Mental Disorder Characteristics And Risk Factors Of Rural Young Suicides In China

Backgroud"Suicide is applied to all cases of death resulting directly or indirectly from a positive or negative act of victims himself, which he knows will produce this result." Every year approximately1,000,000people die by suicide. The rate of suicide is16per100,000people, accounting for one suicide case in every40seconds. In China suicide rate (1995-1999) is23.2per100,000people and suicide is the fifth common cause of death. Suicide is still a major public health issue and social problem though suicides rate is in a declining tendency in China.Compared with the Western countries, there are four unique characteristics of Chinese suicide:(1) Regional:Rural suicide rates are two-fold to three-fold greater than the urban suicide rates. However, it is no significant different in the West.(2) Age:Likely with the West, there are two peaks in the curve of suicide rate among different ages,15-34age group and over60age group. However, The rural suicide rate is four-fold to five-fold than urban among those suicides older than60.(3) Gender:Suicide rate of male is little higher than female’s, the male/female suicide ratio is1.1:1. However, in the West, the ratio is three-fold to five-fold.(4) Mental disorder:In China only30%-63%suicide cases were associated with mental disorder while the association rate was90%in the West.According the unique characteristics of Chinese suicide, Prof. Zhang Jie put forward the Strain Theory for Suicide. The Theory is the best model to understand and explain the unique characteristics of Chinese suicide. The strain theory of suicide postulates that conflicting and competing pressures in an individual’s life usually precede a suicide. Strain makes individual feel pain and hopelessness and causes mental disorder or suicidal behavior. Mental disorder is the most important risk factor of suicidal behavior. However, in these20years, suicides rate is in a declining tendency while the prevalence rate of mental illness is in an upward trend. The opposite tendencies of suicide rate and mental disorder rate indicate that it is necessary to understand the characteristics and risk factors with and without mental disorder and review the effect of metal illness in Chinese suicidal behavior.Objectives(1) To compare characteristics and risk factors of15-34years old rural suicides with and without mental disorders.(2) To explore the effect of mental disorder on Chinese suicidal behavior.(3) To explore the effect of strain on mental disorder and suicidal behavior.(4) To explore the possibility of the Strain Theory for Suicide and the Social Reference Theory for prevention suicide.Methods1. Subjects and MethodWe randomly selected16counties or cities in Hunan, Liaoning and Shandong provinces. Then consecutively sampled rural residents aged15-34years who died by suicide during the period through October2005to June2008. The rural living residents at the same age range were randomly sampled as controls of those suicides. Totally392suicides and400controls were included in this study.2. Instruments2.1General Information:gender, age, educational years, marital status, personal and family annual income, religion, physical diseases, family suicide history, pesticide stored in the family.2.2Semi-Structured Interview about Suicidal Story:suicidal time, suicidal site, suicidal method; things happened before and after suicide, aspirations of suicides, ect.2.3Suicidal Behavior Characteristics:We used the first8items of Beck Suicide Intent Scale to measure the intensity of death intent among suicides.2.4Psychological Traits:Beck Hopelessness Scale (1974, BHS), Dickman Impulsivity Inventory (DII), State-Trait Anxiety Inventory (STAI) and Coping Response Inventory (CRI).2.5Life Events:Based on the Paykel Life Events Scale (1971, IRLE), we added20 items to the original44items so that totally64items were used to record events for one year before suicide or the interview.2.6Social Support:Duke Social Support Index (DSS1) was used.2.7Mental disorders:the Structured Clinical Interview for DSM-Ⅳ Axis I Disorders Research Version (SCID-I) was used.3. Statistical AnalysisSPSS16.0was used for data analysis. For numerical variables, t test, t’ test or Mann-Whitney U test were applied according to the distribution types of data. For categorical variables, Pearson Chi-square test and Fisher’s exact test were used to estimate the probabilities. Rayleigh test was used for testing whether the central tendency existed in suicide date and time. Multivariate Logistic regression models were applied to discuss risk factors for suicide among rural young with and without mental disorders, respectively. The Classification Tree Analysis was used to explore the cluster characteristics of rural