Independent Study Topic:

Suicide mortality trends by sex, age, method in young adults in Taiwan, 1971-2015

Background: Origin of Problem

There were six National Taiwan University (NTU) students committed suicide
in one year from June 2016 to May 2017. The age of NTU students are between 18
and 30 mostly. Their development stages are late adolescence and early adulthood.
The ratio of undergraduates and graduates is roughly 1:1.

The ones who successfully committed suicide cause tremendous impacts to

their friends and relatives, and the community they are in. When suicidal or
self-mutilated incidents occurred in campus, the monitoring of psychological impact
on other students, immediately action by campus administration and the possible
occurrence of suicide cluster is a very important public health issue. Since young
people are more susceptible to the suicidal incidents than the elderly, especially
those who are mentally fragile or have experienced suicidal attempt would reappear
suicidal attempt or self-mutilation by the incident.

Apart from actively concerning about the intervention of campus, due to the
suicidal cause varies from time, place, culture, and social condition, further study and
discussion of young students’ suicidal behavior from proximal (individual factor) to
remote (social, environmental factors…) is needed, in order to provide effective
suicide prevention recommendation.

Recollection of Articles:
Suicidal Epidemiology

Suicide has become common problem internationally. There are about one
million people died of suicidal globally each year, which is 1.4% of world death toll.

The suicidal death toll varies from area, sex gender, age, time, race, and
method of registration. In terms of demographic variables, e.g. sex gender, age…,
male’s suicide rate is higher than female’s, and risk of suicide escalates with ages in
western countries. Taiwan has similar distribution in sex gender and age after 1980s.
The highest suicide rate in terms of age is the elderly in most countries, but the
tendency eases. On the other hand, the suicide rate of the young, especially male
has raised.

As indicated by the WHO publication, Preventing Suicide: A Global

Imperative, in September 2014, suicide death occurs every 40 seconds globally.
Standardized age suicide rate in 2012 is roughly 11.4 persons per hundred million
people. WHO foresees such ratio would remain until 2030. In other words, the
causes affecting suicide are very diversified, complexed, and fluctuated. Therefore,
there is no one all suicide prevention strategy.

Importance of young suicidal problem

Suicide is the second biggest cause of death of the young, second only to accident.
Male’s suicide rate is higher than female’s in general. For young male, there are 19.2
suicide deaths out of every hundred million people ages 15-24; 28.3 suicide deaths
out of every hundred million people ages 25-34. There are at least 164,000 young
people age under 25 died of suicide every year globally.

Many community based researches found, 10% adolescence stated

self-mutilation experience; many have no lack of clear suicide intention. Only one
eighth of them would go to hospital seeking for help among those self-mutilation
adolescences. This indicates that there are many hidden self-mutilations. Those
young people who have suicidal attempt or self-mutilation experience are all very
fragile and prone to be affected by suicidal incident.

Suicide Studies all over the world found suicide ideation would occur rapidly
in adolescence. Cross countries researches found one third of the people who has
suicide ideation would commit suicide. 60% of who has suicide attempt commits
suicide within one year as soon as they have suicide ideation. This indicates that if
adolescence needs to be care and assisted when suicide ideation was found, to avoid
the further formation of suicide action.

Related researches also indicate lifetime prevalence of suicide ideation and

suicide attempt are 9.2% and 2.0% respectively. The lifetime prevalence of suicide
plan and non-lethal suicide attempt are 3.1% and 2.7% respectively.

The economic loss and social cost related to suicides of the young are less
reported. However, suicide of the young comes with more potential years of life lost,
which could cause the decrease of the entire national suicide rate, and cloud the
potential years of life lost. Concerning the economic loss and social cost related to
suicides of the young, a scholar estimated the social loss would be 1.67 million
pounds by using the commodity price of UK in 2009 as a reference.

Therefore, young suicide related issues are important public health matters.

Researches in suicide and its prevention

The occurrence of suicide is a combination of risk factors such as: gene, biology,
phycology, society and culture, accompany with personal trauma and experienced
loss. Many scholars use different models to explain how the inner or outside risk
factors and its connection among them influencing one’s suicide.

Those risk factors includes: social aspect e.g. lack of social cohesion, the rapid
changes of social structure or values, economic crisis; and environmental aspect e.g.
the availability of suicidal tools, reachability of Medicare and media propagation.

Personal factors on the other hand include: physiological difference,

childhood adversity (child abused physically or mentally), social life factor when born
(mother’s age, whether single parent, birth order, family size, development of
personal traits, cognitive impairment, anxiety and melancholy, behavioral
disinhibition.

