33 Suicide study and suicide prevention in mainland China

Detailed descriptions of suicide can be found in Chinese historical writing, novels, and poetry, yet empirical suicide research has only developed in the past decade in China. Rigorous statistics on suicide have not been available until recently, and the systematic study of suicide is still at its preliminary stages. In this chapter, existing epidemiological data of suicide in mainland China is reviewed, ensued by a brief discussion about cultural views on suicide. Subsequently, there is an analysis of the possible influences of socio-economic and sociocultural changes leading to transitions in public health and suicidal behaviour. The available suicide statistics reveal certain dissimilarities to other statistics across the world: China is the only country with statistics showing an equal amount or more of female suicides. Furthermore, about one-third of the persons who commit suicide have no diagnosis of mental illness. In China, the suicide rate among rural residents is three to five times higher than that of urban residents. The high suicide rates among rural residents are strongly linked to the most frequent suicide method, which is the consumption of poisons, especially pesticides. The final section of the chapter is a discussion of the implications of available suicide studies on suicide prevention.

Before 1949, there were no official statistics about suicide in China. During this time, in the People's Republic of China, suicide statistics were not accessible for public information or academic research. For the first time in 1987, the Ministry of Health reported official mortality statistics that include deaths from suicide to the World Health Organization (WHO 1989). However, exact annual suicide rates are still not available at national and local levels for three major reasons. First, there is no systematic check for the cause of death in China. The cause of death is investigated in depth only when the death is suspected to be a crime, otherwise it is reported by physicians or family members. Second, China has not had a functioning registration system at national or provincial levels until today. The official mortality statistics provided to the WHO are based on data from about 10 per cent of the population (more than 100 million individuals). Finally, in almost all official reports on mortality, suicide is categorized within ‘injury and poisoning’ (Ministry of Health 2007), a category that encompasses death by various injuries, traffic accidents, foodpoisoning, suicide, and homicide.

Estimations of China's suicide rate have mainly been based on two data resources: the first data resource is the Death Registry in Certain Regions (DRCR), provided by the Ministry of Health. The DRCR data is provided by China's provinces and municipalities, who collect data in selected counties and cities with a relatively good reporting mechanism. The sample of DRCR covers about 100 million people but it is not a randomized one. The second data resource is the Disease Surveillance Point system (DSP) established by the Chinese Centre for Disease Control and Prevention (China CDC), formerly the Chinese Academy of Preventive Medicine. DSP used stratified technology to sample xiang/town (a xiang is an administrative unit between a cun—village—and county) or districts in cities and obtained a sample size of more than 10 million people (Ministry of Health Department of Disease Control and Chinese Academy of Preventive Medicine 1995). The DSP sample is more representative than the DRCR sample, but 15 per cent of the disease surveillance points are not included in the sample originally collected (Yang et al. 1992) and replaced by neighbourhood xiang instead. In addition, urban residents are over-represented in the sample (Phillips et al. 2002a). Based on these two data resources, a wide range of suicide rates have been estimated. For example, reported rates for 1990 range from 13.9 (He and Lester 1999) to 30.3 (Murry and Lopez 1996b). Among all studies of suicide rates performed in China, those mentioned below are influential.

At a WHO–Ministry of Health joint meeting held in Beijing in November 1999, the vice minister of the Ministry of Health officially reported a national suicide rate of 22.2 per 100,000 in 1993 (Yin 2000), and estimated that over 250,000 individuals died from suicide every year. A recently released official report (Disease Prevention and Control Bureau of MOH et al. 2007) estimated the number of suicide death was 193,000 in 2005.

The 1999 World Health Report (WHO 1999) estimated a suicide rate of 32.9/100,000 (413,000 suicides) in 1998 in China, much higher than the official figures. The 2001 World Health Report (WHO 2001b) dramatically down-tuned the suicide rate of China, reporting the average suicide rate for the years 1996 to 1998 to be 14.0/100,000, thus the average suicide rate decreased by 17 per cent from the period between 1988 to 1990.

