- Email: [email protected]
Suicide and self-harm in South Asian immigrants
SUICIDE IN SPECIFIC SUB-GROUPS
Suicide and self-harm in South Asian immigrants
What’s new? C
Comparative suicide rates are higher in older south Asian women
C
There is lack of evidence based interventions for self harm and suicide prevention in South Asians
Faria Khan Waquas Waheed
Abstract have shown that the proportion of the population from nonwhite minority ethnic groups increased by 53% between 1991 and 2001, from 3 million to 4.6 million (or 7.9% of the total UK population). Approximately 35% of these immigrants belong to families of South Asian origin (Pakistan, India, and Bangladesh).1 This population is diverse in terms of age, education, occupation, and religious affiliation.
Since earliest recorded times people have attempted and completed suicide. The reasons and methods of suicide show variations across cultures. UK censuses carried out in 2001 revealed that the proportion of the UK population belonging to a non-white minority ethnic group increased, from 3 million to 4.6 million (or 7.9% of the total UK population). This population is diverse in terms of age, education and occupation. Based on available research over the years, an increase in number of suicides, particularly among Asians, has been reported. Social and cultural factors, mainly social integration and religion, play an important part in determining varying rates of suicide. Cross-sectional surveys suggest that factors to do with people’s attempts to commit suicide relate to both their home culture and the culture of the host country e ‘acculturation stress’. This may increase the likelihood of attempted suicide. Committing suicide by burning, poisoning and using pesticides are common in female migrants. Despite a comparatively high prevalence of depression, self-harm and suicide, there is a lack of treatment evidence for these ethnic minority groups, which results in a delay in help-seeking and in accessibility and awareness of pathways of care. Issues that are related to the person’s sociocultural background should be examined in particular while assessing for suicide risk. Additionally, there is a need to look at risk and protective factors in these ethnic groups, which can guide us in developing culturally sensitive interventions.
Historical and religious background Since earliest recorded times, humans have attempted and completed suicide, and the reasons and methods of suicide show variation across cultures. For example, ancient Hindu texts allowed individuals to kill themselves: ‘Sati’ (a Hindu widow throwing herself on to her husband’s funeral pile) has existed as an act of ritual suicide amongst Hindus for several centuries. Although now unlawful, it still occurs occasionally in India. Cultural factors and gender role expectations of being a good wife play a significant role in the act and its consequences. Other religions, particularly Islam, forbid suicide, and this is the main reason why suicide is unlawful and still remains a socially unacceptable act, especially for Muslims.
Rates of suicide in South Asian immigrants
Keywords acculturation stress; culture; ethnicity; non-fatal self-harm;
Suicide rates among the immigrant population in the UK were first published in the national analysis of immigrant mortality in the 1970s. Since then, a consistent increase in the number of suicides among the Asian immigrant population has been reported.2 A series of publications by Raleigh and Balarajan on rates of suicide in ethnic minorities in the UK showed that standardized mortality rates for suicide were three times higher than national rates for young Indian females (aged 15e34 years), with an excess mortality rate of 43%. Rates were lower for Indian males and elderly Indian women than for the corresponding members of the white population.3,4 These mortality rates appear to be rising. Recent analysis of suicide mortality data (1999e2003) shows that the age-specific suicide rate in young women of South Asian origin was lower than that for women in England and Wales. The suicide rate in those over 65 years was double that of England and Wales.5 Immigrants from the Indian subcontinent settled in non-Western countries such as Malaysia and Fiji have rates of suicide up to six times greater than those of the native populations.2
South Asian immigrants; suicide
Substantial numbers of migrants from Asia, Africa, Eastern Europe, and the Caribbean islands reside in Western countries, particularly the UK, North America, and Australia. UK censuses
Faria Khan MRCPsych MSc Healthcare Management is a Consultant in Child and Adolescent Psychiatry at Early Intervention in Psychosis services, Lancashire, UK. She qualified from Punjab University, Pakistan, and trained in psychiatry in Pakistan, Ireland, and the UK. Her research interests include first-episode psychosis in autism, mental health of adolescent ethnic minorities, and child mental health service development. Conflicts of interest: none declared. Waquas Waheed MRCPsych is Academic Consultant Psychiatrist and Honorary Clinical Lecturer at the University of Manchester, UK. He qualified in Pakistan and trained in Pakistan, Coventry, and Manchester. His research interests include mental health of ethnic minorities and developing innovative culturally sensitive interventions. Conflicts of interest: none declared.
