Ethnic differences in self-poisoning: a comparison of Asian and white groups

The global psychological and physical effects of domestic abuse and violence on South Asian women: a qualitative systematic review

Introduction

The purpose of this review is to systematically extract and analyse global academic literature to determine the physical and psychological effects of domestic abuse and violence on South Asian women.

Design

This review employs a qualitative systematic approach and thematic analysis to synthesize the narratives of affected women found in the literature. Given that domestic violence is often concealed and downplayed by various social factors, statistical reports and prevalence data offer only a limited view of the issue due to underreporting. Therefore, qualitative literature is deemed more dependable in this subjective domain as it captures and interprets the experiences and meanings within this under-studied group.

Data sources

Embase, PsycINFO, Google Scholar, Web Of Science, MEDLINE, and ASSIA were searched.

Review methods

All included studies were critically appraised using the CASP tool for qualitative research. Thematic analysis was conducted to develop six themes. Studies excluded did not address the research question, although intersecting population issues could be valuable topics for further research.

Results

The literature indicates severe mental and physical health consequences of domestic violence and abuse, with some traits persisting long-term. The analysis underscores the significant role of resilience, suggesting that individuals can overcome traumatic social experiences without enduring lifelong labels or a deficit model.

Conclusion

The findings provide support for future interventions aimed at recognizing signs of abuse and preventing severe psychological and physical consequences, particularly among South Asian women. Further research is needed to understand the impact on children and other family members affected by the victim's abuse, which falls beyond the scope of this review.

Attempted suicide in South Asian women

Humans have attempted and successfully committed suicide since time immemorial. The reasons for killing or harming oneself vary with cultures and societies and in urban or rural settings.

Migration and mental illness

Human beings have moved from place to place since time immemorial. The reasons for and the duration of these migrations put extraordinary stress on individuals and their families. Such stress may not be related to an increase in mental illness for all conditions or to the same extent across all migrant groups. In this paper, we provide an overview of some observations in the field of migration and mental health, hypothesise why some individuals and groups are more vulnerable to psychiatric conditions, and consider the impact of migration experiences on provision of services and care.

Ideology, Camouflage or Contingency? Racism in British Psychiatry

"...Are we so sure that the racist form of intolerance results chiefly from the wrong ideas of this or that group of people about the dependence of cultural evolution on organic evolution? Might not these ideas be simply ideological camouflage for more concrete oppositions based on a desire to subjugate other groups and maintain a posi tion of power?"

Repetition of attempted suicide among immigrants in Europe

OBJECTIVES

To compare frequencies of suicide attempt repetition in immigrants and local European populations, and the timing of repetition in these groups.

METHOD

Data from 7 European countries, comprising 10 574 local and 3032 immigrant subjects, were taken from the World Health Organization European Multicentre Study on Suicidal Behaviour and the ensuing Monitoring Suicidal Behaviour in Europe (commonly referred to as MONSUE) project. The relation between immigrant status and repetition of suicide attempt within 12-months following first registered attempt was analyzed with binary logistic regression, controlling for sex, age, and method of attempt. Timing of repetition was controlled for sex, age, and the recommended type of aftercare.

RESULTS

Lower odds of repeating a suicide attempt were found in Eastern European (OR 0.50; 95% CI 0.41 to 0.61, P < 0.001) and non-European immigrants (OR 0.68; 95% CI 0.51 to 0.90, P < 0.05), compared with the locals. Similar patterns were identified in the sex-specific analysis. Eastern European immigrants tended to repeat their attempt much later than locals (OR 0.58; 95% CI 0.35 to 0.93, P < 0.05). In general, 32% of all repetition occurred within 30 days. Repetition tended to decrease with age and was more likely in females using harder methods in their index attempt (OR 1.29; 95% CI 1.08 to 1.54, P < 0.01). Large variations in the general repetition frequency were identified between the collecting centres, thus influencing the results.

CONCLUSIONS

The lower repetition frequencies in non-Western immigrants, compared with locals, in Europe stands in contrast to their markedly higher tendency to attempt suicide in general, possibly pointing to situational stress factors related to their suicidal crisis that are less persistent over time. Our findings also raise the possibility that suicide attempters and repeaters constitute only partially overlapping populations.

Gender-differences in risk factors for suicidal behaviour identified by perceived burdensomeness, thwarted belongingness and acquired capability: cross-sectional analysis from a longitudinal cohort study

Background

The Interpersonal-Psychological Theory of Suicidal Behavior (IPT) is supported by recent epidemiological data. Unique risk factors for the IPT constructs have been identified in community epidemiological studies. Gender differences in these risk factors may contribute substantially to our understanding of suicidal risk, and require further investigation. The present study explores gender differences in the predictors and correlates of perceived burdensomeness, thwarted belongingness and acquired capability for suicide.

Methods

Participants (547 males, 739 females) aged 32–38 from the PATH through Life study, an Australian population-based longitudinal cohort study (n=1,177) were assessed on perceived burdensomeness, thwarted belongingness and acquired capability for suicide using the Interpersonal Needs Questionnaire and Acquired Capability for Suicide Survey, and on a range of demographic, social support, psychological, mental health and physical health measures. Gender differences in the predictors of the IPT constructs were assessed using linear regression analyses.

Results

Higher perceived burdensomeness increased suicide ideation in both genders, while higher thwarted belongingness increased suicide ideation only in females. In females, thwarted belongingness was uniquely related to perceived burdensomeness, while greater physical health was significantly associated with greater thwarted belongingness in males but not in females. There were trends suggesting greater effects of being single and greater perceived burdensomeness for men, and stronger effects of less positive friendship support for women associated with greater thwarted belongingness.

