The impact of improving suicide death classification in South Korea: a comparison with Japan and Hong Kong

Understanding the Fluctuations in Korea's Suicide Rates: A Change-Point Analysis and Interrupted Time Series Analysis

BACKGROUND

Korea has witnessed significant fluctuations in its suicide rates in recent decades, which may be related to modifications in its death registration system. This study aimed to explore the structural shifts in suicide trends, as well as accidental and ill-defined deaths in Korea, and to analyze the patterns of these changes.

METHODS

We analyzed age-adjusted death rates for suicides, deaths due to transport accidents, falls, drowning, fire-related incidents, poisonings, other external causes, and ill-defined deaths in Korea from 1997 to 2021. We identified change-points using the 'breakpoints' function from the 'strucchange' package and conducted interrupted time series analyses to assess trends before and after these change-points.

RESULTS

Korea's suicide rates had three change-points in February 2003, September 2008, and June 2012, characterized by stair-step changes, with level jumps at the 2003 and 2008 change-points and a sharp decline at the 2012 change-point. Notably, the 2003 and 2008 spikes roughly coincided with modifications to the death ascertainment process. The trend in suicide rates showed a downward slope within the 2003-2008 and 2008-2012 periods. Furthermore, ill-defined deaths and most accidental deaths decreased rapidly through several change-points in the early and mid-2000s.

CONCLUSION

The marked fluctuations in Korea's suicide rate during the 2000s may be largely attributed to improvements in suicide classification, with potential implications beyond socio-economic factors. These findings suggest that the actual prevalence of suicides in Korea in the 2000s might have been considerably higher than officially reported.

Suicide risk among patients with cancer by sex in Japan: A population-based study

BACKGROUND

In Japan, few studies have examined suicide risk for five-year relative survival rates for cancer sites. Since five-year relative survival rates differ by sex, we aim to examine suicide risk for patients with cancer separately for men and women.

METHODS

We estimated the risk of suicide among patients with cancer by sex in Japan compared to the general population, using standardized mortality ratios (SMRs). Patients with cancer diagnosed between January 1, 1985-December 31, 2013 and registered in the Osaka Cancer Registry were followed-up with for up to 10 years. The outcome was suicide death. In addition, cancer sites were classified into three prognosis groups based on five-year relative survival rates: good (> 70%), moderate (40-70%), poor (< 40%).

RESULTS

Among 623 995 patients with cancer observed for 2 349 432 person-years, 1210 patients died by suicide (867 men and 343 women). The SMRs were almost equal for men (1.66, 95% CI, 1.55-1.77) and women (1.65, 95% CI, 1.48-1.83). SMRs for cancer prognosis groups were 1.01 (95% CI, 0.84-1.22) for men and 1.47 (95% CI, 1.24-1.73) for women in the good group, 1.53 (95% CI, 1.39-1.68) for men and 1.74 (95% CI, 1.47-2.05) for women in the moderate group, and 2.54 (95% CI, 2.27-2.85) for men and 1.87 (95% CI, 1.43-2.46) for women in the poor group.

CONCLUSIONS

In this population, both sexes had higher suicide risk with poor prognosis, but the difference in SMRs between the good and poor groups was smaller for women than men.

Age- and cause-specific contributions to increase in life expectancy at birth in Korea, 2000-2019: a descriptive study

BACKGROUND

Korea's life expectancy at birth has consistently increased in the 21st century. This study compared the age and cause-specific contribution to the increase in life expectancy at birth in Korea before and after 2010.

METHODS

The population and death numbers by year, sex, 5-year age group, and cause of death from 2000 to 2019 were acquired. Life expectancy at birth was calculated using an abridged life table by sex and year. The annual age-standardized and age-specific mortality by cause of death was also estimated. Lastly, the age and cause-specific contribution to the increase in life expectancy at birth in the two periods were compared using a stepwise replacement algorithm.

RESULTS

Life expectancy at birth in Korea increased consistently from 2010 to 2019, though slightly slower than from 2000 to 2009. The cause-specific mortality and life expectancy decomposition analysis showed a significant decrease in mortality in chronic diseases, such as neoplasms and diseases of the circulatory system, in the middle and old-aged groups. External causes, such as transport injuries and suicide, mortality in younger age groups also increased life expectancy. However, mortality from diseases of the respiratory system increased in the very old age group during 2010-2019.

CONCLUSIONS

Life expectancy at birth in Korea continued to increase mainly due to decreased mortality from chronic diseases and external causes during the study period. However, the aging of the population structure increased vulnerability to respiratory diseases. The factors behind the higher death rate from respiratory disease should be studied in the future.

Classification of suicidal behavior calls in emergency medical services: a systematic review

BACKGROUND

The aim of this systematic review was to examine the classification of calls for suicidal behavior in emergency medical services (EMS).

METHODS

A search strategy was carried out in four electronic databases on calls for suicidal behavior in EMS published between 2010 and 2020 in Spanish and English. The outcome variables analyzed were the moment of call classification, the professional assigning the classification, the type of classification, and the suicide codes.

RESULTS

Twenty-five studies were included in the systematic review. The EMS classified the calls at two moments during the service process. In 28% of the studies, classification was performed during the emergency telephone call and in 36% when the professional attended the patient at the scene. The calls were classified by physicians in 40% of the studies and by the telephone operator answering the call in 32% of the studies. In 52% of the studies, classifications were used to categorize the calls, while in 48%, this information was not provided. Eighteen studies (72%) described codes used to classify suicidal behavior calls: a) codes for suicidal behavior and self-injury, and b) codes related to intoxication, poisoning or drug abuse, psychiatric problems, or other methods of harm.

