The roles of culture and gender in the relationship between divorce and suicide risk: A meta-analysis

Unravelling the threads: understanding the interplay of Cultural values, female workforce engagement, human development index and suicide rates

PURPOSE

Suicide is a major public health problem across the world. Extensive research on the field shows that suicide is affected by several sociological, economic, and cultural risk factors. Over the last century, social changes have driven the reshaping of traditional gender roles, often in an uneven fashion, strongly depending on context. This study proposes updated findings on the impact that changes in traditional gender roles could have on suicide rates METHODS: It will do so by examining the correlation between female labor force participation (FLPR) and sex-specific suicide rates. Moreover, it will examine this association depending on human development (HDI) and Hofstede's individualism index. To do so, data from 2010 to 2019 from 47 countries is collected from the WHO, ILOSTAT and UN agencies' websites.

RESULTS

Analysis show a significant interaction between FLPR, HDI and individualism index scores on male suicide rates (p = 0.002). There is a negative association between FLPR and male suicide rates in relatively lower HDI countries, while in very high HDI countries an increase in FLPR is correlated with an increase in male suicide rates. Similar trends but no significant interaction is observed for female suicide rates.

CONCLUSION

This study suggests that female participation is beneficial for male population as it reduces male suicide rates. However, this association appears to be context dependent. In countries where institutional adjustment is already established, and human development is very high, other factors might be of interest in examining the trends of suicide rates among men and women.

The role of economic news in predicting suicides

In this paper we explore the role of media and language used to comment on economic news in nowcasting and forecasting suicides in England and Wales. This is an interesting question, given the large delay in the release of official statistics on suicides. We use a large data set of over 200,000 news articles published in six major UK newspapers from 2001 to 2015 and carry sentiment analysis of the language used to comment on economic news. We extract daily indicators measuring a set of negative emotions that are often associated with poor mental health and use them to explain and forecast national daily suicide figures. We find that highly negative comments on the economic situation in newspaper articles are predictors of higher suicide numbers, especially when using words conveying stronger emotions of fear and despair. Our results suggest that media language carrying very strong, negative feelings is an early signal of a deterioration in a population's mental health.

Love Is Not All You Need: Understanding the Association Between Relationship Status and Relationship Dysfunction With Self-Directed Violence in Veterans

INTRODUCTION

Research indicates that being married is associated with reduced risk of suicide and self-directed violence (SDV) relative to being divorced. Simultaneously, difficulties within relationships predict poorer health outcomes. However, research on relationship status rarely examines relationship functioning, obfuscating the joint contribution of these variables for SDV risk.

METHOD

Veterans (N = 1,049) completed a survey that included assessment of relationship status, relationship functioning, and SDV history. Logistic regression models tested how (a) relationship status, (b) relationship dysfunction, and (c) being divorced compared to being in a low- or high-dysfunction relationship were associated with SDV, controlling for several intrapersonal risk factors.

RESULTS

Veterans in a relationship did not differ in SDV history compared to divorced/separated veterans. However, more dysfunction within relationships was associated with greater odds of a history of SDV and suicidal cognitions. Finally, SDV histories were more likely among veterans endorsing high-dysfunction relationships compared with (a) low-dysfunction relationships and (b) divorced veterans.

CONCLUSION

It may be insufficient to only consider relationship status when evaluating interpersonal risk factors for SDV. A single item assessing relationship dysfunction was associated with enacted SDV and suicidal cognitions over and above intrapersonal risk factors. Integrating such single-item measures into clinical practice could improve identification and subsequent tailored intervention for veterans at greater risk for SDV.

Decoding Suicide Decedent Profiles and Signs of Suicidal Intent Using Latent Class Analysis

Importance

Suicide rates in the US increased by 35.6% from 2001 to 2021. Given that most individuals die on their first attempt, earlier detection and intervention are crucial. Understanding modifiable risk factors is key to effective prevention strategies.

Objective

To identify distinct suicide profiles or classes, associated signs of suicidal intent, and patterns of modifiable risks for targeted prevention efforts.

Design, Setting, and Participants

This cross-sectional study used data from the 2003-2020 National Violent Death Reporting System Restricted Access Database for 306 800 suicide decedents. Statistical analysis was performed from July 2022 to June 2023.

Exposures

Suicide decedent profiles were determined using latent class analyses of available data on suicide circumstances, toxicology, and methods.

Main Outcomes and Measures

Disclosure of recent intent, suicide note presence, and known psychotropic usage.

Results

Among 306 800 suicide decedents (mean [SD] age, 46.3 [18.4] years; 239 627 males [78.1%] and 67 108 females [21.9%]), 5 profiles or classes were identified. The largest class, class 4 (97 175 [31.7%]), predominantly faced physical health challenges, followed by polysubstance problems in class 5 (58 803 [19.2%]), and crisis, alcohol-related, and intimate partner problems in class 3 (55 367 [18.0%]), mental health problems (class 2, 53 928 [17.6%]), and comorbid mental health and substance use disorders (class 1, 41 527 [13.5%]). Class 4 had the lowest rates of disclosing suicidal intent (13 952 [14.4%]) and leaving a suicide note (24 351 [25.1%]). Adjusting for covariates, compared with class 1, class 4 had the highest odds of not disclosing suicide intent (odds ratio [OR], 2.58; 95% CI, 2.51-2.66) and not leaving a suicide note (OR, 1.45; 95% CI, 1.41-1.49). Class 4 also had the lowest rates of all known psychiatric illnesses and psychotropic medications among all suicide profiles. Class 4 had more older adults (23 794 were aged 55-70 years [24.5%]; 20 100 aged ≥71 years [20.7%]), veterans (22 220 [22.9%]), widows (8633 [8.9%]), individuals with less than high school education (15 690 [16.1%]), and rural residents (23 966 [24.7%]).

Conclusions and Relevance

This study identified 5 distinct suicide profiles, highlighting a need for tailored prevention strategies. Improving the detection and treatment of coexisting mental health conditions, substance and alcohol use disorders, and physical illnesses is paramount. The implementation of means restriction strategies plays a vital role in reducing suicide risks across most of the profiles, reinforcing the need for a multifaceted approach to suicide prevention.

Divorce and risk of suicide attempt: a Swedish national study

BACKGROUND

Prior research has reported an association between divorce and suicide attempt. We aimed to clarify this complex relationship, considering sex differences, temporal factors, and underlying etiologic pathways.

