Soc Psychiatry Psychiatr Epidemiol (2005) 40: 64–71
1007/s00127-005-0849-6
ORIGINAL PAPER
Huong Tran Thi Thanh · Guo-Xin Jiang · Tuong Nguyen Van ·
Duc Pham Thi Minh · Hans Rosling · Danuta Wasserman
Attempted suicide in Hanoi, Vietnam
Accepted: 2 July 2004
■ Abstract Background Attempted suicide is a key pre-
dictor of suicide, which is among the dominant causes of
young people’s deaths worldwide. Very little is known
about the characteristics of suicide attempters in Asia,
especially in Vietnam. Methods Medical records of 509
patients (515 attempted-suicide events) admitted to
Bach Mai General Hospital in Hanoi, Vietnam from 1
January 1999 to 30 April 2001 were analysed according
to the criteria of the WHO Multicentre Study of At-
tempted Suicide. Results The suicide attempters’ mean
age was 28.3 ± 12.9 years. Nearly half (48.7 %) were aged
15–24. The female-to-male ratio of patients living in ur-
ban areas (2.1:1) was higher than in rural areas (1.2:1).
In urban areas, students (32 %) and homeworkers (28 %)
and, in rural areas, farmers (56 %) and students (17 %)
were the salient occupational categories.Acute life stres-
sors were the main causes (73.8 %) of suicide attempts.
Only in some 6 % of cases had a psychiatric illness been
diagnosed before the suicide attempts. As a means of at-
tempting suicide, intoxication with analgesics and an-
tipyretics (e. g. paracetamol) with low medical lethality
scores was a frequent method among the urban patients,
the majority of whom (81 %) consequently stayed in
hospital less than 24 h. Pesticide and rat poison, more
commonly (57.2 %) used by attempters in rural areas,
had higher medical lethality scores and also necessitated
H. T. T. Thanh · T. N. Van · D. P. T. Minh
Hanoi Medical University
Hanoi, Vietnam
H. Rosling
Division of International Health
Dept. of Public Health Sciences
Karolinska Institutet
Stockholm, Sweden
H. T. T. Thanh · G.-X. Jiang · D. Wasserman
Swedish National Centre for Suicide Research and Prevention
of Mental Ill-Health (NASP)
and Dept. of Public Health Sciences
SPPE 849
Karolinska Institutet
Solna, Stockholm, Sweden
E-Mail: Danuta.wasserman@ipm.ki.se
DOI 10.
more prolonged hospital treatment. Conclusions Some
suicide-preventive strategies used in the West for young
people may be applicable in Vietnam. Reducing access to
pesticides and rat poison is comparable to western ef-
forts to make paracetamol or firearms less freely avai-
lable. Skills in resolving family and other conflicts can be
taught in schools according to WHO’s suicide-preven-
tion resources for teachers.
■ Key words attempted suicide – hospital records – age
– gender – causes – methods – psychiatric diagnoses –
prevention – Vietnam
Introduction
Attempted suicide is one of the strongest predictors for
suicide, which is one of the leading causes of death
worldwide among people under the age of 45 [1–3]. It is
being gradually recognised as a major health problem
that urgently calls for vigorous preventive action.World-
wide, suicide and attempted suicide are increasingly
common nowadays, in ever younger age groups.Accord-
ing to information from the Vietnamese Ministry of
Health [4], suicide is among the ten leading causes of
death for the entire population of all age groups. How-
ever, vital statistics from censuses in Vietnam do not
provide comprehensive data on causes of death. No data
at all are collected on attempted suicide.
Hospital statistics are the only available source of in-
formation for assessing the frequency of suicide and at-
tempted suicide in Vietnam. The present study is the
first one to analyse case records of Vietnamese suicide
attempters. This study is also one of the few studies in
Asia in which attempted suicide is analysed [5–8]. Since
attempted suicide is a very strong predictor for future
suicide [9] and, simultaneously, as a non-lethal act,
opens a window of opportunity for prevention, we
sought to identify risk factors in self-destructive behav-
iour with a view to tailoring future preventive pro-
grammes in Vietnam.
 65

