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Keywords:

  • China;
  • elderly;
  • suicide

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. EPIDEMIOLOGY OF SUICIDE AMONG THE ELDERLY IN CHINA
  5. SUICIDE METHODS
  6. REASONS FOR SUICIDE IN THE ELDERLY
  7. RELATIONSHIP BETWEEN ELDERLY SUICIDE AND MENTAL ILLNESS
  8. FUTURE DIRECTIONS TO PREVENT SUICIDE IN THE ELDERLY
  9. REFERENCES

Suicide in mainland China shows unique demographic patterns with age: the over-65 age group has the highest rate of completed suicide, reaching 44.3–200 per 100 000, which is four to five times higher than the Chinese general population. Rural suicide rates among the elderly are three to five times higher than the urban rates. The gender ratio of suicide in the elderly shows a reversal to those younger than 60 years of age in China. In addition, suicide methods and causes are different from those in Western countries. In the present paper, the profile of suicide among the elderly in China is delineated, including the prevalence, characteristics, underlying reasons and measures of preventing it.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. EPIDEMIOLOGY OF SUICIDE AMONG THE ELDERLY IN CHINA
  5. SUICIDE METHODS
  6. REASONS FOR SUICIDE IN THE ELDERLY
  7. RELATIONSHIP BETWEEN ELDERLY SUICIDE AND MENTAL ILLNESS
  8. FUTURE DIRECTIONS TO PREVENT SUICIDE IN THE ELDERLY
  9. REFERENCES

Once called the ‘sleeping giant’, China now faces a different kind of growth: its aging population. More than 10% of its 1.3 billion citizens are over the age of 60 years.1 Since 1999, China has become an aging country, along with many European countries. Unfortunately, unlike European countries, which became rich before their populations became old, in China, the population is growing old before it becomes rich. With the aging population growing quickly over the last 50 years and due to accelerate further in the coming 50 years, China hasn't prepared well for its aging population. Furthermore, due to China's rising economy and socioeconomic changes, along with the well-known one-child policy, the elderly, as well as younger adults, face unfamiliar challenges. The elderly encounter many problems, such as declining health, and losing relatives and friends. Along with the changing culture, they suffer from ‘empty nest’ and uncertain healthcare and welfare policies. Anxiety disorders, depression and suicide are not uncommon among the elderly.

EPIDEMIOLOGY OF SUICIDE AMONG THE ELDERLY IN CHINA

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. EPIDEMIOLOGY OF SUICIDE AMONG THE ELDERLY IN CHINA
  5. SUICIDE METHODS
  6. REASONS FOR SUICIDE IN THE ELDERLY
  7. RELATIONSHIP BETWEEN ELDERLY SUICIDE AND MENTAL ILLNESS
  8. FUTURE DIRECTIONS TO PREVENT SUICIDE IN THE ELDERLY
  9. REFERENCES

Today, China has the world's largest elderly population with 143 million people aged 60 years and older in 2004.2,3 China's elderly population has more than tripled over the last 50 years since the People's Republic of China conducted its first census in 1953. Over the next 50 years, the growth of China's aging population will accelerate. By 2050, it is predicted that there will be 400 million people aged 60 years and older.2 Currently, 65.8% of the elderly population lives in countryside.2 The female elderly outnumber the male elderly by 4.64 million.

China has the third highest rate of suicide in its elderly population. Over the age 55, suicide rates in China begin to increase and continue to increase with age, to which the rural elderly contribute much more than urban elderly.4,5 Suicide rates among the elderly in China vary from a range of 44.3 to 200.0 per 100 000.6,7 In comparison, the suicide rate in the general Chinese population is 23 per 100 000, while the global average is 10.7 per 100 000.8,9 The number of rural elderly suicides largely accounts for the high Chinese elderly national suicide rate. In large cities like Beijing, suicidal behaviors have a low prevalence.10,11 Rural elderly suicide rates are three to five times higher than those in urban areas.4,12 The wide discrepancy between rural and urban rates hold true for all age groups in China.4 However, the female-to-male ratio of suicide among the elderly is reversed in the population aged younger than 60 years. For the younger population, female suicide rates exceed male rates by an average of 26%, with young rural female rates being 66% higher than rates among young rural males. For older people, the female-to-male ratio is 1/1.1 in urban areas and 1/1.5 in rural areas.4,13

