Suicide and attempted suicide—China, 1990-2002

Morbidity and Mortality Weekly Report, June 11, 2004 by M.R. Phillips, G. Yang

Suicide is the fifth leading cause of death overall in China and the leading cause of death in persons aged 15-34 years (1). During 1995-1999, approximately 287,000 persons died each year from suicide, a national rate of 23 per 100,000 population (1). In addition, an estimated 2 million suicide attempts occur each year (2). To characterize suicides and attempted suicides in China, analyses were conducted of 1) a psychological autopsy study comparing suicides with other injury deaths and 2) three studies of attempted suicides. This report summarizes the results of these analyses, which indicated that 58% of China's suicides were caused by ingesting pesticide, 91% of suicide victims had never visited a mental health professional, and 45% of suicide attempts were impulsive acts performed after considering suicide for [less than or equal to] 10 minutes. To reduce suicides and suicide attempts, prevention strategies directed at disrupting patterns of suicidal behavior should be implemented in China.

Information about 895 persons who died from suicide (i.e., cases) and 701 who died from other injuries (i.e., controls) was obtained from a national case-control psychological autopsy study (which collected information about the psychological state of the deceased and risk factors for suicide) conducted during 1996-2000 by Beijing Hui Long Guan Hospital and the Chinese Center for Disease Control and Prevention (3). The selected sample initially totaled 1,854 persons; 258 persons were excluded for various reasons (e.g., persons were aged [less than or equal to] 10 years or appropriate family members declined to participate of could not be located), and 29 additional persons were not included in the logistic regression analysis because data were missing on one or more variables. Deaths attributed to suicide and other injuries were investigated at three urban and 20 rural disease surveillance points (DSPs), selected to be geographically representative of the 145 DSPs in the national surveillance system. Data regarding demographics of the decedents, potential risk factors for suicide, and methods of suicide were provided by family members and other associates in two independent interviews. The median time from death to interview was 11 months (range: 8-14 months). Both backward and forward inclusion of variables in unconditional logistic regression equations were used to identify the most stable model of risk factors for suicide. Age, sex, and location of residence were considered known risk factors for suicide in China; all odds ratios were adjusted to account for these variables. Details of these methods have been described previously (3).

Information about attempted suicides was collected from a retrospective study of all reported suicide attempters (approximately 15,000 persons), based on review of emergency department records at 24 hospitals in northern China during 1990-2002. In addition, demographic and risk factor information was collected from two case-control studies of 635 subjects treated for serious suicide attempts (i.e., requiring [greater than or equal to] 6 hours of hospitalization), identified from a total of 1,450 suicide attempters treated in nine general hospitals primarily serving rural populations of northern China during 19982002.

Suicides

In the psychological autopsy study, among the 895 suicide victims, the median age was 42 years (range: 12-94 years); 49% (441) were female; 63% (563) suffered from a mental illness *; 27% (239) had made previous suicide attempts; 47% (414) had relatives, friends, or associates with a history of suicidal behavior; and 9% (77) had visited a mental health professional at any time in their lives. The most common negative life events in the year before death were financial problems, 40% (358); serious physical illness, 38% (341); and marital conflict, 35% (310). A total of 58% (517) of the suicide victims died by ingesting pesticide or rat poison; of these persons, 62% (320 of 517) received unsuccessful medical resuscitation before death, and 70% (344 of 494) used pesticides stored in the home, usually in an unlocked cupboard.

Results of the unconditional logistic regression analysis identified 10 independent risk Factors for suicide (Table). Among the 1,567 persons who died from suicide and other injuries, suicide risk increased with exposure to multiple risk factors. One percent (two of 223) of persons with fewer than two risk factors died from suicide; 20% (73 of 366) with two or three risk factors died from suicide; 72% (379 of 524) with four or five risk factors died from suicide; and 94% (428 of 454) with six or more risk factors died from suicide.

Suicide Attempts

Among 14,771 suicide attempters treated in 24 general hospitals in northern China, females outnumbered males by 2.5 to 1 (10,492 to 4,279), the median age was 29 years (range: 10-97 years), and two thirds (9,676) of all attempters were young adults aged 15-34 years. Approximately 90% (13,433 of 14,771) of the attempts were by self-poisoning; 54% (7,973) of all attempts were by ingestion of medications (usually anti-anxiety agents or sleeping pills), 28% (4,103) by ingestion of pesticides, and 9% (1,357) by ingestion of other toxins (e.g., household cleaners). Among the 10,581 patients treated in hospitals that primarily serve rural or urban populations, ingestion of pesticides was four times more common among persons treated in rural hospitals (43%; 2,533 of 5,954) than among those treated in urban hospitals (10%; 457 of 4,627) (p<0.01), and 66% (1,667 of 2,533) of the pesticide self-poisonings treated in rural hospitals were among women. Often, the suicide attempts were impulsive; among 594 serious suicide attempters treated in nine hospitals in northern China, 45% (270) reported considering suicide for [less than or equal to] 10 minutes before their attempts.