Characteristics of young rural Chinese suicides: a psychological autopsy study

Developing the Psychological Strain Scales (PSS): Reliability, Validity, and Preliminary Hypothesis Tests

Since its inception, the Strain Theory of Suicide has been tested and supported in a number of empirical studies. This social psychological theory can be employed as a complementary conceptualization to account for suicidal behaviors as well as mental disorders. However, the lack of consistent measurements of the strains limits the application of the theory in scientific research. Our research team has developed such scales for future testing of the Strain Theory of Suicide in a more systematic approach. For the initial items to measure the four strains (value, aspiration, deprivation, and coping), we solicited approximately 40 items for each strain with high face validity by about 30 fellow researchers. A preliminary examination of about 160 items for consistency and validity, with a sample of about 300 college students, yielded 20 consistent items for each of the four strain scales. Then, a second study was conducted at a different university with approximately 500 students to further streamline each of the four strain scales and test the validity of each with corresponding established scales and variables. As a result, 15 items were selected for each of the four Psychological Strain Scales (PSS). In correlation and multiple regression analyses, we found support for the hypotheses regarding the positive associations between psychological strains measured by the PSS and psychopathology including suicidal ideation. Follow up research with the new scales needs to be carried out in order to test the effects of psychological strains on suicide and mental disorders for various populations.

Effects of value strains on psychopathology of Chinese rural youths

The Strain Theory of Suicide postulates that psychological strains usually precede mental disorders including suicidal behavior. This paper focuses on the effect of conflicting social value strains on the individual's psychopathology. We analyzed the data of 2031 respondents who were proxy informants for suicides and community living controls in a large scale psychological autopsy study in rural China, with the CES-D depression measure for the psychopathology. Individuals having experienced value conflicts between Confucian gender role and gender equalitarianism in modern society scored on depression significantly higher than the individuals who do not experience the value conflict, and it is also true when several other relevant variables were held constant in the multiple regression model. This study supports the hypotheses that people who confront value conflicts are likely to experience psychopathological strain, and the higher the level of strain, the stronger the depression.

Pesticide poisoning in Zhejiang, China: a retrospective analysis of adult cases registration by occupational disease surveillance and reporting systems from 2006 to 2010

OBJECTIVE

Despite the rapid industrialisation and urbanisation over the past 30 years, agriculture is one of the largest economic sectors in China and the unregulated use of pesticides result in extensive pesticide poisoning. The objective of this study was to analyse pesticide poisoning cases registration received by Zhejiang Provincial Center for Disease Control and Prevention, China.

DESIGN

Register-based study.

SETTING

Cases registered regarding pesticide poisoning. Data were obtained from the Occupational Disease Surveillance and Reporting Systems in Zhejiang province from 2006 to 2010, which contains anonymous records representing general population of Zhejiang province, China.

PARTICIPANTS

All cases registered as pesticide poisoning were identified.

PRIMARY OUTCOME

Monthly and age-group pesticide poisoning death rates were calculated.

RESULTS

A total of 20 097 pesticide poisoning cases with 1413 deaths were recorded during the study period. There were 10 513 male pesticide poisoning cases with 782 deaths, and 9584 females with 631 deaths. Pesticide poisoning occurred mostly in non-occupational exposure (79.86%), in which the majority (85.77%) of the cases was of intentional pesticide poisoning. The occupational exposure was most common in men during the farming season. The death rate increased stepwise with age, and the pesticide suicide rate was higher in the older age group.

CONCLUSIONS

Pesticide poisoning remains a major health problem in China, and further recommendations to reduce the pesticide poisoning are required.

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.

Psychological strains found in the suicides of 72 celebrities

The interpretation of suicide involves theories from many disciplines, and the strain theory of suicide is a social-psychological model that attempts to account for this complicated behavior. We have earlier explored the presence of psychological strains in a number of diverse samples of suicides and in the present study, we identified the strains experienced throughout the lives as documented in the biographies of 72 celebrities. The biographies were systematically identified through a number of requirements and composed by one of the authors of this study years before the strain theory of suicide was proposed. A graduate student coder, who was unaware of the strain theory of suicide, was hired to carry out a content analysis of the biography essays and categorize the life events and the responses of the suicide in terms of the four types of strains. Of the 72 suicides, one had no strains, one had all the four strains, four had only one, 30 had two, and 36 had three strains. The most common strain was aspiration strain (97%), followed by deprivation strain (89%), value strain (54%) and coping deficiency strain (4%). It is also noted that religious celebrities were more likely to experience value strain, while those celebrities who had experienced a downhill path in their careers were more likely to experience deprivation and coping strains. This analysis of the 72 celebrity suicides supported the strain theory of suicide.

