Outcome And Risk Factors Of Attempted Suicide In Rural China:a Prospective Study

1 BackgroundSuicide is a public and social problem worldwide.Suicide brings huge economic and psychological burden to families and society.Global suicide report by World Health Organization in 2012 declared that:?The suicide rate in the whole was 11.4 per 100,000 with nearly 804,000 died of suicide;?The suicide rate of the males and the females was 15.0 and 8.0 per 100,000,respectively;?The elderly above 70 years old had the highest suicide rate in the most area worldwide;?Suicide was the second leading death in the age group of 15-29;?The rate of attempted suicide was 40 times higher than that of suicide on the whole.In recent decades,the suicide rate of China and Shandong Province is obviously decreasing.The ratio of rural/urban and female/male is decreasing simultaneously.Although the two peaks of the suicide rate associated with age in the end of the 20th century disappears,the suicide rate of the elderly is still high and has increasing trend.Suicide is a complicated behavior.Risk factors of suicide mainly include personality,individual and socio-economic factors,psychiatric and psychological factors,genetic factors and biological factors.It is estimated that the rate of suicidal behaviors among suicide attempters is about 10%-30%.Attempted suicide is the most important risk factor of the following suicide and attempted suicide.Many studies have found that repeated suicidal behaviors are associated with mental disorders,younger age,experiencing negative life events and so on.Violent suicide methods used in the first suicide attempt may lead to repeated suicidal behavior.However,the relationship between gender and repeated suicidal behavior is not identified and need more researches to certify.2 Objectives(1)To assess methods used to investigate suicide attempters and controls in the follow-ups in this study;(2)To describe the differences of socio-economic,psychological and psychiatric factors between suicide attempters and controls in the first interview and follow-ups;(3)To explore the change of important risk factors associated with attempted suicide;(4)To estimate suicide rate and explore the chacteristics and risk factors of repeated suicidal bahavior.3 Methods3.1 Subjects and procedure of investigationThe investigation sites of the first interview were chosen from three rural counties in the Disease Surveillance Points of Shandong Province,including Tengzhou,Ningyang and Penglai.All the villages in the three counties were used to collect suicide attempters from October 1,2009 to March 31,2011.The information of suicide attempters was derived from medical charts and reports from different level hospitals in the counties.Workers of local Centers for Disease Control and Prevention(CDC)were responsible to verify and collect attempted suicide.1:1 paired controls were also collected from the three counties matched with similar age(no more than 3 years),same gender,same village,no genetic relationship and without suicide history.The follow-up studies interviewed all the individuals from the first investigation,including the suicide attempters and controls.We interviewed subjects themselves and informants instead if subjects themselves were loss to follow up.This method could improve the rate of follow-up,The first follow-up was conducted from October to December in 2012 and the second was from October to December in 2016.We all used questionnaires in the first interview and follow-ups by face to face interviews.All the interviewers were trained before investigation.The spots of investigation were in the hospital of town,clinic or home of informants.We did not begin to interview until the informed consents were got.3.2 InstrumentsThis study used questionnaires structured with basic information,standard scales and instruments diagnosing mental disorders.It included basic information questionnaire,suicidal behavior questionnaire(including Suicide Intent Scale),Psychological Strain Scale,Life Event Scale,psychological scales(Duke Social Support Index,Self-esteem Scale,Center for Epidemiologic Studies Depression Scale and State-Trait Anxiety Inventory)and Structured Clinical Interview for DSM-?.In addition,repeated suicidal behavior scale was added to the follow-ups.3.3 Statistical analysisWe used SPSS 16.0 to carry out statistical analysis.X2 test,t test or U test were used for characteristics comparison.Generalized Estimating Equation was used to analyze changing situation of risk factors associated with attempted suicide and risk factors of repeated suicidal behaviors.4 Main results4.1 Reliability evaluationBasic information and psychological characteristics were similar between targets and matched informants.Informant interviewing could better reflect information of targets.In addition,there was no difference among three interviews considering age and gender distribution.Cronbach's a of scales used in this study were mostly above 0.7,which reflected better reliability.4.2 Comparisons between suicide attempters and controls in the first interview and follow-upsDifferences of demographic factors were not significant in the follow-ups.Whereas the differences of negative life events,social support,self-esteem,depression,anxiety and mental disorders were still statistically significant.4.3 Changing situation of risk factors associated with attempted suicideCompared with first interview,the rate of negative life events associated with attempted suicide had a decreasing trend both in the first follow-up(RR=0.165,95%CI:0.099-0.275),and in the second follow-up(RR=0.238,95%CI:0.142-0.399).The second follow-up had an increasing trend compared with the first follow-up.There was no statistically significant difference associated with controls.The prevalence of mental disorders associated with attempted suicide had a decreasing trend in the follow-ups(First follow-up,RR=0.477,95%CI:0.293-0.778;Second follow-up,RR=0.290,95%CI:0.181-0.463).There was no statistically significant difference associated with controls.Compared with the first interview,the score of social support associated with attempted suicide had an increasing trend in the first follow-up(RR=8.742,95%CI:3.214-23.775);and no statistically significant difference in the second follow-up.Compared with the second follow-up,the score of social support associated with attempted suicide had an increasing trend in the first follow-up(RR=12.705,95%CI:3.784-42.656).There was no statistically significant difference associated with controls.There was no statistically significant difference associated with trend of self-esteem score associated with attempted suicide.Compared with first interview,the score of depression associated with attempted suicide had a decreasing trend in the follow-ups.There was no statistically significant difference associated with controls.Compared with the first interview,the score of social support associated with attempted suicide had a decreasing trend in the first follow-up(RR=0.021,95%CI:0.003-0.128),and no statistically significant difference in the second follow-up.Compared with the second follow-up,the score of social support associated with attempted suicide had a decreasing trend in the first follow-up(RR=0.021,95%CI:0.003-0.133).The changing trend associated with controls was similar with attempted suicide.4.4 Characteristics and risk factors of repeated suicidal behaviorsThe incidence density of repeated suicidal behavior in the two follow-ups is 1.57/100 and 1.41/100 personal years.The elderly had higher incidence density than the non-elderly.The elder male had the highest incidence density.There was nearly no difference between the first and repeated suicidal behavior.Suicide methods used in the first suicide were mainly ingesting pesticide(79%).Although ingesting pesticide was still the most used methods(36%)in repeated suicidal behavior,the methods began to be diverse and incline to violent suicide methods.Compared with suicide only once,suicide above once had the characteristics of advancing age,anxiety,physical illness and mental disorders.There were 11 repeated suicidal behaviors,including 7 suicide once,3 suicide twice and 1 suicide three times.Advancing age(RR=1.047,95%CI:1.007-1.088),anxiety(RR=1.050,95%CI:1.015-1.087)and mental disorders(RR=26.245,95%CI:3.170-217.305)were the risk factors of repeated suicidal behavior.5 Conclusions(1)Informant is a good substitution for target if target is loss to follow up.While the inclusion criteria of informant must be controlled.(2)The differences of psychiatric and psychological condition are statistical significances between suicide attempters and controls after first suicidal behavior.Compared with first interview,the overall psychiatric and psychological status of suicide attempters are better in the follow-ups.(3)The incidence density of repeated suicidal behavior is higher.The elderly has higher incidence density than the non-elderly.(4)Compared with attempted suicide once,suicide above once has a poor psychological and psychiatric condition.(5)Risk factors of repeated suicidal behavior are advancing age,anxiety and mental disorders in rural Chinese.