METHODS

We used Swedish longitudinal national registry data for a cohort born 1960-1990 that was registered as married between 1978 and 2018 (N = 1 601 075). We used Cox proportional hazards models to estimate the association between divorce and suicide attempt. To assess whether observed associations were attributable to familial confounders or potentially causal in nature, we conducted co-relative analyses.

RESULTS

In the overall sample and in sex-stratified analyses, divorce was associated with increased risk of suicide attempt (adjusted hazard ratios [HRs] 1.66-1.77). Risk was highest in the year immediately following divorce (HRs 2.20-2.91) and declined thereafter, but remained elevated 5 or more years later (HRs 1.41-1.51). Divorcees from shorter marriages were at higher risk for suicide attempt than those from longer marriages (HRs 3.33-3.40 and 1.20-1.36, respectively). In general, HRs were higher for divorced females than for divorced males. Co-relative analyses suggested that familial confounders and a causal pathway contribute to the observed associations.

CONCLUSIONS

The association between divorce and risk of suicide attempt is complex, varying as a function of sex and time-related variables. Given evidence that the observed association is due in part to a causal pathway from divorce to suicide attempt, intervention or prevention efforts, such as behavioral therapy, could be most effective early in the divorce process, and in particular among females and those whose marriages were of short duration.

Suicide prevention in Hong Kong: pushing boundaries while building bridges

Hong Kong is a natural laboratory for studying suicides-small geographic footprint, bustling economic activity, rapidly changing socio-demographic transitions, and cultural crossroads. Its qualities also intensify the challenges posed when seeking to prevent them. In this viewpoint, we showed the research and practices of suicide prevention efforts made by the Hong Kong Jockey Club Centre for Suicide Research and Prevention (CSRP), which provide the theoretical underpinning of suicide prevention and empirical evidence. CSRP adopted a multi-level public health approach (universal, selective and indicated), and has collaboratively designed, implemented, and evaluated numerous programs that have demonstrated effectiveness in suicide prevention and mental well-being promotion. The center serves as a hub and a catalyst for creating, identifying, deploying, and evaluating suicide prevention initiatives, which have the potential to reduce regional suicides rates when taken to scale and sustained.

Female Labor-Force Participation as Suicide Prevention: A Population Study in Taiwan

OBJECTIVE

Female labor-force participation (FLFP) has been theorized as contributing to higher suicide rates, including among women. Evidence on this relationship, however, has been mixed. This study explored the association between FLFP and suicide in an understudied context, Taiwan, and across 40-years.

METHODS

Annual national labor-participation rates for women ages 25-64, and female and male suicide-rates, for 1980-2020, were obtained from Taiwan's Department of Statistics. The associations between FLFP rates and sex/age-stratified suicide-rates, and between FLFP rates and male-to-female suicide-rates ratios were assessed via time-series regression-analyses, accounting for autoregressive effects.

RESULTS

Higher FLFP rates were associated with lower female suicide-rates (ß = -0.06, 95% CI (Credibility Interval) = [-0.19, -0.01]) in the adjusted model. This association held in the age-stratified analyses. Associations for FLFP and lower male suicide-rates were observed in the ≥45 age-groups. FLFP rates were significantly and positively associated with widening male-to-female suicide-rates ratios in the adjusted model (ß = 0.24, 95% CI = [0.03, 0.59]).

CONCLUSION

This study's findings suggest that FLFP protects women from suicide, and point to the potential value of FLFP as a way of preventing suicide. In Taiwan, employed women carry a double-load of paid and family unpaid care-work. Child care-work is still done by mothers, often with grandmothers' support. Therefore, this study's findings contribute to evidence that doing both paid work and unpaid family care-work has more benefits than costs, including in terms of suicide-protection. Men's disengagement from family care-work may contribute to their high suicide rates, despite their substantial labor-force participation.

Patterns in suicide by marital status in Hong Kong, 2002-2020: Is marriage still a protective factor against suicide?

BACKGROUND

Marriage has long been considered protective against suicide, but shifting social norms since 2000 in Hong Kong raise doubts regarding whether this is still the case. The aim of the study was to investigate the changing association between suicide and marital status.

METHODS

Official suicide data for 2002-2020 in Hong Kong were obtained. Suicide rates and suicide risk ratios were calculated by gender, age group, and marital status (married, never-married, widowed, divorced/separated).

RESULTS

Suicide risk decreased significantly over time for men and women of all ages. People who were never-married, divorced/separated, had significantly higher suicide risks than their married counterparts. Increasing suicide risks over time were observed for never-married men aged 20-49 years, never-married women aged 35-49 years, and divorced/separated men aged 20-34 years. Widowed men and women of any age had higher suicide risks compared with previous studies in Hong Kong.

LIMITATIONS

Marital status is a time-varying covariate, and the time spent in a given marital status could affect suicide risk. Some age and gender subgroups had much smaller sample sizes than others, thus it is possible that our suicide risk estimates were overestimated.

CONCLUSIONS

Despite rapidly social changing in Hong Kong during the study period, marriage remains a strong protective factor against suicide for men and women. The protective effect is particularly evident for younger people. Increasing suicide rates for divorced/separated, never-married, or widowed people suggest that they require more psychosocial support.

Marital status and suicidal behavior in South Asia: A systematic review and meta-analysis

Background and Aims

The connection between marital status and suicidal behavior has been poorly assessed in South Asia. We aimed to see the proportion of marital status in individuals with suicidal behavior in South Asian countries.

Methods

We followed PRISMA guidelines and registered the protocol in advance (PROSPERO 2023 CRD42023399906). A systematic search was conducted in Medline, Embase, and PsycINFO. Meta-analyses were performed to pool the proportion of married individuals with suicidal behavior (total [suicide + suicide attempts], suicide, and suicide attempt) in South Asian countries. We considered suicidal behavior consist of suicide and suicide attempts (nonfatal).

Results

Our search identified 47 studies for this review from 6 countries published from 1999 to 2022 with a sample size ranging from 27 to 89,178. The proportion of married individuals was 55.4% (95% CI: 50.1-60.5) for suicidal behavior, 52.7% (95% CI: 44.5-60.7) for suicides, and 43.1 (95% CI: 32.9-53.9) for suicide attempts. The proportion of married persons among suicide attempts varied significantly across countries (p = 0.016) which was highest (61.8%; 95% CI: 57.2-66.2) in India, followed by Bangladesh (52.5%; 95% CI: 41.8%-62.9%) and Pakistan (45.1%; 95% CI: 30.9-59.9). The pooled proportions did not differ significantly in relation to the quality of the studies (p = 0.633).