The Global Burden of Disease (GBD) study (Murry and Lopez 1996a,b) applied several adjustments to the mortality data from DSP to estimate 343,000 suicides in 1990 (30.3 per 100,000).

Based on the DRCR data from 1995 to 1999, adjusted according to unreported deaths and projected to the corresponding population, Phillips et al. (2002) reported an average annual suicide rate of 23 per 100,000 and a total of 287,000 suicide deaths per year.

In most countries of the world, the sex ratio (male to female) of completed suicides is around 3:1, and at the same time, women attempt suicide approximately three times more often than men (Murry and Lopez 1996a; WHO 2002; Sudak 2005). Some studies have shown that in Asian countries the male to female ratio is much lower than that of Western countries (Murry and Lopez 1996a; He and Lester 1997). However, studies in China present a different picture. Our studies in local samples show that the male: female ratio of suicide is about 1:1 (Xu et al. 1999, 2000), while most other studies show that women committed suicide more often than males (Murry and Lopez 1996a, b; Yang et al. 1997; Philipps et al. 2002; Yip et al. 2005).

For all demographic groups, suicide is rare before puberty, though mass media reports that suicide among young people has increased in recent years. Generally, rates increase in nearly direct proportion to age, with the highest suicide rates in the elderly and a peak in the 19–34 age group. Studies in Western countries reveal that the suicide rate of adolescents and young adults has increased since 1950 (Bertolote 2001). Studies in China show that the age distribution of suicide follows the general picture of Western countries, but that the peak suicide rate in the 15–34 age group is much higher (Yang et al. 1997; Phillips et al. 1999; Xu et al. 1999; Phillips et al. 2002a). According to a widely cited study (Phillips et al. 2002a) suicide is the leading cause of death in individuals 15–34 years of age, accounting for 18.9 per cent of all deaths. The average suicide rate of this age group was 26.0/100,000 from 1995 to 1999, while at the same stage the average suicide rate of the group aged 60 to 84 was 68.0/100,000.

According to French sociologist Emile Durkheim, strong social cohesion leads to lower suicide rates in rural areas, and individualism or egoism contributes to the high suicide rates in urban centres (Durkheim 1897, 1951). Based on an analysis of the suicide rate in Finland between 1800 and 1984, Stack linked suicide with urbanization (Stack 2000c). In China, however, almost all epidemiological studies reveal that the suicide rate of rural residents is three to five times higher than that of their urban counterparts (Phillips et al. 1999; Xu et al. 1999; Xu et al. 2000; Phillips et al. 2002a; Yip et al. 2005). Generally, the suicide rate of urban residents is around 10/100,000, lower than the world average of 15.7/100,000 (WHO 2001a), while the suicide rate is over 25/100,000 in Chinese rural areas, much higher than the world average (Murry and Lopez 1996a, b; Yang et al. 1997; Yip 2001; Xiao et al. 2003). A methodological question of this comparison is that suicide statistics only covered regular residents in cities. Currently, we don't know how the urban suicide rate will change if suicide of mobile workers from rural areas are counted.

Reduction of means, for example, limiting the availability of guns and poison, is widely believed to be an effective strategy of suicide prevention (see also Part 10C in this book). Epidemiological studies indicate that suicide methods employed are not only related to the availability of means (Kellermann et al. 1992), but also to socio-economic and cultural variables (Lee et al. 2005). Overall, males use violent and lethal means while females use less violent and less lethal methods. In countries with large agricultural communities such as China, India and Sri Lanka, pesticides are widely used for suicide. In China, ingesting poisons, particularly pesticide, is the most frequently used method of suicide. Almost all epidemiological and psychological autopsy studies find that nearly two-thirds of all committed suicides were due to poisoning (Yang et al. 1997; Xu et al. 1999, 2000; Phillips et al. 2002b).

