Suicide and self-harm emergency department presentations in culturally and linguistically diverse people

What's the issue?

The rate of emergency department (ED) presentations for people who have self-harmed or experienced thoughts of suicide has remained consistent over the past decade from 120.6 per 100 000 in 2011–2012 to 104.6 per 100 000 in 2021–2022.1

Many people who have self-harmed or experienced thoughts of suicide are triaged by emergency staff and mental health nurses, and care is provided on a case-by-case basis.

Responsive, person-focused care provided by ED nursing staff can improve a person’s experience in care and support emergency staff to identify and manage a person’s self-harm and suicide risk. It is important that the type of support and interactions provided by mental health nurses and ED staff are suitable for all individuals.

There is high diversity among people accessing emergency care for self-harm and suicidal thoughts and behaviours however little is known about the rate of presentations by people from culturally and linguistically diverse backgrounds. In addition, cultural identity is largely recorded by ED staff as free text in triage notes with varying levels of detail.

While Australian research indicates that the prevalence of both self-harm and suicide ideation may be lower in culturally and linguistically diverse populations, these populations may experience unique risks relating to self-harm, mental health and willingness to engage with medical services relating to cultural and societal beliefs, experiences and language barriers.

Understanding how people of culturally and linguistically diverse backgrounds use EDs following self-harm or when experiencing suicidal thoughts is important to develop and implement appropriate and responsive care.

What was done?

The researchers examined the following:

  • The proportion of people who present with self-harm and/or suicidal thoughts that are from culturally and linguistically diverse backgrounds.
  • How cultural and linguistic identity is classified in the triage notes.
  • Psychosocial factors recorded in triage notes.
  • Presentations between those from culturally and linguistically diverse backgrounds and those who are not in relation to the nature of service use during and after the initial presentation to ED.
  • Rates of re-presentation for self-harm and suicide between those from culturally and linguistically diverse backgrounds and those who are not.

To achieve this the researchers undertook a cross-sectional study of self-harm and suicidal ideation-related presentations to the ED of a major Victorian metropolitan hospital between 12 January 2012 and 31 December 2019.2

This hospital is situated in an area where the proportion of culturally and linguistically diverse persons is greater than the national average.2

Data was taken from the self-harm monitoring system for Victoria's electronic medical records, and additional coding was undertaken to identify self-harm and suicidal ideation-related attendances.

People were determined as being from a culturally and linguistically diverse background if the triage comment indicated that the individual either speaks a language other than English as their primary language, or if they were born in a non-English speaking country.

The researchers then examined the data to identify common psychosocial and economic factors across presentations, and compared the differences in presentations and follow-up presentations between culturally and linguistically diverse, and non-culturally and linguistically diverse data.

What was found?

General findings:

  • There were 15,606 self-harm and suicide ideation presentations between 2012 and 2019.
  • Presentations for self-harm and suicidal thoughts were roughly equal.
  • Culturally and linguistically diverse backgrounds, and non-culturally and linguistically diverse backgrounds groups were similar in socioeconomic status and age.

Findings among those identified as culturally and linguistically diverse:

  • There were 202 presentations (1.3% of the total sample) from 150 individuals (some were repeat presentations).
  • There were more presentations from men than women.
  • Presentations were more often for suicide ideation (n = 131, 64.9%) than for self-harm (n = 71, 35.2%).

Differences identified:

The culturally and linguistically diverse group were:

  • 73% less likely to report current or past alcohol and/or drug use.
  • More than twice as likely to report occupational or financial stressors.
  • More likely to present at the ED during business hours (n = 94, 46.5%) than those not from culturally and linguistically diverse backgrounds (n = 5140, 33.4%).
  • Half as likely to be triaged at categories 1 (immediately life-threatening) or 2 (imminently life-threatening or important time-critical treatment or very severe pain).
  • More likely to receive a mental health assessment, compared to those not from culturally and linguistically diverse backgrounds (64.1%).
  • More frequently admitted to a general medical ward or mental health unit, compared to those not from culturally and linguistically diverse backgrounds (64.1%).
  • 24% less likely to re-present to ED.

The findings of this study may be limited due to the imprecise methodology of using triage notes to identify cultural and linguistic identity, and the fact that the data was taken from a hospital with a higher-than-average culturally and linguistically diverse population in its catchment area.

Why are the findings important?

The data used for this study may not give a true indication of ED presentations as cultural and linguistic status was largely based on triage notes such as languages spoken, but language is only one aspect of identity. Researchers highlight the need to improve data collection in ED and healthcare settings.

ED staff may benefit from having access to professionally trained medical interpreters to support culturally and linguistically diverse presentations to improve understanding and outcomes. Furthermore, staff training to improve patient care in culturally responsive ways may improve outcomes and experiences for both patients and staff. Evidence suggests that people from culturally and linguistically diverse backgrounds are less likely to understand their condition and feel in control of their health compared to their counterparts following a trauma admission.3

The findings of this study showed that nearly half of ED presentations by people from culturally and linguistically diverse backgrounds for self-harm and suicidal thoughts occurred during business hours. The researchers suggest that barriers to accessing primary care may be a reason ED departments were accessed at higher rates.

The researchers highlight the opportunity to improve aftercare for culturally and linguistically diverse people given that after ED, they were more frequently admitted to a general medical ward or mental health unit.

Notes

1

Australian Institute of Health and Welfare. 2023b. “Intentional Self-Harm Hospitalisations by States and Territories.” https://www.aihw.gov.au/suicide-self-harm-monitoring/data/intentional-self-harm-hospitalisations/intentional-self-harm-hospitalisations-by-states

2

Robinson, J., K. Witt, M. Lamblin, et al. 2020. “Development of a Self-Harm Monitoring System for Victoria.” International Journal of Environmental Research and Public Health 17: 9385.

3

Le, K. D. R., K. Le, A. Shahzad, and S. J. Lee. 2024. “The Role of Language Barriers on Hospital Outcomes in Culturally and Linguistically Diverse Patients Following Trauma Admission.” Trauma Care 4: 107–119

Study information

Authors

  • Gowri Rajaram
  • Jo Robinson
  • Lu Zhang
  • Katrina Witt

Study originally published

9 September 2024

Read the full paper

Translated on Life in Mind

28 October 2024

Citation

Rajaram G, Robinson J, Zhang L, Witt K. Emergency department use following self-harm and suicide ideation: an analysis of the influence of cultural and/or linguistic diversity using data from the Self-Harm Monitoring System for Victoria (2012–2019). Int J Ment Health Nurs. 2024;33(4):123-134. doi:10.1111/inm.13411.