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Suicide and Attempted Suicide --- China, 1990--2002
Suicide is the fifth leading cause of death overall in China and the leading cause of death in persons aged 15--34 years (1). During 1995--1999, approximately 287,000 persons died each year from suicide, a national rate of 23 per 100,000 population (1). In addition, an estimated 2 million suicide attempts occur each year (2). To characterize suicides and attempted suicides in China, analyses were conducted of 1) a psychological autopsy study comparing suicides with other injury deaths and 2) three studies of attempted suicides. This report summarizes the results of these analyses, which indicated that 58% of China's suicides were caused by ingesting pesticide, 91% of suicide victims had never visited a mental health professional, and 45% of suicide attempts were impulsive acts performed after considering suicide for <10 minutes. To reduce suicides and suicide attempts, prevention strategies directed at disrupting patterns of suicidal behavior should be implemented in China.
Information about 895 persons who died from suicide (i.e., cases) and 701 who died from other injuries (i.e., controls) was obtained from a national case-control psychological autopsy study (which collected information about the psychological state of the deceased and risk factors for suicide) conducted during 1996--2000 by Beijing Hui Long Guan Hospital and the Chinese Center for Disease Control and Prevention (3). The selected sample initially totaled 1,854 persons; 258 persons were excluded for various reasons (e.g., persons were aged <10 years or appropriate family members declined to participate or could not be located), and 29 additional persons were not included in the logistic regression analysis because data were missing on one or more variables. Deaths attributed to suicide and other injuries were investigated at three urban and 20 rural disease surveillance points (DSPs), selected to be geographically representative of the 145 DSPs in the national surveillance system. Data regarding demographics of the decedents, potential risk factors for suicide, and methods of suicide were provided by family members and other associates in two independent interviews. The median time from death to interview was 11 months (range: 8--14 months). Both backward and forward inclusion of variables in unconditional logistic regression equations were used to identify the most stable model of risk factors for suicide. Age, sex, and location of residence were considered known risk factors for suicide in China; all odds ratios were adjusted to account for these variables. Details of these methods have been described previously (3).
Information about attempted suicides was collected from a retrospective study of all reported suicide attempters (approximately 15,000 persons), based on review of emergency department records at 24 hospitals in northern China during 1990--2002. In addition, demographic and risk factor information was collected from two case-control studies of 635 subjects treated for serious suicide attempts (i.e., requiring >6 hours of hospitalization), identified from a total of 1,450 suicide attempters treated in nine general hospitals primarily serving rural populations of northern China during 1998--2002.
In the psychological autopsy study, among the 895 suicide victims, the median age was 42 years (range: 12--94 years); 49% (441) were female; 63% (563) suffered from a mental illness*; 27% (239) had made previous suicide attempts; 47% (414) had relatives, friends, or associates with a history of suicidal behavior; and 9% (77) had visited a mental health professional at any time in their lives. The most common negative life events in the year before death were financial problems, 40% (358); serious physical illness, 38% (341); and marital conflict, 35% (310). A total of 58% (517) of the suicide victims died by ingesting pesticide or rat poison; of these persons, 62% (320 of 517) received unsuccessful medical resuscitation before death, and 70% (344 of 494) used pesticides stored in the home, usually in an unlocked cupboard.
Results of the unconditional logistic regression analysis identified 10 independent risk factors for suicide (Table). Among the 1,567 persons who died from suicide and other injuries, suicide risk increased with exposure to multiple risk factors. One percent (two of 223) of persons with fewer than two risk factors died from suicide; 20% (73 of 366) with two or three risk factors died from suicide; 72% (379 of 524) with four or five risk factors died from suicide; and 94% (428 of 454) with six or more risk factors died from suicide.