CONCLUSION

Despite the existence of international disease classifications and standardized suicide identification systems and codes in EMS, there is no consensus on their use, making it difficult to correctly identify calls for suicidal behavior.

Increased risk of suicidality in patients with psoriasis: A Nationwide cohort study in Korea

BACKGROUND

Psoriasis has a devastating psychological impact on patients' quality of life. However, the relationship between suicidality and psoriasis remains unclear.

OBJECTIVE

This study analysed and compared the risk of suicidality (suicidal ideation, suicide attempt and completed suicide) between patients with psoriasis and the general population.

METHODS

This nationwide, population-based, retrospective, cohort study analysed the Korean National Health Insurance Service claim data from 2005 to 2018.

RESULTS

The study included 348,439 patients with psoriasis aged over 18 years and with age- and sex-matched controls. The risk of suicidality was higher in the psoriasis group than in the control group [adjusted hazard ratio (aHR) 1.21; 95% confidence interval (CI), 1.18-1.24]. The aHR of suicidality was higher in the psoriatic arthritis group (aHR, 1.46; 95% CI, 1.39-1.54) than in the psoriasis-alone group (aHR, 1.17; 95% CI, 1.13-1.20). However, the severity of psoriasis and suicidality showed no correlation (mild psoriasis group: aHR, 1.22; 95% CI, 1.18-1.25; moderate-to-severe psoriasis group: aHR, 1.16; 95% CI, 1.10-1.23).

CONCLUSION

Patients with psoriasis have an increased risk of suicidality. In particular, the presence of arthritis in patients had a more significant effect on the risk of suicidality.

Risks of suicide among family members of suicide victims: A nationwide sample of South Korea

OBJECTIVE

Identifying the risks of completed suicide in suicide survivors is essential for policies supporting family members of suicide victims. We aimed to determine the suicide risk of suicide survivors and identify the number of suicides per 100,000 population of suicide survivors, bereaved families of traffic accident victims, and bereaved families with non-suicide deaths.

METHODS

This was a nationwide population-based cohort study in South Korea. The data were taken from the Korean National Health Insurance and Korea National Statistical Office between January 2008 and December 2017. The relationship between the decedent and the bereaved family was identified using the family database of the National Health Insurance Data. Age and gender were randomly matched 1:1 among 133,386 suicide deaths and non-suicide deaths. A proportional hazard model regression analysis was conducted after confirming the cumulative hazard using Kaplan-Meier curves to obtain the hazard ratio (HR) of completed suicide in suicide survivors.

RESULTS

Using 423,331 bereaved families of suicide victims and 420,978 bereaved families of non-suicide deaths as the control group, HR of completed suicide in suicidal survivors was found to be 2.755 [95% confidence limit (CL): 2.550-2.977]. HR for wives committing suicide after husbands' suicide was 5.096 (95% CL: 3.982-6.522), which was the highest HR among all relationships with suicide decedents. The average duration from suicide death to suicide of family members was 25.4 months. Among suicide survivors, the number of suicides per 100,000 people was 586, thrice that of people in bereaved families of traffic accident victims and in bereaved families of non-suicide deaths.

CONCLUSION

The risk of completed suicide was three times higher in suicide survivors than in bereaved families with non-suicide deaths, and it was highest in wives of suicide decedents. Thus, socio-environmental interventions for suicidal survivors must be expanded.

Is suicide underreported? Evidence from Japan

PURPOSE

The underreporting of suicides has been a serious global concern among scholars and policymakers. Several studies have sought to detect the prevalence of underreporting by examining whether suicide mortality rates are negatively correlated with those due to unknown intent or causes. This study adds to the literature by examining the potential underreporting of suicides in Japan, where suicide rates have greatly declined in the recent years.

METHODS

We compiled subnational data from 47 prefectures between 1995 and 2016, obtained from Vital Statistics of Japan. We examined whether (1) mortality rates due to unknown intent or causes increased as suicide rates decreased; and (2) major socioeconomic causes of suicide (unemployment and divorce rates) had any relationship with the deaths due to unknown intent or causes.

RESULTS

Our analysis indicates that mortality rates due to unknown intent or causes were uncorrelated with suicide rates and the above socioeconomic indicators.

CONCLUSIONS

In Japan, the frequency of suicides has no systematic relationship with deaths due to unknown intent or causes, suggesting the accuracy of suicide statistics.

Spain's suicide statistics: do we believe them?

PURPOSE

There is a widespread belief that suicides around the world are under-counted. A substantial proportion of suicides may have been inappropriately registered as accidental or of undetermined cause or intent. There is reason to explore to what extent low suicide rates in some nations could be partly attributable to under-counting.

METHODS

Mortality statistics of most countries are available on-line. Numbers of suicide deaths in Spain, and in England and Wales (E & W), in male and female 5-year age groups, in each year between 2014 and 2018, were documented, along with deaths coded to ICD-10 accident or 'undetermined death' categories. Crude mortality rates were calculated using official population figures. Single year suicide, undetermined death, and non-transport accidental death rates of 12 other nations were calculated.

RESULTS

Spain's crude suicide rate per 100,000 remains low (7.89) compared to other nations; its event of undetermined intent (EUI) death rate was 0.09 (contrasting with E & W's 1.74). Its accidental poisoning rate is much lower than that of E & W. The study showed much higher rates of ill-defined/unknown cause deaths in late life in Spain (both genders) than in E & W, and age-associated increases in accidental drowning rates parallel with increased suicide by drowning.

