中国自杀率_费力鹏_柳叶刀

For personal use. Only reproduce with permission from The Lancet Publishing Group. ARTICLES THE LANCET • Vol 359 • March 9, 2002 • www.thelancet.com 835 Summary Background A wide range of suicide rates are reported for China because official mortality data are based on an unrepresentative sample and because different reports adjust crude rates in different ways. We aimed to present an accurate picture of the current pattern of suicide in China on the basis of conservative estimates of suicide rates in different population cohorts. Methods Suicide rates by sex, 5-year age-group, and region (urban or rural) reported in mortality data for 1995–99 provided by the Chinese Ministry of Health were adjusted according to an estimated rate of unreported deaths and projected to the corresponding population. Findings We estimated a mean annual suicide rate of 23 per 100 000 and a total of 287 000 suicide deaths per year. Suicide accounted for 3.6% of all deaths in China and was the fifth most important cause of death. Among young adults 15–34 years of age, suicide was the leading cause of death, accounting for 19% of all deaths. The rate in women was 25% higher than in men, mainly because of the large number of suicides in young rural women. Rural rates were three times higher than urban rates—a difference that remained true for both sexes, for all age-groups, and over time. Interpretation Suicide is a major public-health problem for China that is only gradually being recognised. The unique pattern of suicides in China is widely acknowledged, so controversy about the overall suicide rate should not delay the development and testing of China-specific suicide-prevention programmes. Lancet 2002; 359: 835–40 See Commentary page 813 Introduction The official report on mental health by the Chinese government,1 presented at a WHO-Ministry of Health collaborative meeting held in Beijing in November, 1999, identified suicide as one of the priorities for mental-health work in China, and reported a national suicide rate for 1993 of 22·2 per 100 000. When applied to China’s large population, this rate translates to over 250 000 suicide deaths per year and makes suicide one of the leading causes of death for the country. The Ministry of Health has provided WHO with official mortality statistics that include deaths from suicide since 1987,2 but the 1999 report represented the first high-level recognition of the public- health importance of suicide for China. Despite the availability of official figures, reported estimates of China’s suicide rate vary over a wide range; for example, reported rates for 1990 range from 13.93 to 30·34 per 100 000. This disparity stems from two separate causes. Like many developing countries, China does not have a complete vital registration system; the official mortality figures provided to WHO are based on data from about 10% of the population (more than 100 million individuals). This sample is collected from locations that have relatively good reporting mechanisms, so it has a much higher proportion of urban residents than is true of the population as a whole. Given the large differences in urban versus rural suicide rates (rural rates are three-fold higher than urban rates), presentation of the suicide rate in the overall sample as China’s national rate, as is done in some of the WHO statistical annuals2 and by several authors,5–7 seriously underestimates China’s suicide rate. The second reason for the confusion is that the Global Burden of Disease (GBD) study4,8 and the 1999 WHO World Health Report9 estimate much higher suicide rates for China than the official figures from the Chinese Ministry of Health published in the WHO statistical annuals.2 The GBD study applied several adjustments to mortality data from China’s Disease Surveillance Points system to estimate 343 000 suicides in 1990 (30·3 per 100 000), and WHO used similar methods to estimate 413 000 suicides in 1998 (32·9 per 100 000). On the basis of these results—which are about 40% higher than official Chinese figures—China accounts for 21% of the world’s population but for 44% of all suicides in the world and for 56% of all female suicides in the world.10 In this paper, we aim to present an accurate picture of the current pattern of suicides in China on the basis of conservative estimates of the rates of suicide in different sex, age, and region cohorts. We use the most recent mortality data for China provided by the Ministry of Health, and detailed population and mortality estimates from China’s Bureau of Statistics, to estimate the numbers and rates of suicide in China for 1995–99. The reliability of these figures and the reasons for the differences between these conservatively adjusted “official” suicide rates and the much higher rates estimated by the GBD study and WHO are discussed. Methods The statistical division of the Chinese Ministry of Health provided mortality data (with categories