SPECIAL ARTICLES

Epidemiology of in Korea

Jin Pyo Hong, M.D.,1 Myeng Ji Bae, M.D.,1 Tongwoo Suh, M.D., DrPH.2

1Department of Psychiatry, University of Ulsan College of Medicine, Asan Medical Center, 2Korea Institute of Health and Social Affairs, Seoul, Korea

Key words: Suicide, , Suicidal attempt. Abstract [ Psychiatry Invest 2006; 3 (2):7-14] In 2002, an estimated 877,000 lives were lost world- wide 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 seri- ous 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 The suicidal mortality rate in Korea is quite high negative act of the victim himself, which he knows compared to those in other OECD countries and the will produce that result".1 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 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 3 tal health network to prevent suicide and to detect and suicide rates have increased by 60%. 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 divided into predisposition, proximal stressors or Medical Center, 388-1 Poongnap-dong, Songpa-gu, Seoul, triggers.5 Psychiatric illness is a major contributing Korea (138-736) Tel: +82-2-3010-3421, Fax: +82-2-485-8381, factor, and more than 90% of those who commit E-mail: [email protected] suicide have a Diagnostic and Statistical Manual of

7 Suicide epidemiology

Mental Disorders, Fourth Edition (DSM-IV) psy- Methods chiatric 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 . 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 In Korea, the rapid increase in the suicidal rate in attempts. recent years has meant that suicide has become a serious public health and social problem. Results 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 , 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 tality rate increased, reaching 25.2 in 2004, the high- Gender-specific differences are also noticeable. Up to est level recorded so far. the mid 90s the difference between the genders 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 sui- Changes 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, dur- ing 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 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 1990s, a sharp increase in the mortality rate was only increase in OECD nations. observed in those over 40, while little change was Annual Country 1980-1989 1990-2004 observed amongst teenagers. The mortality rates of the 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 crisis of 1997, only to increase again after 2001. Denmark 26.71 (1982) 18.87 (1993) -3.11 Subsequently, the ratio between the mortality rates of 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 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 The changes of the suicide mortality rates among 17.06 (1982) 14.09 (1994) -1.58 the OECD nations including Korea are shown in 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 Switzerland) revealed decreased or steady rates, in Ireland 7.60 (1982) 11.19 (1995) 3.02 contrast to Korea which shows an annual increase of USA 11.86 (1982) 11.07 (1996) -0.49 16.8%. This rapid increase is the highest among the Iceland 9.66 (1982) 10.21 (1995) 0.43 OECD nations. The Netherlands 10.31 (1982) 8.70 (1995) -1.30 Spain 4.80 (1982) 6.91 (1995) 2.84 Rates of suicidal ideas and attempts Italia 6.78 (1982) 6.84 (1993) 0.08 Suicidal ideas 8.08 (1982) 6.50 (1997) -1.44 Portugal 8.32 (1982) 5.57 (1996) -2.83 According to the 1998 National Health and Nutrition Mexico 2.21 (1982) 3.78 (1995) 4.22 Survey, one fourth of the Korean population above the Greece 3.34 (1982) 2.92 (1996) -0.96 age of 10 have "thought of attempting suicide during the past 12 months" (Table 2). This survey reveals the Source: OECD (1999), OECD Health Data 1999 existence of gender differences with 1 out of 5.2 males Korea National Statistical Office (1983), Annual statistical report on Causes of death and 1 out of 3.3 females reporting a suicidal ideation. Korea National Statistical Office (2004), The is consistent with national statistics that show Annual statistical report on Causes of death 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, and suicide mortality according to age and sex in 1998.

Suicidal attempt rate (%) Suicide mortality rate (%) Suicidal idea rate (%) in the general among those in the general among those among those with population with suicidal idea population with suicidal idea suicidal attempt

Total 25.0 1.01 4.0 0.022 0.087 2.15

Sex 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

Age 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

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 , 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 13 other countries. ing, economics, migration, and depression. While a WHO working group14 and others15 have expressed confidence in the use of international suicide statis- Discussion tics, the impact of different reporting systems can The rise of the suicidal rate not be ignored. In the US, Kleck estimated that about 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 18 the young generation in Korea. High in the 15-29 year-old age groups in western countries. 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 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

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