Disclosures and Acknowledgments

Title

Self-harm in adult victims of human trafficking accessing secondary mental health services in England

Disclosures and acknowledgments

This report is independent research commissioned and funded by the Department of Health Policy Research Programme (Optimising Identification, Referral and Care of Trafficked People within the National Health Service [NHS]; 115/0006). The views expressed in this publication are those of the authors and not necessarily those of the Department of Health. The funder had no role in the design or conduct of the study, collection, management, analysisor interpretation of the data or writing of the report. The study was supported by the Clinical Records Interactive Search (CRIS) system funded and developed by the National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London and a joint infrastructure grant from Guy’s and St Thomas’ Charity and the Maudsley Charity.The corresponding author had full access to all data in the study and had final responsibility forthe decision to submit for publication.

RB is supported by an Early Career Fellowship from Australia’s National Health and Medical Research Council (NHMRC; #1104644). SO, LMH, and CZ received support from the Department of Health Policy Research Programme (115/0006). LMHis also supported by an NIHR Research Professorship (NIHR-RP-R3-12-011) and by the NIHR South London and Maudsley NHS Foundation Trust Biomedical Research Centre-Mental Health. RD is supported by a Clinician Scientist Fellowship from the Health Foundation, working with the Academy of Medical Sciences.SK is supported by an Australian National Health and Medical Research Council Senior Research Fellowship (APP1078168).

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ABSTRACT

Objective:This study estimated the prevalence, correlates and mental health service responses to self-harm among adult victims of human trafficking accessing secondary mental health services in England.

Methods: A clinical recordsdatabase was searched to identify trafficked adultswho accessed secondary mental health services in South London from 2006-2012. A matched cohort of non-trafficked patients was selected. Data were extracted on self-harm, socio-demographic, clinical and service use characteristics. Logistic regression models compared trafficked and non-trafficked patients.

Results: Data were analysed for 84 trafficked adults; 28 (33%)had self-harmed prior to care and 21 (25%) self-harmed during care. After self-harming, trafficked patients were more likely than non-trafficked patients to be admitted as a psychiatric inpatient(AOR = 2.81; 95%CI =1.12–6.50),but less likely to attend an emergency department (AOR = 0.47, 95%CI = 0.23–0.95).

Conclusions: Self-harm is prevalentamong trafficked adults accessing secondary mental health services;mental health professionalshave a crucial role to play in supporting survivors, including through the assessment and prevention of self-harm and suicide, and ensuring sensitive and humane responses to self-harm.

Human trafficking is the recruitment of people - through means such as the use of deception, threat or coercion - for the purposes of exploitation (1). It is frequently characterised by psychological, physical or sexual abuse (2), and trafficked people often suffer from post-traumatic stress disorder, depression, and anxiety (3-5). They are also at heightened risk of substance abuse and other self-destructive and risk-taking behaviours(6). Yet, empirical research examining self-harm in trafficked adults is lacking.Recently, Kiss et al.(7) reported a high prevalence of past month suicide attempts among trafficked adults (5%) and children (5%) in contact with post-trafficking services in Cambodia, Thailand and Vietnam, and of past month self-harm among trafficked children in the same region (7). However,to date there have been no published studies examining self-harm among trafficked adults or among trafficked people in contact with mental health services (8). This is a notable gap because the link between trafficking and self-destructive behaviours - and the strong association between self-harm and subsequent suicide (9) - may place this population at heightened risk of early mortality.

Using data from a historical cohort study, this study aimed to (a) estimate the prevalence and correlates of self-harm among adult victims of trafficking accessing secondary mental health services in London, UK (b) examine mental health service responses to self-harm among adult victims of trafficking, and (c) compare mental health service responses to self-harm in patients who had and had not been trafficked.

METHODS

Data were collected as part of a historical cohort study of trafficked and matched non-trafficked patients in contact with secondary mental health services at South London and Maudsley (SLaM) National Health Service Foundation Trust between 1stJanuary 2006 and 31stJuly 2012.

Data were obtained from the CaseRecords Interactive Search (CRIS) system, which allows the searching and retrieval of pseudo-anonymised full patient records(10).Cases were SLaM patients whose care team had recorded concerns that they may have been trafficked.Terms used to search CRIS records included: “victim of trafficking”, “sex trafficking”, “trafficked”, “traffiked”, “trafiked”, “sex traffickers”, “human trafficking”, “forced prostitution”, “child trafficking”, “people trafficking”, “forced labour”, “trafficking”, “sexual slavery”and “Poppy Project” (an organisation in the UK providing support, advocacy and accommodation to trafficked women).