CONCLUSIONS

Reportedly low suicide rates in Spain could be partly attributable to increased rates of 'hidden suicide' (accidental drowning, male accidental poisoning, and possibly ill-defined/unknown cause deaths, but not EUIs). It would be appropriate (and not just in Spain) to increase numbers of verbal and/or forensic autopsies in questionable 'undetermined' cases.

Risks of suicide attempts after prescription of zolpidem in people with depression: a nationwide population study in South Korea

OBJECTIVES

To investigate the association between zolpidem prescription and suicide attempts in people with depression.

METHODS

A nationwide, population-based electronic medical records database from the Health Insurance Review & Assessment Service of South was used to investigate the incidence rate ratios (IRRs) of suicide attempts and probable suicide attempts in people with depression before and after zolpidem prescription using self-controlled case series design.

RESULTS

In a total of 445 people who attempted suicide and 23 141 people who attempted probable suicide attempt, the IRRs of suicidal behavior during the risk periods before and after zolpidem prescription increased compared with those at the baseline. The IRRs gradually increased and peaked immediately before the prescription of zolpidem. The IRR was 70.06 (95% CI: 25.58-191.90) on day 2 before zolpidem prescription and 63.35 (95% CI: 22.99-174.59) on day 1 after zolpidem prescription in the suicide attempt group. The IRR was 24.07 (95% CI: 20.50-28.26) on the day before zolpidem prescription and 14.96 (95% CI: 12.21-18.34) on the day after zolpidem prescription in the probable suicide attempt group. The ratios declined eventually after zolpidem was prescribed.

CONCLUSIONS

Although zolpidem prescription was associated with an increased risk of suicide attempts in people with depression, the risk increased and peaked immediately before zolpidem prescription. The risk declined gradually thereafter. This result indicates that the risk of suicide attempts increases at the time of zolpidem prescription. However, zolpidem prescription does not contribute to additional increase in the risk of suicide attempts.

Risk of Suicide Attempt after Thyroidectomy: A Nationwide Population Study in South Korea

OBJECTIVE

To investigate the association between thyroidectomy and suicide attempt.

METHODS

A nationwide population-based electronic medical records database of South Korea between January 1, 2009 and June 30, 2016 was used to investigate incidence rate ratios (IRRs) of suicide attempts and probable suicide attempts before and after thyroidectomy using a self-controlled case series design.

RESULTS

In 2,986 patients who attempted suicide or probable suicide, the IRRs of suicidal behaviors during risk periods one year before and after thyroidectomy were investigated. Generally, after thyroidectomy, there was no increase in IRR compared to the non-risk period. When data were analyzed according to thyroidectomy type, after partial thyroidectomy, IRR increased up to 1.43 (95% CI: 1.03-1.98, p=0.032) in the days 91-181 period. In the subgroup with major depressive disorder (MDD), the IRR increased up to 1.74 (95% CI: 1.21-2.51, p=0.003) before thyroidectomy, and increased up to 1.67 (95% CI: 1.16-2.41, p=0.006) after thyroidectomy.

CONCLUSION

Although the general risk of suicide attempt was not increased after thyroidectomy, patients with MDD showed increased risk of suicide attempt before and after thyroidectomy. These results suggest that suicidality should be evaluated when depressive symptoms are present in patients who have undergone thyroidectomy.

Quantifying the contributions of age, sex, methods, and urbanicity to the changing suicide rate trends in South Korea, 2001-2016

PURPOSE

Suicide rates in South Korea have been one of the highest in the world. The aim of this study is to quantify the contributions of age, sex, method, and place of residence to the trends of the suicide rates between 2001 and 2016 in South Korea.

METHODS

Using the suicide data obtained from the South Korean National Death Registration data set for the years 2001-2016, a Joinpoint regression analysis was conducted to determine if there was a significant change in the trend of suicide rates. Next, a decomposition analysis method was used to quantify the contributions of age, sex, method, and places of residence to the changes in the suicide rates.

RESULTS

Suicide rates increased between 2001 and 2010, and decreased between 2010 and 2016. Among all the age groups, the 65-79 age group contributed most to the rise (18% in men and 7% in women) and fall (- 15% in men and - 14% in women) of suicide rates. Men contributed much more than women to the increasing trend of suicide rate (63.0% vs. 37.0%). Hanging was the key method of suicide, dominating the ups and downs of the suicide rates. The rates of suicide by pesticide poisoning have been decreasing since 2005 and suicide by charcoal burning continued to increase against a decreasing trend of suicide rate during the period of 2010-2016. The gap of the metropolitan-city-rural suicide rates was narrowing during the period under study, although the rural areas remained to have the highest suicide rates.

CONCLUSION

The ups and downs of suicide rates in South Korea were not uniform across different sociodemographic groups. Age, sex, method, and place of residence contributed differently to the changes in suicide rates. Suicide prevention measures can be more focused on certain age-sex-method-region subgroups.

Suicide in Elderly Patients with Hip Fracture: A South Korean Nationwide Cohort Study

BACKGROUND

The purpose of the present study was to evaluate the incidence rate (IR) of suicide in elderly patients with hip fracture on the basis of a nationwide cohort and to analyze the change in the hazard ratio for suicide after hip fracture over time in comparison with a control group.

