Social Determinants influencing self-harm methods, care seeking pathways and outcomes among adults attending a tertiary care hospital In Mysuru - A mixed methods study.

Suicide is a growing public health concern world-wide. It has been observed that one individual dies of suicide every 40 seconds.(1) The third leading cause of death among young adults is suicide. Around 73% of global suicides occur in low and middle income countries (2). Research shows that in 2014, SDRs were twice as common in men as in women, and this disparity grew to 2.5 times by 2021.(3)

The state-run general hospitals in the country bear the major burden of these self-harm cases. The adverse social factors such as early exposure to socioeconomic disadvantage, early life adversities, poor education, unfavourable working conditions, gender inequalities, migration and finally loneliness and social isolation during the old age collectively form social determinants of mental health. (4)

Yadav et al explored the suicide death rates (SDR) from 2014 to 2021 by retrieving the data National Crime Records Bureau (NCRB). Age group, gender, socioeconomic status, marital status, education and occupation were the major factors that determined the rates of suicide. The rates of suicide among men and women were higher in the age group of 30 to 44 years and 18 to 29 years respectively. It was higher among married men and women. Women in all levels of education showed substantially lesser suicide rates as compared to men. Daily wage earners were more prone to suicide. The most common method of suicide was hanging.(3)Though NCRB provides a crucial data, there is limited information with regards to access to care pathways and clinical outcomes of self-harm.

Monitoring incidences of suicide is a crucial component of suicide prevention. Efforts have been made previously in 2012 in a state-run general hospital in Mysore to establish a hospital based self-harm register (SHR) to demonstrate its feasibility, operationalization and its usefulness. This was the first SHR to be established in a general hospital in India and is maintained at the Department of Psychiatry at the general hospital. The care pathways demonstrated in this SHR showed how only very few patients of self-harm underwent a psychiatric assessment and most were discharged from the casualty without any assessment.(5)

The proven feasibility and findings from this SHR guided the research group under the Global Challenge Research Fund (GCRF) to establish an evidence based Southeast Asia SelfHarm Initiative (SASHI) in the late 2015 which was a collaborative spearheaded by the Centre for Mental Health and Society at Bangor University and it brought together researchers from South Asia and the UK to build capacity around self-harm research.(6,7)

SASHI was established in 2018 in the city of Mysore which is located in South India and captured data across three diverse settings – a state run government general hospital, a private medical college and a private hospital. It aimed to support effective strategies for addressing self-harm and suicide in South Asia by strengthening research infrastructure and enhancing local expertise, with a strong focus on developing robust surveillance systems.(7).

The SASHI was in operation from 2017 to 2022. The SASHI SHR register has captured extensive data on the sociodemographic details (age, gender, socioeconomic status, marital status, education, occupation), date and time of presentation to the hospital, mode of arrival at the hospital, person who brought the patient, state of the patient during arrival, health professional who assessed the patient, burns related questions, description of the event of self-harm, its course in the hospital and its final outcomes (death, disability, Discharged Against Medical Advice (DAMA), psychiatric diagnosis, length of hospital stay and time taken to treatment).

The SASHI SHR included poisoning (medication and nonmedication), burn injury, hanging, drowning, fall from height, fall in front of train, selflaceration, firearm injury and unspecified self-harm as the inclusion criteria.(8)The self-harm data was captured for approximately 3600 men and women between the age groups of 18 to 85 years. In a subset of these patients (approximately 600) in-depth patient based interviews were conducted to understand how social factors influenced access to care and service utilization.

SASHI has established a platform in the city of Mysore which allows me to pursue my doctoral study. It gives an unique opportunity to examine how social determinants like age, gender, socio-economic status, education, occupation, religious beliefs and social/family support influence the methods, care pathways and outcomes following an act of self-harm in adults.

The SASHI initiative laid the foundation for the current SAMASTH project - Systems Approach for MAnagement of self-harm by integrating Surveillance with mental health Training in general Hospitals in South India which aims to roll out and assess a comprehensive programme across three major state-run general hospitals in South India.

This initiative includes the introduction of a robust electronic self-harm register (e-SHR) for surveillance alongside a mental health training component designed for clinical staff.(9).

However the already available data from the SASHI SHR will not aid in understanding the lived experiences of self-harm survivors in terms of the care pathways sought, the barriers and facilitators involved in access and utilization of health services. Hence from the current SAMASTH project, e-SHR, a narrative inquiry will be conducted with the current self-harm survivors, their care givers, health service providers and key stakeholders in the government in this regard.

References:
1. Wu Y, Wang L, Tao M, Cao H, Yuan H, Ye M, et al. Changing trends in the global burden of mental disorders from 1990 to 2019 and predicted levels in 25 years. Epidemiol Psychiatr Sci. 2023 Nov 7;32:e63.
2. Suicide [Internet]. [cited 2025 May 13]. Available from: https://www.who.int/newsroom/fact-sheets/detail/suicide
3. Yadav S, K AK, Cunningham SA, Bhandari P, Mishra US, Aditi A, et al. Changing pattern of suicide deaths in India. Lancet Reg Health - Southeast Asia [Internet]. 2023 Sep 1 [cited 2025 May 13];16. Available from: https://www.thelancet.com/journals/lansea/article/PIIS2772-3682(23)00125-7/fulltext
4. Kirkbride JB, Anglin DM, Colman I, Dykxhoorn J, Jones PB, Patalay P, et al. The social determinants of mental health and disorder: evidence, prevention and recommendations. World Psychiatry. 2024 Feb;23(1):58–90.
5. A feasibility study to establish a Deliberate Self-harm Register in a state hospital in southern India. | British Journal of Medical Practitioners [Internet]. [cited 2025 May 13]. Available from: https://www.bjmp.org/content/feasibility-study-establish-deliberate-selfharm-register-state-hospital-southern-india
6. (PDF) A hospital-based self-harm register in Mysore, South India: Is follow-up of survivors feasible in low and middle income countries? ResearchGate [Internet]. 2024 Dec 9 [cited 2025 May 13]; Available from: https://www.researchgate.net/publication/355404295_A_hospital-based_selfharm_register_in_Mysore_South_India_Is_followup_of_survivors_feasible_in_low_and_middle_income_countries
7. The South Asia Self Harm Initiative | South Asia Self Harm Initiative (SASHI) Project | Bangor University [Internet]. [cited 2025 May 13]. Available from: http://sashi.bangor.ac.uk/
8. Bebbington E, Poole R, Kumar SP, Krayer A, Krishna M, Taylor P, et al. Establishing SelfHarm Registers: The Role of Process Mapping to Improve Quality of Surveillance Data Globally. Int J Environ Res Public Health. 2023 Feb 1;20(3):2647.
9. Institute of Public Health Bengaluru [Internet]. [cited 2025 May 13]. SAMASTH. Available from: https://iphindia.org/samasth/