International Review of Psychiatry

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Suicide in Asia

K.C. Wei & H. C. Chua

To cite this article: K.C. Wei & H. C. Chua (2008) Suicide in Asia, International Review of
Psychiatry, 20:5, 434-440, DOI: 10.1080/09540260802397446
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International Review of Psychiatry, October 2008; 20(5): 434–440

Suicide in Asia

K. C. WEI & H. C. CHUA

Department of General Psychiatry, Institute of Mental Health, Woodbridge Hospital, Singapore

Abstract
Suicide is a major problem worldwide, and suicides in Asian countries account for as much as 60% of all suicides in the
world. There are many unique features in suicides within this ethnically-diverse continent, from the methods used, to the
putative risk factors. Much research still needs to be done to guide efficacious and culturally relevant interventions in suicide
prevention; existing literature suggests a strong focus for programmes that address restricting access to pesticides, increasing
crisis counseling activities, improving the accessibility and delivery of mental health services, and promoting responsible
media reporting of suicide and related issues. There is a need for coordinated national suicide plans to be developed that are
sensitive to the socioeconomic and cultural factors in the local context.

Introduction go unreported due to the great social stigma of

The World Health Organization (WHO) estimates
that 873,000 people worldwide die by suicide each
year. This represents 1.4% of the global burden of
diseases (WHO, 2006). Asian countries are major
contributors, accounting for approximately 60% of
all suicides in the world. In absolute numbers, given
the size of their populations, suicides in the two
most-populated Asian countries of China and India
already make up 30% of the suicides in the world.
The number of suicides in China alone is 30%
greater than the total number of suicides in the whole
of Europe (Bertolote & Fleischmann, 2002).
Despite the large numbers seen above, the
magnitude of the problem in Asia is likely much
larger than it appears from the reported figures.
Many Asian countries do not report suicide data to
WHO (Vijayakumar, 2005), which has also noted
that some countries in the WHO-designated Western
Pacific Region (which includes most Asian nations)
do not even maintain accurate mortality data, less so
with regards to suicide. In some places, the only
existing data are those produced by the local police;
in others data exist based on just emergency ward
records or on psychiatric/general hospital records.
For the countries that regularly report suicide rates,
their accuracy may be in doubt due to variable
registration systems or population estimates. Other
legal, social and religious factors unique to the
Western Pacific Region may lead to further under-
estimation of numbers. For example, suicides often
diagnosed mental illness and suicide on the family
for many Asian societies. In addition, suicide and
attempted suicide are still considered criminal acts in
some Asian countries. In India, for these reasons,
there have been reports of suicide cases being
preferentially sent to private hospitals, that neither
record such cases as suicide nor report them to the
police, instead diagnosing them as ‘accidental’
(Khan, 2002).
Suicide rates and trends in Asia
With these limitations in the accuracy of suicide data
in mind, there is nonetheless a huge variation in the
reported suicide rates amongst Asian countries.
A few Asian nations rank amongst the highest in
the world, such as Japan (24 per 100, 000 per year
per 100,000 head of population), South Korea (23.8
per 100, 000 per year per 100,000 head of popula-
tion) and Sri Lanka (21.6 per 100, 000 per year
per 100,000 head of population); while others, such
as the Philippines, had rates as low as 2.1 per
100,000 per year (WHO, 2008). There has been an
increase in the suicide rates for many countries over
the last decade, with the steepest rises seen in the
nations with highly developed economies such as
Japan, South Korea, Hong Kong.
South Korea, in particular, saw the increase of its
suicide rate from only 10.6 per 100,000 in 1995 to
23.8 per 100,000 in 2004. In the last decade, South
Korea has seen a period of rapid acceleration in
globalization of the country, with the evolution from

