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Economic fluctuations and suicide: A comparison of Taiwan and Hong Kong

Ying-Yeh Chen a,b,*, Paul SF Yip c,d, Carmen Lee d, Hsiang-Fang Fan a, King-Wa Fu e

a Taipei City Psychiatric Centre, Taipei City Hospital, Taipei, Taiwanb Institute of Public Health and Department of Public Health, National Yang-Ming University, Taipei, Taiwanc Department of Social Work and Social Administration, University of Hong Kong, Hong Kongd Center for Suicide Research and Prevention, University of Hong Kong, Hong KongeJournalism and Media Studies Centre, University of Hong Kong, Hong Kong

a r t i c l e i n f o

Article history:

Available online 21 October 2010

Keywords:

Taiwan

Hong Kong

Suicide

Unemployment

Economic fluctuations

Charcoal burning suicide

a b s t r a c t

This study examines the impact of unemployment on suicide rates in Taiwan and Hong Kong during the

period of rising unemployment (1997e2003) and its subsequent decline (2003e2007), with 2003 as the

turning point. During these initial years of high unemployment, suicide rates increased markedly in Hong

Kong and Taiwan; however, as employment conditions improved, suicide rates fell in Hong Kong but

continued to increase in Taiwan. ARMAX time-series models with appropriate time lags were used to

assess the impact of unemployment on suicide rates for both periods. It was found that for Taiwan, the

unemployment rate was positively related with the suicide rate for both males and females during the

period of high unemployment, whereas a negative relationship was observed as the rate of unemploy-

ment decreased. On the other hand, the reduction in suicide rates since 2003 was not statistically

significantly related to the improvement of employment conditions for Hong Kong; whereas the suicide

rate in Taiwan still remained at a high level due to the increasing number of charcoal burning suicide

deaths despite improvements in employment conditions.

In conclusion, lower unemployment was not necessarily associated with lower suicide rates. Exoge-

nous factors other than economic ones have been suggested to be important for understanding differ-

ences in suicide patterns in Hong Kong and Taiwan. The impact of employment conditions on suicideacross different countries deserves further investigation.

2010 Elsevier Ltd. All rights reserved.

Introduction

Recent studies have shown that general mortality ratesfluctuate

with economic conditions, rising in expansions and falling in

recessions (Khang, Lynch, & Kaplan, 2005; Tapia Granados, 2008;

Tapia Granados & Diez Roux, 2009). The only exception is suicide,

which tends to increase in unfavorable economic environments

(Chan, Yip, Wong, & Chen, 2007; Chang, Gunnell, Sterne, Lu, &

Cheng, 2009; Chen, Chou, Lai, & Lee, 2010; Gunnell, Peters,

Kammerling, & Brooks, 1995; Khang et al., 2005; Morrell, Taylor,Quine, & Kerr, 1993; Norstrom, 1995; Tapia Granados, 2008; Tapia

Granados & Diez Roux, 2009; Yu et al., 2007). In other words,

structural socioeconomic conditions may have a substantial impact

on suicidal behavior. The association between unemployment

conditions and the increase in suicide rates is particularly prom-

inent among working age males, still most often the breadwinners

in society (Blakely, Collings, & Atkinson, 2003; Chan et al., 2007;

Chen et al., 2010; Platt & Hawton, 2000; Tapia Granados, 2005 ). A

recent meta-analysis of the association between suicide and

socioeconomic characteristics of geographical areas revealed that

studies from Asian countries, compared to research from the West,

were more likely to observe a positive impact of adverse socio-

economic conditions on the increase in suicide rates (Rehkopf &

Buka, 2006).

In addition to the ecological correlation between societal

economic fluctuations and suicide mortality, individual level dataalso indicate that suicide is more common among the unemployed

andamongthose whoare marginalized in thelabormarket (Agerbo,

2005; Blakely et al., 2003; Platt & Hawton, 2000; Qin, Agerbo, &

Mortensen, 2003). However, there have been debates about

whether the unemploymentesuicide relationship at the individual

level is causal or is actually confounded by health selection(i.e. poorer health or mental health leading to suicide as well as

unemployment) (Agerbo, 2003; Preti, 2003). Only well-designed

longitudinal follow-up studies are able to provide convincing

evidence for the unemployment-suicide link, but conducting

such studies is extremely labor intensive and time consuming.

