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

Beyond the barriers: South Asian women’s experience of accessing and receiving psychological therapy in primary care

Purpose

A number of initiatives have been developed to ensure easy access to mental health services for Black and Asian Minority Ethnic (BAME) communities. Improving Access to Psychological Therapies (IAPT) is a service that delivers first line interventions for South Asian women; however, little is known about what makes IAPT accessible for this population. This paper aims to explore South Asian women’s experiences of accessing psychological therapy and whether therapy within IAPT helps individuals to re-frame their experiences within their own cultural context.

Design/methodology/approach

A qualitative approach was used. Semi-structured interviews were carried out with South Asian women who accessed an IAPT service. Ten participants took part in the study and interviews were analysed using thematic analysis.

Findings

Six themes were identified; access, experience, cultural framework, therapist characteristics, expectations and “sticking with it”. Having a good therapeutic relationship with the therapist was key. While cognitive behavioural therapy (CBT) enabled clients to manage their symptoms, manualised CBT led to a sense of dissatisfaction for some. Clients spoke of having to make a forced choice to either deny their culture or leave their culture at the door to access therapy. Cultural and religious exclusion had a negative impact on therapy particularly for those whose difficulties were related to their cultural or religious context.

Practical implications

Culture and religion continues to be excluded from psychological therapy for South Asian Women. A cultural shift is required from within IAPT services to maintain engagement for this group. Further clinical implications are discussed.

Originality/value

While the experiences of Black and Asian ethnic minority groups accessing secondary mental health services has been explored, this study explores and highlights the experiences of South Asian Women accessing therapy in primary care, and uniquely identifies the processes that enable women to engage in therapy.

Female Gender, Marital and Family Problems, and Feelings of Guilt Are Related to Self-Immolation Suicide Attempts

BACKGROUND

Self-immolation (SI) is considered one of the most painful, dramatic, and at the same time most inexplicable methods of suicide, with a high social impact. Prevalence rates are particularly high in Iran, and in north-western Iran specifically. Here, we report sociodemographic, psychological, and psychiatric characteristics of patients attempting self-immolation (PSIs), compared to patients with accident burns (PABs).

METHOD

Patients referred to the Burns Emergency Unit of the Besat Hospital (Hamadan, Iran) were enrolled in the present study between winter 2015 and summer 2016. After burn-related treatments and surgery, a thorough interview was undertaken covering sociodemographic characteristics, burn-related information, and psychiatric background.

RESULTS

A total of 79 patients were enrolled. Among these, 19 (31.7%) had attempted suicide via SI. Compared to the PABs, the PSIs were predominantly females; they reported family and marital problems as the main triggers for SI. The psychiatric interviews indicated that PSIs often suffered from major depressive disorders, adjustment disorders, and bipolar disorders. The prevailing feelings reported were guilt and shame. A binary logistic regression showed that feelings of guilt and marital and family problems predicted SI.

CONCLUSIONS

The prevalence of SI was surprisingly high. Marital and family conflicts as a proxy for highly distressing social interactions, along with female gender and feelings of guilt and shame were strongly associated with SI. Family and couple counseling specifically tailored to difficulties experienced by women might reduce the risk of SI.

Self-burning in Iraqi Kurdistan: proportion and risk factors in a burns unit

To determine the rate of self-burning among all burns patients admitted to the Burns and Plastic Surgery Centre at Sulaimani University in Iraqi Kurdistan and to identify the risk factors and motives, all burns patients, aged 8 years and over, admitted between 1 September 2009 and 30 April 2010 were surveyed. Of the 200 patients interviewed, 54 (27%) reported self-burns and 146 (73%) reported accidental burns. The risk factors for self-burning included mental illness, female gender and younger age. Almost two-thirds of those who reported self-burns (32, 60.4%) had intended to kill themselves. The most commonly cited reasons for the act were family problems (24, 44%) and marital problems (13, 24%). Burns in the self-burning group were more severe and were associated with a higher mortality rate (34, 63%) than in the accidental burns group (29, 20%).

Observations on self-incineration characteristics in 24 years (1993-2016) of autopsies in the city of Milan

Self-incineration is one of the most dramatic and lethal suicide methods. It is rarely reported in Western countries and is more frequent in developing regions. We illustrate the forensic cases of self-immolation occurring over 24 years in the city of Milan, Italy, highlighting the main issues of such a complex and rare suicide. We selected 33 cases of self-incineration among 23,417 autopsies (4022 suicides) performed at the Department of Legal Medicine of the University of Milan over a period of 24 years (1993-2016). Several parameters were included and analysed: gender and age of the victims, pathological history, previous suicide intentions/attempts, duration of burning, place of death or discovery of the corpse, circumstantial data of fatal events and autopsy findings, with particular attention to thermal injuries. Self-incineration was found in 0.8% of total suicides and 0.14% of total autopsies. One of these cases involved a complex modality (association with plastic-bag suffocation). The typical characteristics of the victim were an Italian man with psychiatric illness, frequently moved by passion, existential discomfort and economic problems. During the 24-year period, the number of cases of self-incineration progressively reduced. This study provides a general overview in one of the biggest metropolitan Italian areas and is one of the few works performed on this topic. It may be helpful in understanding and studying such an unusual manner of suicide.

