| BackgroundSuicide or Completed Suicide refers to the behavior by individuals who fully understand the fatal consequences of this action and choose conscious self-destructive behavior leading to their death. Each year about 100 million people died by suicide in the world, and the number of attempted suicides was 10 times more than completed suicide. In China, suicide was the number 1 cause of death for individuals aged 15-34, and about 93% of those suicides occurred in rural areas. Suicide as a social phenomenon is an important public health problem in terms of sociology, psychology, biology and medicine.In the West, suicide research has been conducted over a long period of time, and researchers have discovered many risk factors including mental illness, suicide attempt history, physical illness, chronic or acute relationship problems, stressful life events, low socioeconomic status, being single, unemployed and so on. Mental illness was the most important risk factor for suicide where about 90% of the people who committed suicide suffered from one or more mental disorders. Suicide research in China was far behind that in the West. According to Chinese epidemiological investigations, the prevalence of Chinese suicides had three characteristics:1) the suicide rate for women was higher than that of men. Chinese women's suicide rate was 1.25 times that of men; 2) the rural suicide rate was much higher than the urban rate. The rural suicide rate was 3.27 times of that in urban areas; 3) the age curve for the overall suicide rate showed two peaks, the first suicide peak was 15-34 years old, and the second peak was above 60 years old. Recently the prevalence of Chinese suicide has changed. That change mainly showed that the male suicide rates tended to be close to or higher than female rates, and the gap of suicide rates between urban and rural locations had been narrowed. But, it was still recognized that the rural suicide rate continues to be higher than urban, there was still a 15-34 years peak, and suicide was still a social phenomenon, caused by various factors. Some researchers found that people who had higher depression scores 2 weeks before committing suicide, history of suicide attempts, acute stress intensity, poor quality of life, serious chronic psychological stress, severe interpersonal conflict, friends or acquaintances who had had suicidal behavior, constituted the major risk factors for potential suicides or for suicidal people.Based on the sociological, psychological, and biological point of view, Western scholars had put forth a lot of suicide theories, which had gone mainly in three directions:First, in the area of sociology, represented by Durkheim. In the view of Durkheim, the cause of an individuals' suicide experience stems from a lack of "social adaptability." He proposed the concepts of "social integration" and "social anomie," and he introduced four different types of suicide:the self-serving type of suicide (Egoistic Suicide), the altruistic type of suicide (Altruistic Suicide), a violation type of suicide (Anomic Suicide) and the fate type of suicide (Fatalistic Suicide).Second, in the area of psychology and social psychology, this was determined to be the dominant suicide theory. There were several other differing emphases in that psychology and social psychology theory also included Psychoanalytic theory, Behavior theory, Structural theory and Cognitive theory. Psychoanalytic theory considered that suicide was a failure response, due to excessive development of the superego, long-term psychological conflicts which consumed excess energy and ultimately led to death. Behaviorists believed that suicide was due to lack of learning. Cognitive theorists believed that in the cognitive process problems or frustrations were internalized and negative emotions emerged. The negative emotions resulted in a long-term reduction in cognitive awareness which ultimately lead to suicide.Third, in the area of biology, including neurobiology and the relationship between genes and suicide, researchers found that insufficient levels of serotonin may cause depression and eventually suicide, specifically impulsive suicide. In recent years, researchers had found that some gene loci, such as the serotonin transporter gene and the tryptophan hydroxylase gene, might have a strong correlation to suicide. Recently, genetic studies of suicide have taken a new direction. Most theoretical models had been integrated according to social, psychological, and mental health risk factors, and most were complex, and difficult to verify by quantitative method. Most of the theories were based on western psychological characteristics and social conditions and they could not explain the exact cause of Chinese suicides under their unique social and cultural Chinese background. Thus, Professor Zhang Jie created the Strain Theory of Suicide to explain the specific, root causes of Chinese suicides. Strain theory originated from inconsistent pressure, which came from two or more competing ideas or social experiences of individuals. Strain was different from normal pressure and there must be multiple stressors contributing to strain. There were four different sources of Strain:1) Conflict between different values. When people agreed with conflicting values at the same time they will experience an inordinate amount of uncoordinated pressure.2) Deviation of aspirations and reality. When there were wide gaps between personal aspirations and the difficulties of reality, people experience a troubling, mismatched set of pressures. 