* Corresponding author. 309 Songde Road, XinYi District, Taipei City Psychiatric

Center, Taipei, Taiwan. Tel.: 886 2 27263141.

E-mail address: [email protected] (Y.-Y. Chen).

Contents lists available at ScienceDirect

Social Science & Medicine

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / s o c s c i m e d

0277-9536/$ e see front matter 2010 Elsevier Ltd. All rights reserved.

doi:10.1016/j.socscimed.2010.09.043

Social Science & Medicine 71 (2010) 2083e2090
mailto:[email protected]://www.sciencedirect.com/science/journal/02779536http://www.elsevier.com/locate/socscimedhttp://dx.doi.org/10.1016/j.socscimed.2010.09.043http://dx.doi.org/10.1016/j.socscimed.2010.09.043http://dx.doi.org/10.1016/j.socscimed.2010.09.043http://dx.doi.org/10.1016/j.socscimed.2010.09.043http://dx.doi.org/10.1016/j.socscimed.2010.09.043http://dx.doi.org/10.1016/j.socscimed.2010.09.043http://www.elsevier.com/locate/socscimedhttp://www.sciencedirect.com/science/journal/02779536mailto:[email protected]

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A case-control design that takes account of mental disordersmay be

a more plausible alternative. However, the results of some case-

control studies have been inconsistent (Beautrais, Joyce, & Mulder,

1998; Jones, Forster, & Hassanyeh, 1991; Newman & Bland, 2007).

The aim of this study is to provide empirical evidence to

demonstrate how changing economic environments impact suicide

rates in Hong Kong and Taiwan, which have experienced dramatic

economic decline and expansion for the period 1997e2007. Taiwan

(with a population of 23 million) and Hong Kong (7 million), two

major economic centers in Asia, have both witnessed dramatic

changes in suicide rates over the past decade (1997e2007). The

suicide rate for Hong Kong increased from 12.6 per 100,000 in 1997

to a historical high of 18.6 in 2003, returning to about 14.5 in 2007,

a 50% increase up to 2003 and 30% decrease thereafter, whereas

Taiwans suicide rate increased from 10.0 per 100,000 in 1997 to

14.2 in 2003 and to 17.2 in 2007 e a 70% monotonic increase in

a decade. The suicide rate in Taiwan had leveled off a bit in

2007e2009. One important contributing factor in this sharp rise is

related, at least in part, to the emergence of a newsuicide methode

burning barbecue charcoal in a closed space to induce carbon

monoxide poisoning (Kuo et al., 2008; Liu, Beautrais, Caine, Chan,

Chao, Conwell et al., 2007; Yip & Lee, 2007). The rapid rise in the

use of this new method is believed to be related to economicdownturns for the period (1997e2003) (Chan, Yip, Au, & Lee, 2005;

Chang et al., 2009). Furthermore, after the media portrayed carbon

monoxide poisoning as a painless and peaceful way of eliminating

financial burdens; charcoal burning suicides dramatically increased

by 30% in Hong Kong and 20% in Taiwan during high rates of

unemployment during 1997e2003 (Liu et al., 2007). The unem-

ployment rate in 2003 was 7.9% and 5.0% for Hong Kong and

Taiwan, respectively e historically high figures in both places.

Research has indicated that this novel method of suicide has drawn

a new cohort of people to engage in suicidal behaviors who

otherwise would not have tried to kill themselves (Chan et al.,

2005; Chen, Lee, Chang, & Liao, 2009; Kuo et al., 2008; Liu et al.,

2007; Yip & Lee, 2007). The marked increases in the suicide rate

in both Taiwan and Hong Kong for the period 1997e

2003 weredriven by a complex amalgamation offinancial disruptions, fear of

losing jobs, and adjustment to a rapidly changing external envi-

ronment, as well as by the rapid rise in charcoal burning suicide

(Chan et al., 2005; Liu et al., 2007; Yip & Lee, 2007 ).