Conclusions

Men and women differ in the pattern of psychological characteristics that predict suicide ideation, and in the factors predicting vulnerability. Suicide prevention strategies need to take account of gender differences.

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

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.

Immigration and suicidality in the young

OBJECTIVES

Little research has focused on the relation of immigration and suicidal behaviour in youth. Nevertheless, the impact of migration on the mental health of youth is an issue of increasing societal importance. This review aimed to present studies on the prevalence of suicidal behaviour in immigrant youth in various countries and to provide possible explanations for suicidal behaviour in immigrant youth, especially regarding acculturation.

METHODS

The review included a literature search to locate articles on the subject of suicidal behaviour in immigrant youth in the context of acculturation.

RESULTS

Studies on suicidal behaviour in culturally diverse youth are few and most of the existing research does not differentiate ethnic minorities from immigrants. Studies on epidemiology and on specific risk factors were found regarding various immigrant youth including Hispanics in the United States, Asians in North America and Europe, as well as comparative studies between different immigrant groups in specific countries.

CONCLUSIONS

The relation between immigration status and suicidal behaviours in youth appears to vary by ethnicity and country of settlement. Time spent in the new country as well as intergenerational communication and conflicts with parents have, in many of the studies, been related to suicidality in immigrant youth. Summing up, there is a clear and urgent need to further pursue the work in this field, to develop targeted public health interventions as well as psychosocial treatment for preventing suicide in these youth.

Do specialist community public health nurses assess risk factors for depression, suicide, and self-harm among South Asian mothers living in London?

Evidence indicates that suicide rates are higher in South Asian women in the United Kingdom compared with other ethnic groups, suggesting increased vulnerability to attempted suicide and mental distress in these women. Specialist Community Public Health Nurses (SCPHNs, including health visitors) are in an ideal position to assess such risk. The objectives are to determine whether SCPHNs assess known risk factors for depression, self-harm, and suicide during initial contact with South Asian mothers in London; the extent to which these risk factors are documented in the nursing records; and whether their assessments of South Asian women differ from those of other ethnic groups. Structured content analysis of semistructured interviews with 8 SCPHNs and analysis of 60 matched pairs of SCPHN records were carried out in an inner London community. The results revealed that SCPHNs assessed general risk factors for postnatal depression and some culture-specific factors when assessing South Asian mothers. Documentation of risk factors was under-represented in the SCPHN records and there was a significant difference between the documented risk factors for South Asian women and women from other ethnic groups. While SCPHNs understood some aspects of South Asian culture, service improvements must be made to ensure better care provision.

Epidemiologic characteristics and trends of fatal suicides among the elderly in Taiwan

Taiwan has one of the highest suicide rates in the world, especially among its elderly. The epidemiologic characteristics and trends of the surging elderly suicide rates from 1993 to 2003 are described, with a special emphasis on the risk groups, the methods used in suicide, and their geographical variations. Data on annual mortality for persons over 65 years of age with external cause-of-death codes E950-E959 were obtained from the Death Certification data file provided by the Department of Health and used in the analysis. The suicide rate for each 5-year age group over 65 years old increased during the 11-year period. Elderly males had the highest suicide rate and experienced an increased rate of 49% during the decade. The average suicide ratio between elderly males and females was about 2:1. Never-married males had the highest age-adjusted as well as sex- and marital status-specific suicide rates, and showed an increased rate of 66% over the 11-year period. Geographical variations in suicide rates were significant, with the lest urbanized eastern Taiwan having a higher rate than other regions. Hanging, strangulation, and suffocation were the most used methods for committing suicide by the elderly, but their use had decreased from 63% to 54% during the decade; but jumping off a building and drowning increased significantly. Variation in suicide rate among months was not significant. With the increase in the elderly suicide rate, more governmental and societal interventions are needed to alleviate this social and human problem.

The epidemiology of intentional non-fatal self-harm poisoning in the United States: 2001-2004

INTRODUCTION

Suicide attempts through intentional poisoning are an important public health concern. This investigation sought to determine the different US incident rates of poisonings (with intent to do self-harm) by race, sex, and gender.

METHODS

We used data from the National Electronic Injury Surveillance System--All Injury Program (NEISS-AIP) to describe differences in incidence rates of non-fatal, self-harm poisonings evaluated in US emergency departments (ED) from 2001 to 2004. WISQARS defines self-harm as "either confirmed or suspected from injury or poisoning resulting from a deliberate act inflicted on oneself with the intent to take one's own life or harm oneself."

RESULTS

From 2001 to 2004, there were 976,974 (95% Confidence Interval (CI) 772,884 - 1,181,065) non-fatal self-harm poisonings reported in US Emergency Departments. Young white females between 15 to 19 years of age were at highest risk with an incidence rate of 248 per 100,000 (95% CI 180 - 315). Females had higher rates of self-harm poisonings than males: the rate for females was 101 per 100,000 (95% CI 81 - 123); the rate for males was 66 per 100,000 (95% CI 51 - 81), p < 0.001. Whites had slightly higher rates than blacks, and significantly higher rates than Hispanics: whites rates were 71 per 100,000 (95% 51 - 91); black rates were 65 per 100,000 (95% CI 35 - 96), and Hispanic rates were 23 per 100,000 (95% 10 - 37). There was a significant increase in the incidence rate from 2002 to 2003 (p < 0.001). Incident rates decreased for females and males older than 19 years of age (p < 0.001 for males and females).

