Characteristics of young rural Chinese suicides: a psychological autopsy study

1. Characteristics of young rural Chinese suicides: a psychological autopsy study J. Zhang1*, W. Wieczorek1, Y. Conwellet al

2. Background • Method • Results • Conclusions

3. 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)

4. Background • 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 )

5. 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

6. 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

7. Method Controls • 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

8. 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)

9. 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.

10. Method Interviewing 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

11. 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.

12. Method Measures • 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

13. 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),

14. Method Integrating the information from different sources • Two proxy interviews • Three principles(Kraemer et al. 2003)

15. Results Suicides: 392(178 females and 214 males) Controls:416(214 females and 202 males)

16. Results: table 1:

17. 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)

18. Results: table 2:

19. 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

20. Results • Protecting factor:Education , family annual income,Being married(for man) • pesticides or farming chemicals stored at home, The traditional and modern value scores

21. 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

22. 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

23. Conclusions • Cultural value strain: modern values (gender equalitarianism) and traditional values (Confucian paternalism) clash • Suicide prevention programs in China should incorporate culture-specific considerations

24. Discussion mental disorder marriage and marital experience religion/religiosity impulsivity psychological strain

25. Mental disorder

26. 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

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

28. marriage and marital experience

29. 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

30. 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

31. 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

32. religion/religiosity

33. 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

34. impulsivity

35. 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

36. psychological strain

37. 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

38. 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.

39. 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

40. 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

41. 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

42. Something in question • excluded cases of accidental or natural death in which suicidal intent was questioned may miss some suicidal cases

43. 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

44. 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

45. 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

46. 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

47. 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

48. Thank you !