Eligibility was assessed by reviewing patients' clinical notes and correspondence between the healthcare team and other professionals involved in the patients' care. Records were screened against the study inclusion criteria using the United Nations definition of human trafficking (i.e. the recruitment or movement of people, by means such as force, fraud, coercion, deception, and abuse of vulnerability, for the purposes of exploitation) and included both international and internal trafficking(11). One researcher assessed eligibility and a second researcher (SO) independently assessed the first ten records and an additional random 10% of records. Full details are provided elsewhere(5).

Amatched cohort of non-trafficked adult patients was produced using computer-generated random selection from all potential controls whomet matching criteria.Up to four controls per case were selected. Cases and controls were matched for gender, age, [+/- 2 years], primary diagnosis, psychiatric inpatient admission at first contact, and year of most recent service contact.

Data were extracted on socio-demographic, clinical, and service use characteristics (described in full elsewhere(12)). The following terms, derived from the self-harm literature (13), were used to search electronic health records for references to self-harm: “self-harm”, “self harm”, “DSH”, “suicid*”, “overdos*”, “electrocut*”, “hang*”, “ligature*”, “burn*”, “lacerat*” and “cut”. Data on self-harm prior to and during contact with SLaM services, and on emergency department attendancesand psychiatric inpatient admission(voluntary and/or compulsory)following self-harm,were extracted by SO.

Logistic regression models were fitted to compare prevalence of, and service responses to, self-harm by trafficked and non-trafficked patients, using a random intercept for the match identifier to allow for possible correlation between matched individuals. Models comparing trafficked and non-trafficked patients’ self-harm while accessing SLaM care included as an a priori confounder the duration of time in contact with SLaM services (calculated by subtracting date of first referral from date of final discharge, excluding any periods between referrals, with an upper date limit of January 24th 2013). Models comparing trafficked and non-trafficked patients’ emergency department attendance and psychiatric admissions after self-harm includedhistory of self-harm (i.e. self-harm prior to contact with SLaM) and the duration oftime in contact with SLaM services. As<10% of data were missing for all variables included in logistic regression models; complete case analysis wasused. Ethics approval was granted by an independent Research Ethics Committee (Oxfordshire C, reference 08/H0606/71). The CRIS Oversight Committee gave approval for this study (11/025).

RESULTS

Ninety-eight trafficked patients were identified. Data are reported for the 84 trafficked patients who had a recorded ICD-10 diagnosis and could be compared with a matched sample of non-trafficked adults. Most trafficked patients were female (66; 79%), aged in their twenties (mean: 26.9 years, SD: 6.8; 45% aged 18-25), had been trafficked for the purpose of sexual exploitation (46; 55%) and had escaped the trafficking situation(84; 100%).Data on type of exploitation were missing for 22 (26%) patients. Trafficked patientsoriginated from 33 different countries, with Nigeria (16; 19%), China (7; 8%) and Uganda (7; 8%)jointly accounting for more than one third of all patients. The most prevalent diagnoses were affective disorders (33; 39%),PTSD / severe stress / adjustment disorder (27; 32%) and schizophrenia and related disorders (14; 17%). The majority of trafficked patients were referred for care following contact with other health services including primary care (29; 35%), emergency departments (25; 30%) and maternity services (8; 10%). Other sources of referral included the police and the voluntary sector.

Table 1 summarises the self-harm data from matched trafficked (N=84) and non-trafficked(N=287) patients. Almost one thirdof trafficked patients (28; 33%) reported a history of self-harm prior to SLaM contact. More than one fifth (21; 25%) self-harmed whilst under the care of SLaM, of whom 13 (62%) had a recorded history of self-harm. Of the 21 trafficked patients who self-harmed whilst under SLaM care, 12 (57%) were admitted as a psychiatric inpatient following self-harm and six (29%) were compulsorily detained. Ten trafficked patients who self-harmed (48%) had a diagnosis of an affective disorder and five (24%) had a diagnosis of PTSD, severe stress or adjustment disorder. Self-poisoning (9; 43%), attempted hanging (6; 29%) and cutting (5;24%) were the most frequently reported methods of self-harm among trafficked patients. Medical records included information about the circumstances of self-harm for 18 of the 21 trafficked patients who self-harmed while under SLaM care. Several trafficked people were described as suffering from low mood and feelings of failure and hopelessness, with no specific trigger identified. Others were described as experiencing command hallucinations to self-harm, or as wanting to escape intrusive thoughts and distress relating to their experiences while trafficked. Other triggers included claims for immigration protection being refused, participating in criminal proceedings against traffickers, impending eviction, relationship difficulties, and financial problems.