CONCLUSION

Recently, the incidence of self-harm poisoning has risen considerably. It rose from 75 (CI 53-98) per 100,000 in 2002 to 94 (CI 74-115) per 100,000 in 2003; incidence remained relatively steady in 2004. Whites have higher incidence rates than blacks and significantly higher incidence rates than Hispanics. Females are at higher risk than males, and adolescent white females are at highest risk. An understanding of the demographic factors associated with self-harm poisoning may provide useful information to improve prevention and treatment strategies.

Ethnicity, gender and mental health: social worker perspectives

BACKGROUND

This paper draws on a two-year Department of Health research study on social worker conceptualisations of ethnicity, gender and mental health. The findings and discussion are placed within the 'culturalist' and an 'integrative' perspective on the mental health needs of Asian women. It is argued that the culturalist perspective has led to an overemphasis of individual and group differences in theoretical and practice debates, and by design or default has resulted in an under-emphasis of the interconnections between 'race', ethnicity, gender and social class, as well as an underemphasis on the adequacy and appropriateness of existing service provision. The importance of the latter is highlighted in its integrative nature in pointing to the interconnections between race, ethnicity, gender and social class.

AIMS

To study professional perspectives to enhance understanding of the interconnections of ethnicity, gender, social class and mental health, to promote improved policy, provision and practice.

METHODS

Semi-structured interviews with social work professionals to obtain their perceptions of Bangladeshi women's mental illness, well-being, sources of stress and service provision.

RESULTS

In understanding the mental health situation of Bangladeshi women, a thematic analysis identified a multiplicity of factors including poverty, poor and overcrowded housing, racism, language, culture, religion, and gender and patriarchy. Low use of social services by Bangladeshi women, combined with fear and mistrust and lack of familiarity, raised important concerns about unmet need.

CONCLUSIONS

Social worker perceptions demonstrate an understanding that suggests that the experience of ethnicity is gendered and that gender relations are ethnically distinct and impacted by social class. The paper highlights the importance of understanding patriarchy and gender relations, as well as the wider context of race and ethnicity and the interconnections between ethnicity, gender and social class.

Exploring the meaning of separation in second-generation young South Asian women in Britain

OBJECTIVES

To explore the experiences of young second-generation South Asian women living in Britain; to try and understand their experiences, deconstruct the term cultural conflict and understand it within a psychological framework. In particular, the aim was to explore issues of separation and individuation, and the meanings attributed to these concepts.

DESIGN

An interview-based study using Interpretative Phenomenological Analysis to analyse the data.

METHODS

Interviews were conducted with six second-generation South Asian women aged 16-20, who had no prior contact with mental health services.

RESULTS

Five main themes were identified from the analysis: differences in the meaning of adulthood, community policing, pressures and stressors, protective factors/coping and barriers to coping.

CONCLUSIONS

The participants' perceived differences in the meaning of adulthood in Asian cultures in comparison with Western cultures. These differences, in conjunction with the community policing that they were exposed to, contributed to the pressures and stressors - in particular lack of control and a desire to make individual decisions. The results indicated that the differences in the meaning of adulthood in a collective culture challenged the assumptions of the separation-individuation model, and was a key element in cultural conflict. This highlighted the complexities of generalizing research findings across all social groups, and questioned the validity of applying existing psychological theory to this population. The clinical implications of coping/protective factors and barriers to coping were discussed.

Rates, risk factors & methods of self harm among minority ethnic groups in the UK: a systematic review

BACKGROUND

Studies suggest that the rates of self harm vary by ethnic group, but the evidence for variation in risk factors has not been synthesised to inform preventive initiatives.

METHODS

We undertook a systematic literature review of research about self harm that compared at least two ethnic groups in the United Kingdom.

RESULTS

25 publications from 1765 titles and abstracts met our inclusion criteria. There was higher rate of self harm among South Asian women, compared with South Asian men and White women. In a pooled estimate from two studies, compared to their white counterparts, Asian women were more likely to self harm (Relative Risk 1.4, 95%CI: 1.1 to 1.8, p = 0.005), and Asian men were less likely to self harm (RR 0.5, 95% CI: 0.4 to 0.7, p < 0.001). Some studies concluded that South Asian adults self-harm impulsively in response to life events rather than in association with a psychiatric illness. Studies of adolescents showed similar methods of self harm and interpersonal disputes with parents and friends across ethnic groups. There were few studies of people of Caribbean, African and other minority ethnic groups, few studies took a population based and prospective design and few investigated self harm among prisoners, asylum seekers and refugees.

CONCLUSION

This review finds some ethnic differences in the nature and presentation of self harm. This argues for ethnic specific preventive actions. However, the literature does not comprehensively cover the UK's diverse ethnic groups.

The effect of using NHS number as the unique identifier for patients who self-harm: a multi-centre descriptive study

Background

Processing personal data for research purposes and the requirement of anonymity has been the subject of recent debate. We aimed to determine the proportion of individuals who present to emergency departments with non-fatal suicidal behavior where an NHS number has been successfully traced and to investigate the characteristics of patients associated with non-capture.

Method

This was a descriptive study of people attending after self-harm using allocation of NHS numbers as main outcome measurement. Data from the Multicentre Monitoring of Self-Harm Project from 3 centres in England were used to identify consecutive patients (N = 3000) who were treated in six emergency departments in Oxford, Manchester and Leeds in 2004 and 2005 following self-harm.

