Suicide means used by Chinese rural youths: a comparison between those with and without mental disorders

The trend of suicide and self-harm in the Chinese population from 2018 to 2022 based on ambulance medical emergency cases: a retrospective study

Objective

This study investigates the trends of suicide and self-harm in Nanjing, China, through 4 years of data collection, aiming to provide valuable information for developing effective suicide prevention strategies.

Methods

This descriptive study analyzed Nanjing Emergency Medical Center (NEMC) ambulance records from Nanjing (2018-2022) to investigate suicide and self-harm events. Out of 689,305 records, 4,261 cases were included after exclusions. The study categorized incidents into 4,103 suicide events and 158 self-harm cases. Descriptive statistics and content analysis were conducted to identify characteristics and themes related to these events, with age groups defined according to American Medical Association standards.

Results

The study highlights drug poisoning as the leading method, accounting for 63.56% of the 4,103 suicide events. It notes significant trends by age, gender, and season, with males showing higher rates of self-harm. The study emphasizes the need for targeted prevention strategies, particularly focusing on drug-related suicides among adults and adolescents, as well as the prevalence of various self-harming behaviors.

Conclusion

To reduce self-harm and suicide, interventions must be strengthened for women, who experience higher rates. Key strategies include regulating pesticides and psychotropic drugs, increasing access to mental health resources, and launching community awareness campaigns. Additionally, training healthcare providers and promoting family education can enhance support for women facing mental health challenges.

Impulsivity in fatal suicide behaviour: A systematic review and meta-analysis of psychological autopsy studies

Our aim is to review and perform a meta-analysis on the role of impulsivity in fatal suicide behaviour. We included papers who used psychological autopsy methodology, assessed adult death by suicide, and included assessment of impulsivity. We excluded papers about assisted suicide, terrorist suicide, or other cause of death other than suicide or postmortem diagnosis made only from medical records or database. 97 articles were identified. 33 were included in the systematic review and nine in the meta-analysis. We found that people who die by suicide with high impulsivity are associated with younger age, substance abuse, and low intention to die, whereas those with low impulsivity were associated with older age, depression, schizophrenia, high intention to die and low social support. In the meta-analysis, suicide cases had higher impulsivity scores than living controls (Hedges' g = 0.59, 95 % CI [0.28, 0.89], p=.002). However, studies showed heterogeneity (Q = 90.86, p<.001, I2=89.0 %). Impulsivity-aggressiveness interaction was assessed through meta-regression (β=0.447, p=.045). Individuals with high impulsivity would be exposed to a higher risk of fatal suicide behaviour, aggressiveness would play a mediating role. People who die by suicide with high and low impulsivity display distinct characteristics, which may reflect different endophenotypes leading to suicide by different pathways.

Suicide prevention in childhood and adolescence: a narrative review of current knowledge on risk and protective factors and effectiveness of interventions

INTRODUCTION

Suicide is a global mental health problem for people of all ages. While rates of suicide in children and adolescents are reported as lower than those in older populations worldwide, they represent the third leading cause of death in 15-19-year-olds. The rates are higher among boys than girls worldwide, though the death rates for girls exceed those for boys in Bangladesh, China, India, and Nepal. There has been a general decrease in adolescent suicide rates over recent decades. However, increases are reported in South East Asia as well as South America over the same time period.

METHODS

A narrative review method has been used to summarize current knowledge about risk and protective factors for suicide among children and adolescents and to discuss evidence-based strategy for suicide prevention in this age group.

RESULTS

Identified suicide risk and protective factors for children and adolescents largely overlap with those for adults. Nevertheless, developmental characteristics may strengthen the impact of some factors, such as decision-making style, coping strategies, family and peer relationships, and victimization. The implementation of evidence-based suicide preventive strategies is needed. Restricting access to lethal means, school-based awareness and skill training programs, and interventions delivered in clinical and community settings have been proven effective. The effectiveness of gatekeeper training and screening programs in reducing suicidal ideation and behavior is unproven but widely examined in selected settings.