METHODS

Patients with hip fracture and their matched controls were selected from the National Health Insurance Service-Senior cohort (NHIS-Senior) of the Republic of Korea. The NHIS-Senior consists of 558,147 people selected by a 10% simple random-sampling method from a total of 5.5 million subjects ≥60 years of age in 2002. Risk-set matching (1:2) on the propensity score was performed with use of a nearest neighbor matching algorithm with a maximum caliper of 0.1 for the hazard components. The IR of suicide and 95% confidence interval (CI) were calculated on the basis of a generalized linear model with a Poisson distribution. The effect size was presented as a hazard ratio (HR) with use of the Cox proportional-hazard model with a robust variance estimator that accounts for clustering within matched pairs.

RESULTS

A total of 11,477 patients with hip fracture and 22,954 matched controls were included. The mean duration of follow-up was 4.59 years, generating 158,139 person-years. During follow-up, a total of 170 suicides were identified. Comparisons at up to 180 days and 365 days showed that patients with hip fracture were at higher risk for suicide than matched controls (p = 0.009 and 0.004, respectively; stratified log-rank test). During the first 180 days of follow-up, 14 suicides were identified in patients with hip fracture during 11,152 person-years (IR, 266.1 per 100,000 person-years; 95% CI, 157.6 to 449.4). Patients with hip fracture were 2.97 times more likely to kill themselves than their matched controls during the same period (HR = 2.97; 95% CI, 1.32 to 6.69).

CONCLUSIONS

Hip fracture in elderly patients increased suicide risk within a year. A new approach to psychiatric evaluation and management is needed in elderly patients with hip fracture.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fatal intentional drowning in Australia: A systematic literature review of rates and risk factors

INTRODUCTION

Unintentional drowning deaths are only part of the drowning profile, with little attention being paid to intentional drowning in Australia. Strategies for the prevention of intentional drowning deaths are likely to be different from unintentional. Quality documentation, analysis and dissemination of intentional deaths data is crucial for developing appropriate strategies for prevention.

OBJECTIVE

To conduct a systematic literature review to investigate the mortality rates and risk factors of intentional drowning deaths in Australia.

METHODS

A systematic search guided by PRISMA was performed using Ovid MEDLINE, CINAHL, PsycINFO (ProQuest), Scopus, Google Scholar, and BioMed Central databases to locate relevant original research articles published between 2007 and 2018.

RESULTS

Ten papers reporting the mortality rates and risk factors of intentional drowning deaths in Australia published between 2007 and 2018, with study periods of the included articles spanning from 1907 to 2012, were reviewed. Most studies investigated suicidal drowning deaths in Australia, none reported homicidal drowning deaths. The downward trend of fatal suicide drowning was identified in Australia. The annual rate of intentional drowning between 1994 and 2012 can be inferred from eight studies, ranging from 0.06 to 0.21 for nation-wide mortality rates. The highest annual state-wide mortality rate was identified in the state of Queensland, ranging from 0.02 to 0.11 per 100,000 individuals. Of four studies examining the risk factors of fatal intentional drowning in Australia, being of older age groups, being female, and the presence of substance use were identified as important factors for suicidal drowning deaths. The national-scale proportion of suicide drowning in Australia, ranging from 2% to 3% of all intentional self-harm deaths, was also identified.

CONCLUSION

Limited publications reporting the mortality rates and risk factors of intentional drowning deaths in Australia were identified. Being of older age groups and being female were recognised as factors for suicide drowning deaths, and psychoactive substances were widely identified amongst cases. Future research on improving death reporting systems and the legal framework for medico-legal death investigation, along with the investigation of the risk factors of intentional drowning, are required to inform the planning, implementation, and evaluation of prevention interventions for intentional drowning deaths in Australia.

Risk of Suicide and Self-harm Is Increased After Bariatric Surgery-a Systematic Review and Meta-analysis

BACKGROUND

Bariatric surgery is endorsed by multiple societies as the most effective treatment for obesity. Psychosocial functioning has also been noted to improve for most patients after bariatric surgery. However, some studies have shown an increase in post-operative suicide risk. The aim of this study was to review the published literature and evaluate the association of bariatric surgery with suicide events and suicide/self-harm attempts in patients who have undergone weight loss surgery.

METHODS

MEDLINE and Embase were searched from inception through January 2018 for retrospective or prospective studies reporting mortality outcomes and self-harm or suicide rates after bariatric procedures. The primary outcome was the pooled event rate with 95% confidence interval (95% CI) for suicide. Secondary outcomes were suicide/self-harm attempts after bariatric surgery compared to same population prior to surgery and to matched control subjects, with the respective calculated odds ratios (OR) and 95% CI.

RESULTS

From 227 citations, 32 studies with 148,643 subjects were eligible for inclusion. The patients were predominantly females (76.9%). Roux-en-Y gastric bypass (RYGB) was the most commonly performed procedure (58.9%). The post-bariatric suicide event rate was 2.7/1000 patients (95% CI 0.0019-0.0038), while the suicide/self-harm attempt event rate was 17/1000 patients (95% CI 0.01-0.03). The self-harm/suicide attempt risk was higher after bariatric surgery within the same population with OR of 1.9 (95% CI 1.23-2.95), and compared to matched control subjects, OR 3.8 (95% CI, 2.19-6.59).

CONCLUSIONS

Post-bariatric surgery patients had higher self-harm/suicide attempt risk compared to age-, sex-, and BMI-matched controls. Various pre- and post-surgical psychosocial, pharmacokinetic, physiologic, and medical factors may be involved.