Psychometric characteristics of Chinese version of Barratt Impulsiveness Scale-11 in suicides and living controls of rural China

The Barratt Impulsiveness Scale-11 (BIS-11) is an important tool for measuring impulsivity in suicide research. This study aimed to assess psychometric characteristics of Chinese version of BIS-11 in suicides and controls of rural China. Data of 200 pairs of suicide cases and living controls were collected by psychological autopsy method. The Cronbach's alpha coefficients of BIS-11 were 0.936 for suicides, and 0.892 for living controls. Convergent validity analysis demonstrated a significantly positive correlation between the scores of BIS-11 with the scores of Beck Hopelessness Scale and Trait Anxiety Inventory. Confirmatory factor analyses indicated that the BIS-11 structure was basically suitable in rural China. With its high reliability, few items in BIS-11 may need a modification in order to further improve the construct validity of this instrument for suicide research in rural China.

A psychological autopsy study of suicide among Inuit in Nunavut: methodological and ethical considerations, feasibility and acceptability

INTRODUCTION

The increasing global prevalence of suicide has made it a major public health concern. Research designed to retrospectively study suicide cases is now being conducted in populations around the world. This field of research is especially crucial in Aboriginal populations, as they often have higher suicide rates than the rest of the country.

OBJECTIVE

This article presents the methodological aspects of the first psychological autopsy study on suicide among Inuit in Nunavut. Qaujivallianiq Inuusirijauvalauqtunik (Learning from lives that have been lived) is a large case-control study, including all 120 cases of suicide by Inuit that occurred in Nunavut between 1 January 2003 and 31 December 2006. The article describes the research design, ethical considerations and strategies used to adapt the psychological autopsy method to Nunavut Inuit. Specifically, we present local social and cultural issues; data collection procedures; and the acceptability, reliability and validity of the method.

METHOD

A retrospective case-control study using the psychological autopsy approach was carried out in 22 communities in Nunavut. A total of 498 individuals were directly interviewed, and medical and correctional charts were also reviewed.

RESULTS

The psychological autopsy method was well received by participants as they appreciated the opportunity to discuss the loss of a family member or friend by suicide. During interviews, informants readily identified symptoms of psychiatric disorders, although culture-specific rather than clinical explanations were sometimes provided. Results suggest that the psychological autopsy method can be effectively used in Inuit populations.

Gender-specific differences among patients treated for suicide attempts in the emergency departments of four general hospitals in Shenyang, China

OBJECTIVE

We aimed to identify gender-specific characteristics of suicide attempters admitted to general hospital emergency departments in urban China.

METHODS

The Structured Clinical Interview for the DSM-IV, the Suicide Ideation Scale, the Hamilton Depression Rating Scale and a quality of life measure were administered to 239 suicide attempters who were treated consecutively in the emergency departments of four general hospitals randomly selected in Shenyang, China.

RESULTS

Among the 239 enrolled subjects, 53 (22.2%) were men, and 186 (77.8%) were women. Compared to women, men were more likely to be a minority, live with their families and/or suffer from substance-related disorders. Men were less likely to be living alone or cohabitating. Women were more likely to express suicide ideation compared with men. Thirty-seven (69.8%) men and 129 (69.4%) women had mental illness. The prevalence of psychiatric diagnosis was not significantly different between men and women (χ(2)=.004, df=1, P=.95).

CONCLUSION

The rate of attempted suicide is higher among women than among men in the emergency departments of urban China. Except for race, living situation and suicide ideation, there are few gender differences regarding socio-demographic and clinical characteristics in the current study that are not consistent with reports from other countries. However, similar to other studies, men are more likely to suffer from substance-related disorders than are women. The unique, gender-specific characteristics pertaining to suicide attempters in urban China emphasizes the need for gender-specific interventions in future clinical treatment.