DISCUSSION

Since most studies have been conducted in western countries, future research should assess the effectiveness of these promising strategies in different cultural contexts. The use of more rigorous study designs, the use of both short- and long-term follow-up evaluations, the larger inclusion of individuals belonging to vulnerable groups, the evaluation of online intervention, and the analysis of programs' cost-effectiveness are also required.

Self-Transcendence Mediates the Relationship between Early Trauma and Fatal Methods of Suicide Attempts

BACKGROUND

Early trauma is known to be a risk factor of suicide-related behavior. On the other hand, people who attempt suicide using a fatal method are reported to be more likely to complete suicide. In this study, we assumed that early trauma affects an individual's temperament and character and thereby increases the risk of a fatal method of suicide attempts.

METHODS

We analyzed 92 people with a history of previous suicide attempts. We compared the Temperament and Character Inventory-Revised scores between the groups with and without early trauma, and between the groups with and without a history of suicide attempt using fatal methods through an analysis of covariance with age, sex, and presence of a psychiatric history as covariates. A mediation analysis was conducted of the relationship between early trauma and fatal methods of suicide attempt with self-transcendence as a mediator.

RESULTS

Higher self-transcendence was reported in the fatal group (27.71 ± 13.78 vs. 20.97 ± 12.27, P = 0.010) and the early trauma group (28.05 ± 14.30 vs. 19.43 ± 10.73, P = 0.001), respectively. The mediation model showed that self-transcendence mediates the relationship between early trauma and fatal methods of suicide attempt. The 95% confidence intervals for the direct and indirect effect were (-0.559, 1.390) and (0.026, 0.947), respectively.

CONCLUSION

Self-transcendence may mediate the relationship between early trauma and fatal methods of suicide attempt. Self-transcendence may be associated with unhealthy defenses and suicidal behavior for self-punishment and may constitute a marker of higher suicide risk.

Comparing Suicide Attempters With and Without Mental Disorders: A Study of Young Adults in Rural China

Over 90% of suicides in the West could be diagnosed with mental disorders, while only 50-70% of Chinese suicides had mental disorders. Using data from a case-control study on suicide attempt, we aimed to compare characteristics and risk factors between suicide attempters with and without mental disorders. Demographic and social psychological characteristics were compared between attempters with and without mental disorders. 19.1% of the suicide attempters were diagnosed with mental disorders. Suicide attempters with mental disorders endured more strain than those without. Strain was an independent risk factor for suicide attempt among people without mental disorders. Psychological strain might be an important reason for both mental disorders and following suicide attempt. More efforts on suicide prevention should be spent on people without mental disorders. The impact of social psychological factors, such as religion, negative life events, and psychological strains should be considered.

Suicide Means Used by the Older Adults in Rural China: A Comparison Between Those Using Pesticides and Other Means

BACKGROUND

The most frequently used means of committing suicide was pesticide poisoning in rural China, yet little is known about the characteristics and risk factors for suicides committed with pesticides compared to those committed via other means in older adults.

METHODS

The participants were 242 older adults (aged 60 or older) who had committed suicide in the rural areas of 3 provinces (Shandong, Hunan, and Guangxi) in China. This study was conducted using the psychological autopsy (PA) method.

RESULTS

In univariate analyses, no statistically significant differences were found between those who committed suicide with pesticide or with other means in terms of demographic and clinical variables except age, prevalence of mental disorders, suicidal intent, number of recent life events, social support, hopelessness, impulsivity, and depressive symptoms (P > .05); age, history of suicide attempts, having pesticides available at home, the total number of life events, and the number of long-term life events were significantly different (P < .05) between the 2 groups. In multivariate logistic regression model, the factors associated with committing suicide with pesticides were the availability of pesticides at home (odds ratio [OR] = 3.48, 95% confidence interval [CI]: 1.99-6.08) and the number of long-term life events (OR = 0.87, 95% CI: 0.78-0.97).