Correspondence: K. C. Wei, MBBS, MMED(Psychiatry), Department of General Psychiatry, Institute of Mental Health, Woodbridge Hospital, 10 Buangkok
View, Singapore 539747. Tel: 63892000. E-mail: ker_chiah_wei@imh.com.sg
ISSN 0954–0261 print/ISSN 1369–1627 online ß 2008 Informa Healthcare USA, Inc.
DOI: 10.1080/09540260802397446

traditional and collective moral values to an individ-
ualistic and materialistic culture. It has been argued
that this led to decreased social integration and
increased incidence of social problems, such as drug
abuse, crime and divorce; and some researchers
have, in fact, correlated the rising suicide rates in
the country with measures of social integration/
regulation (Ben Park & Lester, 2006).
Hong Kong, similarly, witnessed a steep rise of
suicides in the past 10 years following the transition
from British rule in 1997. The increase of its suicide
rates, from 11.8 per 100,000 in 1995 to 18.6 per
100,000 in 2004, had paralleled the post-1997
economic downturn, during which unemployment
had reached a historic high of 8.3% in 2003. It is
significant that the unemployed are overrepresented
among those who committed suicide – about 48% of
the 25–59-year age group (HKSAR Government,
2002). The rise in suicides is especially prevalent in
this economically active middle-aged group, many of
whom were plunged into debt in the years following
the Asian financial crisis (Chan, Yip, Au & Lee,
2005). It has also been put forward that the increase
in suicide rates has been contributed to by
a continual decline of family support and
a disintegration of the family structure in Hong
Kong (Yip, Chi & Yu, 1998), which had witnessed
a doubling of its divorce rates from 1991 to 2001
(Census and Statistics Department, 2002). It can be
argued that in a family-centric Asian society com-
pared to some other societies which place a lower
value on collectivism, intact marriages and families
play a crucial role in social integration. They are
therefore very important protective factors against
suicide (Laidler, 1998).
The methods of suicide
The methods of suicide commonly employed in any
country are strongly influenced by its general
availability (Gunnell, Middleton & Frankel, 2000).
Therefore it is of no surprise that in Asia, two highly
accessible means of suicide, by ingestion of pesticides
in rural areas, and jumping from heights in more
urbanized cities, predominate. In China, 62%
of suicide deaths were due to the ingestion of
agricultural chemicals or rat poison, mostly stored
in the home (Phillips et al., 2002). 89% of the pesti-
cide deaths occurred in rural farming households.
In Sri Lanka, which saw its suicide rate increase by
over 700% since the 1960s, found that the increase
was almost entirely due to the rise in fatal self-
poisoning with pesticides, as the incidence of all
other methods has remained stable (Eddleston,
Ariaratnam & Meyer, 1999). The rise of suicides in
the country coincided simply with the introduction of
Suicide in Asia 435
pesticides into everyday use during the agricultural
revolution (Eddleston & Phillips, 2004).
Jumping from tall buildings is common in indus-
trialized cities, accounting for almost half of suicides
in Hong Kong (Yip & Tan, 1998), and more than
three-quarters of suicides in Singapore (Loh et al.,
2007). The high proportion of suicides from jumping
from heights in Singapore is not unexpected,
given that over 90% of its population live in high-
rise buildings which have open walkways with no
restriction of access even for non-residents. The
frequent portrayal of suicides by jumping in local
television dramas probably also played a role in the
predominance of this method in the small island city
(Loh et al., 2007).
Another prominent example of how the media has
influenced both the method and number of suicides
in a country (Hawton & Williams, 2002), is that of
charcoal burning in Hong Kong (Lee, Chan, Lee &
Yip, 2002). In 1998, a single suicide by this method
was reported dramatically and extensively by the
local media. Within 2 months, it had become the
third most common method of suicide (Chan, Lee &
Yip, 2003). By three years later in 2001, it accounted
for 28% of all suicides in Hong Kong, replacing the
traditional hanging as the second most commonly
used suicide method (Yip, Law & Law 2003). What
was more alarming was that the period during which
charcoal burning became prevalent was also asso-
ciated with a steep rise in suicide rates, implying that
an additional population was dying from suicide due
to this novel method.
A similar trend regarding the use of hydrogen
sulphide gas as a means of suicide seems to be
emerging in Japan (The Economist, 2008). Although
official data are not available, it is estimated to be
responsible for more than 50 deaths by suicide in the
country from January to April 2008 (Alford, 2008).
What is worrying is that this method involves the risk
of harm to bystanders, and there has been heightened
media coverage due to the many buildings that were
evacuated due to its use. It is also highly publicized
over the Internet, with many online sites that
function as suicide bulletin boards promoting hydro-
gen sulphide as a quicker, less complicated method
of ending it all.
It is important to highlight the role cultural and
religious factors may play in influencing the means
and even the prevalence of suicide in any society.
It is debatable whether the higher suicide rates
in Japan are contributed by its popular history
which celebrates suicide as an act of selfless
devotion (McCurry, 2006). An example is the
influence of the traditional practice of hari-kiri, an
honourable way of killing oneself as a demonstration