Conclusion

This review identified married persons died more than others by suicide in South Asian countries while single persons attempted suicide than married. As the current study did not assess any cause-and-effect association, a cautious interpretation is warranted while considering married marital status as a risk factor.

The differential impacts of social deprivation and social fragmentation on suicides: A lesson from Hong Kong

INTRODUCTION

Little research has conducted to examine the association between social deprivation and social fragmentation, overall and method-specific suicide risk, and how these associations may change over time. This study investigated the association between social deprivation and social fragmentation with overall and method-specific suicide in Hong Kong from 1999 to 2018.

METHODS

Suicide death data of each small tertiary planning unit (STPU) was obtained from the Census and Statistics Department of Hong Kong. Socio-economic characteristics in STPU level were obtained from Census and Bi-census. Exploratory principal component analysis was used to construct the social deprivation (SDI) and social fragmentation indices (SFI) based on the socio-economic characteristics. Bayesian hierarchical modelling was conducted to explore the association between SDI and SFI with overall and method-specific suicide over time, controlling for population density and male-to-female ratio.

RESULTS

Higher risk of suicide was generally observed around Kowloon Peninsula and some parts in the Northern, Northwestern and Southwestern areas depending on methods. The effect of SDI and SFI on suicide risk varied by years and methods. In 2014-2018, for every 10% increase in SDI, the suicide risk for overall, jumping, hanging, and charcoal burning elevated by 22% (95%Crl = 10%-37%), 26% (95%Crl = 12%-41%), 31% (95%Crl = 14%-51%), and 21% (95%Crl = 4%-42%) respectively.

CONCLUSION

Spatial variations and effects of SDI and SFI on overall and method-specific suicide risks varied by different periods. SDI was observed to be a stronger factor in the recent years. Situations should be monitored, and interventions should be implemented and adjusted accordingly to the changes.

Single and combined effects of marital status, education attainment, and employment status on suicide among working-age population: A case-control study in South Korea

Background

Suicide in the working-age population is an important public health issue. This group is heterogeneous regarding marital status, education level, and employment status, which are generally important socioeconomic factors for suicide, and has a wide age range. This study aims to explore the individual and combined effect of these socioeconomic factors on suicide in different age groups among the working-age population.

Methods

This study utilized a population-based case-control design for the working-age population in South Korea. Suicide cases were identified in Korean Governmental Death Registry from 2008 to 2017, and eight controls from Korea Community Health Survey were matched to each case by gender, age group, and year of suicide. Conditional logistic regression models estimated the relationship between marital status and socioeconomic status (SES) including educational attainment and employment status and suicide and examined the combined effect of the SES indicators and marital status on suicide.

Results

Low education, single status, and unemployment or economically inactive status were associated with suicide, but their magnitude varied across SES indicators. The association between SES and suicide was more pronounced in younger adults. The suicide risk was highest among divorced women aged 25–34 years (OR = 7.93; 95% CI: 7.21–8.72). Individuals experiencing two social adversities among SES or marital status had a significantly increased suicide risk. Those who are divorced and unemployed or economically inactive have the highest suicide risk, specifically among men aged 24–35 years (OR = 17.53; 95% CI: 14.96–20.55).

Conclusions

Marital status, education attainment, and employment status have a separate and combined impact on suicide among the working-age population. Specifically, the divorced and unemployed or economically inactive status amplified suicide risk, predominantly among young adults. Monitoring and intervention for those young adults should be considered for suicide prevention.

•

Using a case-control design, we were able to demonstrate single as well as the combined impact of socioeconomic status on suicide.

•

Poor SES was associated with suicide, but its magnitude varied across SES indicators. The suicide risk was highest among divorced adults.

•

Individuals with two different types of poor SES and single status had an increased suicide risk. Specifically, those who are divorced and unemployed or economically inactive have the highest suicide risk.

•

The pattern of the association between socioeconomic status and suicide was dependent on age. The association between SES and marital status and suicide was more pronounced in younger adults.

The relative importance of macro versus micro geographical scale in explaining suicide variation in Seoul, South Korea 2014–2016

Background

As ecological factors are getting attention as important determinants of suicide, it is important to identify the unit at which the largest variation exists for more tailed strategy to prevent suicide. We examined the relative importance of two administrative levels for geographic variation in the suicide rate between 2014–2016 in Seoul, the capital city of Korea.

Methods

Two-level linear regression with Dongs (level 1) nested within Gus (level 2) was performed based on suicide death data aggregated at the Dong-level. We performed pooled analyses and then year-stratified analyses. Dong-level socioeconomic status and environmental characteristics were included as control variables.

Results

The overall age- and sex- standardized suicide rate across all Dongs decreased over time from 24.9 deaths per 100,000 in 2014 to 23.7 deaths in 2016. When Dong and Gu units were simultaneously considered in a multilevel analysis, most of the variation in suicide rate was attributed to within-Gu, between-Dong differences with a contribution of Gu-level being small and decreasing over time in year (Variance partitioning coefficient of Gu = 5.3% in 2014, <0.1% in 2015 and 2016). The number of divorce cases per 100,000 explained a large fraction of variation in suicide rate at the Dong-level.

Conclusions

Findings from this study suggest that ecological micro-area unit is more important in reducing the geographic variation in the suicide rate. More diverse ecological-level data needs to be collected for targeted area-based suicide prevention policies in Korea.

Parental education and youth suicidal behaviours: a systematic review and meta-analysis

AIMS

Lower parental education has been linked to adverse youth mental health outcomes. However, the relationship between parental education and youth suicidal behaviours remains unclear. We explored the association between parental education and youth suicidal ideation and attempts, and examined whether sociocultural contexts moderate such associations.

METHODS

We conducted a systematic review and meta-analysis with a systematic literature search in PubMed, PsycINFO, Medline and Embase from 1900 to December 2020 for studies with participants aged 0-18, and provided quantitative data on the association between parental education and youth suicidal ideation and attempts (death included). Only articles published in English in peer-reviewed journals were considered. Two authors independently assessed eligibility of the articles. One author extracted data [e.g. number of cases and non-cases in each parental education level, effect sizes in forms of odds ratios (ORs) or beta coefficients]. We then calculated pooled ORs using a random-effects model and used moderator analysis to investigate heterogeneity.