It is reported that psychiatric disorders are present in at least 90 per cent of suicides (Rich and Runeson 1992; Appleby et al. 1999; Beautrais 2001; Mann et al. 2005; Sudak 2005). Depression is the most frequently cited illness linked with suicide, followed by schizophrenia, alcohol abuse disorder, other substance abuse disorders and personality disorder (Roy 2000). In China, retrospective studies utilizing the official death registry report that less than one-third of all suicides have a diagnosis of mental disorders (Xu et al. 1999, 2000; Zhang et al. 2000; Zhao and Ji 2000; Xiao et al. 2003). These studies underestimate the prevalence of mental disorders among those who commit suicide because disorders remain under-diagnosed and under-reported in the death registry. Recently, more rigorous psychological autopsy studies show that about two-thirds of all suicides have a diagnosis of mental disorder (Phillips et al. 2002b; Zhang et al. 2004). This figure is still much lower than those reported in Western countries.

To summarize, the main feature of suicide in China is that rural females have a higher suicide rate than expected according to statistics from many areas across the world. Although there has been no systematic investigation of this unique pattern of suicide, several theories have been put forward to explain the phenomena. First, the availability of pesticides and other poison substances may convert a significant proportion of rural female suicide attempters into completed suicides. In Western countries, suicide attempts in females are more numerous than in males, and the usual method is poisoning by different types of medications. In China, the equivalent means for poisoning are pesticides, which are a lot more toxic and more often lead to suicide. Limiting access to poisons, thus has been suggested to be a priority in suicide prevention in China by many domestic and international researchers (Yang et al. 2005).

Second, the health care system in Chinese rural areas is often not qualified when a suicide attempter needs emergency rescue (Zhou et al. 2008). Clinics in cun (villages) are accessible to most suicide attempters, but there is barely any equipment or technology to rescue individuals with pesticide ingestion. Health care providers in village clinics generally receive less than two years of medical training. About half of the health stations and all county general hospitals can provide qualified emergency service to suicide attempters, but in many cases, suicide attempters have died before they are sent to such institutions for help, as there is no convenient transportation available and the distance to qualified institutions is often too far.

Third, mental health service is not available in most Chinese rural areas. Less than 50 per cent of counties (the population size of most counties vary from 300,000 to 1,500,000) have a mental hospital providing basic service to patients with psychotic disorders. Most rural health care providers only receive three years or less of medical education and have very limited knowledge and skills in mental health (Tang et al. 2005). As a result, it is estimated that only 5 per cent of patients with depression and 30 per cent of the patients with schizophrenia receive systematic treatment. There has been no crisis intervention and suicide prevention in Chinese rural areas until today.

Finally, socio-conomic and cultural variables such as stigmatization, pressure on delivering male babies, poverty due to low educational level and low socio-economic status may contribute to distress and to the high suicide rate of rural women.

There is no community registry for attempted suicide in China, and consequently, it is very difficult to estimate the prevalence of attempted suicide in the country. Generally, the prevalence of attempted suicide is estimated to be 8–10 times that of completed suicides. If this estimation is applicable to China, then there are about 3 million individuals attempting suicide every year. Hence, attempted suicide is also an important social and public health concern (Beijing Huilongguan Hospital Center of Clinical Epidemiology 2000).

Small-scale community epidemiological studies reported a variety of attempted suicide rates in China. In the WHO multi-site intervention study on suicidal behaviours (SUPRE-MISS), China's chosen site, the Yuncheng County, reported lifetime suicide attempts of 2.4 per cent, while the range of all 10 participated sites varied from 0.4 per cent (Hanoi) to 4.2 per cent (Brisbane) (Bertolote et al. 2005). In a sample of junior high school students, the lifetime prevalence was reported to be 4.74 per cent (Zhou et al. 2005). Several studies using samples from emergency services indicate that the male to female ratio is around 2.5:1; that less than 50 per cent of the attempters have a diagnosis of mental disorders; and that more than 70 per cent tried to attempt suicide by self-poisoning (Zhang et al. 2000; Li et al. 2001, 2005; Pearson et al. 2002; Liu and Xiao 2002).