3) Relative deprivation. When it was discovered that other people with the same or similar backgrounds enjoyed a superior situation than theirs, they will experience a troubling mismatched set of pressures.4) The lack of coping skills while facing to crisis. People facing a serious crisis while lacking appropriate coping skills, will experience uncoordinated pressure and strain. Strain theory fully considered interactions between social, psychological and mental factors.Most researchers believed that Strain theory was the root source of suicide. Strain might directly lead to suicidal ideation or attempted suicidal behavior. Strain might lead to depression, schizophrenia and other serious mental disorders, and then lead to suicide. Mental disorders might be the intermediate variable between Strain and suicide and social and psychological factors might be modification factors in the relationship of Strain and suicide. The social psychological factors might be a synergistic effect (risk factors), or an antagonistic effect (protective factors). Objectives1. To measure the Strain level for Chinese rural young adults aged 15-34 according to the existing measurement tools, and to compare the differences of Strain experience between rural youth suicide and normal controls.2. To explore the relationship between different types of Strain and suicide, and to evaluate the impact of Strain on rural young suicide.3. To study relationship between the various types of Strain and social/psychosocial factors and mental disorders.4. To explore and verify the suicide Strain theory using structural equation modeling techniques.MethodThe case-control study was adapted and a psychological autopsy method was used to collect information on Chinese rural, young adults aged 15-34. We chose Shandong, Liaoning and Hunan provinces as the study areas and 16 counties were randomly selected using by sequential sampling. The study was conducted from October 1,2005 to June 30,2008, and the individuals who completed suicide aged 15-34 were included as the case group, while in the same community, normal living people of the same age were randomly selected as controls. The list of suicide originated from the death monitoring system of the Chinese Center for Disease Control and Prevention. The survey was completed on 392 completed suicides and 416 living controls.For each suicide case, two knowledgeable informants were selected to provide the information. The principles of choosing effective informants were choosing the person who knew the deceased person best or at least very well. The first survey informants were normally family members of the deceased person, such as parents, siblings, or spouses, etc. Second choice informants were generally close friends or nearby neighbors. For each normal living control, we also selected two similar informants, so the principle of choosing informants was the same as that for the case group. In order to avoid people's bereavement reactions or intense emotions and to reduce information bias, we interviewed these informants 2-6 months after the suicide. Face to face interviews were facilitated to collect information using questionnaires.The survey involved in these interviews included:1) the general situation, including gender, age, residence location, ethnicity, years of education, marital status, whether or not living alone, family size, employment status, family income, religion, physical illness, family history of commit suicide, family history of mental illness, etc.; 2) half-set interview outline, including the process of suicide, the events before and after commit suicide, what specifically happened to cause people to commit suicide, whether the suicide subject was very disappointed, etc.; 3) Strain measurement scales were used, including the Desire to Achieve Aspiration, Relative Deprivation, Coping Resources Inventory(CRI), the Criterion of Confucianism Affect on Men, the Criterion of Confucianism Affect on Women, Values Conflict Scale, etc.; 4) social and psychological questionnaires, including Life Event Scale, Social Support Inventory, Dickman Impulsivity Inventory (DⅡ), Trait Anxiety Inventory (State-Trait Anxiety Inventory, STAI), etc.; 5) mental disorder questionnaires, including Beck Hopelessness Scale (BHS), Hamilton Rating Scale for Depression (HAM-D), and Structured Clinical Interview for DSM-Ⅳ(SCID).Results1. The prevalence for Strain existed both in the suicide and control groups, and there were significant differences between the suicide and the control groups in the 8 variables measuring Strain. In the suicide group, the scores of the Strain for Relative Deprivation (3.62±0.92), the Criterion of Confucianism Affect on Women (2.98±0.57) and the Strain for Deviation of Aspirations and Reality (2.90±1.35) were higher in the suicide group. The scores of Strain for Relative Deprivation (3.03±0.58), the Criterion of Confucianism Affect on Men (2.70±0.56) and the Strain for Deviation of Aspirations and Reality (2.55±1.48) were higher in control group. The scores for Strain experienced in the suicide group were significantly higher than that in the control group (P<0.001 or P=0.001).2. In the suicide group, the scores for Strain of Relative Deprivation between women and men were significantly different (3.73 vs.3.49, P=0.01). The scores for Strain of the Criterion of Confucianism Affect on Women were significantly different (3.05 vs.2.89, P= 0.008) between men and women. The scores for Weak Concept of Gender Equality were significantly different (1.79 vs.1.63, P<0.001) between men and women. In the control group, only the scores for Strain of the Weak Concept of Gender Equality were significantly different (1.67 vs.1.56, P= 0.007) between men and women.3. Considering the Strain, psychosocial and mental factors, multivariate logistic regression