CONCLUSION

The older adults who committed suicide by pesticides and those using other means are probably the same population. The main determinant of choosing pesticides as suicide means was likely the availability of pesticides at home. Suicide risk among older adults might be reduced by placing appropriate restrictions on access to pesticides.

Psychiatric morbidity and suicidal behaviour in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Psychiatric disorders are reported to be present in 80% to 90% of suicide deaths in high-income countries (HIC), but this association is less clear in low- and middle-income countries (LMIC). There has been no previous systematic review of this issue in LMIC. The current study aims to estimate the prevalence of psychiatric morbidity in individuals with suicidal behaviour in LMIC.

METHODS AND FINDINGS

PubMed, PsycINFO, and EMBASE searches were conducted to identify quantitative research papers (any language) between 1990 and 2018 from LMIC that reported on the prevalence of psychiatric morbidity in suicidal behaviour. We used meta-analytic techniques to generate pooled estimates for any psychiatric disorder and specific diagnosis based on International classification of disease (ICD-10) criteria. A total of 112 studies (154 papers) from 26 LMIC (India: 25%, China: 15%, and other LMIC: 60%) were identified, including 18 non-English articles. They included 30,030 individuals with nonfatal suicidal behaviour and 4,996 individuals who had died by suicide. Of the 15 studies (5 LMIC) that scored highly on our quality assessment, prevalence estimates for psychiatric disorders ranged between 30% and 80% in suicide deaths and between 3% and 86% in those who engaged in nonfatal suicidal behaviour. There was substantial heterogeneity between study estimates. Fifty-eight percent (95% CI 46%-71%) of those who died by suicide and 45% (95% CI 30%-61%) of those who engaged in nonfatal suicidal behaviour had a psychiatric disorder. The most prevalent disorder in both fatal and nonfatal suicidal behaviour was mood disorder (25% and 21%, respectively). Schizophrenia and related disorders were identified in 8% (4%-12%) of those who died by suicide and 7% (3%-11%) of those who engaged in nonfatal suicidal behaviour. In nonfatal suicidal behaviour, anxiety disorders, and substance misuse were identified in 19% (1%-36%) and 11% (7%-16%) of individuals, respectively. This systematic review was limited by the low number of high-quality studies and restricting our searches to databases that mainly indexed English language journals.

CONCLUSIONS

Our findings suggest a possible lower prevalence of psychiatric disorders in suicidal behaviour in LMIC. We found very few high-quality studies and high levels of heterogeneity in pooled estimates of psychiatric disorder, which could reflect differing study methods or real differences. There is a clear need for more robust evidence in order for LMIC to strike the right balance between community-based and mental health focussed interventions.

Being left-behind, mental disorder, and elderly suicide in rural China: a case-control psychological autopsy study

BACKGROUND

Suicide rate among rural elderly is the highest among all age groups in China, yet little is known about the suicide risks in this rapidly growing vulnerable population.

METHODS

This matched case-control psychological autopsy study was conducted during June 2014 to September 2015. Consecutive samples of suicides aged 60 or above were identified in three provinces (Shandong, Hunan, and Guangxi) in China. Living comparisons were 1:1 matched with the suicides in age (±3 years old), gender, and living location. Risk factors included demographic characteristics, being left-behind, mental disorder, depressive symptoms, stressful life events, and social support.

RESULTS

A total of 242 suicides and 242 comparisons were enrolled: 135 (55.8%) were male, mean (s.d.) age was 74 (8) years. The most frequently used suicide means were pesticides (125, 51.7%) and hanging (95, 39.3%). Independent risks of suicide included unstable marital status [odds ratio (OR) 4.19, 95% confidence interval (CI) 1.61-10.92], unemployed (compared with employed, OR 4.43, 95% CI 1.09-17.95), depressive symptoms (OR 1.34, 95% CI 1.21-1.48), and mental disorder (OR 6.28, 95% CI 1.75-22.54). Structural equation model indicated that the association between being left-behind and suicide was mediated by mental disorder, depressive symptoms, stressful life events, and social support.