Although there is scant empirical research, two different points of view have been advanced in the literature concerning cultural notions in relation to suicide and its prevention. Hsieh and Spence (1982) suggested, based on their historical study of suicide in pre-modern China, that suicide in Chinese culture was often positively evaluated and was actually encouraged by the state. In a cross-cultural study of suicide in Chinese and American societies, Chiles et al. (1989) suggested that, when compared to suicidal patients in the United States, Chinese suicidal patients are less likely to communicate suicidal intent and to experience concerned, supportive care. Using a quantitative questionnaire, Yang et al. (1999) found that health care providers in China hold a positive attitude toward suicide. In a recent qualitative study in northern China, Li et al. (2004) reported that most individuals interviewed expressed tolerant and sympathetic attitudes toward suicide.

Chinese perspectives on suicidal behaviour have been shaped throughout the long history of Chinese civilization. Thus, it is essential to begin our analysis with a brief examination of Chinese cultural and religious traditions.

Among all Chinese cultural influences, Confucianism, both as a philosophy and a religion, is the most important. Daoism and Buddhism are also important doctrines in Chinese history, but they have not been as influential as Confucianism (see Part 1, Chapter 3 in this book). Chinese attitudes toward death, including suicide, are influenced by such Confucian virtues as zhong (faithfulness), xiao (filial piety), ren (humanness) and yi (righteousness or justice). In feudal China, the Confucian Analects, the classic of Filial Piety and other Confucian classics were used as textbooks for primary education for almost all students, who were required to recite them fluently. In the period of the Republic of China (1911–1949), as China gradually opened the door to Western science and culture, particularly because of the influence of the ‘new cultural movement’, Confucian classics were no longer used in most public schools, but private schools continued to teach them. More importantly, the Confucian tradition was officially emphasized by the Kuomintang, which was the dominant political force in this period. Since 1949, the Confucian tradition has been criticised by both the Chinese government and some intellectuals influenced by Western cultural beliefs. During the Cultural Revolution (1966–1976), Confucianism was systematically condemned. Nonetheless, traditional Confucian beliefs still remain central to the lived experience of people in mainland China and have recently been re-emphasized by the mainstream culture.

Filial piety, which means showing respect and taking care of one's parents and ancestors, is among the most ancient and central values in Chinese culture. The Xiao Jing, the classic text on filial piety, which was written two thousand years ago, states:

Filial piety is the basis of virtue and the source of culture. The body and the limbs, the hair and the skin, are given to one by one's parents, and to them no injury should come: this is where filial piety begins.

(Zeng Zi pp. 326–327)

Because the body is held in trust to the parents and ancestors, the classic of filial piety ruled out neglect of the body, and most certainly suicide. Zeng Zi, one of the most famous disciples of Confucius, said he had been very careful to protect his body from injury and he was proud that he could take care of his own body until his death. Lun Yu, records the following story in the Analects of an unknown author, which is a collection of dialogues between Confucius and his disciples.

The philosopher Zeng Zi was sick and called to him the disciples of his school, to say to them:

Uncover my feet, uncover my hands. It is said in the Book of Poetry, ‘We should be apprehensive and cautious, as if standing on the brink of a deep gulf, as if treading on ice’, and so have I been. Now and hereafter, I know my escape from all injury to my person, O! ye, my little children.

Anonymous (1992)

Although the Confucian virtue of filial piety is not explicitly taught in public education in the People's Republic of China, it is implicitly encouraged by the government and the mass media. For instance, all three editions of the Constitution of China published in 1952, 1980, and 1986 respectively, insist that every person should take care of their parents. Beliefs about filial piety and family cohesion are still highly valued across Chinese society.

