Coping Skill as a Moderator Between Negative Life Events and Suicide Among Young People in Rural China Long Sun1 and Jie Zhang1,2 1 2
Shandong University School of Public Health Center for Suicide Prevention Research Buffalo State, State University of New York
Objective:
In the present study, we aim to test whether the approach or the avoidance coping skill can be a moderator between negative life events and suicide, and to test the deficient coping strain in the strain theory. Method: This sample comprised 392 suicide cases and 416 community living controls, aged 15–34 years, from 16 rural counties in China. An established psychological autopsy method and a case–control design were used in this study. The 48-item Coping Response Inventory evaluated the degree of coping skills of the people who died by suicide. Results: Results indicated that the avoidance coping skill, but not the approach coping skill, can moderate between negative life events and suicide. Conclusion: The low level of the avoidance coping skill may represent a C 2014 Wiley Periodicals, Inc. J. Clin. promising variable for screening for suicide risk in rural China. Psychol. 71:258–266, 2015. Keywords: suicide; negative life event; approach coping skill; avoidance coping skill; moderator; China
Data from the China Ministry of Health–Vital Registration (MOH-VR) system showed that, in 2010, suicide rates were 10.01 per 100,000 people in rural areas and 6.86 per 100,000 people in urban areas (MOH, 2011). Compared to Western countries, there are three unique characteristics of Chinese suicides: (a) the suicide rates for women were about the same as those for men; (b) the suicide rates in rural areas were almost doubled those in urban areas; and (c) there existed two peaks in the curve of suicide rates among different ages, 15–34 and 60–84 years of age (Phillips, Li, & Zhang, 2002; Qin & Mortensen, 2001). So, Chinese rural people aged 15–34 years were at a higher risk for suicide compared with those in Western countries. Several risk factors are associated with suicide in Chinese young people. Previous studies have identified negative life events as an important risk factor of suicide (Liu & Tein, 2005; Rubenowitz, Waern, Wilhemson, & Allebeck, 2001). A study conducted in China showed that about 98.6% of the people who died by suicide experienced negative life events during the past year (Li, Phillips, & Zhang, 2008; Yen et al., 2005). Another study showed that 92.3% of the people who died by suicide experienced at least one type of negative life event (Zhang & Ma, 2012). A longitudinal study in the United States also found that negative life events were associated with suicide, showing that 99.8% of the people who died by suicide experienced negative life events (Yen et al., 2005). Coping skill was another factor associated with suicide (Curry, Miller, Waugh, & Anderson, 1992; Horesh et al., 1996; Spirito, Overholser, & Stark, 1989), which is defined as “the person’s cognitive and behavioral efforts to manage the internal and external demands of the person–environment transaction that is appraised as taxing or exceeding the resources of the person” (Folkman, Lazarus, Gruen, & DeLongis, p572, 1986). Although coping mechanisms can be classified as various systems, two distinct modes were often found: approach coping and
We declare that there are no conflicts of interest. The research was supported by the United States National Institute of Mental Health (R01 MH068560), but had no role in study design, data collection, data analyses, data interpretation, or the writing of the article. Please address correspondence to: Jie Zhang, Department of Sociology, State University of New York College at Buffalo, 1300 Elmwood Avenue, Buffalo, New York 14222; e-mail: [email protected] JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 71(3), 258–266 (2015) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp).