Hawton thinks treatment or assistance toward a melancholy patient should

notice whether his (her) close family members or friends having suicidal or
self-mutilation behavior. These could be influences whether he (she) deems suicide
as a solution for relieving pressure, and emerging suicidal ideation. If suicidal tools
are at hand, he (she) would commit suicide.

Unfortunately, there is no effective formula to prevent suicide in practice. It is

still difficult to foresee whether or not a person would commit suicide even if we
acknowledge all risk factors. In a way it is because of the occurrence of suicide is not
usual; entire social, economic, and environmental factors change through time would
affect the outcome of suicide prevention. Furthermore, current researches show the
most prominent suicide prediction factor is the past suicide attempt or
self-mutilation behaviors. Nonetheless, its population attributable fraction (PAF) is
7.2-2.9% merely, far less than the 60% PAF of smoking to lung cancer.

In personal oriented suicide prevention work, using sorts of scales filtering

out high risk group to get involve suicide prevention, would occur false positive
problems. One time filtering would also occur false positive. Because in suicide
researches, people suffers from suicidal ideation only a small portion would have
suicide attempt; even smaller portion would commit suicide. Take US as an example:
every year there are 3.3% of population would seriously consider committing suicide,
1% would develop suicide plan and 0.6% would appear suicidal attempt, and 0.01%
commit fatal suicide. The above information reflects the multi-facet and complexity
of suicide and its related behaviors. Suicide ideation and commit suicide may not be
different only on degree of suicide, but probably also existing different operation
mechanisms.

Although most suicides have psychological disease such as melancholy, those

who have psychological disease or suicidal ideation would not commit suicide mostly.
Thus, the suicide research must not study only common psychological diseases
related to suicides, but transcends to explore life course factors, such as: gene from
preborn to old age, environment…etc.

In hence, we can use social ecological model to construct micro factors

(individual aspect), as well as mezzo and macro factors (risk factors and protection
factors of social, economic, culture aspects) which influence suicide.

Researches on Micro Factors (Personal Aspect) of Suicide and Suicide Related

Behaviors
Most cited traditional suicidal risk factors nowadays can only predict personal
suicidal ideation. Yet, not be able to sort out people who would take action from
these people who are full of suicidal ideation. In other words, development of
suicidal ideation and further progress to suicide attempt should be deemed as
different processes. Therefore, should have different explanations and predictive
factors. Klonsky etc. called it “Ideation to Action”. Under the structure of Ideation to
Action, there are three explanation models to predict suicide and suicide related
behaviors, including: Interpersonal Theory of Suicide, Integrated
Motivational-Volitional (IMV) Theory, and Three-Step Theory.

Interpersonal Theory of Suicide: Interpersonal Theory think suicide contains

three factors. When a person think him(her)self as burdens of others (perceived
burdensomeness), and alienates from others, cannot integrate into family, good
friends, important social groups, and become one of them. This kind of lacking of
belongingness interpersonally and perceived burdensomeness are the most proximal
state of mind developing suicidal ideation. However, whether a person would
commit suicide, still have to consider if he (she) is capable of suicide. When a person
is more and more not afraid of dying, more resistant to pain or setback, possessing of
tools and knowledge to end life, having past self-mutilation experience, then this
person has higher ability to commit suicide.

Integrated Motivational-Volitional (IMV) Theory:

This theory consolidates early suicide theories. It thinks suicide is a behavior
interacting between muti-factors, not only a production of psychological diseases. In
IMV model, two dimensions could develop suicidal behavior. And motivational phase
is used to describe how suicidal ideation becomes a risk factor. When a person
suffers from setback, cannot escape from the environment of setback and pressure,
and is trapped in a dilemma, if motivational moderators exists, including low social
support etc., suicide ideation could be developed. Nevertheless, what really makes a
person with suicidal ideation turn into suicidal action is volitional moderators, which
includes self-mutilation history, ability to commit suicide, possessing of suicide tools
and knowledge.

Three-Step Theory:
This theory considers the thought of suicide mainly comes from the pain of
psychology and emotion, and must be accompanied with sense of hopeless. When a
person’s agony exceeds beyond his (her) connectedness with others, interests, roles,
plans, objectives, and meaning of life, his (her) suicidal ideation will be strong. At this
moment, connectedness is a protection factor of a suicidal behavior. Whether a
person take suicidal action, determined by if he (her) is capable of committing
suicide, including personal physics, used to assumption of pains due to past
experience, increasing the endurance of pain so not afraid of dying, equipped with
knowledge and tools of committing suicide.