Age, period, cohort trends of suicide in Japan and Korea (1986-2015): A tale of two countries

Japan and South Korea have among the highest suicide rates in the world. However, the age, gender, and time trends in each country differ substantially. Age-Period-Cohort (APC) analysis of suicide rates was conducted to better understand these differences. Using age- and gender-specific data on suicide between 1986 and 2015 in Japan and Korea, we implemented APC analysis to decompose the country-specific trends into age, calendar period, and birth cohort effects. APC analysis revealed three trends: (1) there was a sharp increase in suicide around retirement age in Korea but not in Japan (age effect); (2) there was a dramatic increase in suicide during the three decades of observation in Korea (period effect) whereas rates were more stable in Japan; and (3) the post-War generation in Japan (including baby boomer) had lower rates of suicide compared to generations born before 1916 or after 1961 (birth cohort effect), whereas suicide rate has increased linearly in each generation in Korea. Although Japan & Korea share high suicide rates, our APC analysis suggests divergent causes underlying these trends. Japanese suicide rates plateaued among the cohorts who experienced the post-War rapid economic growth (women born in 1951-1956 and men born in 1916-1961) (birth cohort effect) due to a strong social safety net for this cohort, while suicide rates in Korea continue to rise with each generation and is particularly elevated in post-retirement age. Japan and Korea need to pay more attention to suicide prevention in more recent birth cohorts.

Trends in pesticide suicide in South Korea, 1983-2014

AIMS

Self-poisoning using pesticides is among the major methods of suicide worldwide, and accounts for one-fifth of suicides in 2006-2010 in South Korea. We investigated long-term trends in pesticide suicide rates in South Korea and factors related to these trends.

METHODS

We calculated age-standardised rates of pesticide suicide in South Korea (1983-2014) using registered death data. We used graphical approach and joinpoint regression analysis to examine secular trends in pesticide suicide by sex, age and area, and a time-series analysis to investigate association of pesticide suicide rate with socioeconomic and agriculture-related factors. Age, period and cohort effects were examined using the intrinsic estimator method.

RESULTS

Age-standardised rate of pesticide suicide fluctuated between 1983 and 2000 before it markedly increased in 2000-2003 (annual percent change 29.7%), followed by a gradual fall (annual percent change -6.3%) in 2003-2011. Following the paraquat ban (2011-2012), there was a marked reduction (annual percent change -28.2%) in 2011-2014. Trend in pesticide suicide was associated with divorce rate but not with other factors studied. Declines in pesticide suicide in 2003-2011 were most noticeable in younger groups and metropolises; by contrast, elderly adults aged 70+ living in rural areas showed an upward trend until after the 2011-2012 paraquat ban, when it turned downward. In the age-period-cohort modelling, having been born between 1938 and 1947 was associated with higher pesticide suicide rates.

CONCLUSIONS

Pesticide suicide trend changed substantially in South Korea over the last three decades. Effective prevention should include close monitoring of trends and strong regulations of toxic pesticides.

Pattern of intentional drowning mortality: a total population retrospective cohort study in Australia, 2006-2014

BACKGROUND

While a downward trend in unintentional drowning deaths in Australia has been observed, little is known about intentional drowning mortality. Limited information on intentional drowning death impedes the planning, implementation, and evaluation of prevention strategies. This study aims to describe rates of intentional fatal drowning in Australia and compare these to other categories of drowning.

METHODS

Data were sourced from the Australian Bureau of Statistics (ABS) over a 9-year period (2006-2014). Rates and trends of intentional drowning were compared with unintentional, water-transport related and undetermined intent drowning. Rates of intentional drowning deaths across gender, age groups, states/territories, remoteness of residence and First Peoples of Australia were calculated. Relative risk (RR) (95% confidence interval [CI]) was calculated, and chi-square tests of independence were performed (p < 0.05).

RESULTS

The crude mortality rate for intentional drowning deaths in Australia over the study period was 0.23/100000, lower than unintentional drowning (0.89/100000). Males were 1.6 (CI: 1.4-2.0) times more likely than females to intentionally drown, however females made up a significantly larger proportion of intentional drowning deaths (38.2%) compared to unintentional deaths (22.4%) (χ2 = 47.3; df = 1; p < 0.05). A significant linear association between age group and intentional drowning was observed (χ2 = 131.3; p < 0.05), with individuals aged 75 years and over 32.6 times more likely to intentionally drown. Non-Indigenous peoples were 4.1 times more likely to intentionally drown in comparison to First Peoples of Australia. Residents of Inner Regional, Outer Regional, and Major Cities were 4.2 times (CI: 0.6-30.0), 4.1 times (CI: 0.6-29.9), and 4.0 times (CI: 0.6-28.6) more likely to intentionally drown, respectively, compared with residents of Very Remote areas.

CONCLUSIONS

This study adds to the limited evidence currently available about intentional drowning rates and trends in Australia. Being male, of older age groups, non-Indigenous, residing in Inner and Outer Regional areas, and Major Cities were risk factors for intentional drowning deaths. Improving data collection systems and furthering understanding of the risk factors of intentional drowning, as well as the development, implementation, and evaluation of prevention programmes, are required to reduce the risk of intentional drowning death in Australia.

Exploring Mortality Rates for Major Causes of Death in Korea

Background:

The trends and patterns of the mortality rates for causes of death are meaningful information. They can provide a basis for national demographic and health care policies by identifying the number, causes, and geographical distribution of deaths.

