Suicides and medically serious attempters are of the same population in Chinese rural young adults

Near-Fatal Self-Harm Among Canadian Adolescents

OBJECTIVE

To evaluate the clinical features of Canadian adolescents admitted to the intensive care unit (ICU) for medically serious self-harm.

METHODS

2700 Canadian paediatricians were surveyed monthly over two years (January 2017 to December 2018) through the Canadian Paediatric Surveillance Program to ascertain data from eligible cases.

RESULTS

Ninety-three cases (73 female; age 15.2 ± 1.5) met the case definition. Four provinces reported the majority of cases: Quebec (n = 27), Ontario (n = 26), Alberta (n = 21), and British Columbia (n = 8). There were 10 deaths, 9 by hanging. Overdose and hanging were the most frequently reported methods of self-harm (74.2% and 19.4%, respectively). Overdose was more common in females (80.8% females vs. 50% males; χ² = 7.8 (1), p = .005), whereas hanging was more common in males (35% males vs. 15.1% females, χ² = 3.9 (1), p = .04). More females than males had a past psychiatric diagnosis (79% vs. 58%; χ² = 4.1 (1), p = .06), a previous suicide attempt (55.9% vs. 29.4%, χ² = 3.8 (1), p = .05), and prior use of mental health service (69.7% vs. 27.8%, χ² = 10.4 (1), p = .001). Family conflict was the most commonly identified precipitating factor (43%) of self-harm.

CONCLUSIONS

Among Canadian adolescents admitted to the ICU with medically serious self-harm, females demonstrate a higher rate of suicide attempts and prior mental health care engagement, whereas males are more likely to die by suicide. These findings are consistent with data from other adolescent samples, as well as data from working-age and older adults. Therefore, a sex-specific approach to suicide prevention is warranted as part of a national suicide prevention strategy; family conflict may be a specific target for suicide prevention interventions among adolescents.

Suicide and non-suicide mortality and associated risk factors among suicide attempters: A 10-year follow-up of a large cohort in rural China

Previous suicide attempt is a strong risk factor for subsequent suicide and other causes of mortality, but evidence from China is sparse. In this study, follow up face-to-face interviews were conducted with suicide attempters or a key informant, and any subsequent deaths were examined through local cause-of-death censoring databases to ascertain details surrounding the death. Competitive risk models and Cox proportional hazard regression models were used to ascertain significant risk factors of suicide, non-suicide and overall deaths following suicide attempt. Predictive nomograms were also constructed to predict the probability of suicide, non-suicide, and overall deaths. A total of 1103 suicide attempters were successfully interviewed with an average follow-up time of 7.48 (7.38-7.57) years. The cumulative rates of suicide at 1, 2, 3, 5 and 10 years were 0.27%, 0.63%, 0.91%, 1.56%, and 1.83%, respectively. Factors significantly associated with subsequent suicide were advancing age, history of suicide attempt, and mental disorders. Significant risk factors for non-suicide death included males, advancing age, and physical illness. Overall deaths during the follow-up period were associated with males, advancing age, physical illness, and mental disorders. Predictive models showed good ability with satisfactory C-indexes (between 0.77 and 0.86) and excellent calibration performance in predicting the varying causes of subsequent death among suicide attempters in rural China.

Prediction of recurrent suicidal behavior among suicide attempters with Cox regression and machine learning: a 10-year prospective cohort study

BACKGROUND

Research on predictors and risk of recurrence after suicide attempt from China is lacking. This study aims to identify risk factors and develop prediction models for recurrent suicidal behavior among suicide attempters using Cox proportional hazard (CPH) and machine learning methods.

METHODS

The prospective cohort study included 1103 suicide attempters with a maximum follow-up of 10 years from rural China. Baseline characteristics, collected by face-to-face interviews at least 1 month later after index suicide attempt, were used to predict recurrent suicidal behavior. CPH and 3 machine learning algorithms, namely, the least absolute shrinkage and selection operator, random survival forest, and gradient boosting decision tree, were used to construct prediction models. Model performance was accessed by concordance index (C-index) and the time-dependent area under the receiver operating characteristic curve (AUC) value for discrimination, and time-dependent calibration curve along with Brier score for calibration.