of loyalty, indignation or atonement. These can lead
to a social psyche with a low resistance of suicide as
436 K. C. Wei & H. C. Chua
a way out to address personal crisis. In India, self-
immolation was culturally sanctioned in the practice
of ‘suttee’, when widows would set fire themselves
after their husbands died (Lester, Kavitha & Mangai,
1999). This has led to the use of this method in about
10% of suicides in the country, despite it being one
of the most painful ways to die.
The protective effect of some religions, especially
Islam, against suicide is well-documented (Conklin
& Simpson, 1987). Countries with large Muslim
populations generally have low suicide rates. And
even in the cosmopolitan city of Singapore, when
comparing the suicide rates of the 3 main races of
Chinese, Malays and Indians, the lowest suicide rates
were found in the Malays, who are predominantly
Muslims (Kua & Ko, 1992; Loh et al., 2007). This
can largely be explained by the strong sanctions
against suicide posed by the Islamic religion (Lester,
2000), which views it as a form of homicide, as well
as its prohibition against alcohol, the use of which is
a known risk factor for suicide. In addition, Muslims
are commonly taught a problem-solving method by
reciting certain Quranic verses in times of acute
stress, thereby reducing impulsive suicidal acts.
Risk factors in Asia
Of the published reports in the last 4 decades
studying specifically the psychiatric diagnoses of
people who die by suicide, strikingly more than
80% came from Europe and North America, and
merely 1.3% originated from developing countries
(Bertolote, Fleishmann, de Leo & Wasserman,
2003). In Asia, the number of psychological autopsy
case-control studies, which provide more accurate
and comprehensive data on risk factors, is especially
small. The limited number of such investigations that
have been carried out, mainly in China (Phillips
et al., 2002), Hong Kong (Chiu et al., 2004), Taiwan
(Cheng, Chen, Chen & Jenkins, 1995), and India
(Vijayakumar & Rajkumar, 1999), reflect a strong
association between suicide and mental illness,
especially for the conditions of schizophrenia, alco-
holism and mood disorders. The data obtained from
these studies is comparable to those in the west, with
the exception of China, in which a relatively lower
63% of suicides had diagnosable psychiatric dis-
orders (Phillips et al., 2002).
For schizophrenia, data from Taiwan, India and
China have shown that between 6% and 8% of
people who committed suicide had suffered from this
disorder, far higher than the actual prevalence of the
condition in the population (Vijayakumar, 2005).
In a Singapore case-control study of suicide in
psychiatric patients, psychotic symptoms in the
form of auditory hallucinations and delusions were
associated with significantly increased risk of suicide
(Thong, Su, Chan & Chia, 2008). Alcohol abuse or
dependence was present in 44% and 34% of suicide
completers in Taiwan (Cheng et al., 1995) and India
(Vijayakumar & Rajkumar, 1999) respectively. What
is worthy of note is that the risk of suicide appears to
decrease with age for those suffering from schizo-
phrenia, with one Taiwanese study revealing 85% of
patients with schizophrenia who had killed them-
selves were below the age of 30 when they died (Hu
et al., 1991). In contrast, suicide rates were low in the
early years of alcohol abuse or dependence, but peak
during middle-age, when the social disintegrative
effects of the alcohol habit on marital, family and
social relationships become prominent. Other con-
sequences such as unemployment and physical
illness during this time also increase the individual’s
vulnerability to suicidal behaviour.
The link between depression and suicide appears
more tenuous in China as well as India. In the
national case-control psychological autopsy study
(Phillips et al., 2002) in China, the number of
suicides linked to depression is only 40%, relatively
low compared with many other countries, where the
association with depression can be as high as 88%
(Lonnqvist, 2000). Similarly in India, mood dis-
orders including major depressive disorder were
found only in 25% who had committed suicide
(Vijayakumar & Rajkumar, 1999).
What stood out more in the studies within these
two most populated countries was the role acute life
stressors play in precipitating suicide. In China,
negative life-events and acute depressive symptoms
(of less than two weeks duration) were found to be
more significantly linked to suicide than the presence
of a mental disorder (Phillips et al., 2002). In the
Chennai study (Vijayakumar & Rajkumar, 1999),
more than 60% of those that have committed suicide
had only brief and mild-to-moderate depressive
symptoms, likely as a result of acute psychosocial
stressors. Marital problems and other family difficul-
ties were identified as significant proximal causes to
suicide in the case-control studies in China (Phillips
et al., 2002), Taiwan (Cheng et al., 1995) and India
(Vijayakumar & Rajkumar, 1999). Job loss and major
financial setbacks, such as bankruptcy, have also
often been cited as important precursors. This was
evident in the study by Phillips, where 40% of
suicides were linked to preceding financial problems.
Suicides following financial losses have similarly
been highlighted in some descriptive studies. An
example is a recent spate of suicides reported in
Southern India, which was directly attributed to the
losses incurred from the failure of cotton crops
(Stone, 2002).
Interestingly, investigations in India (Ponnudurai
& Jeyakar, 1980) and Pakistan (Khan & Reza, 2000)
have highlighted the increased incidence of suicide in