Objective:

To explore and analyze the characteristics of the mortality rates for major causes of death in Korea.

Methods:

Some common data analysis methods were used to describe the data. We also used some visualization techniques such as heat maps and line plots to present mortality rates by gender, age, and year.

Results:

Our analysis shows the crude mortality rates have continually decreased over the last 25 years from 1983, though they have increased slightly since 2006. In addition, the top eight causes of death accounted for 80% of all Korean deaths in 2015. During the period 2005-2015, the leading cause of death was cancer in male and circulatory diseases in female. The trend for respiratory diseases shows a steep upward trend in males, while a similar trend can be observed for respiratory and nervous system diseases in females.

Conclusion:

The deaths for circulatory, respiratory, nervous system, digestive, and infectious diseases are the highest in the age 80 to 84, while cancer is the leading cause of death for ages 75 to 79. In addition, the mortality rates for circulatory, nervous, and respiratory diseases increase rapidly after the age of 80. Therefore, policies on health and welfare for the elderly are getting more and more important.

The influence of undetermined deaths on suicides in Shanghai, China

PURPOSE

In global forensic practice, some suicides were misclassified as undetermined deaths, leading to suicide underreporting. In this study, we aimed to explore the influence of undetermined deaths on suicides in Shanghai, China.

METHODS

The police records on suicide verdicts and undetermined deaths in Pudong, Shanghai, from 2004 to 2016 were used. In this study, undetermined deaths have been classified into three levels of suicide possibilities namely, probable, possible, and highly unlikely. Probable suicides were presumed as misclassified suicides. Poisson regression was used to calculate the rate ratio ("RR") of probable suicides compared to suicide verdicts. Poisson regression was also used to calculate the annual percentage change ("APC") of the original suicide rates (crude suicide rates based on the suicide verdicts) and adjusted suicide rates (crude suicide rates based on the suicide verdicts and probable suicides).

RESULTS

Among the 1,318 underdetermine deaths, 560 (42.5%) were classified as probable suicides. The overall RR was 0.23 (95% CI 0.21-0.26): 0.15 (0.13-0.17) for the locals' RR and 0.22 (0.19-0.26) for the migrants' RR. The APCs of the original and adjusted suicide rates were - 2.0 (- 3.1 to - 0.9) and - 2.9 (- 3.8 to - 2.0), respectively, for the overall population.

CONCLUSIONS

The number of suicides could be 23% higher than the reported cases. Suicides were more likely to be underreported in migrants than in the locals. Thus, it is important to improve suicide monitoring and the surveillance systems in China.

The Burden of Acute Pesticide Poisoning and Pesticide Regulation in Korea

BACKGROUND

This study aimed to estimate the burden of acute pesticide poisoning and to determine its trend with recently implemented pesticide regulations.

METHODS

Disability-adjusted life-years (DALYs) were calculated as the sum of years of life lost (YLLs) and years lived with disability (YLDs) due to acute pesticide poisoning using the methods of the Global Burden of Disease Study 2013. The values of YLLs, YLDs, and DALYs were stratified by sex, age groups, intentionality of poisoning, and causative agents.

RESULTS

From 2006 to 2014, DALYs decreased by 69% (from 69,550 to 21,742). The decreasing tendency of DALYs was especially marked from 2011. The total burden of acute pesticide poisoning was mainly caused by YLLs and intentional pesticide poisoning. The highest DALYs due to acute pesticide poisoning occurred in those in their 40s and 50s; however, the decreased rates of DALYs were higher in those aged 10-49 years than in those aged more than 50 years. Herbicides including paraquat contributed to the largest proportion of total DALYs.

CONCLUSION

As this is the first study to quantify the burden of acute pesticide poisoning using DALYs, our results provide comprehensive evidence of the importance of using strict regulations to prevent public health hazards due to acute pesticide poisoning.

Age, Period, and Cohort Effects on Suicide Mortality in South Korea, 1992⁻2015

Although the effects of age, period, and cohort (APC) on suicide are important, previous work in this area may have been invalid because of an identification problem. We analyzed these effects under three different scenarios to identify vulnerable groups and thus overcame the identification problem. We extracted the annual numbers of suicides from the National Death Register of Korea (1992⁻2015) and estimated the APC effects. The annual average suicide rates in 1992⁻2015 were 31.5 and 14.7 per 100,000 males and females, respectively. The APC effects on suicide were similar in both sexes. The age effect was clearly higher in older subjects, in contrast to the minimal changes apparent during earlier adulthood. The birth cohort effect showed an inverted U shape; a higher cohort effect was evident in females born in the early 1980s when period drift was larger than 3.7%/year. Period effect increased sharply during the early 1990s and 2000s. We found that elderly and young females may be at a particularly high risk of suicide in Korea.

Air Pollution and Suicide in 10 Cities in Northeast Asia: A Time-Stratified Case-Crossover Analysis

BACKGROUND

There is growing evidence suggesting an association between air pollution and suicide. However, previous findings varied depending on the type of air pollutant and study location.

OBJECTIVES

We examined the association between air pollutants and suicide in 10 large cities in South Korea, Japan, and Taiwan.

