Among the one million suicide deaths worldwide each year, as many as 60% occur in Asia. The World Health Organization (WHO) found higher suicide rates among the elderly in rapidly industrialized Asian countries such as China, Hong Kong, Japan, South Korea, Malaysia, and Singapore, compared to the corresponding rates of recently industrializing Asian countries like Vietnam and Sri Lanka (WHO, 2014). As a case in point, suicide rates in South Korea have been the highest in the world since 2003 and are rising especially among older people (Hong and Knapp, Reference Hong and Knapp2014). Suicide attempts and older age are strong predictors of completed suicide (Szanto et al., Reference Szanto, Gildengers, Mulsant, Brown, Alexopoulos and Reynolds2002; Simon et al., Reference Simon, Chang, Zeng and Dong2013) and, as such, are important in guiding our efforts for suicide prevention; however, most epidemiological studies focus on completed suicides across all ages rather than understanding the reasons behind suicide attempts in older populations.
Zhang and colleagues conducted a community-based population survey to estimate the two-week prevalence of attempted suicide in a sample of 8,399 people aged 60 years or older who have lived in urban Shanghai for more than five years. Their current report (Zhang et al., Reference Zhang2017) has been selected as paper of the month for International Psychogeriatrics. The authors found that 7–8 out of 1,000 older people in their sample attempted suicide and more than 80% of them made multiple attempts over a period of two weeks. Sadness and fear were the two dominant independent predictors of attempted suicide when other potential risk factors were considered, such absence of caregivers, less independence in performing activities of daily living and more depression, anxiety, obsessive–compulsive symptoms and anger.
Why are suicide attempts a special case among the elderly in East Asia? Relationships in families and communities in East Asia have been shaped by Confucian moral values over more than 2,000 years (Palley, Reference Palley1992). Within the Confucian tradition, adult children take good care of their parents and try to make them happy, while the elderly parents strive to live meaningful lives alongside their children. In traditional East Asian societies, the suicide of an elderly parent would be considered as their children's failure to care for them, thereby bringing dishonor and bad reputation to the family. The moral responsibility of the children to look after their parents has been cultivated in Asia through a deep-rooted social ethos of honoring older people, of having strong family traditions at home, and of following relevant public policies that encourage children to take care of elderly parents and make them happy.
Since the middle of the 20th century, regional industrialization – the so called modernization – has taken place in Asian countries like Japan, Korea, Taiwan, Hong Kong, and Singapore, and is in the process of happening in mainland China, India, Thailand, Indonesia, Philippines, Vietnam, Cambodia, Myanmar, and Sri Lanka. This has caused a rapid social and economic transition toward transforming a person who used to be tied to a family, a community and a set of traditional values, into an individual with the liberty to live a life of their own in pursuit of acquiring goods and relying on services. The process of rapid industrialization in East Asia witnessed ever increasing broken family ties. People from an older generation end up in a very vulnerable position: They lived their lives with the expectation that their children would take care of them when old like they had taken care of their parents, but they now realize that this expectation is void. Life for them may become empty and meaningless, leading to sadness, or full of worry about having to survive alone, leading to fear.
Are the consequences of industrialization in East Asia any different to the social and economic changes that the West faced after the Industrial Revolution – for example, in England where it all started in the middle of 18th century – that brought about urbanization, the collapse of patriarchy and the empowerment of younger people, women and the “working classes”? The Industrial Revolution in the West broke strong family ties and small intimate communities whose members depended on each other for survival, in the same way that modernization has done in East Asia. The notable difference is that this change occurred in the West over more than two centuries, whereas in East Asia it took only a few decades. A strong social centripetal force was caused by this whirlwind of change; those who are not strong enough to survive it, are pushed out. The high rates of suicide and suicide attempts in East Asia are indicative of this.
The cost of rapid industrialization in East Asia has been the breakdown, or at least the changing nature, of its traditional family and community networks, especially in metropolitan areas like Shanghai, China. Without such networks and without enough time to adapt to these changes, older people are more exposed to sadness and fear, the two dominant independent predictors of suicide attempts found by Zhang et al. (Reference Zhang2017). Interestingly, the absence of a caregiver was no longer a significant risk factor for suicide attempts when sadness and fear were entered into the predictive model. This suggests that, as there is no return to bygone times in East Asia when close-knit communities and duty-bound adult children used to look after their elders, we need to focus our creativity and energy on finding ways to make those from an older generation feel happier and safer in the context of modern societies.