According to Durkheim's work on suicide, the impact of socioeconomic change is central to the classic theories of suicide.14 China has experienced rapid socioeconomic change since the cultural revolution from 1966 to 1976 and following the economic reforms that began in 1978. Unfortunately, Chinese suicide figures were almost blank before 1987. Suicide became a major health problem for the country only after 1989 when the Chinese government released data on the rates of suicide. This makes it impossible to indicate long-term suicide trends in China. Research regarding the change in suicide rates is scarce. No studies have focused on elderly suicide trends. Taking the general population or total number of elderly people as subjects for investigation, the average rates of suicide in China declined in the period from 1991 to 2000.12,15 However, when taking region age-specific suicide rates into account, these findings indicate that the substantial decrease in suicide rates occurred among the younger population and in the urban elderly. In rural areas, the rates of suicide in the older age groups fluctuated, but remained high over the same period.12

SUICIDE METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. EPIDEMIOLOGY OF SUICIDE AMONG THE ELDERLY IN CHINA
  5. SUICIDE METHODS
  6. REASONS FOR SUICIDE IN THE ELDERLY
  7. RELATIONSHIP BETWEEN ELDERLY SUICIDE AND MENTAL ILLNESS
  8. FUTURE DIRECTIONS TO PREVENT SUICIDE IN THE ELDERLY
  9. REFERENCES

Chinese researchers have found that pesticides are frequently used as substances for suicide in rural areas. Ingestion of agricultural chemicals or rat poison was the most common method (34.3–66.6%). Other common methods include hanging (7.7–43.8%), drowning in rivers or wells (3.2–14.3%), jumping from heights (2.6–6.5%), poisoning with other substances (7.0%), traffic accidents (0.1–2.7%), electrocution (1.2%) and carbon monoxide poisoning (0.3–0.9%).6,16 By comparison, the rank order of ways of committing suicide in India is drowning, hanging, poisoning and miscellaneous methods. In China and India, the two Asian countries, the methods contrast with those reported in Western countries, where firearms are the most common instruments of suicide, followed by hanging and drug ingestion, respectively.

The most common methods of suicide in the elderly in China are the same as in the general population. As with their younger counterparts, older people mostly died by ingesting pesticides or rat poison, whereas hanging was more common among the elderly than in younger adults.17 Few researchers have compared elderly suicide methods by region. Xu et al. took a partial sample and indicated that ingestion of poison or medicine are more common in rural areas than in urban areas (68.2 vs 37.7%).18 In rural areas of China, farmers usually store pesticides or rat poison inside or close to the household. The fact that pesticides and rat poison are commonly used for suicide partly reflects their common availability.

REASONS FOR SUICIDE IN THE ELDERLY

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. EPIDEMIOLOGY OF SUICIDE AMONG THE ELDERLY IN CHINA
  5. SUICIDE METHODS
  6. REASONS FOR SUICIDE IN THE ELDERLY
  7. RELATIONSHIP BETWEEN ELDERLY SUICIDE AND MENTAL ILLNESS
  8. FUTURE DIRECTIONS TO PREVENT SUICIDE IN THE ELDERLY
  9. REFERENCES

Previous studies have investigated the risk factors of suicide in the general Chinese population. Phillips et al. studied 519 cases of suicide from 23 geographically representative sites in China and found that high depression symptom scores, previous suicide attempts and severe acute stress were the main risk factors for suicide.16 However, there is a lack of well-designed investigations that show the risks or reasons of elderly suicide in China, especially by international standards. The authors of a Chinese study of 304 cases of elderly people who committed suicide identified the life events that occurred prior to suicide and found that the three most common negative life events were acute or chronic physical illness or injury (59.2%), major changes in diet, sleeping or other daily routines (37.8%) and financial difficulties (34.5%).19 Xu et al. investigated elderly suicide in some of the urban and rural areas of Hunan province (central China), and showed that the rank order of causes of rural elderly suicide was family conflict (76.3%), chronic illness (20.0%) and economic difficulty (3.5%), while in urban areas it was chronic illness (45.3%), family conflict (37.7%) and mental illness (16.9%).18 The causes of suicide in urban areas are similar to those in Japan, in which the rank order is physical illness (46.1%), psychiatric disorders (19.4%), pessimism (14.0%), economic difficulty (5.0%) and personal relationships (4.0%).20 Chinese studies have also shown that low education and being widowed are risk factors for suicide in the elderly.21

Chinese scholars have presented the ‘lost theory’ hypothesis to interpreters as the reason for suicide in the elderly. According to the ‘lost theory’, aging is a natural process of life which is characterized by continual loss, including loss of health, loss of social role, loss of relatives and friends, and loss of life aim. A person suffers from a series of ‘lost events’ as they age, which triggers a psychological crisis. A lack of support from society or family during the time of crisis can lead that elderly person to suicide.22 The ‘lost theory’ could explain why conflicts with family members (loss of proper family support and relationships), chronic illness (loss of health) and economic difficulty (loss of independence or social role) are the most important events to trigger suicide in the elderly.