PSYCHIATRY 8:7
Suicidal ideation and self-harm in South Asian immigrants Self-harm and suicide rates follow largely the same pattern. Lifetime attempted suicide was reported by 3% of the sample in the UK
261
Ó 2009 Published by Elsevier Ltd.
SUICIDE IN SPECIFIC SUB-GROUPS
Ethnic Minority Psychiatric Illness Rates in the Community Survey. Low rates were reported by men (with the exception of Irish males) and higher rates amongst females of Pakistani and Indian origin.6 Other studies of rates of self-harm from hospitalbased samples follow a similar pattern, with higher rates in South Asian females compared with white females and South Asian males. However, there do not appear to be differences in the rates of self-harm in South Asian and white adolescent females.7,8
Despite the fact that the earlier generations of immigrants strived to adhere to their own cultural systems, with the passage of time later generations are becoming increasingly westernized in their approach to life and social values. The rate of acculturation is much higher in later generations of immigrants who have been born and brought up in the West. Effect of religion Amongst ethnic minority groups, Muslims have lower rates of suicide compared with practising Hindus or Sikhs.11 This trend is evident not only in the UK but also in other countries, such as Fiji and South Africa, where they have settled as minorities.2
Comparison of associated factors Cultural issues Social and cultural factors, mainly social integration and religion, play an important part in determining varying rates of suicide in different parts of the world (Figure 1). Cross-sectional surveys in North America suggest that factors associated with people’s suicide attempts relate both to their home culture and to the culture of their host country.9,10 Over time, immigrants tend to experience ‘acculturative stress’ when trying to assimilate with the host culture. Rates of acculturative stress experienced vary with individuals, and first- and second-generation family members may acculturate at a different pace. This often leads to conflicts within the family and may increase the likelihood of attempted suicide.9,10 Most immigrant communities have retained their traditions and cultural identity even after years of living abroad. Migrants can experience emotional and physical stress, in addition to having to deal with a new culture, language, and social norms. Traditionally, an extended family is the structure of a subcontinent family, with multiple generations living together. The male is the head, breadwinner, and decision-maker of the family. The elderly are respected and honoured, and preference is given to male children. Arranged marriages are commonplace. Girls are very well protected and are expected to be virgins at the time of marriage e the family and community will reject an unmarried pregnant girl. Marriage has to be respected as an institution and personal sacrifices are expected, particularly from women, to keep a marriage intact in spite of mounting marital conflicts.
Social class differences Based on coroners’ verdicts, the proportion of suicides amongst professionals and managerial people from the Indian subcontinent is higher than among those of lower socio-economic status. Doctors and dentists, in particular, are over-represented.3,4 Culture-specific precipitating factors Young adolescents, particularly girls, become caught between two cultures and develop two identities: an identity for home and another identity for school. They have disciplinary arguments with parents around cultural issues, such as having a relationship with a white person, opposition to arranged marriages, expectation of entering higher education, and eventually planning to take up employment. This asynchronous acculturation leads to interpersonal conflicts within the immediate family and is a source of psychological distress. South Asian adolescents also tend to have more problems with siblings compared with their white counterparts.7 Married women commit suicide mainly because of problems in their relationships with in-laws, punctuated by repeated insults, taunts, and marital violence. Other factors can include their inability to bear children, particularly male children. These factors are cited as reasons for the higher rates of suicide amongst South Asian female immigrants compared with females from white or other ethnic minority populations.
Ethnic density Ethnic density refers to the proportion of either a specific or all groups of ethnic minorities in a particular geographical area.12 In areas of lower ethnic density, rates of self-harm rise with increasing ethnic density. After a peak (when ethnic density is around a standard deviation below the study area mean), selfharm then decreases with a further increase in the density.13
Model for stress and suicide in minority ethnic groups Vulnerability factors Female gender Social roles Cultural identity Low educational level
Maintaining factors Acculturation stress Parental expectations Lack of social support Lack of help-seeking Lack of appropriate services
Differences in methods of suicide Suicide by hanging has been reported as the most common method employed by immigrants to the UK from the Indian subcontinent. Suicide by burning, and poisoning using pesticides, are common among female migrants. South Asian females are over-represented amongst cases of self-inflicted burns in all such cases reported in UK.2
Precipitating factors Interpersonal problems Marital conflict Domestic violence
Presence of mental illness There is a lack of evidence regarding diagnosis of mental illness in ethnic minority suicide victims, despite this being the most
Figure 1
PSYCHIATRY 8:7
262
Ó 2009 Published by Elsevier Ltd.