The Mental Health Status of South Asian Women in Britain

This article reviews the research on the mental health status of South Asian women living in UK. It reports on the findings from epidemiological studies of the prevalence of depression, suicide, parasuicide, deliberate self-harm and eating disorders in this community. Focus is on research studies that describe cultural influences on conceptualisations and expressions of distress, help seeking behaviours and alternative coping strategies. The influence of acculturation and “culture conflict” as they impact upon women's mental health is also highlighted. The review concludes by considering, first, salient cultural and religious concepts identified in studies that may facilitate understanding South Asian women's mental ill health, and second, the urgent need to develop gender, linguistic and culturally sensitive mental health services for women of South Asian origins now citizens of UK.

A qualitative study of the background and in-hospital medicolegal response to female burn injuries in India

Background

Most burns happen in low- and middle-income countries. In India, deaths related to burns are more common in women than in men and occur against a complex background in which the cause – accidental or non-accidental, suicidal or homicidal – is often unclear. Our study aimed to understand the antecedents to burns and the problem of ascribing cause, the sequence of medicolegal events after a woman was admitted to hospital, and potential opportunities for improvement.

Methods

We conducted semi-structured interviews with 33 women admitted to two major burns units, their families, and 26 key informant doctors, nurses, and police officers. We used framework analysis to examine the context in which burns occurred and the sequence of medicolegal action after admission to hospital.

Results

Interviewees described accidents, attempted suicide, and attempted homicide. Distinguishing between these was difficult because the underlying combination of poverty and cultural precedent was common to all and action was contingent on potentially conflicting narratives. Space constraint, problems with cooking equipment, and inflammable clothing increased the risk of accidental burns, but coexisted with household conflict, gender-based violence, and alcohol use. Most burns were initially ascribed to accidents. Clinicians adhered to medicolegal procedures, the police carried out their investigative requirements relatively rapidly, but both groups felt vulnerable in the face of the legal process. Women’s understandable reticence to describe burns as non-accidental, the contested nature of statements, their perceived history of changeability, the limited quality and validity of forensic evidence, and the requirement for resilience on the part of clients underlay a general pessimism.

Conclusions

The similarities between accident and intention cluster so tightly as to make them challenging to distinguish, especially given women’s understandable reticence to describe burns as non-accidental. The contested status of forensic evidence and a reliance on testimony means that only a minority of cases lead to conviction. The emphasis should be on improving documentation, communication between service providers, and public understanding of the risks of burns.

Suicide among immigrants in Europe--a systematic literature review

BACKGROUND

Concerns about increased suicide risk among immigrants to European countries have been raised. We review the scientific literature on differences in suicide among immigrants compared with the majority populations in Europe's major immigration countries.

METHODS

We searched the databases PubMed and PsycINFO for peer-reviewed epidemiological studies published in 1990-2011, which compared suicide risks of adult immigrant groups with the risks of the majority population in European countries. Hits were screened by two researchers.

RESULTS

We included 24 studies in the review. No generalizable pattern of suicide among immigrants was found. Immigrants from countries in which suicide risks are particularly high, i.e. countries in Northern and Eastern Europe, experienced higher suicide rates relative to groups without migration background. Gender and age differences were observed. Young female immigrants from Turkey, East Africa and South Asia are a risk group.

CONCLUSION

Immigrants 'bring along' their suicide risk, at least for the initial period they spend in the immigration country. Health-care planners and providers need to be aware of this 'imported risks'. However, most immigrant groups do not have an increased suicide risk relative to the local-born population; some may even experience substantially lower risks.

Migrant pathways to community mental health centres in Italy

BACKGROUND

Many studies indicate that migrants in western countries have limited access to and low utilization of community mental health centres (CMHCs) despite the high prevalence of mental disorders.

AIMS

We aimed to compare migrant pathways to care across four CMHCs located in different Italian provinces and to identify pathway to care predictors.

METHODS

Migrants attending the four CMHCs between 1 July 1999 and 31 December 2007 were included in the study. Data were gathered retrospectively from clinical data sets and chart review.

RESULTS

Five hundred and eleven (511) migrants attended the four CMHCs, 61% were referred by GPs or other health services and 39% followed non-medical pathways to care (self-referral or through social and voluntary organizations), with important site variations. Younger age and being married were predictors of medical pathways to care; lacking a residence permit and having a diagnosis of substance abuse were related to non-medical pathways.