C 2014 Wiley Periodicals, Inc. DOI: 10.1002/jclp.22140
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avoidance coping (Herman-Stabl, Stemmler, & Petersen, 1995; Phelps & Jarvis, 1994). Generally, approach coping is directed at problem solving and incorporates strategies aimed at doing something to change the stressful situation, such as seeking information or advice and an appraisal of the situation. Avoidance coping is aimed at reducing psychological discomfort by cognitive avoidance, seeking alternative rewards, acceptance/resignation, and abreacting the noxious stimulus without trying to modify the situation (Folkman & Lazarus, 1986; Moos, 1993). The relations between the two modes varied from study to study (Feifel & Strack, 1989; Finset & Andersson, 2000; Miller, 1987). Although previous studies have identified that both negative life events and coping skills were associated with suicide, few studies have reported the relationship among them. In Chinese college students, passive coping styles mediated the relation between life stress and suicide ideation, but the moderating effect was not found (Zhang, Wang, Xia, Liu, & Jung, 2012). Among suicide attempters and nonattempters, the moderating effect of active and passive problem solving between negative life event stress and suicidal ideation was found (Linda, Marroqu´ın, & Miranda, 2012). Another study conducted with adolescence inpatients also showed that problem solving moderated the associations between life event stress and suicidal behavior (Grover et al., 2009). The strain theory implies that coping skills could be a moderator between negative life events and suicide: There are some people who, when facing a life crisis, have deficient coping skills and thus are at a higher risk of suicide than others (Zhang & Lester, 2008; Zhang, Tan, & Lester, 2013). A crisis may be a pressure or stress in daily life (Zhang, 2010, 2012). So, coping skills can help people to not only solve a life crisis but also reduce the risk of suicide. In other words, the relationship between negative life events and suicide can be moderated by coping skills. Although both the strain theory and previous studies suggest that coping skills can moderate between negative life events and suicide, few studies have explored the moderating effect of coping skills between negative life events and suicide victims, especially in China. Also, the different effects of both the approach and the avoidance coping skills in people who died by suicide should be discussed. In the present study, we aim to test whether the approach or the avoidance coping skill can be a moderator between negative life events and suicide, which may be helpful for suicide prevention.
Methods Study Sample and Design The sample for this study comprised people aged 15 to 34 years from rural China. We examined rural young women and men who died by suicide and various risk factors in comparison with community living controls from the same specific populations. The established psychological autopsy methods and a case–control design were used to investigate the environmental and other factors of rural young people who died by suicide. We selected three provinces in China for the study: Liaoning, an industrial province located in Northeast China; Hunan, an agricultural province in Central South China; and Shandong, a province with economic prosperity in both industry and agriculture that is located on the eastern coastal area of China midway between Liaoning and Hunan. Sixteen rural counties were randomly selected from the three provinces (six from Liaoning, five from Hunan, and five from Shandong). In each of the 16 counties, people aged 15–34 years who died by suicide were consecutively recruited from October 2005 through June 2008. Similar numbers of community living controls were recruited in the same counties about the same time periods. After successful interviews with the informants of the people who died by suicide, a total of 392 suicide cases were entered for study, among which 178 were women and 214 men. In each of the 16 counties, a project coordinator from the county-level Center for Disease Control and Prevention (CDC) monitored suicide occurrences. In each of the three provinces, a project director from either the provincial CDC or the university the study was affiliated with received reports on suicide cases each month.
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Community Control Selection The community living control group was a random sample stratified by age range and county. In each province, we used the 2005 census database of the counties in our research. For each suicide, we utilized the database of the county where the deceased lived to randomly select a living control in the same age range (i.e., 15–34). As to gender, the random selection of living controls aged 15–34 years from each county database yielded approximately 50% men and 50% women, which also approximated the gender distribution of suicide cases in the study. The control sample did not exclude individuals who had been diagnosed with mental disorders or previous suicide attempts. This way, the prevalence of mental disorders and suicidal attempts can be assessed in the rural general populations aged 15–34 years, and, more important, the effects (direct, moderating, and intervening) of mental disorders of people who died by suicide can be studied. Below we discuss specific sampling methods for suicide cases and living controls.
Information Sources We interviewed two informants for each suicide and control. We also used proxy information from the controls to obtain some parallel data from the suicide cases. However, we recognized that the type of informants, rather than the number of informants, used in psychological autopsy studies was an extremely important and complex consideration (Kraemer et al., 2003). We selected the informants based on the context or environment (how people observe the target, e.g., home vs. nonhome setting). This way, each informant was carefully selected to optimize the information available on each case so that home, work, family and nonfamily aspects were included in the data. Based on the above-mentioned considerations, we used the following three guidelines for the inclusion of informants:
r
r
r
Suicide informants were selected based on recommendations from the village head and village doctor. The control group informants were recommended by the controls themselves, who were the most familiar with the subject’s life and circumstances and were available for and consented to in-person interviews. The research team then randomly selected the informants. We tried, however, to avoid interviewing, as much as possible, the husbands and in-laws of women who died by suicide because of family disputes. Interviewing these people could result in very biased reports, especially if marital infidelity and family oppression were possible causes of suicide. Although target persons could be as young as 15 years of age, informants had to be 18 years of age or older. Characteristics of the informants for both suicides and controls were noted in a standardized fashion (i.e., most recent contact, number of contacts in the last month, frequency of contacts in the last year, number of years informant has known the target, relationships, and the informant’s impression of their familiarity with the target). For both the suicide cases and the controls, informant 1 represented a parent, spouse, or another important family member, and informant 2 was a friend, coworker, or a neighbor.