SUICIDE IN SPECIFIC SUB-GROUPS
common cause of suicide in Western countries. The EMPIRIC study found that subjects who had attempted suicide in the past had higher distress scores.14 Some 6% of all suicides committed within 12 months of contact with psychiatric services were by people from ethnic minority populations. The most common method of suicide was hanging; violent methods were more common than in white patient suicides. Schizophrenia was the most common diagnosis. Patients from ethnic minorities were more likely to have been unemployed than white patients and to have had a history of violence and recent non-compliance. In around half of the cases of suicide, this was the first episode of self-harm.15 Depression has been reported to be less common in the selfharming South Asian population. Impulsive acts of self-harm due to interpersonal stress are more frequent, especially in the adolescent age group.7
Assessment following a recent suicide attempt in people from ethnic minority groups8 Assess the following: C
C C C C C C C
Migration (if indicated) and associated stressors and social support Cultural identity and cultural alienation Gender-role expectations Type of family network (e.g. extended, nuclear) Social support and confidantes Cultural idioms of distress and expectations Any previous racial life events Note that suicidal motivation may be interpreted by the attempter in terms of cultural expectations of behaviour
Delay in seeking help Box 1
Evidence suggests that South Asian females seek help at the point of desperation very late in the course of their problems.16 This phenomenon can be explained by the cultural factors discussed above, whereby seeking help for mental distress is considered stigmatizing and socially unacceptable. South Asian females are half as likely to obtain medical attention following attempted suicide compared with white British and Irish patients. The participants in this study16 also agreed that an inability to speak English increased their sense of isolation, and that the absence of a confiding relationship was also a precipitating factor for their behaviour. The women used self-harm as a response to social isolation and as a logical behaviour to reduce distress and ask for help.16
groups, the therapeutic processes and delivery mechanisms for the interventions need to be tailored to make them more appropriate and acceptable. Specific preventive actions must take account of the ethnic variations of clinical indices of risk and include more effective treatment of psychosis.18 Bhugra and Hicks piloted an educational pamphlet about depression and suicidality.19 After reading the pamphlet, significantly more women assessed themselves as willing to confide in their clinicians, friends, and spouses if they felt depressed or suicidal, rather than not telling anyone. In addition, more women reported that they felt antidepressants were helpful for depression after they had read the pamphlet. These changes remained 4e6 weeks later.19
Pathways to care Participants in a qualitative study16 stated that they would be unable to access mainstream services because they would not be able to trust the providers of these services. The fear of the community ‘grapevine’ even prevents these women from seeking help from their general practitioners (GPs). They worried that ‘the GP might be your family GP and may tell your parents’ or ‘it would go down on your record’. The women also feared that the general practice staff or the GP might be part of the local community. As stated above, these women already have a feeling of isolation, and this is increased by the barriers to accessing GPs and other service providers.16 An audit of the management of self-harm in accident and emergency departments revealed that South Asian women were managed differently, even though there were no differences in their clinical presentation and risk assessment women compared with white females. Interpersonal family conflicts were the main precipitating factors, yet these women were sent back home under the care of their GP, whereas white women were referred more frequently to mental health services.17
Assessment General principles of suicide risk assessment are applicable, although issues specific to the person’s sociocultural background should also be investigated (Box 1). Language must never be allowed to create a barrier to assessment, and properly trained interpreters should be involved. Training healthcare staff in using interpreters will
Prevention strategies C
C
C
C
Lack of treatment evidence and services In spite of comparatively high rates of depression, self-harm, and suicide, there is a lack of treatment evidence for South Asian immigrants. Evidence-based interventions are available for the general population but, owing to the specific needs of these
PSYCHIATRY 8:7
School-based health education programmes: awareness, peer support, teacher awareness, parental awareness Community-based health education programmes: work with print, electronic media, voluntary, and religious organizations Culturally sensitive psychological interventions: psychological therapies adapted and delivered by non-conventional methods (e.g. telephone, self-help) Culturally sensitive health services: enhance cultural competence of staff at all tiers of health services; support for at-risk groups and enhancing the maintenance of interventions
Box 2
263
Ó 2009 Published by Elsevier Ltd.
