Office and the data of the National Health Interview ... This data is based on the population mortality sta- ..... tries
SPECIAL ARTICLES
Epidemiology of Suicide in Korea Jin Pyo Hong, M.D.,1 Myeng Ji Bae, M.D.,1 Tongwoo Suh, M.D., DrPH.2 Department of Psychiatry, University of Ulsan College of Medicine, Asan Medical Center, 2Korea Institute of Health and Social Affairs, Seoul, Korea
1
Key words: Suicide, Epidemiology, Suicidal attempt.
Abstract
[ Psychiatry Invest 2006; 3 (2):7-14]
In 2002, an estimated 877,000 lives were lost worldwide through suicide. In Korea, suicidal deaths have increased very rapidly since the economic crisis in
Introduction
1997, and suicide is regarded as one of the most serious public health and social issues in Korea. This study
Suicide is not only the primary emergency for the
examines the current situation and trends of the recent-
mental health professional, but also a major public
ly increasing rates of suicidal deaths, ideas, and
health problem in the world. Suicide's history goes
attempts in Korea.
back at least to the earliest human written records
This study reanalyzed the 20-year statistics of suici-
(e.g., Socrates, Seneca). The traditional or legal
dal deaths recently published by the National Statistical
definition of suicide was first given clarity by
Office and the data of the National Health Interview
Emile Durkeim, who defined suicide as "a death
Survey conducted in 1995 and 1998.
resulting directly or indirectly from a positive or negative act of the victim himself, which he knows
The suicidal mortality rate in Korea is quite high
will produce that result".1
compared to those in other OECD countries and the rate of increase is the highest. The rate of suicidal idea
In 2002, an estimated 877,000 lives were lost
is high among males, those in their late teens and those
worldwide through suicide, representing 1.5% of
in their seventies. The suicidal attempt rate is higher
the global burden of disease or more than 20 mil-
among females and those in their late teens.
lion disability-adjusted life-years (years of healthy
Suicide, one of the important causes of death in the
life lost through premature death or disability).2
younger age group, has a greater socioeconomic impact
The global mortality rate is estimated to be 16 per
than other common causes of death in the older age
100,000; One death every 40 seconds. The WHO
group. Therefore, we are in urgent need of a public men-
further reports that in the last 45 years worldwide
tal health network to prevent suicide and to detect and
suicide rates have increased by 60%.3 Suicide is
treat early mental health problems leading to suicide.
now among the three leading causes of death among those aged 15-44 (both sexes). 4 Suicidal behavior has multiple causes that are broadly
Correspondence: Jin Pyo Hong, M.D., Department of Psychiatry, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Poongnap-dong, Songpa-gu, Seoul, Korea (138-736) Tel: +82-2-3010-3421, Fax: +82-2-485-8381, E-mail:
[email protected]
divided into predisposition, proximal stressors or triggers.5 Psychiatric illness is a major contributing factor, and more than 90% of those who commit suicide have a Diagnostic and Statistical Manual of
7
Suicide epidemiology
Methods
Mental Disorders, Fourth Edition (DSM-IV) psychiatric illness. 6-8 Suicide results from various complex sociocultural factors and is more likely to
This data is based on the population mortality sta-
occur during periods of socioeconomic, family and
tistics and death certificates registered between 1990
individual crisis (e.g. loss of a loved one, employ-
and 2004 provided by the Korean National Statistical
ment or honor).
Office. The prevalence of suicidal idea and attempts
Suicide attempts are up to 20 times more fre-
were derived from the National Health Interview
quent than completed suicides. Although suicide
Surveys conducted in 1995 and 1999 by the
rates have traditionally been the highest among
Department of Health and Welfare and the Korea
elderly males, suicide rates among young people
Institute for Health and Social Affairs. The present
have been increasing to such an extent that they are
study presents the gender- and age-specific suicide
now the group at highest risk in one third of all
rates, the average annual rates of suicide per 100,000
countries.
population, and the rates of suicidal ideas and attempts.
