Surveillance for self-harm: an urgent need in low-income and middle-income countries
Authors: Lakshmi Vijayakumar, Gregory Armstrong
Journal: The Lancet Psychiatry (2019)

Low-income and middle-income countries (LMICs) account for around 75% of the estimated 800 000 annual deaths by suicide globally.1WHOPreventing suicide: a global imperative. World Health Organization, Geneva2014Google Scholar There is an imperative to obtain better self-harm (both fatal and non-fatal) data from LMICs to inform prevention strategies and the allocation of scarce resources. Hospital-based self-harm surveillance systems are recommended by WHO as a crucial source of epidemiological data.2WHOPractice manual for establishing and maintaining surveillance systems for suicide attempts and self-harm. World Health Organization, Geneva2016Google Scholar Such systems have additional value in LMICs, where the prevalence, methods of, and risk factors for self-harm can vary from those in high-income countries. In The Lancet Psychiatry, the excellent paper by Duleeka Knipe and colleagues3Knipe D Metcalfe C Hawton K et al.Risk of suicide and repeat self-harm after hospital attendance for non-fatal self-harm in Sri Lanka: a cohort study.Lancet Psychiatry. 2019; (published online July 1.)http://dx.doi.org/10.1016/S2215-0366(19)30214-7Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar shows the importance of a hospital-based self-harm surveillance system in a rural area of Sri Lanka. This paper provides estimates of the risk of repeat self-harm (3·1%, 95% CI 2·4–3·9) and suicide (0·6%, 0·4–1·1) in individuals within 12 months of presentation to hospital after a previous self-harm episode. These results contrast with a systematic review and meta-analysis by Carroll and colleagues,4Carroll R Metcalfe C Gunnell D Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis.PLoS One. 2014; 9e89944Crossref PubMed Scopus (326) Google Scholar which was predominantly based on research from HICs and reported a substantially higher risk of repeat non-fatal (16·3%, 95% CI 15·1–17·7) and fatal (1·6%, 1·2–2·4) self-harm at 12 months, and that the risk of repeat non-fatal self-harm was considerably lower across the few studies in Asia (10·0%, 7·3–13·6). Consequently, the authors posit that repeat self-harm might be lower in LMICs than in HICs.3Knipe D Metcalfe C Hawton K et al.Risk of suicide and repeat self-harm after hospital attendance for non-fatal self-harm in Sri Lanka: a cohort study.Lancet Psychiatry. 2019; (published online July 1.)http://dx.doi.org/10.1016/S2215-0366(19)30214-7Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar If this is true, why? Possible explanations are diverse and multifaceted5Mohamed F Perera A Wijayaweera K et al.The prevalence of previous self-harm amongst self-poisoning patients in Sri Lanka.Soc Psychiatry Psychiatr Epidemiol. 2011; 46: 517-520Crossref PubMed Scopus (13) Google Scholar and include a higher case-fatality rate at first episode in LMICs, thus removing high-risk patients from the pool; a lengthier hospital stay after self-harm in LMICs, allowing high-risk patients to be monitored for longer; and a typically younger age profile of individuals who self-harm in LMIC populations, with evidence indicating that repeat self-harm is more frequent in cohorts with an older average age.4Carroll R Metcalfe C Gunnell D Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis.PLoS One. 2014; 9e89944Crossref PubMed Scopus (326) Google Scholar Moreover, important aetiological differences might have a role. Psychiatric disorders are thought to be more common in people who self-harm in developed countries compared with developing countries.6Hawton K Saunders K Topiwala A Haw C Psychiatric disorders in patients presenting to hospital following self-harm: a systematic review.J Affect Disord. 2013; 151: 821-830Crossref PubMed Scopus (146) Google Scholar In south Asia, for example, greater emphasis is given to sociocultural and socioeconomic factors, along with factors such as impulsivity, alcohol use, shame, and social, interpersonal, and family-based stressors, which might have a greater role in this region than in high-income settings.7de Silva D Suicide prevention strategies in Sri Lanka: the role of socio-cultural factors and health services.Ceylon Med J. 2003; 48: 68-70Crossref PubMed Scopus (6) Google Scholar The implication of these differences is that perhaps there is less chronicity of self-harm behaviour in settings where psychiatric disorders have a somewhat reduced role and in which situational stressors and impulsivity are emphasised. Notwithstanding the importance of this discussion, we lack sufficient evidence to make firm claims about the prevalence of repeated self-harm in LMICs. We also cannot ascertain whether these findings concern Asian countries only rather than LMICs more broadly—eg, lower levels of repeat self-harm have also been observed in the high-income country Taiwan.8Chung CH Lai CH Chu CM Pai L Kao S Chien WC A nationwide, population-based, long-term follow-up study of repeated self-harm in Taiwan.BMC Public Health. 