Results

NHS number was available between 55–73% of individuals across centres. Characteristics associated with non-recording of NHS number in more than one centre included those from ethnic minority groups (Oxford: chi-squared statistic = 13.6, df = 3, p = 0.004; Manchester: chi-squared statistic = 13.6, df = 3, p ≤0.001) and the homeless or living in a hostel or other institution (Oxford: chi-squared statistic = 40.9, df = 7, p = <0.001; Manchester: chi-squared statistic = 23.5, df = 7, p = 0.001). Individual centre characteristics included being of male gender (Leeds: chi-squared statistic = 4.1, df = 1, p = 0.4), those under 25 years (Oxford: chi-squared statistic = 10.6, df = 2, p = 0.005), not being admitted to general hospital (Leeds: chi-squared statistic = 223.6, df = 1, p ≤0.001) and using self-injury as a method of harm (Leeds: chi-squared statistic = 41.5, df = 2, p ≤0.001).

Conclusion

Basing research studies on NHS number as the unique identifier, as suggested by the Data Protection Act 1998 and the Patient Information Advisory Group, would exclude some of the most vulnerable groups for further self-harm or suicide. This bias may also affect other research registers.

A Note on Recent Trends in Suicide in Fiji

The incidence of suicides and attempted suicides is one indicator of mental health and life satisfaction within the population. The trends in suicidal behaviour vary with sex and ethnicity within the population, and underscore the impact of culture on people's lives and wellbeing. Although incidence of suicide provides important information, there has been no systematic reporting of data within the country. The only source of national data is the statistics unit of Fiji's police force, who record all deaths that were not caused by disease, along with such data as the sex and ethnicity of the deceased. The police are willing to provide information on suicide to researchers and government bodies, within the constraints of having the staff and other resources needed to provide such information. The present article explores what we know about this important social issue, and investigates some potential ways forward for dealing with it at individual and group levels.

Ethnocultural aspects of suicide in young people: a systematic literature review part 1: Rates and methods of youth suicide

The study of ethnocultural aspects of suicidal behaviour is, at the moment, still a neglected area. The relatively few studies available are mainly on adults; young people usually are not examined separately. The authors reviewed 82 publications on youth suicide that have addressed, to different degrees, the ethnicity/culture of the population studied. Following a description of the main characteristics shared by these researches (e.g., predominance of studies on Blacks, Whites, and Hispanics; lack of qualitative methodology, etc.), the rates and methods of youth suicide, from a cross-cultural perspective are discussed.

Suicidality and migration among adolescents in Hong Kong

Suicide as a cause of death among adolescents and migration as a component of population have been growing in importance. Very little research has been conducted on the connections between migration and suicidality among adolescents in Hong Kong, and so is the aim of this article. It uses census and registration data to study suicide mortality, and sample survey data collected for this purpose to investigate suicide attempt, suicide ideation, and self-injurious behavior. Relations between suicidality and socio-demographic/psychological factors replicated those found in the literature. Duration of residence was found important for the study of suicide among migrants. In both the bivariate and multivariate analyses, although the suicidality levels for short-duration (less than 10 years) adolescent migrants were very much lower than the local-born counterparts, those for the long-duration (10 years or more) migrants were very much higher. The findings support the Healthy Migrant Hypothesis and other related hypotheses in migrant mortality studies. They also reveal, in the light of the Integration Theory of Suicide, the problem of migrant integration into the host culture and society, an important social problem for the government to solve.

Brief communication: differences between ethnic groups in demographic and clinical features of patients admitted and assessed after deliberate self-harm: a retrospective case-note study

BACKGROUND TO THE STUDY

When compared to the United Kingdom general population, rates of deliberate self-harm (DSH) are increased among certain ethnic groups, particularly in those from the Indian diaspora.

AIM

To investigate differences between ethnic groups in the demographic and clinical features of patients admitted after episodes of DSH and subsequently assessed by a nurse-led DSH liaison team.

METHOD

A retrospective case-note study (N = 297) with completion of a standardized data collection instrument. The ethnic origin of each patient was assessed by a variety of means.

RESULTS

Asian patients (n = 38) were more likely to be female (p = 0.043), married (p = 0.027), and cite problems with their partner (p = 0.017) as a precipitant to DSH. The indigenous group (n = 234) were more likely to have previous contact with psychiatric services (p = 0.023), to have used alcohol preceding DSH (p = 0.014), and to have a criminal record (p = 0.007).

CONCLUSIONS

In this population, the demographic and clinical features of patients assessed after DSH vary significantly with ethnic group. A case-control study is warranted to examine these differences in more detail.

Self-harm in the UK: differences between South Asians and Whites in rates, characteristics, provision of service and repetition

BACKGROUND

Rates of self-harm appear high in South Asian young women in the United Kingdom (UK) although previous studies were mostly small. Data on treatment and outcomes for South Asians are lacking. This study compared rates of self-harm, socio-demographic and clinical characteristics, provision of services and risk of repetition by ethnicity.

METHOD

A prospective cohort of adult self-harm attendees (n = 7185), aged 15 and over presenting to four emergency departments in the cities of Manchester and Salford, UK over a 4-year period.

RESULTS

The study included 299 South Asians. South Asian women aged 16-24 years were more likely to self-harm than Whites of the same age group (1010.9 vs. 754 per 100,000). Across all age groups the rates of self-harm were lower in South Asian men compared to White men and to South Asian women. South Asian women were significantly more likely to report relationship problems within the family than White women (32% vs. 19%, P = <0.001). South Asians were less likely than Whites to report depressive symptoms and to be offered specialist mental health services (Rate ratio = 0.75), and more likely to be referred back to the GP (Rate ratio = 1.83). South Asians were less likely to attend with a repeat episode (Rate ratio = 0.56).

