Background
Methods
1 | Size of the study population of relevance | Range 0–1 |
2 | Power calculation: whether performed or not | Range 0–1 |
3 | Confounding: degree of adjustment for obvious confounders | Range 0, none; 1, age/gender; 2, age/gender and socio-economic indicators |
4 | Ethnicity definition: whether explicit, accurate and hypothesis based | Range 0, none; 1, a definition; 2, self assigned; 3 rated on basis of self identification and parental origins |
5 | Deliberate self harm: whether attempts had been made to ensure the episode was an actual self harm | Range 0, none; 1 self report; 2, some attempt at measurement; 3, well defined and measured |
Author | Ethnicity definition | Population from sample is taken | Sample size | DSH or Suicide rating scale? | Data sources | Quality Rating |
---|---|---|---|---|---|---|
*Bagley 1972 | Defined by oppression. Black refers to those who lack economic power, and do not control their destinies. White as oppressors. | South London A&E Department. 206 consecutive Admissions to casualty Followed up over 18 months | 25 Black (2 completed suicide, 23 recovered) Black included the following: Caribbean (48%), Indian and Pakistani (20%), African (16%) Cypriot (16%). 25 White in comparison group | No | Hospital records | 2 |
*Bhugra 2003 | South Asian (Indian sub-continent origin) or White | All adolescents presenting to local East London Hospital in 1 year period for DSH | 76 cases: 15 South Asian (12 women) 46 White (38 women) 6 Middle Eastern (4 women) 9 Black (9 women) | No | Case notes and interviews | 1 |
*Bhugra 2004 | South Asian: self ascribed origin: individuals whose parents, grandparents or themselves originate in Indian sub-continent | All adolescents presenting to hospital services in West London in a 1 year period for DSH | 76 cases: 15 South Asian (12 women) 46 White (38 women) 6 Middle Eastern (4 women) 9 Black (9 women) | No DSH scale DACS (DSH Assessment by Clinicians Schedule) | Case notes and interviews | 2 |
*Bhugra 1999a | Self-ascribed OPCS census categories & case notes. | Patient's aged 16–64 presenting with DSH to general, medical, accident or psychiatric services within local hospital in West London. | 434 patients presenting with suicidal behaviour. 90 Asian cases of attempted suicide | No Numbers of people presenting with DSH or attempted suicide | Hospital records, interview, GP records | 4 |
*Bhugra et al 1999b | Self-ascribed OPCS census categories & case notes. | Patients aged 16–64 and resident in the areas for at least six months, presenting with DSH to general, medical, accident or psychiatric services in West London | Comparison of first 27 Asian women presenting with DSH with 27 matched controls (Asian women attending GP surgeries for other reasons) | Numbers of DSH or attempted suicide (DACS : DSH Assessment by Clinicians Schedule)) | Hospital records, interview | 4 |
* Burke 1976a | Self assigned Place of birth known for 2695 cases Of 2075 with no place of birth, a 10% sample selected and case notes examined. 2.5% were of Asian origin | Admissions following attempted suicide to Birmingham hospital during a four year period: 1969–1972 Under 65s admitted with poisoning | 68 admissions with Asian place of birth 16 cases: iatrogenic or accidental cases 52 deliberate self poisoning cases | No. Admission to Birmingham hospitals following self poisoning used as entry criterion and definition for inclusion | Case notes | 3 |
*Burke 1976b | Self assigned Place of birth known for 2695 cases Of 2075 with no place of birth, a 10% sample selected and case notes examined. 2.5% were of Asian origin | Admissions following attempted suicide to Birmingham hospital during a four year period: 1969–1972 Under 65s admitted with poisoning | 60 admissions with place of birth in West Indies | No | Case notes | 3 |
