Matched case-control study of medically serious attempted suicides in rural China

BACKGROUND: Suicide rates in rural China are two-fold to three-fold those in urban China but the reasons for this large difference remain unclear. AIM: Assess the characteristics and risk factors of medically serious suicide attempts in rural China. METHODS: A comprehensive 2 to 3 hour structured interview was administered by psychiatrists to 297 medically serious suicide attempters (defined as those who remained in hospital for 6 hours or longer) treated in the emergency room of the People's Hospital of Yuncheng County in Shandong Province and, separately, to their accompanying co-resident family members. A parallel interview was administered to control subjects matched for age and gender from the same village who had never made a suicide attempt and to their co-resident family members. Risk factors for attempted suicide were identified using Cox regression models. RESULTS: Among the 297 suicide attempters, 74% were female, 78% were farmers, their mean (sd) age was 33.2 (14.6) years, their mean length of formal schooling was 4.8 (3.1) years, 80% had attempted suicide by ingesting pesticides, 57% reported considering suicide for five minutes or less before acting, 76% had a score of less than 50 (range, 0 to 100) on the planning subscale of the Suicide Intent Scale, 11% had made prior attempts, and only 38% met DSM-IV criteria for a current mental disorder. After controlling for gender, age, location of residence and prior suicide attempt (in the matched analysis), risk factors identified in the multivariate analysis included a low level of education, having relatives or associates with prior suicidal behavior, experiencing four or more negative life events in the prior year, a low quality of life and low family cohesion over the prior month, high depressive symptom scores over the prior two weeks, and (only assessed in a subsample) high impulsivity and aggression. CONCLUSION: Many of the medically treated suicide attempts in rural China are low-intent attempts by the ingestion of pesticides in persons who do not meet criteria of a mental disorder but have high levels of impulsiveness and aggression. This profile is different from that seen in high-income countries so it will require a different approach to the prevention of suicidal behavior, an approach that is less focused on the identification and treatment of mental disorders and more focused on limiting access to agricultural poisons and training impulsive individuals about self-regulation of their emotions and behaviors.