SUICIDE IN SPECIFIC SUB-GROUPS
10 Hovey JD, King CA. Acculturative stress, depression, and suicidal ideation among immigrant and second-generation Latino adolescents. J Am Acad Child Adolesc Psychiatry 1996; 35: 1183e92. 11 Raleigh VS, Bulusu L, Balarajan R. Suicides among immigrants from the Indian Subcontinent. Br J Psychiatry 1990; 156: 46e50. 12 Bhui K, McKenzie K, Rasul F. Rates, risk factors and methods of self harm among minority ethnic groups in the UK: a systematic review. BMC Public Health 2007; 7: 336. 13 Neeleman J, Wilson-Jones C, Wessley S. Ethnic density and deliberate self-harm; a small area study in South East London. J epidemiol Community Health 2001; 55: 85e90. 14 Weich S, Nazroo J, Sproston K, et al. Common mental disorders and ethnicity in England: the EMPIRIC study. Psychol Med 2004; 34: 1543e51. 15 Hunt IM, Robinson J, Bickley H, et al. Suicides in ethnic minorities within 12 months of contact with mental health services. National clinical survey. Br J Psychiatry 2003; 183: 155e60. 16 Chew-Graham C, Bashir C, Chantler K, Burman E, Batsleer J. South Asian women, psychological distress and self-harm: lessons for primary care trusts. Health Soc Care Community 2002; 10: 339e47. 17 Cooper J, Husain N, Webb R. Self-harm in the UK: differences between South Asians and Whites in rates, characteristics, provision of service and repetition. Soc Psychiatry Psychiatr Epidemiol 2006; 41: 782e8. 18 Bhui KS, McKenzie K. Rates and risk factors by ethnic group for suicides within a year of contact with mental health services in England and Wales. Psychiatr Serv 2008; 59: 414e20. 19 Bhugra D, Hicks MH. Effect of an educational pamphlet on helpseeking attitudes for depression among British South Asian Women. Psychiatr Serv 2004; 55: 827e9.
increase the quality of such three-way communication. Owing to possible sensitivities, the use of family members as interpreters should be avoided.
Prevention of suicide in South Asian immigrants The key to developing effective prevention strategies is to employ them at the right time and to make them culturally sensitive. With no differences in suicide rates in adolescents and then a sudden rise in the rates among young women, this offers us a chance to focus on this window of opportunity. Further research into risk and protective factors at this level can guide us in developing our interventions (Box 2). A
REFERENCES 1 National Statistics. United Kingdom national census 2001. Also available at: http://www.ons.gov.uk/about-statistics/classifications/ archived/ethnic-interim/index.html (accessed May 2009). 2 Patel SP, Gaw AC. Suicide among immigrants from the Indian subcontinent: a review. Psychiatr Serv 1996; 47: 517e21. 3 Raleigh VS. Suicide patterns and trends in people of Indian subcontinent and Caribbean origin in England and Wales. Ethn Health 1996; 1: 55e63. 4 Raleigh VS, Balarajan R. Suicide and self-burning among Indians and West Indians in England and Wales. Br J Psychiatry 1992; 161: 365e8. 5 McKenzie K, Bhui K, Nanchahal K, Blizard B. Suicide rates in people of South Asian origin in England and Wales: 1993e2003. Br J Psychiatry 2008; 193: 406e9. 6 Crawford MJ, Nur U, McKenzie K, Tyrer P. Suicidal ideation and suicide attempts among ethnic minority groups in England: results of a national household survey. Psychol Med 2005; 35: 1369e77. 7 Bhugra D, Baldwin DS, Desai M. Attempted suicide in west London, I. Rates across ethnic communities. Psychol Med 1999; 29: 1125e30. 8 Bhugra D, Desai M. Attempted suicide in South Asian women. Adv Psychiatr Treat 2002; 8: 418e23. 9 Hovey JD. Acculturative stress, depression, and suicidal ideation in Mexican immigrants. Cultur Divers Ethnic Minor Psychol 2000; 6: 134e51.
PSYCHIATRY 8:7
FURTHER READING Yazdani A, Marshall H. Young Asian women and self-harm: a mental health needs assessment of young Asian women in Newham, East London. A qualitative study. London: Newham Innercity Multifund and Newham Asian Women’s Project, 1998. (Discusses cultural issues around self-harm and describes how to meet health service needs.)