In Korea, the rapid increase in the suicidal rate in recent years has meant that suicide has become a
Results
serious public health and social problem. Epidemiological reviews of suicide rates are valu-
Serial changes of suicide rates (1990-2002)
able for the delineation of trends, the prioritization of risk groups and the provision of clues to its eti-
The suicide mortality rate in Korea did not show
ology. The objective of this paper is to review the
any evident changes until the early 1990s. However,
current situation and trends of the recently increas-
after 1997, the year of the IMF crisis in Korea, there
ing suicidal deaths, ideas and attempts in Korea.
was a sharp increase, followed by a drop in the rate
FIGURE 1. Suicidal rates (per 100,000) in Korea, 1989-2004.
8
Hong JP et al.
of increase which has continued ever since. In 1998,
not account for the increments can also be noted by
the number of suicide mortalities was 8,569, which
examining the cases of suicide mortality in China,
is a 42.4% increment compared to the 6,022 suicide
where suicide ranks fifth (287,000 cases) in terms of
mortalities in 1997. The number of suicide mortali-
the total number of mortalities and over 2 million peo-
ties per 100,000 persons also increased from 13.1
ple attempt suicide despite China’s soaring economic
(1997) to 18.5 (1998). After 2001, the suicide mor-
growth.9 Gender-specific differences are also noticeable. Up to
tality rate increased, reaching 25.2 in 2004, the high-
the mid 90s the difference between the genders
est level recorded so far. The changes in the suicide mortality rates during the
remained at a steady level, but afterwards the differ-
past 20 years suggest that there is an overall relation
ence between the genders increased, a shift which can
between the suicide mortality rate and economy cycle.
also be seen in other regions of the world.10
Compared to the 80s and early 90s, however, the suiChanges in suicide mortality among age
cide mortality rate also increased 2-fold during the
groups
early 90s to mid 90s and the years 2000 and 2001, during which Korea enjoyed a good economy. This
Figure 2 reveals the changes in the suicide mortality
implies that reasons other than the economy, such as
rates among the different age groups. Until the 90s, the
increases in divorce and the aging of the population,
rates remained at a steady level, however since the mid
have also contributed. The fact that the economy does
90s mortality rates have rapidly increased. The incre-
FIGURE 2. Changes in suicide mortality rate (/100,000) among age groups between 1983-2001
9
Suicide epidemiology
ment however differed among age groups. Since the
TABLE 1. International suicide rates (per 100,000) and annual increase in OECD nations.
1990s, a sharp increase in the mortality rate was only observed in those over 40, while little change was
Country
1980-1989
1990-2004
Annual Increase (%)
middle-aged and elderly rapidly increased during the
Korea
6.81 (1982)
25.2 (2004)
16.82
early 90s and decreased slightly after the economic
Hungary
39.73 (1982)
28.44 (1995)
-2.54
Finland
22.44 (1982)
24.68 (1995)
0.73
Denmark
26.71 (1982)
18.87 (1993)
-3.11
Switzerland
22.68 (1982)
18.59 (1994)
-1.64
the elderly (over 65) and young (aged 15-24) increased
France
19.11 (1982)
17.53 (1995)
-0.66
from 1.2 (1983) to 4.8 (2001).
Luxemburg
19.50 (1982)
17.13 (1997)
-0.86
observed amongst teenagers. The mortality rates of the
crisis of 1997, only to increase again after 2001. Subsequently, the ratio between the mortality rates of
Czech
19.72 (1986)
17.00 (1993)
-2.10
Comparison of suicidal rates among OECD
Austria
25.08 (1982)
16.92 (1997)
-2.59
nations
Belgium
19.71 (1982)
16.25 (1992)
-1.91
New Zealand
11.90 (1982)
14.54 (1994)
1.68
Japan
17.06 (1982)
14.09 (1994)
-1.58
Poland
11.25 (1989)
13.32 (1996)
2.44
Table 1. Korea ranked 26th among the 28 OECD
Canada
14.10 (1982)
12.56 (1995)
-0.89
nations in terms of the suicide mortality rates in 1982,
Germany
18.76 (1982)
12.32 (1997)
-2.67
but jumped to second place in 2004. Nations that
Sweden
17.38 (1982)
12.26 (1996)
-2.46
ranked high (Hungary, Finland, Denmark, and
Norway
13.51 (1982)
11.84 (1995)
-1.01
Australia
11.74 (1982)
11.50 (1995)
-0.16
7.60 (1982)
11.19 (1995)
3.02
11.86 (1982)
11.07 (1996)
-0.49
9.66 (1982)
10.21 (1995)
0.43
The changes of the suicide mortality rates among the OECD nations including Korea are shown in
Switzerland) revealed decreased or steady rates, in
Ireland
contrast to Korea which shows an annual increase of
USA
16.8%. This rapid increase is the highest among the
Iceland
OECD nations.
