Suicide by charcoal burning in Taiwan: implications for means substitution by a case-linkage study

Objective This study estimated the incidence of suicide mortality among suicide attempters in Taiwan and assessed the extent of means substitution among subjects with a non-fatal attempt and a subsequent fatal attempt during the study period. Methods A total of 5,261 suicide attempters registered in a surveillance system of a metropolitan catchment area from 2004 to 2005 were followed through 2005. Linkage to the death certification system revealed that 72 died by suicide. The association of completed suicide with the suicide method used at index attempt was examined using Cox proportional hazards regression. Incidence rate for the subsequent lethal suicide was estimated based on life tables. Results The 1-year incidence rate of suicide mortality was 0.017: 0.026 in males and 0.013 in females. There was a strong association between burning charcoal as the method used at the index attempt (relative hazard = 4.1, P < 0.001) and completed suicides. Those who used the method of burning charcoal at the index attempt frequently used the same means in a subsequent attempt leading to suicide mortality. However, a majority of suicide completers (59.1%) who died by burning charcoal had used a different method at their index attempt. Conclusions Persons who attempt suicide by charcoal burning are a high-risk group for completed suicide. Those who burned charcoal in a suicide attempt were likely to use the same method in a later lethal attempt, and charcoal burning was a frequent cause of death among those who used different methods in earlier attempts. Charcoal burning should be a target for suicide prevention efforts.     

The contribution of charcoal burning to the rise and decline of suicides in Hong Kong from 1997–2007

Background  

There has been scant research exploring the relationship between choice of method (means) of self-inflicted death, and broader social or contextual factors. The recent emergence and growth of suicide using carbon monoxide poisoning resulting from burning charcoal in an enclosed space (hereafter, “charcoal burning”) was related to an increase in the overall suicide rate in Hong Kong. The growth of this method coincided with changing economic conditions. This paper expands upon previous work to explore possible relationships further.     

The suicide risk of discharged psychiatric patients

BACKGROUND: The suicide risk of psychiatric patients fluctuated along the course of their illness and was found to be high in the immediate post-discharge period in some settings. The epidemiology and psychiatric services for the suicide population in Hong Kong have differed from those of the West (i.e., low youth suicide rate, high elderly suicide rate, high female/male ratio, and heavily government-subsidized psychiatric service). This study examined the suicide rates within a year of discharge from psychiatric inpatient care in Hong Kong. METHOD: Discharges from all psychiatric hospitals or psychiatric wards in general hospitals in Hong Kong from 1997 through 1999 were followed up for suicides (ICD-9, E950-E959) and "undetermined" causes of deaths (E980-E989) by record linkage with the Coroner's Court until their deaths or Dec. 31, 2000. The suicide rates (/1000 person-years at risk) and standardized mortality ratios (SMRs; assigning a value of 1 to the same age- and sex-specific suicide rates in the general population) were calculated. RESULTS: 21,921 patients (aged over 15 years) were discharged from psychiatric hospitals from 1997 through 1999. Two hundred eighty patients committed suicide within 1 year of discharge; 85 suicides (30%) occurred within 28 days after discharge. The SMRs for suicide in the first 28 days after discharge were 178 (95% CI = 132 to 235) for females and 113 (95% CI = 86 to 147) for males. These rates were 4.0 (95% CI = 2.7 to 5.6) times higher for females and 4.6 (95% CI = 3.2 to 6.3) times higher for males than the rate in the rest of the year. Young adults had higher SMRs than the elderly. No specific diagnoses had higher suicidal risk than others. Calculations including undetermined causes of deaths (N = 53) gave similar results. CONCLUSION: The immediate post-discharge period carries a high risk of suicide for psychiatric patients. The high-risk groups are young adults and females. No diagnosis appears to carry a particularly high risk.     

Suicide in Hong Kong

Coroners' statistics indicated there were 684 suicides for the whole of Hong Kong in 1981. This gave a crude suicide rate of 18.1 per 100,000 population aged 15 years and over and constituted 2.7% of all deaths reported in that year. Only a few data were recorded in all coroners' files but additional data were obtained from police records on 168 of these suicides. The age and sex distribution among the suicides as well as the effect of marital and employment status on suicide rates were found to be similar to western countries. Jumping from a height was the most common method of suicide (47.2%) followed by hanging (30.8%). Psychiatric illness and chronic physical disability were two most important precipitating causes of suicide (39.8% and 35.7% respectively). Twenty per cent had a history of previous attempts with one-third occurring within six months of their completed suicide. Over 40% had communicated their suicide intention to others, while 19% left a note. 'Psychiatric' cases as a group had special features: there were more in the younger age groups, more with records of previous suicide attempts and more chose readily available methods.     

