Self-harm is not simply a psychiatric diagnosis, but a behaviour found worldwide with varying cultural, social, psychological and personal causes. Despite its global nature, most of our definitions come from high-income countries and thus overlook global variations in meaning and context.
It is estimated that there are 14 million episodes of self-harm worldwide each year (around 60 per 100,000 people) and this is likely to be an underestimate given its stigmatised nature (Vos et al., 2020). Self-harm can occur at any age and is most common in young people with rates continuing to rise (Griffin et al., 2018). Repetition is frequent, though in many low- and middle-income countries (LMICs), the most common method – self-poisoning with pesticides – has high fatality rates and so repeated episodes are less common (Knipe et al., 2019).
Although there is no consensus on how self-harm should be conceptualised with regards to ‘non-suicidal’ or ‘suicidal’, the risks of self-harm are clear: within a year of hospital presentation, 1.6% die by suicide (Carroll et al., 2014). Despite this association, self-harm receives far less political and research attention than suicide.
The recent Lancet Commission on self-harm integrates evidence from lived experience, Indigenous knowledge and LMIC contexts to update our current understanding of self-harm and identifies actions to improve the lives of people who self-harm worldwide (Moran et al., 2024).
There are an estimated 14 million episodes of self-harm worldwide each year. This Lancet Commission covers lived experiences from around the globe.
Methods
The Lancet Commission on self-harm is the culmination of five years of collaborative work by a big group of international researchers whose aim was to capture information about the breadth and depth of self-harm.
Four working groups were convened:
- Lived experience,
- Indigenous populations,
- Low- and middle-income countries (LMICs) and
- Individual and societal influences.
Each working group synthesised the relevant existing literature, employing a mixed-methods approach, drawing on both quantitative epidemiological data and lived experience from qualitative studies.
The outputs from each working group were further refined by sharing their findings at workshops with Commissioners and meetings with key stakeholders in order to incorporate wider perspectives.
Although the study was not designed as a formal systematic review, the methodology chosen was extensive and reflective in its nature, thus allowing the authors to comprehensively consider global perspectives of self-harm.
Results
The Lancet Commission on self-harm fundamentally frames self-harm as a complex behaviour shaped by cultural, social and economic factors rather than simply a psychiatric diagnosis. The report highlights how stigma, punitive laws and the lack of specific training in healthcare services both impeded help-seeking behaviours and impaired the quality of compassionate and effective care provided.
Marginalised groups, such as Indigenous communities, experience disproportionately high rates of self-harm, and this is thought to be influenced by structural disadvantage, the socio-political impact of colonisation and intergenerational trauma (Chan et al., 2018). The authors emphasised that self-harm remains neglected in global policy and research compared with suicide prevention. This disparity highlights a significant gap in working towards specific and effective self-harm prevention efforts.
The Commission identified ways in which to improve the current approach towards self-harm and outlined twelve key recommendations to guide health and social care policy and practice:
Governments
- Adopt a whole-of-government approach to address upstream drivers of self-harm such as poverty, inequality and access to lethal means
- Decriminalise self-harm
- Prioritise developing culturally-adapted interventions in LMICs
- Prioritise self-determination and building healthy societies for Indigenous peoples and thus empowering cultures
Service delivery
- Individuals with lived experience should be supported to participate in the design and delivery of healthcare services by co-production
- Services should be developed that target individuals who repeatedly self-harm
- Health and social care professionals should be trained in compassionate assessment and management of self-harm including appropriate staff support
Media and wider society
- Stories around self-harm should focus on recovery and help-seeking, ideally by individuals with lived experience
- The online media industry should take greater responsibility for the safety of its users
Researchers and research funders
- Funding should be directed towards LMICs where the self-harm burden is the greatest
- Establish global self-harm monitoring systems which will require robust, anonymised and safe systems
- Mixed-methods research should be prioritised with biopsychosocial and social ecological approaches
These recommendations aim to set out a clear roadmap for transforming self-harm policy and practice by shifting away from unhelpful, punitive and short-term responses towards culturally sensitive, compassionate and evidence-based care that addresses root causes and supports long-term recovery on a global scale.
The Lancet Commission on self-harm fundamentally frames self-harm as a complex behaviour shaped by cultural, social and economic factors rather than simply a psychiatric diagnosis.
Conclusions
The authors conclude that self-harm is a neglected public health issue that is multifactorial in its nature and drivers.
Systemic changes are necessary on a large scale in order to achieve widespread and effective prevention efforts.
The report calls for a redesign of the approach towards mental health care using compassionate and non-punitive responses alongside government-level efforts to address the social drivers of health.
The authors conclude that self-harm is a neglected public health issue that is multifactorial in its nature and drivers.
