article21307292

Dutch Health Care Inspectorate’s Supervision System for Suicides of Mental Health

An Examination of the Dutch Health

Care Inspectorate’s Supervision System

for Suicides of Mental Health Care Users

Annemiek Huisman, M.Sc. Paul B. M. Robben, Ph.D. Ad J. F. M. Kerkhof, Ph.D.

OObjective: This study examined characteristics of suicides among men- tal health care users reported between 1996 and 2006 to the Dutch Health Care Inspectorate and the inspectorate’s follow-up responses. The aims were to determine whether follow-up was associated with par- ticular characteristics and whether the responses could be improved in accordance with guidelines for treatment of suicidal patients. Methods: Information about patient and treatment characteristics was collected from a sample of 505 of the 5,483 suicide notifications between 1996 and 2006. The 1996–2005 sample included an equal number of cases to which the inspectorate did and did not respond. The 2006 sample in- cluded the first 205 notifications in that year. Results: For 2006 notifi- cations the response rate was 37%. The responses most frequently ad- dressed how and whether the suicide was evaluated and the adequacy of treatment for the psychiatric disorder. A follow-up response was more likely when the suicide involved a young patient or a patient treat- ed in a mental health care setting for less than a year or when the noti- fication was accompanied by the mental health institution’s plans for im- proving its policies. A response was less likely when the patient was dis- charged from inpatient care in the three months before the suicide. Since 2002 responses have more frequently emphasized the importance of suicide risk assessment, in accordance with guidelines. Conclusions: The inspectorate might improve its supervision system by placing greater emphasis on addressing suicidal impulses and treating older and chronically suicidal patients and patients soon after inpatient dis- charge. (Psychiatric Services 60:80–85, 2009)

Several studies have shown that suicide. Audits in the United King-

suicide and mental illness are

closely linked (1). Psychiatric patients are a priority group in sever- al national suicide prevention strate- gies in various countries (2,3), but only a small number of studies have examined the clinical care that psy- chiatric patients received before their

dom (4) and Australia (5) found sev- eral treatment-based risk factors for suicide among users of mental health services, including inadequate assess- ment and treatment of psychiatric disorders and psychosocial problems, problems with inpatient observation, and poor continuity of care. About

20% of the suicides of these mental health service users were considered to be preventable.

The Netherlands is one of the few European countries with a continu- ous national supervision and audit procedure for suicides of patients re- ceiving mental health care. The sys- tem has been in operation since 1984. Whenever such a suicide occurs, the therapist responsible for the patient and the medical director must write a notification to the Health Care In- spectorate, which is an independent organization under the Minister of Health, Welfare, and Sport.

The notification must include de- tails of the suicide and the mental health care delivered and an evalua- tion of policies in place for dealing with suicidal patients. The inspector may ask for more information and in some cases may require the health care service to improve the care that is offered to suicidal patients. In gen- eral, the aim of this procedure is not to evaluate individual suicide notifica- tions but to identify structural prob- lems in mental health care services. Some 550 suicide notifications are submitted per year, which account for 36% of all suicides annually in the Netherlands.

The supervision system of the Health Care Inspectorate is designed to improve the quality of care for sui- cidal patients and ultimately to pre- vent suicide. However, its effective- ness has never been evaluated. The study presented here is a preliminary step in this evaluation. The aim was to describe the management of sui-

Ms. Huisman and Dr. Kerkhof are affiliated with the Department of Clinical Psychology, VU University, Amsterdam, Van der Boechorststraat 1, Amsterdam 1081BT, Netherlands (e-mail: a.huisman@psy.vu.nl). Dr. Robben is with the Health Care Inspectorate, Utrecht, Netherlands.

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cide notifications by the inspectorate and to compare its responses with re- cent guidelines for suicide preven- tion (6) to determine whether super- vision could be improved. In addi- tion, changes in the manner in which the inspectorate has responded to sui- cide notifications over time was ex- amined. The results will be used in further studies to assess the impact of the inspectorate’s supervision.

Methods

Suicide files were made available by the Health Care Inspectorate for the period 1996–2006. All suicide notifi- cations from this period were identi- fied (N=5,483), and a total of 505 were selected. For 1996–2000, a total of 100 notifications were selected, and 200 were selected for 2001–2005. For 2006 the first 205 suicide notifi- cations submitted that year were ob- tained. A relatively large number of cases from recent years were exam- ined, because these were considered to be most representative of the cur- rent procedures of the inspectorate. Files from earlier years were studied to gain insight into historical develop- ments in the management of suicide notifications.

For 1996–2005 an equal number of suicide notifications with and without a response from the inspectorate were randomly selected. A response was defined as further questions, re- marks, or suggestions by the inspec- tor after the initial notification or a personal conversation between the inspector and the person who sent the notification. No follow-up was de- fined as a simple letter from the in- spectorate acknowledging receipt of the notification with no further ques- tions or remarks. A total of 227 sui- cide notifications had a response from the inspectorate, and 278 notifica- tions had no follow-up. The selection of notifications was conducted in this manner to permit comparison of cas- es with and without a response and to determine whether inspectors re- sponded more frequently to certain patient or treatment characteristics. A pen-and-paper instrument was used to gather data on relevant characteris- tics, including patients’ demographic characteristics and the responses of the inspectorate.

Responses to suicide notifications by inspectors were examined both quantitatively and qualitatively. The nature of the response was classified into three categories: a request for ad- ditional information, remarks or sug- gestions for improvement, and further contact with the mental health service or other involved services.

All responses were also subjected to a detailed qualitative analysis, facil- itated by ATLAS.ti software. An open coding scheme was derived from the questions and remarks of the inspec- tors, and every response was as- signed a preliminary code independ- ently by the first two authors. The codes were further refined, and a clear definition was generated for each until a comprehensive coding scheme was created that accurately reflected the responses. By use of this coding scheme, each response was reviewed independently by the second author, and inconsistencies in coding were discussed until agree- ment was reached.

The responses of the inspectorate to suicide notifications were then compared with the American Psy- chiatric Association’s (APA’s) Prac- tice Guideline for the Assessment and Treatment of Patients With Sui- cidal Behaviors (6) to establish whether the responses were in ac- cord with the guideline. The guide- lines note that the most important aspects are frequent suicide risk as- sessments on the basis of protective and risk factors, treatment planning to reduce suicide risk, continuity of care, and a restrained use of no-sui- cide contracts.

The relationship between charac- teristics of the suicide notifications and the likelihood of a response by the inspectorate was examined by cross-classifying whether or not the inspectorate responded on the basis of patient and treatment variables (age, gender, diagnosis, suicide meth- od, inpatient versus outpatient sta- tus, discharge from inpatient care, duration of treatment, warning sig- nals of suicide, discussion of suicidal- ity with the therapist, and lessons learned as a result of the suicide). Chi square tests were computed on that distribution, and the signifi- cance threshold was set at .01 to

compensate for the possibility of finding significance by chance when conducting such a large number of comparisons.