The purpose of the study was to investigate the char-
acteristics of suicide attempters in terms of gender, age,
occupation, causes, methods, medical lethality of the
suicide attempt and presence of somatic and psychiatric
diagnoses. The aim was also to describe similarities and
differences between risk factors for suicide attempt in
Vietnam and in the West [10–12].
Subjects and methods
Retrospective analysis was performed on all hospital records of at-
tempted-suicide patients admitted to Bach Mai National Referral
Hospital in Hanoi, from January 1999 to April 2001. This is the largest
hospital in Hanoi, with 1,500 beds. The hospital’s catchment area in-
cludes urban, suburban and rural areas. In addition, a number of
cases are referred from adjacent provincial hospitals in the Red River
delta. The patients treated in the hospital include both patients pre-
senting directly and those referred, as well as paying and insurance
patients.
All patients who seek hospital care following intoxication are ex-
amined at the hospital’s Poison Control Centre, established in 1999.
Some of them are referred to the Department of Psychiatry for psy-
chiatric treatment.
All individual case records at Bach Mai Hospital are stored sepa-
rately for each department and unit, as well as for each year of ad-
mission. The records of all 3,027 patients admitted to the Poison Con-
trol Centre and the Department of Psychiatry were reviewed by the
research criteria described below. The validity of the clinical diag-
noses of attempted suicide was assessed in the light of notes in the
medical records about the patients’ and family members’ verbal state-
ments and farewell notes or letters, if any.
The attempted-suicide diagnoses were re-evaluated according to
the research criteria of the WHO Multicentre Study of Attempted Sui-
cide [10]. A checklist developed in the WHO Multicentre Study was
used to record data on gender, age, residence (rural or urban area), oc-
cupation, date of the event, causes and attempted-suicide methods
used. The methods of attempting suicide were classified according to
the tenth version of the International Classification of Diseases (ICD-
10). The diagnosis of attempted suicide was made primarily by hos-
pital doctors, not for research reasons, but solely for clinical purposes.
The suicide attempts were classified in terms of their degree of med-
ical severity according to the lethality rating scale [13].Three hundred
and ninety patients at the Poison Control Centre and 25 from the De-
partment of Psychiatry fulfilled the research criteria used in our
study. In addition, our analyses included 94 patients from the Poison
Control Centre who were diagnosed as intoxicated by clinicians, but
found to fulfil our research criteria for attempted suicide. Psychiatric
diagnosis before attempted suicide was made by psychiatrists.
Statistical analyses were performed using EPI INFO software. Sta-
tistical significance for differences between different groups was as-
sessed using chi-square and Fisher’s exact tests where appropriate.
Student’s t test was used for continuous variables.
Results
During the 28-month study period, 515 episodes of at-
tempted suicide by 509 patients, 189 males (37.1 %) and
320 females (62.9 %), were recorded. A total of 484 pa-
tients received treatment at the Poison Control Centre
and 25 at the Department of Psychiatry. Attempted-sui-
cide events numbered 209 in 1999, 260 in 2000 and 46 in
the first 4 months of 2001.
■ Age
The mean (± SD) age of the suicide attempters was 28.3
(± 12.9) years, with no significant difference (p = 0.40)
between the men (27.6 ± 11.6) and the women
(28.6 ± 13.6 years). The highest proportion of the pa-
tients, in both rural and urban areas, was found in the
15–24 age group (48.7 % of all patients) followed by
those aged 25–34 (Table 1). Among suicide attempters
from urban areas (64.2 %), the mean (± SD) age was
27.7 ± 12.3 years and, in those from rural areas, it was
29.2 ± 13.8 years.
■ Residence and occupation
The female-to-male ratio of patients from urban areas
(2.1:1) was higher (p = 0.001) than that of patients from
rural areas (1.2:1). More than half the patients from the
urban areas were students (32 %) or homeworkers
(28 %), while farmers (56 %) followed by students (17 %)
made up the highest proportions of patients from the
rural areas.
More than half the patients from both urban and
rural areas aged under 25 years were students (53.8 %).
Among those aged 25 years and over, homeworkers
made up the largest occupational category (41.4 %).
Other occupations represented in small numbers in-

Table 1 Numbers of attempted-sui-

cide patients in Bach Mai hospital during Numbers of attempted-suicide patients
1999, 2000 and 2001 (4 months), by age Urban Rural
and residence
Age group (years) Male (%) Female (%) All (%) Male (%) Female (%) All (%)