Strengths and limitations
A key strength of this report lies in its wide scope which combines both quantitative epidemiological data with qualitative lived experience of individuals who self-harm. The inclusion of diverse global viewpoints enhances the breadth of understanding provided by confronting the previously primarily Western-centric viewpoints of self-harm. These perspectives additionally add weight to the significance of culture, social and economic contexts and structural inequalities in shaping these behaviours. The authoring team is multidisciplinary and international, adding further credibility and depth to the findings. Collaborations such as these foster dialogue between researchers in the same field of interest but with differing and often complementary experiences.
One limitation is in relation to the methodology – as this is not a formal systematic review, there was no pre-registered protocol or detailed search strategy identified. Subsequently, there is potential selection bias due to unclear inclusion or exclusion criteria, meaning that some regions or topics may be underrepresented.
As noted by the authors, prevalence estimates are likely to understate the true burden of self-harm given common issues such as under-reporting, non-presentation to healthcare and poor surveillance systems. The qualitative results may be subject to observer and performance bias with limited descriptions about validation or triangulation methods. Conflicts of interest were openly declared, with several authors having received funding from national research agencies, policy institutions, and pharmaceutical companies, which may warrant scrutiny regarding any potential influence on how the evidence and recommendations were framed.
While these limitations exist, they do not diminish the importance of this landmark Commission – the first to synthesise global epidemiology, lived experiences, and culturally diverse perspectives on self-harm. Future work could strengthen impact through further protocol-driven methods.
Though the commission faced some methodological limitations, these do not diminish the importance of this landmark report, which is the first to synthesise global epidemiology, lived experiences and culturally diverse perspectives on self-harm.
Implications for practice
The Commission’s findings call for meaningful change in the way we understand self-harm. Framing it as a complex behaviour which is shaped by social and cultural factors, rather than solely a mental health symptom, challenges us to shift towards compassionate and socioculturally-informed care.
In practical terms, this means engaging people with lived experience throughout service design, implementation, and evaluation. Co-produced services are better positioned to meet actual needs, whether that involves non-judgmental listening, ongoing support beyond crisis moments, or creating safe environments to discuss self-harm openly (Groot et al., 2020). Training for healthcare and social care professionals should emphasise the diverse roles self-harm may play, rather than assuming a single explanation.
Policy must also evolve – decriminalisation of self-harm is urgent and governments should instead prioritise addressing upstream drivers such as poverty, inequality, and social exclusion, and restrict access to highly lethal means, particularly pesticides in affected regions. Media and online platforms have a responsibility to promote hopeful, recovery-focussed narratives and protect vulnerable individuals.
Improved data and research are crucial and funding should target LMICs and marginalised populations, alongside establishing global surveillance systems. Research must integrate quantitative data with lived-experience perspectives to provide a comprehensive understanding.
Drawing from my own experience supporting young adults in crisis, I have witnessed how brief assessments and rapid discharges can often fail to provide effective care at an individual level. The Commission’s emphasis on continuous, person-centred support reflects the change that is desperately needed.
If these recommendations are implemented, care may be transformed from our current, relatively limited clinical models, to an inclusive and global approach that truly supports individuals who self-harm.
The Commission calls for changes to practice, policy and research to ultimately shift towards a global approach that truly supports individuals who self-harm.
Statement of interests
No conflicts of interest to declare
Links
Primary paper
Moran P, Chandler A, Dudgeon P, et al. The Lancet Commission on self-harm. The Lancet. 2024;404(10461):1445-1492. doi:10.1016/S0140-6736(24)01121-8
Other references
Carroll R, Metcalfe C, Gunnell D. Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis. PLoS One. 2014;9(2):e89944. Published 2014 Feb 28. doi:10.1371/journal.pone.0089944
Chan S, Denny S, Fleming T, Fortune S, Peiris-John R, Dyson B. Exposure to suicide behaviour and individual risk of self-harm: Findings from a nationally representative New Zealand high school survey. Aust N Z J Psychiatry. 2018;52(4):349-356. doi:10.1177/0004867417710728
Griffin E, McMahon E, McNicholas F, Corcoran P, Perry IJ, Arensman E. Increasing rates of self-harm among children, adolescents and young adults: a 10-year national registry study 2007-2016. Soc Psychiatry Psychiatr Epidemiol. 2018;53(7):663-671. doi:10.1007/s00127-018-1522-1
Groot, B., Haveman, A., & Abma, T. Relational, ethically sound co-production in mental health care research: epistemic injustice and the need for an ethics of care. Critical Public Health, 2020;32(2), 230–240. https://doi.org/10.1080/09581596.2020.1770694
Knipe D, Metcalfe C, Hawton K, et al. Risk of suicide and repeat self-harm after hospital attendance for non-fatal self-harm in Sri Lanka: a cohort study. Lancet Psychiatry. 2019;6(8):659-666. doi:10.1016/S2215-0366(19)30214-7
Vos, T., Lim, S. S., Abbafati, C., Abbas, K. M., Abbasi, M., Abbasifard, M., … & Bhutta, Z. A. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The lancet, 396(10258), 1204-1222.
