Suicide and self-harm

Summary

Suicide and self-harm are major health and societal issues worldwide, but the greatest burden of both behaviours occurs in low-income and middle-income countries. Although rates of suicide are higher in male than in female individuals, self-harm is more common in female individuals. Rather than having a single cause, suicide and self-harm are the result of a complex interplay of several factors that occur throughout the life course, and vary by gender, age, ethnicity, and geography. Several clinical and public health interventions show promise, although our understanding of their effectiveness has largely originated from high-income countries. Attempting to predict suicide is unlikely to be helpful. Intervention and prevention must include both a clinical and community focus, and every health professional has a crucial part to play.

Introduction

Data from WHO suggest that, globally, suicide accounts for at least 700 000 deaths per year. The actual number is likely to be much higher because of under-recording. Suicide has become a defining health and societal issue in many countries.¹ Self-harm (self-poisoning or self-injury with varying degrees of suicidal intent) is even more common, with an estimated 14·6 million individuals affected each year.² Suicide has received a great deal of attention during the COVID-19 public health emergency,³ and its prevention will continue to be a priority as we move into subsequent phases and eventual recovery from the pandemic.

Many people who die by suicide have a history of self-harm, and previous self-harm is the strongest risk factor for suicide, at least in high-income settings.⁴ Despite suicide and self-harm sometimes being seen as distinct concepts, here we discuss them together, given that many of the principles of intervention and prevention are common to both.

Suicide and self-harm are intensely individual experiences that are often markers of unbearable psychological pain; however, suicide and self-harm are also affected by societal factors. It has been known for at least a century that economic adversity is associated with higher suicide rates. Clinicians need to be at the forefront of suicide prevention efforts, because policy makers and the public will look towards clinicians for leadership, particularly in low-income and middle-income countries (LMICs). Public health factors need to be recognised, and the role of mental and physical health must also be acknowledged—a proportion of people who die by suicide have a psychiatric disorder at the time of death, and many, particularly in older age groups (eg, those older than 65 years), have a physical illness.5, 6 Most of these individuals, at least in high-income settings, will have consulted health services in the year before they die,⁷ some having harmed themselves. Each clinical encounter should be seen as an opportunity to intervene.

Stigma remains a serious issue in clinical and non-clinical settings, and the language we use is important. Suicide might not be openly discussed, or might even be perceived as a selfish act. Many people who self-harm have a poor experience of health care: “In many cases, staff lacked compassion. Such as invalidating my distress, stigmatising responses such as ‘wow you really meant to kill yourself, didn't you!!', exclaiming at the severity of my previous scarring and saying I was ‘adding to the collection', saying that my pain threshold must be high and deciding not to give me any pain relief or medications when stitching or cleaning wounds (almost as if it was to be a punishment for self-harming), saying that I was ‘wasting time' and other people had ‘real' injuries.”⁸

Patients report that clinicians might blame them or deny them access to high quality care because of the erroneous belief that providing good care will encourage future episodes. Such attitudes might be partly related to a lack of knowledge and understanding. Clinicians also need to be aware that some individuals view their self-harm as a coping strategy to manage psychological distress or even prevent suicide.

In this Seminar we aim to provide an update on suicide and self-harm with a global and practical focus. We also discuss current and emerging issues. Further discussion of the terminology used throughout the Seminar and the importance of language are included in the appendix (pp 2–3).