Understanding the impact that socio-economic deprivation can have on the risk of self-harm and suicide can have serious implications in the development of prevention and management strategies and is also very important when considering the treatment needs of individuals.
Socio-economic deprivation (SED) refers to the financial and social disadvantages experienced by an individual or community (Lamnisos et al., 2019). Evidence has suggested that self-harm and suicide risk are influenced by both area-level deprivation and individual-level deprivation, with higher levels of self-harm and suicide found in more deprived areas (Cairns et al., 2017). However, these findings are inconsistent, as area-level SED does not always correspond to individual-level SED (Kapur et al., 2013).
Moreover, the relationship between deprivation and presentation to hospital following self-harm is unclear. Previous research has suggested that individuals from areas with less SED who present to hospital following self-harm are at a greater risk of suicide (Geulayov et al., 2019); whereas other recent research has reported contradictory findings (O’Neill et al., 2019).
The authors of this study, Geulayov et colleagues (2022), aimed to explore the relationship between socio-economic deprivation (SED) and:
- Individual and clinical characteristics;
- Methods of self-harm;
- Existing problems prior to self-harm.
Deprived areas are associated with higher levels of self-harm and suicide risk.
Methods
Setting
Researchers included presentations of individuals following self-harm to emergency departments of five general hospitals in Oxford, Manchester and Derby (from the Multicentre Study of Self-Harm in England).
Sample
There were 108,092 presentations to hospitals by 57,306 individuals aged 15 years and over who had attended the hospitals after non-fatal self-harm between January 1st, 2000 and December 31st, 2016.
Data collection and measures
Patient information was collected through the completion of psychosocial assessments by specialist psychiatric clinicians, or extracted from emergency department databases. Individuals who had died as a direct result of self-harm were excluded.
Deprivation was assessed using the English Index of Multiple Deprivation (IMD), an official measure of deprivation in small geographical areas in England. This scoring uses information on income, employment, health, disability, education, skills, training, barriers to housing and services, living environment, and crime, to derive a relative deprivation score for each area. Areas across England then are ranked from 1 (most deprived) to 32,844 (least deprived).
Data analysis
Researchers described the characteristics of patients who presented to hospital after self-harm, according to their area-level deprivation. Researchers also examined the prevalence of problems preceding self-harm in relation to level of deprivation, restricted to only patients who received a psychosocial assessment.
Results
Analytic sample: 108,092 presentations to hospitals by 57,306 persons
- Overall, 45% of self-harm hospital presentations were by individuals from areas ranked nationally as most deprived (areas that score more than twice the national average on deprivation measures).
- Only 13% of presentations were by individuals from the least deprived areas (which score half the national average on deprivation measures).
- Previous history of self-harm was more prevalent in more deprived areas.
- Individuals from the most deprived areas tended to be male or from non-white ethnic backgrounds.
Problems preceding self-harm sample: 60,773 presentations by 34,188 persons
- Mental health difficulties were cited as preceding problems in 29.3% of presentations to hospital.
- Problems in relationships with friends were more common in the most deprived group compared with other groups.
- Financial, employment, or education issues were more commonly reported by those from less deprived areas.
- Relationship difficulties with romantic partners and family were more commonly reported by those from less deprived areas.
- Similar levels of physical, sexual, and emotional abuse, as well as drug and alcohol problems, were reported across all groups.
- In 10% of presentations, abuse (physical, sexual, or emotional) was cited as a problem which preceded individuals’ self-harm. This finding was similar across all levels of deprivation.
- Alcohol and drugs were cited as difficulties in 23% and 7.4% of presentations, respectively. This also appeared to be similar across different levels of deprivation. However, the proportion of missing data on alcohol and drug problems was particularly high among patients from the most deprived areas (where up to 20% of data were missing).
Of all hospital presentations in socio-economically deprived areas, males and non-white ethnic background individuals were over-represented.
Conclusions
- The findings from this study indicate that there is a clear association between socioeconomic deprivation and self-harm, with individuals who live in areas with high levels of deprivation more likely to present to hospital following self-harm than individuals living in areas with low levels of deprivation.
- There was a large variation in areas with greater deprivation in terms of gender, ethnicity, forms of self-harm, and previous self-harm.
- It is important to note that nearly a third of participants reported experiencing mental health problems prior to presentation to hospital, and nearly a quarter reported having problems with alcohol prior to presentation.
45% of the hospital presentations for self-harm were by individuals from areas ranked nationally as most deprived.
Strengths and limitations
The authors conducted research with collected information for over 17 years which allows for sufficient data to examine sub-groups within socially deprived areas. There was a diverse sample included in the study as the researchers looked at catchment areas that encompass the areas with the highest and lowest levels of social deprivation. It’s also noteworthy that the deprivation score took various factors into account, e.g., income, employment, housing, living environment, and crime; capturing an holistic picture of the population under examination. Certain limitations have been identified in relation to the study design and reporting of the methodology and findings including:
- The proportion of missing data was greater for individuals from the most deprived areas, and so may not be representative of all groups. Therefore, we should interpret the findings with caution.