Interviewing Procedures First, the local health agency or village administration visited the informants. After the informant signed the informed consent form, an interview time was scheduled. Interviews for informants of suicides were scheduled between 2 and 6 months after the suicide incident, and interviews for informants of living controls were scheduled as soon as the control targets and their informants were identified. One trained interviewer interviewed each informant separately, in a private place of a hospital or clinic or the informant’s home. The average time for each interview was 2.5 hours. Raters could not be blinded to case status due to the fact that the cases were deceased and the controls were living. Inter-rater reliability was established and maintained by limiting the principal data-gathering role to the 24 trained clinical interviewers and by comparing duplicate
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ratings of the interviewers on a regular basis. The same interviewers participated in data collection for both case and control samples, promoting inter-rater reliability across that study. The institutional review board of a U.S.-based university as well as the research ethical committees of the collaborating universities approved the study protocol before data collection began. Informed consent was obtained from each of the proxy information interviewees.
Measures In this study, predicting variables included gender, age, education years, religious belief, marital status, mental disorders, approach coping skill, avoidance coping skill, and negative life events. We measured gender as 0 = women and 1 = men. The sample ranged in age from 15 to 34 years, with a mean of 26.24 and a standard deviation of 6.28. Education years ranged from 0 to 18 years, with a mean of 8.29 and a standard deviation of 2.72. The variable of province was estimated by Liaoning (1), Hunan (2) and Shandong (3). There are four questions which were used to assess the religious beliefs of the target persons. The first question asked what religion the target persons believed in: Taoism, Muslim, Christianity, Catholics, Buddhism, others, or no belief. The second question asked how many times, on average, the target persons attended religious events in a month. The third question asked whether the target persons believed in God. The final question asked whether the target person believed in the afterlife. Any positive responses (having a religious belief, attending religious events, believing in God or afterlife) were recoded into 1 = yes, whereas others were recoded into 0 = no. Because there were few informants who were separated, widowed or divorced, marital status was dichotomized as 0 = never married and 1 = ever married, with the latter including those who were currently married, divorced, separated, or widowed. Those who were unmarried were asked whether they were dating or in a love relationship. In the traditional rural society of China, most girls in love or dating are in similar social and psychological status with married women. For example, they need to suffer the strain from the partner’s family. Therefore, in this study the category of never married included only those who have never married and not currently in love. Psychiatrists from each team convened at a consensus meeting to determine the diagnoses for mental disorders of both suicides and controls using a Chinese version of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID; Spitzer, Williams, Gibbon, & First, 1988; Gu & Chen, 1993), which was provided by the Kaohsiung Medical College’s Department of Psychiatry in Taiwan. Interviewers presented all of the informants’ responses, and Drs. Gu Jing-Shun and Chen Yung-Cheng were the translators. We obtained permission to use the work. The Chinese version of the SCID has been used in Taiwan and Hong Kong for the past few years as well as in our pilot data collection. Our preliminary study of the pilot data supported the validation of the Chinese version of the SCID used in Chinese samples. Subjects who were diagnosed for any mental disorders were recoded into 1 = yes, while others were recoded into 0 = no. The Coping Response Inventory (CRI; Moos, Brennan, Fondacaro, & Moos, 1990) was used to measure the coping skills of those who died by suicide and the living controls. The CRI is a 48-item scale and includes two subscales: the Approach Coping scale, which assesses logical analysis, positive reappraisal, seeking guidance and support, and taking problem-solving action, and the Avoidance Coping scale, which assesses cognitive avoidance, acceptance/resignation, seeking alternative rewards, and emotional discharge. The percentage of agreement from the two informants was 82.6%. The revised version of Interview for Recent Life Events (IRLE; Paykel, Prusoff, & Uhlenhuth, 1971) was used to measure the number of life events that happened during the 12 months before the suicide incident or the interview for living controls. The IRLE is a 64-item scale and includes 19 culturally specific items. The proxy respondents were also asked if the mentioned life event was a positive or negative one for the target person, and only the number of negative life events was involved in this study. We analyzed the correlation of the responses between the two informants: the correlation coefficient was 0.529 (p = 0.000) for the Approach Coping scale and 0.402 (p = 0.000) for the Avoidance Coping scale.