The Netherlands
Rates of suicidal ideas and attempts
Suicidal ideas According to the 1998 National Health and Nutrition Survey, one fourth of the Korean population above the
10.31 (1982)
8.70 (1995)
-1.30
Spain
4.80 (1982)
6.91 (1995)
2.84
Italia
6.78 (1982)
6.84 (1993)
0.08
United Kingdom
8.08 (1982)
6.50 (1997)
-1.44
Portugal
8.32 (1982)
5.57 (1996)
-2.83
Mexico
2.21 (1982)
3.78 (1995)
4.22
Greece
3.34 (1982)
2.92 (1996)
-0.96
age of 10 have "thought of attempting suicide during Source: OECD (1999), OECD Health Data 1999
the past 12 months" (Table 2). This survey reveals the
Korea National Statistical Office (1983), Annual statistical report on Causes of death
existence of gender differences with 1 out of 5.2 males and 1 out of 3.3 females reporting a suicidal ideation.
Korea National Statistical Office (2004), Annual statistical report on Causes of death
The is consistent with national statistics that show higher urges and attempts for suicide in females, while males reveal higher suicidal mortality.11
Suicidal attempts
The rate of suicidal idea according to age group
According to the 1998 National Health Nutrition
reveals an "N" shape distribution with those in their late teens and over seventy showing the highest rates.
Survey in Korea, one out of every 100 persons above
Over one third of these two subgroups considered com-
the age of 10 has "attempted suicide during the past 12
mitting suicide during the previous 1 year period.
months". Gender differences are noted, with this figure
10
Hong JP et al.
TABLE 2. One year rate of suicide idea, suicide attempt and suicide mortality according to age and sex in 1998. Suicidal attempt rate (%) Suicidal idea rate (%)
Suicide mortality rate (%)
in the general population
among those with suicidal idea
in the general population
25.0
1.01
4.0
0.022
0.087
2.15
Men
19.1
0.82
4.3
0.032
0.165
3.84
Women
30.4
1.16
3.8
0.012
0.040
1.03
10-14
18.9
1.18
6.3
0.002
0.011
0.17
15-19
37.4
2.00
5.4
0.010
0.026
0.49
20-29
23.4
1.04
4.4
0.018
0.076
1.71
30-39
21.2
1.24
5.9
0.022
0.105
1.79
40-49
23.3
1.06
4.5
0.027
0.117
2.58
50-59
25.0
0.98
3.9
0.030
0.122
3.10
60-69
26.2
0.42
1.6
0.032
0.123
7.63
70-
35.3
0.44
1.3
0.042
0.120
9.57
Total
among those among those with with suicidal idea suicidal attempt
Sex
Age
Source: Korea National Statistical Office (1999), Annual statistical report on Cause of death National Health and Nutrition Interview Survey (1998) reanalysis
including 1 out of 122 persons for males and 1 out of
over fifty manifested a relatively low rate of putting
86 for females.
suicidal thoughts into action.
When analyzed by age group, teenageres show the
The relationship of suicide mortality with suicide
highest rate of suicidal attempts. Those in their late
ideas and attempts
teens (15~19 years old) showed an especially high
As previously mentioned, the suicide mortality rate
rate of attempted suicide, which attained 1 out of 50
of those above the age of 10 in Korea is 0.022%; 22
persons.
out of 100,000. This rate is one of the highest in the
Among those who experienced suicidal ideas,
world. Gender differences are noted with rates of 32
4.0% attempted to take their own lives, while one
out of 100,000 persons for males and 12 out of 100,000
out of 25 persons who thought of committing suicide
for females. The suicide mortality rates increase with
actually carried it out. The rate of actually commit-
age. The suicide mortality rate of those over seventy
ting or attempting suicide among those with suicidal
was 42/100,000.