CONCLUSIONS

Young South Asian women are at high risk of self-harm, but their clinical risk appears to be lower in terms of the accepted contextual factors contributing to risk. Potentially useful service provision may include an interpersonal problem solving approach although to be effective, interventions would need to be acceptable to South Asian women and culturally appropriate.

Self-harm in British South Asian women: psychosocial correlates and strategies for prevention

OBJECTIVE

To review the rates of self-harm in British South Asian women, look into the factors that contribute to these high rates of self-harm and discuss possible strategies for prevention and provision of culturally sensitive service for South Asian women who harm themselves.

METHOD

Review.

RESULTS

South Asian women are significantly more likely to self harm between ages 16-24 years than white women. Across all age groups the rates of self harm are lower in South Asian men as compared to South Asian women. These women are generally younger, likely to be married and less likely to be unemployed or use alcohol or other drugs. They report more relationship problems within the family. South Asian women are less likely to attend the ER with repeat episode since they hold the view that mainstream services do not meet their needs.

CONCLUSION

South Asian women are at an increased risk of self harm. Their demographic characteristics, precipitating factors and clinical management are different than whites. There is an urgent need for all those concerned with the mental health services for ethnic minorities to take positive action and eradicate the barriers that prevent British South Asians from seeking help. There is a need to move away from stereotypes and overgeneralisations and start from the user's frame of reference, taking into account family dynamics, belief systems and cultural constraints.

Gender differences in suicide risk by socio-demographic factors in Hong Kong

Some peculiarly low male-to-female suicide ratios have been reported in the Far Eastern populations. This article attempts to investigate whether there are gender differences in suicide risk by socio-demographic factors in Hong Kong, and hereby to explain the low male-to-female suicide ratios. The effects of marital status, duration-of-residence, and occupational status on suicide are first studied by periodic suicide rates in 1990-1992, and 2000-2002, then by Poisson regression. Some interesting results are found: Unlike most findings elsewhere, migration in Hong Kong did not induce suicide; occupational status was negatively related to suicide only for men but not for women; the particularly low male-to-female suicide ratio was not due to a larger protection from marriage for men than for women as reported in the literature, but very probably to a very high suicide rate for the non-working population. The authors suggest some plausible explanations of the findings and hence further research to be conducted.

Cultural traits and immigration: hostility and suicidality in Chinese Canadian students

Suicidality has been related to inwardly directed aggression. We compared convenience samples of 89 Canadian students of Chinese origin (CC) and 81 Canadian students from other backgrounds on measures of suicidality, hostility and aggression. The Chinese Canadian group reported higher levels of suicidality and hostility than the group of other Canadians. However, aggressive behaviors directed toward self or others were less frequent among Chinese Canadians. No differences were found between men and women. The results are interpreted by invoking the influence of Chinese culture on emotional restraint, particularly as regards aggressiveness.

Migration and mental health

OBJECTIVE

Migration and its accompanying stressors affect migrating individuals and their families. The process of migration is not simple or straightforward. The aim of this review is to distil existing information on how migration influences individuals' mental state and how it determines help seeking as well as pathways to care.

METHOD

The review relies on published studies in both MEDLINE and non-MEDLINE journals as well as relevant monographs. The search was employed using migration, ethnic communities, stress and other relevant words for purposes of the review.

RESULTS

The review provides a background on the typology of migration, its impact on communities as well as individuals. Furthermore, the relationship of mental illness to migration is explored and described. Future research plans are advocated in relationship with these findings.

CONCLUSION

Migration is and can be a very stress-inducing phenomenon. Yet not all migrants go through the same process. The clinician needs to be aware of coping strategies as well as resilience among migrants.

Globalisation and mental disorders. Overview with relation to depression

BACKGROUND

Globalisation is the process by which traditional boundaries of cultures are changing. Industrialisation, urbanisation and influence of the media are influencing idioms of distress across cultures.

AIMS

To discuss the role of globalisation, using the epidemiology, diagnosis, clinical presentation and treatment of depression across various cultures as an example.

METHOD

Recent studies focusing on transcultural aspects of depression were reviewed and summarised.

RESULTS

Cultural, social and religious mores account for variations in the presentation of depression across cultures. Somatic symptoms are common presenting features throughout the world and may serve as cultural idioms of distress, but psychological symptoms can usually be found when probed. Feelings of guilt and suicide rates vary across cultures and depression may be underdiagnosed.

CONCLUSIONS

Training packages could enhance clinicians'cultural competency in multicultural settings. However, globalisation is likely to influence idioms of distress and pathways to care in ways that are difficult to predict.

Inception rates of deliberate self-harm among adolescents in West London

BACKGROUND

Studies have suggested that inception rates of deliberate self-harm among different ethnic group adolescents are broadly similar.

AIMS

We set out to study the rates of adolescent self-harm over a calendar year in Ealing--part of West London.

METHODS

All cases of deliberate self-harm presenting to the A&E department and paediatrics were identified and socio-cultural factors studied. Ethnicity was obtained using self-ascription.

RESULTS

A total of 76 cases were identified over one year. Using the at risk population as denominator, no differences in inception rates were noted according to ethnicity. Overdoses were the commonest method used for deliberate self-harm.

CONCLUSIONS

The similarities between the Asian and white adolescents suggest that some common aetiological factors may be at play. The risk factors may be related to gender rather than ethnicity in this age group.

