Characteristics of young rural Chinese suicides: a psychological autopsy study.

BACKGROUND: Patterns of suicide rates in China differ in many ways from those in the West. This study aimed to identify the risk factors characteristic for young rural Chinese suicides. METHOD: This was a case-control psychological autopsy (PA) study. The samples were suicides and living controls (both aged 15-34 years) from 16 rural counties of China. We interviewed two informants for each suicide and each control with pretested and validated instruments to estimate psychosocial, psychiatric and other risk factors for suicides. RESULTS: The prevalence of mental disorders was higher among the young Chinese who died by suicide than among the living controls, but was lower than among suicides in the West. Marriage was not a protecting factor for suicide among young rural Chinese women, and never-married women who were involved in relationships were about three times more likely to commit suicide than single women who were unattached. Religion/religiosity was not a protecting factor in Chinese suicide, as it tended to be stronger for suicides than for controls. Impulsivity was significantly higher for suicides than for controls. Psychological strain, resulting from conflicting social values between communist gender equalitarianism and Confucian gender discrimination, was associated significantly with suicide in young rural Chinese women, even after accounting for the role of psychiatric illness. CONCLUSIONS: Risk factors for suicide in rural China are different from those in the West. Psychological strain plays a role in suicide. Suicide prevention programs in China should incorporate culture-specific considerations.

Increased use of antidepressants and decreasing suicide rates: a population-based study using Danish register data.

OBJECTIVE: The objective of the present study was to examine if the change in the suicide rate is associated with individuals' use of antidepressants as has been suggested by ecological studies. DESIGN: Decomposition of suicide rates by antidepressant treatment group. SETTING: Population-based record linkage. PARTICIPANTS: All individuals aged 50 years and older living in Denmark between 1 January 1996 and 31 December 2000 (N = 2,100,808). MAIN OUTCOME MEASURES: Suicide rates are calculated according to current antidepressant treatment status (no treatment, tricyclic antidepressants (TCA), selective serotonin reuptake inhibitors (SSRI), other antidepressants). The change in the suicide rate during 1996-2000 was decomposed by treatment group. RESULTS: Only one in five older adults dying by suicide was in treatment at the time of death. Whereas the male suicide rate declined by 9.7 suicides per 100,000, recipients of antidepressants contributed to the decline by 0.9 suicides. Women redeeming antidepressant prescriptions accounted for 0.4 suicides of the observed reduction of 3.3 per 100,000. The average suicide rates for men receiving TCA and SSRI were 153.3 and 169.0 per 100,000 person-years, respectively. Among older women, both TCA and SSRI users had an average suicide rate of 68.8 per 100,000 over the period examined. CONCLUSIONS: Just a small proportion of older adults dying by suicide were found to be in treatment with antidepressants at the time of death. Individuals in active treatment with antidepressants seem to account for 10% of the decline in the suicide rate. Nevertheless, suicides might be prevented by more effective treatment.

Homelessness among patients with schizophrenia in rural China: a 10-year cohort study.

OBJECTIVE: To explore the frequency and risk factors of homelessness among a previously identified cohort of patients with schizophrenia in rural China. METHOD: A 10-year follow-up investigation among a 1994 cohort (n = 510) of patients with schizophrenia was conducted in Xinjin County, Chengdu, China. RESULTS: Thirty-nine patients (7.8%) experienced homelessness during the follow-up period. The rate of homelessness was 0.9 per 100 person-years during the 10-year follow-up period. Four significant predictors of homelessness remained in the final logistic regression model: living in shabby or unstable house or shelter, positive family history of mental disorders, without income of the patient, and unmarried, divorced, or separated. Risk of homelessness increased substantially with exposure to multiple risk factors. CONCLUSION: Substantial numbers of homeless patients with schizophrenia are challenges for mental health care and public health. Appropriate community-based services, especially housing services, should be crucial for prevention of homelessness in patients with schizophrenia.

Culture, risk factors and suicide in rural China: a psychological autopsy case control study.

OBJECTIVE: Previous research on sociocultural factors for Chinese suicide have been basically limited to single case studies or qualitative research with ethnographic methodology. The current study examines the major risk factors and some cultural uniqueness related to Chinese rural suicide using a quantitative design. METHOD: This is a case control study with 66 completed suicides and 66 living controls obtained from psychological autopsy interviews in rural China. RESULTS: Both bivariate analyses and the multiple regression model have found that the Chinese rural suicide patterns are basically similar to those in most other cultures in the world: strong predictors of rural Chinese suicide are the psychopathological, psychological, and physical health variables, followed by social support and negative and stressful life events. Other significant correlates include lower education, poverty, religion, and family disputes. CONCLUSION: Culture has an important impact on suicide patterns in a society.