The vignette below is an example of how filial beliefs have a strong hold in China today and can be related to suicidal behaviour and attitudes. In the following case, drawn from research conducted in China, a relative of a suicidal patient tries to convince her that suicide is not acceptable behaviour for a good daughter.

Ms Wu, a 19-year-old high school graduate, was sent to the emergency room at a large teaching hospital in south central China for loss of consciousness. According to her parents, Ms Wu was in a coma when they returned home from work. Ms Wu, their only child, ‘had a good record of health history, cooked breakfast for the family and showed no sign of any disease when we left for work that morning’. After a careful examination, the emergency physician made a diagnosis of possible attempted suicide by taking an overdose of sleeping pills. Upon inquiring, Ms Wu's mother noted that Ms Wu failed to pass the university entrance examination three months earlier, while nearly half of her classmates passed it. Her father, a construction worker, wanted Ms Wu to continue to attend an extension course in the local high school to prepare for the next year's examination. However, Ms Wu, ashamed by her failure, was reluctant to return to school and considered instead becoming a worker. A few days before this interview, Ms Wu applied for a job in a textile manufacturing factory. Her father was very angry about this and, after he quarrelled with her, said he no longer wanted Ms Wu to be his daughter.

After having recovered from the coma, Ms Wu told the interviewer that her parents had been very good to her, but their expectations were too high. Before and after she failed this year's examination, her parents put great pressure on her to take the next examination, but she felt that she lacked the talent to pass this very competitive test and would rather quit school to be a worker. She did not want to face further failure and to continue to disappoint and anger her parents. Therefore, she attempted suicide.

Influenced by the idea of filial piety, Ms Wu could not rebel against her parents, and leave the family to start an independent life like many Western young adults might do in the same situation. The following dialogue, recorded by the author of this chapter, took place between Ms Wu and her aunt, a high school teacher in her late 30s, in the hospital ward four days after Ms Wu's attempted suicide. Informed consent to describe this dialogue was obtained orally:

Aunt: How are you doing, my child?

Wu: I am OK now. Thank you for coming to see me.

Aunt: Here are some apples for you. My child, how can you be so silly to take so many sleeping pills? They could have killed you!

Wu: Aunt … I know.

Aunt: My child, do you know you are the only child of your parents? They love you so much. In these two days they have eaten nothing. Your mother told me yesterday that if you do not recover, she cannot live any more.

Wu: I, I …

Aunt: You do not know how your parents take care of you. When you were ill, even with a light cold, they worried a lot about you. Your father has only a primary education and he wishes you to have the highest education they can afford. How could they live if you died? (She cries.) Nowadays children do not understand how to respect their parents.

Wu (crying): Aunt, I know I was wrong. I will not do this again.

Aunt: My good child!

According to Chinese cultural beliefs, one should take care of one's parents by respecting and obeying their ideas and attitudes, helping them to be happy when they are alive and giving them the best food and living conditions. When the parents die one should honour them and work to immortalize them. Many Chinese parents feel deep guilt if their offspring die when they remain alive because they believe parents should always die before their children. In this case, although Ms Wu's aunt did not mention the importance of being filial, the idea that suicide goes against ideas of respect for one's parents is quite clear. When Ms Wu's aunt says ‘Do you know you are the only child of your parents?’, this can be understood as ‘how can you leave your parents alone?’. At the end of the conversation it seems that Ms Wu is convinced that her attempted suicide is unfilial to her parents, something she must have considered both before and after her suicide attempt.