from the 9th revision of the International Classification of Diseases) for Suicide rates in China, 1995–99 Michael R Phillips, Xianyun Li, Yanping Zhang Beijing Suicide Research and Prevention Center, Beijing Hui Long Guan Hospital, Beijing 100096, China (M R Phillips MD, X Li MD, Y Zhang MD); and Department of Social Medicine, Harvard Medical School, Boston, MA, USA (M R Phillips) Correspondence to: Dr Michael R Phillips (e-mail: phillips@public3.bta.net.cn) For personal use. Only reproduce with permission from The Lancet Publishing Group. ARTICLES 836 THE LANCET • Vol 359 • March 9, 2002 • www.thelancet.com 1995–99 from its vital registration system. These data provide the rates of death by cause and sex for 18 5-year age-groups for urban and rural residents (a total of 72 cohorts). Over the 5 years, this system recorded 3·53 million deaths and 78 000 suicides from a sample population of, on average, 110 million individuals located in 21 provinces, 36 cities, and 85 counties. The data are based on physicians’ death certificates, which are submitted to police departments by family members and then forwarded to the municipal, provincial, and national departments of health. Families are required to present death certificates to get permission for cremation or burial. Over the 5 years, 57% of the population covered by this registration system was urban (from cities), but data from China’s Bureau of Statistics11 indicate that the proportion of the population living in cities during this period was only 22%. We adjusted for this regional unrepresentativeness by projecting the sex-specific, age- specific, and region-specific mortality rates in the vital registration data for each year to the total population for each year reported by the Statistics Bureau;11 the proportion of the total population assigned to each of the 72 cohorts is based on the proportions found in the Statistics Bureau’s 1995 1% sample survey11 (a nationally representative sample of 12·4 million individuals). Mortality estimates reported by the Statistics Bureau for each year are used to estimate the rate of unreported deaths in the Ministry of Health vital registration system. The expected number of deaths in each cohort is estimated by distribution of the total number of deaths for each year reported by the Statistics Bureau11 to the 72 cohorts; the proportion of total deaths assigned to each cohort is based on the proportion of deaths in each cohort in the 1995 sample survey,11 which identified 79 619 deaths. The rate of unreported deaths for each year in each age, sex, and region cohort in the Ministry of Health vital registration system is then estimated by comparison of the expected number of deaths in the cohort (based on the Statistics Bureau data) with the number of deaths predicted by applying the Ministry of Health’s overall crude death rate for the cohort. Finally, the total number of suicides for each cohort in each year was calculated by adjusting the suicide rate in the Ministry of Health data by the estimated rate of unreported deaths and then applying this adjusted rate to the population of the cohort in the specified year. The mean annual number of suicides for the different cohorts are the simple means over the 5 years, and the mean rates are the combined number of suicides divided by the combined size of the cohort over the 5-year period. The national, region- specific, and sex-specific numbers and rates of suicide were Population Age-group (years) group 15–34 35–59 60–84 All ages Population Suicide % of all Population Suicide % of all Population Suicide % of all Population Suicide Number % of all (millions) rate* deaths due (millions) rate* deaths due (millions) rate* deaths due (millions) rate* of deaths due to suicide to suicide to suicide suicides to suicide Region Rural 342·5 30·3 20·4% 264·4 29·5 6·3% 95·0 82·8 2·1% 981·2 27·1 26 916 4·0% Urban 91·3 10·2 10·3% 81·5 8·3 2·5% 27·3 16·7 0·5% 254·5 8·3 21 098 1·5% Rural/urban ·· 2·98 ·· ·· 3·56 ·· ·· 4·96 ·· ·· 3·27 ·· ·· ratio Sex Women 216·2 32·1 29·0% 169·0 25·6 7·7% 63·1 64·3 2·0% 606·7 25·9 156 841 4·4% Men 217·6 20·0 12·1% 176·9 23·4 4·4% 59·2 72·0 1·7% 629·0 20·7 130 173 2·9% Male/female ·· 0·62 ·· ·· 0·91 ·· ·· 1·12 ·· ·· 0·80 ·· ·· ratio Sex by region Rural women 170·5 37·8 31·0% 128·3 31·3 8·7% 49·2 77·9 2·3% 480·3 30·5 146 335 4·9% Rural men 172·0 22·8 13·1% 136·1 27·8 4·9% 45·8 88·0 2·0% 500·9 23·9 119 580 3·3% Rural male/ ·· 0·60 .. ·· 0·89 ·· ·· 1·13 ·· ·· 0·78 ·· ·· female ratio Urban women 45·7 10·8 15·8% 40·6 7·5 3·1% 13·9 16·1 0·6% 126·4 8·3 10 506 1·7% Urban men 45·6 9·5 7·4% 40·8 9·0 2·1% 13·4 17·3 0·5% 128·0 8·3 10 592 1·3% Urban male/ ·· 0·89 ·· ·· 1·20 .. ·· 1·08 ·· ·· 1·00 ·· ·· female ratio Total 433·9 26·0 18·9% 345·9 24·5 5·6% 122·3 68·0 1·8% 1235·7 23·2 287 013 3·6% population *Per 100 000. Following the classification of the urban and rural population used by the Chinese Ministry of Health, the urban population