CONCLUSIONS

Unstable marital status, unemployed, depressive symptoms, and mental disorder are independent risk factors for suicide in rural elderly. Being left-behind can elevate the suicide risk through increasing life stresses, depressive symptoms, mental disorder, and decreasing social support. Elderly suicide may be prevented by restricting pesticides, training rural physicians, treating mental disorders, mitigating life stress, and enhancing social connection.

Suicide by pesticide poisoning remains a priority for suicide prevention in China: Analysis of national mortality trends 2006-2013

BACKGROUND

Despite recent declines, suicide remains a priority for China. Ease of availability of high-lethality suicide methods, such as pesticides and firearms, contributes to the overall incidence and is an important target for suicide prevention. This study investigates whether changes in the distribution of methods of suicide have contributed to the recent reduction in suicide in China.

METHOD

Suicide rates (2006-2013) were calculated using the Chinese Disease Surveillance Points system, stratified by gender, age group, and urban-rural residence, to investigate trends in suicide over the study period. Multilevel negative binomial regression models were used to investigate associations between socio-demographic factors and method-specific suicide.

RESULTS

The most common method of suicide in China for both males and females was pesticide poisoning, followed by hanging. All methods declined over the study period, with the exception of suicide by jumping in males. Suicide rates for pesticide poisoning and for hanging increased exponentially with age in those aged over ≥45 years in both sexes. Pesticide poisoning declined from 55% to 49% of all suicides, while hanging increased from 27% to 31%.

LIMITATIONS

This was an ecological study of a time series of suicide rates, with risk factor adjustment being limited to population-level point estimates derived from a single census.

CONCLUSIONS

Suicide by pesticide poisoning and hanging remain the leading methods of suicide in China. Changes to the safe use of pesticides and targeted prevention initiatives to restrict access, along with socio-economic development and urbanisation, are likely contributors to declines in suicide by pesticide poisoning.

Factors associated with the choice of suicide method in Kermanshah Province, Iran

BACKGROUND

Identification of factors in the choice of suicide methods is important in understanding the phenomenon.

OBJECTIVES

We aimed to quantify the effect of gender, age, living area, education level and marital status on the choice of suicide method among residents of Kermanshah province in the west of Iran.

DESIGN

A cross-sectional study of all completed suicides from March 2006 to September 2013.

SETTING

Kermanshah Province, Iran.

METHODS

Data were extracted from suicide forms in the electronic files of the Forensic Medicine Organization. A total of 1901 (1138 men), suicide cases were identified. After preliminary analysis, a multinomial logistic model was fitted to the data to test and quantify the impact of each influential factor on the choice of suicide method. The relative risk of each suicide method over hanging as the reference method was estimated by calculating relative-risk ratios from the multinomial logistic model.

MAIN OUTCOME MEASURES

Relative risk of suicide by self-immolation, drug and toxic poisoning and firearms.

RESULTS

We found that women are at a higher relative risk than men for suicide by self-immolation, intentional drug poisoning and toxic poisoning. The relative risk of suicide by self-immolation and intentional drug poisoning was higher for urban residents and young individuals. On the other hand, men and rural residents were at higher relative risk of suicide by firearm.

CONCLUSIONS

In Kermanshah province, the impact of rapid social changes on women and the availability of firearms in rural areas and drugs in urban households require more attention in any suicide prevention planning.

LIMITATIONS

The lack of data prevented analysis of factors that may be more influential in choosing suicide.

Characteristics of Chinese rural young suicides: who did not have a strong intent to die

BACKGROUND

In exploration of the risk factors of the Chinese rural young suicide, previous researchers found low prevalence of mental problems, high degree of impulsivity, and great proportion of lethal pesticide consumption. It noticed that some of the young suicides in rural China did not intend to die from the suicidal behavior which was only instrumentally used for certain gains.

AIMS

This study aims to look into the characteristics of those young suicides who did not really intend to die and compare them with those young suicides who had a strong intent to die.

METHODS

Subjects were 386 suicides aged 15-34years in the rural areas of three provinces in China. The data were obtained by psychological autopsy method. The degree of suicidal intent of the subjects was evaluated by the first 8 items of Beck's Suicide Intent Scale (SIS).