To determine whether the manage- ment of suicide notifications by the inspectorate had changed between 1996 and 2006, responses from re- cent years (2002–2006) were com- pared with those from an earlier peri- od (1996–2001) by using chi square tests.

Results

Patient characteristics

Demographic and clinical characteris- tics of the sample are summarized in Table 1. A typical patient was a mid- dle-aged male in outpatient treatment who had a diagnosis of depression.

The number of responses to sui- cide notifications in each of the three categories is shown in Table 2. In- spectorate responses for 227 of the 505 suicide notifications were exam- ined. The inspectorate responded to 75 of the 205 notifications (37%) in 2006.

Qualitative analysis of responses

The inspectorate’s responses to the suicide notifications were classified into 13 broad categories (Table 3). The greatest number of questions or remarks concerned evaluation of the care provided to the patient. The most common question in this re- spect was, “Has the suicide been evaluated and what were the results of the evaluation?” Other frequently asked questions involved whether the patient received adequate treat- ment for his or her psychiatric disor- der. Questions also addressed the na- ture, purpose, and progress of the treatment and the clinician’s deci- sions about appropriate treatment settings.

The importance of adherence to treatment guidelines was stressed by the inspectorate in 36% of the re- sponses. In the Netherlands there are national guidelines for the treat- ment of various psychiatric disorders but not for suicidality. The responses often contained questions about whether the clinician adhered to the treatment guidelines for the psychi- atric disorder in question. Another question addressed whether guide-

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Table 1

Characteristics of 505 users of mental health services who died by suicide in the Netherlands, 1996–2006

Characteristic N %

Gender Male 280 55 Female 225 45

Age 15–20 11 2 21–30 58 12 31–40 113 22 41–50 134 27 51–60 95 19 >60 92 18

DSM diagnosis Primary axis I diagnosis

Depressive disorder 218 43 Schizophrenia or other

psychotic disorder 141 28 Bipolar disorder 36 7 Substance use disorder 41 8

Alcohol 22 4 Drug 41

Both Anxiety disorder Other disorder

Comorbid secondary diag- nosis of a substance use disorder

Alcohol Drug Both

Treatment status Inpatient

Outpatient

15 3 22 4 47 9

81 16 35 7 32 6 14 3

154 30 351 70

lines for the treatment of suicidal pa- tients were in place at the agency, and if so, whether the clinician ad- hered to them. In the case of re- sponses to notifications of suicides by inpatients, questions were asked about policies on safety, patient priv- ileges, and monitoring.

In 29% of the responses the ques- tions or remarks addressed collabo- ration with other practitioners or services, and in 15% continuity of care was a focus. These questions and remarks were made most fre- quently in responses that involved suicide among patients who had been recently discharged from inpa- tient care or who had changed treat- ment setting. The responses ad- dressed transfer of information and consultation between therapists or services involved in the patient’s care and the frequency of aftercare ap- pointments.

dressed in 27% of the 227 responses. Most common were questions about whether and how risk assessment took place and whether suicidality was discussed periodically with the patient. Specific remarks addressed the importance of telling the patient about an elevated suicide risk in the first weeks of using antidepressant medication, taking the expression of suicidal ideation or behavior serious- ly, and communicating about suicide risk with other therapists involved in the patient’s care.

Questions about medication (in- cluded in 27% of responses) and about psychiatric assessment (18%) were usually straightforward: what medication was prescribed, or what was the DSM psychiatric diagnosis? Other questions involved the assess- ment of the primary psychiatric disor- der and any comorbid disorders, the accuracy of diagnoses, and the appro- priateness of the medication.

In 14% of the responses the ques- tions and remarks specifically re- ferred to management of the pa- tient’s suicidal impulses. Generally, this involved a question about whether and how the therapist had managed this risk.

Fifteen percent of responses in- cluded questions or remarks about the involvement of the patient’s fam- ily, and 7% addressed aftercare for the bereaved relatives. The inspec- torate stressed that mental health services must involve the patient’s family in the assessment and treat- ment of suicidal patients and must offer aftercare to the bereaved fami- ly after a suicide.

The significance of the role of the psychiatrist was emphasized in 12% of the notifications. In some cases the patient had not been seen by a psy- chiatrist. The inspectorate took the

position that a psychiatrist must exer- cise responsibility and see patients personally, especially in assessment of psychiatric disorders and suicide risk and prescription of psychotropic drugs.

Seven percent of responses con- cerned the patient’s treatment non- compliance and issues regarding in- voluntary hospitalization. In these cases, the patient usually refused mental health care or regularly missed appointments, to which the therapist did not take an active ap- proach. The inspectorate recom- mended in these cases that noncom- pliant patients must be approached more actively by mental health servic- es. Other responses included a ques- tion about whether involuntarily hos- pitalizing the patient was considered and whether it would have been bet- ter to have done so.

Critical remarks and suggestions for improvement The inspectors made critical re- marks in 106 notifications. They ad- dressed the lack of guidelines for suicide prevention, the lack of suffi- cient continuity of care and collabo- ration between therapists involved, insufficient involvement of a psychi- atrist in suicide risk assessment and prescription of medication, inade- quate assessment of suicide risk, in- adequate psychiatric treatment and inaccurate psychiatric diagnosis, and insufficient attention to communica- tion and signals from relatives of the patient.

Characteristics associated with inspectorate responses Characteristics of the suicide notifica- tions to which inspectors responded more or less frequently are summa- rized in Table 4.

Suicide risk assessments were ad-

Table 2

Categories of 227 inspectorate responses to notifications of mental health service

users who died by suicide in the Netherlands, 1996–2006

Category N %

Additional information requested Remarks or suggestions for improvement Contact or discussion with the therapist, medical

104 21 106 21

director, or services involved

17 3

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Changes in responses 1996–2006

In the 2002–2006 period inspectors were significantly more likely to em- phasize the importance of suicide risk assessment than in the 1996– 2001 period (37% and 19%; χ2=6.4, df=1, p= .01). In addition, the con- tent of responses about risk assess- ment appears to have changed. In earlier years questions were simpler and mainly addressed whether risk was assessed. In the later period questions were more elaborate and more often required a detailed as- sessment on the basis of risk factors for suicide.

For all other variables (listed in Table 3) no differences were found.

Correlation between responses and APA guidelines In general, the inspectorate’s 1996– 2006 responses were in line with APA guidelines. Important aspects of the responses were adequate psychiatric treatment, cooperation with other therapists involved in the patient’s care, continuity of care, and provision of aftercare for the bereaved family. In addition, responses about suicide risk assessment corresponded in- creasingly with the guidelines in the most recent years examined.

However, use of no-suicide con- tracts was addressed only once in all 227 of the inspectorate’s responses to suicide notifications, although 23% of the notifications indicated that a no- suicide agreement was arranged with

the patient, including patients who had a diagnosis of a psychotic disor- der, highly impulsive patients, and those with serious addiction.