analysis was conducted in the whole sample, and ultimately 12 variables were extracted into the equation. Those variables were:Weak Positive Coping (OR= 5.020), Values Conflicts (OR= 0.538), Marital Status (OR= 0.336), Caucus Relationship (OR= 0.408), Family History of Suicide (OR= 3.317), Family Status (OR= 0.571), Negative Life Events (OR= 1.376), Years of Education (OR= 0.844), Dysfunctional Impulsivity (OR= 1.176), Hopelessness (OR= 2.339), Depression (OR= 9.141) and Mental Illness (OR= 4.787). We also conducted multivariate logistic regression analysis for men, and there were 10 variables extracted into the equation, including the Strain of Relative Deprivation (OR= 1.767), Strong Negative Coping (OR= 2.646), Weak Positive Coping (OR= 3.772), Values Conflicts (OR= 0.399), The Relationship With Their Parents (OR= 1.924), Years Of Education (OR0.715), Dysfunctional Impulsivity (OR= 1.162), Hopelessness (OR= 1.113), Depression (OR= 37.871) and Mental Illness (OR= 8.385). The multivariate logistic regression analysis was also conducted in women, and there are 9 variables. Those variables were Weak Positive Coping (OR= 7.337), Marital Status (OR= 0.213), Caucus Relationship (OR= 0.192), Family Status (OR= 0.315), Negative Life Events (OR= 1.624), Dysfunctional Impulsivity (OR= 1.213), Hopelessness (OR= 1.150), Depression (OR= 11.123) and Mental Illness (OR= 3.833).4. Considering the Strain, psychosocial and mental factors, we constructed structural equation model for rural, youth suicide in China. In the path diagram, where factors pointed at suicide, mental disorders had the largest path coefficient which was 0.73, followed by Strain whose path coefficient was 0.67, and the path coefficient of social psychological factors was 0.66. Strain factor and social psychological were strongly correlated with each other and the correlation coefficient was 0.84, the path coefficients for the Strain factor and mental disorder was 0.62.Conclusions1. Both in the suicide group and the living control group, relative poverty was the most important issue leading to suicide. Hoping to get rich was the most pressing issue in people's minds and people were highly likely to experience the Strain of relatively poverty and its related pressures ending in suicide. The Strain of relative deprivation was the most important Strain experience. Deprived rural people with limited capacity would find it harder to achieve their aspiration or, in reality, the difficulties perceived by deprivation hindered their desire to achieve, thus it was generally easy, almost natural, for them to feel the Strain of deviation of their aspirations and their reality. In women, the variables of strong negative coping, values conflicts and the concept of gender equality (the weaker sex) were the three significant Strain variables both in the suicide and the control group. This indicated that while facing crises, negative coping skill might be at the same level for suicidal women and the women control group, and may be relatively lower than men. Women might generally agree with the concept of gender equality and that would lead to a relatively small Strain experience. Men were more likely to experience the Strain of relative deprivation. Recently, the status of women has become more enhanced and gender equality has become more popular. Men might experience more Strain as a result of such change.2. Considering all the various risk factors for suicide, mental disorders were still the most important risk factor in this research sample. Meanwhile, lack of proper and positive coping capacity was also a very important, high risk factor. Comparing high risk factors between men and women, we conclude that the impact of Strain experience for men might be greater than that for women. For men, the impact of the Strain of relative deprivation might be higher than that for women. Men might be more susceptible to realistic issues, such as financial or material impact. Both men and women might commit suicide because of the lack of positive coping skills while facing a serious crisis; however, the ability of men to withstand such a crisis might be weaker than that of women, because male suicide attempts were caused by a lack of positive coping skills but they could also choose an incorrect, negative response while stressed and facing the crisis. That decision and consequent behavior could also lead to suicide--the most extreme action to avoid reality and to avoid dealing with reality.3. Through this research and the final model we could infer that Strain was a very important risk factor in rural young suicide; Strain experience might also affect mental disorders, and Strain might lead to suicide by influencing an individuals' mental status. There was a strong relationship between Strain and social psychological factors, and social psychological factors might directly lead to suicide or they could lead to a Strain experience resulting in suicide.4. This study comprehensively considered the distribution of Strain experience in Chinese rural young adults, and 8 variables were constructed to measure the status of Strain experience. The differences of Strain experiences between suicide and the controls were compared, and the impact of Strain experiences on suicide was comprehensively measured. Epidemiological methods and social psychology theory were combined to explore risk factors for Chinese rural young suicides, and the theoretical model of suicide was preliminarily established using structural equation modeling techniques. This was the first research in which the suicidal theoretical model was successfully verified using quantitative techniques. |
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