CONCLUSIONS

Pathways to CMHCs are complex and influenced by many factors. Non-medical pathways to care seem to be frequent among migrants in Italy. More attention should be paid to developing psychiatric consultation liaison models that also encompass the social services and voluntary organizations.

Self-burning in Iraqi Kurdistan: proportion and risk factors in a burns unit

To determine the rate of self-burning among all burns patients admitted to the Burns and Plastic Surgery Centre at Sulaimani University in Iraqi Kurdistan and to identify the risk factors and motives, all burns patients, aged 8 years and over, admitted between 1 September 2009 and 30 April 2010 were surveyed. Of the 200 patients interviewed, 54 (27%) reported self-burns and 146 (73%) reported accidental burns. The risk factors for self-burning included mental illness, female gender and younger age. Almost two-thirds of those who reported self-burns (32, 60.4%) had intended to kill themselves. The most commonly cited reasons for the act were family problems (24, 44%) and marital problems (13, 24%). Burns in the self-burning group were more severe and were associated with a higher mortality rate (34, 63%) than in the accidental burns group (29, 20%).

Trends in suicide among migrants in England and Wales 1979-2003

OBJECTIVE

Trends in suicide death rates among migrants to England and Wales 1979-2003 were examined.

METHODS

Age-standardised rates derived for eight country of birth groups.

RESULTS

For men born in Jamaica, suicide death rates increased in 1999-2003. There were declines in rates for men and women from India and from Scotland, men from East Africa and Northern Ireland and women from the Republic of Ireland. For both men and women born in Scotland or the Irish Republic, despite declines for some, rates remained higher than for England and Wales born. Rates among men from Pakistan were consistently lower than men born in England and Wales.

CONCLUSION

These analyses indicate declining trends for most migrant groups and for England and Wales-born women, but adverse trends in death rates for some country of birth groups.

Attempted suicide in immigrants from Turkey: a comparison with Swiss suicide attempters

BACKGROUND/AIMS

Turkish migrants have been shown to have an increased rate of suicide attempts as compared to native local populations and also to people in Turkey. In this study we conducted in-depth interviews with patients regarding their reasons for the attempt.

SUBJECTS AND METHODS

Seventy Turkish immigrants admitted to the emergency unit of the Basel University Hospital after a suicide attempt were interviewed. Seventy Swiss suicide attempters, matched for age and sex, served as a comparator (case-control study).

RESULTS

Turkish immigrants showed high rates of suicide attempts. The gender ratio (women/men) was 2.2; 38.6% of all Turkish suicide attempters were women aged between 15 and 25 years. Most patients mentioned problems in their partnerships as the main reason for the suicide attempt (63% of Swiss and 54% of Turkish patients); 14% of the Swiss but none of the Turkish suicide attempters named social isolation as a cause; 9% of the Turkish patients reported 'threat of loss/rejection of status as refugee' as the main reason. Immigrants used analgesics more often, whilst Swiss patients tended to favour benzodiazepines.

CONCLUSIONS

Our study suggests that cultural and immigration-specific issues play a role in the suicidal behaviour of immigrants. Turkish women aged between 15 and 25 years seem to be at an especially high risk.

Suicide by burning in the South Asian origin population in England and Wales a secondary analysis of a national data set

Objectives A descriptive analysis of suicide by burning in England and Wales in the general population and in people of South Asian origin. Design A cross-sectional secondary analysis of a national data set. Setting A population study of all those who died by suicide in England and Wales between 1993 and 2003 inclusive. Participants All cases of suicide and undetermined intent identified by the Office for National Statistics for England and Wales. A computer algorithm was used to identify people of the South Asian origin from their names. There were 55 140 suicides in the UK between 1993 and 2003. The ratio of male to female suicides was 3:1. There were 1455 South Asian suicides identified by South Asian Name and Group Recognition Algorithm. Primary and secondary outcome measures Death by suicide and undetermined intent, as determined by Coroner's Inquest. ICD9 codes E958.1 and E988.1 and ICD10 codes X76 and Y26. Results 1.77% of suicides in the general population and 8.45% of suicides in the South Asian origin population were by burning. The suicide rate by burning was 0.8/100 000 person-years for England and Wales and 2.9/100 000 person-years for the South Asian origin population. The odds of suicide by burning were increased in the South Asian group as a whole (OR 3.06, 95% CI 2.30 to 4.08). Those born in Asia and Africa were at higher risk than those born in the UK (OR 2.69, 95% CI 2.01 to 3.60 and OR 2.10, 95% CI 1.46 to 3.01, respectively). The increased risk was for those aged 25-64 years. Conclusion Suicide by burning remains a significant issue in the South Asian origin working-age population in England and Wales. A prevention strategy could target working-age people of South Asian origin born abroad as they are at the highest risk. More in depth research on the reasons for using this method may help to identify possible prevention strategies.