youth at high risk of suicide with and without mental illness.ResultsTotally392suicide cases and400controls were entered into the study.1. General InformationThere were significant differences between suicides with or without mental illness and controls in educational years, marital status, personal and family annual income, status in the family, superstation believing, party member, physical diseases, family suicidal history and family pesticide store. There were significant differences between suicides with mental disorder and controls in gender and age. And in gender, age, family annual income, status in the family and physical diseases, suicides with and without mental illness had significant differences.2. Suicidal behaviorCompared with suicides with mental illness, victims without mental disorders had lower SIS total score (P=0.001), easier to intervention (P=0.004) and discovery (P=0.048), fewer final acts in anticipation of death (P=0.003), fewer active preparation for suicide (P=0.002), and more overt communication of intent before suicide (P<0.001).The first5means used by suicides with mental disorders were:pesticides112(59.6%), hanging25(13.3%), drowning11(5.9%), other kinds of poison10(5.3%), overdoes7(3.7%). And the first5means used by victims without mental illness were:pesticides148(72.5%), other kinds of poison17(8.3%), hanging16(7.8%), drowning9(4.4%), overdoes5(2.5%). The most common means used by both suicides with and without mental illness was pesticide ingestion. However, compared with suicides without mental illness, suicides with mental disorders were more likely using the violent ways (P<0.001).It is significant different of the peak date for suicides with and without mental disorder.3. Psychological traitsCompared with controls, suicides with or without mental illness had relatively higher level of hopelessness and trait anxiety. And compared with victims without mental disorders, suicide with mental illness had relatively higher level of hopelessness and trait anxiety.Suicides with or without mental disorders had higher level of the total score on impulsivity and dysfunctional impulsivity than controls. Suicides with mental disorders had lower score on functional impulsivity (P<0.001) than victims without mental disorders and controls, and the latter two groups had no significant difference with each other in the functional impulsivity (P=0.598). Suicides with mental disorders had lower score on dysfunctional impulsivity than suicides without mental illness (P=0.005).Suicides with or without mental illness had lower score on Approach Coping than controls, and suicides with mental disorders had lower score than the without (P=0.044). Suicides with or without mental illness had higher score on Cognitive Avoidance, Acceptance/Resignation, and Emotional Discharge but lower score on Seeking Alternative Rewards (P<0.001) than controls. Suicides with mental illness had higher score on Acceptance/Resignation (P=0.001) but lower score on Seeking Alternative Rewards than the without (P<0.001).4. Negative life eventsThere was699and with an average of3.7negative life events occurred in suicides with mental illness group, and the number was623and with an average of3.1in suicides without mental illness group, and405and with an average of1.0in controls group. Same negative life event had different effect level on the three groups. Suicides with and without mental disorders had higher level of total stimulation amounts of life events (P<0.001) than controls, and suicides with mental illness had higher level of total stimulation amounts of life events than victims without (P<0.001).5. Social supportSuicides with and without mental illness had lower social support than controls (P<0.001). Suicides with mental disorders had lower social support than suicides without mental illness (P<0.001), either.6. Multivariate analysis results of risk factors for suicide among rural youngFor rural young suicides with mental illness:high scores of Dysfunctional Impulsivity, Feelings about the Future (Hopelessness Scale), Loss of Motivation (Hopelessness Scale), Acceptance/Resignation (CRI), low personal income, low scores of Functional Impulsivity, Seeking Guidance and Support (CRI), Seeking Alternative Rewards (CRI), Negative Life Events about Love, Healthy, or be Beaten increased risks of suicide.For rural young suicides without mental illness:high scores of Dysfunctional Impulsivity, Feelings about the Future (Hopelessness Scale), Expectation with Hopelessness (Hopelessness Scale), low level of education and personal income, un-marital status, low score on Seeking Guidance and Support (CRI), Seeking Alternative Rewards (CRI), Negative Life Events about Love, or Heated Argument with Family Members increased risks of suicide.7. Cluster characteristics