< 15 2 (1.9) 8 (3.6) 10 (3.0) 2 (2.4) 2 (2.0) 4 (2.2)

15–24 53 (50.5) 109 (49.1) 162 (49.5) 37 (44.0) 49 (50.0) 86 (47.3)
25–34 34 (32.4) 56 (25.2) 90 (27.5) 27 (32.1) 23 (23.5) 50 (27.5)
35–44 11 (10.5) 25 (11.3) 36 (11.0) 6 (7.1) 11 (11.2) 17 (9.3)
45–54 3 (2.9) 8 (3.6) 11 (3.4) 2 (2.4) 6 (6.1) 8 (4.4)
55–64 1 (1.0) 7 (3.2) 8 (2.4) 8 (9.5) 3 (3.1) 11 (6.0)
≥ 65 1 (1.0) 9 (4.1) 10 (3.1) 2 (2.4) 4 (4.1) 6 (3.3)
Total 105 (100.0) 222 (100.0) 327 (100.0) 84 (100.0) 98 (100.0) 182 (100.0)
66

cluded retailers (5.7 %), workers (4.7 %), intellectuals
and artists (3.6 %), artisans (2.8 %), civil servants and
clerks (2.4 %), and soldiers, police officers and disabled
veterans (1.4 %) (Table 2).
■ Monthly and daily distribution
Attempted suicides peaked in the month of April, with
more suicide attempts in the rural areas. The monthly
distribution was similar for males and females, with the
lowest figures in January. Most attempts took place be-
tween 9 a. m. and midnight (Fig. 1). The mean number of
hourly attempted-suicide events was 22.5 between
9 a.m. and midnight, and significantly higher than six at-
tempts during the remainder of the 24 h (p < 0.001).
■ Causes of suicidal acts
Documented causes were found for 435 (84.5 %) of all at-
tempted-suicide events. The most frequent causes were
conflicts in the family (73.8 %), mainly with partners
and parents (Table 3). Conflicts in the family were more
common (p < 0.001) among females (80.3 %) than males
(62.7 %). The other major cause was disease (Table 3). In
terms of conflicts as causes of the suicide attempt, there
was no significant difference (p = 0.06) between the ur-
ban (76.8 %) and the rural areas (68.4 %). Other causes
included financial problems (2.8 %) and study problems
(1.8 %).

Table 2 Occupations of attempted-suicide patients,

by gender and area of residence Patients from urban area Patients from rural area
Occupation n (%) n (%)

Homeworkers 90 (28.3) 13 (7.4)

Students 103 (32.4) 29 (16.6)
Retailers 25 (7.9) 3 (1.7)
Intellectuals and artists 18 (5.7) 1 (0.6)
Workers 16 (5.0) 7 (4.0)
Retired 18 (5.7) 10 (5.7)
Artisans 14 (4.4) 0 (0.0)
Civil servants 10 (3.1) 2 (1.1)
Soldiers, police officers and veterans 2 (0.6) 5 (2.9)
Farmers and farm labourers 0 (0.0) 98 (56.0)
Other occupations 22 (6.9) 7 (4.0)
Total 318 (100.0) 175 (100.0)

Fig. 1 Diurnal distribution of at-

tempted suicide
 67

Table 3 Causes of attempted-suicide

events, by gender and area of residence Number of events in urban area Number of events in rural area
Causes Male (%) Female (%) All (%) Male (%) Female (%) All (%)

Family conflicts 57 (63.3) 158 (83.2) 215 (70.7) 44 (62.0) 62 (73.8) 106 (68.4)
Diseases (somatic and mental) 10 (11.1) 16 (8.4) 26 (9.3) 15 (21.1) 13 (15.5) 28 (18.1)
Financial problems 5 (5.6) 4 (2.1) 9 (3.2) 3 (4.2) 0 (0.0) 3 (1.9)
Addiction 6 (6.7) 0 (0.0) 6 (2.1) 0 (0.0) 0 (0.0) 0 (0.0)
Problems in study 2 (2.2) 4 (2.1) 6 (2.1) 0 (0.0) 2 (2.4) 2 (1.3)
Alcoholism 2 (2.2) 0 (0.0) 2 (0.7) 2 (2.8) 0 (0.0) 2 (1.3)
Others 8 (8.9) 8 (4.2) 16 (5.7) 7 (9.9) 7 (8.3) 14 (9.0)
Total 90 (100.0) 190 (100.0) 280 (100.0) 71 (100.0) 84 (100.0) 155 (100.0)