''What are you?'' A recurring question in a cross-cultural psychiatrist's life and career

This article contributes to the Transcultural Psychiatry special issue of autobiographical articles on: ''The Personal and the Professional: Lives and Careers of Cultural Psychiatrists.'' The author describes influences and themes in her professional development as a cross-cultural psychiatrist and academic. Growing up as a part-Chinese, part-white child in rural Midwestern America resulted in frequently being asked: ''What are you?'' This abrupt, bald, but essential question eventually became a useful tool in the productive, repeated re-working of identity, values, and goals throughout her personal and professional life. Experiences of being an outsider, family histories, and early observations of racism are linked to later interests in cross-cultural psychiatry, ethics, and the protection of vulnerable populations. She describes her research on cross-cultural measurement, depression, suicidality, domestic violence and violence in war. Issues of career advancement and internal conflict are described for women academics who occupy three simultaneous, primary roles: academic, doctor and mother. The theme of ''crossing,'' as in ''cross-cultural,'' indicates the effort and intention required to move between races, cultures, classes, intellectual disciplines, personal and professional identities, clinical and academic roles, and social roles allocated to men and women.

Suicides by country of birth groupings in England and Wales: age-associated trends and standardised mortality ratios

INTRODUCTION

Suicide rates in England and Wales have declined in recent years. A better understanding of age-associated trends in different ethnic groups may inform strategies to sustain this decline.

MATERIALS AND METHODS

This study examines suicide rates and age-associated trends in England and Wales by country of birth (used as a proxy for ethnicity) using the latest available national mortality data.

RESULTS

The main findings were (a) suicide rates were generally higher in males than females in all age bands in all country of birth groups except the China group, where suicides rates were higher in females than males in the older age bands; (b) male suicide rates increased with ageing in the Indian sub-continent group and female suicide rates increased with ageing in the Africa and China groups; (c) male standardised mortality ratios (SMRs) were generally higher in the younger age bands in the Eastern Europe and Caribbean groups and generally lower in the Australasian, Middle East and Western Europe groups; (d) male SMRs were generally higher in the older age bands in Eastern Europe, Caribbean, Australasian and Western Europe groups and lower in all age bands in the Indian sub-continent group, and (e) female SMRs were generally higher in the older age bands in the China, Africa and Caribbean groups.

CONCLUSION

There is a need for epidemiological data on suicides in BME groups, including age-associated trends, trends over time, risk and protective factors and methods of suicide to inform suicide prevention strategies.

An association between month of birth and method of suicide

Abstract Background. A statistically significant association between season of birth and suicidal behaviour has been reported. However, the effect of month of birth on the choice of suicide method is yet to be established. Aim. This study examines the association between commonly used methods of suicide and season of birth using data on suicide collected over a 21-year period in England, Wales and Scotland. The sample size available, in excess of 52,000 suicides, greatly exceeds all previous studies in this field. Method. Data on suicides registered between 1979 and 2000® were obtained from the Office for National Statistics (ONS) for England and Wales, and the General Register Office (GRO) for Scotland. Our analyses include all suicides [ICD 9 codes; E950- E959] and undetermined injury deaths [E980-E989], reported between 1979 and 2000 in England, Wales and Scotland for persons born between 1941 and 1966. We used Poisson and negative binomial generalised linear models (GLMs) with seasonal harmonic components. Results. Adjusting for the year of birth, the model predicts that the average increase in risk of suicide between the trough (October) and the peak (May) of the seasonal component is 17.9% (95% CI= 13-33%). For males the estimated increase in risk was 15% (95% CI 5-22%) and for females 27% (95% CI 8-47%). The effect of month of birth on suicide applied to all commonly used methods, with the exception of suicide by burning (SBB) with a significant increase of 16% (95% CI 2-37%) in people born in January compared to other methods. Conclusion. Our results replicate our earlier finding of an association between season of birth and suicide incidence. Birth rates of persons who kill themselves show a disproportionate excess in spring compared to other months. The unexpected observed finding in suicide by burning (SBB) may represent the effect of latitude and warrants further examination. Seasonality of birth in suicide may enhance our understanding of some biological aspects in its aetiology and give directions for future research.

Method of suicide in the mentally ill: a national clinical survey

Comparisons of psychiatric patients who die by suicide using different methods are scarce. We aimed to establish the methods of suicide used by those who are currently or have recently been in contact with mental health services in England and Wales (N = 6,203), and describe the social and clinical characteristics of suicides by different methods. We found that hanging, self-poisoning, and jumping (from a height or in front of a moving vehicle) were the most common methods of suicide, accounting for 79% of all deaths. The implications of these and other findings are discussed.