METHODS

We used a two-stage meta-analysis. First, we conducted a time-stratified case-crossover analysis to estimate the short-term association between nitrogen dioxide (NO₂), sulfur dioxide (SO₂), and particulate matter [aerodynamic diameter ≤10μm (PM₁₀), aerodynamic diameter ≤2.5μm (PM_2.5), and PM_10–2.5] and suicide, adjusted for weather factors, day-of-week, long-term time trends, and season. Then, we conducted a meta-analysis to combine the city-specific effect estimates for NO₂, SO₂, and PM₁₀ across 10 cities and for PM_2.5 and PM_10–2.5 across 3 cities. We first fitted single-pollutant models, followed by two-pollutant models to examine the robustness of the associations.

RESULTS

Higher risk of suicide was associated with higher levels of NO₂, SO₂, PM₁₀, and PM_10–2.5 over multiple days. The combined relative risks (RRs) were 1.019 for NO₂ (95% confidence interval [CI]: 0.999, 1.039), 1.020 for SO₂ (95% CI: 1.005, 1.036), 1.016 for PM₁₀ (95% CI: 1.004, 1.029), and 1.019 for PM_10–2.5 (95% CI: 1.005, 1.033) per interquartile range (IQR) increase in the 0-1 d average level of each pollutant. We found no evidence of an association for PM_2.5. Some of the associations, particularly for SO₂ and NO₂, were attenuated after adjusting for a second pollutant.

CONCLUSIONS

Our findings suggest that higher levels of air pollution may be associated with suicide, and further research is merited to understand the underlying mechanisms. https://doi.org/10.1289/EHP2223.

Discerning suicide in drug intoxication deaths: Paucity and primacy of suicide notes and psychiatric history

OBJECTIVE

A paucity of corroborative psychological and psychiatric evidence may be inhibiting detection of drug intoxication suicides in the United States. We evaluated the relative importance of suicide notes and psychiatric history in the classification of suicide by drug intoxication versus firearm (gunshot wound) plus hanging/suffocation-the other two major, but overtly violent methods.

METHODS

This observational multilevel (individual/county), multivariable study employed a generalized linear mixed model (GLMM) to analyze pooled suicides and undetermined intent deaths, as possible suicides, among the population aged 15 years and older in the 17 states participating in the National Violent Death Reporting System throughout 2011-2013. The outcome measure was relative odds of suicide versus undetermined classification, adjusted for demographics, precipitating circumstances, and investigation characteristics.

RESULTS

A suicide note, prior suicide attempt, or affective disorder was documented in less than one-third of suicides and one-quarter of undetermined deaths. The prevalence gaps were larger among drug intoxication cases than gunshot/hanging cases. The latter were more likely than intoxication cases to be classified as suicide versus undetermined manner of death (adjusted odds ratio [OR], 41.14; 95% CI, 34.43-49.15), as were cases documenting a suicide note (OR, 33.90; 95% CI, 26.11-44.05), prior suicide attempt (OR, 2.42; 95% CI, 2.11-2.77), or depression (OR, 1.61; 95% CI, 1.38 to 1.88), or bipolar disorder (OR, 1.41; 95% CI, 1.10-1.81). Stratification by mechanism/cause intensified the association between a note and suicide classification for intoxication cases (OR, 45.43; 95% CI, 31.06-66.58). Prior suicide attempt (OR, 2.64; 95% CI, 2.19-3.18) and depression (OR, 1.48; 95% CI, 1.17-1.87) were associated with suicide classification in intoxication but not gunshot/hanging cases.

CONCLUSIONS

Without psychological/psychiatric evidence contributing to manner of death classification, suicide by drug intoxication in the US is likely profoundly under-reported. Findings harbor adverse implications for surveillance, etiologic understanding, and prevention of suicides and drug deaths.

A longitudinal comparison of age patterns and rates of suicide in Hong Kong, Taiwan and Japan and two Western countries

Suicide data relating to 1979-2014 were obtained from three East Asian jurisdictions (Taiwan, Hong Kong, Japan) and two 'Western' countries (Australia, New Zealand). Rates and age patterns of suicide have changed markedly since 1979. Graphs of these patterns largely remained either upward-sloping, bimodal or flat (uniform) over the 36 years, male commonly differing from female, and East Asian patterns more like each other than those of the Western countries. Japan's male middle-aged suicide rate reached a peak in 1999-2003, which, like increased rates among working age males in Hong Kong and Taiwan, has been attributed largely to consequences of Asian financial crises. Male to female ratios of suicide rates have remained higher in the Western countries, but late life suicide rates have decreased to varying extents in all five jurisdictions. Identifying reasons for differences between jurisdictions in their suicide rates and patterns at particular times, and over time, is likely to point to factors (period, cohort, psychosocial or cultural) that protect against or foster suicidal ideation. This avenue of research may assist in identifying ways of preventing suicide.

High stress, lack of sleep, low school performance, and suicide attempts are associated with high energy drink intake in adolescents

Objective

Although an association between energy drinks and suicide has been suggested, few prior studies have considered the role of emotional factors including stress, sleep, and school performance in adolescents. This study aimed to evaluate the association of energy drinks with suicide, independent of possible confounders including stress, sleep, and school performance.

Methods

In total, 121,106 adolescents with 13–18 years olds from the 2014 and 2015 Korea Youth Risk Behavior Web-based Survey were surveyed for age, sex, region of residence, economic level, paternal and maternal education level, sleep time, stress level, school performance, frequency of energy drink intake, and suicide attempts. Subjective stress levels were classified into severe, moderate, mild, a little, and no stress. Sleep time was divided into 6 groups: < 6 h; 6 ≤ h < 7; 7 ≤ h < 8; 8 ≤ h < 9; and ≥ 9 h. School performance was classified into 5 levels: A (highest), B (middle, high), C (middle), D (middle, low), and E (lowest). Frequency of energy drink consumption was divided into 3 groups: ≥ 3, 1–2, and 0 times a week. The associations of sleep time, stress level, and school performance with suicide attempts and the frequency of energy drink intake were analyzed using multiple and ordinal logistic regression analysis, respectively, with complex sampling. The relationship between frequency of energy drink intake and suicide attempts was analyzed using multiple logistic regression analysis with complex sampling.