■ Somatic and psychiatric morbidity
in suicide attempters
The proportion of patients with somatic and/or mental
diseases in the rural areas was almost twice that in the
urban areas (p = 0.008).
There were 29 cases with a diagnosis of mental dis-
orders predating the suicide attempt. Of these, 12 pa-
tients came from the urban and 17 from the rural areas.
Among them, there were 11 cases with a diagnosis of
schizophrenia, five cases of depression and 13 cases of
various other mental disorders. There were seven cases
of epilepsy diagnoses predating the suicide attempt, and
18 other cases of somatic diseases such as cancer, tuber-
culosis, diabetes and heart disease. Only 4 (0.9 %) at-
tempted-suicide events were associated with alco-
holism.
■ Suicide-attempt methods and medical lethality
In more than half (55.6 %) of the suicide attempts in the
urban areas, non-opioid analgesics, antipyretics and
anti-rheumatics had been used (X60 according to ICD-
10), while in the rural areas pesticides (X68) accounted
for 57.1 % of the attempts (Table 4).
Most of the attempted-suicide patients who used
drugs with sedative effects were fully conscious, or con-
scious but drowsy, while many patients who attempted
suicide using pesticides and rat poison were subject to
higher medical lethality and more often needed emer-
gency treatment (Table 5). The proportion of suicide at-
tempters who had used drugs with sedative effects and
were fully conscious or conscious but drowsy was sig-
nificantly higher among urban than rural patients
(p < 0.0001), and also significantly higher among fe-
males than among males (p < 0.001).
Among patients who used drugs without sedative ef-
fects and those who ingested pesticides or rat poison, the
proportion incurring injuries and receiving emergency
treatment was significantly higher in the rural than in
the urban areas (p < 0.001). The proportion of females
was also significantly higher than that of males
(p < 0.05).

Table 4 Methods of attempted-suicide events, by

area of residence Number of events Number of events
in urban area in rural area
Methods (ICD-10 code) n (%) n (%)

X60: non-opioid analgesics, antipyretics and antirheumatics 184 (55.6) 43 (23.6)

X61: antiepileptic, sedative-hypnotic, anti-Parkinsonism 71 (21.5) 23 (12.6)
and psychotropic drugs
X62: narcotics and psychodysleptics 1 (0.3) 0 (0.0)
X63: other drugs acting on the autonomic nervous system 4 (1.2) 1 (0.5)
X64: other unspecified drugs, medicaments and 14 (4.2) 3 (1.6)
biological substances
X65: alcohol 3 (0.9) 2 (1.1)
X66: organic solvents and halogenated hydrocarbons 1 (0.3) 0 (0.0)
and their vapours
X68: pesticides 46 (13.9) 104 (57.1)
X70: hanging, strangulation and suffocation 3 (0.9) 4 (2.2)
X80: jumping from a high place 1 (0.3) 1 (0.5)
X83: other specified means 1 (0.3) 0 (0.0)
X84: by unspecified means 2 (0.6) 1 (0.5)
Total 331 (100.0) 182 (100.0)
68

Table 5 Lethality rating scale of attempted-suicide

events, by area of residence Number of events Number of events
in urban area in rural area
Lethality rating scale n (%) n (%)

For drugs with sedative effects

00: fully conscious and alert 136 (41.1) 25 (13.7)
01: conscious but drowsy 78 (23.6) 10 (5.5)
02: lethargic, with diminution in intellectual ability 12 (3.6) 12 (6.6)
03: asleep but easily aroused 1 (0.3) 2 (1.1)
04: comatose – withdrawal from painful stimuli, reflexes
intact, injury sufficient for hospitalisation 7 (2.1) 6 (3.3)
05: comatose – no withdrawal from painful stimuli, most
reflexes intact; no respiratory or circulatory depression; injury
sufficient for ICU monitoring 0 (0.0) 2 (1.1)
07: comatose – all reflexes absent; respiratory depression
with cyanosis or circulatory failure and shock or both 18 (5.4) 12 (6.6)
For drugs without sedative effects and for other ingested substances
00: no or minimal medical consequences or treatment 13 (3.9) 2 (1.1)
02: some injury and treatment in emergency room or on
outpatient basis 60 (18.1) 96 (52.7)
04: injury sufficient for hospitalisation – vital signs and level
of consciousness may be affected 2 (0.6) 9 (4.9)
06: major systematic effects, e. g. gastrointestinal perforation,
renal failure, blood haemolysis or shock; vital signs unstable 0 (0.0) 1 (0.5)
For jumping
00: minor bruises only – no treatment necessary 0 (0.0) 1 (0.5)
02: sprains or minor injuries – no bone, ligament, or tendon
damage; no internal bleeding, tissue or brain damage 1 (0.3) 0 (0.0)
For hanging
05: hospitalisation and resuscitation required 3 (0.9) 4 (2.2)
Total 331 (100.0) 182 (100.0)