Suicide notifications without follow-up The 278 suicide notifications without follow-up by the inspectorate were studied qualitatively to gain more in- sight into possible reasons for a lack of follow-up and to determine whether there were, despite the lack of follow-up, indications of structural problems in the mental health care provided. From the perspective of the APA guidelines, several possible signs of shortcomings in the mental

health care provided were observed and are discussed below.

Incomplete or inadequate risk as- sessment. In 59 notifications without follow-up (21%), therapists underes- timated the risk of suicide despite the presence of several risk factors. Previ- ous suicide attempts were labeled as “merely a cry for help” in nine notifi- cations, and thus the suicide risk was estimated to be low. In addition, in nine cases mental health care workers were unaware of the suicidal history of the patient or knew nothing about suicidal intent expressed by the pa- tient to family members or fellow pa- tients by the patient.

Another problem in the area of

Table 3

Issues addressed in 227 inspectorate responses to suicide notifications involving

suicides of mental health service users in the Netherlands, 1996–2006a

Issue N %

Evaluation of the suicide Treatment of the psychiatric disorder Treatment guidelines Collaboration with other practitioners or services Suicide risk assessment Medication Psychiatric assessment Continuity of care Involvement of the patient’s family in treatment Treatment of suicidality Role of the psychiatrist Aftercare for relatives Noncompliance and involuntary hospitalization

135 60 86 38 82 36 66 29 62 27 61 27 40 18 33 15 33 15 32 14 27 12 15 7 15 7

a Many responses addressed more than one issue.

Table 4

Characteristics of suicide notifications involving 505 mental health service users in the Netherlands, 1996–2006, by

whether or not the characteristic was present and whether the inspectorate responded

Characteristic present

N of Characteristic responses %

Characteristic absent

N of responses % χ2a p

Patient was less than 35 years old Patient was treated in mental health care for less than a year Patient was still in an initial registration procedure Fellow patients had signals of an imminent suicide in the

months before the suicide Unclear whether the clinician discussed suicidality with the patient Notification contained plans to improve mental health care

as a result of the suicide Patient was discharged from inpatient care in the 3 months

before the suicide

68 52 159 72 53 155 24 67 203

13 68 214 44 57 183

76 59 151 54 38 173

43 3.46 .06 42 4.39 .04 43 7.39 .01

44 4.40 .04 43 5.46 .02

40 14.41 <.01 48 4.52 .03

a df=1

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poor risk assessment was that atten- tiveness to suicide risk had waned, es- pecially for patients who had a history of severe suicidality but who did not report current suicidal ideation (N=15) and for patients who were chronically suicidal (N=15).

Insufficient continuity and intensity of care. Continuity of care was not al- ways adequate. In 11 notifications without follow-up, the patient com- mitted suicide while on a waiting list for treatment or while involved in a registration procedure that lasted sev- eral months, despite the patient’s se- vere psychiatric symptoms or crisis. In 14 cases that were not followed up by the inspectorate, follow-up appoint- ments after discharge from inpatient care took weeks or months (range of three weeks to three months). In 17 other cases the emergency service did not assess suicide risk in time or did not make an appointment with the pa- tient within a few days of referral or of the patient’s initial contact with servic- es, and the patient committed suicide before being seen.

Unwarranted trust in no-suicide contracts. In 28 notifications without follow-up, a no-suicide contract was arranged with a patient and the ther- apists involved considered the sui- cide risk to be reduced. In seven cas- es the patient’s willingness to enter a contract was sufficient to result in transfer to an open ward. Moreover, in five cases arrangement of a no- suicide contract seemed to be the only safety measure taken; other measures, such as more intensive care or a safety plan, were not car- ried out.

Inadequate decisions about hospi- talization. In 14 cases without follow- up, patients in crisis weren’t hospital- ized because hospitalization was thought to be risk enhancing, presum- ably because these patients had a per- sonality disorder. In addition, seven patients committed suicide while on a waiting list for inpatient admission.

Inadequate communication. Inad- equate communication between mental health care workers, especial- ly about suicidality, may have led to insufficient transfer of information and suicide risk management in 19 notifications for which no follow-up was received.

Insufficient monitoring of severely depressed or psychotic patients. For six notifications that involved suicide of a hospitalized patient and for which no follow-up was received, the patient was able to run away from a closed ward on repeated occasions.

Inadequate communication with the patient’s family. In 16 cases with- out follow-up, the patient’s relatives were either unable to discuss their concerns about the suicidality of their relative with the therapists or they were not involved in treatment de- spite the patient’s severe suicidality.

Discussion

This study was undertaken as a first step in a research program to evaluate the suicide notification procedure ad- ministered by the Health Care In- spectorate in the Netherlands. The results show that in 2006 approxi- mately 37% of all mental health work- ers who reported a suicide received further questions or remarks from the inspectorate. Inspectors’ responses were mostly focused on the thorough evaluation of circumstances and care surrounding the suicide. Another main point of interest to the inspec- torate was the treatment of psychi- atric disorders in accordance with treatment guidelines. Compared with responses to suicide notifications be- tween 1996 and 2001, recent respons- es have more often stressed the im- portance of conducting suicide risk assessment, which is in line with APA guidelines.

Certain aspects of the notifications led to more or less frequent respons- es. Inspectors’ responses depended on the treatment status of the patient who died by suicide and tended to depend on the patient’s age and time in treatment. The proportion of re- sponses was larger for patients who were young or at the beginning of treatment, and it was smaller for pa- tients who were recently discharged from inpatient care. These findings suggest that the inspectorate focuses especially on patient groups and time periods for which suicide pre- vention efforts are considered most effective. Apparently inspectors be- lieved that there were few opportu- nities for prevention among elderly persons, those with chronic illnesses,

and those in the postdischarge peri- od, although patients in the postdis- charge period are widely recognized to be at high risk of suicide (7). There may be opportunities for the inspectorate to emphasize more ef- fective suicide prevention in the postdischarge period.

Inspectors tended to pay special attention to suicides in which fellow patients had noticed signals of an im- minent suicide in the months before and when it was unclear whether the clinician had discussed suicidality with the patient or whether the pa- tient had been treated as suicidal. These aspects were apparently re- garded as important considerations for suicide prevention. Moreover, these findings may demonstrate the gradually growing awareness in the field and within the inspectorate that suicidal impulses need specific at- tention in addition to the usual treat- ment for psychiatric disorders. The inspectorate could further promote such awareness, as recommended in the APA guidelines.

A notable result is that only one of the inspectorate’s 227 responses ad- dressed use of no-suicide contracts, although such contracts were used in about one in five of the cases re- viewed by the inspectorate. Con- tracts were made with patients who had addictive or psychotic disorders or who were highly impulsive, which is discouraged by APA guidelines for the treatment of suicidal patients (6).

