different terms describe these phenomena, however there is no standardization within the terminology. This review evaluated the definitions and assessment tools of seven terms - (i) 'psychotic experiences'; (ii) 'psychotic-like experiences'; (iii) 'psychotic-like symptoms'; (iv) 'attenuated psychotic symptoms'; (v) 'prodromal psychotic symptoms'; (vi) 'psychotic symptomatology'; and (vii) 'psychotic symptoms'.

METHODS

EMBASE, MEDLINE, and CINAHL were searched during February-March 2019. Inclusion criteria included 1989-2019, full text, human, and English. Papers with no explicit definition or assessment tool, duplicates, conference abstracts, systematic reviews, meta-analyses, or no access were excluded.

RESULTS

A total of 2238 papers were identified and of these, 627 were included. Definitions and assessment tools varied, but some trends were found. Psychotic experiences and psychotic-like experiences were transient and mild, found in the general population and those at-risk. Psychotic-like symptoms were subthreshold and among at-risk populations and non-psychotic mental disorders. Attenuated psychotic symptoms were subthreshold but associated with distress, risk, and help-seeking. Prodromal psychotic symptoms referred to the prodrome of psychotic disorders. Psychotic symptomatology included delusions and hallucinations within psychotic disorders. Psychotic symptoms was the broadest term, encompassing a range of populations but most commonly involving hallucinations, delusions, thought disorder, and disorganization.

DISCUSSION

A model for conceptualizing the required terms is proposed and future directions needed to advance this field of research are discussed.

Tedium vitae in stroke survivors: a comparative cross-sectional study

OBJECTIVES

Suicide is best studied by deconstructing the psychological experiences preceding suicidal death. We assessed the characteristics of tedium vitae (feeling tired of life) after first ever stroke in Nigerian survivors.

METHODS

Using the Schedule for Clinical Assessment in Neuropsychiatry, tedium vitae was assessed in 130 stroke survivors attending rehabilitation in a large Nigerian university hospital. Global cognitive and executive dysfunctions were evaluated, respectively, using the Mini Mental State Examination and the modified Indiana University Token test. All participants had their index stroke 3 to 24 months before recruitment into the study. We also examined a comparative group of 130 age, gender, and education matched apparently normal persons who were unrelated to the stroke survivors. Associations were explored using univariate and multivariate logistic regression analyses.

RESULTS

Tedium vitae was experienced by 16 (12.3%) stroke survivors compared with 5 (3.9%) in the comparative group (O. R = 3.5, 95% C. I = 1.3-9.9, p = 0.018). Among stroke survivors, those who were retired were more likely to experience tedium vitae (56.2%, p = 0.045). In analyses adjusting for the effect of systemic hypertension, cognitive dysfunction, retirement and marital separation, there was a 3.5-fold increase in the odds of experiencing tedium vitae after surviving a stroke (O. R = 3.5, 95% C. I = 1.1-11.6, p = 0.042).

CONCLUSIONS

Tedium vitae is a common suicidal experience after stroke and may be among the earliest perceptible pointer to impending poststroke suicide. It is easy to assess and may be less costly to obtain an adequate sample size in studies aiming to understand the phenomenon of suicide in the stroke population.

Suicidal Thoughts and Contexts in Black African Stroke Survivors

OBJECTIVES

Poststroke suicide has not been studied in Black Africans. We assessed the characteristics and contexts of serious suicidal thoughts after first-ever stroke in Nigerians.

METHODS

Using a comparative cross-sectional design, we consecutively recruited 130 stroke survivors attending rehabilitation in a large university hospital. Also included were 130 age-, sex-, and education-matched caregivers who were unrelated to stroke survivors. Along with clinical and historical details, cognitive functions, experience of serious suicidal thoughts, and major depressive disorder (MDD) were independently assessed using validated semi-structured interviews.

RESULTS

Serious suicidal thoughts were present in 20 (15.4%) stroke survivors and 19 (14.6%) controls. Poststroke suicidal thoughts occurred in the contexts of MDD ( P < .001), marital separation ( P = .019), and cognitive dysfunction ( P = .037). In a multivariate logistic regression model including age, gender, MDD, marital separation, and cognitive dysfunction as covariates, poststroke MDD and marital separation led to 5.6-fold (95% confidence interval [CI]: 3.5-21.0) and 4-fold (95% CI: 1.2-14.0) increases, respectively, in the odds of serious suicidal thoughts.

