| Background Suicide has been one of major social and public health issues worldwide.Over the past two decades,the suicide rates in China have generally shown a marked downward trend.The decline of suicide rate in rural areas is faster than that in urban areas,and that in females is faster than that in males,especially in rural areas.In the past,suicidal theories mainly explained the suicidal mechanism from biomedicine,psychopathology and sociology,but it was difficult to explain the characteristics of suicide in China different from those in Western countries.In China,suicide rate is higher in rural areas than in urban areas,higher in females than in males,with low prevalence of mental disorders,double peaks of age and strong impulsiveness.Professor Zhang Jie,a sociologist,put forward the Strain Theory of Suicide on the basis of George and Blau's Social Exchange Theory,Durkheim's Theory of Social Anomie and Social Integration,Merton's Social Anomie Theory of Deviant Behavior,Agnew's General Strain Theory,Festinger's Cognitive Dissonance Theory and Zhang's Social Relativity.Psychological strain is different from pressure or stress,which contains at least two conflicting social factors.In the path from strains to suicidal behaviors or mental disorders,strain may be moderated by psychosocial factors,and it can also be intervened or strengthened by psychopathological factors.There could be at least four types of strains:Value Strain,Aspiration Strain,Relative Deprivation Strain and Coping Strain.Compared with non-serious attempted suicide,serious attempted suicide is more likely to lead to future suicide deaths.The strain theory has been mainly validated in suicide deaths and other groups,but it is seldom used to fully test the relationship between serious attempted suicide and strains.Objectives Using the Strain Theory of Suicide,we examined the relationship between strain and serious attempted suicide.Including:(1)Analyze the strain factors related to serious suicide attempt;(2)Compare strain differences among different sociodemographics,including between the cases with different age groups and the corresponding controls,between the cases of different occupations and the corresponding controls,between the cases of different genders and the corresponding controls;(3)Compare strain differences among different clinical characteristics,including between the cases with(without)mental disorder and the controls(including in the cases with and without mental disorder),between first timer and repeated timers and among different levels of suicide intent.The negative life events and direct causes embodied strain were further analyzed.Finally,it will be tested that strain(s)is(are)significantly associated with serious attempted suicide among rural population with different characteristics.(4)Analyze the correlations between strains,sociodemographic and psychopathological factors;(5)Based on the Strain Theory of Suicide,the mechanism and process of serious suicide attempt or mental disorder caused by strains were validated using Structural Equation Model.Methods This study was a case-control study design.Semi-structured interview was used to collect information.13 county-level cities in Shandong Province(Longkou,Zoucheng,Junan,Chengwu,Dongming,Juancheng,Donge,Juanxian,Gaotang,Lijin)and Hunan Province(Changsha,Hengnan and Leiyang)were selected using convenient sampling method.All serious suicide attempt data were derived from two general hospitals in each county based on their size,popularity and large inpatient enrollment.During the survey period(May 2012-July 201 3),serious suicide attempt registered in the emergency departments or admission departments of general hospitals were selected using sequential sampling.A medically serious suicide attempt was defined as one that required hospital admission for over 24 hours,and met one of the following treatment criteria:(1)Treatment in specialized units(intensive care unit,hyperbaric unit,burns unit),(2)Surgery under general anesthesia(superficial cuts that did not require surgical repair were excluded),and(3)Extensive medical treatment(beyond gastric lavage,activated charcoal,or routine neurological observations)including antidotes for drug overdoses,telemetry,or repeated tests or investigations.The inclusion criteria of cases were:(1)meeting the definition of a serious suicide attempt;(2)rural permanent population;(3)be willing to sign informed consent and cooperate with the investigation.Exclusion criteria:(1)do not meet the definition of a serious suicide attempt;(2)non-agricultural,temporary or migrant population living within six months of residence;(3)end one's lives without subjective intention;(4)be unwillingness to sign informed consent and refuse to be investigated many times.The inclusion criteria of controls were:(1)within 3 years of age;(2)the same gender;(3)living in the same rural or adjacent villages;(4)be willing to sign informed consent and cooperate with interviews.Exclusion criteria:(1)close relatives or persons closely related to the cases,such as neighbors;(2)persons with conflict of interest with the cases.Doctors from each hospital provided information about each serious suicide attempt to the research group,and then interviewers were led by village committee or village doctors to conduct household interviews.The interview place was usually arranged in the interviewee's home.The average duration of each interview was 1.5 hours.The village committee or the village doctor selected the eligible control group,and the same interviewer used the same interview instrument to conduct interviews.The research team compiled the Interview Questionnaire on the Health Status of Residents,which included sociodemographics,characteristics of serious attempted suicide(Beck Suicide Intent Scale,Interview for Recent Life Events),personality and psychological characteristics(Dickman Impulsivity Scale,Trait Anxiety Scale,Duke Social Support Index),psychopathological characteristics(Beck Hopelessness Scale,Center forEpidemiologic Studies Depression Scale,mental disorder(SCID));psychological strains(value conflict measured Value Strain;whether or not the biggest wish was realized and how much it was hindered measured Aspiration Strain;Relative Deprivation Strain measured