Introduction
Suicide is one of the leading causes of death worldwide, impacting all ages, genders, and regions worldwide [
1]. According to the World Health Organization, more than 700,000 people worldwide die by suicide yearly [
2]. From a global perspective, suicide mortality has been rising in recent years [
1], which requires urgent attention and targeted prevention.
China used to be one of the nations with relatively high suicide mortality in the world, and there were significant urban-rural, gender, and age disparities in prior suicide mortality in China [
3,
4]. Studies by Phillips et al. approximated the suicide mortality rate in China between 1995 and 1999 to be 23 per 100,000 [
4]. The suicide mortality rate in rural regions was three times that of urban areas, while the mortality rate was found to be 25% higher in females than males [
4]. Considering the scarcity of suicide research at that time, the alarmingly high suicide mortality and the unique pattern drew substantial attention. In the subsequent decades, China has undergone profound social changes, including economic growth, increased urbanization, an aging populace, and improved management of lethal substances [
5]. Prior studies have documented a considerable reduction in overall suicide mortality rates in China over recent decades [
6‐
10]. Shifts in suicide mortality patterns in relation to urban-rural, gender, and age demographics have also been decidedly dramatic [
11]. For example, based on joinpoint regression analyses, Jiang et al. revealed a significant decrease in suicide mortality rates in China from 2002 to 2015, and uncovered a reversal in suicide mortality trends for males and females post-2006 [
6]. By examining suicide mortality data encompassing 33 Chinese provinces, Zhang et al. found a 65% reduction in suicide mortality in China from 1990 to 2017. Also, the male-to-female suicide ratio shifted from 0.88 to 1.56 during this period [
12]. Drawing on data from the China Health Statistics Yearbook, Liu et al. determined that urban residents and women experienced greater reductions in suicide mortality compared with rural inhabitants and men, respectively [
10].
Previous studies have provided a reference for data on suicide research in China. However, an expansive, thorough examination of lifespan suicide risk variation, period and cohort suicide risk, and potential underlying causes has yet to be conducted. Additionally, previous suicide mortality trend investigations have been restricted to relatively short intervals, with a lack of assessments spanning periods longer than 30 years. It is unclear whether suicide mortality and the epidemiological distribution of suicide mortality rates in China have changed. Therefore, this study will employ Joinpoint regression analysis and an age-period-cohort model to evaluate long-term suicide mortality patterns from 1987 to 2020, using data sourced from the National Health Commission’s death registration system in China. The findings would provide certain reference for understanding suicide epidemiology in China and proposing suicide prevention strategies.
Discussion
Based on the Joinpoint regression and age-period-cohort framework, this study provided the first comprehensive overview of long-term patterns in suicide mortality in China from 1987 to 2020, highlighting the disparities between urban and rural regions. From a holistic perspective, both crude and age-standardized suicide mortality rates in China experienced a persistent decline during these years, including in urban and rural areas, with the suicide risk of rural groups declining faster. The downward trend in the suicide rate may reflect the effect of economic improvement, urbanization, and the consequent much more limited household access to pesticides in China. However, the recent slower decrease in suicide mortality also reminded us to guard against a possible suicide backlash. In terms of specific demographic categories, suicide mortality rates continued to diverge based on factors such as age, gender, and rural-urban disparity, albeit in new patterns. For one, youngsters aged 20–29 and the elderly were at higher suicide risk in the whole population, especially individuals aged 20–24. Moreover, females had a higher suicide risk than males, but there existed a trend reversal between genders in groups above 45. Remarkably, rural populations aged 10–45, especially females of reproductive age, carried a substantially higher suicide risk than their urban counterparts. Both period and cohort effects regarding suicide rates experienced steeper declines in rural regions as compared to urban areas. Lastly, a notable difference in suicide risk trends was observed among urban and rural populations over the age of 50 – while the gap in suicide risk between males and females widened with age in urban areas, this was not the case in rural regions. These findings could provide certain reference for future suicide prevention efforts in China.
Our study’s findings, demonstrating a reduction in China’s overall suicide mortality, aligns with previous research [
6,
7,
9,
10]. In contrast to countries such as America, Japan, and South Korea [
28,
29], China’s suicide mortality rate has been on the decline for over thirty years. Earlier research implies that this reduction could be attributed to several socioeconomic factors including economic growth, rapid urbanization, improved medical emergency systems and transportation, enhanced healthcare accessibility, and reduced availability of lethal pesticides in rural areas [
30‐
33]. Since 1987, China’s urbanization has significantly increased, reaching a rate of 45.4% according to China’s seventh national census [
34]. With the lower suicide mortality in urban areas, the urbanization process seems to have positively contributed to declines in suicide mortality by providing better emergency medical systems and healthcare accessibility. Moreover, since 2000, China has witnessed a gradual decline in the unemployment rate among its labor force, which might have contributed positively to the overall reduction in the country’s suicide rate on a macroscopic scale [
35]. Previous studies have shown that rising unemployment rates may lead to health detriments, consequently heightening the risk of suicide [
36‐
38]. However, the downward trend in suicide mortality in rural communities has been slower since 2006. This could be primarily attributable to the escalating aging population [
39], increased workforce migration [
40], the issue of left-behind children and the elderly in rural areas [
39,
41] and the global economic recession [
42,
43]. These challenges could impede the rapid decrease in suicide mortality in China. Given that China’s suicide mortality rate is already relatively low globally, it is plausible that the current trend may persist.