264
Ó 2009 Published by Elsevier Ltd.
Suicide and self-harm in South Asian immigrants
What’s new? C
Comparative suicide rates are higher in older south Asian women
C
There is lack of evidence based interventions for self harm and suicide prevention in South Asians
Faria Khan Waquas Waheed
Abstract have shown that the proportion of the population from nonwhite minority ethnic groups increased by 53% between 1991 and 2001, from 3 million to 4.6 million (or 7.9% of the total UK population). Approximately 35% of these immigrants belong to families of South Asian origin (Pakistan, India, and Bangladesh).1 This population is diverse in terms of age, education, occupation, and religious affiliation.
Since earliest recorded times people have attempted and completed suicide. The reasons and methods of suicide show variations across cultures. UK censuses carried out in 2001 revealed that the proportion of the UK population belonging to a non-white minority ethnic group increased, from 3 million to 4.6 million (or 7.9% of the total UK population). This population is diverse in terms of age, education and occupation. Based on available research over the years, an increase in number of suicides, particularly among Asians, has been reported. Social and cultural factors, mainly social integration and religion, play an important part in determining varying rates of suicide. Cross-sectional surveys suggest that factors to do with people’s attempts to commit suicide relate to both their home culture and the culture of the host country e ‘acculturation stress’. This may increase the likelihood of attempted suicide. Committing suicide by burning, poisoning and using pesticides are common in female migrants. Despite a comparatively high prevalence of depression, self-harm and suicide, there is a lack of treatment evidence for these ethnic minority groups, which results in a delay in help-seeking and in accessibility and awareness of pathways of care. Issues that are related to the person’s sociocultural background should be examined in particular while assessing for suicide risk. Additionally, there is a need to look at risk and protective factors in these ethnic groups, which can guide us in developing culturally sensitive interventions.
Historical and religious background Since earliest recorded times, humans have attempted and completed suicide, and the reasons and methods of suicide show variation across cultures. For example, ancient Hindu texts allowed individuals to kill themselves: ‘Sati’ (a Hindu widow throwing herself on to her husband’s funeral pile) has existed as an act of ritual suicide amongst Hindus for several centuries. Although now unlawful, it still occurs occasionally in India. Cultural factors and gender role expectations of being a good wife play a significant role in the act and its consequences. Other religions, particularly Islam, forbid suicide, and this is the main reason why suicide is unlawful and still remains a socially unacceptable act, especially for Muslims.
Rates of suicide in South Asian immigrants
Keywords acculturation stress; culture; ethnicity; non-fatal self-harm;
Suicide rates among the immigrant population in the UK were first published in the national analysis of immigrant mortality in the 1970s. Since then, a consistent increase in the number of suicides among the Asian immigrant population has been reported.2 A series of publications by Raleigh and Balarajan on rates of suicide in ethnic minorities in the UK showed that standardized mortality rates for suicide were three times higher than national rates for young Indian females (aged 15e34 years), with an excess mortality rate of 43%. Rates were lower for Indian males and elderly Indian women than for the corresponding members of the white population.3,4 These mortality rates appear to be rising. Recent analysis of suicide mortality data (1999e2003) shows that the age-specific suicide rate in young women of South Asian origin was lower than that for women in England and Wales. The suicide rate in those over 65 years was double that of England and Wales.5 Immigrants from the Indian subcontinent settled in non-Western countries such as Malaysia and Fiji have rates of suicide up to six times greater than those of the native populations.2
South Asian immigrants; suicide
Substantial numbers of migrants from Asia, Africa, Eastern Europe, and the Caribbean islands reside in Western countries, particularly the UK, North America, and Australia. UK censuses
Faria Khan MRCPsych MSc Healthcare Management is a Consultant in Child and Adolescent Psychiatry at Early Intervention in Psychosis services, Lancashire, UK. She qualified from Punjab University, Pakistan, and trained in psychiatry in Pakistan, Ireland, and the UK. Her research interests include first-episode psychosis in autism, mental health of adolescent ethnic minorities, and child mental health service development. Conflicts of interest: none declared. Waquas Waheed MRCPsych is Academic Consultant Psychiatrist and Honorary Clinical Lecturer at the University of Manchester, UK. He qualified in Pakistan and trained in Pakistan, Coventry, and Manchester. His research interests include mental health of ethnic minorities and developing innovative culturally sensitive interventions. Conflicts of interest: none declared.