married compared to single or divorced women,
contrary to the expectation that being married is
a protective factor. Specific factors that are associated
with suicide and more unique to marriage in this part
of the world are early marriage and motherhood, lack
of autonomy in choosing a marital partner, and
economic dependence on the husband. Among
married women who engage in suicidal behaviour,
marital and family conflict, especially with in-laws, is
a major predisposing factor (Khan & Reza, 1998).
The problem of domestic violence against women is
also widespread (Firkree & Bhatti, 1999). It can be
argued that being married is associated with a greater
number of life stressors on women in a more
chauvinistic Asian society such as in India, acting
as precipitants towards suicidal acts.
The enormous stressors faced by Asian women,
contributed by their lower social status in the family
and perceived lack of control over their own lives,
could also partly account for the relatively higher
rates of women suicides in Asia. This is evident in the
narrower male-to-female ratio of suicides seen in
many Asian countries (Yip, Callanan & Yuen, 2000),
as compared to the 3:1 or 4:1 ratio that is consistently
reported in the west. For example, in Pakistan, the
male to female ratio is placed at 2:1, while even in
urban Singapore this ratio is of the order of about 1.5
male suicides to every female suicide (Parker & Yap,
2001; Loh et al., 2007). India is noted for its near-
equal rates between men and women (Mayer &
Ziaian, 2002). For China, the gender ratio is even
reversed, with the suicide rate higher in women than
men, especially in the rural areas. Another possible
explanation for the relatively high suicide rates in
women in rural China is the predominant use
of highly lethal pesticides and rat poison as a means
of self-harm. Women tend to have higher rates of
attempting suicide, but the easy availability and
widespread use of highly lethal methods implies
a much higher fatality rate (Yip & Liu, 2006).
The relationship between socioeconomic status
and suicide is usually examined through proxy
measures. Low income and unemployment has
been established as a major contributing risk factor
for suicides in many Asian countries (Gururaj, Issac,
Subbakrishna & Ranjani, 2004; Yamasaki, Sakai &
Shirakawa, 2005; Loh et al., 2007). This is not
surprising considering the value placed on work and
financial ability in most Asian societies. Many urban
Asian cities such as Hong Kong and Singapore have
seen their suicide rates increase or fall in tandem with
their employment rates and state of their economies.
In Japan, the strong work ethic and emphasis on
occupational loyalty and performance has tragically
led to the rise of the phenomenom called ‘karoji-
satsu’, which are occupation-related suicides asso-
ciated with long working hours and heavy workloads
Suicide in Asia 437
(Takashi, Takeo & Yoshitomo, 2005). Suicides
associated with gambling debts are also common,
especially in China or other countries with a large
Chinese population, where gambling has long been
a major social problem (Phillips, Liu & Zhang,
1999).
The presence of co-morbid medical conditions is
well-known to be associated with increased suicidal
risk. This is similarly noted among suicide studies
from Asia (Cheng et al., 1995; Phillips et al., 2002;
Thong et al., 2008). The associated physical
illnesses are generally chronic, debilitating, deterio-
rating, painful and stigmatizing; such as HIV or
AIDS, cancers and chronic renal failure (Harris &
Barraclough, 1994). Interestingly, in the
Singaporean study of suicide in psychiatric patients,
many of those who have died from suicide had
physical illnesses that were not given definite formal
diagnoses, but instead were recorded as complaining
of distressing pain or weakness (Thong et al., 2008).
In China, the psychological case-control study by
Phillips placed the presence of physical illness within
the context of its effects on family members in the
month before death. The odds ratio for death by
suicide for someone who has medical illnesses
with ‘mild effect’ on the family compared
to ‘moderate to severe effect’ on the family is
3.2 versus 10.8 respectively (Phillips et al., 2002).