* ≠ Burke 1980 | As Burke 1976 a, b-same samples | Attempted suicide (1969–1972) and admitted to Birmingham hospitals 100 patients followed up until Jan 1969-average follow up period of 5 years | 52 West Indian (3 had made 2 previous attempts) 48 Asian (three had made two attempts and one died at admission) | No Classification based on attempted suicide and psychiatric history: 1. no psych history, 2. psych care at time of attempt 3. psych care before attempt 4 psych care following attempt | Medical, psychiatric records from GP, hospital and coroner | 3 |
*Biswas 1990 | Not given Asians selected on basis of Asian names | A & E presentations to Bradford Royal Infirmary, with self poisoning before or on 1st March 1987 | 72 (38 Asian, 34 White) adolescents aged < or = 17 yrs | No "self-poisoning" from case notes | Case notes | 1 |
*± Dean et al 1976 | Place of birth: country comparisons of rates of Non-fatal self poisoning: but no comparison of ethnic groups. | All deaths registered as suicides between 1970–72 | 333 | Admissions for poisoning and adverse reactions in E, W & § Rep of Ireland Assumed all for DSH and not adverse reactions: assessed assumption on 80 admissions. Of 80, 82.5% confirmed to be DSH. | Population census | 5 |
*Goddard 1996 | Based upon 1991 census. GP notes for clarification on 22 of them: 14 white, 7 black, 1 other. Black Caribbean, Black African, Black Other, Indian, Pakistani, Bangladeshi, Chinese, Asian, Other White. Groups collapsed into white, black, and other Asian | Total referrals to specialist centre at Maudsley Hospital Age > 10 First referral following DSH | Total 100 White: 64 Black :28 Other 8 | No Standardised Maudsley assessment sheet: summary of symptoms, diagnosis, treatment, emotional symptoms and antisocial behaviour | Hospital records and OPCS | 2 |
*Handy 1991 | Parent & children's place of birth Parents UK born = British Asian born = Asian | Presenters to child guidance clinic, Walsgrave hospital Coventry | 50 Adolescents 25 Asian 25 White | No Self poisoning on presentation | Medical records | 1 |
± Hawton 2002 | None given White Asian Black Other | Pupils in 41 schools in England: Oxfordshire, Northamptonshire, and Birmingham. 90% of pupils aged 15 and 16 | 6020 pupils White 2356 Asian 371 Black 68 Other 74 | Question on self harm Asked for description of the act and consequences Classified by 3 independent ratings using agreed definitions | Self report questionnaire | 6 |
*Kingsbury 1994 | No definition Asian: Indian, Pakistani, Sri Lankan | 12–18 year old attendees at West Middlesex hospital A&E. following overdose, Feb 1987-April1998 | 50 Total 113 Asian, 37 Caucasian 13 lost due to premature discharge and failure to attend follow up OPA | Pallis suicide intent scale | Hospital records, semi-structured interview questionnaire | 4 |
*Lockhart 1987 | Ethnic origin: no definition Asian West Indian, Europid | Adults admitted after self poisoning to inner London General hospital. Two time periods: from 1) Nov 1971 to Feb 1972. 2) Sept 1983-June1984 Adults over 15 | 1971/72 Europid = 80 Asian = 1 WI = 0 Other = 1 1983/84 Euro = 72 Asian = 6 WI = 7 Other = 1 | No | Questionnaire completed for each patient | 0 |
*McGibben 1992 | No definitions Denominators established from Asian names in electoral register and racial breakdown obtained from school data | Admissions to Coventry hospitals for overdose aged < 16 between 1982–90 92% of admissions referred for opinion and therefore included in sample | 340 referrals for overdose 1982–90 295 admitted for DSH 222 girls 73 boys 45 Asian of which 37 were girls | No. Deliberate self poisoning | Hospital records, population denominators from city of Coventry, 1981 census data, Coventry school pupil census | 0 |
*McKenzie 1995 | White i.e. self or parents UK born, Afro-Caribbean =both parents born in Caribbean | Admissions for psychosis to 2 London psychiatric hospitals 1985/March 986 – Feb 1988 Oct 1988-August 1989 Recent (5 year) onset of psychosis Four year follow up | 191 in total, but follow up data on 166 (87%) available 53 Afro-Caribbean 60 White | No WHO life chart HADS WHO disability assessment schedule PSE at baseline | Interview | 7 |