South Asian women, psychological distress and self-harm: lessons for primary care trusts

The present paper reports an investigation of the self-reported needs of South Asian women suffering distress and mental health problems which may lead to self-harm and suicide, and uses the data to define indicators of good practice for primary care. The design was a qualitative study using focus group discussion. Four focus groups of South Asian women (using existing women's groups in Manchester, UK) formed the setting for this study. Each focus group was facilitated by one of the authors, and the discussions occurred in Urdu, English and Punjabi. An interview guide was used, although the direction of the discussions followed the women's agenda. Notes were taken during the focus group discussions. Analysis of notes to define themes and emergence of framework was carried out. The data were analysed according to the principles of framework analysis. A range of systemic issues were described by respondents including: social, political and economic pressures; domestic violence; poverty; language problems; family and children's issues; and health. These experiences were reinforced by an extremely efficient community grapevine and were evident in described experiences such as: racism and stereotyping of Asian women; Asian communities and Islam; and the concept of izzat (honour) in Asian family life, which was seen as a major influence in the lives of Asian women. These experiences were thought to result in mental distress, which was described in a variety of ways by the women. The women saw self-harm as a usable coping strategy to deal with their distress. Perceived barriers to services were described by the women. Services tended to be accessed only at a point of desperation, rather than prior to crisis points. This indicated the need for services to be able to respond rapidly when Asian women did ask for help. Whilst the present paper describes a local study, thus limiting its generalisability, the use of such work in commissioning local health and social services is outlined. A number of indicators for good practice were drawn up in relation to addressing systemic issues in service provision using these findings. Such indicators will be of use by primary care trusts in developing, commissioning and monitoring services for this patient group.

Correlates of suicidal behaviors among Asian American outpatient youths

Medical record abstraction was conducted at an ethnic-specific mental health outpatient clinic to identify correlates of suicidal behaviors in a sample of 285 Asian American youths. Some risk factors, such as parent-child conflict and age, which have been associated with suicidality in majority group youths, predicted suicidality in this sample, whereas other risk factors, such as gender, did not generalize to this sample. Acculturation interacted with the risk factor of parent-child conflict to predict suicidality. Less acculturated Asian youths were at proportionally greater risk for suicidality under conditions of high parent-child conflict than were their more acculturated counterparts. This finding underscores the importance of culture as a context for determining the relevance of stressors for potentiating psychopathology.

Suicidal Behavior in South Asians in the UK

Summary: Rates of deliberate self-harm have been reported to be higher among South Asians, especially women, in the UK. Two studies collected information on inception rates of deliberate self-harm in the UK and reported that rates of attempted suicide are much higher among South Asian women especially those aged 18-24. These rates are associated with high rates of cultural alienation and previous attempts. The implications of cultural conflict are discussed in this context. In addition, a hypothetical model of interrelationship of factors for both adults and adolescents is described.

Preliminary study of non-psychotic disorders in people from the Indian subcontinent living in the UK and India

OBJECTIVE

The prevalence of anxiety and depressive disorders in people of South Asian origin in the UK is not accurately known.

METHOD

A population-based study of UK residents from the Indian subcontinent was screened for anxiety and depressive disorders with the Self-Rating Questionnaire (SRQ) and for life events using the brief list of threatening life events. Similar measures were administered to siblings in India.

RESULTS

The UK sample included 223 Sikhs, 100 Hindus and 49 Muslims. Elevated SRQ scores were recorded in 5%, 13% and 23%, respectively, of men from these groups and in 16%, 27% and 57%, respectively, of females. Subjects reporting one or more threatening life events (most commonly unemployment and financial problems) also had raised SRQ scores. A total of 117 siblings in India reported similar SRQ scores to their index subjects in the UK, but reported more threatening life events, notably deaths and illness in the family and financial problems.

CONCLUSION

This preliminary study indicates that psychiatric disorder in ethnic groups varies across religious groups. The prevalence may be high in some religious groups in association with social difficulties. The patterns of stress in India and the UK are different.

An epidemiological profile of elderly suicides in Hong Kong

Suicide rates in Hong Kong increased with age, and the highest suicide rate occurred among the oldest age groups. Hong Kong has one of the highest elderly suicide rates in the world. The elderly suicide rate was four to five times above the average. Furthermore, gender differences were observed among different marital status groups. For example, single males had a much higher rate than single females and married males had a higher rate than their widowed counterparts. The suicide rate for an economically inactive person was six times higher than for an active one. Jumping has become increasingly common and seems to substitute for other methods of suicide. Winter months and the Chinese New Year period had the lowest suicide occurrence. Some explanations are given.

Age, sex, marital status and suicide: an empirical study of east and west

The relationships among age, sex, marital status and suicidal behaviour in Australia and Hong Kong showed disparity in age-specific suicide rates among the four marital status groups, never married, married, widowed and divorced, for both sexes in the two locations. Examining the coefficients of preservation suggested the coefficient for never married to married in all cases was larger than 1, except for the groups of teenagers aged 15-19 years for both sexes and of elderly women aged 60 years or over in Hong Kong. The widowed or divorced groups have lower suicide rates than the married women among the elderly in Hong Kong. Hong Kong women seem not to have been benefited in marriage as much as men. Responsibility and workload in married life rather than low social status are the likely reasons for the relative high female suicide rate in Hong Kong. Possible cultural and environmental factors which are somewhat speculative (yet to be confirmed) are discussed.

Overdose among youth in Bahrain: psycho-social characteristics, contact with helping agencies and problems

A one year cohort of 67 overdose attempts among youth (15-24 years) was examined as part of a case control study. The prevalence rate of 105 per 100,000 population is lower than reported rates in the West but higher than those for the region. The majority of attempters were females and nationals who used paracetamol, and their suicide intent was low. Thirteen percent visited a helping agency in the previous week and 18% in the previous month. The most common difficulties preceding the overdoses were problems with parents, school or work, social isolation and problems with boyfriends, or girlfriends respectively. Adjustment disorder was the most common diagnosis followed by depression. A seasonal variation was noted with 46% of the cases occurring in the summer months. The implications of these findings with respect to future policy making and prevention were discussed.