Risk factors for suicide in the immediate post-discharge period

BACKGROUND: Suicide risk is highest in the first few months following psychiatric in-patient care. Most data on post-discharge suicides have come from Western countries. Many studies collected cases of suicide over a long post-discharge period and did not focus on this high-risk period. This study aims to describe the characteristics and examine the risk factors of suicides occurring in the immediate post-discharge period in Hong Kong. METHODS: A case-control study based on discharged patients from all psychiatric hospitals/units in Hong Kong in 1997-1999. Suicides occurring within 60 days of discharge from psychiatric hospitals (N = 97) were ascertained by record linkage with Coroner's court data. Controls were matched for age, gender, diagnoses, discharge hospitals, and dates of discharge. Possible risk factors were extracted from in- and out-patient records, and were identified by conditional logistic regression. RESULTS: The commonest diagnosis and suicide method were schizophrenia and falling from a height, respectively. There were no significant case-control differences in the drug treatment received. Risk factors for suicides were: previous deliberate self-harm (OR = 2.3, 95% CI = 1.07-5.05), admission for deliberate self-harm (OR = 3.2, 95% CI = 1.3-7.8), compulsory admission (OR = 3.1, 95% CI = 1.1-8.7), living alone (OR = 5.8, 95% CI = 1.4-23), work stresses (OR = 5.4, 95% CI = 1.5-18) and being out of contact (OR = 7.9, 95% CI = 1.87-33). The overall number of risk factors had greater screening efficacy for suicide than any single factor. CONCLUSIONS: Vulnerable (previous suicidality) and uncooperative (compulsory admission and out of contact) patients who live alone and are exposed to work stresses are prone to immediate post-discharge suicide. Thorough treatment of the circumstances leading to the index admissions, management of work stresses, improved engagement in follow-up care and systematic assessment of suicide risk are indicated.     

Characteristics of youth suicide in Hong Kong

This paper explores the intrapersonal and sociocultural factors behind youth suicide in Hong Kong. The coroner's court reports of consecutive population-based youth suicide (below age of 25 years,n=303) cases from 1986 to 1992 were reviewed. Compared with other countries, Hong Kong had low male but high female youth suicide rates. The number of undetermined deaths did not significantly affect the estimated suicide rates. Cross-cultural differences in youth suicide rates may be understood from a differential distribution of risk factors and cultural attitudes towards role behaviours and suicide. Youth suicides in Hong Kong were characterised by a high prevalence of psychiatric disturbances and age-normative precipitants; both findings bear great resemblances to samples studied elsewhere. The results were evaluated in light of studies in different sociocultural backgrounds and highlighted the universality and specificity of youth suicide in Hong Kong.     

Suicides by jumping from a height in Hong Kong: a review of coroner court files

Purpose

Jumping from a height is the most common method for suicide in Hong Kong and other urban cities, but it remains understudied locally and internationally. We used Coroner records in exploring the ecological factors associated with these deaths and the personal characteristics of persons who jumped to their death (hereafter, “jumping suicides”). We compared suicides by jumping with all other suicides and examined the suicides that occurred at ten different jumping sites.

Methods

The Coroner’s files of all suicides in Hong Kong from 2002 to 2007 included 6,125 documented deaths.

Results

2,964 (48.4 %) involved jumping during the study period. Eighty-three percent (83 %) of suicide jumps occurred in residential buildings, and of these, 61% occurred from the decedent’s own home. Jumping suicides differed from non-jumping suicides in terms of their socio-demographic characteristics (e.g., for male: 60.8 vs. 67.3 % of jumping suicide and non-jumping suicides, p < 0.0001) and the presence of physical illness (44.4 vs. 42.7 % for jumping and non-jumping suicides, p < 0.0001). While statistically significant, these differences are relatively modest. In contrast, 40.7 documented illnesses vs. 23.1 % for jumping and non-jumping suicides (p < 0.0001).