RESULTS

We included a total of 59 articles (63 study samples, totalling 2 738 374 subjects) in the meta-analysis. Lower parental education was associated with youth suicidal attempts [OR = 1.12, 95% Confidence Interval (CI) = 1.04-1.21] but not with suicidal ideation (OR = 1.05, 95% CI = 0.98-1.12). Geographical region and country income level moderated the associations. Lower parental education was associated with an increased risk of youth suicidal attempts in Northern America (OR = 1.26, 95% CI = 1.10-1.45), but with a decreased risk in Eastern and South-Eastern Asia (OR = 0.72, 95% CI = 0.54-0.96). An association of lower parental education and increased risk of youth suicidal ideation was present in high- income countries (HICs) (OR = 1.14, 95% CI = 1.05-1.25), and absent in low- and middle-income countries (LMICs) (OR = 0.91, 95% CI = 0.77-1.08).

CONCLUSIONS

The association between youth suicidal behaviours and parental education seems to differ across geographical and economical contexts, suggesting that cultural, psychosocial or biological factors may play a role in explaining this association. Although there was high heterogeneity in the studies reviewed, this evidence suggests that the role of familial sociodemographic characteristics in youth suicidality may not be universal. This highlights the need to consider cultural, as well as familial factors in the clinical assessment and management of youth's suicidal behaviours in our increasingly multicultural societies, as well as in developing prevention and intervention strategies for youth suicide.

Dying in a foreign land: A study of completed suicides among foreign workers in Singapore

Suicide is a public health issue that impacts a nation's resident and non-resident populations alike. Singapore has one of the largest non-resident (work permit holder) populations in the world, yet very little attention has been given to examining suicide in this population. The current study examined the case materials of all 303 non-resident completed suicides in Singapore in the period January 2011 to December 2014. Their basic profiles were compared with that of the 1,507 resident cases in the same period. A sample of 30 death notes written by non-residents were randomly selected and thematically analyzed to supplement the descriptive findings and discussion. Results showed that suicides were highest among males, those aged 21-35 years old, and South Asians. Most non-resident suicide cases did not have known physical or mental health issues, prior suicide attempts, or suicide notes. Suicide decedents from South Asia and Europe most frequently used hanging, while jumping was most common among decedents from other regions. Relationship and health problems emerged as the top two suspected triggers for suicide based on our analysis of the suicide notes. The unique situation of working abroad may increase non-residents' vulnerability in general, while adverse life events such as relationship and health issues may be too overwhelming to bear, especially when support services are not readily available and accessible. The results have implications for suicide prevention among this neglected group of people who choose to work in foreign lands.

Socio-economic determinants of suicide rates in transforming China: A spatial-temporal analysis from 1990 to 2015

Background

China has experienced dramatic social changes in the last three decades. This study aimed to investigate socio-economic factors related to suicide rates in China from 1990 to 2015, and examine how the impacts of these factors on suicide rates changed over time.

Methods

Suicide rates in 31 provinces in mainland China between 1990 and 2015 were obtained from the Global Burden of Disease (GBD) Study 2019. Temporal-spatial modelling was applied to assess the effects of GDP per capita, urbanization, migration, employment, divorce, proportions of children and older adults on provincial overall, male and female suicide rates.

Findings

The overall suicide rate in China declined from 18·1 /100,000 in 1990 to 8·6 /100,000 in 2015, with considerable spatial variation in the magnitude of decline across provinces. The protective effects of increasing in GDP per capita, and urbanization, on provincial suicide rate were strong in 1990 (log GDP: -3·56 [95% CI: -6·15, -0·96], urbanisation: -0·07 [-0·14, -0·01]), however these effects were negligible by 2015. The association between employment and suicide rates has shifted from positive to negative over the study period, while migration remained a constant risk factor for high suicide rates (0·04 [0.00, 0·09]).

Interpretation

This study highlighted the dynamic effects of economic and social factors on suicide rates in the context of transforming China. To maintain further reductions in suicide rates cannot rely simply on improving people's materialistic and economic conditions. A more holistic approach to improve overall population well-being is needed.

Funding

Humanities and Social Sciences Prestigious Fellowship (37000320) and the General Research Fund (17611619) at the University of Hong Kong.

Do partnership dissolutions and living alone affect systemic chronic inflammation? A cohort study of Danish adults

BACKGROUND

Partnership breakups and living alone are associated with several adverse health outcomes. The aim of this study, carried out in Denmark, is to investigate whether accumulated numbers of divorces/partnership breakups or years lived alone across 26 years of adult life are associated with levels of inflammation, and if vulnerability with regards to gender or educational level can be identified.

METHODS

4835 participants from the Copenhagen Aging and Midlife Biobank (CAMB) aged 48-62 years were included. Data on accumulated numbers of partnership breakups and years living alone were retrieved from a national standardised annual register. Inflammatory markers interleukin 6 (IL-6) and high sensitivity C-reactive protein (hsCRP) were measured in blood samples. Multivariate linear regression analyses were adjusted for age, educational level, early major life events, body mass index, chronic diseases, medicinal intake affecting inflammation, acute inflammation and personality scores.

RESULTS

For men, an association was found between an increasing number of partnership breakups or number of years living alone and higher levels of inflammatory markers. No such association was found for women, and no evidence of partnership breakups and educational level having a joint effect was found for either gender.

CONCLUSION

The findings suggest a strong association between years lived alone or accumulated number of partnership breakups and low-grade inflammation for middle-aged men, but not for women. Among those of either sex with a lower level of education, no specific vulnerability to accumulated years lived alone or number of breakups was identified.

A cross-sectional study of mental health and suicidality among trans women in São Paulo, Brazil

BACKGROUND

Trans women have been shown to experience disproportionately poor outcomes in physical and mental health. Although it is common to talk about the violence against trans people, little is still known about mental health outcomes and experiences of suicidality among trans women, particularly in developing countries. This study aims to investigate risk factors and associations with mental health, suicide ideation and suicide attempts among trans women in the largest metropolitan area in Brazil.

METHODS

Trans women living in São Paulo were recruited between May 2017 and July 2019 using the long-chain peer referral method Respondent-Driven Sampling. Multivariate regression models were used to investigate the associations with K10 score classification (logistic) and suicidal ideation/suicide attempt (ordinal logistic).