is the population of cities and the rural population is the population of towns and counties. Table 1: Mean annual rates of suicide in different population groups in China, 1995–99 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 S ui ci de d ea th s pe r 1 0 0 0 0 0 p op ul at io n 0 Age (years) 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 Rural women Rural men Urban women Urban men Rates of suicide in China, 1995–99 For personal use. Only reproduce with permission from The Lancet Publishing Group. ARTICLES THE LANCET • Vol 359 • March 9, 2002 • www.thelancet.com 837 men, but this difference was mainly due to the large number of suicides in young rural women. Suicide rates among young rural women were 66% higher than rates among young rural men, whereas rates in men were somewhat higher than in women among middle-aged urban residents and among elderly residents of both urban and rural areas. Suicide accounted for 3·6% of all deaths in China and was the fifth most important cause of death (table 2). It was the 4th most important cause of death for rural women, the 8th most important cause for urban women, the eighth most important cause for rural men, and the 14th most important cause for urban men. The toll was particularly high among young adults: suicide was the leading cause of death in individuals 15–34 years of age, accounting for 18·9% of all deaths. In this age-group, it was the leading cause of death for rural and urban women, and the second most important cause of death (after motor-vehicle accidents) for rural and urban men. In rural women aged 15–34 years, suicides accounted for almost a third of all deaths, and the rate of death by suicide was 7·3-fold higher than that from medical complications during pregnancy, childbirth, and the puerperium (37·8 vs 5·2 deaths per 100 000). calculated by combining the numbers from the corresponding cohorts. The rates of death for other causes considered in the vital registration mortality data were calculated in the same manner. Yearly rates were standardised to the distribution of the 1995 population. Role of the funding source None of the funding sources for the Beijing Suicide Research and Prevention Center had any role in the study design, data collection, data analysis, data interpretation, or writing of the report. Results As shown in table 1 and the figure, we found that rural suicide rates were an average of three-fold higher than urban rates, and that these differences held true for men and women and in all age-groups. Moreover, the increase in suicide rates from middle age onwards was much more striking in rural areas than in urban areas, and started at an earlier age in the rural areas. Given these high rural rates and the large proportion of the population that lives in rural areas, 93% of all suicides occurred among rural residents. Rates in women were an average of 25% higher than in Rank Cause of death Rate of Proportion death* of all deaths in group (%) Rural women 1 Chronic bronchitis, emphysema, and asthma 117·40 18·95 2 Cerebrovascular disease 102·62 16·56 3 Pneumonia 31·27 5·05 4 Suicide and self-inflicted injury 30·47 4·92 5 Perinatal conditions 24·72 3·99 6 Pulmonary heart disease 18·35 2·96 7 Stomach cancer 15·58 2·52 8 Liver cancer 14·78 2·39 9 Acute myocardial infarction 13·94 2·25 10 Birth trauma, hypoxia, and birth asphyxia 12·89 2·08 11 Oesophageal cancer 12·52 2·02 12 Tracheal, bronchial, and lung cancers 11·52 1·86 13 Road-traffic accidents 11·04 1·78 14 Drowning 10·64 1·72 15 Chronic rheumatic heart disease 8·61 1·39 All causes 619·52 100·00 Rural men 1 Chronic bronchitis, emphysema, and asthma 122·41 16·89 2 Cerebrovascular disease 115·70 15·96 3 Liver cancer 36·30 5·01 4 Gastric cancer 27·75 3·83 5 Pneumonia 26·86 3·71 6 Road-traffic accidents 26·50 3·66 7 Tracheal, bronchial, and lung cancers 25·91 3·57 8 Suicide and self-inflicted injury 23·87 3·29 9 Perinatal conditions 21·69 2·99 10 Oesophageal cancer 21·32 2·94 11 Pulmonary heart disease 18·05 2·49 12 Acute myocardial infarction 17·12 2·36 13 Drowning 17·08 2·36 14 Chronic liver disease and cirrhosis 15·59 2·15 15 Pulmonary tuberculosis 11·61 1·60 All causes 724·85 100·00 Urban women 1 Cerebrovascular disease 102·42 21·09 2 Chronic bronchitis, emphysema, and asthma 53·44 11·00 3 Tracheal, bronchial, and lung cancers 22·60 4·65 4 Acute myocardial infarction 21·09 4·34 5 Diabetes mellitus 14·62 3·01 6 Gastric cancer 11·66 2·40 7 Liver cancer 11·02 2·27 8 Perinatal conditions 9·76 2·01 Rank Cause of death Rate of Proportion death* of all deaths in group (%) Urban women (continued) 9 Pulmonary heart disease 9·28 1·91 10 Road-traffic accidents 8·40 1·73 11 Colon and rectal cancers 8·34 1·72 12 Suicide and self-inflicted injury 8·31 1·71 13 Pneumonia 8·04 1·65 14 Nephritis and nephrosis 7·37 1·52 15 Breast cancer 7·25 1·49 All causes 485·64 100·00 Urban men 1 Cerebrovascular disease 126·82 20·36 2 Chronic bronchitis, emphysema, and asthma 62·03 9·96 3 Tracheal, bronchial, and lung cancers 48·05 7·72 4 Liver cancer 30·79 .. 