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Table 1 The Number of Missing Items for the CRI Percentage of the missing < 1% 1%–2% 2%–3% 3%–4%
Item number 3, 8, 11, 19, 1, 2, 7, 12, 16, 20, 24, 27, 31, 32, 33, 36, 39, 40, 44, 46, 4, 6, 9,13, 14, 15, 18, 22, 23, 25, 26, 28, 30, 34, 35, 37, 38, 41, 47 5, 10, 17, 21, 29, 42, 43, 45, 48
Note. CRI = Coping Response Inventory.
Integrating the Information From Different Sources There were two proxy interviews for each suicide case and living control. The majority of the responses pertaining to the target person were the same or quite similar. For different responses, we integrated the data with the following three principles. For demographic information, we basically relied on the answers from the informant, who had the best access to the information. For example, a family member should be able to tell the target person’s age and birth date more accurately than a friend. Second, in estimating the cultural values of the target person, we used the higher score of the two informants’ responses if they were different. Finally, to determine a diagnosis with the SCID, we selected the response representing a positive symptom, because the other informant may not have had an opportunity to observe the specific characteristic or behavior. We applied these three guidelines in integrating responses of both suicide cases and controls. We used mean imputation to fill all of the missing data. The following four variables did not have missing data: gender, age, education years, and province. For religious belief, there was only one response (0.1%) that was missing, and for marital status, there were three responses (0.4%) that were missing. We listed the number of missing responses for each item of the CRI in Table 1. In this study, we used integrated information reported from two informants. The methodology which has been tested in previous studies were shown to be reliable (Zhang et al., 2003).
Statistical Analysis We used SPSS for Windows (version 16.0) for data analysis and t tests or chi-square tests to compare the difference on categorical and continuous variables across groups. We performed a hierarchical logistic regression analysis to examine the moderating effect of coping skills between negative life events and suicide. All tests were two-tailed and a p value of < 0.05 was considered statistically significant.
Results Characteristics of Suicide Cases and Controls In this study, the sample comprised 392 suicide cases and 416 community living controls. The characteristics of the sample and study variables are shown in Table 2. The people who died by suicide were older and had a lower level of education (t = 9.661, p = 0.000), suffered from a mental disorder (χ2 = 206.365, p = 0.000), had a lower level of the approach coping skill (t = 23.138, p = 0.000), had a higher level of the avoidance coping skill (t = −1.867, p = 0.048), and had more negative life events (χ2 = 152.686, p = 0.000) than community living controls.
The Moderating Effect of Coping Skills Between Negative Life Events and Suicide We conducted a hierarchical logistic regression analysis to examine the moderating effect of coping skills between negative life events and suicide (see Table 3). The results of the moderating effect of the avoidance coping skill were statistically significant, shown Model B, but the results
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Table 2 Comparison of Sample Characteristics Between Suicides and Controls Variables
Cases (n = 392)
Controls (n = 416)
t/χ2
214 (54.6) 26.84 (6.37) 7.39 (2.76)
202 (48.6) 25.69 (6.16) 9.14 (2.39)
2.942 −2.591** 9.661*** 0.763
174 (44.4) 119 (30.4) 99 (25.3) 31 (7.9) 263 (67.1) 187 (47.7) 20.72 (12.29) 36.72 (9.70) 355 (90.6)
179 (43.0) 138 (33.2) 99 (23.8) 24 (5.8) 297 (71.4) 16 (3.8) 38.92 (10.01) 35.48 (9.08) 211 (50.7)
Gender, male, n (%) Age, mean (SD), yrs Education, mean (SD), yrs Province, n (%) Liaoning Hunan Shandong Religion belief, yes, n (%) Marital status, ever married, n (%) Mental disorders, yes, n (%) Approach coping skill, mean (SD) Avoidance coping skill, mean (SD) Negative life events, yes, n (%)
1.456 1.756 206.365*** 23.138*** −1.867* 152.686***
Note. A one-tailed test was used. *p < 0.05. **p < 0.01. ***p < 0.001.
