Completed Suicide And Its Correlates Among The Rural Elderly In China

1. Background:Suicide means deliberate self-harm behavior with clear intent to end one’s life. Suicide has become a serious public health problem worldwide, causing severe burden to the individuals, their family, and the community. In most countries, suicide rates increase with age, with the elderly suffering the most. In China, suicide rates for people over 65 years old range from 44.3/100,000 to 200/100,000, reported from different resources, and are about 5 fold of the rates for the whole population. According to the China Ministry of Health, about 44％ of all suicide deaths in 2009-2011 in mainland China were aged 65 years and older, of whom 79％ were rural residents. Furthermore, suicide behavior among the elderly are reported to be characterized as with higher suicide intent and adequate preparation; the most common suicide methods among older rural Chinese residents are pesticide and hanging.Suicide behavior is subject to effect of multiple correlates, and prevention of suicide depends substantially on identification of such correlates. For studying completed suicide, Psychological Autopsy (PA) is a common and feasible method, which helps reconstruct information of the deceased by interviewing their intimate family member or close friends. By obtaining information about the time before suicide, researchers could then analyze and identify possible correlates. Due to specific situations, it is almost impossible for any individual PA study to investigate all possible factors. Usually, factors affecting suicide behavior included in a retrospective PA study are categorized into psychiatric disorders, personality traits and psychological status, physical illnesses, social background and life events, functional disorders, and access to suicide means, etc.2. Objectives:By conducting the current study, we aimed:2.1 To investigate characteristics of the elderly suicide deaths in rural China;2.2 To explore possible correlates of male and female suicide death among the rural elderly in China;2.3 And to discuss possible intervention and prevention strategies.3. Methods:3.1 Subjects and Sampling:This was a 1:1 matched case-control design. Suicide cases were aged 60 years and older while committing suicide; controls were matched on gender, age (±3 years), same community, and without suicide history. Data was collected by face-to-face interview using Psychological Autopsy method. For each suicide case and control, two informants that were familiar with the subject were interviewed; the living control was also interviewed. Sample was recruited from local disease surveillance counties in rural Shandong and Hunan; suicide events included in this study happened during May 1st,2014-September 30th,2015.3.2 Measurements:Socioeconomic information:Personal information included gender, age, occupation, education level, marriage, religion belief, etc. Family background included annual family income, suicide history in family, and storage of pesticides.Health information:Physical health included prevalence of serious or chronic physical illnesses, self-reported health status, and self-perceived extent of pain. Mental disorders were investigated by using SCID.Standard instruments:Suicide Behavior Questionnaire, Suicide Intent Scale (SIS) were used to investigate characteristics of suicide behavior; Life Event Scale for the Elderly (LESE), Duke Social Support Inventory (DSSI), Geriatric Depression Scale (GDS), Activities of Daily Living scale (ADL), and simplified UCLA Loneliness Scale (ULS-6) were employed to evaluate psychological and functional status.3.3 Statistical Analysis:SPSS 16.0 was used for data editing and analysis, X2 test and Student t test were used for characteristics comparison. Univariate conditional Logistic regression model was employed to explore possible correlates; interaction analysis between correlates was conducted.4. Results:4.1 Characteristics of Rural Elderly Suicide DeathsInformation of 171 suicide cases aging over 60 years old and matched controls were collected from rural Shandong (92 pairs) and Hunan (79 pairs), of which 97 (56.7％) were males and 74 (43.3％) were females. Mean ages for the 171 suicide cases were 73.98±8.36 (mean age was 74.86±8.79 for the male and 72.82±8.16 for the female, P=0.124). In terms of age distribution, the 75-85 group had most elderly suicide cases in rural Hunan, while two peaks (61-63 and 75-83) were observed in elderly suicide cases in rural Shandong. Most of the elderly suicide cases suffered from negative life events within 12 months before death (98.9％of suicide cases from Shandong and 100.0％from Hunan), among which health related negative life events were the most common(96.7％vs.98.7％, P=0.389).Prevalence of physical illnesses in suicide