Characteristics of young rural Chinese suicides:a psychological autopsy study

J. Zhang1*, W. Wieczorek1, Y. Conwellet al

BackgroundMethodResultsConclusions

Background• the fifth leading cause of death, 23 per 100 000 and a total of 287 000 suicide deaths per year(Phillips et al. 2002a)• rural rates two- to threefold greater than urban rates •Women higher than among men(Durkheim, 1897/1951; Wang et al. 2008)•The age pattern of Chinese suicide is generally a bimodal one: young adulthood and the elderly group(Ji et al. 2001; Phillips et al. 2002a; Zhang et al. 2002•young adults 15–34 years of age, suicide is the leading cause of death, accounting for 19% of all deaths in this age(Phillips et al. 2002a)

Hong Kong(1.1), Singapore (1.3), Japan (1.8), Taiwan (1.5), India(1.4), Philippines (1.5), South Korea (2.2) (Canetto &Sakinofsky, 1998; WHO, 1999; Taiwan Government,2003).

Asian culture and additional factors specific a case-control psychological autopsy(PA) study

with a focus on cultural and other risk factors for this subpopulation

the deep-rooted Confucian patriarchy and sexist orientation

the communist egalitarianism Frustration(modern values and traditional

values )

Background

Method

Study population and design aged 15–34 years living in rural areas of China young rural women and men who had died

by suicide community-living controls from the same

specific populations Pilot studies

Method Sampling:October 2005 to June 2008, Liaoning:six counties Hunan:five counties Shandong:five counties excluded cases of accidental or natural death in which

suicidal intent was questioned hospitals :the primary place village doctors xiang health agency Be aware of all the deaths the Centers for Disease Control and Prevention (CDC) telephone or fax:daily the county CDC the provincial CDC

monthly

MethodControls the general population exposure (suicide risk) the same possibility of being selected or exposed

as the case Exclude accidental deaths, did not exclude mental

disorders or previous suicide attempts With regard to gender, the random selection of

controls aged 15–34 years approximately equal numbers of males and females

approximated to the gender distribution of suicide cases in the study

Method

Information sources each suicide and each control, we

interviewed two informants based on the context or environment (how

people observe the target ; for example, home versus non-home setting)

Method Suicide informants were recommended by the village head

and the village doctor and then selected by the research team control group informants were recommended by the

controls themselves and then selected by the research team with similar principles

Informants had to be aged >=18 years the first informant was always a parent, spouse or another

important family member, and the second informant was always a friend, co-worker or neighbor

we avoided recruiting husbands and in-laws of those female suicides associated with family disputes.

MethodInterviewing procedures a personal visit Upon their agreement between 2 and 6 months interviewed separately by one trained interviewer in a private place Inter-rater reliability: limiting the principal data-

gathering role, comparison of duplicate ratings of the interviewers

Method

Measures Variables:age,education, family annual

income, marital and dating status, religion, pesticide availability, traditional gender values, modern gender values, gender value strain, impulsivity, and mental disorder.

MethodMeasures younger (<25 years) and older (>=25 years) age Education low (<7 years) and high (>=7 years) Annual income ‘never married and not dating’, ‘never married but

dating’, ‘ever married’ religion and religiosity: four questions Taoism, Islam, Protestantism,

Catholicism,Buddhism, other, and none Pesticide availability

Method

The traditional gender value scale:12 items The modern gender value scale:8 items The gender value strain Responses for the traditional scale :low (0–2.5),

middle(>2.5 to<3.5) and high (3.5–5) Responses for the modern scale:low(0–4) and high

(>4–5) Impulsivity:the 12-item scale(Dickman ,1990) Diagnoses: DSM-III-R (SCID; Spitzer et al. 1988; Gu &

Chen, 1993),

Method

Integrating the information from different sources

Two proxy interviews Three principles(Kraemer et al. 2003)

ResultsSuicides: 392(178 females and 214 males)

Controls:416(214 females and 202 males)

Results: table 1:  

Results: table 1: Two groups differed significantly on a wide range of

factors:education, family income, marital status and dating, religion/religiosity, pesticide stored at home, gender value strains, impulsivity, and mental disorder

The prevalence of mental disorders was higher among the young Chinese who died by suicide than among the living controls

the suicides :47.7%(n=187) the living controls:2.6% (n=11)

Results: table 2:

Results: table 2:

Risk factors:mental disorder, Impulsivity, Religion/religiosity(might be), the value strain, the interactive effect of the two conflicting cultural values(to young rural women), a single woman was dating or in a love relationship

never-married women who were involved in relationships were about three times more likely to commit suicide than single women who were unattached