RESULTS

The median follow-up time was 7.79 years, and 49 suicide attempters had recurrent suicidal behavior during the study period. Four models achieved comparably good discrimination and calibration performance, with all C-indexes larger than 0.70, AUC values larger than 0.65, and Brier scores smaller than 0.06. Mental disorder emerged as the most important predictor across all four models. Suicide attempters with mental disorders had a 3 times higher risk of recurrence than those without. History of suicide attempt (HR = 2.84, 95% CI: 1.34-6.02), unstable marital status (HR = 2.81, 95% CI: 1.38-5.71), and older age (HR = 1.51, 95% CI: 1.14-2.01) were also identified as independent predictors of recurrent suicidal behavior by CPH model.

CONCLUSIONS

We developed four models to predict recurrent suicidal behavior with comparable good prediction performance. Our findings potentially provided benefits in screening vulnerable individuals on a more precise scale.

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

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

Psychometric properties of the psychological strain scales (PSS) in suicide attempters and community controls of rural China

BACKGROUND

Psychological Strain Scales (PSS) were developed to measure four types of strain comprising value strain, deprivation strain, aspiration strain, and coping strain. This study aimed to evaluate the psychometric properties of the Chinese version of 40-item PSS in suicide attempters and community controls of rural China.

METHODS

Data of this study came from the investigation of 132 suicide attempters and their paired community controls matched with the same sex, age (±3 years) and residence in five counties in rural Shandong, China. The Chinese version of PSS, the Center for Epidemiologic Studies Depression Scale (CES-D), the Trait Anxiety Inventory (TAI) and the Self-esteem Scale (SES) were administered and reliability test and validity test of the PSS were conducted.

RESULTS

Cronbach's α and Guttman Spilt-Half coefficient of PSS was 0.942 and 0.842 for suicide attempters, and 0.950 and 0.874 for community controls. For both suicide attempters and community controls, the Exploratory Factor Analysis indicated a one-factor structure of each strain scale, which accorded with the original factor structure proposed by the authors. The scores of the total PSS and four subscales were positively correlated with the scores of CES-D and TAI; and negatively correlated with the score of SES, which indicated a good performance in convergent validity.

LIMITATIONS

This study was limited to its generalizability to the Chinese urban population.

CONCLUSIONS

The Chinese version of the 40-item PSS has satisfactory psychometric properties in terms of reliability and validity in Chinese rural suicide attempters and community controls.

The Role of Depressive Symptoms in Suicide Attempt in Rural China

Depression is a well-established predictor of suicidal behaviors, yet its effects among Chinese rural suicide attempters are understudied. In this study, we examined the role of depressive symptoms with other common risk factors, such as impulsivity, among medically serious suicide attempters. A case-controlled study was conducted in 13 rural counties in China. Medically serious suicide attempters (n = 791) and 791 nonsuicidal controls matched for sex and age range (±3 years) in the same location were recruited and interviewed to obtain information with regard to demographics, depressive symptom severity, and psychological strain measures. Both depressive symptoms, assessed with the Center for Epidemiological Studies Depression Scale, and psychological strains predicted suicide attempt risk, and psychological strains significantly predicted depressive symptoms. Depressive symptoms fully mediated the relations between value strain, deprivation strain, and suicide attempt risk, and partially mediated the associations among aspiration strain, coping strain, and suicide attempt risk. The reduction of psychological strains may help decrease both depression and suicidal behaviors.

The age-specific characteristics of medically serious suicide attempters aged 15-45 years in rural China

This aim of this study was to identify unique characteristics of serious suicide attempters across different age groups. Face to face interviews were conducted with medically serious suicide attempters in rural hospitals in two provinces in China (n = 791). The sample included three age groups: 15-24, 25-34, and 35-45. While there were some consistent patterns that emerged across the age groups, there were also some significant age-related patterns that emerged. Serious suicide attempters aged 15-24 were more likely to be well educated, never married, hold Party membership, and impulsive, and to be least likely to perceive social support and be in a peasant occupation. This category also had the highest proportion of males, although still predominantly female. Those aged 24-25 were more likely to have a family history of suicide, somewhat educated, and moderately likely to be married. Those aged 35-45 were more likely to have limited education, to be ever married, to have mental disorders, to store pesticides in their home, and the least likely to be impulsive. These results highlight age-specific intervention strategies in addressing suicide.