Reliability and validity of the Center for Epidemiological Studies Depression Scale in 2 special adult samples from rural China

Few studies on the validation of the Center for Epidemiological Studies Depression Scale (CES-D) in Chinese have been conducted in the samples from rural area, whereas the mental health problems among rural Chinese deserve more attention. For instance, the suicide rate in rural China is about 3 times that of the urban rate. This study aimed at assessing reliability and validity of the CES-D in 2 special adult samples in rural China, with data obtained by face-to-face interviews. One sample consisted of the proxy informants for subjects who committed suicide, and the other was of the proxy informants for living controls. For each person who committed suicide and each control, a family member and close friend served as informants. This study focused on informants themselves (not the persons who committed suicide or the living control himself/herself). Suicide informants (n = 781) who had experienced the suicide of a relative or close friend in the past 6 months were compared with the control informants (n = 832) who had no such experience. Internal reliability was satisfactory (Cronbach coefficients were .949 for suicide informants and .880 for control informants). Good concurrent validity and criterion validity were found by analyzing the relations to negative life events and the Scale for Suicide Ideation. Confirmatory factor analyses indicated that 3-factor structure (positive affect, interpersonal problems, depressive mood and somatic symptoms combined) had good fit in rural Chinese. These findings suggested that the CES-D had good reliability and validity when applied in these 2 adult samples in rural China. Factor structure analyses of the CES-D indicated that "somatization" process of expressing depressive symptoms still existed among rural Chinese.

Patterns of life events preceding the suicide in rural young Chinese: a case control study

BACKGROUND

Previous studies on the Chinese suicide found some life events prior to the suicide different from those in the West, but there is a lack of summary of the Chinese life event patterns to better understand the effects of the social structure on Chinese suicide.

AIM

We tried to identify the life events that precede the Chinese rural youth suicides and compare them with what are found in the West, so as to find the patterns that are particularly true in the Chinese culture contexts.

METHODS

Suicide cases were investigated with a psychological autopsy study in rural China, and local community living controls were also interviewed with the same protocol.

RESULTS

We collapsed 64 negative life events into six categories: (1) Marriage/Love, (2) Family/Home, (3) Work/Business, (4) Health/Hospital, (5) Law/Legal, (6) Friend/Relationship. About 92.3% of the suicides studied had experienced at least one type of negative life events. The three most common negative life events categories in the past one year were Family/Home (60.7%), Health/Hospital (53.8%) and Marriage/Love (51.3%) in the rural young suicide victims.

CONCLUSIONS

Among the negative life events, those related to family relations, love affairs, and marital issues were most likely to precede a suicide of rural suicides in China, and it is especially true of rural young women. Family is an important social institution in rural China for suicide prevention efforts.

Measuring Chinese psychological traits and social support with Western developed instruments in psychological autopsy studies

OBJECTIVE

Suicide is the fifth leading cause of death in China and the leading cause of death among adults aged 15 to 34 years. Thus, it is important to identify psychometrically sound instruments that can be successfully used to assess risk and protective factors for suicide in Chinese populations.

METHOD

Using the psychological autopsy method, we explored the possibility of applying 4 psychological scales (Dickman Impulsivity Instrument, State-Trait Anxiety Inventory Form Y, Beck Hopelessness Scale, Duke Social Support Index) developed and commonly used in the West to Chinese culture. Sixteen counties from three provinces in China were selected as sampling sites in which 392 suicide cases and 416 community living controls aged 15 to 34 years were obtained.

RESULTS

Significant differences were found between the suicide victims and living controls on all four measures and their respective subscales indicating that the instruments are useful tools in identifying suicidal individuals through proxy data in rural China.

CONCLUSIONS

These findings may have important implications for the development and enhancement of more effective suicide prevention strategies in China.