The Asian financial crisis, which took off in late 1997, reached its

greatest economic slump in 2003 due to the SARS epidemic. The

economies and economic conditions of Hong Kong and Taiwan

graduallyimprovedfromthe secondhalfof 2003during 2003e2007

(Directorate-General of Budget Accounting and Statistics Executive

Yuan Taiwan, 2009; International Monetary Fund, 2009), but the

aftermath of severe financial crises is usually deep and protracted,

andit wasestimatedthat thebanking crisisand consequentdeclines

in output and employment lasted in Hong Kong for about six years

(from 1997/1998e

2003) following the Asian financial crisis(Reinhart & Rogoff, 2009). A prominent economic decline was also

observed in Taiwan (Chen, 2008). Although there was a slight

economicexpansion in Taiwan after2001,it was short-lived and was

quickly overturned by the increase in oil prices in 2002, followed by

the SARS epidemic in 2003 (Chen, 2008). Economic conditions

started to improve, however, during 2003e2007, with both Taiwan

andHongKongentering a stageof economic expansion (Chen,2008;

Reinhart& Rogoff, 2009). Using unemployment rates as an example,

in Taiwan, the unemployment rate before 2000 was generally

around 3%; the yearly average unemployment rate reached a

historical peak of about 5.0% in 2002 and 2003; the rate then grad-

ually decreased to 3.7% in 2007, reflecting a steady recovery of the

economy during 2003e2007. Similarly, in Hong Kong, the unem-

ployment rate reached a high of 7.3% and 7.9% in 2002 and 2003

respectively; the rate steadily decreased thereafter to 4.0% in 2007.

Overall, the year 2003 can be viewed as a turning point for

employment conditions in Taiwan and Hong Kong, with both

economic entities somewhat recovering during the period 2003e

2007. The fluctuation in unemployment rates in Taiwan and Hong

Kong from 1997to 2007provides an opportunity to examine suicide

rates e particularly charcoal burning suicides, which have not

previously beenstudiede in relation to employmentconditions. It is

of interestto comparethe similaritiesand differences in suicide rates

in generaleand in charcoal burning suicide in particulare inTaiwan

and Hong Kong during the course of this economic transformation,

since not only are the methods of suicide used in these two places

similar, but they also have a common cultural inheritance and

a similar ethnic composition.

Methods

Data Collection

Dependent variables

Official monthly suicide mortality data from Taiwan and Hong

Kong were available from the Department of Health of the Execu-

tive Yuan of Taiwan and the Coroners Court of Hong Kongrespectively for the period 1997e2007. Suicide is coded as

E950e959 in the International Classification of Diseases, Ninth

Revision (ICD-9) (World Health Organization, 1977) and X60-84 in

ICD-10 (World Health Organization, 1992). Prior studies have

shown no marked differences in the coding of suicide deaths

between the two ICD revisions (Brock & Griffiths, 2003).

There is no specific coding for charcoal burning suicide under

the ICD classification system. It is usually coded under E952 and

X67: intentional self-poisoning by other gases and vapors. In both

Taiwan and Hong Kong, E952/X67 contributed to less than 2% of

suicide deaths before 1998, revealing a stark difference from the

current figure of approximately 30% in both areas. Coronial docu-

ments reveal that 95.6% and approximately 88% of the E952/X67

cases in Hong Kong and Taiwan respectively were charcoal burningsuicides (Lin, Chen, Huang, & Lu, 2008; Liu et al., 2007). Overall, the

majority of E952/X67 cases in both Taiwan and Hong Kong today

are charcoal burning suicides. In the current paper, we refer to

suicide methods covered by these two codes as charcoal or other

gas poisoning.

Independent variables

Main predictor: unemployment rate. The unemployment rate is one

of the most commonly used socioeconomic indicators of the

economic well-being of a geographic area and is most often used by

researchers to indicate economic fluctuations (Watkins, 1985). The

unemployment rate data for Taiwan and Hong Kong were derived

from the monthly manpower survey report, 1997e2007 (Center for

Suicide Research and Prevention, 2009; Directorate-General ofBudget Accounting and Statistics Executive Yuan Taiwan, 2009).

Other control covariates. The divorce rate, the Gross Domestic Pro-

duct (GDP) percapita, andseasonality within a year were controlled

in the model as these factors were also possible determinants of

suicide rates according to previous studies (Gunnell, Middleton,

Whitley, Dorling, & Frankel, 2003; Ho, Chao, & Yip, 1997).