ideation is slightly higher in males (4.3%) than in
One out of 1,136 who experienced suicidal ideas and
females (3.8%).
one out of 46 who attempted suicide succeeded. In
Those in their early teens revealed the highest rate of
other words, 87 out of 100,000 persons who thought of
suicidal attempts amongst those with such thoughts.
committing suicide attempted to take their lives. and 2
One out of 16 persons who had suicidal ideas actually
out of 87 succeeded.
went on to attempt suicide. On the other hand, those
When analyzed by gender, males who experienced
11
Suicide epidemiology
suicidal idea or attempted suicide showed higher suici-
Comparison of suicidal rate in OECD coun-
dal mortality rates than females; 165 out of 100,000
tries
males who experienced suicidal ideas carried it out
Our data revealed that the suicide rate in Korea is
and, amongst these, 4 actually killed themselves. On
the one of the highest in developed countries. The
the other hand, 40 out of 100,000 females who experi-
highest annual rates are observed in Eastern Europe,
enced suicidal ideas carried it out. and only one of
where 10 countries report more than 27 suicides per
them subsequently died.
100,000 persons. Latin American and Muslim coun-
Generally, the mortality rates of those who attempted
tries report the lowest rates, viz. fewer than 6.5 per
suicide or had suicidal ideas increased with age.
100,000.12 Durkeim argued that "each society has a
Especially, the suicidal mortality rateof early teens
definite attitude toward suicide....characteristic of the
attempters was one out of 588, whereas the correspond-
society under consideration.1 He suggested several
ing rate for over seventies attempters was one out of 10.
factors which could be considered to play a role in
That is to say, the suicide attempt rate in adolescents
determining suicide rates; climate, latitude and sun-
is higher than that in the elderly, but elderly people
shine, contagion, religion and education, social sup-
who attempt suicide show a higher suicide mortality
port by family and political society, genetic buffer-
rate than adolescents. These trends are also seen in
ing, economics, migration, and depression.13 While a
other countries.
WHO working group14 and others15 have expressed
Discussion
confidence in the use of international suicide statis-
The rise of the suicidal rate
not be ignored. In the US, Kleck estimated that about
tics, the impact of different reporting systems can 26% of suicides are incorrectly certified as acciden-
The suicidal rate has been increasing at an alarming
tal and undetermined.16 However, underreporting of
rate since 1997. According to the annual statistical
suicides was said not to be common in many
report of the Korea National Statistical Office (2004),
studies.17
suicide has become the second most frequent cause of
Major rises in suicide rates occurred among those
death in men aged 10 to 39, and the third in men aged 40-49. Suicide is also the second most frequent cause
over 40 in Korea, while the rates amongst teenagers did
of death in women aged 10-19, and the first in women
not show much change in recent years. However, sharp
aged 20-39. Suicide is a major cause of death among
rises (approximately 200%) in suicide rates were found
the young generation in Korea. High unemployment
in the 15-29 year-old age groups in western countries.18
rates, the breakdown of the family support system
This result suggests that our unique social stress might
caused by high divorce rates and cultural changes, and
have an impact on the suicidal behavior of middle and
the poverty observed after the foreign exchange crisis
old aged Koreans.
in 1997 might have affected the rise of suicide in
Suicidal ideas and attempts
Korea. The number of death certificates reported by non
Suicidal ideas are very common in the general
medical doctors has progressively decreased. This has
population and are 25 times more common than
led to a decline in the number of undetermined causes
suicidal attempts. Furthermore, for every suicide
of death, which might have contributed to the rises
completion, there are nearly 45 suicide attempts.
observed in suicide rates to some extent.
The rates of suicidal idea and attempts are more
12
Hong JP et al.
References
frequent in the late teens, but actual suicide mortality rates are higher in old age. These results are
1. Durkhiem E. Suicide: A Study in Sociology. Translation
consistent with the previous findings from western
by Spaulding JA and Simpson G. New York: Free Press
countries.10
1952.