Among 14,771 suicide attempters treated in 24 general hospitals in northern China, females outnumbered males by 2.5 to 1 (10,492 to 4,279), the median age was 29 years (range: 10--97 years), and two thirds (9,676) of all attempters were young adults aged 15--34 years. Approximately 90% (13,433 of 14,771) of the attempts were by self-poisoning; 54% (7,973) of all attempts were by ingestion of medications (usually anti-anxiety agents or sleeping pills), 28% (4,103) by ingestion of pesticides, and 9% (1,357) by ingestion of other toxins (e.g., household cleaners). Among the 10,581 patients treated in hospitals that primarily serve rural or urban populations, ingestion of pesticides was four times more common among persons treated in rural hospitals (43%; 2,533 of 5,954) than among those treated in urban hospitals (10%; 457 of 4,627) (p<0.01), and 66% (1,667 of 2,533) of the pesticide self-poisonings treated in rural hospitals were among women. Often, the suicide attempts were impulsive; among 594 serious suicide attempters treated in nine hospitals in northern China, 45% (270) reported considering suicide for <10 minutes before their attempts.
Reported by: MR Phillips, MD, Beijing Suicide Research and Prevention Center, Beijing Hui Long Guan Hospital; G Yang, MD, Institute of Basic Medical Sciences, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China.
This report characterizes suicides and suicide attempts in China, which are marked by a high proportion of pesticide ingestion and infrequent previous treatment by mental health providers. The studies described in this report also support the substantial roles of impulsive behavior and acute stressors in suicidal behavior in China. A previous comparison of 164 impulsive suicide attempts (i.e., those in which victims reported considering suicide for <2 hours before their attempts) and 142 nonimpulsive attempts determined that impulsive attempters were younger, were more likely to live in rural villages, had a better quality of life before the attempt, had less severe depressive symptoms, were less likely to have a mental disorder, had less suicidal intent, and had more acute precipitating life events (5).
Similar to other countries, suicide attempts in China are more common among women than men (6). However, in China, especially in rural areas, a high proportion of suicide attempters ingest pesticide, and the resuscitating capabilities of local health-care providers are less than optimal. Therefore, self-inflicted injuries are more likely to result in death in rural China than in locations where less lethal suicide methods are used or where resuscitation services are more successful (7). These factors result in an overall increase in rural suicide rates and a relative increase in female suicide rates.
The findings in this report are subject to at least three limitations. First, the psychological autopsy study might be subject to bias by those providing information about the deceased and the lack of blinding of the interviewer regarding cause of death; however, data obtained by the study's methods have been determined valid (8). Second, unlike the majority of psychological autopsy studies, this study used deceased persons rather than living persons as controls. The advantage of using deceased persons as controls is that information providers have all experienced the recent death of a family member or associate, but the disadvantage is that statistical methods are required to adjust for differences in age and sex distributions. Finally, the retrospective studies on attempted suicides were limited to sites in northern China and did not include suicide attempts managed without hospital care or attempts misreported by the patient as unintentional.
To develop targeted prevention strategies, several efforts are under way to improve surveillance and better understand the characteristics of suicidal behavior in China. Possible prevention activities include 1) restricting access to suicide means, particularly pesticides and toxic drugs, 2) expanding social support networks for persons at high risk, 3) implementing health-promotion campaigns focused on mental health and suicide, 4) improving health providers' ability to recognize and manage psychiatric problems associated with suicide, 5) instituting community-based screening programs to identify persons at high risk, 6) expanding crisis support services and targeted mental health services for persons at high risk, and 7) increasing the ability of primary care facilities to manage the medical complications of suicide attempts. Further development, implementation, and evaluation of these interventions will require the participation and coordination of multiple ministries (e.g., health, agriculture, education, public security, labor and welfare, broadcasting, and media) and organizations (e.g., Women's Federation, Youth League, academic associations, and funding organizations).
The Chinese government is considering development of a national suicide prevention plan (9). A workshop on the proposed plan held in Beijing in November 2003 included government leaders, leaders of nongovernment organizations, and representatives of international organizations. The consensus of participants was that the State Council and local governments in China should establish suicide-prevention committees with the responsibility and resources needed to develop, implement, and monitor national, regional, and local suicide-prevention plans.
* Based on results of a standardized instrument using criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
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