■ Days of hospital care
Most of the suicide attempters (56.8 % of males and
77.6 % of females) stayed in hospital for no more than 1
day, and less than 10 % were hospitalised for more than
4 days. The proportion receiving less than 2 days’ inpa-
tient care was significantly higher (p < 0.001) in the ur-
ban (81.5 %) than in the rural areas (48.9 %).
Discussion
■ Methodology
cide currently being performed in Hanoi by our research
group will provide an answer in the near future.
However, suicide attempters in the West who are
treated in hospital also represent only a minority of all
suicide attempters. Many never seek hospital care, and
the number of attempted suicides based on population
surveys is almost twice as high as hospital admissions
would suggest [14]. The attempted-suicide diagnoses in
our study were validated and coded according to the
ICD-10 classification and the criteria used in the WHO
Multicentre Study of Attempted Suicide [10], which
gives a reliable basis for comparison with results ob-
tained in other studies.

This is the first publication about suicide attempters in

Hanoi, Vietnam. All suicide attempters who seek hospi-
tal care at Bach Mai Hospital in Hanoi are treated at the
Poison Control Centre, established in 1999, and the De-
partment of Psychiatry. The patients analysed in the
present study, who had attempted suicide, were consecu-
tively admitted to the hospital during the study period.
However, the true number of suicide attempters in the
catchment area is higher, since rates for suicide at-
tempters seeking inpatient care are very low in our
study. One explanation may be that persons who attempt
suicide in Vietnam do not seek hospital care. As to
whether this is true, a population study of attempted sui-
■ Young suicide attempters and family conflicts
Age
In this study, patients aged 15–24 years made up the
largest single age group, accounting for 48.7 % of all at-
tempters, in comparison with 28 % in the European
WHO study of attempted suicide. The mean age of sui-
cide attempters in European [10] and other western
studies [12, 15] is approximately 30–35 years. In our
Vietnamese study, attempters were much younger. The
magnitude of the problem of suicide among young peo-