RESULTS

A total of 763 trans women were included in the study. Over one quarter (26.5%) of trans women had been diagnosed with anxiety in the past, and close to one in five (19.1%) trans women had received a diagnosis of depression. More than two in five (41.9%) trans women had moderate to severe psychological distress. More than half of all participating trans women reported having previously either experienced suicidal ideation or attempted to take their own lives (25.0 and 31.2% respectively). In multivariate regression, moderate to severe psychological distress was associated with homelessness, income, current sex work, use of stimulant drugs, history of physical abuse, depression diagnosis and access to mental health treatment. Suicidal ideation and suicide attempts were associated with race/skin color, living arrangements, marital status, current sex work, history of sexual violence, depression and PTSD diagnoses, access to mental health treatment and psychological distress.

CONCLUSIONS

This study showed that there is a significant association between mental health conditions, lack of treatment for these conditions and suicidality among trans gender women. Findings point to the need for a structural transformation in Brazil that enables a reduction in the social inequality and violence that impact the mental health of trans women. A number of recommendations to achieve this are provided.

Antecedents of Suicide Among Active Military, Veteran, and Nonmilitary Residents of the Commonwealth of Virginia: The Role of Intimate Partner Problems

Intimate partner problems increase suicide risk, particularly among active service members and veterans. Age, marital status and military service status may modify the role of intimate partner problems in suicide. Methods: Participants included 6255 men who died by suicide at 18 years of age and older and who actively, previously, or never served in the military. Reports of intimate partner problems prior to suicide were documented by the Virginia Department of Health. Results: Unmarried active service members, above middle age, were more likely than veterans and individuals without prior military service to have associated reports of intimate partner problems. Conclusion: Life stages and relationship context may influence the role of intimate partner problems as a risk factor for suicide.

Association of Long Working Hours With Marital Status Changes in South Korea: A Cohort Study

OBJECTIVE

This study investigated the relationship between long working hours and the incidence of divorce or separation among Korean female and male workers.

METHODS

A cohort study was conducted in 125,108 Korean workers, married at baseline, who attended health examinations between 2012 and 2017 and had been followed annually or biennially until December 31, 2018. The weekly working hours and marital status changes were measured using self-administered questionnaires. This study was performed using sex stratification.

RESULTS

In a multivariable-adjusted model, by comparing working hours->52 hours/week with 35 to 40 hours/week-the hazard ratios (95% confidence intervals) for incidents of divorce or separation were 1.60 (1.03-2.49) and 0.86 (0.66-1.12) in females and males, respectively.

CONCLUSIONS

This study showed that long working hours could contribute to marital status changes in Korean female workers.

Variable Circumstances of Suicide Among Racial/Ethnic Groups by Sex and Age: A National Violent-Death Reporting System Analysis

Suicide rates vary by race/ethnicity, but little is known about how the circumstances that contribute to suicide differ across racial/ethnic groups. This study investigated suicide circumstances among non-Hispanic Whites, non-Hispanic Blacks, non-Hispanic Asian/Pacific Islanders, non-Hispanic Native American/Alaskan Natives, and Hispanics by sex and age. Using de-identified National Violent Death Reporting System (NVDRS) Restricted Access Database files from 2006-2015, we examined proximal circumstances of suicide among decedents aged 10 years and older. Hierarchical logistic regression analysis revealed racial/ethnic differentials in non-alcohol substance abuse problem, intimate partner problem, and physical health problem across sex and age, controlling for potential confounders. Study findings highlight priority areas for suicide interventions.

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.

Prevalence and correlates of suicidality in Andalusia (Spain): Results of the epidemiological study PISMA-ep

BACKGROUND

Suicidality is an important public health problem. Hence, the aims of this study are to report prevalence rates and correlates of suicidality in Andalusia (Southern Spain).

METHODS

This is a cross-sectional household survey conducted on a representative sample of adults living in Andalusia. 4507 subjects were interviewed using the Mini International Neuropsychiatric Interview (MINI) to assess suicidality and standardized instruments were employed to evaluate associated variables. A multivariate logistic regression analysis was used to explore independent associations with suicidality.

RESULTS

Current prevalence of suicidality was 6.4%, 4.4% showed death wish, 1.4% had ideas of self-harm, 2.4% had suicidal thoughts, 1.1% had a suicidal plan, 0.6% had attempted suicide during the month prior to the interview, and, lastly, 2.6% reported to have had any sort of suicide attempt during his/her previous life. Independent factors associated with suicidality were being female, older age, not having a stable couple, lower levels of social support, having had physical childhood abuse experience, having experienced an increasing number of stressful life events, higher neuroticism scores, having a family history of mental disorder and nicotine or drugs dependence.

LIMITATIONS

The instrument employed to measure suicidality is a screening tool rather than a more in-depth diagnostic measure. We have not included all potential correlates of suicidality. This is a cross-sectional study which cannot establish causal relationships between exposures and outcomes.

CONCLUSIONS

This is the first epidemiological study in Andalusia on suicidality offering important results of clinical interest for suicide prevention.

A Test of the Three-Step Theory of Suicide among Chinese People: A Study Based on the Ideation-to-Action Framework

The aim of this study was to test the Three-Step Theory (3ST) of suicide in a sample of college students in China (N = 1,097). All participants completed a battery of questionnaires indexing psychological pain, hopelessness, connectedness, suicide capacity, suicide ideation, and suicide attempt. The prevalence of suicide ideation and suicide attempt among the sample were 21.42% and 3.83%, respectively. The hierarchical regression analysis showed that psychological pain and hopelessness interacted to predict suicide ideation, and that connectedness was the most protective against ideation in those high on both pain and hopelessness. Suicide capacity differentiated attempters from ideators above and beyond current suicide ideation. These findings provide preliminary evidence for the validity of 3ST of suicide within Chinese contexts. Implications for suicide prevention and intervention and future research directions are also discussed.

Making Sense of Chinese Employees' Suicide Ideation: Does Meaning in Life Matter?

Drawing on the self-determination theory and conservation of resources, our research shed light on the linkage between organizational autonomy support and suicide ideation. Specifically, this study examined whether the negative influence of autonomy support on suicide ideation is mediated via meaning in life, and if employee's autonomy orientations constitute a boundary condition of this relationship. To test the hypothesized model, data were collected from professional employees (N = 687) across six organizations of various business sectors. The findings supported our proposed hypotheses and showed that individuals' meaning in life mediated the linkage between autonomy support and suicide ideation. As suggested, hypothesized relations were moderated by employee's disposition in such a way that autonomy support influences meaning in life of employees high on autonomy orientation, but not of employees low on autonomy orientation. The study discussed implications and future research avenues.

The association between long working hours and marital status change: middle-aged and educated Korean in 2014-2015

Background

We investigated the association between long workhours and marital status change from married to divorced or separated status that might have bad health effects.

