Prevalence, correlates and common methods of non-suicidal self-injury in South Asia: a systematic review

INTRODUCTION

The dynamics of self-harm vary substantially around the world, yet it is severely under-researched outside of a small number of high-income 'Western' countries. South Asia is disproportionately impacted by suicide, yet we know less about non-suicidal self-injury (NSSI) in the region.

OBJECTIVE

To review and summarise evidence on the prevalence, correlates and common methods of NSSI in South Asia.

METHODS

We searched Medline, Embase and PsycINFO for the period 1 January 2000 to 31 August 2023, for peer-reviewed observational studies. A total of 11 studies from eight South Asian countries that reported prevalence and/or correlates of NSSI were included in this review. We assessed the quality of the studies using the Study Quality Assessment Tools for Observational Cohort and Cross-Sectional Studies. We used meta-regression to describe the sources of heterogeneity. Abstracted data were summarised using thematic synthesis.

RESULTS

For non-clinical populations, the 12-month prevalence of NSSI ranged from 3.2% to 44.8%, and the lifetime prevalence ranged from 21% to 33%. For clinical populations, the 12-month prevalence of NSSI ranged from 5% to 16.4%, while the lifetime prevalence ranged from 2% to 27%. Male sex, unemployment, financial stress, history of suicidal behaviour and depression were associated with a higher risk of NSSI. Better access to counselling services, higher self-esteem and self-knowledge were associated with a lower risk of NSSI.

CONCLUSION

The burden of NSSI in South Asia appears to be high in both clinical and non-clinical populations. Further research, especially with general population samples, is needed to build evidence on the epidemiology, context and meaning of NSSI in South Asia to inform the design of context-specific interventions.

PROSPERO REGISTRATION NUMBER

CRD42022342536.

Adolescent self-harm in Ghana: a qualitative interview-based study of first-hand accounts

BACKGROUND

Recent prevalence studies suggest that self-harm among adolescents in sub-Saharan Africa is as common as it is in high income countries. However, very few qualitative studies exploring first-person accounts of adolescent self-harm are available from sub-Saharan Africa. We sought to explore the experiences and first-person perspectives of Ghanaian adolescents reporting self-harm - for deeper reflections on the interpretive repertoires available in their cultural context for making sense of self-harm in adolescents.

METHODS

Guided by a semi-structured interview protocol, we interviewed one-to-one 36 adolescents (24 in-school adolescents and 12 street-connected adolescents) on their experiences of self-harm. We applied experiential thematic analysis to the data.

RESULTS

Adolescents' description of the background to their self-harm identified powerlessness in the family context and unwanted adultification in the family as key factors leading up to self-harm among both in-school and street-connected adolescents. Adolescents' explanatory accounts identified the contradictory role of adultification as a protective factor against self-harm among street-connected adolescents. Self-harm among in-school adolescents was identified as a means of "enactment of tabooed emotions and contestations", as a "selfish act and social injury", as "religious transgression", while it was also seen as improving social relations.

CONCLUSIONS

The first-person accounts of adolescents in this study implicate familial relational problems and interpersonal difficulties as proximally leading to self-harm in adolescents. Self-harm in adolescents is interpreted as an understandable response, and as a strong communicative signal in response to powerlessness and family relationship difficulties. These findings need to be taken into consideration in the planning of services in Ghana and are likely to be generalisable to many other countries in sub-Saharan Africa.

Self-harm with suicidal and non-suicidal intent in young people in sub-Saharan Africa: a systematic review

BACKGROUND

Self-harm, whether attributed to suicidal or non-suicidal motives, is associated with several poor outcomes in young people, including eventual suicide. Much of our understanding of self-harm in young people is based on literature from Europe (particularly, the UK), North America, and Australia. We aimed to synthesise the available evidence on prevalence, the commonly reported self-harm methods, correlates, risk and protective factors, and reasons for self-harm, in adolescents (aged 10-25 years) in sub-Saharan Africa.

