Male and female Traveller patients, older than 50 years of age, had the highest risk of presenting with self-harm in Irish EDs. This finding may be associated with the mental distress experienced by the eldest Travellers, due to discrimination or poor physical health [22, 9]. The risk of suicide-related ideation was higher for older female Travellers over the age of 50 and for male Travellers between the ages of 30 to 39 years old. Although there is no previous research on ideation hospital presentations for ethnic minorities per se, an Australian study has indicated that Indigenous persons had 2·8 (95% CI 2·62–2·93) higher rates of suicidal presentations (self-harm, non-suicidal self-injury, suicidal ideation combined) than non-Indigenous people . Same study found that overseas born patients had lower rates of suicidal presentation than Australian born, and this is in consistence with our findings of low rates for non- White Irish born groups.
Our research further supports existing evidence which suggests that there is a high prevalence of alcohol and drug misuse in the Traveller community, [15, 16] while the request of Traveller patients not to involve any significant other in suicide prevention interventions, may reflect cultural stigma when experiencing emotional pain . In terms of the high substance misuse prevalence, psychosocial perspectives view this misuse among the Traveller community as the outcome of multiple factors, such as: the social acceptability of alcohol; the limited understanding of dependency and complacency about problematic use within the community; unemployment; lack of employment; lack of educational opportunities; the ongoing loss of Traveller identity in Irish society; and, diminishing anti-drug culture among the Traveller community [16, 25, 14].
The current findings should be treated with caution due to a number of limitations. Firstly, the data analysed are presentation-related and not individual based, therefore there is a possibility that an individual was presented more than once in this cohort. Furthermore, the NCPSHI is a dedicated service implemented in 24 out of the 26 adult ED’s in Ireland, therefore the data presented is not a complete national profile. Moreover, our findings should be treated with caution, as they reflect the risk associated with those presenting to an ED and not with people experiencing suicidality in the community level.
Although we tried to control for any ethnicity bias by excluding the Unknown ethnic groups from the rates section, it should be noted that the demographic information of ethnicity was self-reported to the clinicians and we could not control the underreporting of any ethnicity group. We combined the Asian, Black & Other ethnic groups in the main analyses but as we are aware that mixing cultures and ethnicities may result in bias as there are not homogenous, supplementary tables provide information on these ethnic groups in more detail (supplementary Table S1). The availability of data that ranged between 11 and 24 months for the study period, is related to a number of factors, mainly: the absence of a CNS in specific periods due to maternity or sick leave, and due to lack of recruitment for the specific posts.
To our knowledge this is the first study exploring emergency department presentations due to suicide-related outcomes for Irish Travellers at a national level. Ireland’s National Strategy to Reduce Suicide, 2015-2024, Connecting for Life  highlights the traveller population as a priority group with vulnerability to an increased risk of suicidal behaviour. Considering the finding that a significant proportion of Irish Travellers do seek help for their suicidal behaviours and thoughts in Irish hospitals, EDs should be viewed as a vital suicide intervention point for the Traveller community. Given that EDs could act an appropriate environment to stabilise suicidal crisis , the development of cultural competency training of the ED staff for the Irish Traveller culture may help to improve their post-ED help-seeking for suicidal-related behaviours and thoughts [24,28].
Considering the lack of Irish evidence on the risk of self-harm for ethnic groups, our results of the lowest risk of self-harm for Asian patients could only be compared with UK findings, highlighting that Asian people, specifically males, are least likely to present with self-harm or repeated self-harm compared to other ethnicities .
Based on the need to explore ethnic inequities, both in clinical practice as well as in research investigations for self-harm, our findings among different ethnic groups provide space for implementing tailor made suicide prevention policies. Furthermore, in the absence of ethnicity data in self-harm and suicide statistics in Ireland, the use of the NCPSHI data is important, as it is the first national database to systematically capture the risk of suicide-related outcomes among ED patients of different ethnicities. Further Irish health services should record ethnicity as a core data item.
The NCPSHI is to our knowledge the first dedicated ED service for self-harm and ideation internationally implemented and qualitative analysis has indicated that service users feel that this service is compassionate and the lack of this programme in other EDs results in negative impacts for patients . Given that the NCPSHI is not available in all 24/7 EDs of Ireland, further implementation initiatives should be considered in order to support those in need of suicide-related hospital interventions presenting in non NCPSHI services.