In modern Chinese societies, suicide victims are sometimes openly accused of being irresponsible, selfish, individualistic, acting against filial values, and even being immoral. An example was the suicide of Shamao in the beginning of 1991. Shamao, a well known 39-year-old essay writer in Taiwan, was, in a newspaper, accused of being ‘greatly unfilial’ and ‘irresponsible’, because she committed suicide when her mother was suffering from late stage cancer and needed her love and care (Zhong 1991). Individuals who commit suicide are frequently accused for similar reasons. Wei Minlun, a famous writer in modern China, has recently criticised those fans who committed suicide following Zhang Guorong, an influential singer who committed suicide in 2005, as ‘totally inconsiderate to their parents’ and causing them extreme pain (Sichuan News Net 2005).

Faithfulness is another traditional Chinese cultural belief that has great influence on the evaluation of suicidal actions. In the Confucian classics, being faithful is an important part of ren (humanness) and yi (righteousness or justice), the correct approach to human relations and a proper way for persons to deal with each other, leading to positive efforts for the good of others. In order to achieve the virtue of ren and yi, it is necessary to be faithful to both others and oneself. As discussed in the previous section, the Confucian school generally objects to deliberate destruction of one's own body. However, the virtues of ren and yi were considered more important than one's life by Confucius and his followers. For example, Confucius said in the Analects that ‘The determined scholar and the men of virtue will not live at the expense of injuring their virtue. They will sacrifice their lives to preserve their virtue’ (Anonymous 1992).

Mencius, the Confucian scholar next only to Confucius himself in importance, said:

I like fish and I like bear's paws. If I cannot have the two together, I will let the fish go, and take the bears paws. So, I like life, and I also like righteousness. I like life indeed, but there is that which I like more than life, and therefore, I will not seek to possess it in any improper way. I dislike death indeed, but there is that which I dislike more than death, and therefore there are occasions when I will not avoid danger.

Mencius (1992)

Although suicide is not directly mentioned here, the idea that one might have to give up one's own life for faithfulness to ren and yi has influenced the attitudes of Chinese toward suicide for nearly twenty-five centuries. Until today, the words ren and yi are still used in Chinese society in sayings such as ‘to kill oneself to achieve the virtue of ren’ or ‘to achieve the goal or to die’.

In Chinese history, suicide committed because of faithfulness can be found in three categories:

This type of suicide often takes place in order to keep national secrets or for national interests. Chinese culture openly admires this kind of behaviour. Many stories have been devoted to honouring those who killed themselves in wartime, when their sacrifices were important to national or group interests. Because many Chinese believe that to be killed or to be captured is a humiliation only for themselves and their country, they killed themselves when being killed or captured by an enemy seemed inevitable.

This has been expressed very clearly in the well-known saying ‘If we have no freedom, we would rather die.’ In China, as in some other East Asian countries such as Korea and Japan, committing suicide to express one's ideal is not uncommon. For example, almost everyone in China knows the death of Qu Yuan, a patriotic poet who is said to have drowned himself more than two thousand years ago when the emperor refused to heed his advice (Ning 1998). Chinese people believe that Qu Yuan's suicide was a protest to the emperor, and a sacrifice to society.

An often used method to express one's loyalty is hunger strike. Although the purpose of it or a similar self-destructive demonstration may not be to kill oneself, it is considered to be a kind of suicidal action for one's ideals, and is thus supposed to receive a sympathetic response from society.

This was widely practised in feudal China and its traces can still be found in modern Chinese societies. One commonly practised form of suicide is that of the wife's out of loyalty to her husband. Hsieh and Spence (1982), in their historical study, described four circumstances for a wife's suicide:

Many stories, such as A biography of women, written by Liu Xiang of the Han dynasty and revised by others in feudal China (Liu 2003), have been devoted to recording this kind of suicide in Chinese history.