Conclusions

Means restriction is a key strategy for suicide prevention. Installation of physical barriers, one of the mean restriction strategies, at common places for suicide has strong evidence to avert suicides without substitution effects. There seems to be challenges to implement physical barriers to prevent residential jumping suicides. Simply applying physical barriers to preclude jumping in Hong Kong appears to be difficult given its ubiquitous “high-rise” residential dwellings. Hence, we also need to develop alternative strategies aimed at preventing people from becoming suicidal.     

Suicide after discharge from psychiatric inpatient care: a case-control study in Hong Kong

OBJECTIVE: To identify the risk period and the risk factors for suicide in Chinese psychiatric patients after discharge from inpatient psychiatric treatment. The nature of psychiatric aftercare provided to these patients was also explored. METHOD: A case control study with 73 patients who were discharged from a large psychiatric unit in Hong Kong between January 1996 and December 1999 and had received coroners' verdict of suicide or undetermined death within the same period. Controls were 73 surviving patients discharged from the same unit. They were individually matched for sex, age, psychiatric diagnosis, and date of discharge. RESULTS: Post-discharge clustering of suicides was observed among the cases. Nearly 80% of them died within 1 year of discharge. The most common principal diagnosis among the cases was schizophrenia and related psychotic disorders. Multivariate analysis showed that suicide was associated with: unemployment (OR = 12.2, 95% CI = 2.1 - 70.4), past suicidal attempts (OR = 3.4, 95% CI = 1.2 - 9.6), maternal mental illness (OR = 13.4, 95% CI = 1.0 - 170.0), and suicidal ideation or attempt before the last admission (OR = 5.0, 95% CI = 1.4 - 18.0). The psychiatric aftercare received by cases and controls were generally similar. However, cases were more likely to have had contact with health care services in the last week before death (OR = 4.0, 95% CI = 1.3 - 11.9). CONCLUSIONS: Suicidal risk is high in Chinese psychiatric patients soon after discharge. They share some common risk factors for suicide identified in Western studies but several differences are evident: the predominance of schizophrenia in the suicides; the lower prevalence of substance abuse and comorbidity; the low proportion of patients living alone; and the increased clinical contact before death but the less suicidal intent expressed in Chinese patients. It is necessary to consider these socio-cultural factors in assessment of suicidal risk and implementation of suicide prevention strategies in Chinese psychiatric patients.     

Risk of suicide after attempted suicide in the population of Slovenia from 1970 to 1996.

OBJECTIVE: All suicide attempts cannot predict suicide, therefore we examined those characteristics of suicide attempt which could most accurately predict completed suicide. SUBJECT AND METHODS: Subjects were all individuals registered as committed suicides (N=16,522) or attempted suicides (N=15,057) in the register of suicides of the Republic of Slovenia between 1970 and 1996. Log linear analysis of a frequency table was used to uncover relationship between categorical variables. RESULTS: The model we found fit between variables: mode, number of repetitions and type, then between number of repetitions, type and gender, and between mode, type and gender. DISCUSSION: The risk of suicide in those who previously attempted suicide is approximately 773 times higher than the risk of suicide without a previous suicide attempt. Those who attempt suicide by hanging (hanging being in Slovenia the most frequent mode of completed suicide) are at even greater risk to commit suicide. CONCLUSION: Our data suggests that clinicians should heighten their awareness that any suicide attempt can in some 20% predict suicide. Someone who has attempted suicide by hanging is at the highest risk of suicide.     

Aspects of suicide and parasuicide

Five aspects of suicidal behaviour in Edinburgh from 1968 to 1974 were examined. The data referred to 478 suicidal deaths and to parasuicide (attempted suicide) admissions to the Regional Poisoning Treatment Centre (R.P.T.C.). Firstly: 28 % of suicides were found to have had a parasuicide admission and there was some evidence of a slight excess of deaths in the years immediately following parasuicide. Secondly: among suicides preceded by parasuicide, those with a recent episode (within 2 years of death) were found to be essentially similar to those with a longer interval. Thirdly: a history of previous parasuicide at any time was found to be important in delineating two groups of suicide. Suicides with prior parasuicide died more often from poisoning with drugs and were more likely to have a history of psychiatric treatment; suicides without prior parasuicide died more often from poisoning with domestic gas or violent means, were older, of higher social class and less often married. Fourthly: parasuicides who killed themselves within 2 years of admission to the R.P.T.C. were compared with a group of (broadly nonsuicidal) parasuicides. And lastly: a scale predictive of repetition of parasuicidal behaviour was used in an attempt to distinguish parasuicides who killed themselves from those who did not. The scale did not discriminate between the two groups.     

