Demographic and psychosocial characteristics of self-harm: The Pakistan perspective

Highlights

• The majority of participants reported clear intent to die as the motivator for self-harm and most did not communicate this intent.

• Ingestion of toxic chemicals (insecticides and pesticides) was the most common means of self-harm.

• Interpersonal difficulties were the most commonly cited trigger or antecedent for self-harm followed by financial difficulty.

• Self-harm was more prevalent in females in our sample, who were more likely to be young, single, living in joint family system (extended family system) and with less than 10 years of formal education.

• Some characteristics of those who self-harm in Pakistan are comparable to other populations, raising the possibility of common causal mechanisms. Prevention strategies and treatments developed for self-harm in other contexts could be adapted and applied to the Pakistani population.

Abstract

Self-harm is a major public health issue in Pakistan, yet the characteristics of those who self-harm are under-explored. This is a secondary analysis from a large randomized control trial on the prevention of self-harm, exploring demographic, clinical and psychological characteristics of people who self-harm in Pakistan. A total of 221 participants with a history of self-harm were recruited from medical wards of three major hospitals in Karachi. The Beck Scale for Suicidal Ideation (BSI), Beck Depression Inventory (BDI), Beck Hopelessness Scale (BHS), and Suicide Attempt Self Injury Interview (SASII) assessment scales were completed. The sample consisted predominantly of females (68.8%) in their 20′s. Interpersonal difficulties were most commonly reported as the main antecedent to the self-harm, followed by financial difficulties. Participants had high severity scores on BSI, BDI and BHS. Pesticide and insecticide use were (n = 167, 75.6%) the most common methods of self-harm. The findings indicate that some characteristics of those who self-harm in Pakistan are comparable to other populations. This may raise the possibility of common causal mechanisms and processes. Future research needs to examine the efficacy of interventions targeting these risk factors in reducing rates of self-harm and thus suicide.

Introduction

Suicide is the 18th leading cause of death worldwide, accounting for 1.4% of all reported deaths and most occurring in Lower and Middle-Income Countries (LMIC; World Health Organization, 2016). Self-harm is associated with a greater risk of subsequent self-harm (Hawton et al., 2012, Perry et al., 2012), suicide (Hawton et al., 2012, Ribeiro et al., 2015), and all-cause mortality (Bergen et al., 2012). Previous suicide attempt is found to be a significant risk factor for completed suicide in the general population (World Health Organisation, 2014). The implications of self-harm extend beyond the considerable emotional distress involved, to high costs on health services (Sinclair et al., 2011). Detrimental social and psychological effects are also often experienced by the families of patients engaging in self-harm (Ferrey et al., 2016). There is much data on the characteristics of individuals who present at hospital following self-harm from high income countries (Geulayov et al., 2016). This information is useful in guiding prevention and intervention strategies. It should not be assumed that these characteristics are the same in LMICs as in high income countries. Self-harm is still under-researched in Pakistan and epidemiological data are limited (Shekhani et al., 2018). As such less is known about the common characteristics and antecedents of self-harm in these countries.

Many people living in Pakistan face increased economic and social pressures, compared to those in higher-income countries (Husain et al., 2011) and as such these would be expected as common antecedents for self-harm. The Labour Force Survey (2017–18) identified literacy rates of 62.3% in Pakistan (Pakistan Bureau of Statistics, 2018). The average income in this survey reported a monthly income of Rs. 18,754 (GBP 102.46; Pakistan Bureau of Statistics, 2018). These difficulties may be associated with difficult psychological states, including anxiety, depression, hopelessness and suicidal ideation, which in turn are associated with the risk of self-harm (Fox et al., 2015, Fliege et al., 2009).It is important to ascertain the extent to which these characteristics remain consistent across cultures and locations, since variations may imply that distinct mechanisms underlie self-harm in these contexts, and that appropriately tailored interventions are required (Cervantes et al., 2014). For example, there is preliminary evidence of divergence relating to gender differences, prevalence and functions for self-harm across cultures (Gholamrezaei et al., 2017). Data concerning self-harm in Pakistan are scarce. Numerous barriers, including a lack of existing research infrastructure but also the illegal and highly taboo status of self-harm, make it difficult to collect data regarding self-harm in this country. A recent scoping review synthesized literature on self-harm in Pakistan, highlighting the characteristics of this population. Self-harm was more frequent in females of a younger age group (Shekhani et al., 2018). Unemployment was associated with self-harm, but this varied across studies (Shekhani et al., 2018). Self-poisoning with insecticides and pesticides was found to be the most common method in both urban and rural areas (Shekhani et al., 2018). The review identified a gap in evidence exploring clinical characteristics of self-harm in Pakistan (Shekhani et al., 2018).

The aim of this study is to explore demographic, psychological (perceived antecedents, depression, hopelessness and suicidal ideation) and clinical characteristics (e.g. method, suicidal intent) of self-harm, to determine whether the same characteristics apply in Pakistan as they do globally. We also examined the psychological correlates of different antecedents for self-harm (e.g. financial problems, interpersonal problems) to investigate whether different antecedents are associated with a distinct psychological profile. The study was conducted with patients admitted to medical wards after an episode of self-harm.