Explore mezzo and macro factors (social, economic, culture aspects) of suicide and its
related behaviors from suicide trend

Researches on suicide and its prevention requires the combination of personal

aspect and aspects beyond personal, e.g. environmental, social, economic, culture.
Because the most important trait of suicidal epidemiology is, suicide will vary
drastically according to different time, space, culture, race, sex gender, age. Suicide
rate can be ten times among different times and countries. Explanation of these
varies by suicide trend can provide insight outside of personal aspect for cause of
suicide and possible suicide prevention measures.
 According to Taiwanese research data, different sex genders and different age
groups have common time period effect, including three suicidal peaks, namely
1960, 1980 and early 1990s. Possible explanations respectively in order are: 1. social
demographic change and political and cultural conflicts of post Second World War
fusion process of ethnic groups; 2. Variation of unemployment rate due to exodus of
industries in early 1980s; 3. Elevation of unemployment rate because of energy crisis,
economic recession in 1990s. When factors such as GDP per capita, GDP growth,
divorce rate and female labor participation result in the increase of unemployment
rate 1%, male suicide rate would increase 3.1 person per hundred thousand person.

From the variation of suicide rate, we can see regional economic crisis has
different impact on countries in the region. For example, Asian economic crisis
between 1997 and 1998 influenced the society of Japan, Korea and Hong Kong
profoundly. Nonetheless, there are no vivid impact on Taiwan and Singapore.

Trend research can also explore the relationship between information

propagation via media and suicide rate. The research results can be further used to
actively increase the presence of suicide help information on internet platforms
under certain situations.

In order to fully understand the suicidal figures, and then effectively assess
the impact of the suicide prevention intervention measures, trend research can be
used to look into the categorization of death causes related to suicide. Taiwanese
suicide rate could be underestimated by 30% because of wrong categorization of
death causes. Taiwanese society’s hesitation of revealing suicide as the cause of
death could be relevant.

From ways of suicide to suicide prevention

The most evidence based suicide prevention strategy nowadays is the
limitation of suicide tools. Many suicide impulses of suicide attempters occur at
acute emotional frustration period and last a shorter period of time. By means of
restriction of suicide tools would delay suicide action and subsequently lower suicide
impulse.

Removal of suicide tools is a crucial and fundamental prevention method. As

for the question whether limitation of suicide methods would incur substitutions? if
substitution is non-lethal tools, suicide rate would lower. Not to mention such
substitution seldom occurs. Part of the reason could be, when a person at high
suicide risk, his (her) problem solving ability usually is interfered. So their ability to
find substitutions is limited when suicide tools are limited.

Because the epidemic disease trait of suicide methods and trend research
reflect particular social, cultural, economic and religious status in a region, common
suicide methods would be varied according to sex gender and age. Thus, local social
and cultural factors, sex gender, and age aspect need to be understand so as to
formulate a limitation of suicide tools.
 Recent researches including male suicides by fire pieces reached peak in 1988
then decreases gradually in Norway is relevant to the legislation of gun control by
Norwegian government making gun access difficult. Korea banned highly toxic
herbicide - Paraquat in 2011, suicide rate related to pesticide decreases 37% more
than expected, while suicide mortality rate by other means is stable. Moreover, New
Taipei City government of Taiwan demanded supermarket chain stores placing
charcoal on locked shelf to create purchase barrier by delaying 10-15 minutes of
acquiring charcoal from May 1, 2012. A quasi-experimental design using Taipei city
and Yilan city which did not apply for such policy as control group, analyzed how the
increase of charcoal’s purchase barrier affects suicide rate by using charcoal and the
integral suicide rate.

Suicide epidemic disease researchers found that main (popular) suicide

methods cannot be randomly chose. It will be related to chosen methods’ local
accessibility, local cultural acceptability, and whether an individual possess these
suicides method’s knowledge (availability). Therefore, to ponder suicide prevention
strategy, we need to grasp the variation of the main suicide methods of targeted
group, and combines with social and environmental factors and so on in the relevant
interval.

So, monitoring and minding variation of suicide methods, including regional

suicide method variation, the impact of new suicide methods to integral suicide rate,
and the information media propagation status of suicide methods of the famous, is
very important in suicidal prevention.

Knowledge gap and importance of Taiwanese young people’s suicide prevention

Researches in Taiwan related to suicide methods including coal burning,

jumping, and all suicide methods etc. Time frames studied are mostly around 2006
when recent suicide peak occurred in Taiwan. Statistics classified by ages did not
further categorize young generation in more detail. For example, ages are divided
into four groups: 15-24, 25-44, 45-64, over 65. Rough categorization in age tends to
conceal important information in each age group, result in the inability of grasping
trend variation of adolescences or youth group, and also not be able to reflect the
difference of biological, psychological and social development stage among them.