Age stands as a substantial demographic factor influencing suicide rates. The varying risk associated with different age groups necessitates tailored prevention and intervention strategies. This study underscores that both the youth (aged 20–24) and the elderly are two significant high-risk groups for suicide within China. Past research conducted in South America [
44], Europe [
45,
46], and Asia [
47,
48], has consistently shown that those over 50 years of age possess the greatest risk. Factors such as chronic illness, family discord, financial difficulty, and mental disorders may contribute significantly to the suicide rates among the elderly in China [
49,
50]. One study also proposes that the decrease in suicide rates among the elderly may be attributable to enhanced healthcare systems and a reduction in poverty rates [
51]. Moreover, it’s critical to note that age-period-cohort studies, predominantly outside China, have not identified young adults aged 20–24 as the highest suicide risk group. This discrepancy suggests a unique circumstance within China. The causes for increased risk in this age group remain uncertain. In China’s unique exam-oriented context, significant physiological and psychological changes occur between the ages of 20 and 24. If not adequately addressed, the sudden increase in life and work stress would likely contribute to substantial psychological problems. The reason may partly explain the high suicide mortality in this age group. In the future, we need to pay extra attention to high-risk age groups above, and adopt targeted suicide prevention and intervention strategies.
The urban-rural disparity in suicide mortality in China was continuing marked but showed new changing patterns. The primary shift is seen among rural females of childbearing age, who historically had higher suicide risk levels and decline rates compared to their urban counterparts. Prior elevated suicide risk in this demographic was likely attributed to their unfavorable economic conditions, low social status, dependency on family and males, high occupational stress, and lack of adequate medical emergency services for impulsive suicide attempts [
10,
52,
53]. However, increased socio-economic status, improved living conditions, and better access to healthcare have greatly reduced the suicide risk among rural women [
10]. Further contributing to this decline are restrictions on pesticides and a significant rural-urban migration of women [
53,
54]. Second, there were gender trend reversals in suicide risks among urban and rural population aged 50 years and older. Specifically, after age 50, male suicide rates surpass female rates, a finding consistent with previous research [
55]. The gender gap in suicide risk widens with age in urban males and females, but remains relatively stable within their rural counterparts. It’s hypothesized that this trend could be attributed to the faster urban life pace, a heightened sense of self-loss, and diminished family connections among urban retirees, underscoring the need for mental health attention in the wake of increasing urbanization. Finally, while both the period and cohort effects on suicide rates have decreased more in rural areas than urban ones, the patterns of urban and rural suicide rates are converging. This probably stems mainly from China’s urban-rural integration and increased attention to suicide issues over the past 30 years. There is a need for further research to inform targeted suicide intervention strategies, taking evolving urban-rural disparities into account.
This study also has several limitations that require much attention. First, the change of death category coding in 2002 and the alteration of urban-rural definitions in 2005 may introduce bias to the suicide mortality data. Despite obtaining consistent results through mean imputation, we cannot fully eliminate the impact of this issue. The related findings need to be interpreted cautiously. Second, the mortality data in the early years only covered approximately 10% of China’s population, with survey samples mainly from regions with well-established reporting mechanisms, such as eastern and central cities [
4]. The geographical imbalance in the sources of mortality data, inconsistent standards in data quality control, and underreporting of suicide deaths may affect the authenticity of suicide data and introduce bias in temporal analysis [
4,
14]. Although we cannot completely eliminate the inherent limitations of these early data sources, we conducted sensitivity analyses using GBD data from different sources and the adjusted data considering underreporting effects, and obtained conclusions similar to those of this study. Within the currently rather limited framework of accessible suicide data, these analyses could provide a diversified perspective. Third, the huge rural-urban migration population and the method of attributing deaths based on residence registration booklets and the location of death may confound urban and rural mortality rates, requiring careful consideration of their impact on the conclusions of this study. Lastly, like other age-period-cohort analyses, this study is susceptible to potential ecological fallacies. The results derived at the population level could not accurately reflect individual scenarios. Thus, insights gleaned from the age-period-cohort analysis in this study require further validation in future individual-based studies.
Competing interests.
There are no actual or potential conflicts of interest, including any financial, personal, or other relationships with other people or organizations.
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