from family economic status,social relations,education opportunities,job opportunities;Coping Responses Index(CRI)measured Coping Strain).This study carried out strict quality control before,during and after the investigation.According to the data type,t-test,analysis of variance,chi-square test,rank sum test and correlation analysis were used to analyze the data.Conditional logistic regression and unconditional logistic regression were used to analyze the relationship between strain and serious attempted suicide.Structural Equation Model(SEM)was used to analyze the mechanism of strain theory of serious suicide attempt.Results1.Strain and serious suicide attempt:The value strain,aspiration strain,relative deprivation strain and coping strain in cases were significantly higher than those in controls.75.5%(597/791)attempters experienced negative life events,among which"in discord with spouse's mother","quarreling with family" and " quarreling with partner" were mostly significantly associated with serious suicide attempt."Quarreling with partner" was the most likely negative life events leading to suicide(40.7%,213/523),and 70.2%(519/739)of serious suicide attempt were caused by"family conflicts".Conditional logistic regression showed that family suicide history,negative life events,hopelessness,mental disorders(OR=24.294),aspiration strain and coping strain were risk factors,while higher education level and social support were protective factors.2.Strain and medically serious suicide attempt with different sociodemographics 2.1 Different age groups:value strain in both youth group(25-34 years old)and young adult group(35-54 years old)were significantly higher than the controls of the same age range,and the aspiration strain,relative deprivation strain and coping strain among cases were significantly higher than the controls of the same age range.Relative deprivation strain of adolescents(15-24 years old)and youths was significantly lower than that of young adults among suicide attempters."Quarrel with family" was significantly correlated with serious attempted suicide in three age groups."Quarreling with family"(34.0%)was the most likely negative life event leading to suicide in adolescent group,while those in youth group(44.1%)and young adult group(46.1%)were "quarreling with partner".The main direct causes of suicide in adolescent group were "family conflicts" and "emotional problems",the youth group were "family conflicts" and "family financial stress",and the young adult group were"family conflicts" and "mental disorder".Multivariate logistic regression showed that aspiration strain and coping strain were common risk factors related to serious suicide attempt in three age groups and mental disorder was also related to young adult group.2.2.Different occupations:There was no significant difference in value strain between the farmer cases and the controls,while the value strain in non-farmer cases were significantly higher than those in controls,and the aspiration strain,relative deprivation strain and coping strain in both farmer and non-farmer cases were significantly higher than those in controls.The relative deprivation strain and coping strain of farmer suicide attempters were significantly higher than those of non-farmer suicide attempters.The most likely negative life events leading to suicide in both farmers and non-farmers were "quarreling with partner"."Family conflicts" and"family financial stress" were the main direct reasons for the serious suicide attempt in both farmers and non-farmers.Multivariate logistic regression showed that aspiration strain and coping strain were common risk factors related to serious suicide attempt for farmers and non-farmers,and mental disorder was a significant risk factor for farmers.2.3.Gender differences:All strains in male(female)cases were significantly higher than those in the same gender of controls.Whether in the cases or the controls,the value strain of female was significantly higher than that of male;the aspiration strain of male in the cases was significantly higher than that of female."Quarrels with family" was mostly significantly correlated with male serious suicide attempt,and"quarreling with partner" and "quarrels with family" was mostly significantly correlated with female serious suicide attempt.The main direct causes of male(female)attempters mainly included "family conflicts","family financial stress" and"mental disorder".Multivariate logistic regression showed that aspiration strain and coping strain were common risk factors for male and female serious suicide attempt,and mental disorder was a significant risk factors for female.3.Strain and medically serious suicide attempt with different clinical characteristics3.1 Attempters with/without mental disorders and the controls:All strain of the attempters with or without mental disorders were significantly higher than that of the controls."In discord with spouse's mother" was mostly significantly correlated with serious suicide attempt in cases with mental disorders(Adjusted OR=29.400),and "quarreling with partner " was mostly significantly correlated with serious suicide attempt in cases without mental disorders(Adjusted OR=26.457).The most likely negative life event leading to suicide in attempters with and without mental disorders was "quarreling with partner".The main direct causes of suicide in attempters with mental disorders were "family conflicts"(53.8%)and "mental disorders"(20.0%)and in attempters without mental disorders were "family conflicts"(74.2%)and "family financial stress"(9.4%).Multivariate logistic regression showed that aspiration strain and coping strain were common risk factors for serious suicide attempt in attempters with and without mental disorders.Relative deprivation strain and coping strain were significantly higher in attempters with mental disorders than those without mental disorders.Multivariate logistic regression showed that value strain(OR=0.821)had a greater impact on serious suicide attempt without mental disorders.3.2 First timer and repeated timers:Both value strain and coping strain of repeated timers were significantly higher than those of first timers and they experienced more chronic life events.The most likely negative life events leading to