Suicide prevention
Suicide prevention was set as a priority by the World
Health Organization (WHO) in 2000, with over 60
countries lobbying for this. It requires a multi-faceted
approach with universal, selective, and indicated
interventions, covering a broad range of risk factors.
Measures are also more effective if they are coordi-
nated nationally, and the United Nations has
recommended that each country should have
a designated body set up to oversee suicide preven-
tion efforts (United Nations, 1996). However, there
are many difficulties in getting the necessary
resources to coordinate such suicide prevention
initiatives in developing countries, where mental
health has a lower priority and competes with
resources for other conditions. Even for the more
developed nations in Asia, national committees
developing comprehensive suicide prevention plans
and national strategies are rarities.
Japan, with one of the world’s highest suicide rates,
belongs to the few Asian countries with government-
supported nation-wide initiatives. In 2000, the
Japanese Government declared its goal to reduce
the annual incidence of suicide by 30% until 2010.
A National Committee was set up which published
proposals for suicide prevention in 2002, emphasiz-
ing the importance of pre-intervention (assessment of
438 K. C. Wei & H. C. Chua
factors affecting suicide), intervention (identification
of high-risk persons to prevent suicide) and post-
intervention (social support for bereaved family and
friends) (Nakao & Takeuchi, 2006). Japan’s failure to
tackle untreated depression was identified as the
most important factor behind the country’s high
suicide rate (McCurry, 2006), and measures were
mainly targeted at this area. Guidelines for managing
depression were published both for healthcare
professionals and for public servants, recommending
screening tests nationwide. In Singapore the high
suicide rate in the elderly was of great concern in the
1990s. As a result there was a national effort to
examine the problems of the aged population, and an
inter-ministerial committee with representatives from
the Ministry of Health, Community Development,
Labour and National Development was formed. It
spearheaded several initiatives between different
agencies to improve the healthcare and social services
catering to the elderly. These include a programme
for training healthcare providers for early detection
and management of the elderly with depression,
building a network of day centres, homes and respite
care, a telephone helpline for the elderly, as well as
befriending and home-help services. These efforts
contributed to the suicide rates for elderly persons
(65 years and over) more than halving over 5 years
from 42.4 per 100,000 in 1995 to 17.8 per 100,000
in 2000 (Kua, Ko & Ng, 2003).
The prominent role acute stressors play in suicides
in this region emphasizes the importance of preven-
tion strategies based on increasing the accessibility of
counselling services and improving coping skills in
at-risk personnel. In Japan there is a coordinated
effort to expand counselling services to schools and
businesses, coordinated by the National Centre of
Neurology and Psychiatry in Tokyo (McCurry,
2006). In other countries non-government organiza-
tions (NGOs) have emerged to cover the large gap in
such services, setting up crisis centres with encourag-
ing results (Ratnayeke, 1996). Examples are the
Sumithrayo Befrienders in Sri Lanka and Sneha in
India. As these NGOs are often the sole suicide
prevention agency in their countries their roles often
extend beyond crisis intervention to education and
intervention programmes. An example of such
a programme was carried out by Sumithrayao, in
which scheduled weekly visits to at-risk personnel
and volunteer-initiated community projects have
resulted in a sharp decline in attempted as well as
completed suicide rates in the intervention village
(Marecek & Ratnayeke, 2001).
Limiting access to means is an approach to suicide
prevention that is one of the strongest evidences for
efficacy in suicide prevention (Gunnel & Frankel,
1994). This can be as simple as introducing more
automatic barriers on subway platforms to deter