Elderly suicide in Hong Kong--a case-controlled psychological autopsy study.

OBJECTIVE: To examine some of the risk factors for late life suicide in Hong Kong Chinese using a case-controlled psychological autopsy approach. METHOD: Informants of 70 subjects aged 60 or above who had committed suicide as well as a community sample of 100 elderly controls were interviewed. Subjects and controls were assessed for the presence of mental illness, history of suicide attempt and data on health care utilization. RESULTS: Eighty-six per cent of suicide subjects suffered from a psychiatric problem before committing suicide, compared with 9% of control subjects. Among the psychiatric problems, major depression was the commonest diagnosis. Seventy-seven per cent of suicide subjects had consulted a doctor within 1 month of suicide. One-third of suicide subjects had a history of suicide attempt. Rates of current psychiatric diagnosis, rates of medical consultation and history of suicide attempt are all significantly higher in suicide subjects than controls. CONCLUSION: Our findings support the view that depressive disorders and a past history of suicide attempt are risk factors of late-life suicide in the Chinese population of Hong Kong, similar to findings in western studies.

Suicide at 50 years of age and older: perceived physical illness, family discord and financial strain.

BACKGROUND: Mental disorders amplify suicide risk across the lifecourse, but most people with mental disorder do not take their own lives. Few controlled studies have examined the contribution of stressors to suicide risk. METHOD: A case-control design was used to compare 86 suicides and 86 controls aged 50 years and older, matched on age, gender, race and county of residence. Structured interviews were conducted with proxy respondents for suicides and controls. RESULTS: Perceived physical illness, family discord and employment change amplified suicide risk after controlling for sociodemographic covariates and mental disorders that developed > or = 1 year prior to death/interview. Only the effect of physical illness (OR 6.24, 95% CI 1.28-51.284) persisted after controlling for all active mental disorders. CONCLUSIONS: Interventions to decrease the likelihood of financial stress and to help families manage discord and severe physical illness may effectively reduce suicides among middle-aged and older adults.

Poor social integration and suicide: fact or artifact? A case-control study.

BACKGROUND: Sociological studies have shown that poor social integration confers suicide risk. It is not known whether poor integration amplifies risk after adjusting statistically for the effects of mental disorders and employment status. METHOD: A case-control design was used to compare 86 suicides and 86 living controls 50 years of age and older, matched on age, gender, race, and county of residence. Structured interviews were conducted with proxy respondents for suicides and controls. Social integration was defined in reference to two broad levels of analysis: family (e.g. sibship status, childrearing status) and social/ community (e.g. social interaction, religious participation, community involvement). RESULTS: Bivariate analyses showed that suicides were less likely to be married, have children, or live with family. They were less likely to engage in religious practice or community activities and they had lower levels of social interaction. A trimmed logistic regression model showed that marital status, social interaction and religious involvement were all associated with suicide even after statistical adjusting for the effects of affective disorder and employment status. Adding substance abuse to the model eliminated the effects of religious involvement. CONCLUSIONS: The association between family and social/community indicators of poor social integration and suicide is robust and largely independent of the presence of mental disorders. Findings could be used to enhance screening instruments and identify problem behaviors, such as low levels of social interaction, which could be targeted for intervention.

The role of drinking in suicidal ideation: analyses of Project MATCH data.

OBJECTIVE: The associations of suicidal ideation with both the intensity (drinks per drinking day) and frequency of alcohol consumption were examined in a longitudinal study of treated alcoholics. METHOD: The data are from alcohol dependent subjects (1,187 men and 374 women) enrolled in Project MATCH, a multisite clinical trial of psychosocial treatments of alcoholism. Multivariate analyses for correlated data using generalized estimating equation approaches were performed to examine correlates of suicidal ideation at study entry and at 3-, 9- and 15-month follow-up. Analyses were stratified by gender and controlled statistically for depression and alcoholism severity. RESULTS: Suicidal ideation was common among women (15.5%) and men (9.9%) entering treatment, and at least 3.6% of women and 4.2% of men reported suicidal ideation at each follow-up. There were gender patterns in suicidal ideation. In women, intensity was associated with suicidal ideation, but even nonintense drinking became associated with suicidal ideation with more frequent drinking (intensity-frequency interaction). In men, intensity was also associated with suicidal ideation, whereas frequency was unrelated. Antisocial personality disorder in men but not in women, and depression in both groups, were also linked to suicidal ideation. CONCLUSIONS: Suicidal ideation is prevalent among treated alcoholics. Drinking is strongly associated with suicidal ideation and in women even light drinking, if it occurs regularly, is associated with suicidal ideation, with implications for suicide risk-recognition and intervention.

Personality correlates of hopelessness in depressed inpatients 50 years of age and older.