Data analyses

Following the steps stated in Cryer and Chan (2008), time series

analyses with prewhitening procedure were conducted in order to

examine the relationship between monthly suicide rate, St (depen-

dent variable) and monthly unemployment rate, Ut (independent

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variable) at time t. First, we need to determine the correct time lag

between the two time series variables. We differenced (if the series

were found to be non-stationary) and log-transformed (stabilizing

the datavariance)the monthly suicide rateand unemployment rate.

To avoid obtaining spurious correlation between two strongly

autocorrelated time series, a prewhitening procedure was therefore

usedto remove the temporalcorrelationof independent variable,i.e.

making Ut a white noise. Then, we calculated the cross-correlation

function between the prewhitened time series to investigate

whether the suicide rate and unemployment rate were really cross-

correlated and, if so,to determine the time lag lu between them. The

specification of the noise process Zt was obtained by examining the

residuals from an ordinary least squares fit of suicide rate on the

time-lagged unemployed rate. Finally, ARMAX (an autoregressive

moving average model (ARMA) with an exogenous inputs model

(X)) models were fitted to find the estimated coefficients of unem-

ployment rates b and their standard errors.

St b$Utlu Zt

where Stis suicide rateat time t; Utlu is unemployment rate at time

(tlu); and Zt is an autoregressive moving average (ARMA) model

with p autoregressive terms and q moving average terms, usuallydenoted by ARMA p; q c 3t Pp

i 14i$Zti

Pqi 1

qi$3ti;

where c is a constant; 3t is a white noise; and b, 4i and qi are the

coefficients of the model (i 1..p or q)

Results are reported in Table 1. By repeating the above proce-

dures, the monthly divorce rate Dt (with time lag ld) and GDP Gt(with time lag lg) were added into the models as covariates to test

whether there were changes in the adjusted coefficients of the

unemployment rate b.

St b$Utlu c$Dtld d$Gtlg Zt

where c and d are the coefficients of the model.

The relationships between the overall suicide rate, the charcoal

or other gas poisoning suicide rate, and the unemployment rate

from 1997 to 2007 were estimated and stratified by sex. In order to

assess the impact of age on the charcoal burning suicide rate, an

age-gender analysis was carried out. To capture the impact of thechange in employment conditions on the changein suicide rates for

different age groups for the charcoal burning suicide deaths, we

further grouped our analysis into two different periods: 1997e2003

(the period of an increase in the unemployment rate) and

2003e2007 (the period of a decrease in the unemployment rate) to

highlight the intriguing relationship between employment condi-

tions and suicide rates. All analyses were performed using R version

2.10.1 with the TSA package.

Results

Suicide rates, particularly male suicide rates, rose as unem-

ployment rose (1997e2003) in both Taiwan and Hong Kong (Fig. 1a

and b). However, when unemployment decreased in both placesafter 2003, suicide rates in Taiwan continued to rise (Fig. 1a).

Conversely, in Hong Kong, suicide rates declined along with

unemployment rates during the period of economic recovery and

improvements in employment conditions (2003e2007) (Fig. 1b).

Charcoal burning suicide, once an unknown method, has been

a popular method of suicide in both Taiwan and Hong Kong since

1998 (Fig. 2a and b). Charcoal or other gas poisoning was the

second leading cause of suicide deaths in 2003 in Hong Kong

Table 1

ARMAX regression analyses of therelationships betweenunemployment rateand suicide ratetrend,charcoal or other gas poisoning(CB) suicide ratetrendin Taiwanand Hong

Kong, 1997e2007.

Taiwan Hong Kong

1997e2003a 2003e2007b 1997e2003a 2003e2007b

Crude Adjusted# Crude Adjusted# Crude Adjusted# Crude Adjusted#

Overall suicide rate

Unemployment 0.4477** 0.4468* 1.7030*** 1.4226** ns ns ns ns

(se) (0.1724) [8] (0.1875) [8] (0.4116) [5] (0.4136) [5]

Male suicide rate

Unemployment 0.5429** 0.5249** 1.6195** 1.6967** ns ns ns ns

(se) (0.1805) [8] (0.1886) [8] (0.5294) [4] (0.5064) [4]

Female suicide rate

Unemployment 0.5633* 0.4705* 1.0013** 0.7258ns 0.1787* 0.2221* ns ns

(se) (0.2550) [8] (0.2234) [8] (0.3285) [5] (0.3819) [5] (0.0778) [15] (0.0809) [15]