RESULTS

It was found that those suicides that had a strong intent of death were more likely to have higher age, more years of education, live alone, and suffer mental disease. On the other hand, the low intent suicides were more likely to have pesticides at home and to be impulsive. In other words, pesticides and impulsivity killed some Chinese rural young men and women who did not really want to die by suicide.

CONCLUSION

Findings of the study may be translated into practical measures in suicide prevention in China as well as elsewhere in the world.

Health and psychosocial service use among suicides without psychiatric illness

Although mental illness is a major suicide risk factor, some cases of suicide list no symptoms of mental disorder at the time of death. Studying suicides without psychiatric illness has important implications for social work because this group's service needs seem to have been overlooked. The authors of this article conducted a psychological autopsy study of 150 people who committed suicide and 150 age- and gender-matched living controls. Suicides without psychiatric illness showed similar detectable psychopathology as the suicide and living control groups with nonpsychotic psychiatric disorders. Though suicides without psychiatric disorders showed fewer warning signs that could be noticed by their informants, they experienced more negative life events than living controls. The suicide cases without psychiatric illness also seemed to be less protected by enabling factors (such as social support and employment) than living controls with and without psychiatric disorders. Furthermore, they had lower use of services than the control and deceased-with-diagnosis groups. With fewer at-risk signs and poorer enabling resources, they were undetected or unengaged by the existing physical, psychiatric, and psychosocial services. This group should be of concern to social workers, who may develop community-based health education programs and preventive services to meet this vulnerable population's psychosocial needs.

Potential neurochemical links between cholesterol and suicidal behavior

The role of cholesterol in psychiatric diseases has aroused the interest of the medical community, particularly in association with violent and suicidal behavior. Herein, we discuss some aspects of brain cholesterol metabolism, exploring possible mechanisms underlying the findings and reviewing the available literature on the possible neurochemical link between suicide and low or reduced levels of serum cholesterol. Most of the current hypotheses suggest a decreased serotonergic activity due to a decrease in cholesterol in the lipid rafts of synaptic membranes. Some aspects and limitations of this assumption are emphasized. In addition to serotonin hypofunction, other mechanisms have been proposed to explain increased impulsivity in suicidal individuals, including steroid modulation and brain-derived neurotrophic factor decrease, which could also be related to changes in lipid rafts. Other putative markers of suicidal behavior (e.g. protein S100B) are discussed in connection with cholesterol metabolism in the brain tissue.

Completed suicide with violent and non-violent methods in rural Shandong, China: a psychological autopsy study

Background

This study aims to describe the specific characteristics of completed suicides by violent methods and non-violent methods in rural Chinese population, and to explore the related factors for corresponding methods.

Methods

Data of this study came from investigation of 199 completed suicide cases and their paired controls of rural areas in three different counties in Shandong, China, by interviewing one informant of each subject using the method of Psychological Autopsy (PA).

Results

There were 78 (39.2%) suicides with violent methods and 121 (60.8%) suicides with non-violent methods. Ingesting pesticides, as a non-violent method, appeared to be the most common suicide method (103, 51.8%). Hanging (73 cases, 36.7%) and drowning (5 cases, 2.5%) were the only violent methods observed. Storage of pesticides at home and higher suicide intent score were significantly associated with choice of violent methods while committing suicide. Risk factors related to suicide death included negative life events and hopelessness.

Conclusions

Suicide with violent methods has different factors from suicide with non-violent methods. Suicide methods should be considered in suicide prevention and intervention strategies.

Trends in paraquat poisoning in Japan - viewed from surveys on clinical cases

Objective: Paraquat poisoning occurs worldwide, and both the fatality rate and the number of deaths are out of the ordinary. Japan is one of the few countries in the world that have replaced 24% products with 5% products. This report is an attempt to introduce information about paraquat poisoning in Japan.