Carbon monoxide poisoning as a new method of suicide in Hong Kong

The incidence in Hong Kong of intentional carbon monoxide poisonings by burning charcoal in a confined space was investigated. In the two-year study period, 22 (39 percent) of the 56 reported cases occurred in the three months following a highly publicized case in which this method was used to commit suicide; no cases were reported before the publicized incident. Individuals who used this method were younger on average (mean, 39 years) than those who used the more common methods of jumping (mean, 47 years) and hanging (mean, 55 years). The authors speculate that this form of suicide is becoming more prevalent because it has been highly publicized, it is easily carried out, and it is culturally acceptable.     

Changing patterns of suicide in Hong Kong

This paper aims to examine the changes in frequency, distribution and methods of suicide in the past 30 years in Hong Kong, and to explore the sociocultural factors behind such changes. Official data on suicides, undetermined deaths and seven social variables were used to estimate the age-, sex- and method-specific suicide rates and monthly occurrence of suicides, and to measure social changes. A low anomie status has been maintained for the past 30 years in Hong Kong. After accounting for undetermined deaths, suicide rates in adult males and young females (aged 15–24 years) decreased, while the rates in adult females remained stable. The phenomenon may be due to a protective effect of employment in males and by the changing status of women in Hong Kong. Suicide by jumping from heights became increasingly common, but appears to have substituted other means of suicide rather than increasing the overall suicide rate. Winter months had lower suicide rates, and the same circannual rhythm across diverse cultures speaks for a shared socio-biological process underlying suicide.     

Antidepressant drug consumption and public health indicators in Italy, 1955 to 2000

OBJECTIVE: This study investigated the impact of the increasing consumption of selective serotonin reuptake inhibitors (SSRIs) and newer anti-depressants on the following public health indicators: (1) suicide rates, (2) proportion of completed suicides by poisoning with solid or liquid substances, and (3) hospital admissions for depression and proportion of admissions for depression that were first admissions. METHOD: Data collected by IMS Health on antidepressants dispensed in Italy from 1983 to 2000 were obtained from the Italian Ministry of Health, while data on suicide deaths from 1955 to 2000 were obtained from the Italian National Institute of Statistics. RESULTS: In Italy from 1983 to 2000, the use of tricyclic antidepressants remained substantially stable, and the use of SSRIs and newer agents dramatically increased. In contrast, suicide rates for males decreased from 1955 to 1974 and subsequently increased, reaching a peak in 1985 and then declining. In females, suicide rates remained substantially stable until 1978. A subsequent increase occurred up to 1985, followed by a steady decline. Suicide by poisoning using solids or liquids dropped by nearly 50% from 1986 to 2000. Admissions to the hospital for depression showed an erratic pattern; however, no decline was observed. No change was observed in the rate of first admissions for depression. CONCLUSION: Despite a reduction in suicides by poisoning using solids or liquids, the analysis of long-term trends in suicide did not suggest that increases in antidepressant prescribing lie behind recent reductions in population suicides. Furthermore, in Italy, newer antidepressants had no impact on the total number of admissions for depression or on the proportion of all admissions that were first admissions.     

Elderly suicide and the 2003 SARS epidemic in Hong Kong

BACKGROUND: Hong Kong was struck by the community outbreak of Severe Acute Respiratory Syndrome (SARS) in 2003. In the same year, the elderly suicide rate in Hong Kong showed a sharp upturn from a previous downward trend. METHODS: Secondary analyses using Poisson Regression Models on the suicide statistics from the Census and Statistics Department of the Hong Kong Government were performed. RESULTS: In a Poisson Regression Model on the annual suicide rates in elders aged 65 and over in years 1986-2003, 2002 served as the reference year. Suicide rates in 1986-1997 were significantly higher than the reference year, with an Incident Rate Ratio (IRR) of 1.34 to 1.61. However, rates in 1998-2001 did not differ from the reference year significantly, representing stabilization of suicide rates for 4 years after 1997. The elderly suicide rate increased to 37.46/100,000 in 2003, with an IRR of 1.32 (p=0.0019) relative to 2002. Such trend is preserved when female elderly suicide rates in 1993-2003 were analyzed, while suicide rates in elderly men and younger age groups did not follow this pattern. DISCUSSIONS: Mechanistic factors such as breakdown of social network and limited access to health care might account for the findings. These factors could have potentiated biopsychosocial risk factors for suicide at individual levels, particularly in elderly. Female elders, by way of their previous readiness to utilize social and health services instituted in the past decade, are thus more susceptible to the effects of temporary suspension of these services during the SARS epidemic. CONCLUSIONS: The SARS epidemic was associated with increased risk of completed suicide in female elders, but not in male elders or the population under 65 years of age.     