INSERT TABLE 1 HERE

The recorded prevalence of history of self-harm did not differ significantly between trafficked and non-trafficked adults (33% vs. 34%; OR = 1.01, 95%CI = 0.59–1.71). Similarly, the recorded prevalence of self-harmwhilst under the care of SLaM services did not differ significantly between trafficked and non-trafficked adults (21% vs. 32%; AOR = 0.74, 95%CI = 0.41–1.34). However, trafficked adults were significantly less likely to have attended an emergency department after self-harming (57% vs. 84% ; AOR = 0.47, 95%CI = 0.23–0.95) but more likely than non-trafficked adults to be admitted as a psychiatricinpatient after self-harm (57% vs 21%; AOR = 2.81; 95%CI = 1.12–6.50)and to becompulsorily admitted as a psychiatric inpatient after self-harm(6% vs. <1%; AOR = 28.75, 95%CI: = 3.12–264.72).

DISCUSSION

Theprevalenceof recorded self-harm among trafficked adults receiving secondary mental health care from SLaM was high, although no higher than among a matched sample of non-trafficked adult SLaM patients. However,trafficked and non-trafficked patientswho self-harmed experienced different mental health service responses. Trafficked patients were more likely to be admitted as psychiatric inpatients - and to be compulsorily admitted - following an episode of self-harm. This is an important finding becausecompulsory admission - whilst beneficial in many cases and the result of experienced clinical judgment - may be particularly distressing for some trafficked people who may have, during the course of their exploitation, experienced restrictions on their movementsandcontrols on their daily routines.By contrast, trafficked patients were less likely than non-trafficked patients to attend an emergency department following self-harm. This may be a function of the nature and severity of the self-harm episodes, but may also reflect a limitedknowledge of the UK health system, experiences of care in their home countries (especially regarding the cost of care),or other factors not yet understood. . Medical records included basic information about the precipitants of self-harm among trafficked people, including distress relating to their experiences while trafficked and legal, financial, and social stressors. Similar stressors were highlighted by mental health professionals as impacting negatively on trafficked people’s mental health in previous research with this cohort, in particular ongoing or failed asylum claims and a lack of stable accommodation (14). Further research is needed to explore risk and protective factors for self-harm, immediate precipitants of self-harm that may be particularto trafficked adults, and appropriate mental health service responses.

Ross et al. (15) recently reported that, although up to one in seven mental health professionals in the UK may have had contact with a person they knew or suspected had been trafficked, 81% of those surveyed reported that they had received insufficient training to adequately assist trafficked people. It is imperative that mental health professionals understand the issues surrounding human trafficking and are equipped adequately to identify and respond to trafficked people. An enhanced understanding of trafficking may contribute to the implementation of a wider range of treatment options following self-harm.

These are the first published data on self-harm among trafficked adults and among a clinical sample of trafficked people internationally. The data source allowed us to make detailed comparisons between trafficked and non-trafficked patients across a range of outcomes of interest, including service responses to self-harm.

Our study also had some limitations. First, most of our participants were female and, as self-harm is more common in females(13), our findings may not be generalizable to male victims of trafficking. Second, data did not support detailed qualitative analysis (e.g. of precipitants of self-harm) and as data were extracted from a pseudo-anonymised psychiatric case register, it was not possible to collect supplementary data through patient interviews.

The findings of this study demonstrate that self-harm is commonamong trafficked adults accessing secondary mental health services in England. Mental health professionals need to address human trafficking as a serious health risk because, like other forms of violence, it is associated with considerable psychological and physical harm, including self-harm.Given the extreme nature and severe consequences of trafficking, mental health professionals have a crucial role to play in supporting survivors,including through the assessment and prevention of self-harm and suicide, andensuring sensitive and humane responses to self-harm.

References

1.UN. Optional Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention Against Transnational Organized Crime, G.A. Res. 55/25(2000). United Nations. 2000.

2.Oram S, Stöckl H, Busza J, Howard LM, Zimmerman C. Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: systematic review. PLoS medicine. 2012;9(5):615.

3.Abas M, Ostrovschi NV, Prince M, Gorceag VI, Trigub C, Oram S. Risk factors for mental disorders in women survivors of human trafficking: a historical cohort study. BMC Psychiatry. 2013;13(1):204.