Suicídio de idosos sob a perspectiva de gênero

Este estudo explora a relação entre suicídio e envelhecimento na perspectiva de gênero, analisando as demarcações socialmente impostas de masculinidade e feminilidade na vida de idosos que cometeram suicídio. Trata-se de estudo qualitativo no qual foram consideradas 50 autópsias psicossociais realizadas com familiares de idosos, pertencentes a 10 municípios brasileiros, nas regiões Norte, Sul, Nordeste e Centro-Oeste. Neste artigo foram identificadas situações referentes a vulnerabilidades de gênero na vida de 13 pessoas que se suicidaram: 10 homens e três mulheres, selecionados pelo seu caráter de exemplaridade. Duas categorias principais foram elencadas: a primeira refere-se às feminilidades, incluindo o "destino de gênero" vivido por mulheres idosas que se suicidam quando não podem mais cuidar e trabalhar. A segunda refere-se a crises nas masculinidades hegemônicas, em que homens idosos morrem após mudanças nos papeis de provedores, ocasionadas pela aposentadoria ou doença. Ressalta-se que as normas de gênero, os códigos de honra, as desigualdades de poder e estereótipos afetam tanto as mulheres quanto os homens em relação à vulnerabilidade para comportamentos suicidas.

A study of deliberate self-harm and its repetition among patients presenting to an emergency department

BACKGROUND

Marked differences have been found in the characteristics of people dying by suicide in Western and Asian countries. However, there is less information available on possible differences for deliberate self-harm (DSH).

AIMS

To compare the characteristics of people presenting to hospital in Hong Kong and Oxford (UK) with DSH, and to assess the outcome of those persons in Hong Kong.

METHODS

A sample of DSH patients admitted to the accident and emergency (A&E) department of a regional hospital in Hong Kong was assessed and followed up 6 months later to assess the risk of repetition of DSH, and was then compared with such patients in Oxford.

RESULTS

The majority of patients in Hong Kong were female (male:female ratio of 1:2.4), young (59% were under 35), and had used self-poisoning (78%). Over one-third were single (37%) and one-fourth unemployed (26%). About half (49%) scored in the high or very high categories of the Beck's Suicide Intent Scale, considerably more so than in Oxford; 44.6% of patients defaulted psychiatric outpatient service during the 6-month follow-up period. The repetition rate within the following 6 months was 16.7%. The number of self-reported adverse life problems, history of childhood sexual and physical abuse, and repetitive self-mutilation were shown to be the factors most strongly correlated with the risk of re-attempt. Alcohol problems were much lower than in Oxford.

CONCLUSIONS

The findings show that DSH patients in Hong Kong show some marked differences compared to those in Oxford. Implications for the prevention of repeated DSH in Hong Kong are discussed.

Global functioning and suicide among Chinese rural population aged 15-34 years: a psychological autopsy case-control study

As the relationship between global functioning and young suicide remains unclear in rural China, this study was aimed to explore the relationship between them. Data of 391 rural suicides and 416 controls, all aged 15-34 years in three provinces in China were used for this study. The Global Assessment of Functioning (GAF) scale was adopted to assess global functioning of suicides and controls. The results showed that GAF score was stronger than mental illness in predicting suicide in China. Different correlates of GAF score were found between suicides and controls. Unsurprisingly, GAF score was significantly correlated with mental illness in both suicides and controls. Different characteristics were also found among three types of suicide which were classified using GAF score. Assessing global functioning is useful and GAF scale should be regularly used in suicide prevention practice.

The next generation of psychological autopsy studies. Part I. Interview content

The psychological autopsy (PA) is a systematic method to understand the psychological and contextual circumstances preceding suicide. The method requires interviews with one or more proxy respondents (i.e., informants) of decedents. The methodological challenges that need to be addressed when determining the content of these research interviews for PA studies are described and recommendations are made for meeting these challenges in future PA investigations. Ways to improve the data collected about mental disorders and life events--domains that are assessed in almost all PA studies--are discussed at length. Other understudied content areas considered include the role of personality traits, medical illness and functional limitations, availability of lethal agents, medications, and select distal variables including child maltreatment and family history of mental disorders and suicide. The benefits and challenges to using common protocols across studies are also discussed.