The high rates of suicidal idea and attempts in
2. World Health Organization: World Health Report 2003:
youths can be explained as follows; First, many sui-
Shaping the Future. Geneva, Switzerland: World Health
cide attempts by youths can be viewed as a strate-
Organization; 2003. Available at: http://www.who.int/
gic action on the part of the youth to resolve con-
whr/2003/en/whr03_en.pdf.
flicts within him or her self or with others. Youths
3. World Health Organization: International suicide statis-
have little direct economic or familial power, and
tics, 1999. Available at: http://www.befrienders.org/suicide/statistics.htp.
given such situations, self-injury can be used to sig-
4. Girard C. Age, gender and suicide: a cross-sectional
nal distress or to encourage a response from others.
analysis. Am Soc Rev 1993; 58:553-574.
Second, contagion effects are more influential;
5. Mann JJ. A current perspective of suicide and attempted
Youths are more likely to attempt or commit suicide
suicide. Ann Intern Med 2002; 136:302-311.
themselves, when a friend or family member
6. Barraclough B, Bunch J, Nelson B, Sainsbury P. One hun-
attempts or commits suicide. Finally, the rise in the
dred cases of suicide: clinical aspects. Br J Psychiatry
youth suicide rate over time can be explained, to
1974; 125:355-373.
some extent, by the increased share of youths living
7. Dorpat TL, Ripley HS. A study of suicide in the Seattle
in homes with a divorced parent. The rate of suicide
area. Compr Psychiatry 1960; 1:349-359.
mortality is the highest among the elderly.
8. Robins E, Murphy GE, Wilkinson RH Jr, Gassner S,
However, it has been suggested that the elderly
Kayes J. Some clinical considerations in the prevention
consider suicide as a rational choice when the
of suicide based on a study of 134 successful suicides.
expected value of the future utility of being alive is
Am J Public Health 1959; 49:888-899.
less than the value of death (escape from distress
9. Suh TW. The current trends of suicide mortality and
and loneliness), so they are more prone to suicidal
the role of community mental health center. 2003 Community mental health workshop: Suicide preven-
death.11
tion program in community mental health center.
While much is known about the epidemiology of
2003.
suicide, more remains to be clarified. Psychological
10. Moscicki EK. Epidemiology of suicide. International
autopsy studies of suicide cases and the establish-
Psychogeriatrics 1995; 7 (2):137-148.
ment of a detailed national suicide data system can
11. Cutler DM, Glaseser EL, Norberg KE. Explaining the
facilitate research into suicide and the establishment
rise in youth suicide. NBER Working Paper Series 7713
of a suicide prevention program in Korea. Suicide, as
(http://www.nber.org/papers/w7713.pdf), National
one of the important causes of death in the younger
Bureau of Economic Research. 2000. 12. World Health Organization: Country reports and charts
age group has a greater socioeconomic impact than
Web page. Available at: http://www.who.int/mental_
other common causes of death in the older age
health/prevention/suicide/country_reports/en/index.html.
group. Therefore, we are in urgent need of a public 13. Helliwell JF. Well-being and social capital: Does suicide
mental health network to prevent suicide and to
pose a puzzle? NBER Working Paper Series 10896
detect and treat early mental health problems in the
(http://www.nber.org/papers/w10896), National Bureau
primary health care system.
of Economic Research. 2004.
13
Suicide epidemiology
14. World Health Organization: Changing patterns in suicide
17. Hlady WG, Middaugh JP. The underrecording of suicide in state and national record, Alaska, 1983-1984. Suicide Life Threat Behav 1988; 18:237-244.
behavior. Regional Office for Europe. Copenhagen. 1982.
18. C a n t o r C H , L e e n a a r s A A , L e s t e r D , S l a t e r P J , Wolanowski AM, O'Toole B. Suicide trends in eight predominantly English-speaking countries 19601989. Soc Psychiatry Psychiatr Epidemiol. 1996; 31 (6):364-373.
15. Sainsbury P, Barraclough BM. Differences between suicide rates. Nature 1968; 21; 220 (173):1252. 16. Kleck G. Miscounting suicides. Suicide Life Threat Behav 1988; 8:219-236.
14