ple makes it a major concern, and WHO is focusing on
suicide-preventive activities among young people [16,
17].
Female-to-male ratio
The female-to-male ratio in Vietnam, for attempters
from the urban and rural areas combined, was 1.7:1. This
figure is similar to that in many European and western
countries. However, this ratio was much lower in rural
areas alone where almost equal numbers of males and
females attempting suicide were found. Somewhat sim-
ilar results are reported in one study from Europe (on
men in Helsinki, Finland) where the female-to-male sui-
cide ratio was 0.9:1 [18].
Causes
As a cause of attempted suicide in Vietnam, financial
problems were reported by only 6 % of urban and 4 % of
rural males in the present study. On the other hand, con-
flicts with partners and other family members were
found to be the main cause, whereas mental and/or per-
sonality disorders proved to be uncommon. Similar re-
sults have also been reported previously from other
Asian countries [5–8] and psychiatric morbidity is dis-
cussed below.
Unemployment and economic hardship as risk fac-
tors in attempted suicide in Western males have been
discussed elsewhere [15, 19].
There are no strong legal or religious prohibitions
against self-destructive behaviour in the Vietnamese
culture. In a cultural environment of this kind, family or
other types of conflict – a well-known psychosocial
stressor – can result in impulsive suicide attempts, espe-
cially among youngsters, without any underlying psy-
chiatric illness being present, when firm support from
their various networks is simultaneously lacking.
Some theories focus on the low status of rural females
in many developing countries and emphasise the do-
mestic violence due to family conflicts to which they are
subject [3]. This may well be valid for young suicide at-
tempters in rural Vietnam as well.
In the West, adolescents who report suicide attempts
show a significantly lower level of family support. They
also report much more physical and/or sexual abuse
than non-attempters [20]. An ongoing qualitative case
study interview among young suicide attempters in
Vietnam will give more information.
■ Methods of attempting suicide
The majority of the suicide attempters in the present
study used intoxication (ICD-10 codes X60-X69) in their
suicide attempts. The majority of attempts in the rural
areas were by means of pesticides, rat poison or other
chemicals used in agriculture (ICD-10 code X68). This
method, which is almost unheard of in both attempted
69
suicide and suicide in the West, has been reported as a
common suicide method in China [21]. The existence of
potent pesticides in most people’s homes makes pesti-
cides easily available and probably cheap, compared
with medications used for intoxications, as a method of
suicide and attempted suicide in Vietnamese urban ar-
eas. Attempted suicide in urban areas by means of anal-
gesics and antipyretics such as paracetamol and ro-
tunda, a traditional medicine with an action similar to
paracetamol (X60), and with tranquillisers (X61),
closely resembles western patterns of suicide-attempt
methods [10]. In many western countries, over-the-
counter sale of paracetamol has been restricted to small
quantities [22] or sale of analgesics confined to pre-
scription only, in order to reduce accessibility to these
dangerous means of attempting or committing suicide.
There were no attempted suicides with firearms in
our material,since firearms are not accessible to the gen-
eral population in Vietnam. Firearm possession is pro-
hibited, except for military personnel and policemen. In
countries where firearms are easily accessible, such as
the USA, they are often used as a method in suicide and
attempted suicide not only by adults, but also by the vul-
nerable and desperate young people who use their par-
ents’ weapons [23].
■ Psychiatric morbidity
Personality and/or psychiatric disorders are closely as-
sociated with attempted suicide in Europe [24]. In our
Vietnamese study, only 6 % of attempted-suicide pa-
tients were diagnosed with mental disorders. There may
be several explanations why such low numbers of sui-
cide attempters received psychiatric diagnoses.
First, this study is based on medical records. Diag-
noses were made by doctors not for research, but for
clinical purposes. Diagnostic traditions in Vietnam and
other Asian countries probably differ from those in the
West.
The findings of one study of completed suicides from
China [21] showed a relatively low rate of mental illness.
The authors found that many of the suicides among peo-
ple who did not have a mental illness were impulsive acts
of pesticide ingestion, occurring immediately after an
intense interpersonal conflict. Adjustment disorder,
post-traumatic stress disorder (PTSD) and depression
are more rarely diagnosed in Asia, not only among peo-
ple who attempt and commit suicide, but also among
psychiatric patients [21].
In the West nowadays, depression is acknowledged as
a mental illness and the prevalence of depression is high
in both population-based and hospital-based investiga-
tions [25]. However, depression in the West may be over-
diagnosed. Depression is a multifaceted concept, and
prevalence figures in the West probably also include var-
ious types of grief reactions, forms of natural despon-
dency and adjustment disorders with depressed mood,
along with the most intransigent forms of depression,
70
such as melancholia and major depression with psy-
chotic symptoms.
It cannot be excluded that the local tradition in Viet-