The ‘lost theory’ partly explains the unique Chinese situation where the rate of suicide in the elderly rural population is much higher than in its urban counterparts. We know from the aforementioned data that the rate of suicide in the rural elderly is as high as two to five times that of the urban elderly. Furthermore, the rates of suicide in the urban elderly are decreasing significantly during these decades while the rates of rural elderly remain high. The reasons behind the difference might be attributed to different social forces. In China, the difference in average annual income between rural and urban areas may be two to fivefold. The disproportion becomes larger when non-currency factors are counted, such as health insurance, endowment insurance and unemployment insurance. The decrease in the rate of suicide in the elderly might have been due to the improvement in long-term care systems in urban areas. We speculate that in rural areas, the elderly committed suicide partly because of the lack of social support. The higher suicide rates in rural regions may be related to limited social resources and to conflicts concerning certain traditions experienced in the setting of social change in these areas.

With the changes in the market economy emphasizing reliance on individual effort together with the birth control policy of one child per family, the extended family structure of 4:2:1 has become the norm (two sets of grandparents, two parents and one child). There is an emphasis on personal success and happiness, which may conflict with the responsibility of caring for elderly members of the family. The tradition of filial piety and respect for the elderly is diminishing and the elderly are increasingly being regarded as consumers of resources within the family and in society as a whole. More and more, older people are living in an ‘empty nest’ (an empty home in which the elderly live alone without their children). It is not surprising that during the decades of Chinese social change, elderly suicide rates are still high, especial in rural areas.

RELATIONSHIP BETWEEN ELDERLY SUICIDE AND MENTAL ILLNESS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. EPIDEMIOLOGY OF SUICIDE AMONG THE ELDERLY IN CHINA
  5. SUICIDE METHODS
  6. REASONS FOR SUICIDE IN THE ELDERLY
  7. RELATIONSHIP BETWEEN ELDERLY SUICIDE AND MENTAL ILLNESS
  8. FUTURE DIRECTIONS TO PREVENT SUICIDE IN THE ELDERLY
  9. REFERENCES

In contrast to the strong association of suicide with mental illness in the West, in traditional Chinese culture suicide has generally been depicted as a social or moral act. When a person committed suicide, the victim's relatives and friends always felt sad and asked ‘Did he (or she) meet tremendous difficulty? Or had he (or she) been under huge stress to prevent losing face?’ This unique culture might have brought bias to studies which investigated the relationship between suicide and mental illness. China is unique in that it has a low level of mental illness in suicide victims in the general population (0–30% vs >90% in the West), in particular, depression. Phillips et al. found a 40% depression rate in Chinese victims using a rigorous methodology, which was still low compared to the 60% found in Western countries.7,16,23 Studies of the correlation of elderly suicide in mainland China and mental illness are rare. A Chinese study of 304 cases of elderly suicide using psychological autopsy investigated the prevalence of mental illness in people who committed suicide. The authors found that 68.0% of 178 elderly people with chronic physical illness and 60.0% of 126 elderly people without chronic illness had mental illness. In addition, 101 elderly people with chronic illness and 38 without chronic illness had suffered from mood disorders.24 However, only 11.5% of the 304 elderly people had ever consulted with psychological professionals.

Although the novel study by Phillips et al. showed that mental illness is not uncommon in suicide victims, the rate of mental illness among them is still significantly lower in mainland China than in Western countries. Against this background, a case-controlled psychological autopsy study conducted by Chiu et al. of Chinese elderly people who had committed suicide in Hong Kong showed that 86% had suffered from a psychiatric condition before their deaths compared with 9% of community control individuals.25 Hong Kong is a cosmopolitan city with a Western social structure and mental health system, whereas in mainland China, more traditional Chinese cultural values predominate, with a mental health policy radically different from that of Hong Kong. On account of these, the relatively low prevalence of mental illness among the elderly who commit suicide in mainland China might be explained by the cultural influence and mental health system. Traditional culture could contribute to several methodological problems in studies conducted on suicide in the elderly, such as respondents being unwilling to or unaware of how to provide information, Western diagnostic instruments of psychological symptoms being insensitive to Chinese in rural areas, and even Chinese professionals not regarding mental illness as a major risk, but as a socioeconomic problem. Limited mental health services would also be problem in mainland China, especially in rural areas. Studies have shown that people with mental illness are very unlikely to have been exposed to mental health services.16,22 Furthermore, for those who received mental health services, the level of psychiatric training and expertise may have been inadequate to diagnose any mental disorders. Under-treatment and under-diagnosis of mental illness partially explain the discrepancy between mainland China and the West or Hong Kong. More importantly, great numbers of depressed rural elderly not receiving treatment also may explain the high suicide rates.