cases from Shandong was significantly higher than their counterparts from Hunan (88.0％vs.75.9％, P=0.038). Cases in Shandong showed relatively lower prevalence of mental disorders than those in Hunan, although the difference was not significant (42.4％vs.55.7％, P=0.083). Among specific types of mental disorders, mood disorders presented the highest prevalence in both provinces (35.9％vs.50.6％,P=0.052), followed by schizophrenia disorders (14.1％vs.16.5％,P=0.673), anxiety disorders (12.0％vs.6.3％, P=0.208), and substance use disorders (4.3％vs.5.1％, P=1.000).4.2 Features of Suicide BehaviorMost suicide among the rural elderly happened in daytime (64.9％), within their own home (91.2％). Various reasons for suicide were observed, among which severe physical illnesses (51.5％) and psychiatric or psychological disorders (16.4％) were mostly reported. Over half (54.4％) of the cases committed suicide by ingesting pesticide, while hanging (37.4％) was the second most common method. Previous suicide attempts were observed in 18.7％of the suicide cases. A large proportion of the cases did not get proper medical treatment after the suicide events.4.3 Correlates of Completed Suicide among the Rural Elderly4.3.1 Single Variable Analysis between Suicide Cases and ControlsNo significant difference of age and gender were observed between suicide cases and their matched controls (P>0.05). For both genders, suicide cases showed lower rates of being married than their controls (P=0.019 for men and P=0.031 for women). Incidence of negative life events among suicide cases were significantly higher than that among the controls (male:99.0％vs.84.5％, P<0.001; female:100.0％vs.89.2％, P=0.011). Most common negative life events were health related issues (male:97.9％ vs.80.4%,P<0.001; female:97.3% vs.83.8%, P=0.005), followed by family issues (male:70.1% vs.47.4%,P=0.001; female:56.8% vs.45.9%, P=0.188). Incidence of social issues was relatively lower (male:22.7% vs.19.6%, P=0.598; female:16.2% vs. 18.9%,P=0.666).Discrepancy of health status between suicide cases and controls were more commonly observed among men than among women. For male subjects, the suicide cases presented higher prevalence in both physical illnesses (82.5% vs.68.0%, P=0.020) and mental disorders (53.6% vs.2.1%, P<0.001) than their matched controls. For female subjects, however, no significant differences between cases and controls were observed in prevalence of physical illness (82.4% vs.73.0%, P=0.167), anxiety disorder (.5% vs.5.4%, P=0.347), and self-perceived extent of pain (P=0.271), although prevalence level among cases was still relatively higher. For both genders, distributions of scores evaluated by standard instruments were statistically different between cases and controls (P<0.001 or P<0.05), with suicide cases presenting poorer functional and psychological status.4.3.2 Conditional Logistic Regression and Interaction AnalysisAccording to the conditional Logistic regression results, being married appeared as protective factor for rural older men (OR=0.113,95% CI: 0.017-0.756), while high GDS score increased the risk for suicide death (OR=1.528,95%CI:1.202-1.943). As for the female subjects, GDS score (OR=9.161,95% CI:0.862-97.327) and mental disorders (OR=1.387,95% CI:1.120-1.717) were included in the final regression model, both as risk factors for suicide death.Interaction effects were observed between correlates in both genders. Positive interaction was observed between high GDS score and being married in men (OR=1.029,95% CI:1.010-1.047). Higher GDS score and mental disorders were also found to have positive interactions in women (OR=1.145,95% CI:1.066-1.229).5. Conclusions and Implications:5.1 Conclusions:(1) More men die of suicide than women in rural Chinese populations aging over 60 years; most rural elderly suicide cases are characterized with poor health conditions and education level, and high incidence level of negative life events.(2) Most rural elderly suicide deaths happen during daytime at their own home; the most common reasons for suicide include severe physical illness and psychiatric/ psychological disorders.(3) The most common suicide method among the elderly in rural China is ingesting pesticide, followed by hanging; hanging is more commonly employed by men than by women.(4) Depression, mental disorder and marriage status are possible correlates for completed suicide among the elderly in rural China, with interactions between different factors.5.2 Implications:(1) Continuous effort should be dedicated to improving social and medical support system for the aging populations in rural China.(2) Better social support environment should be built and maintained on community level.(3) More attention should be focused on older people’s physical and mental health conditions in rural China.