CB suicide rate

Unemployment ns ns 0.2157* 1.0539ns ns ns ns ns

(se) (0.1090) [7] (0.8070) [7]

Male CB suicide rate

Unemployment ns ns 2.4735* 1.2933ns ns ns ns ns

(se) (1.1420) (0.9290) [7]

Female CB suicide rate

Unemployment (se) 0.0578*** 0.0581*** ns ns ns ns 0.1084* 0.5974ns

(0.0123) [8] (0.0125) [8] (0.0494) [1] (0.3597) [1]

Note: *p < .05, **p < .01, ***p < .0001.

Crude: regression analyses with unemployment rate as the single predictor and suicide rate as outcome variable.

# Adjusted: regression analyses assessing the relationship between unemployment rate and suicide rate adjusting for GDP and divorce rate.

[ ]: time lag lua period of increase of unemployment rate.b

period of decrease of unemployment rate.

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(second to jumping) and Taiwan (second to hanging). After 2003,

the reduction in suicide rates can be attributed to the decrease in

suicides from charcoal or other gas poisoning in Hong Kong

during the period of lower unemployment rates (2003e2007)

(Fig. 2). Nonetheless, in Taiwan, charcoal or other gas poisoning as

a means of suicide, which emerged during the period of wors-

ening employment conditions, continued to display an upward

trend during the period of improving employment condition,

2003e2007 (Fig. 2a).

Table 1 presents the results from an ARMAX regression proce-

dure analyzing the relationship between detrended unemployment

rates and suicide rates on monthly basis for Taiwan and Hong Kong

for the two periods 1997e

2003 and 2003e

2007, which aremodeled separately. For Taiwan, a positive relationship between

suicide and unemployment rates for both sexes during 1997e2003,

with a time lag of eight months, was detected. In other words, the

unemployment rate eight months earlier was shown to be posi-

tively related to the suicide rate eight months later. Also, for the

period 1997e2003 with a high unemployment rate, a significant

positive relationship was found among Taiwanese females, but not

among males, between the rates of suicide resulting from charcoal

or other gas poisoning and an increase in unemployment (see Table

1). When compared to the rate for their male counterparts, the rate

of suicide by charcoal or other gas poisoning for females was more

closely linked to a higher rate of unemployment. During the period

of improving employment condition (2003e2007), the opposite

relationship (negative) was observed between the unemployment

rate and the overall suicide rate for both sexes with a shorter time

lag of 4e5 months, whereas a positive relationship still remained

for charcoal or other gas poisoning suicide deaths for males.

However, after adjustment of the other covariates, GDP and the

divorce rate, the rates of suicide by charcoal or other gas poisoning

werefound not to be significantly related to unemployment rate for

both sexes during periods of economic recovery. Apparently there

were other factors which were possibly more related to the

increase in suicide during the period. The overall suicide rates were

negatively correlated to unemployment rates in Taiwan during the

periods of economic recovery (2003e2007), indicating a discon-

nection between unemployment and suicide rates in times of

improving employment conditions in comparing to 1997e

2003.For Hong Kong, only female suicide rates were found to be

positively related to unemployment rates for the period 1997e

2003 with a long time lag of 15 months. However, a negative

relationship was observed between the female suicide rates for

charcoal/other gas poisoning suicide and unemployment rates

before adjusting of other covariates for the period 2003e2007.

After adjustment of other covariates, the significant relationship

between female suicide rates and unemployment rates during

economic recovery became insignificant as well.

Age-gender specific analysis was performed to examine the

impact of unemployment rates on charcoal or other gas poisoning

suicide rates. For Hong Kong, suicide by charcoal or other gas

poisoning among the three age groups (15e24, 25e59, and 60 or

over) were not related to unemployment rates. For Taiwan, during

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Suicidedeathsper100,0

00

0.00

1.00

2.00

3.00

4.00

5.00

6.00

Unemploymen

rrate(%)

Increase of unemployment rate Decrease of unemployment rate

Female suicide rate

Unemployment rate

Male suciide rate

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007


0

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

Unemploymentrate(%)


Female suicide rate

Male suicide rate

Unemployment rate

a

b

Fig. 1. (a) Overall and sex-specific suicide rate trends in relation to economic fluctuations in Taiwan, 1997e2007. (b) Overall and sex-specific suicide rate trends in relation to

economicfl

uctuations in Hong Kong, 1997e

2007.


