Gender-Specific Factors Associated with Suicide Attempts among the Community-Dwelling General Population with Suicidal Ideation: the 2013 Korean Community Health Survey

Suicide is one of the most serious and urgent public health issues in Korea in part because the suicide rate is continuously and rapidly increasing. Suicide is the fourth leading cause of death in Korea behind malignant neoplasm, cerebrovascular disease, and heart disease (1). In 2014, the suicide rate was 27.3 per 100,000 people, which is 2.4 times higher than the Organization for Economic Cooperation and Development (OECD) average and the highest among OECD members (2).

It is important to identify the risk factors for suicidal ideation and suicide attempts in the general population because these suicidal behaviors are positively associated with completed suicide (2). Although many risk factors for suicide attempts have been identified (3-15), more effective intervention strategies for mental health and suicide prevention can be developed when the gender-specific underlying risk factors for suicide attempts are better understood (16). To our knowledge, however, few studies have examined gender-specific risk factors for suicide attempts in a large general population. Furthermore, although many studies have investigated the relationships between sociodemographic factors and suicide attempts, relatively few studies have evaluated the associations of socio-family relationships, health behaviors, and health status with suicide attempts.

Therefore, this study confirmed gender differences in the traditional risk factors associated with suicide attempts, providing evidence and a basis for improved suicide prevention policies. We also examined novel risk factors for suicide attempts according to gender using national survey data from a large sample of the general Korean population with suicidal ideation.

Suicide rates are higher among males than females in almost all countries (17) and the suicidal mortality for males is 2.4-fold higher than that for females in Korea (1). However, previous findings regarding the association between gender and suicide attempts have been inconsistent; some studies found that females have a greater risk for lifetime suicide attempts compared with males (5,6,8,10), while others found that gender was not associated with suicide attempts (7,11-13,15). Until now, the association between gender and suicide attempts had not been determined in Korea, although gender was not significantly associated with suicide attempts in this study (data not shown).

The suicide mortality per 100,000 persons in Korea increases with age from 4.5 deaths in those between the ages of 10 and 19 years to 78.6 deaths among those 80 years and over (1). Although a few studies have found no association between age and suicide attempts (8,11), many studies have reported that suicide attempts are predicted by a younger age (5,6,12,15). In this study, we found that suicide attempts were predicted by a younger age in both males and females, suggesting that younger age is a potent predictor of suicide attempts in both genders.

Studies have observed a significant association between marital status and suicide attempts, reporting that people who are unmarried, separated, or divorced are more likely to have suicide attempts than those who are married (3-5,10,12). However, other studies have found that marital status is not associated with suicide attempts (7,11,15). In the present study, males who were widowed, divorced, or separated participants had a higher risk for suicide attempts than that of male participants who were married, whereas the risk was lower risk for females. It is difficult to explain the opposing associations between marital status and suicide attempt according to gender in our study. One possible explanation is that males are more vulnerable after losing their spouse, while females are more likely to be supported by meaningful social and familial networks (18). In other words, compared with females, males have no safety social connections after marital breakdown. Another study also showed that divorce has a negative effect on suicidal mortality only among males (18). Further research is needed to confirm the gender-specific effect of marital status on suicide attempts.

A majority of studies have shown that education level is not independently associated with suicide attempts (7,8,10-13,15), while only one study reported a significant association (6). Lower levels of education are significantly associated with higher suicide rates in Korea (9), possibly because educational status has a more significant impact on social variables, such as occupation and income, in Korea than in other countries. In the present study, a lower level of education was an independent risk factor for suicide attempts in females, but not in males, suggesting that education level affects females more strongly.

Household economic status and financial problems are not associated with suicide attempts (8,13,15), although people with poor financial perceptions, compared with people with good financial perceptions, are more likely to have suicidal ideation (10). This study found that household income was significantly associated with suicide attempts in males but not in females. One possible explanation relies on traditional gender roles in Korea in which the family’s breadwinner is most often male. Only among males was unemployment a significant factor associated with suicide attempts in unadjusted models, although this association decreased after fully adjusting for other factors. Recipients of National Basic Livelihood Security System, which is the Korean social assistance system, were identified as being at risk for suicide attempts among females. Although there were gender differences in the factors associated with suicide attempts, the present results showed that socioeconomic status (SES) indicators such as education, income, employment, and social assistance, were significantly associated with suicide attempts. Previous research has shown that low SES characteristics are directly associated with the risks of suicide (19) and suicide attempts (14).