nam is to diagnose depression only for very severe de-
pressive states, such as melancholia or major depression
with psychotic symptoms. The numbers of suicide at-
tempters in Vietnam who were diagnosed with schizo-
phrenia and other severe psychiatric disorders in the
present study appear to tally well with the results ob-
tained in our previous study of suicide attempters from
Sweden [24].
Alcoholism and alcohol addiction, which are com-
monly found in western studies among both males and
females who attempt or commit suicide [26, 27], were
very rare in our material from Vietnam. This probably
mirrors cultural patterns: attempting to escape conflicts
and stressful situations by resorting to alcohol is less
common there than in the West.
Western studies point to the conclusion that psychi-
atric disorders are preconditions for attempted suicide
and suicide. However, studies of completed suicides
from China [21], India [28], Malaysia [29] and Sri Lanka
[30, 31] show that a substantial number of persons who
committed suicide were not suffering from any psychi-
atric disorder at the time. This undoubtedly applies to
suicide attempters in Vietnam as well. One main reason
for the low prevalence of psychiatric disorders among
suicide attempters might well be differences in help-
seeking behaviour, acceptance of psychiatric hospitals,
stigma of mental disorders, reluctance to give mental di-
agnosis to a young person.
It seems that suicidal acts in Asian countries are more
often due to severe stress from acute life events, such as
family or other conflicts. Psychosocial conditions may
be a crucial cause of attempted suicide, regardless of
whether the suicide attempter has an underlying psy-
chiatric illness, and seem to be more important predic-
tors of suicidal behaviour than psychiatric disorders.
More investigation of a qualitative nature is needed
to elucidate the complex relationship between psy-
chosocial stress factors and mental ill-health in suicidal
behaviour, and the culturally embedded problems
linked to individual and family perceptions. Further
field studies by our group, both on a population and a
hospital basis, are currently under way in Vietnam.
■ Cry for help
The majority of suicide attempts took place between 9
a. m. and midnight, i. e. during the part of the day when
people’s chances of being alone are relatively small.
From previous studies [27, 32], it is known that the sui-
cide attempters are consciously or unconsciously seek-
ing attention and help. The same seems to apply to the
Vietnamese suicide attempters. Whether they had com-
municated their suicidal intent previously is unknown
from this study, but deserves further research since
recognition of suicidal communication is a key preven-
tive measure [2]. In our study, the numbers of attempted
suicides were low in January and February. This coin-
cides with the Tet Festival – the Vietnamese New Year
celebration that, according to the lunar calendar, is al-
ways in January or February. The fact that national
events like Ramadan, which consolidate family and so-
cial ties, can reduce rates of attempted suicide has been
reported, and can be utilised in suicide prevention [33].
Conclusion
■ Suicide prevention
Based on the present study, some preventive action in
Vietnam can already be applied.
The results of our study show the key role of psy-
chosocial stressors as a cause of attempted suicide in
Vietnam. There are no strong religious or legal prohibi-
tions against suicidal behaviour in Vietnam. People, es-
pecially young ones experiencing acute stressors who do
not have underlying mental disorders and who receive
limited social support, may attempt suicide impulsively
in a permissive environment. Therefore, testing of cer-
tain preventive strategies seems not only appropriate,
but necessary, if life is to be saved. These strategies in-
volve enhancing public awareness of the importance of
recognising suicidal communication and distress in
young people. They also involve trying to teach children
and school pupils how to solve mental problems arising
from life stressors, such as family conflicts, etc.
In this work, the WHO resources for teachers regard-
ing how to prevent suicidal behaviour, an ultimate con-
sequence of mental ill-health, could be useful [16, 17].
The other usable population-oriented measure would be
reducing access to pesticides by, for example, raising
public awareness of the need to keep these potent poi-
sons under lock and key or available only to authorised
persons.
■ Acknowledgements Thanks are due to the National Swedish Cen-
tre for Suicide Research and Prevention of Mental Ill-Health (NASP)
and the Department of Public Health Sciences, Karolinska Institutet,
both in Stockholm, Sweden. These two Swedish institutions, in co-op-
eration with the Hanoi Medical School, are developing a national pro-
gramme of suicide prevention for Vietnam.
This study was funded by the Swedish International Development
Cooperation Agency (Sida) within the programme of collaboration
between Hanoi Medical University and Karolinska Institutet.
References
1. WHO World Health Report 2001 (2001) Geneva: WHO
2. Wasserman D (ed) (2001) Suicide: an Unnecessary Death. Lon-
don: Martin Dunitz
3. WHO World Report on Violence and Health (2002) Geneva:
WHO
4. Ministry of Health (2000) Yearbook of Health Statistics. Hanoi:
Medical Publishing House (in Vietnamese)
5. Adityanjee DR (1986) Suicide attempts and suicides in India:
cross-cultural aspects. Int J Soc Psychiatry 32:64–73