METHOD

We searched MEDLINE, PsycINFO, PubMed, African Journals OnLine, and African Index Medicus for records from 1950 through August 2019, without language restrictions. We supplemented the database searches by searching relevant portals for postgraduate theses, reference harvesting, contacting authors for unpublished studies, and hand searching relevant print sources. We applied narrative synthesis to the evidence.

RESULTS

Seventy-four studies from 18 sub-Saharan African countries met the inclusion criteria. The median lifetime prevalence estimate was 10·3% (interquartile range [IQR] 4·6% - 16·1%); median 12-month prevalence estimate was 16·9% (IQR: 11·5% - 25·5%); median 6-month prevalence estimate was 18·2% (IQR: 12·7% - 21·8%); and the median 1-month prevalence estimate was 3·2% (IQR: 2·5-14·8%). Studies from Western sub-Saharan Africa reported the highest 12-month prevalence estimates (median = 24·3%; IQR = 16·9% - 27·9%). Clinical samples commonly reported overdose, whereas self-cutting was most commonly reported in non-clinical samples. Academic failure, sexual, emotional, and physical abuse, romantic relationship problems, family conflict, depression, and previous self-harm were identified as key correlates of self-harm. No study reported protective factors against self-harm.

CONCLUSION

Variation in estimates was explained by small sample sizes and variation in definitions and measures used. Exploration of associations, risks and protective factors was based upon concepts and measures derived from high income countries. More detailed and culturally sensitive research is needed to understand the context-specific risks and protective factors for self-harm in adolescents in sub-Saharan Africa.

A systematic review on the relationship between childhood exposure to external cause parental death, including suicide, on subsequent suicidal behaviour

BACKGROUND

Exposure to parental death in childhood has been associated with offspring suicide risk, although the strength of this association is unclear. The primary aim of this systematic review was to synthesise primary studies on the relationship between childhood exposure to external cause parental death, including suicide, and subsequent suicidal behaviour in adulthood. The secondary objective was to compare suicide-related outcomes of exposure to parental suicide with the outcomes of exposure to other external cause parental deaths.

METHODS

A systematic review was conducted using guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Ovid MEDLINE, Cochrane Library, Ovid PsycINFO, Web of Science, CINAHL and EMBASE were searched from January 2008 until November 2018. Two researchers independently screened the articles, performed data extraction and assessed quality of evidence using the Newcastle-Ottawa Scale.

RESULTS

Of the 618 studies identified, 26 were included for review. Only one study found no significant association between childhood exposure to suicide and increased suicide risk in adulthood. Four studies suggested the risk of suicidality in adulthood was greater for those exposed to parental suicide compared to other external cause deaths.

LIMITATIONS

The use of national registers in many studies did not allow for all variables of interest to be examined. Selective samples also limited the generalizability of findings.

CONCLUSIONS

A strong association between parental suicide and suicidal behaviour in adult offspring exists. Interventions for bereaved youth should consider the long-term effects of parental suicide and target individual and environmental-level risk factors for subsequent suicidality.

The Quest for Meaning Around Self-Injurious and Suicidal Acts: A Qualitative Study Among Adolescent Girls

Introduction: Suicide and non-suicidal self-injury (NSSI) are major problems in adolescent psychiatry and share numerous clinical characteristics. The principal objective of this study is to describe the subjective experience of adolescent girls and young women who present NSSI and/or suicidal behaviors and to determine the common aspects and the specificities of each experience. Method: This exploratory study is based on a procedure that is qualitative, phenomenological, and inductive. The data were collected from two semi-structured interviews each of 18 girls and young women aged 12-21 years, who were receiving care from a psychiatrist specializing in adolescents and who at least once had harmed themselves by NSSI or attempted suicide, or both. The thematic data analysis was performed by applying the methods of interpretative phenomenological analysis. Results: The results are described around four superordinate themes: relationships with the self, with others/otherness, with the body, and with death; they are then subdivided into 13 themes. Several themes appeared common to both types of behavior, especially the relational dimension of self-harming acts. The process of separation-individuation seems complex for these youth. Conclusion: The results underline the relational aspects of the self-harming behavior (NSSI or suicidal) among adolescent girls. These aspects also appear to be expressed in the family sphere, the social sphere, in contact with peers, and also at a societal level when the community no longer addresses adolescents' difficulties. When the process of subjectification does not appear to reach completion, self-aggressive behavior is seen as an ultimate attempt to regain a feeling of autonomy.

