Adolescent suicide attempters in Hong Kong and the United States
Introduction
Although suicide is a public health problem worldwide (World Health Organization, 2001), most research in suicidality has been conducted with Western populations. This study examined characteristics of community sample of adolescents from Hong Kong and the United States (US), who indicated that they had made a suicide attempt at least once in the past. In both cultures, we also examined a control group matched for sex, age and depressive symptoms.
Cultures can be compared descriptively for levels (prevalence or frequency) of behaviors and risk factors, such as rates of suicide attempts or mean group differences in cognitive variables such as hopelessness. Alternatively, they can be compared analytically for processes (such as differences in association between risk factors such as hopelessness and outcomes such as suicidality). Because mean group differences provide little causal information to help explain outcomes within or between cultures, they are generally of less interest than information about culturally relevant processes (Tanaka-Matsumi, 2001). In line with these priorities, this paper examines culturally moderated relationships between risk factors and suicidal behaviors.
Specific risk factors may influence suicidality differentially across cultures for various reasons. Markus and Kitayama (1991) have proposed that in individualistic cultures, positive feelings come from a sense of autonomy, of personal accomplishment and agency. In contrast, in collective cultures, positive feelings depend upon the sense of connection to others and of fulfilling obligations. Therefore, stress in important relationships may be more closely linked to suicidal behaviors in collective than in individualistic cultures. Culture may also influence the salience of different kinds of risk factors. Triandis (1994) has suggested that individualists are more influenced by “internal” events such as cognitions, whereas communal culture members are more influenced by external regulations and norms. Emphasis on external rather than internal control of events may also reduce the focus on cognitive variables such as hopelessness (Chiles et al., 1989).
Suicidal ideation has been found to be prevalent among adolescents in Hong Kong (Chan, 1995; Stewart, Lam, Betson, & Chung, 1999), and attempt rates (Lam, Stewart, Ho, & Youth Sexuality Study Task Force, 2001; Wong, Stewart, Ho, Rao, & Lam, 2005) are similar to those reported for adolescents in the US (Center for Disease Control, 2002). Correlates of suicidal ideation were likewise similar among adolescents in Hong Kong (Stewart, Betson, Lam, Chung, Ho, & Chung, 1999; Wong et al., 2005), and in Mainland China (Hesketh, Ding, & Jenkins, 2002). Gender differences in suicidality in many aspects mirror those in the West. Girls in Hong Kong reported overall higher levels of suicidal ideation, expressed intent (Stewart, Lam et al., 1999) and made attempts (Wong et al., 2005) more frequently than did boys, and Accident and Emergency Department admittances in Hong Kong in the 10–19 year age group showed a boy/girl ratio of 1:11 (Yip & Chiu, 1998). Rates of completed suicide in Hong Kong were lower than in the US for boys. However, the rates were comparable for girls, with suicide as the most frequent cause of death for young women between the ages of 15 and 24 years (Yip, 1997). The overall sex ratio for completed suicides was less discrepant in Hong Kong than in the US: in 1998, it was 23.2 men to 5.3 women per 100,000 in the latter versus 19.5 men to 10.4 women per 100,000 in Hong Kong (World Health Organization, n.d.).
Information about sociocognitive variables and their associations with suicidal ideation and attempt in Chinese cultures is less available. Earlier analyses of the larger data set of 2272 participants, from which the participants of this study were drawn, examined the relationship of cognitive variables with depressive symptoms (Stewart et al., 2004) and to suicidal ideation (Stewart et al., 2005). Hopelessness, diminished self-efficacy and cognitive distortions were associated with depressive symptoms concurrently in both cultures, and predicted depressive symptoms and suicidal ideation, six months later in longitudinal analyses. Hopelessness was the strongest of the cognitive variables in concurrent association with suicidal ideation, and offered unique prediction to suicidal ideation concurrently and prospectively, even when depressive symptoms were controlled.
Investigators examining groups in Mainland China have suggested that depression as a risk factor for suicide attempts may be less prevalent than in the West, particularly among females who make suicide attempts (Pearson & Liu, 2002; Pearson, Phillips, He, & Ji, 2002; Phillips, Li, Zhang, & Eddleston, 2002). However, there is some contradiction in their own studies on this count in a case-control study of psychological autopsies of successful adult suicides; high depressive symptoms characterized those who killed themselves and those who died of other injuries (Phillips, Yang, et al., 2002). The role of depression as a risk factor for suicide attempts among Chinese adults or adolescents compared to those in the West has not been directly examined.
