Elsevier

The Lancet

Volume 360, Issue 9347, 30 November 2002, Pages 1728-1736
The Lancet

Articles
Risk factors for suicide in China: a national case-control psychological autopsy study

https://doi.org/10.1016/S0140-6736(02)11681-3Get rights and content

Summary

Background

Suicide is the fifth most important cause of death in China, but the reasons for the high rate and unique pattern of characteristics of those who kill themselves are unknown.

Methods

We pretested, and then administered a comprehensive interview to family members and close associates of 519 people who committed suicide and of 536 people who died from other injuries (controls) randomly selected from 23 geographically representative sites in China.

Findings

After adjustment for sex, age, location of residence, and research site, eight significant predictors of suicide remained in the final unconditional logistic regression model. In order of importance they were: high depression symptom score, previous suicide attempt, acute stress at time of death, low quality of life, high chronic stress, severe interpersonal conflict in the 2 days before death, a blood relative with previous suicidal behaviour, and a friend or associate with previous suicidal behaviour. Suicide risk increased substantially with exposure to multiple risk factors: none of the 265 deceased people who were exposed to one or fewer of the eight risk factors died by suicide, but 30% (90/299) with two or three risk factors, 85% (320/377) with four or five risk factors, and 96% (109/114) with six or more risk factors died by suicide.

Interpretation

Despite substantial differences between characteristics of people who commit suicide in China and the west, risk factors for suicide do not differ greatly. Suicide prevention programmes what concentrate on a single risk factor are unlikely to reduce suicide rates substantially; preventive efforts should focus on individuals exposed to multiple risk factors.

Introduction

Analysis of recent mortality data from the Chinese Ministry of Health1 shows that suicide is the fifth most important cause of death in the country, accounting for about 287 000 deaths per year. The WHO 1999 World Health Report2 suggests that suicide is China's fourth most important public-health problem in terms of disability-adjusted life years (DALYs) lost. In China, the rural suicide rate is three-fold the urban rate and there are more suicide deaths among women than men. These patterns are different from those reported in other parts of the world.1, 3 The reasons for this difference and for the relatively high rate of suicide in China are unknown.

To better understand the risk factors for suicide in China, and to develop a suicide-prevention plan specific to this country, we did an unmatched case-control study to identify the characteristics and causes of suicide in the country. We used the psychological autopsy method4, 5 to compare characteristics of people who died by suicide with those of people who died by other types of injury.

Section snippets

Study population

In most case-control studies of suicide, the control group comprises living individuals,6, 7, 8 but we decided to have a control group of people who had died of other causes, because of important methodological advantages4, 5, 9 that are especially relevant in our setting. With a control group of deceased individuals, the sources of information used to assess risk factors are informants who have recently experienced the death of a family member or close associate—and are therefore more

Results

Of the 1220 deaths selected for detailed investigation, appropriate respondents could not be located in 67 cases, participation was refused in 65, data were lost in the mail in 22, and the psychiatric interview was incomplete in one (figure). The median time from death to interview was 11 months (IQR 8–14). The median combined interview time for each case was 3·4 h (2·8–4·2).

In 80 (7·5%) of the 1065 deaths available for analysis, we decided on a cause of death that differed from that recorded

Discussion

Cost-effective ways to address the health scourges faced by developing countries, such as HIV/AIDS, tuberculosis, smoking, depression, and suicide are needed. However, strategies must be developed with a detailed understanding of how biological, social, economic, and cultural variables interact to produce the local constellation of risk factors, protective factors, and treatment networks for these conditions. During the 6 years it took to complete this project, we became aware of the myriad of

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