Psychiatry of old age and ethnic minority older people in the United Kingdom

This review examines the demographic changes, the epidemiology of mental disorders and suicides, the potential risk and protective factors, access to secondary care old age psychiatry services (OAPSs) and the policy context pertaining to older people from ethnic minority groups in the United Kingdom. The number of older people from ethnic minority groups is increasing. The prevalence of mental disorders in older people from ethnic minority groups is either similar to or higher than that in the indigenous population. Therefore, the number of older people from ethnic minority groups with psychiatric morbidity is also increasing. Ethnic minority older people also have inequity of access to secondary care OAPSs. There is an urgent need to develop and implement practical strategies to improve access by older people from ethnic minority groups to OAPSs.

Suicide rates in people of South Asian origin in England and Wales: 1993-2003

BACKGROUND

Low rates of suicide in older men and high rates in young women have been reported in the South Asian diaspora worldwide. Calculating such suicide rates in the UK is difficult because ethnicity is not recorded on death certificates.

AIMS

To calculate the South Asian origin population suicide rates and to assess changes over time using new technology.

METHOD

Suicide rates in England and Wales were calculated using the South Asian Name and Group Recognition Algorithm (SANGRA) computer software.

RESULTS

The age-standardised suicide rate for men of South Asian origin was lower than other men in England and Wales, and the rate for women of South Asian origin was marginally raised. In aggregated data for 1999-2003 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.

CONCLUSIONS

Older, rather than younger, women of South Asian origin seem to be an at-risk group. Further research should investigate the reasons for these changes and whether these patterns are true for all South Asian origin groups.

Forced marriage

This article examines factors that are salient to understanding forced marriages and provides an overview of the issue. It aims to promote awareness in the UK, where there is a need for services to develop appropriate responses, as primary care and the local psychiatric services are not geared up to tackle such transcultural issues.

Do hot spots of deprivation predict the rates of suicide within London boroughs?

INTRODUCTION

The ecological associations between suicide rates and different indices of deprivation within London have been investigated at least for half a century. In the present study, the association between rates of suicide with newly developed hot spots of deprivation index within London boroughs have been studied taking into account the results of the spatial dependency between suicide rates in nearby boroughs.

METHODS

Suicide data were provided by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. The hot spots index of deprivation and the population counts were provided by the Department of the Environment, Transport and the Region (DETR) and Office for the National Statistics (ONS), respectively.

RESULTS

The results show that there is no strong spatial dependency between suicide rates in the London boroughs, the 'hot spots' index of deprivation predicts the rates of suicide in males 30-49, better than other age and sex groups. The rate of suicide decreases with decreasing deprivation as indicated by the 'hot spots' index.

CONCLUSION

These findings suggest that at the London boroughs the 'hot spots' index of deprivation (together with other socio-economic and social fragmentation indices) should be considered as a potential explanatory variable to explain the effects of age on rates of suicide in men and women.

Suicide risk among persons with foreign background in Denmark

There is a dearth of knowledge about factors correlated with suicide risk among minority groups in Western societies. In the present study we compared suicide risk among persons with foreign background with that of the majority population to determine whether certain minority groups are at a particular risk for suicide, as well as to illuminate gender differences herein. Suicide risk was generally higher among persons with foreign background compared with the majority population and the risk was highest among Nordic-born persons. Overall, suicide risk was significantly lower among Asian-born persons; however, there were gender differences in correlations between ethnicity and suicide risk.

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.

Burn patterns of Asian ethnic minorities living in West Yorkshire, UK

Whereas burn morbidity and mortality have been well studied among natives of Southeast Asia, few have studied the epidemiology of burn injury among UK Asian ethnic minority immigrants. A 1 year prospective study of all patients presenting with burns to Bradford Royal Infirmary was carried out. Four hundred and sixty patients were studied, 188 (41%) were Asian ethnic minorities. The average patient age was 17 years for the Asian group and 27 years for the non-Asian patients. Contact burns were responsible for 29% of injuries in Asian patients and 19% in the other group. Thirty-seven percent of contact burns in the Asian ethnic minority group were caused by hot irons. Eleven percent of Asian patients had treated their burn with inappropriate remedies including saiti, butter, and toothpaste. There were no significant differences between Asian and non-Asian patients in terms of large or deep burns, nor in mortality. Morbidity and mortality from burn injury among UK Asian patients and other groups in the UK are similar; however, a disproportionate number of Asian patients sustain smaller burns. Much of this is behaviour related, and it is hoped that through preventative measures a marked reduction in the number of Asian ethnic minority burns can be achieved.