6. Chiu LP (1989) Attempted suicide in Hong Kong. Acta Psychiatr
Scand 79:425–430
7. Pan PC, Lieh-Mak F (1989) A comparison between male and fe-
male parasuicides in Hong Kong. Soc Psychiatry Psychiatr Epi-
demiol 24:253–257
8. Wai BH, Hong C, Heok KE (1999) Suicidal behavior among
young people in Singapore. Gen Hosp Psychiatry 21:128–133
9. Retterstøl N, Mehlum L (2001) Attempted suicide as a risk factor
for suicide: treatment and flow-up. In: Wasserman D ed. Suicide:
an Unnecessary Death. London: Martin Dunitz, pp 125–132
10. Schmidtke A, Bille-Brahe U, et al. (1996) Attempted suicide in Eu-
rope: rates, trends and sociodemographic characteristics of sui-
cide attempters during the period 1989–1992. Results of the
WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatr
Scand 93:327–338
11. Hjelmeland H, Nordvik H, et al. (2000) A cross-cultural study of
suicide intent in parasuicide patients. Suicide Life Threat Behav
30:295–303
12. Beautrais AL (2001) Suicides and serious suicide attempts: two
populations or one? Psychol Med 31:837–845
13. Beck AT, Beck R, Kovacs M (1975) Classification of suicidal be-
haviors: I. Quantifying intent and medical lethality. Am J Psychi-
atry 132:285–287
14. Ramberg IL, Wasserman D (2000) Prevalence of reported suici-
dal behaviour in the general population and mental health-care
staff. Psychol Med 30:1189–1196
15. Beautrais AL, Joyce PR, Mulder RT (1998) Unemployment and
serious suicide attempts. Psychol Med 28:209–218
16. WHO (2000) Department of Mental Health. Preventing suicide:
a resource for teachers and other school staff. Geneva: WHO
17. Wasserman D, Narboni V (2001) Guidelines for suicide preven-
tion in schools. National Centre for Suicide Research and Pre-
vention of Mental Ill-Health. Stockholm, pp 1–95
18. Ostamo A, Lönnqvist J (2001) Attempted suicide rates and trends
during a period of severe economic recession in Helsinki,
1989–1997. Soc Psychiatry Psychiatr Epidemiol 36:354–360
19. Pirkola S, Isometsa E, Heikkinen M, Lonnqvist J (1997) Employ-
ment status influences the weekly patterns of suicide among al-
cohol misusers. Alcohol Clin Exp Res 21:1704–1706
71
20. Garnefski N, Arends E (1998) Sexual abuse and adolescent mal-
adjustment: differences between male and female victims. J Ado-
lesc 21:99–107
21. Phillips MR, Yang G, Zhang Y, Wang L, Ji H, Zhou M (2002) Risk
factors for suicide in China: a national case-control psychologi-
cal autopsy study. Lancet 360:1728–1736
23. Leenaars A (2001) Controlling the environment to prevent sui-
cide. In: Wasserman D (ed) Suicide: an Unnecessary Death. Lon-
don: Martin Dunitz, pp 259–264
24. Persson ML, Runeson BS, Wasserman D (1999) Diagnoses, psy-
chosocial stressors and adaptive functioning in attempted sui-
cide. Ann Clin Psychiatry 11:119–128
25. Üstün TB, Kessler RC (2002) Global burden of depressive disor-
ders: the issue of duration. Br J Psychiatry 181:181–183
26. Nielsen AS, Bille-Brahe U, Hjelmeland H, Jensen B, Ostamo A, Sa-
lander-Renberg E, Wasserman D (1996) Alcohol problems
among suicide attempters in the Nordic countries. Crisis 17:
157–166
27. Wasserman D,Varnik A (1998) Suicide-preventive effects of per-
estroika in the former USSR: the role of alcohol restriction. Acta
Psychiatr Scand 394(Suppl):1–4
28. Vijayakumar L, Rajkumar S (1999) Are risk factors for suicide
universal? A case-control study in India. Acta Psychiatr Scand
99:407–411
29. Teoh J (1974) An analysis of completed suicide by psychological
post-mortem. Ann Acad Med Singapore 3:117–123
30. de Silva HJ, Kasturiaratchi N, Seneviratne SL, et al. (2002) Suicide
in Sri Lanka: points to ponder. Ceylon Med J 45:17–24
31. Eddleston M, Sheriff MH, Hawton K (1998) Deliberate self harm
in Sri Lanka: an overlooked tragedy in the developing world.BMJ
317:133–135
32. Wasserman D (1989) Passive euthanasia in response to at-
tempted suicide: one form of aggressiveness by relatives. Acta
Psychiatr Scand 79:460–467
33. Daradkeh TK (1992) Parasuicide during Ramadan in Jordan.
Acta Psychiatr Scand 86:253–254