Self harm – a culture-bound syndrome? Ghana and UK experience

Self-harm or parasuicide is generally believed to be rare in low- and middle-income countries. The subject was hardly mentioned, let alone taught, as a topic throughout my undergraduate medical training in Ghana. In my medical school clinical years and throughout my work as a house officer in the largest teaching hospital in Ghana, I never saw or head of a single case of self-harm. I later worked as a medical officer (hospital-based general practice) in a busy district hospital for 3 years and here too I never encountered such a case.

I am not aware of any publications from Ghana on the subject. There are a few papers from Nigeria, a neighbouring West African country. Eferakeya (1984) found the prevalence to be 7 per 100 000, whereas 2 years later Odejide et al (1986) found a 6-month rate of 2.6 per 100 000. These rates are very low compared with UK rates of 251 per 100 000 for males and 323 per 100 000 for females (Schmidtke et al, 1996).

I had a cultural shock in my first psychiatric senior house officer post in the UK when I quickly realised that self-harm was the ‘bread and butter’ of emergency psychiatric practice. The question that bothered me and still remains unanswered is whether this is a culture-bound syndrome.

Could it be that the extended family system as opposed to the nuclear family, religious beliefs, social services provision, individualism, materialism, issues of abuse, healthcare provision and other factors that are different account for the apparent differences in rates of self-harm?

Ghana does not have a free national health service; a so-called cash and carry system operates whereby patients pay for services. This has huge disadvantages, but one unintended advantage could be that the financial implications may act as a deterrent to self-harm unless the act is in response to psychotic phenomena. The attitude of healthcare workers is also important. Owing to huge pressures on health facilities and inadequate training of health workers in the assessment and treatment of self-harm, such professionals are, in my opinion, likely to be unsympathetic to patients who self-harm. Their distress may be viewed as self-inflicted and therefore not deserving professional care and attention. This in effect could result in such patients not being treated sympathetically and with dignity, leading to subsequent under-reporting of cases.