The inspectorate was more likely to respond to a suicide notification when mental health institutions at- tached plans for improvement to the notification. In its responses the in- spectorate both supported the in- tended improvements and acknowl- edged the flaws in the mental health care delivery that the institutions themselves admitted. However, in some cases the inspectorate did not respond, although the notification contained indications of possible flaws in care delivery. This finding seems to indicate that the inspec- torate neglected to address some shortcomings. Moreover, inspectors did not respond in the same manner to all notifications involving the same themes, which suggests a somewhat arbitrary element.

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In general, mental health care providers are concerned about possi- ble disciplinary measures by the in- spectorate; however, the findings of this study show that in cases of suicide notifications, such measures seldom follow. In none of the inspectorate’s 227 responses to suicide notifications were disciplinary measures taken, and only a small percentage (3%) of suicide notifications led to an exten- sive inquiry into the case.

Some limitations should be noted. The results of this study depend on the quality and comprehensiveness of suicide notifications. Additional re- search is in progress to evaluate these aspects of the notifications. The re- sults of the qualitative analyses are based on the authors’ interpretations of whether treatment was consistent with APA guidelines (6) and therefore are not conclusive. In addition, a rel- atively large number of tests were conducted, and it is possible that some associations were found by chance. Replication is needed to con- firm the factors that determine whether the inspectorate responds to a notification.

The notification procedure is

meant to provide supervision of the quality of health care service delivery and to improve care for suicidal pa- tients in the future. As such the in- spectorate’s procedure can be a pow- erful tool in promoting suicide pre- References vention. Further research is in

Acknowledgments and disclosures

This research was funded by the Health Care Inspectorate in the Netherlands.

The authors report no competing interests.

progress to examine the influence of the suicide notification procedure on the quality of care in mental health services and to examine how mental health services view the notification procedure.

Conclusions

The results show that supervision in mental health care can be optimized in accordance with guidelines for the treatment of suicidal patients. The inspectorate might enhance its review procedure by more consis- tent supervision, continuing empha- sis on systematic suicide risk assess- ment, more emphasis on the specif- ic treatment of suicidal impulses, more attention to the treatment of older patients who are chronically suicidal and to patients newly dis- charged from inpatient care, and more focus on a restrained use of no-suicide contracts.

1. Bertolote JM, Fleischmann A, De Leo D, et al: Psychiatric diagnoses and suicide: revisit- ing the evidence. Crisis 25:147–155, 2004

2. National Suicide Prevention Strategy for Eng- land. London, Department of Health, 2002

3. National Strategy for Suicide Prevention: Goals and Objectives for Action. Rockville, Md, US Public Health Service, 2001

4. Appleby L, Shaw J, Amos T, et al: Suicide within 12 months of contact with mental health services: national clinical survey. British Medical Journal 318:1235–1239, 1999

5. Burgess P, Pirkis J, Morton J, et al: Lessons from a comprehensive clinical audit of users of psychiatric services who commit- ted suicide. Psychiatric Services 51:1555– 1560, 2000

6. American Psychiatric Association: Practice guideline for the assessment and treatment of patients with suicidal behaviors. Ameri- can Journal of Psychiatry 160(Nov suppl): 1–60, 2003

7. Huisman A, Kerkhof AJFM, Robben PBM: Guidelines for the treatment of suicidal pa- tients: an overview [in Dutch], in Jaarboek Voor Psychiatrie en Psychotherapie 2007– 2008, 10th ed. Edited by Schene AH, Boer F, Jaspers JPC, et al: Houten, Netherlands, Bohn Stafleu van Loghum, 2007

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Estadisticas- China rural

Mental Disorders and Suicide Among Young Rural Chinese: A Case-Control Psychological Autopsy Study

Jie Zhang, Ph.D. Shuiyuan Xiao, M.D., Ph.D. Liang Zhou, M.D., Ph.D.

Objective: The authors examined the prevalence and distribution of mental disorders in rural Chinese 15–34 years of age who committed suicide. They hypoth- esized that mental illness is a risk factor for suicide in this population and that the prevalence of mental illness is lower in fe- males than in males.

Method: In this case-control psychologi- cal autopsy study, face-to-face interviews were conducted to collect information from proxy informants for 392 suicide vic- tims and 416 living comparison subjects. Five categories of DSM-IV mental disorders (mood disorders, schizophrenia and other psychotic disorders, substance use disor- ders, anxiety disorders, and other axis I disorders) at the time of death or interview were assessed using the Chinese version of the Structured Clinical Interview for DSM- IV. Sociodemographic variables, social sup- port, and life events were also assessed.

Suicide is an important public health and mental health problem in China. The recently released Report on Injury Prevention in China revealed suicide rates to be 22.6, 22.4, 22.1, 19.3 and 19.3 per 100,000 in 1995, 1998, 2000, 2003, and 2005, respectively (1). Empirical studies in recent years have reported several unique findings on the pattern of suicide in China compared with other coun- tries, mainly Western countries. First, unlike in most other countries, Chinese women are as likely as, or more likely than, men to commit suicide (2–4). Second, consistent with findings in many Western countries, the suicide rate among older adults is the highest among all age groups in China, but another, smaller peak occurs in the 15- to 34-year-old age group (3). Third, the suicide rate in rural areas of China is three to five times higher than that in ur- ban areas (2, 3, 5).

Mental health has been a major area in which suicide is investigated. In the West, over 90% of suicides are associ- ated with mental illness (6–8). In China, it has been esti- mated that only about 30% of suicide victims had a psy- chiatric diagnosis listed in official death registry data (9). In a nationally representative psychological autopsy study (N=519), Phillips and colleagues (10) reported that 40% of suicide victims were diagnosed with depression, 7% with

Results: The prevalence of current mental illness was 48.0% for suicide vic- tims and 3.8% for comparison subjects. Among suicide victims, mental illness was more prevalent in males than in females (55.1% compared with 39.3%). A strong association between mental illness and suicide was observed after adjustment for sociodemographic characteristics. Other risk factors included having a lower edu- cation level, not being currently married, having a lower level of social support, and having a history of recent and long-term life events. Additive interactions were ob- served between mental illness and lower level of social support.

Conclusions: Although mental illness is a strong risk factor for suicide, it is less prevalent among rural Chinese young people who committed suicide, particu- larly females, in comparison with other populations in China and in the West.

(Am J Psychiatry 2010; 167:773–781)

schizophrenia, and 7% with alcohol dependence. Other risk factors—which included depression, previous suicide attempt, acute and chronic stressful life events, and lower quality of life—were similar to those seen in the West (10). Zhang et al. (11) found that 76% of rural suicide victims (N=66) had a diagnosable mental illness. However, these studies added little information to our understanding of the high suicide risk among rural Chinese and the unique patterns of distribution of suicide across age and gender because of either the use of injury deaths as controls (10) or small sample size (11).