Prevalence of psychiatric diagnoses in individuals who die by suicide or attempt suicide in China based on independent structured diagnostic interviews with different informants

Many individuals who die by suicide or attempt suicide have no pre-existing psychiatric record. In these cases determination of the presence of mental illness at the time of the suicidal act depends on diagnostic interviews with different informants, but the reliability of such interviews is unknown. To address this issue, the current study from northern China conducted independent diagnostic interviews (by different psychiatrists) with a co-resident family member and another associate of 151 suicide decedents, with 120 individuals who attempted suicide, and with two proxy informants for each suicide attempter. In the suicide decedent group, 56% of interviews with family members and 50% with other associates resulted in one or more psychiatric diagnosis; the concordance (kappa) of these two respondents for the presence of any current psychiatric disorder, any mood disorder and any other psychiatric disorder were 0.35, 0.32 and 0.41, respectively. In the suicide attempt group, 47% of interviewers with suicide attempters, 31% with family members, and 15% with other associates resulted in a psychiatric diagnosis; the concordance for any current psychiatric disorder, any mood disorder and any other psychiatric disorder between the interview with the suicide attempter and the combined result of the two separate proxy informant interviews were 0.31, 0.34 and 0.39, respectively. We conclude that the concordance of the presence and type of psychiatric diagnosis of individuals with suicidal behavior based on independent structured interviews by psychiatrists with different informants is low to fair and that using multiple informants will increase the identification of psychiatric disorders.

Mental disorders and suicide attempt in rural China

The prevalence of various mental disorders and their age and gender specific characteristics among suicide attempters remains unclear in rural China. This study using 1:1 paired case-control design included 409 suicide attempters and 409 paired controls matched on age, gender and place of residence. Mental disorders were assessed using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders. The prevalence of mental disorders was 32.3% for suicide attempters and 4.9% for paired controls. Mental disorder constituted a significant risk factor for suicide attempt with an adjusted odds ratio of 7.16 (95%CI: 3.65-14.04). The prevalence of mental disorders was higher among male than female suicide attempters. Major depressive disorder was most common in female suicide attempters while alcohol use disorder was most common in the males. The prevalence of mental disorders seemed to increase with age. Suicide attempters of higher ages were more prone to have mood disorders, especially a major depression. Suicide attempters with mental disorders differed from those without mental disorders on a number of socio-economic characteristics and suicidal behavior features. These insights should be taken into account in strategies and efforts to improve mental health care and ultimately to reduce suicidal behavior among residents in rural China.

Suicide attempters with high and low suicide intent: Different populations in rural China

This paired case-control study aimed to compare characteristics between suicide attempters with high and low suicide intent in rural China. We evaluated 409 suicide attempters and their paired controls who were matched with the same gender, age (a difference of no more than 3 years), and similar residence. Compared to paired control, suicide attempt with high and low suicide intent shared the 3 common risk factors of negative life event, high depression score, and low social support score. In addition, mental disorder was an independent risk factor of suicide attempt with high intent. Having a low education level and occupation as a farmer were risk factors of suicide attempt with low intent. Mental disorder and depression were associated with a significantly increased risk of suicide attempt with high intent compared to low intent. Depression was found to be related to suicide attempt with high intent compared to low intent in the subgroups of male or female aged 35-54 or 55-70 years. Distinct characteristics were found in the suicide attempters with different intent. These findings are important and the aim is to transform them into concrete ideas for the prevention of suicide attempt in rural China.

Life satisfaction and degree of suicide intent: A test of the strain theory of suicide

BACKGROUND

Various factors contribute to suicide. Psychological strains are hypothesized to precede suicidal thought and attempt. Life satisfaction can be a measure of relative deprivation strain and aspiration-reality strain.

AIMS

This study was to compare the suicide attempters with various levels of life satisfaction and find out how life satisfaction affects the degree of suicide intent among medically serious suicide attempters.

METHODS

Subjects for study were recruited in some rural counties in China. Interview data were from hospital emergency rooms with medically serious attempters of suicide (n=791). The subjects were aged between 15 and 54years and 293 males and 498 females. Face to face interview was conducted for each suicide attempter with a semi-structural protocol including life satisfaction, physical health, demographic, sociological, and psychological measures, as well as psychological strains.