Methods

A total of 40,654 participants with married status in 2014 were followed up in 2015. Weekly workhours were categorized into four groups: ≤ 40, 41–52, 53–60, and > 60 hours per week. Univariate and multivariate logistic regression analyses were performed to determine the relationship between groups of workhours and marital status change after adjusting for age, total monthly household income, working type, and depression with sex stratification.

Results

The study populations consisted of 8,346 (20.5%) females and 32,308 (79.5%) males. Odd ratios (ORs) of marital status change for females working for more than 60 hours per week was 4.26 (95% confidence interval [CI]: 1.25–14.5), when working less than or equal to 40 hours per week was used as reference in the crude model. ORs of working more than 60 hours per week was 4.57 (95% CI: 1.02–20.5) in female workers when considering age, total household earning per month, working type of daytime, and depression in a dose-response manner. However, for male workers, long workhours were not significantly related to change of marriage status.

Conclusions

Long workhours for more than 60 hours per week had significantly higher risk of divorce or separation in females, but not in males. Further follow-up studies are needed to evaluate long term effects of long workhours on divorce risk.

Analysis of the Effects on Time Between Divorce Decree and Suicide

Background: Divorced individuals carry unique suicide risks, from both acute and chronic exposure to stressors from divorce. Aims: Several statewide data sets were linked to assess the relationship between divorce and suicide. Method: Divorced suicide decedents in the Colorado Violent Death Reporting System, 2004-2015, were matched with divorce decree, using multiple identifiers. Statistically significant differences between the linked cohort and all divorced suicide decedents were assessed using chi-square statistics. Kaplan-Meier survival analyses were conducted assessing which demographics and circumstances had a significant effect on the time between divorce and death. Results: The linkage resulted in 381 divorced suicide decedents linked to a divorce decree. Time between divorce and death ranged from less than 1 year to more than 10 years. Age and intimate partner problems both had significant effects on reducing the survival probability at 1 year and beyond. Limitations: Only 14% of divorced suicide decedents were linked to a Colorado divorce decree. There were noted significant differences between the linked cohort and the total divorced suicide population. Conclusion: Better understanding the relationship between divorce and suicide is imperative to design effective prevention programs for this specific population.

Intimate partner relationship stress and suicidality in a psychiatrically hospitalized military sample

OBJECTIVE

Suicide among United States service members is a significant public health concern. Intimate partner relationship stress may contribute to suicide risk, as a failed or failing relationship is the most commonly documented stressor preceding military suicide attempts and deaths. However, little is known about the manner by which relationship stressors are associated with the experience of military suicidality.

METHODS

A sample of 190 psychiatrically hospitalized military personnel and adult dependents enrolled in an ongoing randomized controlled trial evaluating the efficacy of an inpatient cognitive behavioral treatment for suicidality were included in this study. Analyses examined depression, hopelessness, and suicidality among participants with (n = 105) and without (n = 85) self-reported romantic relationship stress.

RESULTS

Over half (55%) of the sample reported current romantic relationship stress. Compared to participants without current romantic relationship stress, results indicated that individuals reporting current romantic relationship stress were more hopeless (AOR = 1.07 (95% CI: 1.01-1.12), p = 0.020), more likely to endorse multiple suicide attempts (AOR = 1.96 (95% CI: 1.01-3.79), p = 0.046), had higher overall suicide risk (AOR = 2.49, (95% CI: 1.03-6.06), p = 0.044), and were more likely to report that the reason for their suicidality was at least in part to get a reaction from others.

CONCLUSIONS

Findings suggest romantic relationship stress is associated with greater suicide risk, and have clinical implications for suicide prevention and intervention. Future research may examine mechanisms and pathways between romantic relationship stress, suicidality, and prevention and intervention strategies.

The Role of Stigma and Denormalization in Suicide-Prevention Laws in East Asia: A Sociocultural, Historical, and Ethical Perspective

In many Western countries, the criminalization and stigmatization of suicide has given way to a biomedical approach aimed at destigmatizing suicide and treating underlying mental illness. By contrast, in many East Asian countries, suicide has never historically been criminalized or stigmatized. High rates of suicide in Japan, South Korea, and Taiwan have recently led policy makers in those countries to pursue innovative suicide-prevention strategies. The intentional denormalization of harmful behaviors has been discussed in the public health and ethics literatures, particularly with regard to smoking cessation, and could represent a novel mechanism for preventing suicides in East Asia. Using examples from the sociocultural, historical, and legal discourses surrounding suicide in Western and East Asian contexts, we suggest that denormalization can be a justified, culturally relevant suicide-prevention strategy, but that care must be taken to avoid shaming or stigmatizing suicidal individuals. Specifically, we propose the term weak denormalization to refer to an ethically permissible strategy at the mildest end of a spectrum of denormalizing approaches-milder than the reintegrative shaming described in the criminal justice literature, and diametrically opposed to outright stigmatization, which is generally considered ethically impermissible. Given the severe stigma of mental illness in East Asia, adopting the dominant Western view of suicide as solely a psychiatric concern would not be justified. Weak denormalization strategies in East Asia should be culturally tailored and rigorously tested on a small scale. They should include social supports, praise for the bravery of those of who seek help, and strategies to reduce shame regarding perceived social failure.

Decomposing the crude divorce rate in five countries: Singapore, Taiwan, South Korea, the UK, and Australia

Over the past few decades, the level of divorce, measured by the crude divorce rate (CDR), has increased dramatically in both the East and the West, but has recently appeared to fall or level off in some countries. To investigate whether the recent decline or stabilisation of the CDRs reflects the real trends in divorce risk, a decomposition analysis was conducted on the changes in the CDRs over the past 20 years on two western and three East Asian countries, namely, the UK, Australia, Taiwan, South Korea, and Singapore. The following is observed: the decline in the CDRs of the UK and Australia in the 1990s, and of Taiwan and Korea in the 2000s, was mainly due to shrinkage in the proportion of the married population rather than any reduction in divorce risk; only Australia experienced a genuine reduction in divorce risk between 2001 and 2011; and the continuous increase of Singapore's divorce level between 1990 and 2010 may be is an unintentional effect of the government's marriage promotion policies. The shift in the population age structure, and more importantly, the drastic decline in marriage, has seriously distorted the CDRs, making them unreliable indicators for monitoring divorce trends.

