Suicide remains a major public health concern, with more than 5,500 people dying by suicide annually in England and Wales (Office for National Statistics [ONS], 2023).

Individuals from ethnic minority backgrounds, including migrants and their descendants, may often experience greater social adversity which may in turn increase suicide risk (Hunt et al., 2021). Paradoxically, previous research has identified lower suicide rates among most minority ethnic groups, compared to the White British Majority, with the exception of individuals from Mixed heritage (Ward et al., 2024). However, the lack of robust data and small numbers have made investigations of suicide and ethnicity challenging. Ethnicity is not currently routinely recorded on death certificates in the UK and previous research has notably had to rely on names and country of birth as proxies for ethnicity. In addition, previous studies have had to combine different minority groups to allow for meaningful analysis with sufficient power, potentially masking between-group differences (Barrass, 2022).

In the current study, Knipe et al. (2024) aimed to address these shortcomings by using national cohort data, which linked 2011 census data with mortality data from the ONS in England and Wales.

Methods

The study used data from the Public Health Research Database (PHRD), which linked mortality data for England and Wales to the 2011 census. The two datasets were linked using unique National Health Service (NHS) numbers, which are assigned to all individuals registered with a general practice in the UK. Deaths that occurred between 1 January 2012 and 31 March 2019 were included. The analysis was conducted on ethnic group, migrant status (i.e., individuals born outside of the UK), and descendant status (i.e., individuals who identify as non-White British but were born in the UK). Sex ratios, age-standardised suicide rates per 100,000 person-years by sex, and age- and sex-adjusted incidence rate ratios were calculated.

Results

There were 31,644 suicides between January 2012 and March 2019 in England and Wales, of which 3,602 (11%) were in individuals from a minority ethnic background.

Ethnicity

Rates of suicide were lower in almost all ethnic minority groups compared to White British individuals, with the exception of White Gypsy or Irish Travellers, and individuals from Mixed background.

In males, the rates of suicide among individuals from a Mixed background (10.04-14.44 per 100,00), and White Irish background (14.36 per 100,000) were similar to the rate in White British individuals (13.72 per 100,000). The suicide rate in White Gypsy/Irish Travellers was higher (21.12 per 100,000), however, confidence intervals suggest that this rate was not statistically significantly different from that of the White British group. Rates varied from 1.61 to 7.43 per 100,000 in Asian, Black, Arab, and Other groups.

In females, suicide rates among White Gypsy/Irish Travellers (8.65 per 100,000) and Mixed White and Caribbean individuals (7.35 per 100,000) were higher than the rate in White British individuals (4.41 per 100,000).

Age- and sex-specific analyses revealed higher rates of suicide in:

• Older Chinese individuals (both males and females) compared to younger Chinese individuals.
• Working-age White British and White Gypsy or Irish Traveller males compared to both their younger and older counterparts.
• Older Black African females and females of other ethnicities compared to younger or middle-aged females.
• Working-age Mixed White and Caribbean females compared to their younger counterparts.

Migrant status

There were 2,211 (7%) deaths by suicide in the migrant population, and the analysis identified a lower rate of suicide among migrants than in those born in the UK, regardless of ethnicity and sex. In males, rates varied between 4.54 and 11.77 per 100,000, compared to 13.5 per 100,000 in the non-migrant population. In females, rates varied between 0.80 and 6.45 per 100,000, compared to 7.35 per 100,000 in the non-migrant population.

Descendant status

With respect to descendants, 1,474 (5%) died by suicide over the study period. In male descendants, the suicide rate was highest for individuals of White British (13,72 per 100,000), White Other (14.55 per 100,000) and Mixed background (14.64 per 100,000). Rates for other ethnicities varied between 7.22 and 11.47 per 100,000.

In females, risk was most elevated in individuals from Mixed heritage (8.00 per 100,000), followed by Other (5.73 per 100,000), White Other (4.65 per 100,000), and White British (4.39 per 100,000) individuals.

Method of suicide

The authors also examined methods of suicide used by different ethnic groups and found no differences.

Conclusions

Suicide rates were lower in most ethnic minority groups compared to the White British Majority, with the exception of individuals from Mixed backgrounds and White Gypsy or Irish Travellers.

Migrants, regardless of ethnicity, had a lower rate of suicide than the non-migrant population.

In descendants, individuals from a Mixed background had the highest suicide rate, followed by White other and White British individuals.

Strengths and limitations

The current study is a very welcome addition to the literature on ethnicity and suicide. The use of the public health research database allowed the authors to examine the relationship between ethnicity and suicide at a national level over a 63-month period using self-reported ethnicity from the 2011 census. Analyses were conducted on all 18 ONS ethnicity categories and these were only collapsed into six broader categories for migrant and descendant analyses due to smaller numbers. This is also the first study presenting results for migrants and descendants as separate groups.

The reflective statement from the lead author in the methods section on their own background, and the involvement of individuals with lived experience in the interpretation and dissemination of the findings are other notable strengths of this study.