Results

Protecting factor:Education , family annual income,Being married(for man)

pesticides or farming chemicals stored at home, The traditional and modern value scores

Conclusions

Risk factors for suicide in rural China are different from those in the West : mental disorder(SCID)

The uniqueness of young rural Chinese female suicide lies in the effects of marriage and marital experience,religion/religiosity, impulsivity, and psychological strain

Conclusions

Psychological strain plays a role in suicide:patriarchy society

Religion could not be a risk factor for suicide in rural China: no single God to worship and no social support system and coping mechanisms

Conclusions

Cultural value strain: modern values (gender equalitarianism) and traditional values (Confucian paternalism) clash

Suicide prevention programs in China should incorporate culture-specific considerations

Discussionmental disordermarriage and marital experience religion/religiosity impulsivitypsychological strain

Mental disorder

lower prevalence of mental disorder among the young suicides in rural China than among suicides in the West

consistent with the earlier studies of Chinese suicide （ Phillips et al.2002b;Zhang et al.2004）

mental disorder is a strong predictor of suicide risk factors other than mental illnesses

were strongly relevant for Chinese suicides

The uniqueness of young rural Chinese female suicide lies in the effects of marriage and marital experience , religion/religiosity, impulsivity, and psychological strain

marriage and marital experience

the Chinese women who had never been married but were involved in a relationship were at higher suicide risk than their counterparts who were unattached

in traditional culture of rural China, young women being in a love and dating

relationship even before marriage can be confined to the bond – a relationship equivalent to marriage

among young rural Chinese women, being married or the marital experience is not necessarily a protective factor as it is in the West （ Durkheim,1897/1895）

in traditional culture ,when problems arise in the family, women are usually the first to be blamed and held responsible for the problems

young rural Chinese women more likely to feel suppressed and helpless and may go to extremes to resolve （ Zhang,1996）

this effect of marital status on women’s suicide may be cultural specific

a recent study with Chinese samples in Taiwan areas reported that females who never married, were aged <35 and ≥65 years, and widowed at ≥ 65 years had lower suicide odds than females of other marital categories （ Yeh et al. 2008）

for a Chinese woman, staying single or becoming single by either divorce or

widowing is not necessarily detrimental for suicide propensity

religion/religiosity

religion could be a risk factor for suicide in rural China

unlike most other societies in the world to some Chinese , being religious is

equivalent to being superstitious death is a solution to all the problems

and the beginning of a new life

impulsivity

impulsivity is strongly related to suicide in China

consistent with the earlier findings on the effect of impulsivity on Chinese suicide

in conflicts on family politics , which were trivial quarrels, those young people could behave in an extrame way without

deliberating about the result , to win self-dignity

psychological strain

cultural value strain is a risk factor the traditional values and modern values clash

in a rural Chinese woman’s beliefs, strain results

strain involves frustration so unbearable that some solution must be taken to reduce the psychological pressure

strain can lead to criminal behaviors towards others , and when the aggression is inwards , suicide takes place

advantage

one of the largest PA studies in China a case-control study of suicide was used

frequently at home and abroad

but it focused on culture factors in order to identify culture-specific prevention measures for rural China

it is innovative.

In method,not use accidental deaths for the control group that would avoid bias in certain ways （ e.g. higher likelihood of substance misuse or impulsive risk-taking behavior）

No significant difference in age distribution of the control and the 2005 Chinese national census database , support representativeness of the controls in the study

the community-living control group was a random sample stratified by age range and country

for each suicide , they used the 2005 census database of the county where the deceased lived to randomly select a living control in the same age range

Logistic regressions were performed with their variables of interest included in the model

the method that they performed the analyses separately for men and women was innovative

Something in question

excluded cases of accidental or natural death in which suicidal intent was questioned

may miss some suicidal cases

it is said that the suicide rates among rural women is higher than among rural men

but in this study in suicides, female cases were less than male , sample of this study ‘s representativeness of suicides was in question

In measures , they computed a variable with three categories below:

”never married and not dating”

” never married but dating”

”ever married”

but in the results,they said being married is a protective factor for man,not for woman,we can’t find the corresponding evidence

In Table2 , the family annual income was divided into 3 ratings，

RMB<10000 10000≤ RMB<20000 RMB≥20000 but they didn’t explain why and in the results they

did not describe the level of cases’ family annual income, also the difference between suicides and controls.

they only said family annual income was protecting factors for suicide, and was more powerful for men than women ,the result was questioned

suggestion

can do correlation analysis between factors to facilitate interference factors that could interfere in order to indirectly affect the factors that are not easy to change

may add a control group of urban young suicides （ aged 15-34years ） to understand the difference between the two points, and which is characterized by a clear set of characteristics of rural suicide

Thank you !