≠ McKenzie 2003 | Observer defined OPCS 1991 and Gen Register for Scotland White = OPCS white with mother and father born in the UK Caribbean = OPCS Black-Caribbean or Black Other with mother or father born in Caribbean or UK | People with psychosis in a case management trial 3 London 1 Manchester centre | 708 Baseline 203 Caribbean 234 White British Follow up attrition AC: 26 (13%) WB: 35 (15%) Drop outs: AC 20 & 25 WB | No. WHO Life Chart: asked if attempted suicide and frequency Rated on patient report and all sources of information including case notes/relatives/managers | Case notes, interview with family, client, case managers | 8 |
*Merrill 1986 | Whites: born in England, Scotland & Wales South Asians: born in India. Pakistan, Bangladesh, UK (n = 52, 26.5%) & East Africa (5.26%) | Admission to West Midlands Poisons unit for self poisoning with mediation or taking substances not fit for consumption 1 Jan 1979 to 31 Dec 1981 | 1171 975 White 196 Asians (59% Indian, Sikh) | No | Admissions records. Coding sheet completed by admitting clinicians | 4 |
*Merrill 1987 | Place of birth | Admission to West Midlands Poisons unit for self poisoning with mediation or taking substances not fit for consumption 1 Jan 1979 to 31 Dec 1981 | 975 White 130 West Indian (55 born in WI, 75 born in UK but WI parentage) | No | Admissions records. Coding sheet completed by admitting clinicians | 2 |
*Merrill 1988 | Place of birth Irish Scottish English Indian/Pakistan West Indian | A & E attendees at West Birmingham. DSH leading to admission to West Midlands poisons unit Birmingham 1st Jan 1979 to 31st Dec 1981 | 467 Asian: 36 West India: 16 Scottish: 17 English: 364 Irish: 34 | No | Admissions records. Coding sheet completed by admitting clinicians | 3 |
*Neeleman 1996 | Region of birth, ethnicity from OPCS 1991 census: White Black Caribbean Black African Other, Indian Pakistani Bangladeshi Chinese Asian Others | A&E attendees at Kings College Hospital, for intentional overdose, over 6 month period in 1991: 237 patients attended DSH team assessed 48% (113/247) of all attenders. | Total 105 Ethnic Group 83 White (78) 11 African Caribbean (4) 7 Asian (1) 4 African (2) | No Attendance and psychiatric assessment were criteria | Hospital records OPCS | 3 |
*Neeleman 2001 | Observer assigned OPCS categories collapsed into: White African Caribbean Asian | A & E attendees with DSH at two London Hospitals: King's College Hospital (KCH) and Lewisham Hospital (LH). | Attenders: 2352 Analyses for 1643 attending own A&E. Unknown ethnic origin: 184 KCH LH 1341+1011 White: 720 + 608 AC : 212 + 71 Asian : 9 + 23 | No Attendence for DSH, excluded accidents and uncertain cases | Hospital records. 1991 census | 6 |
*Sheth 1994 | None | Adult admitted to Yorkshire burns unit, March 1983 to March 1993, with suicidal burns injury | 234 admissions, 20 of which had suicidal burns injury, 17 of whom were women Of the women 14 (70%) were Asian | No | Case notes | 1 |
*Wright 1981 | Asian (from the Indian sub continent-majority Sikhs) West Indian Caucasian | Admissions to Dudley Road Hospital 1976–79 | 2001 Total 1665 White 160 Caribbean 176 Asian | No | Questionnaire on social, physical, psychiatric history. Filled in by doctors | 0 |
Studies of Adults | ||||||||||||
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Units of Rates | Population of Interest | Statistics as reported in the paper | Summary of Main Findings | |||||||||
Bhugra et al 1999a | Attempted suicide Per 10 000 person years | Women | Women | Men | Young South Asian women are vulnerable to increased rates of DSH. | |||||||
Rate, 95%CI | Rate, 95%CI | Attempted suicide rates highest in South Asian women than other ethnic groups but highest in white men, maybe because inclusion of Irish in white category. | ||||||||||
South Asian | 37.7, 29.02–47.1 | 13.9, 8.9–20.8 | In men highest rate in Whites aged 16–24 and Black people aged 25–34. | |||||||||
White | 23.3, 19.7–27.4 | 24.6, 20.9–28.7 | ||||||||||
Black | 23.9, 13.9–38.7 | 11.3, 4.6–23.2 | ||||||||||
Other | 30.1, 17.6–48.2 | 8.7, 2.8–20.3 | ||||||||||