In Chinese society, it is not only having voluntary extra-marital affairs that are regarded as being unfaithful to one's husband: in some cases, even having been raped is considered unfaithful. The practice of a wife committing suicide because of loyalty to her husband has in some cases been extended to committing suicide for the culturally idealized state of keeping oneself clean and pure. For example, if an unmarried girl is raped or has a voluntary pre-marital affair she is still considered by some Chinese people to be ‘unclean’, or polluted because she can no longer present a ‘pure’ body to her future husband. Suicide for the sake of faithfulness is positively evaluated by Chinese society as heroic, romantic, aesthetic, and moral behaviour. There are even biographies specially designed to honour women who committed suicide out of loyalty to their husbands or to protect the purity of their bodies (Hsieh and Spence 1982).

Many biological, psychological, and biopsychosocial factors have been linked with suicidal behaviour at the level of the individual (Jacobs 1999; Sudak 2005). Explaination of suicide rates and its changes in large populations, however, should be focused on macro social, economic and cultural variables (Durkheim 1951; Phillips et al. 1999; Xiao et al. 2003; Yip et al. 2005). According to an estimation by Phillips et al. (1999), China accounts for 21 per cent of the world's population, but comprises 44 per cent of all suicides in the world. While not everyone agrees with this estimate, there is no doubt that suicide is a major public health and social problem in China. In addition to this, China has experienced huge socio-economic changes in the past three decades. Obviously, it is of great interest to suicidology how macro-demographic, socio-economic, cultural and health transitions have influenced the suicide rates in China.

Studies on the trends of suicide rate in China are scarce, perhaps because of the unavailability of qualified data. According to the 2001 World Health Report released by the WHO, from the 1988–1990 period to the 1996–1998 period, the suicide rate of China decreased to 17.2 per cent (WHO 2001b). Using data from the World Statistics Annual, a study shows that the suicide rates had slightly decreased from 22.6 (22.5–22.7) in 1987 to 19.9 (19.8–20.0) per 100 000 (Qin and Mortensen 2001). Recently, Yip et al. (2005) studied the trends of suicide rates from 1991 to 2000 based on data from the Ministry of Health (i.e. DRCR). They found that national, urban, and rural suicide rates of both men and women decreased significantly for the period of 1991–2000; age-specific suicide rates, however, showed that there were different patterns of changes in suicide rates in rural and urban areas. Suicide rates among the elderly showed the most significant decrease in urban areas, and younger women showed the largest decrease in rural areas; the male to female ratio in suicide increased significantly in the urban areas, but no significant changes were found in rural areas (Yip et al. 2005). The recently released Report on injury prevention in China (Disease Prevention and Control Bureau of MOH et al. 2007) reported the number of suicide deaths to be 226,000, 224,000, 221,000, 193,000 and 193,000 in 1995, 1998, 2000, 2003 and 2005 respectively (Figure 33.1), but suicide rates and its specific distribution are not available from the report.

While the results of the above studies are encouraging, more evidence is needed in order to fully comprehend the change of suicide rates in China.

China's economic reform, which started in 1978, has resulted in the most rapidly expanding economy in the world. Roughly, the per capita income in China has increased from less than 300 USD in 1978 to over 2000 USD in 2006: 43.9 per cent of the whole population lived in cities and towns in 2006 while more than 80 per cent of the population were rural residents at the beginning of the 1980s (National Bureau of Statistics of China 1978–2006). The formerly strict planning economy has become market-oriented.

Studies on the relationship between socio-economic changes and suicide in other countries have provided inconsistent results (Durkheim 1951; Kowalski et al. 1987; Simpson and Conklin 1989; Stack 1993, 2000a, b; Xiao et al. 2003; Otsu et al. 2004; Yip et al. 2005). Epidemiological studies consistently show that in China, the suicide rate of rural residents is three to five times higher than that of urban residents. This strongly suggests that urban life in China is not necessary linked to an increased suicide rate. Conversely, economic development may decrease China's suicide rate in the following ways:

Economic development, however, also brings social problems that may increase suicide rates in a society. Phillips et al. (1999) listed seven social changes that may result in the increase of suicide rates:

One could add more to this list, for example, conflicts of values and lifestyles between old and younger generations, more complicated interpersonal relationships, and more stressful work and living demands, etc.