We demonstrated in previous work (12) that it is feasible to study suicide by using the psychological autopsy meth- od in Chinese social and cultural environments and that instruments developed in the West are reliable and valid for use in China (13). In this study, we used established psychological autopsy methods and a case-control design to examine the prevalence of mental disorders in rural Chinese 15–34 years of age who committed suicide and to examine possible interactions among mental illness, so- cial support, and life events in suicide. To the best of our knowledge, this is the first psychological autopsy study in this specific population using living comparison subjects in China.

This article is discussed in an editorial by Dr. Phillips (p. 731).

Am J Psychiatry 167:7, July 2010

ajp.psychiatryonline.org 773MENTAL DISORDERS AND SUICIDE AMONG YOUNG RURAL CHINESE

TABLE 1. Characteristics of Suicide Victims and Living Comparison Subjects in a Study of Suicide Among Rural Chinese 15–34 Years of Age

Characteristic Suicide Victims (N=392)

Comparison Subjects (N=416)

25.7 6.2 9.6 6.7 37.1 4.4

202 48.6

267 64.2 144 34.6 5 1.2 17 4.1 275 66.1

201 48.3 46 11.1 169 40.6

376 90.4 28 6.7 12 2.9

220 52.9 87 20.9 58 13.9 51 12.3

Mean

SD

Mean

SD

Agea 26.8

6.4 8.5 6.0

54.5

52.3 41.1 6.6 8.9 65.5

61.7 15.1 23.2

58.2 22.2 19.6

17.6 18.1 25.8 38.5

Educationb (years) Duke Social Support Index, total scorec

Male Marital statusc

Currently married Never married Divorced, separated, or widowed

Living aloneb Employed Annual family incomec (yuan)

≤10,000 10,001–19,999 ≥20,000

Number of recent life eventsc 0

1

≥2 Number of long-term life eventsc

0 1 2 ≥3

a Significant difference between groups, p=0.01. b Significant difference between groups, p=0.005. c Significant difference between groups, p<0.001.

Method

Sampling

8.1 29.9

214

205 161 26 35 257

242 59 91

228 87 77

69

71 101 151

N

%

N

%

Three provinces in China—Liaoning, Hunan, and Shan- dong—were chosen for the study. Sixteen rural counties were randomly selected from the three provinces (six from Liaoning, five from Hunan, and five from Shandong). In each county, sui- cide victims 15–34 years of age were consecutively enrolled in the study from October 2005 through June 2008. Similar num- bers of comparison subjects living in the community were re- cruited in the same counties during approximately the same period.

For our study, all village doctors in the research areas were briefly trained on study procedures and were required to report suicidal deaths to local Centers for Disease Control and Preven- tion (CDCs). For suicidal deaths that were not recognized by any health agency, our mortality registry system allowed the village treasurers, who collect fees for each burial or cremation and are aware of all deaths in the village, to notify the county CDC. Whenever necessary, an investigation with the village board and villagers was conducted by the research team to try to ensure that no cases of suicide were missed.

We used the 2005 census database of the 16 counties to ran- domly select a living comparison subject in the same age range (i.e., 15–34 years) and county of residence for each suicide victim.

Measures

We used the Chinese version of the Structured Clinical Inter- view for DSM-IV (SCID) (14) to generate current diagnoses for both the suicide group and the comparison group. Diagnoses were made by psychiatrists on each team in consensus meetings

during which all responses from each informant were presented by the nonpsychiatrist interviewers. Five categories of DSM-IV axis I diagnoses were covered: mood disorders, schizophrenia and other psychotic disorders, substance use disorders, anxiety disorders, and other axis I disorders (stress-related disorders, so- matoform disorder, eating disorders, pathological gambling, and adjustment disorder). Diagnoses of personality disorders and mental disorders with onset in childhood and adolescence (e.g., conduct disorder) were not included. Multiple diagnoses were made if appropriate.

The 23-item Duke Social Support Index (15; possible scores range from 11 to 45) was used to measure social support, and Paykel’s Interview for Recent Life Events (16) was used to measure life events. Twenty life events were added to the original 44 life events in the instrument, so that a total of 64 events were covered in the interview. Life events that occurred no more than 1 month before death or interview were defined as recent life events, and those that occurred more than 1 month before death or interview were defined as long-term life events. Both instruments were vali- dated in our previous study (12).

Training of Interviewers

All interviewers were mental health or public health profes- sionals and were intensively trained for 2 weeks on determination of manner of death, psychological autopsy methods, and admin- istration of the study instruments by U.S. and Chinese experts be- fore beginning data collection. The interrater reliability (kappa) of mental disorder diagnoses and other instruments ranged from 0.72 to 0.90 based on the ratings of all interviewers in three mock interviews conducted after training. A 1-week midterm training of all investigators from the three research sites was carried out in 2007.

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TABLE 2. Diagnoses of Mental Disorders Among Suicide Victims and Living Comparison Subjects in a Study of Suicide Among Rural Chinese 15–34 Years of Age

Diagnosisa

Any axis I disorder at time of death or interview Mood disorders

Major depressive disorder Bipolar disorder Dysthymia Mood disorder due to a general medical condition Mood disorder not otherwise specified

Schizophrenia and other psychotic disorders Schizophrenia Schizoaffective disorder Psychotic disorder due to a general medical condition Psychotic disorder not otherwise specified

Substance use disorders Alcohol use disorder Substance use disorder other than alcohol

Anxiety disorders and other axis I disorders Generalized anxiety disorder Phobic disorder Posttraumatic stress disorder

Anxiety disorder not otherwise specified Other axis I disorders

Acute stress disorder

N % N %

188 48.0 16 3.8 137 34.9 10 2.4 93 23.7 6 1.4 12 3.1 1 0.2 10 2.6 0 0.0 1 0.3 1 0.2 21 5.4 2 0.5 44 11.2 2 0.5 40 10.2 2 0.5 1 0.3 0 0.0 2 0.5 0 0.0 1 0.3 0 0.0 25 6.4 4 0.9 23 5.9 4 0.9 2 0.5 0 0.0 8 2.0 2 0.5 3 0.8 0 0.0 3 0.8 1 0.2 1 0.3 0 0.0 1 0.3 1 0.2 2 0.5 0 0.0 1 0.3 0 0.0 1 0.3 0 0.0

Pathological gambling a The sum of all diagnoses exceeds the number of study subjects with any diagnosis because of multiple diagnoses.

Interviewing Procedures

For suicide victims, interviews with informants were scheduled between 2 and 6 months after the suicide incident; this timing was intended to reduce the impact of acute grief on the interview while minimizing recall bias. Interviews with informants for liv- ing comparison subjects were scheduled as soon as these partici- pants and their informants were identified. Each informant was interviewed separately by one trained interviewer. The average time for each interview was 2.5 hours.

This study was approved by the institutional review boards of State University of New York College at Buffalo; Central South University, Hunan; Provincial Center for Disease Prevention and Control, Liaoning; and Shandong University, Shandong. The re- search nature of the interview and the background of the research project were explained to all interviewees, and informed consent forms detailing the rights of interviewees were read and signed by both parties prior to each interview.