4.Oram S, Abas M, Bick D, Boyle A, French R, Jakobowitz S, et al. Human trafficking and health: a cross-sectional survey of male and female survivors in contact with services in England. American Journal of Public Health. 2016:Online First, e1–e6. doi:10.2105/AJPH.016.303095.

5.Oram S, Khondoker M, Abas M, Broadbent M, Howard LM. Characteristics of trafficked adults and children with severe mental illness: a historical cohort study. Lancet Psychiatry. 2015;2(12):1084-91.

6.Courtois CA. Complex trauma, complex reactions: Assessment and treatment. Psychotherapy: Theory, Research, Practice, Training. 2008;41(4):412-25.

7.Kiss L, Yun K, Pocock, N., Zimmerman C. Exploitation, violence and suicide risk among child survivors of human trafficking in the Greater Mekong subregion. JAMA Pediatrics. 2015; in press.

8.Ottisova L, Hemmings S, Howard LM, Zimmerman C, Oram S. Prevalence and risk of violence and the mental, physical, and sexual health problems associated with human trafficking: an updated systematic review. Epidemiology and Psychiatric Sciences. 2016;Online First:DOI: 10.1017/S2045796016000135.

9.Hawton K, Zahl D, Weatherall R. Suicide following deliberate self harm: long term follow up of patients who presented to a general hospital. British Journal of Psychiatry. 2003;182:537-42.

10.Stewart R, Soremekun M, Perera G, Broadbent M, Callard F, Denis M, et al. The South London and Maudsley NHS foundation trust biomedical research centre (SLAM BRC) case register: development and descriptive data. BMC Psychiatry. 2009;9(1):51.

11.UN. Protocol to prevent, suppress and punish trafficking in persons, especially women and children, supplementing the United Nations convention against transnational organized crime. United Nations General Assesmbly. 2002.

12.Oram S, Khondoker M, Abas M, Broadbent M, Howard L. Characteristics of trafficked adults and children with severe mental illness: a historical cohort study. Lancet Psychiatry. 2015;(in press).

13.Skegg K. Self-harm. The Lancet. 2005;366(9495):1471-83.

14.Domoney J, Howard LM, Abas M, Broadbent M, Oram S. Mental health service responses to human trafficking: a qualitative study of professionals’ experiences of providing care. BMC psychiatry. 2015;15(1):1.

15.Ross C, Dimitrova S, Howard LM, Dewey M, Zimmerman C, Oram S. Human trafficking and health: a cross-sectional survey of NHS professionals’ contact with victims of human trafficking. BMJ Open. 2015;5(8):e008682.

1 | Self-harm in adult victims of human trafficking accessing secondary mental health services
April, 2016

Table 1. Clinical electronic health records data relating to self-harm in84 trafficked adults and 287 non-trafficked adults accessing secondary mental health services in London, UK.

Self-harm variable / Trafficked adults (N=84)
N (%) / Non-trafficked adults (N=287)
N (%) / AOR / 95% CI
History of self-harm prior to receiving care from SLaM / 28 / 33 / 96 / 34 / 1.01 / 0.59-1.712
Self-harm whilst under care of SLaM / 21 / 25 / 91 / 32 / 0.74 / 0.41-1.342
Of those who self-harmed whilst under care of SLaM (n=21 trafficked, n=91 non-trafficked):
First contact with SLaM related to self-harm / 5 / 24 / 32 / 35 / 0.44 / 0.16-1.23
Number of self-harm events whilst under care of SLAM (if >0); (M, SD) / 2.3 / 3.8 / 3.1 / 4 / 1.6 / 0.5-3.9
Attended emergency department after self-harm / 12 / 57 / 76 / 84 / 0.47 / 0.23–0.953
Admitted as inpatient after self-harm / 12 / 57 / 19 / 21 / 2.81 / 1.12–6.503
Compulsory inpatient admission after self-harm / 6 / 29 / NR / NR / 28.75 / 3.12-264.723
Type of self-harm whilst under care of SLaM1(n=21 trafficked, n=91 non-trafficked):1
Poisoning / 9 / 43 / 69 / 76 / 0.47 / 0.23-0.981
Cutting / burning / 5 / 24 / 37 / 41 / 0.52 / 0.21-1.281
Other4 / 10 / 48 / 15 / 16 / 2.74 / 1.14-6.621

M = mean; SD = standard deviation
1Categories not mutually exclusive
2 Adjusted for duration of contact