Table 3
The Moderating Effect of Approach and Avoidance Coping Skill (N = 808) Variable Male Age Education years Province (Reference = Shandong) Liaoning Hunan Religion belief Ever married Mental disease Negative life events Approach coping skill Negative life events * Approach coping skill Avoidance coping skill Negative life * Avoidance coping skill Constant Pseudo R2
Model A
Model B
Model C
1.026 1.014 0.751***
0.841 1.008 0.747***
0.912 1.024 0.794***
0.814 1.051 1.920 0.620** 22.394***
0.845 1.798* 1.645 0.487* 14.163*** 3.338***
0.941 2.956** 1.762 0.399** 10.243*** 2.212*** 0.898*** 0.992
5.492** 0.420
1.026 0.984** 0.982 0.420
28.722*** 0.704
*p < 0.05. **p < 0.01. ***p < 0.001.
of the approach coping skill were not statistically significant, shown in Model C. The moderating effect of the avoidance coping skill was a negative sign (odds ratio = 0.984). More specifically, a high level of the avoidance coping skill had a moderating effect between negative life events and suicide. As shown in Figure 1, people with high levels of negative life events (one standard deviation above the mean) and low levels of the avoidance coping skill have the highest risk of suicide.
Discussion In this sample of young people who died by suicide in rural China, we found that 90.6% of them had experienced negative life events during the past year, similar to the results of previous studies (Li et al., 2008; Zhang & Ma, 2012). According to our analysis, the results of the moderating
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Figure 1. The moderating effect of the avoidance coping skill.
effect of the avoidance coping skill were statistically significant, but not for the approach coping skill. Several studies conducted in both China and Western countries (Abu-Hijleh, 1998; Liu & Tein, 2005; Rubenowitz et al., 2001) have also indicated that negative life events are significant predictors of suicide. Nevertheless, experiencing negative life events cannot be an independent factor for suicide, as some people may respond to the same negative life events in a different way. This study tested the moderating effect of coping skills between negative life events and suicide and found that the avoidance coping skill can be a moderator between them. To the best of our knowledge, this is the first study to test the moderating effect of coping skills between negative life events and suicide. For suicide ideation, some studies illustrated that problem solving moderated the associations between life event stress and suicidal behaviors (Clum & Febbraro, 1994; Grover et al., 2009; Yang & Clum, 1994). Another study showed that the moderating effect of coping skills was not found between life stress and suicide ideation (Dixon, Heppner, & Anderson, 1991; Zhang et al., 2012). Their results revealed that suicide can be aroused by negative life events, and that a low level of the avoidance coping skill can strengthen the risk of suicide. In other words, the avoidance coping skill could be an effective method for ameliorating negative life events. The reason can be explained as follows: As we know, the avoidance coping skill cannot modify the situation, but it is helpful in reducing psychological discomfort. Psychological factors are the most important risk factors for suicide. So, if the avoidance coping skill reduces the level of psychological discomfort, which is an important risk factor of suicide, then the risk of suicidal behavior would be reduced. And since the avoidance coping skill is also helpful for reducing the probability of suicide promoted by negative life events, receiving training in the avoidance coping skill would be helpful for suicide prevention. Our results support that the approach coping skill cannot be a moderator between negative life events and suicide. Our findings also indicate that the approach coping skill did not work effectively when facing negative life events, possibly because the results were based on rural people with low levels of education (about 7 years, the first year in middle school in our sample). Although the approach coping skill was not found to be a moderating effect in our study, it can be an independent, protective factor for suicidal behavior. So, receiving training in approach coping skills can also be helpful for suicide prevention.
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Limitations There are several limitations that should be addressed when interpreting these results. First, the psychological autopsy method was used for the data collection in this study. As data were obtained from the proxy informants, errors and biases can be a problem for the truth of the data. For example, mental disorders diagnosed with SCID without the presence of the target person may not be as accurate as a face-to-face interview between the patient and the psychiatrist. Second, we focused only on the number of negative life events, and the classification of negative life events may also be important risk factors for suicide behavior. Third, researchers could not be blinded to case status, so potentially they might be biased. Fourth, we did not control for the differences between suicides and controls in the analysis; for example, the age among suicides was older than the controls. Finally, the coping skill was measured by the CRI, and the reliability and validity of the scale deserve further tests in Chinese societies.