5 Acute myocardial infarction 30·49 4·90 6 Stomach cancer 23·43 3·76 7 Road-traffic accidents 21·00 3·37 8 Chronic liver disease and cirrhosis 12·46 2·00 9 Oesophageal cancer 11·74 1·89 10 Diabetes mellitus 10·23 1·64 11 Pulmonary heart disease 9·72 1·56 12 Colon and rectal cancers 9·69 1·56 13 Perinatal conditions 9·54 1·53 14 Suicide and self-inflicted injury 8·27 1·33 15 Pneumonia 7·69 1·23 All causes 622·77 100·00 Total population 1 Cerebrovascular disease 110·41 17·02 2 Bronchitis, emphysema, and asthma 107·15 16·51 3 Liver cancer 24·78 3·82 4 Pneumonia 24·66 3·80 5 Suicide and self-inflicted injury 23·23 3·58 6 Tracheal, bronchial, and lung cancers 22·27 3·43 7 Stomach cancer 20·93 3·22 8 Perinatal conditions 20·39 3·14 9 Road-traffic accidents 18·07 2·78 10 Acute myocardial infarction 17·67 2·72 11 Pulmonary heart disease 16·41 2·53 12 Oesophageal cancer 15·16 2·34 13 Drowning 12·00 1·85 14 Chronic liver disease and cirrhosis 11·26 1·73 15 Birth trauma, hypoxia, and birth asphyxia 10·40 1·60 All causes 648·86 100·00 Uses categories from the 9th revision of the International Classification of Diseases. Rates are adjusted for estimated proportions of missing deaths. Following the classification of the urban and rural population used by the Chinese Ministry of Health, the urban population is the population of cities and the rural population is the population of towns and counties. *Per 100 000. Table 2: Leading causes of death in different population groups in China, 1995–99 For personal use. Only reproduce with permission from The Lancet Publishing Group. ARTICLES 838 THE LANCET • Vol 359 • March 9, 2002 • www.thelancet.com The yearly suicide rate (standardised to the 1995 population) was quite stable over the 5-year period, ranging from a low of 22·6 per 100 000 in 1999, to a high of 24·3 per 100 000 in 1997. The rates for the four sex-by-region cohorts varied over a wider range, but there was no clear trend either up or down over the study period: the range in suicide rates for rural women was 29.3–31.7 per 100 000; for urban women 7·8–9·4 per 100 000; for rural men 22·6–25·7 per 100 000; and for urban men 7·6–8·8 per 100 000. There were no important variations in the sex ratios or the rural-to-urban ratios of suicide rates over the 5 years. The method we used for adjustment for uncounted deaths (based on total deaths estimated by the Statistics Bureau) resulted in an overall increase of 18% in the unadjusted suicide rate, but did not alter the pattern or relative importance of suicide. Projecting the rates in the Ministry of Health data to the corresponding population groups without adjusting for uncounted deaths resulted in an overall suicide rate of 19·6 per 100 000; the corresponding mean annual number of suicides (242 544) accounted for 3·4% of all deaths. Discussion China is one of a very few countries that report higher rates of completed suicide in women than in men (others include Kuwait and Bahrain12). Rates in women are only 25% higher than in men, but much press attention13 has focused on the contrast between China and Western countries, in which the male-to-female ratio of completed suicide is almost always greater than 2:1 and frequently greater than 3:1.14 In fact, the sex reversal seen in China is an extension of the lower male-to-female ratio of suicide rates seen in India and some other Asian countries:7 according to estimates from the GBD study,4 the ratios for China, India, and Other Asia and Islands (ie, other parts of Asia) in 1990 were 0·81, 1·10, and 1·48, respectively, whereas the ratios for the other five regions of the world considered in the study ranged from 2·13 (Middle Eastern Cresent) to 4·64 (Sub-Saharan Africa). The impression that Asian women are a high-risk group for suicidal behaviour is also supported by studies that find much higher rates of attempted suicide among young Asian women living in the West than among their Western counterparts.15 What is unique about China is that the sex difference in completed suicide rates is largely driven by the very high rate of suicide in young rural women. In many Western countries, the trend over the past several years has been in the opposite direction: rates in women have been stable or decreasing while rates in men, particularly among young age-groups, have been increasing.16 The rural versus urban differences in China’s suicide rates are larger, more consistent across cohorts, and, arguably, more important than the sex reversal. Few countries provide national rates segregated by urban versus rural residence, so there is much less opportunity for international comparisons than is the case for sex. The data that are available, which mainly come from developed countries, show no clear pattern: some countries have somewhat higher rates in urban areas and other countries have higher rates in rural areas,