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the period of 1997e2003, it was found that the charcoal or other

gas poisoning suicide rate for each of the age groups were not

related to the increase in unemployment. It is important to note

that the proportion of dying from charcoal burning poisoning

among all suicide deaths in Taiwan was still relatively small before

2003 (less than 10%). For the period of improvement of employ-

ment condition (2003e2007), number of charcoal burning suicide

has increased significantly in Taiwan since 2003. The suicide rate

for the age group of 25e59 was shown to be positively related to

unemployment rate with a time lag of 7 months despite a negative

relationship was observed between unemployment rate andoverall suicide rate. Apparently, the impact of unemployment on

the charcoal or other gas poisoning suicide for the two different

age groups 15e24 and 25e59 have cancelled out one another (see

Table 1 and Table 2).

Discussion

We found an upward trend in suicide rates in Taiwan and Hong

Kong in times of increased unemployment. This increase in

unemployment appeared to trigger charcoal burning suicides in

both areas, as suggested by Chang et al. (2009). However, the

improvement in employment conditions for the period 2003e2007

revealed different suicide patterns in Taiwan and Hong Kong. While

we observed a declining trend in overall suicide rates as well as the

rates for suicide by charcoal or other gas poisoning in Hong Kong,

the effect of unemployment rates was shown to not be statistically

significantly related to the decline. The picture was different in

Taiwan, where a divergence in suicide and unemployment rates

was observed during 2003e2007, indicating that suicide rates

continued to rise even after employment conditions improved. Our

results indicate that while suicide rates generally rise in times of

increased unemployment, improving employment conditions is

neither a sufficient nor a necessary condition for suicide rates to

fall. It is important to understand and appreciate the disconnection

between the employment condition and suicide rate at thecommunity level.

Despite the many similarities between Taiwan and Hong Kong in

cultural, ethnic, and economic development, there is a clear

divergence in suicide rates in relation to employment conditions.

This divergence requires an in-depth exploration. It is possible that

factors other than employment conditions account for the contin-

uous rise in suicide rates during periods of economic recovery in

Taiwan. One potential factor could be the influence of exaggerated

media reporting of suicide events. Unlike Hong Kong, where tabloid

journalism has long existed, tabloid journalism did not appear in

Taiwan until the launch of one Hong Kong-based newspaper Apple

Daily in May, 2003 (Pai, 2004). Gaining its readership through

sensationalism, exaggerated headlines, and flashy graphic images,

Apple Daily changed the norms of suicide reporting and news

0.0

0.5

1.0

1.5

2.0

2.5

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007


00

0.00

1.00

2.00

3.00

4.00

5.00

6.00

Unemployment

rate(%)


CB suicide

non-CB suicide

Unemployment rate

0.0

0.5

1.0

1.5

2.0

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007


0

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

Unemploymentrate(%)


CB suicide

non-CB suicide

Unemployment rate

a

b

Fig. 2. (a) Charcoal or other gas poisoning suicide (CB suicide) and all other suicides not in the charcoal or other gas poisoning category (non-CB suicide) in relation to economic

fluctuations in Taiwan,1997e

2007. (b) Charcoal or other gas poisoning suicide (CB suicide) and all other suicides not in the charcoal or other gas poisoning category (non-CB suicide)in relation to economic fluctuations in Hong Kong, 1997e2007.


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reporting in general in Taiwan soon after its entrance into the

market (Audit Bureau of Circulations, 2009). Recently, a series of

studies from Taiwan have pointed to copycat suicides provoked by

extensive media reporting of celebrity suicides (Chen et al., 2010;

Cheng, Hawton, Chen, Yen, Chang et al., 2007; Cheng, Hawton,Chen, Yen, Chen et al., 2007; Cheng, Hawton, Lee, & Chen, 2007),

indicating the increasing influence of the media on suicide-related

deaths in Taiwan.