- Some of the findings may be explained by the large sample rather than clinically significant differences.
- The sample might be selective due to the exclusion of those without a valid postcode and those who had died as a direct result of self-harm.
- The study only used clinical populations. These patients may differ from those who self-harm in the community and do not present to services.
- There were limited details on how they defined and measured different factors preceding self-harm in their psychological assessment.
It would be helpful for the authors to provide more details on how self-harm was defined and measured in the psychological assessments.
Implications for practice
Initial psychological assessments, formulation and interventions should take into account service users’ socio-economic backgrounds and potential systemic changes that can be made in order to reduce the risk of self-harm. The established links between how area-level and individual characteristics may influence the risk of self-harm can help clinicians conceptualise the service users’ difficulties and develop initial hypotheses to drive their action plan and intervention, as well as explore more in-depth the systems surrounding the individual. The study offers insights for policymakers, as reducing deprivation and social inequalities can be proven an important strategy in suicide prevention (Hawton et al., 2001). This could be done by ensuring access to practical support for vulnerable groups, such as employment and financial assistance, or advocating on their behalf when needed (i.e., writing letters of support to access benefits or safe housing).
Culturally-sensitive, individualised and person-centerd practices should be explored and adopted in clinical settings, as these can enhance adherence and predict better outcomes in ethnic minorities (Cooper et al., 2013). This is particularly important in CAMHS services, given the high risk of suicide and self-harm in young people under the age of 18 years old. Clinicians need to approach service users holding in mind their intersectional identities and systemic/structural factors that may influence their presentation and coping mechanisms. Increased awareness can also help clinicians signpost service users to in-person or online support groups to connect with people who share similar experiences.
This study highlights the need for individualised and person-centred clinical approaches to self-harm assessment, formulation and intervention.
Statement of interests
No conflicts of interest to declare.
Contributors
Thanks to the UCL Mental Health MSc students who wrote this blog from Joseph student group: Tatyana Abraham, Kate Jordan, and Lotte Wilcox.
UCL MSc in Mental Health Studies
This blog has been written by a group of students on the Clinical Mental Health Sciences MSc at University College London. A full list of blogs by UCL MSc students can be found here, and you can follow the Mental Health Studies MSc team on Twitter.
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Links
Primary paper
Geulayov, G., Casey, D., Bale, E., Brand, F., Clements, C., Farooq, B., Kapur, N., Ness, J., Waters, K., Patel, A., & Hawton, K. (2022). Socio-economic disparities in patients who present to hospital for self-harm: Patients’ characteristics and problems in the multicentre study of self-harm in England. Journal of Affective Disorders, 318, 238–245.
Other references
Lamnisos, D., Lambrianidou, G., & Middleton, N. (2019). Small-area socioeconomic deprivation indices in Cyprus: development and association with premature mortality. BMC Public Health, 19(1), 1-11.
Cairns, J. M., Graham, E., & Bambra, C. (2017). Area-level socioeconomic disadvantage and suicidal behaviour in Europe: a systematic review. Social Science & Medicine, 192, 102-111.
Kapur, N., Steeg, S., Webb, R., Haigh, M., Bergen, H., Hawton, K., … & Cooper, J. (2013). Does clinical management improve outcomes following self-harm? Results from the multicentre study of self-harm in England. PloS one, 8(8), e70434.
Geulayov, G., Casey, D., Bale, L., Brand, F., Clements, C., Farooq, B., … & Hawton, K. (2019). Suicide following presentation to hospital for non-fatal self-harm in the Multicentre Study of Self-harm: a long-term follow-up study. The Lancet Psychiatry, 6(12), 1021-1030.
O’Neill, S., Graham, B., & Ennis, E. (2019). Emergency department and hospital care prior to suicide: A population based case control study. Journal of affective disorders, 249, 366-370.
Hawton, K., Harriss, L., Hall, S., Simkin, S., Bale, E., & Bond, A. (2003). Deliberate self-harm in Oxford, 1990–2000: a time of change in patient characteristics. Psychological medicine, 33(6), 987-995.
Hawton, K., Harriss, L., Hodder, K., Simkin, S., & Gunnell, D. (2001). The influence of the economic and social environment on deliberate self-harm and suicide: An ecological and person-based study. Psychological Medicine, 31(5), 827–836.
Cooper C, Spiers N, Livingston G, Jenkins R, Meltzer H, Brugha T, et al. Ethnic inequalities in the use of health services for common mental disorders in England. Social Psychiatry and Psychiatric Epidemiology. 2013;48(5):685–92. doi:10.1007/s00127-012-0565-y
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