of rural youthFor rural young suicides with mental illness:(1)62.0%victims were with the score of Feelings about the Future>20.0and Loss of Motivation>29.0;(2)22.7%victims with Feelings about the Future>20.0and Loss of Motivation≤29.0;(3)13.3%victims with Feelings about the Future≤20.0, personal annul income<10,000Yuan, and Seeking Alternative Rewards≤13.0.For rural young suicides without mental illness:(1)40.0%victims were with the score of Feelings about the Future from17.0to24.0and Expectation with Hopelessness>14;(2)30.9%with Feelings about the Future>24.0;(3)12.1%victims with Feelings about the Future≤17.0and Dysfunctional Impulsivity>5.0;(4)9.1%victims with Feelings about the future scored between17.0and24.0, and Expectation with Hopelessness≤14.0;(5)7.9%victims with Feelings about the Future≤17.0and personal annul income<10,000Yuan.8. Suicidal storiesWe got364suicidal stories in our study and we concluded12suicidal reasons (the first10were the reasons of mental illness when the illness first time occurred):inferiority, physical illness, accident occurred in close relationship, further studies failed or learning pressure, economic or business stress, stigma, physical injuries, interpersonal crisis, freedom restriction, emotional crisis, suicidal behavior as a way to control others, influenced by mental illness or alcohol. Such reasons were life events and reflect as strains which were the reason of mental illness and suicide.Conclusions1. Characteristics of suicidal behaviorCompared with young rural suicides without mental illness, suicides with mental disorders were more likely male, elder, lower family income, lower family status, worse physical health, lower level of social support, higher hopelessness and anxiety, lower impulsivity, lower score on Positive Rreappraisal and Seeking Alternative Rewards, higher score on Acceptance/Resignation, higher level of total stimulation amounts of life events; and the suicidal behavior were more likely with preparation and violent means. Though they were died by suicide, they had so many different characteristics just mentioned above, so that it is better to prevent suicide using different measures focusing people with and without mental illness.2. Risk factors of young rural Chinese with mental illnessLow personal income, low level of Functional Impulsivity, high level of Dysfunctional Impulsivity and Hopelessness, low scores on Seeking Guidance and Support and Seeking Alternative Rewards, high score on Acceptance/Resignation, negative life events about emotion or health were risks of suicide for young rural Chinese with mental illness.3. Risk factors of young rural Chinese without mental illnessLow personal income, low level of education, un-marital status, high level of Dysfunctional Impulsivity and Hopelessness, low scores on Seeking Guidance and Support and Seeking Alternative Rewards, high score on Acceptance/Resignation, negative life events about emotion or heated argument with family members were risks of suicide for young rural Chinese without mental illness.4. Cluster characteristics of high risk rural youthLow personal income and high level of Hopelessness were the characteristics of high risk young rural Chinese with and without mental illness. Low level of Seeking Alternative Rewards and high level of Dysfunctional Impulsivity were the unique characteristic for rural youth with and without mental illness, respectively.5. The effect of mental illness on the suicidal behaviorMental illness likely made individual’s functional impulsivity decrease; and with the low level of Approach Coping and Seeking Alternative Rewards, hopelessness increased.6. The strain theory for suicide and the Social Reference TheoryStrain caused mental illness and suicidal behavior. It is a good way by changing reference to decease strain and then to prevent mental illness and suicidal behavior.Innovation and SignificanceIt’s the first time to compare the characteristics of suicidal behavior and risk factors for suicide with and without mental disorders systematically in domestic. This study took the lead on the comparison of differences and similarities of risk factors for suicides with and without mental illness, therefore provided a useful reference for making more targeted suicide prevention and intervention strategies for our country.It’s the first time to use the suicidal stories to find the reasons caused the suicidal behavior. This study testified that strain happened before mental illness and suicidal behavior. Strain was the reason of mental illness and suicide. The Strain Theory and the Social Reference Theory are good to understand and explain the unique characteristics of Chinese suicide. It is a good way to prevent suicides through deceasing individual’s strain level by changing reference.