Attempted suicide rates highest in South Asian women aged 16–24 (92.7/10000 person years), aged 25–34 (34.4) and also high in "other" ethnic women aged 16–24 (75.9 per 100000 person years) and aged 25–34 (41.1). | ||||||||||||
White men also had high rates compared with other ethnic groups in 16–24 (30.2), 25–34 (28.1), 35–44 (30.1), as did black men in 25–34 age group (31.8). | ||||||||||||
Burke 1976a | Per 100 000 population | South Asian Adults | Age |
Female Rate
|
Male Rate
|
Total Rate
| Proportion of South Asians in self harm group was 60% of those expected considering population distributions | |||||
15–24 | 213 | 74 | 123 | |||||||||
25–44 | 95 | 70 | 66 | |||||||||
45–64 | 32 | 0 | 9 | |||||||||
216 | 57 | 79 | ||||||||||
Rate lower than native population (57/100,000, 126/100,000). | Women more common among 15–24 group and men more common at later ages | |||||||||||
Burke 1976b | Per 100 000 persons years | West Indian Adults | Age |
Female
|
Male
|
Total
| Rates among Caribbean females aged 15–24 twice that of males same age. | |||||
15–24 | 514 | 101 | 336 | |||||||||
25–44 | 84 | 66 | 74 | |||||||||
Total | 180 | 56 | 113 | Low risk of attempted suicide in Caribbean people | ||||||||
Dean et al 1976 | Rates | Adults | Rates increasing in all countries, especially in 15–44 age groups, especially among women. | Country comparison of rates, England & Wales rate is greater than those of Scotland, Northern Ireland, or Republic of Ireland | ||||||||
Rates among women in England and Wales are twice the rate for Scotland and Ireland, and four times the rate for Republic of Ireland. | ||||||||||||
Lockhart et al 1987 | Risk expressed as % at two time points 1971 and 1984 | Adults | 1971: 93 patients admitted on 100 occasions from population of 92 720 | An increase in admissions for among West Indians for self-poisoning. | ||||||||
1983/84: 86 patients admitted on 94 occasions from 73 929 | ||||||||||||
Risk of admissions per week halved from 5.8 to 2.5 | ||||||||||||
Incidence rate halved from 326 to 178/100 000 persons a year | ||||||||||||
Rise in WI admissions from 0 to 7%, p < 0.05, fall among South Asians: 1 to 7%. P = 0.13, fall of Europids, p < 0.01 | ||||||||||||
In 1971 and 1981, 6.4% of local population of WI origin | ||||||||||||
In 1983/4: 7% of local population of WI origin | ||||||||||||
McKenzie et al 2003 | OR: unadjusted and adjusted for age, gender, MADRS, education, Diagnosis, time since onset) | Adults |
AC
|
WB
|
OR
|
OR (adjusted) | Lower prevalence of suicidal behaviour in Caribbean origin people with psychosis not present in under 35's. | |||||
Attempted Suicide (AS) | 14 | 29 | 0.52, 0.26 to 1.02 | 0.54, 0.26 to 1.13 | ||||||||
AS for < 35 yo | 12(13%) | 13 (18%) | 0.7, 0.36 to 1.51 | 0.93, 0.37 to 2.32 | ||||||||
AS for > 35 yo | 2(2.1%) | 16 (11.4%) | 0.17 (0.04–0.71) | 0.19 (0.04 to 0.89) | ||||||||
AS or Completed Suicide | 17 | 33 | 0.56, 0.3 to 1.03 | 0.59, 0.3 to 1.14 | ||||||||
(age/gender adjusted = 0.49, 0.26 -0.92, p = 0.06) | ||||||||||||
Caribbean origin patients aged > 35 5 times less likely to attempt suicide | ||||||||||||
No difference in under 35's. | ||||||||||||
Attempted & completed suicide combined Caribbean origin patients aged > 35 4 times less likely. | ||||||||||||
Caribbean origin patients aged < 35 risk same as British whites | ||||||||||||
Merrill et al 1986 | Rates of self poisoning per 100 000 per year | Adults |
UK born
|
Asian born
|
p value
| Rate for self-poisoning higher in Asian females than white females. Culture conflict important. Asian patients less likely to have previously self-poisoned, received psychiatric treatment or psychiatric diagnosis. | ||||||
Men | 25–34 | 438 | 146 | < 0.0005 | ||||||||
35–44 | 240 | 80 | < 0.025 | |||||||||
> 44 | 98 | 28 | < 0.05 | |||||||||
Overall | 190 | 102 | < 0.0005 | |||||||||
Women | ||||||||||||
Overall | 299 | 376 | < 0.05 | |||||||||
Merrill et al 1987 | Rates of self poisoning/100 000 per year | Adult |
West Indian
|
White British
|
p
| Not very different from Asians, could be a reflection of service characteristics rather than ethnic group. | ||||||
Overall | Men | 103 | 190 | < 0.025 | ||||||||