Selection of Information Sources

For each suicide victim and each comparison subject, we tried to interview at least two informants. To obtain parallel data be- tween the two groups, we also used proxy information from the comparison subjects. Those individuals who were most familiar with the subject’s life and circumstances and were available and consented to participate were interviewed by the research team. Although target persons could be as young as 15 years of age, in- formants had to be 18 or older. Characteristics of the informants for both suicide victims and comparison subjects were noted in a standardized fashion, recording most recent contact, number of contacts in the past month and past year, number of years the informant has known the target, the informant’s relationship with the target, and the informant’s impression of their familiarity with the target. For both suicide victims and comparison subjects, the first informant was always a parent, a spouse, or another im-

portant family member, and the second informant was always a friend, coworker, or neighbor. Of all the informants and living comparison subjects we initially contacted, only four informants for suicide victims and six living comparison subjects refused to participate in the study. We replaced them by selecting another four informants and six living comparison subjects.

Where responses of two informants differed on demographic variables or life events, we relied on the answer provided by the in- formant who had the best access to the information. With regard to mental illness, we recorded a symptom as present if it was en- dorsed by either informant because the other informant may not have had an opportunity to observe the specific characteristic or behavior.

Statistical Analysis

Descriptive analyses, t tests, and chi-square tests were carried out to describe and compare the demographic characteristics, level of social support (total score on the Duke Social Support Index), and number of recent and long-term stressful life events of the suicide and comparison groups. Adjusted odds ratios and 95% confidence intervals (CIs) derived from multivariate logistic regressions indicated associations between suicide and risk fac- tors. Years of formal school education were categorized into three groups: <7 years, 7–9 years, and >9 years. The family’s annual income in yuan (renminbi) was categorized into three groups: ≤10,000 yuan, 10,001–19,999 yuan, and ≥20,000 yuan. (During the study period, the exchange rate was approximately 7 yuan to the U.S. dollar.) Marital status was dichotomized as “not cur- rently married” and “currently married,” with the former includ- ing never married, divorced, separated, or widowed and the latter including those who were currently married or involved in a living relationship. Recent life events were categorized into three groups based on the count: 0, 1, and ≥2; and long-term life events were similarly categorized into four groups: 0, 1, 2, and ≥3. Score on the Duke Social Support Index was categorized into three social sup-

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Suicide Victims (N=392)

Comparison Subjects (N=416)

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MENTAL DISORDERS AND SUICIDE AMONG YOUNG RURAL CHINESE

TABLE 3. Categories of Mental Disorders Diagnosed in Male and Female Suicide Victims in a Study of Suicide Among Rural Chinese 15–34 Years of Age

Male (N=214)

N % N

118 55.1 70 87 40.7 51 19 8.9 25 25 11.7 0

Female (N=178)

Categorya

Any mental disorder at time of deathb Mood disordersc Schizophrenia and other psychotic disorders Substance use disordersd

%

39.3 28.7 14.0

0.0 1.7 0.6

Anxiety disorders Other axis I disorders a The sum of all diagnoses exceeds the number of study subjects with any diagnosis because of multiple diagnoses. b Significant difference between groups, p=0.003. c Significant difference between groups, p=0.011. d Significant difference between groups, p<0.001.

FIGURE 1. Prevalence of Mental Illness Among Male and Female Suicide Victims and Living Comparison Subjects

more likely to live alone, and had lower income, less so- cial support, and more recent and long-term stressful life events (all p values <0.05).

Stressful Life Events

The most common recent stressful life events among suicide victims were fight with family members (N=38, 9.7%), fight with spouse/partner (N=34, 8.7%), and losing face (N=16, 4.1%); the most common long-term life events were financial difficulties (N=113, 28.8%), physical illness (N=88, 22.4%), and physical illness of a family member (N=59, 15.1%).

Diagnoses of Mental Disorders

A total of 188 (48.0%) suicide victims and 16 (3.8%) com- parison subjects met criteria for a diagnosis of at least one current mental disorder (Table 2); 29 suicide victims and two comparison subjects had two diagnoses. The most frequently diagnosed mental disorder category among suicide victims was mood disorders (34.9%), followed by psychotic disorders (11.2%) and substance use disorders (6.4%). Ninety-two suicide victims (23.5%) had a past his- tory of mental illness, although of these, nine (9.8%) did not meet criteria for any current mental illness based on our SCID interview. History of past suicide attempt was significantly different between suicide victims with and without mental disorders (26.6% compared with 7.8%; c2=24.57, p<0.001).

Among the suicide victims, 118 of 214 males (55.1%) and 70 of 178 females (39.3%) met diagnostic criteria for at least one mental disorder (Table 3, Figure 1). After other sociodemographic characteristics, social support, and stressful life events were controlled for in a logistic regres- sion model, males were twice as likely as females to have a mental disorder diagnosis (odds ratio=2.06, 95% CI=1.26– 3.36). The prevalence of mental illness in comparison sub- jects was 4.0% for males and 3.7% for females (Figure 1).

Overall and Gender-Specific Multivariate Logistic Regression Models

After adjustment for sociodemographic characteris- tics, social support, and life events in a logistic regression

60

40

20

0

5 2.3 3 1 0.5 1

Male Female

Suicide Victims

Living Comparison Subjects

port groups based on the 33rd and 66th percentiles among case and comparison subjects: scores <32, from 32 to 37, and >37.

An additive model was used to test interactions among mental illness, social support, and recent and long-term life events (17, 18). Interaction in epidemiology refers to the extent to which the joint effect of two risk factors on a disease differs from the inde- pendent effects of each of the factors. It was argued that interac- tion measured on the additive scale was better correlated with bi- ological interaction than when measured on a multiplicative scale (19) and was more related to disease prevention and intervention (20). In our study, the interactions were measured by a synergy index (18, 19) with 95% CIs based on the method described by Andersson et al. (21). Statistically significant interaction was indi- cated if the synergy index was >1 and the 95% CI did not include 1.