PSYCHIATRY 8:7
Suicidal ideation and self-harm in South Asian immigrants Self-harm and suicide rates follow largely the same pattern. Lifetime attempted suicide was reported by 3% of the sample in the UK
261
Ó 2009 Published by Elsevier Ltd.
SUICIDE IN SPECIFIC SUB-GROUPS
Ethnic Minority Psychiatric Illness Rates in the Community Survey. Low rates were reported by men (with the exception of Irish males) and higher rates amongst females of Pakistani and Indian origin.6 Other studies of rates of self-harm from hospitalbased samples follow a similar pattern, with higher rates in South Asian females compared with white females and South Asian males. However, there do not appear to be differences in the rates of self-harm in South Asian and white adolescent females.7,8
Despite the fact that the earlier generations of immigrants strived to adhere to their own cultural systems, with the passage of time later generations are becoming increasingly westernized in their approach to life and social values. The rate of acculturation is much higher in later generations of immigrants who have been born and brought up in the West. Effect of religion Amongst ethnic minority groups, Muslims have lower rates of suicide compared with practising Hindus or Sikhs.11 This trend is evident not only in the UK but also in other countries, such as Fiji and South Africa, where they have settled as minorities.2
Comparison of associated factors Cultural issues Social and cultural factors, mainly social integration and religion, play an important part in determining varying rates of suicide in different parts of the world (Figure 1). Cross-sectional surveys in North America suggest that factors associated with people’s suicide attempts relate both to their home culture and to the culture of their host country.9,10 Over time, immigrants tend to experience ‘acculturative stress’ when trying to assimilate with the host culture. Rates of acculturative stress experienced vary with individuals, and first- and second-generation family members may acculturate at a different pace. This often leads to conflicts within the family and may increase the likelihood of attempted suicide.9,10 Most immigrant communities have retained their traditions and cultural identity even after years of living abroad. Migrants can experience emotional and physical stress, in addition to having to deal with a new culture, language, and social norms. Traditionally, an extended family is the structure of a subcontinent family, with multiple generations living together. The male is the head, breadwinner, and decision-maker of the family. The elderly are respected and honoured, and preference is given to male children. Arranged marriages are commonplace. Girls are very well protected and are expected to be virgins at the time of marriage e the family and community will reject an unmarried pregnant girl. Marriage has to be respected as an institution and personal sacrifices are expected, particularly from women, to keep a marriage intact in spite of mounting marital conflicts.
Social class differences Based on coroners’ verdicts, the proportion of suicides amongst professionals and managerial people from the Indian subcontinent is higher than among those of lower socio-economic status. Doctors and dentists, in particular, are over-represented.3,4 Culture-specific precipitating factors Young adolescents, particularly girls, become caught between two cultures and develop two identities: an identity for home and another identity for school. They have disciplinary arguments with parents around cultural issues, such as having a relationship with a white person, opposition to arranged marriages, expectation of entering higher education, and eventually planning to take up employment. This asynchronous acculturation leads to interpersonal conflicts within the immediate family and is a source of psychological distress. South Asian adolescents also tend to have more problems with siblings compared with their white counterparts.7 Married women commit suicide mainly because of problems in their relationships with in-laws, punctuated by repeated insults, taunts, and marital violence. Other factors can include their inability to bear children, particularly male children. These factors are cited as reasons for the higher rates of suicide amongst South Asian female immigrants compared with females from white or other ethnic minority populations.
Ethnic density Ethnic density refers to the proportion of either a specific or all groups of ethnic minorities in a particular geographical area.12 In areas of lower ethnic density, rates of self-harm rise with increasing ethnic density. After a peak (when ethnic density is around a standard deviation below the study area mean), selfharm then decreases with a further increase in the density.13
Model for stress and suicide in minority ethnic groups Vulnerability factors Female gender Social roles Cultural identity Low educational level
Maintaining factors Acculturation stress Parental expectations Lack of social support Lack of help-seeking Lack of appropriate services
Differences in methods of suicide Suicide by hanging has been reported as the most common method employed by immigrants to the UK from the Indian subcontinent. Suicide by burning, and poisoning using pesticides, are common among female migrants. South Asian females are over-represented amongst cases of self-inflicted burns in all such cases reported in UK.2
Precipitating factors Interpersonal problems Marital conflict Domestic violence
Presence of mental illness There is a lack of evidence regarding diagnosis of mental illness in ethnic minority suicide victims, despite this being the most
Figure 1
PSYCHIATRY 8:7
262
Ó 2009 Published by Elsevier Ltd.