CONCLUSIONS

Serious suicidal thoughts after stroke in this African sample were more common than the reported average prevalence in the global literature. Poststroke major depression was the key reversible risk factor for suicidal thoughts. Depression is treatable and prompt treatment may prevent suicidal deaths and reduce the burden of stroke in black Africans.

Malaria, mental disorders, immunity and their inter-relationships - A cross sectional study in a household population in a health and demographic surveillance site in Kenya

Background

Both malaria and mental disorders are associated with immune changes. We have previously reported the associations between malaria and mental disorders. We now report associations between malaria, mental disorders and immunity.

Methods

A household survey of malaria, mental disorders and immunity was conducted in a health and demographic surveillance system's site of 70,000 population in an area endemic for malaria in western Kenya. A random sample of 1190 adults was selected and approached for consent, blood samples and structured interview.

Findings

We found marginally raised CD4/CD3 ratios of participants with malaria parasites, but no difference in CD4/CD3 ratios for participants with common mental disorder (CMD) or psychotic symptoms. People with psychotic symptoms had increased levels of IL-6, IL-8, and IL-10, and lower levels of IL-1beta. People with CMD had higher levels of IL-8 and IL-10. People with malaria had higher levels of IL-10 and lower levels of TNF-alpha. At the bivariate level, CMD was associated with log TNF-α levels using unadjusted odds ratios, but not after adjusting for malaria. Psychotic symptoms were associated with log IL-10 and log TNF-α levels at the bivariate level while in the adjusted analysis, log TNF-α levels remained highly significant..

Interpretation

This is the first population based study of immune markers in CMD and psychotic symptoms, and the first to examine the 3 way relationship with malaria. Our findings suggest that TNF-α may mediate the relationship between malaria and CMD.

Fund

The study was funded by UK Aid, Department for International Development, Kenya office.

Suicide in a rural area of coastal Kenya

BACKGROUND

Suicide accounts for approximately 1.4% of deaths globally and is the 15th leading cause of death overall. There are no reliable data on the epidemiology of completed suicide in rural areas of many developing countries, yet suicide is an indicator of the sustainable development goals on health.

METHODS

Using data collected between 2008 and 2016 from the Kilifi Health and Demographic Surveillance System in rural Kenya, we retrospectively determined the incidence rate and risk factors for completed suicide.

RESULTS

During the period, 104 people died by suicide, contributing to 0.78% (95% CI = 0.74-1.10) of all deaths. The mean annual incidence rate of suicide was 4.61 (95% CI = 3.80-5.58) per 100,000 person years of observation (pyo). The annual incidence rate for men was higher than that of women (IRR = 3.05, 95% CI = 1.98-4.70, p < 0.001) and it increased with age (IRR = 2.73, 95% CI = 2.30-3.24, p < 0.001). People aged > 64 years had the highest mean incidence rate of 18.58 (95% CI = 11.99-28.80) per 100,000 pyo. Completed suicide was associated with age, being male, and living in a house whose wall is made of scrap material, which is a proxy marker of extreme poverty in this region (OR = 5.5, 95% CI = 4.0-7.0, p = 0.02). Most cases (76%) completed suicide by hanging themselves. Spatial heterogeneity of rates of suicides was observed across the enumeration zones of the KHDSS.

CONCLUSIONS

Suicide is common in this area, but the incidence of completed suicide in rural Kenya may be an underestimate of the true burden. Like in other studies, suicide was associated with older age, being male and poverty, but other medical and neuropsychiatric risk factors should be investigated in future studies.