What's Changed? A Comparison of Army Suicide Surveillance Data to Cases from 1975 to 1982

US Army suicide rates increased significantly in the last decade and have remained high. To inform future research hypotheses, Army suicide surveillance data (2012-2014) were compared to similar Army data for suicides from 1975 to 1982. Preliminary data suggest that suicide rates increased across most demographic groups, but may have decreased among divorced soldiers. Mental health utilization increased over time. Legal problems and physical health problems were identified in a higher percentage of cases in the recent data relative to the 1975-1982 era. Potential implications for suicide prevention are discussed.

Decision-Making in Suicidal Behavior: The Protective Role of Loss Aversion

BACKGROUND

Loss aversion is a central and well operationalized trait behavior that describes the tendency for humans to strongly prefer avoiding losses to making equivalent gains. Human decision-making is thus biased toward safer choices.

AIM

The aim of this study was to explore the relationship between loss aversion and suicidal behavior in a large cohort of adolescents recruited in 30 schools of seven European countries for a longitudinal study (Current Controlled Trials ISRCTN65120704). We hypothesized that individuals with higher loss aversion would be less likely to attempt suicide.

METHODS

A mixed monetary gamble task was used to generate loss aversion scores for each participant. Logistic regression was used to estimate the cross-sectional association between loss aversion and life-time suicide attempts in the baseline sample (N = 2,158; 156 attempters), and incident attempts were predicted in a 4-month prospective model (N = 1,763; 75 attempters). Multiple regression was used to estimate the association between loss aversion and suicidal ideation.

RESULTS

Loss aversion was a significant predictor of attempted suicide in both the cross-sectional (OR = 0.79; P = 0.005) and prospective analysis (OR = 0.81; P = 0.040), adjusting for depression, anxiety, stress, and sex. The correlation between pre and post measures of loss aversion was r = 0.52 (P < 0.001). Interestingly, although depression, anxiety, and stress were associated with suicidal ideation, loss aversion was not (cross-sectional model: P = 0.092; Prospective model: P = 0.390). This suggests that the concept of loss aversion may be useful in understanding the transition from suicidal thoughts to attempts.

CONCLUSION

This and previous studies suggest that altered decision-making is involved in suicide attempts. In our study, we show the involvement of loss aversion in particular, and propose that individuals high in loss aversion are discouraged from carrying out the suicide attempt because of a greater focus on the negative consequences of the decision.

Brief reasons for living inventory: a psychometric investigation

BACKGROUND

The present study aimed at validating the German version of the Brief Reasons for Living inventory (BRFL).

METHODS

Validity and reliability were established in a community (n = 339) and a clinical sample (n = 272). Convergent and discriminant validity were investigated, and confirmatory factor analyses were conducted for the complete BRFL as well as for a 10-item version excluding conditional items on child-related concerns. Furthermore, it was assessed how BRFL scores moderate the association between depression and suicide ideation.

RESULTS

Results indicated an adequate fit of the data to the original factor structure. The total scale and the subscales of the German version of the BRFL had sufficient internal consistency, as well as good convergent and divergent validity. The BRFL demonstrated clinical utility by differentiating between participants with vs. without suicide ideation. Reasons for living proved to moderate the association between depression and suicide ideation.

CONCLUSIONS

Results provide preliminary evidence that the BRFL may be a reliable and valid measure of adaptive reasons for living that can be used in clinic and research settings.

The association between attempted suicide and stock price movements: Evidence from Taiwan

This study is the first comprehensive analysis to investigate the potential association between stock market fluctuations and attempted suicide events as measured by self-inflicted injuries treated in hospitalization. Using nationwide, 15-year population-based data from 1998 through 2012, we observe that the occurrences for the hospitalizations of attempted suicides are apparently predicted by stock price movements. A low stock price index, a daily fall in the stock index, and consecutive daily falls in the stock index have been shown to be associated with increased risk of hospitalization in patients with attempted suicide. More specifically, stock price index is found to be significant impact on attempted suicide in the 45-54 age groups of both genders, whilst daily change is significant for both genders in the 25-34 and 55-64 age groups and accumulated change is only significant in female aged 25-44 and above 65. On the basis of the results, relevant organizations should consider the suicidal factors that relate prime-working-age and near-retirement-age people to better carry out specific suicide prevention measures, and, meanwhile, encourage those people to pay less attention towards daily stock price movements.

Circumstances preceding the suicide of Asian Pacific Islander Americans and White Americans

This study examined the circumstances preceding suicide among Asian and Pacific Islander Americans (APIAs) and White American decedents using data from the National Violent Death Reporting System in the United States. After controlling for gender and age, APIAs had lower rates of recent disclosure of suicide ideation, recent mental health treatment, recent mental health problems, and intimate partner problems, but higher rates of school problems than White Americans. There were also significant Race × Age moderation effects for recent mental health, financial, and school problems and a significant Race × Gender moderation effect for intimate partner problems.

Injury, Interiority, and Isolation in Men's Suicidality

Men’s high suicide rates have been linked to individual risk factors including history of being abused as a child, single marital status, and financial difficulties. While it has also been suggested that the normative influences of hegemonic masculinities are implicated in men’s suicide, the gendered experiences of male suicidality are poorly understood. In the current photovoice study, 20 men who previously had suicidal thoughts, plans, and/or attempts were interviewed as a means to better understanding the connections between masculinities and their experiences of suicidality. The study findings revealed injury, interiority, and isolation as interconnected themes characterizing men’s suicidality. Injury comprised an array of childhood and/or cumulative traumas that fueled men’s ruminating thoughts inhibiting recovery and limiting hopes for improved life quality. In attempting to blunt these traumas, many men described self-injuring through the overuse of alcohol and other drugs. The interiority theme revealed how suicidal thoughts can fuel hopelessness amid summonsing remedies from within. The challenges to self-manage, especially when experiencing muddled thinking and negative thought were evident, and led some participants to summons exterior resources to counter suicidality. Isolation included separateness from others, and was linked to abandonment issues and not having a job and/or partner. Self-isolating also featured as a protection strategy to avoid troubling others and/or reducing exposure to additional noxious stimuli. The study findings suggest multiple intervention points and strategies, the majority of which are premised on promoting men’s social connectedness. The destigmatizing value of photovoice methods is also discussed.

Time-varying associations of suicide with deployments, mental health conditions, and stressful life events among current and former US military personnel: a retrospective multivariate analysis

BACKGROUND

US military suicides have increased substantially over the past decade and currently account for almost 20% of all military deaths. We investigated the associations of a comprehensive set of time-varying risk factors with suicides among current and former military service members.