SUICIDE IN SPECIFIC SUB-GROUPS
common cause of suicide in Western countries. The EMPIRIC study found that subjects who had attempted suicide in the past had higher distress scores.14 Some 6% of all suicides committed within 12 months of contact with psychiatric services were by people from ethnic minority populations. The most common method of suicide was hanging; violent methods were more common than in white patient suicides. Schizophrenia was the most common diagnosis. Patients from ethnic minorities were more likely to have been unemployed than white patients and to have had a history of violence and recent non-compliance. In around half of the cases of suicide, this was the first episode of self-harm.15 Depression has been reported to be less common in the selfharming South Asian population. Impulsive acts of self-harm due to interpersonal stress are more frequent, especially in the adolescent age group.7
Assessment following a recent suicide attempt in people from ethnic minority groups8 Assess the following: C
C C C C C C C
Migration (if indicated) and associated stressors and social support Cultural identity and cultural alienation Gender-role expectations Type of family network (e.g. extended, nuclear) Social support and confidantes Cultural idioms of distress and expectations Any previous racial life events Note that suicidal motivation may be interpreted by the attempter in terms of cultural expectations of behaviour
Delay in seeking help Box 1
Evidence suggests that South Asian females seek help at the point of desperation very late in the course of their problems.16 This phenomenon can be explained by the cultural factors discussed above, whereby seeking help for mental distress is considered stigmatizing and socially unacceptable. South Asian females are half as likely to obtain medical attention following attempted suicide compared with white British and Irish patients. The participants in this study16 also agreed that an inability to speak English increased their sense of isolation, and that the absence of a confiding relationship was also a precipitating factor for their behaviour. The women used self-harm as a response to social isolation and as a logical behaviour to reduce distress and ask for help.16
groups, the therapeutic processes and delivery mechanisms for the interventions need to be tailored to make them more appropriate and acceptable. Specific preventive actions must take account of the ethnic variations of clinical indices of risk and include more effective treatment of psychosis.18 Bhugra and Hicks piloted an educational pamphlet about depression and suicidality.19 After reading the pamphlet, significantly more women assessed themselves as willing to confide in their clinicians, friends, and spouses if they felt depressed or suicidal, rather than not telling anyone. In addition, more women reported that they felt antidepressants were helpful for depression after they had read the pamphlet. These changes remained 4e6 weeks later.19
Pathways to care Participants in a qualitative study16 stated that they would be unable to access mainstream services because they would not be able to trust the providers of these services. The fear of the community ‘grapevine’ even prevents these women from seeking help from their general practitioners (GPs). They worried that ‘the GP might be your family GP and may tell your parents’ or ‘it would go down on your record’. The women also feared that the general practice staff or the GP might be part of the local community. As stated above, these women already have a feeling of isolation, and this is increased by the barriers to accessing GPs and other service providers.16 An audit of the management of self-harm in accident and emergency departments revealed that South Asian women were managed differently, even though there were no differences in their clinical presentation and risk assessment women compared with white females. Interpersonal family conflicts were the main precipitating factors, yet these women were sent back home under the care of their GP, whereas white women were referred more frequently to mental health services.17
Assessment General principles of suicide risk assessment are applicable, although issues specific to the person’s sociocultural background should also be investigated (Box 1). Language must never be allowed to create a barrier to assessment, and properly trained interpreters should be involved. Training healthcare staff in using interpreters will
Prevention strategies C
C
C
C
Lack of treatment evidence and services In spite of comparatively high rates of depression, self-harm, and suicide, there is a lack of treatment evidence for South Asian immigrants. Evidence-based interventions are available for the general population but, owing to the specific needs of these
PSYCHIATRY 8:7
School-based health education programmes: awareness, peer support, teacher awareness, parental awareness Community-based health education programmes: work with print, electronic media, voluntary, and religious organizations Culturally sensitive psychological interventions: psychological therapies adapted and delivered by non-conventional methods (e.g. telephone, self-help) Culturally sensitive health services: enhance cultural competence of staff at all tiers of health services; support for at-risk groups and enhancing the maintenance of interventions
Box 2
263
Ó 2009 Published by Elsevier Ltd.