[Nonfatal suicidal acts in a group of psychiatric inpatients. Situation of Mediterranean immigrants]

We investigated the correlation of belonging to an ethnic cultural minority and nonfatal suicidal acts (suicide attempts), suicidal ideation, and self-injurious behavior in a group of 494 psychiatric inpatients at the time of admission. The frequency of nonfatal suicidal acts was 15.3% in the group of immigrants ( n=111) and 8.9% in the group of German patients. This difference is significant, but the impact of belonging to the immigration group covaries with the impact of female gender and young age (below 45 years). If all three factors come together the risk of suicide attempts increases threefold. In the immigrant group alone, nonfatal suicidal acts were correlated with "transcultural conflicts". In the group of suicide attempters, we tried to assess the risk of suicide with the help of the "suicide risk list" (Pöldinger) and the suicidal intention with the help of the "suicide intention scale" (Pierce). Additionally, we investigated the method of suicide attempts and categorized them into two groups: "hard" and "weak" methods. We did not find any significant difference between immigrants and German patients concerning suicide risk, suicide intention, and choice of the method. Although there are some methodological shortcomings, we interpret our findings as an indication that immigrant inpatients are more involved in managing the additional stress which results from their immigration. Perhaps nonfatal suicidal behavior represents a risky, but insufficient attempt at "solving" transcultural problems in the immigrant group.

Patterns of deliberate self-burning in various parts of the world. A review

This paper reviews the literature on deliberate self-burning (DSB) and compares patterns in various countries. Fifty-five studies of deliberate self-harm or suicide by fire published in the last 20 years were reviewed. They reported on 3351 cases of DSB, including 2296 deaths. India had the highest absolute number of cases, the highest fatality rate, and the highest contribution of self-harm to burns admissions. The highest reported incidence was from Sri Lanka. Male victims generally predominated in Western countries, and females in the Middle East and the Indian sub-continent. Patients were grossly 10 years older in Europe than in Asia. The use and nature of fire accelerants, the possible roles of ethnicity, religion/faith and imitation are discussed. Three broad groups of victims were identified: psychiatric patients (Western and Middle-Eastern countries); those committing DSB for personal reasons (India, Sri Lanka, Papua-New Guinea, Zimbabwe); and those who are politically motivated (India, South Korea). Self-mutilators and self-immolators seem to be fairly distinct groups of people.

Suicides in ethnic minorities within 12 months of contact with mental health services. National clinical survey

BACKGROUND

Information on suicide by psychiatric patients from ethnic minority groups is scarce.

AIMS

To establish the number of patients from ethnic minorities who kill themselves; to describe their suicide methods, and their social and clinical characteristics.

METHOD

A national clinical survey was based on a 4-year sample of suicides in England and Wales. Detailed data were collected on those who had been in contact with mental health services in the year before death.

RESULTS

In total 282 patients from ethnic minorities died by suicide--6% of all patient suicides. The most common method of suicide was hanging; violent methods were more common than in White patient suicides. Schizophrenia was the most common diagnosis. Ethnic minority patients 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, this was the first episode of self-harm. Black Caribbean patients had the highest rates of schizophrenia (74%), unemployment, living alone, previous violence and drug misuse.

CONCLUSIONS

In order to reduce the number of suicides by ethnic minority patients, services should address the complex health and social needs of people with severe mental illness.

The structuring of ethnic inequalities in health: economic position, racial discrimination, and racism

Differences in health across ethnic groups have been documented in the United States and the United Kingdom. The extent to which socioeconomic inequalities underlie such differences remains contested, with many instead focusing on cultural or genetic explanations. In both the United States and the United Kingdom, data limitations have greatly hampered investigations of ethnic inequalities in health. Perhaps foremost of these is the inadequate measurement of ethnicity, but also important is the lack of good data on socioeconomic position, particularly data that address life-course issues. Other elements of social disadvantage, particularly experiences of racism, are also neglected. The author reviews existing evidence and presents new evidence to suggest that social and economic inequalities, underpinned by racism, are fundamental causes of ethnic inequalities in health.

Cultural stereotypes of women from South Asian communities: mental health care professionals' explanations for patterns of suicide and depression

Low rates of treated depression and high rates of suicide in women from some South Asian communities are evident in epidemiological studies in the UK. It is argued here that explanations for these apparent differences are likely to be located in stereotypes of repressive South Asian cultures. This small scale study, utilising focus groups and individual interviews, sought to explore the construction of cultural stereotypes within mental health discourse with specific reference to stereotypes of women from South Asian communities. Mental health carers from a UK inner city area of relatively high social deprivation were targeted. Focus groups were conducted with a range of mental health care professionals who worked in both inpatient and outpatient mental health care services. In addition, individual interviews were conducted with consultant psychiatrists and General Practitioners. Extensive reference is made in this paper to the content of focus groups and interviews and how health carer's knowledge about and experience of South Asian cultures and caring for women from these communities was contextualised. Mental health care professionals constructed cultural difference in terms of fixed and immutable categories which operated to inferiorise Britain's South Asian communities. It is argued that their knowledge is constructed upon stereotypes of western culture as superior to a construction of eastern cultures as repressive, patriarchal and inferior to a western cultural ideal. Ultimately, it is argued that these stereotypes become incorporated as 'fact' and have the potential to misdirect diagnosis and therefore, also misdirect treatment pathways.