Strong connections with family and community support may be protective factors against suicide. This study found weak, but significant, associations for a low frequency of family contact and leisure activity with suicide attempts in females. Family discord is a significant risk factor of suicide in the elderly (20) and social integration (social interaction and religious involvement) is independently associated with suicide in adults (21). However, to date, few studies have examined the effects of socio-family environments on suicide attempts according to gender. Family conflict and a poor relationship with one’s family are more likely to be associated with suicidal ideation and suicide attempts (8,13). Significant associations of subjective (feeling) and objective (living alone or being without friends) loneliness have been found with suicidal ideation and suicide attempts (22) but social support is not significantly associated with either suicidal ideation or suicide attempts (15).

Smoking and risky alcohol consumption have been identified as risk factors for suicide mortality (23). We found that current smoking was associated with suicide attempts in both genders, while frequent drinking was associated in females, but not males. Smoking and alcohol were independently associated with suicide attempts in a meta-analysis (13) and alcohol-use disorders were found to be independently associated with suicide attempts (6). By contrast, it has been reported that neither suicidal ideation nor suicide attempts are predicted by alcohol disorders (12) or alcohol abuse (5). The correlation between unhealthy behaviors (smoking, alcohol abuse, and drug abuse) and psychiatric disorders might explain the relationships of smoking and alcohol consumption with suicide attempts (24).

A current review observed a significant link between life stressors and suicidal behaviors across different age groups and a wide range of countries (25). A stressful event may push a person over the edge and lead to and suicide attempts. The present results show that very high perceived usual stress was significantly associated with suicide attempts in both genders. Depression is a significant predictor of risk of death by suicide (2,26). In the present study, depression was a potent risk factor for suicide attempts in males and females. Moreover, in both genders, the experience of depressive mood was significantly associated with suicide attempts. These findings concur with previous studies reporting significant relationships between depression and suicide attempts (5,8,11,12,15). In a path analysis of elderly subjects, depressive symptoms had the strongest influence on suicidal ideation and suicide attempts (27). In addition, both major and minor depression disorders are significant predictors of suicide in the old elderly (28) and depressive mood is independently associated with suicidal ideation in the general population (29).

Serious physical illness is also a significant predictor of suicide in the old elderly (28). Major physical diseases such as cancer and coronary heart disease significantly elevate the risk of suicide, particularly among women (30). In the present study, however, myocardial infarction and osteoporosis were significantly associated with suicide attempts. More severe chronic diseases are associated with a higher risk of suicide attempts (8), while some studies have shown that physical illnesses or multimorbidity is not associated with suicide attempts (13,15).

Several limitations should be considered when interpreting the present findings. First, the cross-sectional design used in this study prohibited the assessment of causal relationships, and thus it is uncertain whether the identified risk factors were present prior to the occurrences of suicidal ideation and suicide attempts. Second, because the information regarding suicide attempts was retrospectively assessed by self-report, it is possible that there was a recall bias. Third, information about suicide attempts was collected from only those who survived a suicide attempt because suicidal behaviors could not be evaluated from those who completed a suicide. Fourth, it was assumed that only subjects with suicidal ideation would attempt suicide, and as a result, impulsive suicidal attempts without suicidal ideation were not evaluated. However, when the associations between the studied risk factors and suicidal attempts were further analyzed including small numbers of impulsive suicidal attempts without suicidal ideation, similar findings were observed. Despite these limitations, the present study has several strengths. Data from a national survey were used, and thus a large nationally representative sample of the general population was evaluated. In addition, multiple covariates such as sociodemographic information, socio-family relationships, health behaviors, and various health statuses were simultaneously investigated according to gender.

In conclusion, this study identified gender-specific poorly understood risk factors for suicide attempts that may be useful for policy-making and suicide prevention. Gender differences should be considered in the assessment, prevention, and management of future suicide attempts by community policy-makers and clinicians. Further longitudinal studies are needed to characterize the gender-specific causal relationships between risk factors and suicidal behaviors fully.