Men 25–34 | 129 | 438 | < 0.05 | |||||||||
Women > 45 | 30 | 133 | < 0.05 | |||||||||
Rates for over 25s lower for men WI (men: p < 0.001; women: p < 0.005) | ||||||||||||
Merrill et al 1988 | Rates per 100 000 per year | Adult |
Men
|
Asians
|
West Indian
|
English
|
Irish
|
Scottish
| Asian aribbean young females had greater rates than English females. Irish & Scottish of both sexes had higher rates than English. | |||
25–34 yo: | 146***** | 129 | 406 | 662 | 1199* | Power and denominator problems | ||||||
> 35 | 48** | 57* | 131 | 156 | 462***** | |||||||
< 16 | 113***** | 98*** | 236 | 243 | 648***** | |||||||
Women | ||||||||||||
25–34 yo: | 501 | 257 | 447 | 853* | 565**** | |||||||
> 35 | 90 | 37 | 167 | 367***** | 547**** | |||||||
< 16 | 402 | 229* | 341 | 456* | 626* | |||||||
*p < 0.05, ** p < 0.01 ***p < 0.005 ****p < 0.001 *****p < 0.0005 | ||||||||||||
Neeleman et al 1996 | Referral Ratios | Adult | Unadjusted Referral Ratios (Ethnic groups generally younger) for all subjects | Indian female rates of Self Harm are 2.6 times the rate of white women | ||||||||
Men
|
Women
|
All
| UK born Indian females had 7.8 times rate of UK born white females. Unemployment associated with a 9-fold increase in referral rates in whites and 3-fold increase in minorities. | |||||||||
Black Caribbean | 0.56, 0.16–1.43 | 0.61, 0.24–1.26 | 0.61, 0.3–1.09 | |||||||||
South Asian | 0.39, 0.01–2.17 | 1.68, 0.61–3.66 | 1.15,0.46–2.37 | |||||||||
Indian | 0 | 2.6, 0.53–7.6 | ||||||||||
All Ethnic groups | 0.45, 0.17–0.98 | 0.78, 0.45–1.27 | 0.65, 0.41–0.99 | |||||||||
Unadjusted Referral Ratios (Ethnic groups generally younger) for UK born only | ||||||||||||
Men
|
Women
|
All
| ||||||||||
AC | 0.19, 0.00–1.05 | 0.41, 0.08–1.20 | 0.32, 0.09–0.82 | |||||||||
AS | 1.2, 0.03–6.68 | 3.53, 0.96–9.03 | 2.55, 0.83–5.95 | |||||||||
IN | 0 | 7.76, 1.6–22.66 | ||||||||||
Cross validation study: ethnicity assigned on basis of name, to check that referral to DSH may be biased by ethnic group rather than reflect attendance. Only possible for Indian names | ||||||||||||
Attendance ratio Indian Men (indirect standardization): 1.92, 0.52–10.24; Indian women: 3.07, 1.4 to 5.8 | ||||||||||||
Wright 1981 | Annual increase in % admissions | Adult |
Mean annual increase %
|
% born in country of origin for ethnic group
| Self-poisoning is an inarticulate cry for help or even a cry of frustration. | |||||||
1976
|
1979
| |||||||||||
Caucasian | 9.5 | 100 | 100 | |||||||||
West Indian | 31.5 | 69.6 | 48 | |||||||||
Asian | 14.5 | 83.9 | 70.3 | |||||||||
Studies of Adolescents
| ||||||||||||
Hawton 2002 | Prevalence | Adolescents | Males | Females | Lower risk among South Asian females not sustained in multivariate analyses | |||||||
No | % self harm | OR | 95%CI | No | % self harm | OR | 95%CI | |||||
White | 2536 | 3.3 | 1 | 2727 | 11.6 | 1 | ||||||
Asian | 371 | 2.7 | 0.82 | 0.42–1.58 | 254 | 6.7 | 0.55 | 0.33–0.91 | ||||
Black | 68 | 0 | - | - | 89 | 6.7 | 0.55 | 0.24–1.27 | ||||
Other | 74 | 6.8 | 2.14 | 0.84–5.85 | 72 | 13.9 | 1.23 | 0.62–2.42 | ||||
McGibben et al 1992 | Per 1000 persons a year | Adolescents | Overall rates: 2.33/1000/year | Excess admission for DSP in Asian and white girls | ||||||||
Asians = 2.47/1000/year | ||||||||||||
White = 2.31/1000/year | ||||||||||||
Asian boys: 0..88/1000/year | White Boys 1.14/1000/year | |||||||||||
Asian girl: 4.06/1000/year | White Girls: 3.47/1000/year | |||||||||||
(NS) | ||||||||||||
Religion: NS, but a trend for more Sikhs to be admitted: Sikh 3.17/1000/year, Muslim 1.76, Hindu 1.46 | ||||||||||||
Bhugra et al 2003 | Rates of DSH per 10 000 | Adolescents | White | South Asian | Female Self Harm rates are greater than male rates for South Asians & Whites. | |||||||
Male aged 10–14: | 7.3 | 9 | Rates for South Asian and White women aged 14–15 do not differ much | |||||||||
Male aged 14–15: | 62 | - | Self Harm rates greater in white females aged 10–14 compared with South Asian | |||||||||
Female aged 10–14: | 51 | 21 | ||||||||||
Female aged 14–15: | 158 | 127 | ||||||||||
Female aged > 15: | 44 | - |