The incidence of mental illness might truly be low in the elderly victims of suicide in mainland China. In Chinese culture suicide can be justified and rationalized in moral terms; in some sense, the social environment is permissive to suicide in China. Suicide can sometimes carry with it social and cultural significance, such as love loyalty and redeeming oneself from disgrace. Losing a loved one or intense conflicts with relatives are not uncommon causes of impulsive suicide. However, impulsive suicide may not be predominant in the elderly. Therefore, further research is needed to explore the actual prevalence of mental illness or the other risk factors among the elderly in China.

FUTURE DIRECTIONS TO PREVENT SUICIDE IN THE ELDERLY

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. EPIDEMIOLOGY OF SUICIDE AMONG THE ELDERLY IN CHINA
  5. SUICIDE METHODS
  6. REASONS FOR SUICIDE IN THE ELDERLY
  7. RELATIONSHIP BETWEEN ELDERLY SUICIDE AND MENTAL ILLNESS
  8. FUTURE DIRECTIONS TO PREVENT SUICIDE IN THE ELDERLY
  9. REFERENCES

Chinese professionals and organizations are now beginning to call attention to the suicide crisis among the elderly. Given the problem's complexity and enormity, no easy solutions are likely to be found. China still has a long way to go towards lowering its high suicide rate. Tentative proposals include endeavors from the Chinese government, professionals and social support networks.

A comprehensive vital statistics reporting system should be established. The official suicide mortality figures in China are always sourced from the National Ministry of Health based on data from locations that have relatively good reporting mechanisms. The sample has a much higher proportion of urban residents than the population as a whole. Given the large difference between urban and rural elderly suicide rates, an integrated complete vital registration system needs to be built for the entire country.

Healthcare professionals need to be trained to detect suicide risk at multiple front-line levels. Primary care in mainland China is carried out in ‘street block’ clinics in urban areas and clinics staffed by ‘bare-foot doctors’ in rural areas. The latter lack intensive medical training, let alone psychiatric education. A co-operative system needs to be established so that primary care and specific healthcare staff can work together, share information and learn from each other, and so that patients can be transferred in a bidirectional manner in the system. Currently the co-operative system has been initiated in cities, while in the countryside, its practice faces huge difficulties.

Campaigns need to be conducted to improve understanding of mental illness and the availability of treatment for it. Public or private mental health organizations can pass on information to individuals. The media, through TV, radio and newspapers could help educate the public and diminish the stigma of mental illness and suicide.

Health and social welfare systems for the elderly need to be improved, particularly for those in rural areas. The health service in China is constantly transforming. Currently, a market economy system predominates in China, but varies according to region. In big cities, such as Shanghai or Beijing, retired employees have medical coverage provided by government insurance. However, in most rural areas, over 90% of the elderly have to pay healthcare out of their own pockets. To make it worse, the elderly in rural areas have no pension or allowance to support their daily living expenses. Older people who migrate to live in cities with their children experience the same poor healthcare and social welfare. Family support is their only resource. We know that family conflict, chronic illness and economic difficulty are the most important events to trigger suicide in the elderly. These three factors might indicate the same problem for the elderly: lack of financial support for living expenses and healthcare.

Finally, expansion of direct suicide prevention strategies and practical actions should be promoted. These include methods of reducing the number of deaths from pesticide ingestion, such as restricting the availability of pesticide by ensuring supplies are kept in secure facilities, providing telephone hotlines for individuals in distress, and making sure that special family and community care is available to the elderly who have attempted suicide.

Although many difficulties exist, the social changes and liberalization accompanying China's current economic reforms provide a real opportunity to stimulate Chinese public interest in the problem of suicide in the elderly. China is reforming policies to improve the living circumstances of its residents and to help disadvantaged groups, including the elderly, who suffer from economic and health crises. Hopefully, in the near future, the problem of suicide in the elderly in mainland China will be paid more attention by the Government.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. EPIDEMIOLOGY OF SUICIDE AMONG THE ELDERLY IN CHINA
  5. SUICIDE METHODS
  6. REASONS FOR SUICIDE IN THE ELDERLY
  7. RELATIONSHIP BETWEEN ELDERLY SUICIDE AND MENTAL ILLNESS
  8. FUTURE DIRECTIONS TO PREVENT SUICIDE IN THE ELDERLY
  9. REFERENCES