Seasonal variation in suicides re-examined: no sex difference in Hong Kong and Taiwan

The seasonal variation in suicides in Hong Kong and Taiwan during the period 1981 to 1993 was examined using harmonic analysis. A single cycle per year with lowest incidence in the winter months was found in both locations and for both sexes. Despite the regional differences in ascertainment procedures and preferred suicide methods, the absence of a biseasonal distribution of female suicides was consistently observed. This finding was contrary to that reported in many Western countries. A non-shared psychosocial process underlying the cross-cultural difference in the seasonality of female suicide is suggested.     

Suidical ideation in severe depression

Suicidal ideation and communication were investigated for 89 suicide victims with a primary severe depression and matched controls. The selection of patients was based on multiaxial ratings of all hospitalised patients between 1956 and 1969. A blind record evaluation was performed, including scores on Beck's Scale for Suicidal Ideation and additional items apart from that scale. There was no relation between high scores on the Beck's scale and completed suicide. In the male group, suicidal ideation “beyond one's own will” was related to suicide. Female suicides that had made an attempt showed higher suicidal ideation than female suicides who had not. A substantial minority of the women (22%) committed suicide without showing any previous intent. Only 5% of the male suicides had shown no previous intent to commit suicide. Received: 4 December 1998 / Accepted: 8 February 2000     

Methods of youth suicide in New Zealand: trends and implications for prevention

OBJECTIVE: One commonly suggested approach to reducing suicide is to restrict access to potentially lethal means of suicide. This paper summarises recent trends in methods of suicide among young people in New Zealand and examines the feasibility of suicide prevention through restricting access to methods of suicide. METHOD: Data derived from official mortality statistics were used to examine trends, from 1977 to 1996, in methods of suicide among young people aged 15-24 years. RESULTS: During the last two decades, male youth suicide rates in New Zealand doubled, from 20.3 per 100,000 in 1977 to 39.5 per 100,000 in 1996. This increase was accounted for, almost entirely, by increased use of hanging (71% of total increase) and vehicle exhaust gas (26% of total increase). Suicide rates among young females also increased, from 4 per 100,000 in 1977 to 14.3 per 100,000 in 1996. As for males, the increased female suicide rate was largely accounted for by increased rates of hanging and vehicle exhaust gas. CONCLUSIONS: The marked increases in rates of youth suicide in New Zealand during the past two decades are accounted for, almost wholly, by increases in rates of suicide by hanging and, to a lesser extent, vehicle exhaust gas. In 1996 the majority (79.7%) of youth suicides were accounted for by these two methods: hanging (61.5%) and vehicle exhaust gas (18.2%). Both methods are widely available and difficult to restrict, implying that limiting access to means of suicide is a strategy which is unlikely to play a major role in reducing suicidal behaviour among young people in New Zealand.     

Suicide mortality in Southern Italy: 1998-2002

The purpose of the study was to describe the deaths by suicides that occurred in an area of Southern Italy in the period 1998-2002. Data were obtained from death records, and population estimates for each year were provided by the National Institute of Statistics. A total of 367 suicides were retrieved. The number of suicides was stable for the 5 years recorded, with the highest value for 1998, ranging from 1.4% for ages 0 to 14 to 25.1% for ages 25 to 44 years. Age-specific rates of suicide showed that the highest rates were in those 75 to 84 years old. Rates are always higher in males, with a tendency to stability or decrease in all age groups in the years observed, except for males in the 45- to 64-year-old age range, in whom an increase from 5.71 to 7.28 was observed. The suicides increased proportionally with age, in those with the lowest level of education (53.3%) and among retirees (46.5%). Hanging/suffocation (44.1%) and jumping from high places (23.2%) were the most frequently used methods of suicide. Males had higher standardized suicide rates ranging from 5.4 per 100,000 in 1999 to 7.7 in 1998, whereas in females the range was 1.4 per 100,000 in 2001 to 2.4 in 1998. The study shows that suicide rates in Southern Italy are lower compared with national trends.