‘jumpers’, as has been done in Singapore and Japan
(McCurry, 2006). WHO’s report has made recom-
mendations for restricting access to pesticides (Krug,
Dahlberg, Mercy, Zwi & Lozano, 2002), but the
recommended regulations exclude farmers, making
the policy ineffective in the developing world,
especially Asia, where 80% of households farm the
land. Improving pesticide regulations should expand
to include deregistering the highly toxic and only
allowing the use of safer pesticides, adding emetics or
stanching agents to pesticides wherever possible,
educating the public about the proper handling,
storage, and use of pesticides, or even providing
lockers for storing pesticides away from houses so
that they are not close at hand for people facing crisis
situations. Improving medical management of self-
poisoning would also reduce suicide rates signifi-
cantly for the cases of pesticide ingestion. In Sri
Lanka, 12% of patients who had ingested pesticides
required intubation (Eddleston & Phillips, 2004);
and many died from aspiration or respiratory failure
because medical staff in small, rural hospitals do not
have the equipment or skills to intubate or ventilators
to support them. The lack of essential antidotes such
as atropine and specific antitoxins (e.g. for yellow
oleander poisoning in Sri Lanka) (Eddleston,
Senarathna, Mohamed, Buckley & Jubzczak, 2003)
in some rural medical facilities also meant many had
to be transferred to other hospitals, with some deaths
occurring during transfer.
An important but difficult area of suicide preven-
tion is in addressing the role of the media reporting
suicides. This can be done through setting guidelines
for responsible media reporting, and many health
authorities, such as WHO (2000) as well as the
Centre for Disease Control and Prevention (1994),
have made such recommendations for journalists. It
is generally put forward that the media should not
normalize, idealize or sensationalize suicide stories,
but rather to encourage people to seek help when
needed (Pearson, 2003). However, such voluntary
guidelines are often pushed to the side and it is an
uphill task to change journalistic customs. In Hong
Kong newspapers, it was found that the method
and style of presenting suicide news generally
contravenes such guidelines, with 6.2% of suicides
reported in newspapers found on the front page and
the majority of reports presented pictorially and in
a sensational manner (Au, Yip, Chan & Law, 2004).
The authors have recommended that a more useful
strategy would be forming a partnership with active
participation from the media on suicide prevention
so that they could take a more balanced and
responsible approach in reporting. This would
include engaging the media to provide information
on help services, alternatives to suicides and inspiring

stories on those who encountered problems and
overcame them.
Conclusion
The effectiveness of prevention activities in reducing
suicide mortality has been the subject of many
literature reviews, but they clearly show that scien-
tifically sound evaluations of such activities are scarce
(De Leo, 2002). This is especially so for Asia, where
relatively little research work has been done to guide
efficacious and culturally relevant interventions for
suicide prevention, despite the majority of the
world’s suicide occurring in this continent. From
limited data available, this review has attempted to
bring into sharper focus the similarities as well as
differences in suicides between Asian countries and
other nations, from the methods used, to the putative
risk factors. It suggests a strong focus for prevention
programmes that address restricting access to pesti-
cides, increasing crisis counselling activities, improv-
ing the accessibility and delivery of mental health
services, and promoting responsible media reporting
of suicide and related issues. As in the rest of the
world, there is a need to put in place coordinated
national suicide prevention plans that emphasize
collaboration between multiple agencies, and are
sensitive to the socioeconomic and cultural factors in
the local context.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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