Whilst the present study used robust case ascertainment, there are a few limitations. The authors reported that linkage rates differed between ethnic groups, with lower rates among the Black Other and Other groups, and those born in central and western Africa. Indeed, the linkage between mortality data and census data relied on NHS numbers and therefore required that an individual be registered with a general practice. Previous research has highlighted that individuals from ethnic minority backgrounds face barriers when accessing healthcare compared to White groups (Barrass, 2022; Joshi, 2024; Robertson et al., 2021). While the dataset used in the study included 90% of the census population, it is possible that the missing 10% had a greater proportion of individuals from ethnic minority groups.

In addition, the authors also note that there is evidence of greater misclassification of suicide among ethnic minority groups, whereby a death is more likely to be classed as accidental/misadventure. This may also have led to an under-detection of suicides in these groups.

Implications for practice

The study revealed varying patterns in suicide rates between different ethnic groups, sexes and age groups, and the authors concluded that “a single prevention approach is unlikely to be effective for all”.

Healthcare professionals should be aware of the elevated suicide among individuals from a Mixed background. In particular, there should be a better understanding that individuals from this group may face greater invalidation of their ethnic identity, a phenomenon which itself has been linked to suicidal ideation and attempts (Campbell & Troyer, 2007). The authors suggest that interventions could also focus on supporting parents of individuals from a Mixed background and promoting more inclusive school environments.

Interventions for those identifying as White Gypsy or Irish Travellers should focus on the risk factors that have been found to be more prevalent in this population, including mental ill-health, unstable accommodation, poor access to healthcare, and limited help-seeking (Cemlyn et al., 2009).

Migrants were found to be at a lower risk of suicide, however, it is possible that some migrant deaths go undetected as individuals may return to their country when suffering from ill health. Given the prevalence of risk factors in the migrant population that may in turn predispose them to mental ill-health and suicidality, it may still be beneficial for policies to focus on providing greater social, economic, housing and healthcare support to migrants.

Finally, caution should be exercised in relation to the elevated risk identified in the descendant population due to the method used to identify this population. However, the direction of results is similar to that of other international studies and services may want to consider the challenges that this population faces (e.g. lower employment rates, mental ill-health, perceived discrimination; Di Iaso et al., 2024; Dorsett et al., 2018; The Migration Observatory, 2024).

Statement of interests

The author of this blog works at the National Confidential Inquiry into Suicide and Safety in Mental Health, alongside Professor Nav Kapur, one of the authors of the paper discussed in this blog, but had no involvement in the study. The author also identifies as a White French migrant.

Links

Primary paper

Knipe, D., Moran, P., Howe, L.D., Karlsen, S., Kapur, N., Revie, L., & John, A. (2024). Ethnicity and suicide in England and Wales: a national linked cohort study [PDF]. Lancet Psychiatry, 11, 611-619.

Other references

Barrass, L. Suicide rates in ethnic minorities and indigenous people. The Mental Elf, 21 June 2022.

Barrass, L. Common mental health inequalities across racialised groups: the gaps are getting bigger. The Mental Elf, 7 November 2022.

Campbell, M.E., & Troyer, L. (2007). The Implications of Racial Misclassification by Observers. American Sociological Review, 72(5), 750-765. [Abstract].

Cemlyn, S., Greenfields, M., Burnett, S., Matthews, Z., & Whitwell, C. (2009). Inequalities experienced by Gypsy and Traveller communities: A review. Equality and Human Rights Commission [PDF].

Di Iaso, V., Giulietti, C., & Wahba, J. (2024). Mind the gap: Education, employment and mobility of second-generation immigrants in the UK [PDF].

Dorsett, R., Rienzo, C., & Weale, M. (2018). Intergenerational and interethnic mental health: An analysis for the United Kingdom [PDF]. Population, Space and Place, 25(2), e2195.

Fernandez-Reino, M., & Cuibus, M. (2024). Briefing: Migrants and Discrimination in the UK. [PDF].

Hunt, I.M, Richards, N., Bhui, K., Ibrahim, S., Turnbull, P., Halvorsrud, K., Saini, P., Kitson, S., Shaw, J., Appleby, L., & Kapur, N. (2021). Suicide rates by ethnic group among patients in contact with mental health services: an observational cohort study in England and Wales [PDF]. Lancet Psychiatry, 8, 1083-93.

Joshi, E. Barriers to mental health services among British Bangladeshi men. The Mental Elf, 2 August 2024.

Office for National Statistics. (2023). Suicides in England and Wales: 2022 registrations. Retrieved from https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/2022registrations

Robertson, R., Williams, E., Buck, D., & Breckwoldt, J. (2021). Ethnic health inequalities and the NHS [PDF].

Ward, I.L., Finning, K., Ayoubkhani, D., Hendry, K., Sharland, E., Appleby, L., & Nafilyan, V. (2024). Sociodemographic inequalities of suicide: a population-based cohort study of adults in England and Wales 2011–21 [PDF]. European Journal of Public Health, 34(2), 211–217.

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