Results

Characteristics of Case and Comparison Subjects

A total of 392 suicide victims and 416 living comparison subjects were enrolled in the study. No significant differ- ence was observed in age distribution between compari- son subjects and the 2005 Chinese national census data (p>0.05). The characteristics of case and comparison sub- jects are summarized in Table 1. Relative to comparison subjects, suicide victims were about 1 year older, were less educated, were less likely to be currently married, were

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Prevalence of Mental Illness (percent)

TABLE 4. Overall and Gender-Specific Multivariate Logistic Regression Models in a Study of Suicide Among Rural Chinese 15–34 Years of Agea

Predictor

1.05 Male 1.00

95% CI

0.99–1.10

0.79–1.64

0.77–2.02 0.69–2.77

0.55–1.42

2.35–9.79 0.86–2.78

1.61–5.70 0.26–1.47

5.81–20.25 7.15–22.68 10.73

95% CI

0.97–1.11

0.50–1.88 0.36–2.40

0.49–1.59

1.15–7.38 0.61–3.17

0.95–5.68 0.12–1.33

3.63–21.00

4.84–23.80 1.97–7.61

2.61–20.38 2.19–13.80

1.99–10.17 1.20–5.67 0.69–3.13

Age Gender

Female Annual family income (yuan)

≤10,000 10,001–19,999 ≥20,000

Employment Employed Unemployed

Education (years) <7

7–9

>9 Marital status

Currently married

Not currently married Living alone

Yes

No Any diagnosis

1.14

1.24 1.38 1.00

1.00 0.88

4.70 1.55 1.00

1.00 3.03

0.62 1.00

Yes 10.85

No 1.00 Duke Social Support Index, total score

<32 12.74 32–37 3.28 >37 1.00

Number of recent life events ≥2 8.12 1 4.02 0 1.00

Number of long-term life events ≥3 3.25 2 3.13 1 1.41 0 1.00

8.73 1.00

Overall

Adjusted Odds Ratio

Females

Adjusted Odds Ratio

1.04

0.97 0.93 1.00

1.00 0.88

2.91 1.39 1.00

1.00 2.32

0.40 1.00

Males

Adjusted Odds Ratio 95% CI

1.06 0.99–1.14

1.62 0.76–3.43 2.19 0.75–6.43 1.00

1.00 0.87 0.38–1.98

11.60 3.73–25.93 1.83 0.77–4.36 1.00

1.00 4.78 1.78–12.83

1.11 0.31–3.97 1.00

15.68 6.11–40.26 1.00

16.40 6.65–40.41 2.72 1.24–5.98 1.00

11.83 3.76–37.25 3.60 1.46–8.88 1.00

2.60 1.08–6.26 5.04 2.01–12.67 1.65 0.63–4.35 1.00

1.99–5.40

3.06–17.07 2.16–7.48

1.83–5.78 1.78–5.53 0.79–2.52

3.87 1.00

7.29 5.49 1.00

4.50 2.61 1.44 1.00

a For the overall model, Hosmer and Lemeshow test c2=11.560, p=0.172; Nagelkerke R2=0.650; for the model in females, Hosmer and Lemeshow test c2=15.275, p=0.054; Nagelkerke R2=0.583; for the model in males, Hosmer and Lemeshow test c2=8.099, p=0.424; Nagelker- ke R2=0.726.

model, suicide victims were more than 10 times as likely as living comparison subjects to have a mental disorder diagnosis (odds ratio=10.85, 95% CI=5.81–20.25) (Table 4). Other risk factors included having a lower education level, not being currently married, having lower levels of social support, having one or more recent life events, and having two or more long-term stressful life events. After stratifica- tion by gender, the odds ratio of having any diagnosis of mental disorder was 8.73 (95% CI=3.63–21.00) in female suicide victims and 15.68 (95% CI=6.11–40.26) in male suicide victims (Table 4). Other risk factors were similar in both genders except that not being currently married was a risk factor in male but not female suicide victims.

Interaction Among Mental Disorder Diagnoses, Social Support, and Life Events

To simplify interpretation of odd ratios, social sup- port was dichotomized along the median for all case and comparison subjects, number of recent stressful life events was dichotomized as “0” and “at least 1,” and number of long-term life events was dichotomized as “0 or 1” and “at least 2” because increased risk was observed only in those who experienced at least two long-term life events. As shown in Table 5, significant interaction was observed only between mental disorder diagno- sis and lower social support (synergy index=7.626, 95% CI=2.334–24.914).

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TABLE 5. Diagnosis of Mental Disorder, Recent and Long-Term Life Events, and Low er Social Support as Suicide Risk Factors in a Study of Suicide Among Rural Chinese 15–34 Years of Age

Interaction

Diagnosis of mental disorder × lower social support

Diagnosis of mental disorder × one or more recent life events Diagnosis of mental disorder ×

two or more long-term life events

Both Risk Factors

90.2 21.73 24.27

Diagnosis of Mental Disorder Only

9.1 15.56 16.67

No Mental Disorder Diagnosis

4.6 6.56 2.97

Neither Risk Factor (Reference Group)

1.0 1.0 1.0

Synergy Index

7.626 1.029 1.321

95% CI

2.334–24.914 0.325–3.263 0.428–4.082

Likelihood of Suicide (Adjusted Odds Ratioa)

a Adjusted odds ratios were derived from multiple logistic regression models including all independent variables except the two variables tested for interaction.

Discussion

In this study, we used consecutive sampling to enroll suicide victims in 16 randomly selected counties in three provinces in China. Because there is no comprehensive vi- tal reporting system in China, we relied mainly on village doctors and local CDC health professionals to identify eligible cases. To minimize false classifications or missed suicide cases, we trained village doctors in reliable deter- minations of manner of death and, where the case was ambiguous, arrived at consensus based on consideration of additional information from multiple resources, includ- ing village heads and village treasurers. Using these tech- niques, we identified 392 suicide victims over the 2.5-year study period.

Although suicide rates for women have been reported to be higher than those for men in rural China (3), a more recent estimate showed that the rural male-to-female ra- tio for suicide increased from 0.77 in 1991 to 0.94 in 2000 (2). Our study indicated that the suicide rate for men was slightly higher than that for women in this popula- tion. With the continuing improvement in quality of life in rural areas and increased opportunities for rural young women, including easier rural-urban migration in China, the male-to-female ratio for suicide may become closer to that in the West, although it would still be much lower.

The epidemiological assumption is that comparison subjects are representative of the general population in terms of probability of exposure (22). To optimize validity, we did not use accidental deaths for our comparison group because they might be biased in certain ways (e.g., a higher likelihood of substance misuse or impulsive, risk-taking behavior). The fact that proxy informants for comparison subjects were not affected by bereavement must, however, be taken into consideration in interpreting the results.

There was no significant difference in age or gender distributions between the comparison group and 2005 Chinese national census data, supporting the representa- tiveness of comparison subjects in our study. Our results on the prevalences of mood disorders and psychotic dis- orders in our comparison group were comparable to those of previous studies in China, while the prevalences of al- cohol use disorders and anxiety disorders were lower. For

example, in a survey of 5,201 adults in Beijing and Shang- hai, the authors reported a 1-year prevalence of 2.2% for mood disorders, 2.7% for any anxiety disorders, and 1.6% for alcohol abuse and dependence (23). In a large study (N=24,992), Hao and colleagues (24) reported a prevalence of current alcohol dependence of 3.8% in China. Our pri- mary explanations for the lower prevalence of alcohol use disorders and anxiety disorders in our comparison group are the lower prevalence of alcohol use disorders in the younger population in China (25, 26) and the limitations of the psychological autopsy method in detecting these disorders (27).