Political instability may be another factor responsible for the

upswing in suicide rates during periods of improved employment

conditions in Taiwan. Political issues have been prominent sources

of social turmoil in Taiwan since the transfer of political powerfrom

the KMT (Kuomintang, the Nationalist Party) to the DPP (Demo-

cratic Progress Party) between 2000 and 2008 (Wu, 2007). The

potential impact of political turbulence on suicide rates in Taiwan

has been suggested (Chen et al., 2010), but not rigorously investi-

gated. Designing a reliable and valid measure of political stability to

disentangle the relationships between political turbulence and

suicide may help illuminate suicide patterns in Taiwan. Suiciderates in Hong Kong tend to respond to unemployment rates;

however, they have not been shown to be directly proportional to

improvement in unemployment conditions. It seems we still need

to search for other factors to explain thefluctuation of suicide rates.

An additional explanation for the disconnection between

suicide and unemployment rates in Taiwan is the uneven economic

benefits gained in times of economic prosperity. In other words, an

improvement in employment conditions may not benefit every

individual equally. A group of working poor has emerged in Hong

Kong and Taiwan due to relatively low wages and rising living costs

(Center for Suicide Research and Prevention, 2009; Lo, 2007). Prior

research has indicated that financial problems accounted for a high

proportion of suicide deaths in Hong Kong and the emergence of

a signifi

cant number of working poor in the community (Center for

Suicide Research and Prevention, 2009). More than 20% (about

200,000) of the working population earn less than US$750 a month

in Hong Kong, and the medium income of the Hong Kong working

population is US$1250. The most disadvantaged among the

employed may still be at great risk even though unemploymentrates have improved. Also, more employed people chose charcoal

burning suicide over other suicide methods (Chan et al., 2005).

It is noteworthy that unemployment rates in Taiwan have

recovered at a much slower pace than those in Hong Kong. In fact,

even though unemployment rates decreased after 2003 in Taiwan,

they did not return to pre-crisis levels, and protracted economic

stagnation in Taiwan may have resulted in the continued rise in

suicide rates.

Despite many similarities in social-economic conditions Taiwan

and Hong Kong have adopted different measures to lower suicide

ratesin recent years. Recognizing that depression is a key risk factor

in suicide, suicide prevention strategies adopted by Taiwans

Suicide Prevention Center have mainly focused on the early

recognition and treatment of depression (Taiwans Suicide

Prevention Center, 2009). In Hong Kong, however, a more gener-

alized public health approach to lower the suicide rate has been

adopted (Center for Suicide Research and Prevention, 2009).

Determining to what extent suicide rates in Taiwan and Hong Kong

have been affected by these differences in approach deserves

further exploration.

In Taiwan, we did not observe prominent gender differences in

suicide rates in response to changes in employment conditions

during the study period. Among both males and females in Taiwan,

unemployment rates were positively related to suicide rates during

economic recessions and negatively related to suicide rates during

economic prosperity; however, adjusted models indicate stronger

relationships among males, a finding compatible with prior

research results that suggest male suicide rates are more affected

Table 2

Age-specified ARMAX regression analyses of the relationships between unemployment rate and charcoal or other gas poisoning (CB) suicide rate trend in Taiwan and Hong

Kong, 1997e2007.

Taiwan Hong Kong

1997e2003a 2003e2007b 1997e2003a 2003e2007b

Crude Adjusted# Crude Adjusted# Crude Adjusted# Crude Adjusted#

CB suicide rate

Unemployment (se)

15e24 ns ns 0.2690*

(0.1223) [0]

4.9144 ns

(2.8600) [0]

ns ns ns ns

25e59 ns ns 0.3441*

(0.1547) [7]

0.9105 ns

(0.6976) [7]

ns ns ns ns

60 ns ns ns ns ns ns ns ns

Male CB suicide rate

Unemployment (se)

15e24 ns ns 0.4438*

(0.1967) [0]

1.6722*

(0.8421) [0]

ns ns ns ns

25e9 ns ns 0.7516**

(0.2622) [7]

2.4575*

(0.9953) [7]

ns ns ns ns


Female CB suicide rate

Unemployment (se)

15e24 ns ns ns ns ns ns ns ns

25e

59 ns ns ns ns ns ns 0.6217 ns

(0.3461) [1]0.5409 ns

(0.3465) [1]


Note: *p < .05, **p < .01, ***p < .0001.