In this study we examined the relationship between scores on the Beck Hopelessness Scale and the personality traits that constitute the Five-Factor Model in a sample of 77 depressed inpatients, 50 years of age and older. Multiple regression analyses showed that Hopelessness is related to low Extraversion domain scores, and to specific facets of both Extraversion (low positive emotions) and Neuroticism (low self-consciousness, high impulsiveness). Efforts to tie Hopelessness with the motivational, affective, and interpersonal constructs subsumed under Extraversion are warranted.

Emotion traits in older suicide attempters and non-attempters.

BACKGROUND: Emotion is a flourishing area of cross-disciplinary research that can inform traditional approaches to psychopathology. The present study examines emotion traits associated with attempted suicide in a depressed older sample. METHODS: Seven emotion traits were compared in depressed inpatients, age 50 years or older, who either had made a suicide attempt after age 50 (n=47) or had never made a suicide attempt (n=38) as assessed by self-report and a review of available medical records. RESULTS: In univariate analyses controlled for age and sex, late-life suicide attempters were lower in Warmth and Positive Emotions than non-attempters. However, only lower Anxiety was associated with attempter status when all seven emotion traits were included as predictors. Of the attempters, those who had made a greater number of attempts reported lower Positive Emotions and higher Anger/Hostility and Guilt, though only lower Positive Emotions had a significant effect independent of the other emotions. In a subsample of 41 patients whose index admission was precipitated by an attempt, lower Anger/Hostility was associated with higher intent to die, and lower Anger/Hostility and lower Guilt was associated with higher lethality of method. LIMITATIONS: The assessments of emotion traits may have been colored by transient moods, including, for the recent attempters, moods associated with the aftermath of their attempt. Participants who completed the key measures may not be representative of older attempters. CONCLUSIONS: Emotion traits are associated with suicidal behavior in older depressed patients, and the specific type of emotion and the direction of its association depends on the specific suicide variable examined. Emotion traits may be helpful in assessing suicide risk.

Violence, alcohol, and completed suicide: a case-control study.

OBJECTIVE: Violent behavior may represent a risk factor for suicide. The authors tested the hypothesis that violent behavior in the last year of life is associated with completed suicide, even after controlling for alcohol use disorders. METHOD: The authors analyzed data from the 1993 National Mortality Followback Survey, a nationally representative survey conducted by telephone interview with decedents' next of kin. Data on 753 victims of suicide were compared with data on 2,115 accident victims. Decedents ranged in age from 20 to 64. Dichotomous measures of violent behavior in the past year and history of alcohol misuse were derived by using the four-item CAGE questionnaire. Multiple logistic regression was used to evaluate the interactions of violent behavior with alcohol misuse, gender, and age, respectively, in predicting suicide versus accidental death. Education and race were included as covariates. RESULTS: Violent behavior in the last year of life was a significant predictor of suicide; the relationship was especially strong in individuals with no history of alcohol misuse, those who were younger, and women. CONCLUSIONS: Violent behavior distinguished suicide victims from accident victims, and this finding is not attributable to alcohol use disorders alone. Given that violent behavior increases the risk of suicide, violence prevention initiatives may serve to decrease the risk of suicide as well.

Profile of discrete emotions in affective disorders in older primary care patients.

PURPOSE: This research examined whether the frequencies of specific emotions are associated with major and minor depression in older primary care patients. DESIGN AND METHODS: Older primary care patients (N = 146), prescreened with a depression questionnaire, completed a diagnostic interview and an emotions questionnaire. RESULTS: Controlling for age, sex, and other psychiatric and medical illnesses, major depressives differed from nondepressed controls in nine emotions; minor depressives differed from controls in four emotions. Major depressives differed from the controls more in sadness, joy, and interest--but not anger, fear, or guilt--than in comparison sets of emotions. Minor depressives differed from the controls more in sadness and inner-directed hostility--but not guilt, anger, fear, joy, or interest--than in comparison sets of emotions. IMPLICATIONS: The frequencies of discrete emotions are differentially associated with major and minor depression; future research is needed to determine their specific diagnostic and treatment implications.

The validity of proxy-based data in suicide research: a study of patients 50 years of age and older who attempted suicide. I. Psychiatric diagnoses.

OBJECTIVE: To investigate the validity of best-estimate methodology for making psychiatric diagnoses among individuals who attempted suicide. METHOD: Subjects were 80 patients admitted for treatment following a suicide attempt. Psychiatric diagnoses based on structured interviews with subjects were compared with diagnoses made based on interviews with proxy respondents. In both cases, interview information was supplemented with pre-admission psychiatric and medical records to inform diagnoses. RESULTS: Diagnostic agreement, based on kappa coefficients, was substantial for major depression and bipolar disorders, and moderate for non-affective psychoses, organic mood and anxiety disorders. Agreement was substantial for substance dependence but poor for substance abuse disorders. CONCLUSION: Results support best-estimate methodology for making mood and substance dependence diagnoses in research of suicidal behavior in this age group, with potential implications for interpreting postmortem research of completed suicide.