The prevalence of mental illness among our suicide victims was 48.0%, lower than previously reported preva- lences of suicides among all age groups in China (10, 11) but similar to the prevalence (44.7%) reported in a recent study of suicide victims in the 15- to 24-year-old age group (28). We compared our results to those of a systematic re- view of psychiatric diagnoses in suicide victims under 30 years of age (29), a meta-analysis that reviewed 13 reports, most from the West. The prevalence of all psychiatric di- agnoses is not comparable with our data because we did not include personality disorders or disruptive behavior disorders, which were highly prevalent in younger suicide victims in the West. Compared to the meta-analysis, our results indicated a moderately lower rate of mood disor- ders (34.9% compared with 42.1%), a substantially lower rate of substance-related disorders (6.4% compared with 40.8%), and a slightly higher rate of psychotic disorders (11.2% compared with 7.2%). Studies in China have shown that substance-related disorders are less common than in the West (30) and that Chinese young people have a lower risk of alcohol use disorders (25, 26) and are less likely to engage in heavy drinking (31, 32). Thus, this lower preva- lence of substance use disorders among suicide victims probably does not reflect different relationships between substance use and suicide in the East and West.

Because the prevalence of mental disorders in both sui- cide victims and comparison subjects in our study was lower than rates reported for samples from the West, we also compared odds ratios for mental disorders among suicide victims. A systematic review that included 24 psy- chological autopsy case-control studies reported a crude

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A typical suicide by a married rural young woman without any diagnosed mental disorders

Ms. Y, a young mother with a small child, lived in her husband’s family village, although her husband had a job in the city and was often away. She took care of her child and her parents-in-law, and her daily life was routine. She occasionally complained that she had less time to spend with friends than she did before she was married, although she also understood that a married woman’s role was in the home. With her husband away from home, she knew it was her responsibility to show filial piety toward her in-laws. Villagers commented that Ms. Y was a happy and lovely young woman, a model daughter-in-law in the village.

One day, the woman from the compound next door came to her and accused Ms. Y of stealing some eggs from the woman’s henhouse. Ms. Y became indignant and hotly

denied the accusation. But the neighbor persisted, claiming that no one else could have stolen the eggs. The quarrel quickly drew a large crowd of villagers. It was becoming increasingly difficult for Ms. Y to maintain her innocence, to “wash herself clean.” The fight ended with Ms. Y running to her room and crying. As the crowd was dispersing, Ms. Y grabbed a bottle of pesticide stored behind her front door and gulped down a large amount of the liquid. Her last words were, “I didn’t do it. A tree cannot survive without its bark, and person cannot live without face. I will die to prove that I did not steal her eggs.” The villagers arranged for a farm tractor to take Ms. Y to the nearest hospital to have her stomach pumped, but she died before it could get there.

odds ratio of 5.24 for substance-related disorders and 13.42 for mood disorders (33). These ratios are similar to or lower than those in our study, which suggests that the lower prevalence of mental illness we observed in young Chinese rural suicide victims may be due to the difference in prevalence of mental illness in the general population in China.

The prevalence of mental illness was significantly high- er in male than in females suicide victims, and the differ- ence remained significant after controlling for other char- acteristics. This result is consistent with that of a study on suicide victims 15–24 years of age in China (28). No alcohol- or substance-related disorders were diagnosed in female suicide victims, which is consistent with the previously reported low prevalence of alcohol use disor- der (0.2%) among women in China (24). After stratifica- tion by gender, the odds ratio for having a mental disor- der diagnosis was substantially higher among males than among females. This finding suggests that specific suicide prevention and intervention programs targeting Chinese rural females other than identification and treatment of mental illness are needed.

Consistent with previous reports (10, 11), we found that stressful life events and lower levels of social support were important risk factors. Our findings indicate that besides mental illness as a major risk factor for suicide among young people in rural China, other psychological, social, and cultural factors must play important roles, particular- ly in women. Future studies should explore the effects of constructs such as social integration (34), cultural values and norms such as face and impulsivity (35), and psycho- logical strain (36, 37) on Chinese suicide.

The lower prevalence of mental illness among Chinese suicide victims provides a unique opportunity to explore possible interactions between mental disorders and other risk factors in suicide. Additive interactions were found between mental illness and lower levels of social support, but not with recent or long-term life events. Mental illness

may increase an individual’s vulnerability through dam- age to the ability to maintain existing social relationships, to develop new relationships, or to utilize social support.

One of the limitations of this study was size of the liv- ing comparison sample. The total number of living com- parison subjects was too small for a detailed examination of the association between suicide and certain categories of mental disorders. For instance, only two comparison subjects were diagnosed as having schizophrenia. This is probably also a major challenge in other psychologi- cal autopsy studies of suicide. In a recent similar study in Pakistan, only six of 100 living comparison subjects were diagnosed as having mental illness (38). Our suggestion for future studies would be to enroll multiple living com- parison subjects for each suicide victim (e.g., using a 1:2 or 1:3 case-control design) to increase the number of com- parison subjects with mental disorders.

Second, there are several methodological concerns in a case-control psychological autopsy study. The use of proxy informants, the retrospective data collection, the lack of blinding regarding case and comparison subjects, and the potential impact of bereavement and stigma against sui- cide and mental illness on reporting may have an impact on the reliability of the data. Also, our strategy of schedul- ing interviews with proxy informants for suicide victims 2 to 6 months after suicide clearly differed from our strategy with informants for living comparison subjects and could increase the risk of recall bias.

Third, because different groups of interviewers and psy- chiatrists had been working on data collection and diag- noses of mental disorder separately at various research sites for more than 2 years, the reliability of diagnoses across investigators, time, and location was a major chal- lenge. However, the diagnoses made in this study are very likely reliable because of the efforts we put into training for all interviewers and psychiatrists, the excellent interra- ter reliability of diagnoses, and the fact that the prevalence of mental illness among suicide victims and comparison

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subjects did not differ significantly across research sites and across time.

Received Oct. 14, 2009; revision received Jan. 13, 2010; accept- ed Jan. 28, 2010 (doi: 10.1176/appi.ajp.2010.09101476). From the Public Health School, Shandong University, Shandong, China; State University of New York, College at Buffalo, N.Y.; and Central South University, China. Address correspondence and reprint requests to Dr. Liang Zhou, Public Health School, Central South University, 110 Xiangya Rd., Mailbox 29, Changsha, Hunan, China, 410011; zhouliang1976@gmail.com (e-mail).

All authors report no financial relationships with commercial in- terests.

Supported by NIMH grant R01 MH068560 to Dr. Zhang.

The authors thank their data collection collaborators Dr. Jiang Chao in Liaoning, Dr. Xiao Shuiyuan in Hunan, and Dr. Jia Cunxian in Shandong. They also thank Dr. Yeates Conwell, of the University of Rochester, for consultation on the design and implementation of the study, and the study interviewers for their tremendous contribution.

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