SUICIDE IN SPECIFIC SUB-GROUPS
10 Hovey JD, King CA. Acculturative stress, depression, and suicidal ideation among immigrant and second-generation Latino adolescents. J Am Acad Child Adolesc Psychiatry 1996; 35: 1183e92. 11 Raleigh VS, Bulusu L, Balarajan R. Suicides among immigrants from the Indian Subcontinent. Br J Psychiatry 1990; 156: 46e50. 12 Bhui K, McKenzie K, Rasul F. Rates, risk factors and methods of self harm among minority ethnic groups in the UK: a systematic review. BMC Public Health 2007; 7: 336. 13 Neeleman J, Wilson-Jones C, Wessley S. Ethnic density and deliberate self-harm; a small area study in South East London. J epidemiol Community Health 2001; 55: 85e90. 14 Weich S, Nazroo J, Sproston K, et al. Common mental disorders and ethnicity in England: the EMPIRIC study. Psychol Med 2004; 34: 1543e51. 15 Hunt IM, Robinson J, Bickley H, et al. Suicides in ethnic minorities within 12 months of contact with mental health services. National clinical survey. Br J Psychiatry 2003; 183: 155e60. 16 Chew-Graham C, Bashir C, Chantler K, Burman E, Batsleer J. South Asian women, psychological distress and self-harm: lessons for primary care trusts. Health Soc Care Community 2002; 10: 339e47. 17 Cooper J, Husain N, Webb R. Self-harm in the UK: differences between South Asians and Whites in rates, characteristics, provision of service and repetition. Soc Psychiatry Psychiatr Epidemiol 2006; 41: 782e8. 18 Bhui KS, McKenzie K. Rates and risk factors by ethnic group for suicides within a year of contact with mental health services in England and Wales. Psychiatr Serv 2008; 59: 414e20. 19 Bhugra D, Hicks MH. Effect of an educational pamphlet on helpseeking attitudes for depression among British South Asian Women. Psychiatr Serv 2004; 55: 827e9.
increase the quality of such three-way communication. Owing to possible sensitivities, the use of family members as interpreters should be avoided.
Prevention of suicide in South Asian immigrants The key to developing effective prevention strategies is to employ them at the right time and to make them culturally sensitive. With no differences in suicide rates in adolescents and then a sudden rise in the rates among young women, this offers us a chance to focus on this window of opportunity. Further research into risk and protective factors at this level can guide us in developing our interventions (Box 2). A
REFERENCES 1 National Statistics. United Kingdom national census 2001. Also available at: http://www.ons.gov.uk/about-statistics/classifications/ archived/ethnic-interim/index.html (accessed May 2009). 2 Patel SP, Gaw AC. Suicide among immigrants from the Indian subcontinent: a review. Psychiatr Serv 1996; 47: 517e21. 3 Raleigh VS. Suicide patterns and trends in people of Indian subcontinent and Caribbean origin in England and Wales. Ethn Health 1996; 1: 55e63. 4 Raleigh VS, Balarajan R. Suicide and self-burning among Indians and West Indians in England and Wales. Br J Psychiatry 1992; 161: 365e8. 5 McKenzie K, Bhui K, Nanchahal K, Blizard B. Suicide rates in people of South Asian origin in England and Wales: 1993e2003. Br J Psychiatry 2008; 193: 406e9. 6 Crawford MJ, Nur U, McKenzie K, Tyrer P. Suicidal ideation and suicide attempts among ethnic minority groups in England: results of a national household survey. Psychol Med 2005; 35: 1369e77. 7 Bhugra D, Baldwin DS, Desai M. Attempted suicide in west London, I. Rates across ethnic communities. Psychol Med 1999; 29: 1125e30. 8 Bhugra D, Desai M. Attempted suicide in South Asian women. Adv Psychiatr Treat 2002; 8: 418e23. 9 Hovey JD. Acculturative stress, depression, and suicidal ideation in Mexican immigrants. Cultur Divers Ethnic Minor Psychol 2000; 6: 134e51.
PSYCHIATRY 8:7
FURTHER READING Yazdani A, Marshall H. Young Asian women and self-harm: a mental health needs assessment of young Asian women in Newham, East London. A qualitative study. London: Newham Innercity Multifund and Newham Asian Women’s Project, 1998. (Discusses cultural issues around self-harm and describes how to meet health service needs.)
264
Ó 2009 Published by Elsevier Ltd.