Results

Higher stress levels, lack of sleep, and low school performance were significantly associated with suicide attempts (each P < 0.001). These variables of high stress level, abnormal sleep time, and low school performance were also proportionally related with higher energy drink intake (P < 0.001). Frequent energy drink intake was significantly associated with suicide attempts in multiple logistic regression analyses (AOR for frequency of energy intake ≥ 3 times a week = 3.03, 95% CI = 2.64–3.49, P < 0.001).

Conclusion

Severe stress, inadequate sleep, and low school performance were related with more energy drink intake and suicide attempts in Korean adolescents. Frequent energy drink intake was positively related with suicide attempts, even after adjusting for stress, sleep time, and school performance.

Mortality from Unspecified Unintentional Injury among Individuals Aged 65 Years and Older by U.S. State, 1999-2013

Introduction: Recent changes in unspecified unintentional injury mortality for the elderly by U.S. state remain unreported. This study aims to examine U.S. state variations in mortality from unspecified unintentional injury among Americans aged 65+, 1999–2013; Methods: Using mortality rates from the U.S. CDC’s Web-based Injury Statistics Query and Reporting System (WISQARS™), we examined unspecified unintentional injury mortality for older adults aged 65+ from 1999 to 2013 by state. Specifically, the proportion of unintentional injury deaths with unspecified external cause in the data was considered. Linear regression examined the statistical significance of changes in proportion of unspecified unintentional injury from 1999 to 2013; Results: Of the 36 U.S. states with stable mortality rates, over 8-fold differences were observed for both the mortality rates and the proportions of unspecified unintentional injury for Americans aged 65+ during 1999–2013. Twenty-nine of the 36 states showed reductions in the proportion of unspecified unintentional injury cause, with Oklahoma (−89%), Massachusetts (−86%) and Oregon (−81%) displaying the largest changes. As unspecified unintentional injury mortality decreased, mortality from falls in 28 states and poisoning in 3 states increased significantly. Mortality from suffocation in 15 states, motor vehicle traffic crashes in 12 states, and fire/burn in 8 states also decreased; Conclusions: The proportion of unintentional injuries among older adults with unspecified cause decreased significantly for many states in the United States from 1999 to 2013. The reduced proportion of unspecified injury has implications for research and practice. It should be considered in state-level trend analysis during 1999–2013. It also suggests comparisons between states for specific injury mortality should be conducted with caution, as large differences in unspecified injury mortality across states and over time could create bias for specified injury mortality comparisons.

Brief gatekeeper training for suicide prevention in an ethnic minority population: a controlled intervention

BACKGROUND

Suicide is a critical public health problem around the globe. Asian populations are characterized by elevated suicide rates and a tendency to seek social support from family and friends over mental health professionals. Gatekeeper training programs have been developed to train frontline individuals in behaviors that assist at-risk individuals in obtaining mental health treatment. The purpose of this study is to assess the efficacy of a brief, multi-component gatekeeper intervention in promoting suicide prevention in a high-risk Asian community in the United States.

METHODS

We adapted an evidence-based gatekeeper training into a two-hour, multi-modal and interactive event for Japanese-Americans and related stakeholders. Then we evaluated the intervention compared to an attention control using mixed methods.

RESULTS

A sample of 106 community members participated in the study. Intervention participants (n = 85) showed significant increases in all three types of intended gatekeeper behavior, all four measures of self-efficacy, and both measures of social norms relevant to suicide prevention, while the control group (n = 48) showed no significant improvements. Additional results showed significantly higher satisfaction and no adverse experiences associated with the gatekeeper training. The separate collection of qualitative data, and integration with the quantitative survey constructs confirmed and expanded understanding about the benefits of the intervention.

CONCLUSIONS

A brief, multi-modal gatekeeper training is efficacious in promoting positive gatekeeper behaviors and self-efficacy for suicide prevention in an at-risk ethnic minority population of Japanese Americans.

Changes in South Korean urbanicity and suicide rates, 1992 to 2012

OBJECTIVES

Studies have highlighted the association between the degree of urbanicity and spatial disparities in suicide, but few have evaluated its changes across time. We explored the geospatial trends of suicide in South Korea from 1992 to 2012, and their relationship to the nation's evolving urbanicity.

SETTING

South Korea.

PRIMARY OUTCOME MEASURES

Age-sex-specific suicide rate.

RESULTS

Suicide rates increased in all regions of South Korea during the study period. Controlling the effects of age and sex, there was an overall inverse relationship between the degree of urbanicity and regional suicide rates. These associations were, however, attenuated across the periods, as there were smaller increases in suicide rates in mid-sized urban regions as compared to larger cities and to rural areas. Increases over time in the suicide rates among youth and working-age adults were greater in large urban centres and in rural regions. For elders, the increase was far greater in rural regions.

CONCLUSIONS

The association of urbanicity and the geospatial pattern of suicide in South Korea was a dynamic process and varied by age groups across the course of two decades. Internal migration and related social processes most likely contributed to these changes.