Why are psychotic experiences associated with self-injurious thoughts and behaviours? A systematic review and critical appraisal of potential confounding and mediating factors

Psychotic experiences (PEs), including hallucination- and delusion-like experiences, are robustly associated with self-injurious thoughts and behaviours (SITB) in the general population. However, it remains unclear as to why there is an association. The purpose of this systematic review was to elucidate the role of other factors that influence the association between PEs and SITB and, in doing so, highlight potential mechanisms underlying the relationship. A search of electronic international databases was undertaken, including PubMed, PsycINFO and EMBASE, and eligible studies were grouped according to seven confounder categories: sociodemographics, mental disorders, alcohol and substance use, environmental, psychological, intervention and family history/genetic factors. The systematic search strategy identified 41 publications reporting on 1 39 427 participants from 16 different countries. In the majority of studies, where adjustment for other variables occurred, the association between PEs and SITB persisted, suggesting PEs have an independent role. Common mental disorders, psychological distress and negative environmental exposures explained a substantial amount of the variance and therefore need to be considered as potential underlying mechanisms. There was high variability in the variables adjusted for in these studies, and so the question still remains as to whether the association between PEs and self-harm/suicidality can be attributed (fully or in part) to confounding and mediating factors or directly causal mechanisms. Regardless of causality, the now extensive literature reporting an association between these two clinical phenomena supports the broad usefulness of PEs as an indicator of risk for SITB.

Suicidality and associated risk factors in outpatients attending a general medical facility in rural Kenya

BACKGROUND

Low-and-Middle-Income-Countries (LMICs) account for 75% of global suicides. While primary care populations in high-income countries (HIC) typically have higher prevalence of suicidal behavior relative to general populations, few studies have explored suicidal behavior among general medical outpatients in LMICs. This study addresses the research gap by characterizing potential risk factors for suicidal ideation in a large general medical outpatient setting in rural Kenya.

METHODS

A cross-sectional study of adult general medical outpatients attending a rural sub-county hospital in Kaloleni, Kenya. Primary outcomes included major depressive disorder (MDD), posttraumatic stress disorder (PTSD) and suicidal behavior measured by the Mini International Neuropsychiatric Interview (MINI 5.0). We use binary logistic regression to model suicidality, mental disorders, intimate partner violence, and lifetime abuse.

RESULTS

394 outpatients completed the assessment. The prevalence of SI over the past month was 20%. 18% of those with suicidal ideation over the past month also attempted suicide in the past month. Participants who met criteria for MDD (suicidality item removed) were 19 times [CI: 4.56, 79.05] more likely to report suicidal ideation compared to those without MDD (adjusted odds ratio 12.15 [CI: 2.66, 55.49]).

LIMITATIONS

This was a cross sectional study design with convenience sampling and hence vulnerable to selection and recall bias.

CONCLUSION

The prevalence of SI and its strong association with actual suicide attempt in this population, make an urgent public health case for intervention. These data identify MDD as a highly significant correlate of SI.

Psychotic experiences and risk of self-injurious behaviour in the general population: a systematic review and meta-analysis

BACKGROUND

Recent studies suggest that psychotic experiences (PE) in the general population are associated with an increased risk of self-injurious behaviour. Both the magnitude of this association and the level of adjustment for confounders vary among studies. A meta-analysis was performed to integrate the available evidence. The influence of possible confounders, including variably defined depression, was assessed.

METHOD

A systematic review and meta-analysis was conducted including general population studies reporting on the risk of self-injurious behaviour in individuals with PE. Studies were identified by a systematic search strategy in Pubmed, PsycINFO and Embase. Reported effect sizes were extracted and meta-analytically pooled.

RESULTS

The risk of self-injurious behaviour was 3.20 times higher in individuals with PE compared with those without. Subanalyses showed that PE were associated with self-harm, suicidal ideation as well as suicidal attempts. All studies had scope for considerable residual confounding; effect sizes adjusted for depression were significantly smaller than effect sizes unadjusted for depression. In the longitudinal studies, adjustment for psychopathology resulted in a 74% reduction in excess risk.

CONCLUSIONS

PE are associated with self-injurious behaviour, suggesting they have potential as passive markers of suicidality. However, the association is confounded and several methodological issues remain, particularly how to separate PE from the full range of connected psychopathology in determining any specific association with self-injurious behaviour. Given evidence that PE represent an indicator of severity of non-psychotic psychopathology, the association between PE and self-injurious behaviour probably reflects a greater likelihood of self-injurious behaviour in more severe states of mental distress.