Self-immolation a common suicidal behaviour in eastern Sri Lanka

A high number of self-burning injuries are noted in Batticaloa. The epidemiology, outcome and psychosocial aspects of 87 patients admitted with such burns over a 2-year-period was studied. The patients were compared with accidental burns and patients using other methods of suicide. Seventy nine percent of the victims were females and 72% were in the 15-34 years age-group. Most had marital problems. The majority were Tamils, but Muslims were fairly well represented. The median extent of burn was 48% of total body surface area (TBSA), with the top of the body mainly affected. The use of fire proved to have a high mortality in a group of patients who did not really want to die; 61 (70%) died. Mortality was higher than for accidental burns after matching for age and burn extent. The survivors had long hospital stays and suffered severe disfigurement. The cases where the patient denied self-harm, but in which the injuries were suggestive of this motive, were strikingly similar in age, sex and burn extent to the suicide group. In contrast, poison suicide records showed a male predominance and a gross under-representation of Muslims. Fire is a very significant method of suicide in our area. Social make-up and poor problem-solving ability may be contributing factors.

Deliberate self-burning in Mazandaran, Iran

The authors in a prospective descriptive study, via a demographic questionnaire, semi-structured interview and/or psychological autopsy examined 318 cases of self-burning in Mazandaran, Iran during 3 years. The average age was 27 years and 83% of them were female. Most of them were married, home makers and with high school education. Sixty-two percent had an impulsive suicidal intention. The major motive was marital conflict. Ninety-five percent had a psychiatric diagnosis-mostly adjustment disorder and 30% had a chronic physical illness. Mortality rate was 79%. High prevalence of self-burning in the young population, the pattern of demographic factors, their motivations and high prevalence of adjustment disorders highlights the need for making preventive measures, which should be focused on family structure, particularly in relation to marriage.

Suicide by self-immolation in Berlin from 1990 to 2000

We investigated retrospectively the forensic autopsy cases of suicide by self-immolation in Berlin from 1990 to 2000. There were 46 cases (35 men and 11 women), corresponding to 0.76% of all known suicides committed in Berlin during this period. The most common reasons for self-immolation were separation from a partner or financial problems. Two individuals had political reasons. There was a history of mental disturbances in 65% of these suicide cases. The location of the self-immolation was outdoors in 65%, the rest were indoors, except for three victims, who committed suicide in their cars. In nearly all cases, the individuals had doused themselves with an inflammable fluid, usually petrol. One-third of the victims died from burn shock, about 20% from a combination of severe burns and inhalation trauma. The median body surface area burnt was 78% for all cases. The blood had a mean 21% carboxyhemoglobin concentration and 0.07 microg/ml of cyanide. Suicide by self-immolation was committed under the influence of drugs in nine cases and of alcohol in 11 cases.

Suicide in women

This article reviews research into suicide in women during the last 25 years. National rates vary between the extremes of 19/10(5) per year in Sri Lanka and < 1/10(5) per year in the Philippines and Egypt, but almost everywhere rates for women are much lower than male rates, with a median ratio of 2.8/1. The exceptions are in India and China, which report higher rates in young married women. The reproductive process has some influence. While menstruation, hormonal treatment, pregnancy and the puerperium have no major effect, unwanted pregnancy may still lead to suicide under certain circumstances, and severe labour can occasionally do so. Having children protects, but the relative risk is no more than 2.0 in nulliparous women. Social factors also have a limited effect. There are higher rates of suicide in divorced women, but the evidence on widowhood is equivocal. Prosperity and employment have no effect. Sexual abuse, rape and domestic violence undoubtedly lead to suicide attempts, but the evidence on completed suicide is lacking. There are many unanswered questions, especially why rates of completed suicide for women (with a greater prevalence of overt depression) are lower than for men, and why Chinese and Indian women have higher rates. More research is required, especially from developing nations.

Suicide incidence in the Lalitpur district of Central Nepal

Suicide is an important cause of death in developing and developed countries. Because of its multifactorial nature it is often difficult to study. Suicide also brings with it social stigma and, in some cases, legal repercussions. Suicide is generally underreported and, therefore, services directed at decreasing its incidence are not given priority.This retrospective study of suicide deaths over a period of 2 years in the Lalitpur district of rural Nepal demonstrates the complicated issues involved, and suggests some appropriate strategies for addressing suicide risk.

Completed suicide: an update for the general psychiatrist

Objectives: To review the most recent information on completed suicide for the general adult psychiatrist.

Methods: Literature review.

Results: Suicide is the result of a complex interaction of multiple variables. Prediction is highly dependent on clinical evaluation. Predictive factors identify groups better than individuals. Prevention has both clinical and political implications.