A test of the interpersonal-psychological theory of suicidal behaviour in a sample of mental health outpatients

Suicidality is a growing mental health problem, with statistics for South Africa being in line with global estimates. There has, however, been relatively little empirical advancement in the conceptualization of suicidal behaviour in recent years. Joiner’s interpersonal-psychological theory of suicidal behaviour is a relatively new theory that appears to hold promise for advancing our understanding of the mechanisms that underlie suicidal behaviour. The theory proposes that people die by suicide because they want to and because they can. This study sought to test two key hypotheses of the interpersonal-psychological theory of suicidal behaviour using a cross-sectional design and a sample of 239 mental health outpatients. Consistent with theoretical predictions, levels of suicidal ideation were significantly predicted by the interactive effects of high levels of thwarted belongingness and perceived burdensomeness in the presence of high levels of hopelessness in relation to both of these distressing states; with estimates of risk for suicide being most strongly predicted by the interactive effects of suicide ideation and an acquired capability for suicide. These findings are discussed in terms of their implications for theory, practice, and future research.

The Associations Between Children's and Adolescents' Suicidal and Self-Harming Behaviors, and Related Behaviors Within Their Social Networks: A Systematic Review

Social influences-including the suicidal and self-harming behaviors of others-have been highlighted as a risk factor for suicidal and self-harming behavior in young people, but synthesis of the evidence is lacking. A systematic review of 86 relevant papers was conducted. Considerable published evidence was obtained for positive associations between young people's suicidal and self-harming behavior and that of people they know, with those reporting knowing people who had engaged in suicidal or self-harming behaviors more likely to report engaging in similar behaviors themselves. Findings are discussed in relation to a number of methodological and measurement issues-including the role of normative perceptions-and implications for the prevention of suicidal and self-harming behavior are considered.

Metasynthesis of youth suicidal behaviours: perspectives of youth, parents, and health care professionals

BACKGROUND

Youth suicide is a major public health issue throughout the world. Numerous theoretical models have been proposed to improve our understanding of suicidal behaviours, but medical science has struggled to integrate all the complex aspects of this question. The aim of this review is to synthesise the views of suicidal adolescents and young adults, their parents, and their healthcare professionals on the topics of suicidal behaviour and management of those who have attempted suicide, in order to propose new pathways of care, closer to the issues and expectations of each group.

METHODS AND FINDINGS

This systematic review of qualitative studies--Medline, PsycInfo, Embase, CINAHL, and SSCI from 1990 to 2014--concerning suicide attempts by young people used thematic synthesis to develop categories inductively from the themes identified in the studies. The synthesis included 44 studies from 16 countries: 31 interviewed the youth, 7 their parents, and 6 the healthcare professionals. The results are organised around three superordinate themes: the individual experience, that is, the individual burden and suffering related to suicide attempts in all three groups; the relational experience, which describes the importance of relationships with others at all stages of the process of suicidal behaviour; and the social and cultural experience, or how the group and society accept or reject young people in distress and their families and how that affects the suicidal process and its management.

CONCLUSION

The violence of the message of a suicidal act and the fears associated with death lead to incomprehension and interfere with the capacity for empathy of both family members and professionals. The issue in treatment is to be able to witness this violence so that the patient feels understood and heard, and thus to limit recurrences.

South African clinical psychology’s response to cultural diversity, globalisation and multiculturalism: a review

This article reviews responses of South African clinical psychologists to multicultural issues within an increasingly diverse and globalised context. Psychological perspectives on diversity, multiculturalism, and globalisation are presented initially as background to a review of multicultural and cross-cultural clinical psychological research conducted within the South African context. The discussion is located within the context of South African psychologists’ historical response to multicultural issues, within a unique socio-political situation. Implications for ongoing development of relevant clinical psychology services to address the diverse needs of all sectors of South African society are also discussed.