Suicide in elders.

Older persons in the United States are at higher risk for suicide than any other segment of the population. The epidemiology and risk factors for suicide in later life and the most promising approaches to its prevention are reviewed. Available data suggest that psychiatric and physical illnesses, functional impairment, personality traits of neuroticism and low openness to experience, and social isolation are important correlates of late-life suicide. Affective illness is the risk factor with the strongest association. As treatable conditions in most cases, mood disorders are critical targets for preventive interventions. Because 70% of older adults who committed suicide saw their primary care provider within 30 days of death, the primary care setting is an important venue for intervention. Mood disorders are common in primary care practice, but often go undiagnosed and inadequately treated. One important approach to late-life suicide prevention, therefore, is to optimize the ability of primary care providers to diagnose and treat late-life mood disorders and suicidality effectively. Other elders at high risk have no active relationship to primary care. Strategies designed to identify this group and provide them with preventive services through outreach to the community have shown promise as late-life suicide prevention measures as well.

Suicide in the elderly.

Suicide is a major public health problem, with rates rising to their highest levels in many countries and cultures during the second half of life. The risk factors that contribute to later-life suicide are distinctive from those in younger populations. This paper reviews a variety of potential approaches for effective suicide prevention among elders, and considers as well both age-specific and general barriers that impede such efforts. It proposes that future effective measures will need to integrate public health and individual-oriented therapeutic approaches to intervention, and that specific efforts will need to be developed to address the natural history of suicidal processes.

Suicide and Alzheimer's pathology in the elderly: a case-control study.

BACKGROUND: The single most important risk factor for Alzheimer's pathology is age. Elderly individuals are also at increased risk for suicide, but comprehensive studies of the association between Alzheimer's pathology and suicide are lacking. We designed the current study to determine if Alzheimer's disease changes are overrepresented in elderly people committing suicide. METHODS: The design is a case-control study. Cases (n = 28) were subjects older than 60 years of age who completed suicide. For each case, two age- and gender-matched individuals who died naturally were selected as control subjects (n = 56). Neuropathologic examination of hippocampal sections was performed blindly and included a modified Braak scoring system and semiquantitative assessment of neurofibrillary tangles, amyloid deposition, Lewy bodies, and Lewy-associated neurites. Data were analyzed by conditional logistic regression. RESULTS: The brains of individuals who committed suicide had higher modified Braak scores than those of matching control subjects (p =.0028). The number of neurofibrillary tangles in CA1 was not an independent predictor of suicide status in the statistical analysis (p =.16), although the distribution was more highly skewed among the cases (75th percentile of 10.5 for cases, vs. 2 for control subjects). CONCLUSIONS: Severe Alzheimer's disease pathology is overrepresented in elderly patients who complete suicide.

Psychological vulnerability to completed suicide: a review of empirical studies.

Retrospective research shows that close to 90 percent of suicides have a diagnosable psychiatric disorder; however, only a small proportion of individuals with psychopathology take their own lives. This article reviews the empirical literature on psychological vulnerability to completed suicide. A search of the MEDLINE and PsycINFO databases yielded 46 cohort or case-control studies that used standardized or structured assessments of psychological dimensions. Five constructs have been consistently associated with completed suicide: impulsivity/aggression, depression, anxiety, hopelessness, and self-consciousness/social disengagement. Current knowledge of psychological vulnerability to completed suicide could inform social and neurobiological research, and thereby deepen understanding of suicide while potentially bridging these areas of study.

The validity of proxy-based data in suicide research: a study of patients 50 years of age and older who attempted suicide. II. Life events, social support and suicidal behavior.

OBJECTIVE: To investigate the validity of proxy respondent reports of stressful life events, social support and suicidal behavior among individuals who attempted suicide. METHOD: Subjects were 80 psychiatric in-patients admitted following a suicide attempt. Data based on structured interviews with proxy respondents were compared with data based on interviews with subjects (gold standard). RESULTS: Specificity was higher than sensitivity across life event categories, and agreement was substantial for public and observable events (e.g. parent's death) but lower for more ambiguous events. Proxies were good judges of subject reports of frequency of social interaction but not perceived emotional support. Proxies were good judges of past history of suicide attempts and level of suicidal intent. CONCLUSION: Results support proxy-based data on suicidal behavior and certain aspects of social support and stressful life events in research of suicidal behavior in this age group, with potential implications for interpreting postmortem research of completed suicide.