Crude: regression analyses with unemployment rate as the single predictor and suicide rate as outcome variable.

# Adjusted: regression analyses assessing the relationship between unemployment rate and suicide rate adjusting for GDP and divorce rate.

[ ]: time lag lua period of increase of unemployment rate.b period of decrease of unemployment rate.


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by economic conditions (Blakely et al., 2003; Chan et al., 2007;

Chen et al., 2010; Platt & Hawton, 2000; Tapia Granados, 2005 ).

In the case of suicide by charcoal or other gas poisoning, we

found that female rates were more affected by the increase in

unemployment rates in Taiwan during 1997e2003. Although this

finding is counter-intuitive, we have parallel findings in Hong Kong

in that unemployment rates were significantly related to female

suicide rates (but were not related to male suicide rates) when GDP,

divorce rates, and time trend effects were simultaneously consid-

ered. In Hong Kong, we also found that in times of economic

recovery, female rates for suicide by charcoal or other gas poisoning

did not follow the decrease in unemployment rates. Overall, it

seems that female suicide rates were particularly affected by

unemployment conditions in Hong Kong, and that when the

economic situation improved, female rates for suicide by charcoal

or other gas poisoning failed to decrease accordingly (although this

was not statistically significant in the adjusted model). This could

be related to the increase in womens labor force participation in

recent decades in both places; as a result of this, women may be as

affected as men, if not more so, by deteriorating employment

conditions. In addition, working women, often not afforded the

same opportunities as men, are more likely to be given low-skilled,

low-wage jobs with very limited possibility of promotion (Lee,2007; Sung, 2003). This type offemale labor is usually the most

expendable in times of economic recession. It is possible that

a disadvantaged employment situation concomitant with the

socio-cultural treatment of suicide as a protest against social

oppression in a Chinese cultural context (Ji, Kleinman, & Becker,

2001) may have contributed to the gender paradox (i.e. female

suicides were more sensitive to economic conditions) observed in

Hong Kong.

The age and gender stratified analysis for charcoal or other gas

poisoning suicide rates revealed that this specific method of suicide

in middle aged males were positively related to employment

conditions, even though a disconnection between unemployment

and overall suicide rates were found in Taiwan during 2003e2007.

Thefindingindicatesthat although miscellaneous factors other thaneconomic conditions drove up suicide rates in Taiwan during

2003e2007; economic factorwas still an importantdriving forcefor

the increase in charcoal burning suicide rates among middle aged

males. The finding provides further evidence for the observation

that charcoal burning suicide is a method particularly favored by

middle aged males under economic stress (Chan et al, 2005).

There are several limitations that need to be addressed when

interpreting the current results. First, the ecological associations

between population-level unemployment rates and suicide rates

may not be generalized to the individual level. However, prior

psychological autopsy studies using individual-level data in both

Taiwan and Hong Kong have demonstrated the adverse effect of

unemployment on risk of suicide (Chen et al., 2006; Cheng, Chen,

Chen, & Jenkins, 2000). In addition, although we controlled forseveral potential confounders, there are still other factors that may

confound the relationship betweenunemploymentand suiciderates.

Tracing the vicissitude of suicide trends in the course of

economic transitions in Taiwan and Hong Kong, our research has

revealed a complex picture of interactions between employment

conditions, suicide rates, gender, methods of suicide, and country-

specific reactions to contextual socioeconomic conditions. The

continuous rise of the charcoal burning suicide rate in Taiwan,

despite improvements in economic conditions, suggests that we

should consider limiting access to charcoal as a way of preventing

suicide. Preliminary results in Hong Kong have shown that a slow

access strategy of removing charcoal from open shelves in

convenience stores is effective in reducing the rates of charcoal

burning suicide in the community (Yip, 2009; Yip, Law, Fu, Law,

Wong, & Xu, 2010). In Hong Kong, the fluctuation of female

suicide rates with economic downturns has directed the prevention

focus toward improving social policies in relation to labor market

conditions for women. In the face of recent global economic

uncertainty, the troubling trends of suicide in Taiwan and Hong

Kong call for early attention and active intervention.

Acknowledgement

This study was partly supported by a grant from Department of

Health, Taipei City Government (Grant No: 99001-62-016) and

Hong Kong Research Grant Council (784210).

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