repeated attempted suicide were "quarreling with partner"(27.3%)and "quarreling with family"(11.4%).The main direct causes of repeated serious suicide attempt were " family conflicts"(55.0%),"emotional problems"(13.6%)and "mental disorder"(13.6%).Multivariate logistic regression showed that coping strain(OR=2.087)and mental disorder(OR=3.809)were risk factors for repeated serious suicide attempt.3.3 Different levels of suicide intent:Suicide intent was positively correlated with strains.All strains in cases with different levels of suicide intent were significantly higher than those in the corresponding controls.Value strain of high and moderate suicide intent groups was significantly higher than that of low suicide intent group among serious suicide attempters.Both "quarreling with partner" and "quarreling with family " were not significantly related to higher suicide intent.Coping strain was a common risk factor for low,moderate and high suicide intent,and aspiration strain was a risk factor for low and moderate suicide intent.Linear regression showed that aspiration strain(?=0.512)and mental disorder(?=2.722)were associated with increased risk of suicide intent.4.The correlations between strains,psychosocial factors and psychopathological factors:Strains were negatively correlated with social support,and positively correlated with depression,anxiety and hopelessness.Generally speaking,functional impulsivity was negatively correlated with strains and dysfunctional impulsivity was positively correlated with coping strain.5.The process of serious suicide attempt caused by strain:The confirmatory factor analysis model of the dimension of strain theory measurement in case group fitted well(NFI = 0.950,RFI = 0.937,IFI = 0.974,NNFI = 0.967,CFI=0.974,RMSEA=0.036,GFI = 0.973,AGFI = 0.961).Structural equation model showed that fitness of serious suicide attempt model was acceptable(NFI = 0.851,IFI = 0.878,CFI = 0.875,RMESA = 0.070).The path coefficient of strain leading to serious suicide attempt is 0.44,psychopathological factor is 0.81,the path coefficient of strain leading to suicide through the mediation of psychopathological factor is 0.40,the path coefficient of social factor is-0.40,and the path coefficient of social psychological factor leading to suicide through the mediation of psychopathological factor is-0.40.Conclusions1.Significant differences were found on strains between cases and controls and among serious suicide attempters Overall,the strains of the cases were higher than that of the controls.Among the serious suicide attempters,not all strains vary between(among)groups.For example,the relative deprivation strain of young adults was higher than that of adolescents and youths.2.Strain(s)can significantly predict serious suicide attemptAspiration strain and coping strain significantly predicted serious suicide attempt of the whole case group,three age groups,farmers(non-farmers),male(female),cases with and without mental disorder and low or moderate levels of suicide intent.In addition,relative deprivation strain significantly predicted serious suicide attempt in young adult;the value strain had a greater impact on the serious suicide attempt without mental disorders;coping strain and mental disorder significantly predicted repeated serious suicide attempt;coping strain significantly predicted high level of suicide intent,aspiration strain and mental disorder significantly increase suicide intent.9.3 Strain was significantly correlated with psychopathological and psychosocial factors Before and after controlling the confounders,strain was positively correlated with depression,anxiety and hopelessness,and negatively correlated with social support.Both functional and dysfunctional impulsivity were significantly correlated with coping strain.9.4 Negative life events leading to serious suicide attempt Negative life events were mainly related to marriage/love and family,followed by disease/health.The most likely life events leading to suicide were mainly "quarreling with partner" and "quarreling with family".The main direct causes of serious suicide attempt were "family conflicts","emotional problems" and "family financial stress".9.5 Moderating role of social psychological factors and mediating role of psychopathological factors on the relationship between strains and serious suicideattempt Social and psychological factors moderated the psychopathological factors,higher level of social support,functional impulsivity and education significantly reduced the risk of serious suicide attempt;higher level of non-functional impulsivity,more negative life events and family suicide history significantly increased the risk of serious suicide attempt.Depression,hopelessness and mental disorder played a mediating role in the relation between strain and serious suicide attempt.Suggestions The study suggests that we should develop the Strain Reduction Therapy(SRT)and adjust the stressors from the cognitive level;continue to reduce the value strain of youths and young adults,farmers and women;establish a correct outlook on marriage,family and love so as to reduce the aspiration strain;alleviate the psychological imbalance of young adults and reduce the relative deprivation of farmers;improve the ability of farmers to actively cope with crises;establish and improve social support network and make the best of the moderating role of social support;timely intervene in the negative emotional experience of individuals to prevent further development;improve rural education level and focus on families with family history of suicide;strengthen the treatment of mental disorders in young adults,farmers,men and those multiple timers;guarantee the serious physical illnesses and alleviate the strain caused by the illnesses.Strengths First,from looking for the risk factors of suicide behaviors in the past to build a theoretical foundation,this study uses the strain theory to deeply understand serious suicide attempt.Second,the participants are all medically serious suicide attempters which are different from non-serious suicide attempt.Thirdly,it tests the strain theory from multiple perspectives,and puts forward corresponding social measures against suicide according to the elements of the strain theory. |
PDF Full Text Request