Methods: The Japanese Association of Rural Medicine has carried out extensive surveys on clinical cases of pesticide poisoning at its 122 member installations since 2007. Of all the findings, we have picked out and evaluated those concerned with paraquat poisoning.

Findings: Twenty-two out of 28 persons who attempted to commit suicide with paraquat died in 2007–2011. The rate of deaths from suicide attempts with paraquat stands at somewhere near 80% or so even with 5% products, so it appears that the attempts to reduce the death rate did not have the intended effect even with products having a lower concentration.

Conclusion: The “outcome prediction line” propounded in 1979 still stands today, while a wide variety of therapies have been studied. It seems that paraquat should at least be classified into Class Ib (highly hazardous) given that the mortality remains high and efficacious therapies remain elusive.

Characteristics of Chinese rural young suicides by pesticides

BACKGROUND

The major suicide method in rural China today is ingestion of agricultural pesticides.

AIM

This study is to investigate the characteristics of Chinese rural young suicides who died of pesticide ingestion.

METHODS

A sample of 392 suicides from rural China was studied using the psychological autopsy method, and data were analysed for demographic characteristics, the suicide method used, mental disorder and psychological characteristics.

RESULTS

Suicides by pesticide ingestion were enacted more because of impulsiveness and tended to demonstrate less mental illness than those suicides using other means in rural China.

CONCLUSIONS

Accessibility, high toxicity and lethality of the pesticides were risk factors for the suicides of people without a mental disorder in rural China. The use of pesticides is a rational choice and the safe storage of these kinds of farming chemicals should be controlled to prevent certain suicides.

The association between depression and suicide when hopelessness is controlled for

OBJECTIVE

We retested the relationship between major depression and suicide with hopelessness as a control variable, with the hypothesis that the strong relationship between depression and suicide will decrease or disappear when hopelessness is controlled for. Also, hopelessness can be accounted for by psychological strains that resulted from social structure coupled with individual characteristics.

METHOD

This was a case-control psychological autopsy study, in which face-to-face interviews were conducted to collect information from proxy informants for suicide victims and living subjects in rural Chinese 15-34years of age who died of suicide (n=392) and who served as community living controls (n=416). Major depression was assessed by the Chinese version of the Structured Clinical Interview for DSM-IV (SCID). Hopelessness was measured by Beck Hopelessness Scale.

RESULTS

A strong association between major depression and suicide was observed after adjustment for socio-demographic characteristics. When hopelessness was added to the analysis, the depression-suicide relationship was significantly decreased in all the six regression models.

CONCLUSIONS

Although depression, as well as other mental illness, is a strong risk factor for suicide, depression and suicide are both likely to be related to hopelessness, which in turn could be a consequence of psychological strains that resulted from social structure and life events. Future studies may examine the causal relations between psychological strains and hopelessness.

Suicide methods in Asia: implications in suicide prevention

As the largest continent in the World, Asia accounts for about 60% of World suicides. Preventing suicide by restricting access to suicide methods is one of the few evidence-based suicide prevention strategies. However, there has been a lack of systematic exploration of suicide methods in Asian countries. To amend this shortage, the current review examines the leading suicide methods in different Asian countries, their trend, their age- and sex- specific characteristics, and their implications for suicide prevention. In total, 42 articles with leading suicide methods data in 17 Asian countries/regions were retrieved. The epidemiologic characteristics and recent trends of common suicide methods reflect specific socio-cultural, economic, and religious situations in the region. Common suicide methods shift with the introduction of technologies and constructions, and have specific age- or sex-characteristics that may render the restriction of suicide methods not equally effective for all sex and age sub-groups. Charcoal burning, pesticide poisoning, native plant poisoning, self-immolation, and jumping are all prominent examples. In the information society, suicide prevention that focuses on suicide methods must monitor and control the innovation and spread of knowledge and practices of suicide "technologies". It may be more cost-effective to design safety into technologies as a way of suicide prevention while there is no rash of suicides yet by the new technologies. Further research on suicide methods is important for public health approaches to suicide prevention with sensitivity to socio-cultural, economic, and religious factors in different countries.