This paper reviews literature on self-harm and suicide among Indigenous populations in four nations with histories of British colonization, with a more detailed exploration of patterns and primary care considerations in Australian Aboriginal and Torres Strait Islander populations. Issues of definition, under-reporting, lack of reporting, varying coronial practices and the influence of race on investigative procedures make comparisons of suicide rates among indigenous populations problematic. However, international interpretations highlight the impact of the breakdown of cultural structures and historical processes associated with colonization. Recent studies suggest that the predisposition to suicide by vulnerable young people is influenced not only by absolute living standards but also how they view their circumstances relative to those around them. The complexity of associations with mental disorder, alcohol use and ‘meaning’ in an indigenous context are considered. Responses in terms of prevention and treatment are presented, highlighting the importance of hospital-based practitioners as the likely first point of contact. The article concludes by outlining considerations in the primary care management of indigenous self-harm. See Commentary, page 8.