FINDINGS

The multiple linear regression analysis showed that mental disorder, aspiration strain and relative deprivation strain were significant risk factors for high intent of suicide among suicide attempters. The interaction between the two psychological strains also indicated that both failed aspiration and self-perceived low economic status in village play an important role in suicidal intent.

CONCLUSION

Low level of life satisfaction is associated with strong intent for suicide. Lack of life satisfaction is exemplified by relative deprivation perceived by the individuals and the discrepancy between an individual's aspiration for life and his/her reality. The findings from the suicide attempt data in rural China support the Strain Theory of Suicide.

Characteristics of suicide completers and attempters in rural Chinese population

OBJECTIVE

This study aimed to compare the similarities and differences between suicide completers and attempters in rural China.

METHODS

Two paired case-control studies of completed suicide and suicide attempts were conducted in rural Shandong, China. This analysis included 409 suicide attempters (SA) with a mean age of 43.90 (SD=13.31), 117 suicide completers (SC) with a mean age of 50.38 (SD=13.02) and their controls matched by gender, age (within 3years), and residence. Logistic regression models were used to examine risk factors of suicide attempts and completed suicide and the differences between SA and SC.

RESULTS

Compared to their matched controls, suicide attempters and completers shared the following common risk factors: low levels of education (middle school or under) (OR, 95% CI: 2.79, 1.40-5.55 for SA and 16.98, 1.59-181.60 for SC), negative life events (OR, 95% CI: 7.37, 4.73-11.50 for SA and 21.08, 4.74-93.71 for SC), and mental disorders (OR, 95% CI: 7.52, 3.85-14.69 for SA and 22.39, 2.65-189.60 for SC). Compared to suicide attempts, completed suicide was associated with the following risk factors: male gender (OR, 95% CI: 1.75, 1.06-2.90), advancing age (OR, 95% CI: 1.02, 1.00-1.04), poor family economic status (OR, 95% CI: 6.74, 3.22-14.13), prior suicide attempts (OR, 95% CI: 2.43, 1.18-4.97), family suicide history (OR, 95% CI: 2.59, 1.33-5.06), high suicide intent (OR, 95% CI: 1.15, 1.05-1.27), and highly lethal methods (OR, 95% CI: 13.65, 6.51-28.59).

CONCLUSIONS

Although suicide completers and attempters share some common risk factors, suicide completers are more likely to have prior suicide attempts, family suicide history, and higher suicidal intent, and to use highly lethal methods in rural Chinese.

Attitudes towards suicide in urban and rural China: a population based, cross-sectional study

BACKGROUND

Suicide intervention programs have been guided by findings that attitude towards suicide and suicidal behavior may be causally linked. These findings also make it imperative to identify the factors that influence attitudes towards suicide. However, there has been little research on attitudes towards suicide among the general population, especially in low-income and middle-income countries. This population-based, cross-sectional study investigated the associated factors of attitudes towards suicide among a representative sample of urban and rural adult residents in China.

METHODS

A multi-stage, stratified random sampling approach was implemented to select participants. Data were collected by a survey using the Scale of Public Attitudes about Suicide (SPAS). The survey also collected some socio-demographic factors and suicidal history of participants. Statistical tests were conducted to identify associated factors that account for variations in attitudes towards suicide.

RESULTS

The residents in China generally hold a neutral attitude towards suicide. Attitudes towards suicide among Chinese residents were associated with age, duration of formal education, marital status, job and suicidal ideation. Different attitudinal subscales seemed not to share the same risk factors. However, gender, ethnicity, religious belief, housing style and economic status might not influence residents' attitudes towards suicide. Attitudes towards suicide among Chinese urban and rural residents generally had no statistical difference with one notable exception: opinions on whether or not suicides and suicide attempts are different phenomena.

CONCLUSIONS

Age, duration of formal education, marital status, job and suicidal ideation seem to have an impact on attitudes towards suicide among residents. Urban and rural residents have similar attitudes towards suicide with the only statistically significance difference being their opinions on whether or not suicides and suicide attempts are different phenomena.