Stress, coping and suicide ideation in Chinese college students

The study was to examine 1) whether stress and coping styles could significantly predict the probability of suicide ideation; 2) and whether coping styles were mediators or moderators on the association between life stress and suicide ideation. The survey was conducted in a sample of 671 Chinese college students. Approximately twenty percent students reported having suicide ideation. Life stress, active coping styles, and passive coping styles all had independent effect on the probability of suicide ideation. Passive coping styles, especially fantasizing, mediated the relation between life stress and suicide ideation. Moderation hypotheses were not supported. Implications of the findings and future directions were discussed.

Psychometric properties of the Dickman Impulsivity Instrument in suicide victims and living controls of rural China

BACKGROUND

We are not aware of any of impulsivity trait for Chinese rural youths. This study evaluated the psychometric properties of Dickman Impulsivity Instrument in suicide cases and living controls in rural China.

METHODS

The participants, 392 suicide victims and 416 controls were respectively selected, and the psychological autopsy method was used to collect information. The Exploratory Factor Analysis was processed to evaluate the construct validity. The Cronbach's alpha was computed to evaluate the internal consistency, and the Spearman rank correlation coefficients between STAI Trait Anxiety Inventory, Coping Responses Inventory and Dickman Impulsivity Instrument were calculated to evaluate the convergent validity.

RESULTS

Dysfunctional and Functional impulsivity were extracted for both samples. The mean of DI scores in suicide cases was larger than that in controls, but it was reversed for FI. There were no significant differences between DI and FI in suicide cases, but in controls the mean of DI scores was significantly smaller than that of FI. The Cronbach's alpha was around .863 and .779 respectively for DI and FI scales in suicides, and it was around .746 and .680 in controls. The DI and FI were significantly correlated with each other. Both the DI and FI were correlated with Approach and Avoidance Coping Response Inventory, and both of the scales were grossly independent with Trait Anxiety Inventory in two samples.

CONCLUSION

The results indicated that the Dickman Impulsivity Instrument was adequate to measure impulsivity trait for suicide victims and living controls through proxy data in rural China.

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

Reports on Chinese rural youth suicide indicated patterns different from those of the West. Only about 30% to 70% young victims had had diagnoses of psychiatric illnesses (Phillips et al., Lancet 359:835-840, 2002; Xiao et al., Chin J Psychiatry 36:129-131, 2003), and more than 60% of them used pesticides as suicide means (Wang et al., Lancet 372:1765-1773, 2008). To prevent suicides in rural China, it is important to know the choice of means by Chinese young suicide victims with and without mental disorders. Data on suicide cases in China's rural areas gathered from a big psychological autopsy study were studied for demographic characteristics, suicide methods, and the presence of mental disorders. The findings in the suicide victims with and without mental disorders showed significant differences in suicide method selecting. Victims with mental disorders tended to select violent methods compared with those without mental disorders (31.4% vs. 16.2%). Hanging is method more likely chosen by the mentally disordered victims (13.3%) than those without a mental disorder (7.8%). Mental status affects the means choice among the Chinese rural young suicide victims. Among them, the female victims without mental disorders tended to act on impulsivity and used nonviolent means such as pesticide consumption for suicide. This study informs suicide prevention measures in both China and rest of the world.

Psychological strains and youth suicide in rural China

The strain theory of suicide postulates that suicide is usually preceded by psychological strains. A strain can be a consequence of any of four conflicts: differential values, aspiration and reality, relative deprivation, and lack of coping skills for a crisis. This study, with a blend of psychiatric and social predictors of suicide, identified correlates of suicide that are relevant to Chinese culture and tested the strain theory of suicide with Chinese data. We sampled 392 suicides and 416 living controls (both aged 15-34 years) from 16 rural counties in China in 2008 and interviewed two informants for each suicide and each control. We found that marriage and religion/religiosity did not distinguish the suicides from the living controls among Chinese rural young women. Religion/religiosity tended to be stronger for suicides than for controls. Psychological strains in the forms of relative deprivation, unrealized aspiration, and lack of coping skills were significantly associated with suicide, even after accounting for the role of mental illness. The strain theory of suicide forms a challenge to the psychiatric model popular in the West, at least in explaining the Chinese suicide.

Risk factors for rural young suicide in China: a case-control study

BACKGROUND

Suicide is the fifth most important cause of death in China and the leading cause of death among young adults aged 15-34 years. The suicide rate in rural China is three times higher than the urban suicide rate, and the rate in women is higher than in men.