It is unclear today which of the above mentioned factors of a society in transition will prevail on suicide rates in the future China. It seems reasonable to assume that the distribution of suicide will change, and possibly, the suicide rate will decrease in rural areas, while in urban areas, it may remain stable or increasing in the near future.

The term health transition is used to describe the changes over time in a society's health (Caldwell 1996). It encompasses three major components: the decrease of fertility and premature mortality, the increase of life expectancy, the transition of morbidity and death causes from infectious diseases to chronic non-infectious diseases and degenerative diseases. Health transition has been evidenced since the 1950s, with more complete transition in countries with a higher gross domestic product (GDP) and less complete in countries with lower GDP.

China is perhaps one of the countries that have experienced the most rapid health transitions in the world. The total mortality rate of China's population has dropped from 20/1000 in 1949 to 6.43/1000 in 2001. The infant mortality rate has dropped from 200/1000 in 1949 to 28.4/1000 in 2000. The maternal mortality rate has dropped from 150/10,000 in 1949 to 50.2/100,000 in 2001. The average life expectancy has increased from 35 years in 1949 to 71.4 years in 2000 (Lee 2004). The one child per parents policy imposed since the later 1970s has decreased the national fertility from 17.8 per 1000 in 1985 to 12.09 per 1000 in 2006 (Figure 33.2) (National Bureau of Statistics of China 1978–2006).

Although there are almost no systematic epidemiological studies that have investigated the links between health transitions and suicide, there are three major concerns that China's health transition will increase suicide rates nationwide. First, there is a rapid trend of ageing in China. The number of people aged 65 and over accounted for 7 per cent of the total population in 2000 (National Bureau of Statistics of China 2003). From 1982 to 1999 the proportion of people aged 60+ years increased from 7.64 per cent to 10.1 per cent (Lee 2004). It is predicted that this trend will be continue in the first half of the twenty-first century (Figure 33.3) (Wang and Mason 2005).

As the age structure of China keeps changing, the absolute number of elderly will increase rapidly, especially in rural areas where more and more young people are moving to cities and the elderly are left alone, with the traditional family support interrupted. Similar to other parts of the world, the elderly have the highest suicide rate in China and the increased proportion of the elderly may lead to increased suicide rates.

Second, non-infectious diseases have become the leading causes of death and morbidity with the continuing heavy burden of infectious diseases. Chronic course of disease, lowered quality of life and painful experiences can increase suicides (Kelly et al. 1999)

Finally, the one child per parent policy has resulted in serious gender imbalance, especially in rural areas. The male to female ratio at age 1 and age 10 reached 122.65 and 111.39 in 2000, respectively (National Bureau of Statistics of China 2003). Less females, who by tradition are responsible for the care of elderly parents, will impose great stress on both genders and may lead some to suicide.

Suicide was a culturally and politically sensitive topic in China before the late 1980s. A recent analysis of media reports on suicide found that the People's Daily, the largest Chinese newspaper mainly publishing news about Mainland China, had totally ignored suicide during the period 1966–1976 (Liu and Xiao 2007). As China began to provide death statistics that include death by suicide to the WHO since 1987, suicide has been gradually recognized to be an important public health issue in China. A few centres and hotline services dedicated to crisis intervention and suicide prevention have recently been opened in large cities such as Nanjing, Beijing, Shanghai, Shenzhen, Dalian, Changsha, etc. The National Mental Health Schedule 2002–2010, released jointly by the Ministry of Health, Ministry of Public Security, Ministry of Civil Affaires, and China Disabled Person's Federation in 2002, also listed suicide prevention as one of the priorities in mental health development in the first decade of the twenty-first century.

Based on the unique features of suicide in China, the following suicide-prevention strategies have been suggested by both domestic and international experts in the field (Zhai 1997; WHO 2001a; Xiao et al. 2003; Phillips 2004):