Adverse social circumstances and depression in people of Pakistani origin in the UK

BACKGROUND

The social origins of depression in people of Pakistani origin in the UK are not fully understood; they may not be the same as for the indigenous White population.

METHOD

Patients attending a GP's surgery were screened with the Personal Health Questionnaire to detect depressive illness, which was confirmed using the Psychiatric Assessment Schedule; the estimated prevalence of major depression was 42%. Forty-four people with depression and 33 non-depressed comparison subjects were successfully interviewed using the Life Event and Difficulty Schedule, either in Urdu or English.

RESULTS

Seventy-five per cent of the sample were Pakistani born; 57% of cases and 33% of non-cases spoke English with difficulty. Seventy-five per cent of the cases and 36% of the non-cases had experienced an independent severe event and/or a major difficulty (P = 0.0015). Difficulties associated with depression were most commonly in the marital, health and housing categories; overt racial harassment and discrimination were rare.

CONCLUSIONS

This is a preliminary study because of the small sample of GP attenders. The somatic presentation of depression in this population is clear. Acceptable forms of social support and help with marital, housing and employment problems will be needed to help relieve the depression in this population.

Suicides in Hong Kong, 1981-1994

Suicide in Hong Kong is experiencing a slight upward trend. The standardized suicide rate increased by 9.8%, from 10.3 per 100,000 population in 1981 to 11.3 per 100,000 in 1994. About 57% of the increase can be explained by a change in the age composition and the ageing problem in Hong Kong. Suicide ranked seventh in the ten leading causes of death since 1985. It was the leading cause of death in females aged 15-24 years. The female suicide rate in Hong Kong was among the highest in the world. The suicide rate increased steadily with age. Males aged 75 years or over had the highest suicide rate among all age groups in the population. Furthermore, in single males aged 60 years, the suicide rate was 80 per 100,000. The suicide rate for economically inactive persons was 4 times more than for the active. Jumping has become increasingly common and seems to substitute for other methods of suicide. The years of potential life lost were 342 years per 100,000 population in 1994.

Recent stressors and family satisfaction in suicidal adolescents in South Africa

A study of 40 adolescents who had engaged in suicidal behaviours showed that 77.5% of them reported conflict with their parents in the few hours before the event. Significantly more suicidal subjects than controls experienced family conflict, problems at school and problems with boy/girlfriends during the preceding 6 months. The suicidal subjects also expressed significantly lower levels of family satisfaction than the controls. The results support the view that suicidal adolescents are dissatisfied with their family functioning and use suicidal behaviour as a means of communicating their distress.

A study of the geographical distribution of suicide rates in England and Wales 1989-92 using empirical bayes estimates

In order to achieve the suicide reduction targets proposed by the U.K. Government's The Health of the Nation document, it is necessary to determine its geographical distribution. This objective is approached using district level data for England and Wales, aggregated for 1989-92. Two techniques are used, and compared. The first is the traditional method of mapping Standardized Mortality Ratios (SMR), expressed as relative risks. The second technique employed is the relatively new method of empirical Bayes estimates (EBE). It is shown that this is a superior measure for an initial investigation of the distribution of suicide, as relative risks for this comparatively rare condition are highly dependent on the population size of the areas studied. Discernible trends of high risk are shown in high population density, urban areas for both sexes, and in economically depressed agricultural, rural areas for men. The effects of economic hardship, unemployment and social disintegration are suggested as contributing to this distribution in an initiatory or exacerbatory capacity, for those suffering from psychiatric vulnerability or existing mental illness. Suggestions are made for more detailed analyses of high risk areas.

Parasuicide in Pakistan: experience at a university hospital

There have been few reports of parasuicide from Pakistan, where the act is considered to be a criminal offence and the Islamic religion strongly disapproves of it. In order to address the problem, a retrospective case report analysis of all index cases of parasuicide presenting over a period of 3.5 years to a university hospital in Karachi, Pakistan, was undertaken. Our results showed that most of the subjects were young adults, with married women representing the single largest group. Self-poisoning with medication was the most common method, and benzodiazepines the most frequently used drug. Interpersonal conflict with the opposite sex was the most common precipitating cause. In Pakistani culture, marriage appears to be a significant source of stress for women. Reports based on official police records do not reflect the true picture of the problem in Pakistan.

Suicide patterns and trends in people of Indian subcontinent and Caribbean origin in England and Wales

OBJECTIVES

To examine suicide rates and trends in people of Indian subcontinent, east African and Caribbean origin using the latest mortality data available for England and Wales. To compare suicide rates in these groups with the baseline and target rates for suicide in the Health of the Nation strategy.

METHODS

Suicide data for England and Wales for 1988-1992, classified by the country of birth of the deceased, and population denominators from the 1991 Census were used for the analysis. Standardised mortality ratios (SMRs) for ages 15-64 and age-specific ratios were computed, using the age-sex specific rates for England and Wales as the standard. Trends over the preceding decade and suicide by burning were also analysed. Directly age-standardised suicide rates were derived to facilitate comparison with Health of the Nation baseline and target rates.