METHODS

Sixteen counties from three provinces were selected as sampling sites in which 392 suicide cases and 416 community living controls were obtained. For each suicide case and control there were two informants who provided the target person's information. A structured questionnaire including demographics, social and familial environments, and personal characteristics was administered to the informants.

RESULTS

Mental disorders and high hopelessness were found to be strongly related to suicide among Chinese rural young adults. Other suicide risk factors among this population were negative life events, never married but dating, suicide history in family, lack of positive coping skills, lack of social support, dysfunctional impulsivity, and not being a Communist Party/League member.

CONCLUSIONS

The prevalence of mental disorders, although the strongest risk factor among rural young adult suicides in this study, was markedly lower than that in Western countries. Some of the risk factors found in the comprehensive analyses are specific to Chinese culture. "Being a Communist Party/League member" as a protective factor for suicide among Chinese rural youths requires further study and appropriate interpretation.

Suicidal intent among young suicides in rural China

To understand psychometric characteristics of Beck Suicide Intent Scale (SIS) and different characteristics of suicides between high and low intent in Chinese culture. Data of 386 suicides and 416 living controls aged 15-34 years were used to analyze psychometric characteristics of SIS with 6 items. SIS with 6 items had high reliability and validity. Different characteristics were found between suicides with high intent and low intent. Hopelessness, depression, impulsivity, and approach coping skill were common factors of suicide with high and low intent. Education years, marriage, social support, and mental disorders were specific factors of suicide with low intent. High intent suicides had different characteristics from low intent suicides. SIS with 6 items is suitable for use in young rural China.

Mental disorders and suicide among young rural Chinese: a case-control psychological autopsy study

OBJECTIVE

The authors examined the prevalence and distribution of mental disorders in rural Chinese 15-34 years of age who committed suicide. They hypothesized that mental illness is a risk factor for suicide in this population and that the prevalence of mental illness is lower in females than in males.

METHOD

In this case-control psychological autopsy study, face-to-face interviews were conducted to collect information from proxy informants for 392 suicide victims and 416 living comparison subjects. Five categories of DSM-IV mental disorders (mood disorders, schizophrenia and other psychotic disorders, substance use disorders, anxiety disorders, and other axis I disorders) at the time of death or interview were assessed using the Chinese version of the Structured Clinical Interview for DSM-IV. Sociodemographic variables, social support, and life events were also assessed.

RESULTS

The prevalence of current mental illness was 48.0% for suicide victims and 3.8% for comparison subjects. Among suicide victims, mental illness was more prevalent in males than in females (55.1% compared with 39.3%). A strong association between mental illness and suicide was observed after adjustment for sociodemographic characteristics. Other risk factors included having a lower education level, not being currently married, having a lower level of social support, and having a history of recent and long-term life events. Additive interactions were observed between mental illness and lower level of social support.

CONCLUSIONS

Although mental illness is a strong risk factor for suicide, it is less prevalent among rural Chinese young people who committed suicide, particularly females, in comparison with other populations in China and in the West.

Cohort-specific risk of suicide for different mental disorders in China

BACKGROUND

The effect of gender, age, and urban versus rural residence on suicide risk among people with different mental disorders is unknown.

AIMS

To estimate cohort-specific risk of suicide among people with different types of mental disorders using data from China's National Psychological Autopsy Study.

METHOD

Logistic regression models estimated adjusted odd ratios (OR) in 895 suicides and 701 injury deaths.

RESULTS

The adjusted risk of suicide for mood disorders was highest (OR = 44.2) followed by that for other mental disorders (OR = 10.7), anxiety disorders (OR = 10.2), psychotic disorders (OR = 7.4), substance use disorders (2.7) and organic mental disorders (OR = 1.2). Risk of suicide among urban residents with any mental disorder was more than double that of rural residents (OR = 15.5 v. 7.6, P = 0.008).

CONCLUSIONS

The suicide risk associated with mental illness varies by type of illness and by demographic cohort. Lower risk of suicide among rural residents with mental disorders highlights the importance of non-mental health approaches to the prevention and management of suicidal behaviour in rural areas of low- and middle-income countries.