We were interested in variables whose influence on suicidality may be moderated by culture. Interpersonal relationships have been found to be an important risk factor in influencing suicidality in adolescents (Csorba et al., 2003; Spirito, Valeri, Boergers, & Donaldson, 2003) and have theoretical significance in cross-cultural theory (Markus & Kitayama, 1991). We also investigated exposure to suicide, known to be associated with suicidality in western studies (Agerbo, Nordentoft, & Mortenson, 2002; Gould, Greenberg, Velting, & Shaffer, 2003) and in an earlier Hong Kong study (Wong et al., 2005) where it was found to be moderated by depression. However, that study did not include a western comparison group. The findings from our earlier cross-cultural studies of cognitions, depressed mood (Stewart et al., 2004) and suicidal ideation (Stewart et al., 2005) were marked more by similarities between the two cultures in the interrelationships among the variables than by differences. We sought to further the literature by determining whether these cultural similarities are also present when only suicide attempters are examined.
A particular contribution of this study is the inclusion of non-attempter controls showing similar levels of depressive symptoms to the cases. Risk factors for depression are similar to those for suicide attempts (Lewinsohn, Rohde, & Seeley, 1994), and depression is a risk factor for suicide (Gould et al., 2003). Purported risk factors, such as cognitive variables, may be associated with suicidality primarily because of their relationship to depression (e.g. Cole, 1989; Spirito, Overholser, & Hart, 1991, Steer, Kumar, & Beck, 1993). Studies that examine depression-matched control groups, therefore, stand to uncover risk factors that are unique to suicide.
Drawing from a large data set (Stewart et al., 2004), we located adolescents who indicated that they made a suicide attempt, and matched them based on age, sex and depression level, in a nested case-control design. We examined the association of risk factors to suicidality. Furthermore, we investigated whether culture and gender moderated the relationships between the risk factors and suicide attempt status. We derived the following hypotheses regarding culture's moderation of risk for suicide attempts:
- (1)
It has been suggested that depression is less of a risk factor in suicidality among Chinese groups (Pearson & Liu, 2002; Pearson et al., 2002). Suicide attempters in Hong Kong, unlike in the US, may not be much more depressed than non-attempters. Furthermore, controlling for depression may therefore have little effect, and as a result, there would be greater differences between suicide attempters and their depression-matched counterparts in Hong Kong than in the US.
- (2)
Markus and Kitayama (1991) have emphasized the extreme importance of relationships in Asian cultures; discord in interpersonal relationships may therefore explain more variance in suicide attempt in Hong Kong than in the US.
- (3)
Cognitive variables have been proposed as less salient in guiding behavior in collective cultures than in individualistic cultures (Triandis, 1994). Suicide attempters, therefore, may be less discrepant from non-attempters in cognitive variables associated with suicide attempt in Hong Kong compared to the US.
Section snippets
Participants
The original study group that provided the sample for this two-wave study was a pool of 2272 students, aged 14–18 years, from Hong Kong (from 11 schools representing the range of indices of socioeconomic variation) and the US (from seven urban, suburban and rural schools in the Dallas-Fort Worth area). Details about the sampling procedure are available in our earlier publications (Stewart et al. (2004), Stewart et al. (2005)). Eighty-three percent of those who participated at the first wave in
Results
The main interest of this study was in the interaction between risk factors and culture. For this reason, differences between cultures and genders in levels (mean or frequency comparisons) of variables, although reported, are generally not emphasized; cultural and gender differences are interpreted only when they moderate the findings.
Prior to comparing suicide attempters with controls matched for depressive symptoms, we documented that the “risk factors” that we had selected distinguished
Discussion
Our study adds to the literature examining characteristics of suicide attempters in a non-western culture, by (a) investigating a community group, who are more likely to be representative of attempters in cultures where help-seeking is uncommon, (b) including Western counterparts of the same age range who also indicated that they have made a suicide attempt and (c) examining control groups in each culture who reported equivalent levels of depressive symptoms. Depression, current and lifetime
Limitations
This study illustrates some of the difficulties of doing cross-cultural research (also see Stewart & Bond, 2002; van de Vijver & Leung, 1997). The development of equivalent measures is an important problem recognized by cross-cultural methodologists (e.g. van de Vijver & Leung, 1997). We used “imported” instruments, and followed guidelines that have been proposed (e.g. Stewart & Bond, 2002) to adapt such measures. In the process, we lost some items, narrowing the construct to be measured. We
Conclusion
None of the hypotheses we were able to derive from the general cross-cultural literature were supported by our data. Risk factors associated with suicide attempts are strikingly equivalent in adolescents in Hong Kong and the US. The findings suggest that clinicians who encounter youth in both the US and Hong Kong should routinely enquire about depression, cognitions in relation to hopelessness and distortedly pessimistic views of the self and the future, poor interpersonal relationships,
Acknowledgments
This research was supported in part by a grant from the Research Grants Council of the Hong Kong Special Administrative Region, China (Project no. HKU 7016/99 M). We thank Jill Nichols, Markus Glickman and Ella Ho for their help in gathering the data. We also thank W.A. Burroughs for his comments on the manuscript.
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