RESULTS

Suicide ratios were significantly low (SMRs 32, 52 and 55 respectively) in Bangladeshi, Sri Lankan and Pakistani born men at all ages, but raised in young Indian and east African men. Ratios were significantly high in Indian and east African women (143 and 154), with a 2-3 fold excess at ages 15-34 years. Ratios were low in Pakistani and Bangladeshi women overall, but elevated at 15-24 years. For the Caribbean-born, ratios were low overall but raised at ages 25-34. 20% of Asian female suicides were by burning. Indians are a high risk group in terms of the Health of the Nation suicide targets. Suicide trends in the minority ethnic groups reflect national trends.

CONCLUSIONS

This study confirms previous findings of high suicide rates in young Asian women. A new finding is the raised suicide rate in young Caribbeans. High suicide risks among young people from some ethnic minority communities are significant in the context of both the Health of the Nation strategy and recent governmental concern about the need to tackle health variations in the UK. Such deaths are indicative of larger numbers of young ethnic minority adults at risk of mental distress and self harm.

Suicide in Hong Kong 1971-1990: age trend, sex ratio, and method of suicide

This study gives an overview of the suicide rates in Hong Kong in the last 2 decades (1971-1990). It was found that the average suicide rate for the whole population was 11.3 per 100,000 population and it has been quite steady in recent years. The male and female adolescent (age-group 10-24 years) suicide rates were approximately the same, while the ratio of the overall male to female rate was 1.3:1. This indicated a relatively high female rate as compared with other countries. An examination of the suicide rates for various age-groups showed that the rate increased with age. The adolescent suicide rate was not particularly high (4.7 per 100,000 population for the age-group 10-24 years), but that for the elderly was 4-5 times the overall rate (49.5 per 100,000 population for those aged over 70 years). As regards the method of suicide, jumping from a height and hanging predominated in all age-groups. These methods were in great contrast to those used in other countries.

Suicide and self-burning among Indians and West Indians in England and Wales

Suicide levels in England and Wales during 1979-83 were low among males from the Indian subcontinent (SMR 73) and significantly high in young Indian women (age-specific ratios 273 and 160 at ages 15-24 and 25-34 respectively). Suicide levels were low in Caribbeans (SMRs 81 and 62 in men and women respectively) and high in East Africans (SMRs 128 and 148 in men and women respectively). The excess in East Africans (most of whom are of Indian origin) was largely confined to younger ages. Immigrant groups had significantly higher rates of suicide by burning, with a ninefold excess among women of Indian origin. The pressures leading to higher suicide levels among young women of Indian origin highlight the need for making appropriate forms of support and counselling available to this community.

Alcohol and attempted suicide

This study investigates the prevalence of excessive drinking and alcohol-related problems amongst suicide attempts. It also compares the characteristics of attempted suicide by alcohol consumption group. Drinking histories were taken on 250 consecutive attempted suicides admitted to the West Midlands Poisons Unit. Fifty-one per cent of the men and 31% of the women drank more than the weekly limits recommended by the Health Education Council. Of the men, 22.5% drank more than 50 units of alcohol a week and 9.5% of the women drank more than 35 units of alcohol a week. Alcohol-related problems (social problems, alcohol dependence or physical illness) were present in 34% of men and 15.5% of women. These results show a greater incidence of alcohol misuse than previous studies on attempted suicide. This is probably because detailed alcohol histories were taken on all patients. Alcohol misuse is best treated before major alcohol-related problems develop. Those responsible for assessing cases of attempted suicide should be adept at detecting alcohol misuse and instituting appropriate management.

Ethnic differences in adolescent self-poisoning: a comparison of Asian and Caucasian groups

A study of self-poisoning in 25 Asian and 25 Caucasian adolescents is presented. Cultural conflicts were the most important factors in the parasuicidal behaviour of Asian children, whereas a variety of factors accounted for the parasuicidal behaviour of Caucasians with a predominance of a disrupted family background. There was little difference in the type of poisoning and the degree of pre-planning between the two groups.

Sociocultural correlates of eating disorders among Asian schoolgirls in Bradford

A survey of 204 south-Asian and 355 Caucasian schoolgirls was conducted in Bradford using the EAT-26 and the BSQ. At interview, seven Asian girls and two Caucasian girls met DSM-III-R criteria for bulimia nervosa, yielding a prevalence of 3.4% and 0.6% respectively. One Asian girl met DSM-III-R criteria for anorexia nervosa. Factor analyses of the EAT and BSQ supported their cross-cultural conceptual equivalence in this south-Asian population. Among the Asians, high EAT and BSQ scores were associated with a more traditional cultural orientation and not with greater Westernisation. It is probable that these findings reflect the cultural and familial difficulties faced by these Asian girls growing up in Britain.

Age and attempted suicide

Clinical and demographic factors associated with suicide attempts admitted to the West Midlands Poisons Unit over a 2-year period were compared by age group. Risk factors for future suicide (living alone, physical illness, psychiatric illness and high suicidal intent in the attempt) were significantly more common among elderly patients (65 years and over) than middle-aged patients (35-64 years) and significantly less common among young patients (under 35 years) than middle-aged patients. Elderly patients that attempted suicide resemble elderly patients that completed suicide and should be considered at high risk of future suicide.

Ethnic differences in self poisoning: a comparative study between an Asian and white adolescent group

A preliminary retrospective case note study is presented comparing various characteristics of self poisoning between a White and an Asian group of adolescents. A group of 38 Asian and 34 White adolescents of ages 17 years and below, was studied. The results showed that the sex ratio of both samples was similar. Also, "Culture Conflict" was implicated in slightly more of the Asian female self poisoning as compared to the males. Asian females used "non ingestants" significantly more than their White counterparts, and significantly more described their overdose as "accidental". Significantly more White females were in care at the time of the overdose.