2012; 12: 744Crossref PubMed Scopus (16) Google Scholar The study by Knipe and colleagues3Knipe D Metcalfe C Hawton K et al.Risk of suicide and repeat self-harm after hospital attendance for non-fatal self-harm in Sri Lanka: a cohort study.Lancet Psychiatry. 2019; (published online July 1.)http://dx.doi.org/10.1016/S2215-0366(19)30214-7Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar was done in one rural farming area of a single South Asian country, in which there is a preponderance of pesticide and other poisoning as the main method of self-harm. Further interrogation of this phenomenon could investigate whether the incidence of repeat self-harm in LMICs is higher when other self-harm methods (eg, hanging) are more common or in more urban settings across other Asian and non-Asian LMICs. Fleischmann and colleagues9Fleischmann A Bertolote JM Wasserman D et al.Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries.Bull World Health Organ. 2008; 86: 703-709Crossref PubMed Scopus (326) Google Scholar followed a cohort of people who presented to hospital after a suicide attempt in urban centres across five LMICs in south-east Asia, South America, and the Middle East, and observed that 20·0% previously attempted suicide and, in the non-intervention arm of the study, 2·2% died by suicide within 18 months. Such findings emphasise that repeat self-harm undoubtedly remains an important issue in some LMIC settings. Methodologically, estimates of repeat self-harm based on hospital-based surveillance systems might be affected by differences across LMICs in terms of the proportion of hospital presentations following self-harm. A study10Bertolote JM Fleischmann A De Leo D et al.Suicide attempts, plans, and ideation in culturally diverse sites: the WHO SUPRE-MISS community survey.Psychol Med. 2005; 35: 1457-1465Crossref PubMed Scopus (278) Google Scholar estimated the proportion of people in eight LMICs who accessed medical attention after a suicide attempt to be as high as 88·0% in Chennai (India), 56·0% in Colombo (Sri Lanka), and as low as 22·0% in Hanoi (Vietnam).10Bertolote JM Fleischmann A De Leo D et al.Suicide attempts, plans, and ideation in culturally diverse sites: the WHO SUPRE-MISS community survey.Psychol Med. 2005; 35: 1457-1465Crossref PubMed Scopus (278) Google Scholar To obtain better data, a comprehensive surveillance system could use supplementary data sources, for example, primary care clinics and a range of other community informants appropriate to the setting. Although Knipe and colleagues3Knipe D Metcalfe C Hawton K et al.Risk of suicide and repeat self-harm after hospital attendance for non-fatal self-harm in Sri Lanka: a cohort study.Lancet Psychiatry. 2019; (published online July 1.)http://dx.doi.org/10.1016/S2215-0366(19)30214-7Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar draw on their findings to suggest a focus on suicide prevention efforts in those who self-harm might be somewhat less important in LMICs compared with HICs, we would urge some caution. More data from a greater number of surveillance systems are urgently needed to better understand self-harm patterns across different LMIC settings. We declare no competing interests. Risk of suicide and repeat self-harm after hospital attendance for non-fatal self-harm in Sri Lanka: a cohort studyAlthough people who self-harm are an important high-risk group, focusing suicide prevention efforts on those who self-harm might be somewhat less important in LMICs compared with HICs given the low risk of repeat self-harm and subsequent suicide death. Strategies that focus on other risk factors for suicide might be more effective in reducing suicide deaths in LMICs in south Asia. A better understanding of the low incidence of repeat self-harm is also needed, as this could contribute to prevention strategies in nations with a higher incidence of repetition and subsequent suicide death. Full-Text PDF Open Access