METHODS

We did a retrospective multivariate analysis of all US military personnel between 2001 and 2011 (n=110 035 573 person-quarter-years, representing 3 795 823 service members). Outcome was death by suicide, either during service or post-separation. We used Cox proportional hazard models at the person-quarter level to examine associations of deployment, mental disorders, history of unlawful activity, stressful life events, and other demographic and service factors with death by suicide.

FINDINGS

The strongest predictors of death by suicide were current and past diagnoses of self-inflicted injuries, major depression, bipolar disorder, substance use disorder, and other mental health conditions (compared with service members with no history of diagnoses, the hazard ratio [HR] ranged from 1·4 [95% CI 1·14-1·72] to 8·34 [6·71-10·37]). Compared with service members who were never deployed, hazard rates of suicide (which represent the probability of death by suicide in a specific quarter given that the individual was alive in the previous quarter) were lower among the currently deployed (HR 0·50, 95% CI 0·40-0·61) but significantly higher in the quarters following first deployment (HR 1·51 [1·17-1·96] if deployed in the previous three quarters; 1·14 [1·06-1·23] if deployed four or more quarters ago). The hazard rate of suicide increased within the first year of separation from the military (HR 2·49, 95% CI 2·12-2·91), and remained high for those who had separated from the military 6 or more years ago (HR 1·63, 1·45-1·82).

INTERPRETATION

The increased hazard rate of death by suicide for military personnel varies by time since exposure to deployment, mental health diagnoses, and other stressful life events. Continued monitoring is especially needed for these high-risk individuals. Additional information should be gathered to address the persistently raised risk of suicide among service members after separation.

FUNDING

Partly funded by the Naval Research Program.

Robin Williams' suicide: a case study

Introduction:

The world renowned comedian and four-time Oscar nominated actor Robin Williams died on August 11, 2014. From the outset, the news indicated that his death was believed to be a suicide and this was later confirmed to be true by the autopsy reports. Williams had been suffering from severe depression, which is believed to be the leading contributor to his suicide. In this case study, I will highlight the event of the actor's suicide and the main risk factors along with depression leading to his tragic death. As of the end of 2015, no other case study seemed to have addressed or explored the links between the cause (or causes) and events leading to Robin Williams' suicide.

Case description:

Robin Williams was suffering from relationship problems, financial problems, drug addiction, and major depression. All of these factors led to his suicide.

Comments:

The chances of committing suicide drastically increase in the presence of any of the key risk factors. Unfortunately, the actor Robin Williams was dealing with four of the major risk factors all together, which put him at a high risk of committing suicide and eventually led to his tragic death.

Sociodemographic Antecedent Validators of Suicidal Behavior: A Review of Recent Literature

Suicidal behavior and its prevention constitute a major public health issue. Etiology of suicidal behavior is multifactorial. Whereas current research is mostly focused on clinical and biological risk factors, the sociodemographic risk factors for suicidal behavior, first highlighted by Durkheim, have received less attention. Besides the well-known impact of age and gender, sociodemographic variables such as marital and parental status, education, occupation, income, employment status, religion, migration or minority status, and sexual orientation are repeatedly reported to play an important role in suicidal behavior. This narrative review aimed to summarize recent research on sociodemographic risk factors for suicidal behavior and to elicit possible implications for suicide prevention.

Association between the Density of Physicians and Suicide Rates in Japan: Nationwide Ecological Study Using a Spatial Bayesian Model

BACKGROUND

Regional disparity in suicide rates is a serious problem worldwide. One possible cause is unequal distribution of the health workforce, especially psychiatrists. Research about the association between regional physician numbers and suicide rates is therefore important but studies are rare. The objective of this study was to evaluate the association between physician numbers and suicide rates in Japan, by municipality.

METHODS

The study included all the municipalities in Japan (n = 1,896). We estimated smoothed standardized mortality ratios of suicide rates for each municipality and evaluated the association between health workforce and suicide rates using a hierarchical Bayesian model accounting for spatially correlated random effects, a conditional autoregressive model. We assumed a Poisson distribution for the observed number of suicides and set the expected number of suicides as the offset variable. The explanatory variables were numbers of physicians, a binary variable for the presence of psychiatrists, and social covariates.

RESULTS

After adjustment for socioeconomic factors, suicide rates in municipalities that had at least one psychiatrist were lower than those in the other municipalities. There was, however, a positive and statistically significant association between the number of physicians and suicide rates.

CONCLUSIONS

Suicide rates in municipalities that had at least one psychiatrist were lower than those in other municipalities, but the number of physicians was positively and significantly related with suicide rates. To improve the regional disparity in suicide rates, the government should encourage psychiatrists to participate in community-based suicide prevention programs and to settle in municipalities that currently have no psychiatrists. The government and other stakeholders should also construct better networks between psychiatrists and non-psychiatrists to support sharing of information for suicide prevention.

Spatiotemporal variation and social determinants of suicide in China, 2006-2012: findings from a nationally representative mortality surveillance system

BACKGROUND

Suicide in China has declined since the 1990s. However, there has been limited investigation of the potential spatiotemporal variation and social determinants of suicide during subsequent periods.

METHOD

Annual suicide counts from 2006 to 2012 stratified by county, 5-year age group (⩾15 years) and gender were obtained from the Chinese Disease Surveillance Points system. Trends and geographic differentials were examined using multilevel negative binomial regression models to explore spatiotemporal variation in suicide, and the role of key sociodemographic factors associated with suicide.

RESULTS

The suicide rate (per 100 000) in China decreased from 14.7 to 9.1, 2006-2012. Rates of suicide were higher in males than females and increased substantially with age. Suicide rates were higher in rural areas compared with urban areas; however, urban-rural disparities reduced over time with a faster decline for rural areas. Within both urban and rural areas, higher rates of suicide were evident in areas with lower socio-economic circumstances (SEC) [rate ratio (RR) 1.85, 95% confidence interval (CI) 1.31-2.62]. Suicide rates varied more than twofold (median RR 2.06) across counties, and were highest in central and southwest regions of China. A high proportion of the divorced population, especially for younger females, was associated with lower suicide rates (RR 0.60, 95% CI 0.46-0.79).

CONCLUSIONS

Geographic variations for suicide should be taken into account in policy making, particularly for older males living in rural areas and urban areas with low SEC. Measures to reduce disparities in socio-economic level and alleviate family relation stress are current priorities.