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Among the one million suicide deaths worldwide each year, as many as 60% occur in Asia. The World Health Organization (WHO) found higher suicide rates among the elderly in rapidly industrialized Asian countries such as China, Hong Kong, Japan, South Korea, Malaysia, and Singapore, compared to the corresponding rates of recently industrializing Asian countries like Vietnam and Sri Lanka (WHO, 2014). As a case in point, suicide rates in South Korea have been the highest in the world since 2003 and are rising especially among older people (Hong and Knapp, Reference Hong and Knapp2014). Suicide attempts and older age are strong predictors of completed suicide (Szanto et al., Reference Szanto, Gildengers, Mulsant, Brown, Alexopoulos and Reynolds2002; Simon et al., Reference Simon, Chang, Zeng and Dong2013) and, as such, are important in guiding our efforts for suicide prevention; however, most epidemiological studies focus on completed suicides across all ages rather than understanding the reasons behind suicide attempts in older populations.
Zhang and colleagues conducted a community-based population survey to estimate the two-week prevalence of attempted suicide in a sample of 8,399 people aged 60 years or older who have lived in urban Shanghai for more than five years. Their current report (Zhang et al., Reference Zhang2017) has been selected as paper of the month for International Psychogeriatrics. The authors found that 7–8 out of 1,000 older people in their sample attempted suicide and more than 80% of them made multiple attempts over a period of two weeks. Sadness and fear were the two dominant independent predictors of attempted suicide when other potential risk factors were considered, such absence of caregivers, less independence in performing activities of daily living and more depression, anxiety, obsessive–compulsive symptoms and anger.
Why are suicide attempts a special case among the elderly in East Asia? Relationships in families and communities in East Asia have been shaped by Confucian moral values over more than 2,000 years (Palley, Reference Palley1992). Within the Confucian tradition, adult children take good care of their parents and try to make them happy, while the elderly parents strive to live meaningful lives alongside their children. In traditional East Asian societies, the suicide of an elderly parent would be considered as their children's failure to care for them, thereby bringing dishonor and bad reputation to the family. The moral responsibility of the children to look after their parents has been cultivated in Asia through a deep-rooted social ethos of honoring older people, of having strong family traditions at home, and of following relevant public policies that encourage children to take care of elderly parents and make them happy.
Since the middle of the 20th century, regional industrialization – the so called modernization – has taken place in Asian countries like Japan, Korea, Taiwan, Hong Kong, and Singapore, and is in the process of happening in mainland China, India, Thailand, Indonesia, Philippines, Vietnam, Cambodia, Myanmar, and Sri Lanka. This has caused a rapid social and economic transition toward transforming a person who used to be tied to a family, a community and a set of traditional values, into an individual with the liberty to live a life of their own in pursuit of acquiring goods and relying on services. The process of rapid industrialization in East Asia witnessed ever increasing broken family ties. People from an older generation end up in a very vulnerable position: They lived their lives with the expectation that their children would take care of them when old like they had taken care of their parents, but they now realize that this expectation is void. Life for them may become empty and meaningless, leading to sadness, or full of worry about having to survive alone, leading to fear.
Are the consequences of industrialization in East Asia any different to the social and economic changes that the West faced after the Industrial Revolution – for example, in England where it all started in the middle of 18th century – that brought about urbanization, the collapse of patriarchy and the empowerment of younger people, women and the “working classes”? The Industrial Revolution in the West broke strong family ties and small intimate communities whose members depended on each other for survival, in the same way that modernization has done in East Asia. The notable difference is that this change occurred in the West over more than two centuries, whereas in East Asia it took only a few decades. A strong social centripetal force was caused by this whirlwind of change; those who are not strong enough to survive it, are pushed out. The high rates of suicide and suicide attempts in East Asia are indicative of this.
The cost of rapid industrialization in East Asia has been the breakdown, or at least the changing nature, of its traditional family and community networks, especially in metropolitan areas like Shanghai, China. Without such networks and without enough time to adapt to these changes, older people are more exposed to sadness and fear, the two dominant independent predictors of suicide attempts found by Zhang et al. (Reference Zhang2017). Interestingly, the absence of a caregiver was no longer a significant risk factor for suicide attempts when sadness and fear were entered into the predictive model. This suggests that, as there is no return to bygone times in East Asia when close-knit communities and duty-bound adult children used to look after their elders, we need to focus our creativity and energy on finding ways to make those from an older generation feel happier and safer in the context of modern societies.
Conflict of interest
None.