Moreover, to researchers understanding, perhaps due to the prevailing trend

in Taiwan that higher age appears higher suicide rate, there is less research on
adolescence or youth suicide. Although some researches exist toward suicide of
youth group, further steps in analyzing the variation of suicide methods were not
proceed.

Though suicide has receded out of the top ten death cause list in Taiwan,
suicide mortality still ranks No. 2, second to accidental mortality, among the youth;
which in turn accompanies more years of life loss, economic and social cost loss.
What is worthy of notice is, comparing to other elder age groups; the youth is more
vulnerable to the influence of environment, information, media and networks. These
all reflect the importance of research on suicide of the youth. In addition, the
prevention of the suicide of the youth can prevent the possible increasing suicide
rate when they grow up.

In Conclusion, it is very crucial to conduct researches on suicide method trend

of adolescence and the youth in Taiwan.

Research Goal:
To analyze the trend variation of suicide mortality rate and suicide method of the
youth (ages 15-34) in Taiwan between 1971 and 2015, according to their sex gender
and age. Expecting useful references in strategical planning for suicide prevention of
the youth in Taiwan, according to various development stages of the youth would be
generated.

Research Method:
Source of data
Using cause of death data between 1971 and 2015 by the Ministry of Health
and Welfare; ages 15-34 as population of analysis, categorizing into four age groups
according to sex gender: 15-19, 20-24, 25-29, and 30-34. While the mid-year
population data comes from population data yearbook by the Ministry of Internal
Affairs. Calculating the age-standardized mortality rates between ages 15 and 34 by
using World Standard Population 2000.

Definition of Suicide and Suicide Method

Suicide mortality rate are underestimated. Due to some suicides are

miscategorized as unknown cause of death, accidental death of pesticide poisoning,
and suffocation, Chang et al think suicide mortality rate could be underestimated
more than 30% in Taiwan. Therefore, the definition of suicide in this research adopts
The International Statistical Classification of Diseases and Related Health Problems
8th (ICD-8), 9th (ICD-9) and 10th (ICD-10) Revision. Applied year and ICD code of
causes of death see table I. Where codes related to suicide are E950 to E959,
unknown death are E980 to E989 in ICD-8 and ICD-9. Codes related to accidental
pesticide poisoning and suffocating death are E865 and E913 in ICD-8 respectively;
E863 and E913 in ICD-9. Codes related to suicide are X60 to X84, unknown death are
Y10 to Y34, accidental pesticide poisoning is X48, and suffocating death are W75-76,
W83-84 in ICD-10.

The main objective of this research on suicide methods is to avoid

adolescence and the youth commit suicide. The suicide methods studied are top five
suicide methods used in Taiwan which covered 90% suicide death, including solid or
liquid substances poisoning, other gases and vapors poisoning, hanging, drowning or
submersion, jumping.

Statistical Method
 1. Yearly suicide mortality rate by sex gender, age groups and by suicide
methods will be presented by tables and charts to show the trend variation.

Then, we visual-inspect these tables and charts, dividing 1971 -2015 into 9
time periods (every 5 years a time period), using Poisson Regression Model
analyzing suicide mortality rate by sex gender, age groups, and by suicide
methods. To estimate Incident Rate Ratio (IRR) in each category, we use time
period “1971 – 1975” or the time period each suicide method first appeared
as reference group.

2. Our research also adopts Jointpoint Regression to analyze trend of suicide

mortality rate by sex gender and age groups, and by suicide methods.
Jointpoint Regression can find joint point when time trend changes
(increasing or decreasing) significantly. Characteristics of trend variation
during the statistical period can then be presented by linear segments
connected by jointpoints.

3. For the purpose of mastering the trend analysis of suicide methods

according to various definition of suicide, our research, in the meantime,
conducts sensitivity analysis by using cause-of-death data which are
confirmed as suicide only (E950-E958 of ICD-8 and ICD-9; X60-X84 of
ICD-10), so as to understand the impact of the miscategorization of possible
suicide cases to the research result.

Expected Research Contributions

1. Definition of suicide includes suicide confirmation; unknown attempt;
accidental pesticide poisoning and suffocation could be close to the real
distribution of suicide mortality rate of Taiwanese youth.

2. Presenting variation of Taiwanese suicide mortality rate between 1971 and

2015, by sex genders and age groups (ages between 15 and 34; grouping by
every five years of age), particularly the trend in recent 20 years. The
aforementioned research result can be further used as a reference for
suicide prevention strategic planning of Taiwanese adolescence and the
youth in various development stages.

Research Restrictions
This is an ecological study in the field of epidemiology, cannot be used as
inference of a possible individual suicide cause. Furthermore, suicide method’s
preference of young people cannot be used to conjecture the suicidal preferences of
middle-aged or old-aged people.