Conclusions: Reduced access to lethal methods (historically, from barbiturates to modified vehicle exhaust systems and paracetamol), attention to social factors (such as alcohol availability and employment levels) and clinical vigilance, coupled with adequate treatment of psychiatric disorders and close follow-up, should help to reduce suicide rates. Wider cultural issues (eg. religion) are poorly understood and require further research.

Attitudes towards mental health in an urban Pakistani community in the United Kingdom

The aim of this study was to investigate the attitudes of Pakistani families living in an urban area of the United Kingdom, towards mental health issues, to identify the emic models used and compare them with the etic model, predominant in Western medicine. This would allow the exploration of some of the inconsistencies in the research literature relating to the incidence of mental illness in this cultural group. The second aim was to explore the needs of this community, particularly women, in relation to mental health services. Due to problems gaining access to females on their own, interviews were held with family groups. Findings suggested that there were differences in the models of mental illness being employed with greater somatisation of symptoms in the Pakistani group and an emphasis on aggressive behaviour as a significant symptom. Treatment expectations also varied with some emphasis on traditional Pakistani treatments such as Faith healers and Hakims as well as General Practitioners and hospital treatments. Language difficulties, religious and cultural practices were also identified as barriers to female treatment in particular. Recommendations were made for improved training for interpreters and more emphasis on cultural factors and emic models of mental illness as part of medical training.

Patients with suicidal burns and accidental burns: a comparative study of socio-demographic profile in India

This is a prospective study of 50 consecutive admissions to the burns unit. The socio-demographic data was collected using special proforma and interviewing the patients and relatives. All patients were administered the presumptive stressful life event scale (PSLES). Depending on the presence or absence of suicidal intent, patients were divided into two groups. The two groups were then compared with regards to their socio-demographic profile using the unrelated t-test and the Fisher's exact test. The two groups did not differ significantly with regards to age, sex, education, marital status, occupation or monthly per capita income. The patients who had suicidal intent came from joint family, had more stressful life events and suffered larger burns injuries compared with those who experienced accidental burn injuries. The majority of the patients were below the age of 35, unemployed and females outnumbered males in both the groups.

Common mental disorders, explanatory models and consultation behaviour among Indian women living in the UK

Women of Indian origin are said to have a lower rate of recognized common mental disorders and a higher frequency of consultation in primary care than white British. The aim of this study was to evaluate factors, including explanatory models (patient perspectives) of illness, associated with common mental disorders and with frequency of consultation among women of Indian origin in primary care. The investigation was conducted in a general practice in West London with a large Indian population. Consecutive woman attenders of Indian descent were screened with the General Health Questionnaire-12 to identify probable cases of psychiatric morbidity. 100 patients were interviewed with the Revised Clinical Interview Schedule (CIS-R), a specific tool for the diagnosis of common mental disorders, and the Short Explanatory Model Interview, which elicits the individual's conceptualization of his or her illness. Those patients who satisfied CIS-R criteria were classified as 'cases', the others as 'controls'. Common mental disorders were documented in 30% of patients. The general practitioner's diagnosis of common mental disorders had a sensitivity of 17% and a specificity of 91%. Individuals with common mental disorders had a higher frequency of consultation (P = 0.017), were less likely to see depression as an indication for medical intervention and were more likely to withhold some of their concerns from the general practitioner. Incorrect diagnosis by the GP was most likely to occur when patients did not disclose all their complaints. These associations were all statistically significant after adjustment for possible confounders by multiple linear and logistic regression. Women of Indian origin in this sample had rates of common mental disorders similar to those in other UK populations. Differing conceptualizations of common mental disorders may contribute to their underrecognition in women of Indian origin.

Suicide by self-incineration

During a 10-year period (1980-1989), at least 43 cases of self-incineration with lethal outcome took place in Denmark. The incidence seems to be increasing: 11 cases took place in the first 5 years and 32 cases in the last 5 years. An even sex ratio as found (male:female = 23:20). The median age was 43 years, with a broad age range (20-87). Many incidents of self-incineration as a form of political protest were reported in the press especially during the 1960s and 1970s, and the press reports often inspired others to commit suicide in the same way. None of the cases in our investigation were politically motivated or reported in the press, and only one case could have been inspired by another similar case. Other investigations have shown that self-incineration is more common in some cultures than in others, and many have found that a religious motivation was common. In our investigation, all victims were of Danish origin, and a religious motive played no significant role. Most of the victims were suffering from mental illness, and a majority had tried to commit suicide before. None of the victims left a suicide note. The scene was most often at home and indoors--only a minority committed suicide in remote areas of the countryside. Most were found dead at the scene, and the cause of death was usually heat exposure. Only a minority had a lethal carboxy-hemoglobin (CO-Hb) concentration. It is concluded that close cooperation between police, fire experts, and the forensic pathologist is necessary to permit a correct classification of the mode of death in these cases.