Conclusion Despite these limitations, the study can still contribute to our understanding of the mechanism of how negative life events and coping skill affect suicide. The major finding is that a low level of the avoidance coping skill may represent a promising variable for screening for suicide risk in rural China. Training in the avoidance coping skill is also helpful for suicide prevention. The moderating effect of avoidance coping skill between negative life events and suicide may be translated into practical measures in suicide prevention in China as well as elsewhere in the world.
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Shandong University School of Public Health Center for Suicide Prevention Research Buffalo State, State University of New York
Objective:
In the present study, we aim to test whether the approach or the avoidance coping skill can be a moderator between negative life events and suicide, and to test the deficient coping strain in the strain theory. Method: This sample comprised 392 suicide cases and 416 community living controls, aged 15–34 years, from 16 rural counties in China. An established psychological autopsy method and a case–control design were used in this study. The 48-item Coping Response Inventory evaluated the degree of coping skills of the people who died by suicide. Results: Results indicated that the avoidance coping skill, but not the approach coping skill, can moderate between negative life events and suicide. Conclusion: The low level of the avoidance coping skill may represent a C 2014 Wiley Periodicals, Inc. J. Clin. promising variable for screening for suicide risk in rural China. Psychol. 71:258–266, 2015. Keywords: suicide; negative life event; approach coping skill; avoidance coping skill; moderator; China
Data from the China Ministry of Health–Vital Registration (MOH-VR) system showed that, in 2010, suicide rates were 10.01 per 100,000 people in rural areas and 6.86 per 100,000 people in urban areas (MOH, 2011). Compared to Western countries, there are three unique characteristics of Chinese suicides: (a) the suicide rates for women were about the same as those for men; (b) the suicide rates in rural areas were almost doubled those in urban areas; and (c) there existed two peaks in the curve of suicide rates among different ages, 15–34 and 60–84 years of age (Phillips, Li, & Zhang, 2002; Qin & Mortensen, 2001). So, Chinese rural people aged 15–34 years were at a higher risk for suicide compared with those in Western countries. Several risk factors are associated with suicide in Chinese young people. Previous studies have identified negative life events as an important risk factor of suicide (Liu & Tein, 2005; Rubenowitz, Waern, Wilhemson, & Allebeck, 2001). A study conducted in China showed that about 98.6% of the people who died by suicide experienced negative life events during the past year (Li, Phillips, & Zhang, 2008; Yen et al., 2005). Another study showed that 92.3% of the people who died by suicide experienced at least one type of negative life event (Zhang & Ma, 2012). A longitudinal study in the United States also found that negative life events were associated with suicide, showing that 99.8% of the people who died by suicide experienced negative life events (Yen et al., 2005). Coping skill was another factor associated with suicide (Curry, Miller, Waugh, & Anderson, 1992; Horesh et al., 1996; Spirito, Overholser, & Stark, 1989), which is defined as “the person’s cognitive and behavioral efforts to manage the internal and external demands of the person–environment transaction that is appraised as taxing or exceeding the resources of the person” (Folkman, Lazarus, Gruen, & DeLongis, p572, 1986). Although coping mechanisms can be classified as various systems, two distinct modes were often found: approach coping and
We declare that there are no conflicts of interest. The research was supported by the United States National Institute of Mental Health (R01 MH068560), but had no role in study design, data collection, data analyses, data interpretation, or the writing of the article. Please address correspondence to: Jie Zhang, Department of Sociology, State University of New York College at Buffalo, 1300 Elmwood Avenue, Buffalo, New York 14222; e-mail: [email protected] JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 71(3), 258–266 (2015) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp).
C 2014 Wiley Periodicals, Inc. DOI: 10.1002/jclp.22140
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avoidance coping (Herman-Stabl, Stemmler, & Petersen, 1995; Phelps & Jarvis, 1994). Generally, approach coping is directed at problem solving and incorporates strategies aimed at doing something to change the stressful situation, such as seeking information or advice and an appraisal of the situation. Avoidance coping is aimed at reducing psychological discomfort by cognitive avoidance, seeking alternative rewards, acceptance/resignation, and abreacting the noxious stimulus without trying to modify the situation (Folkman & Lazarus, 1986; Moos, 1993). The relations between the two modes varied from study to study (Feifel & Strack, 1989; Finset & Andersson, 2000; Miller, 1987). Although previous studies have identified that both negative life events and coping skills were associated with suicide, few studies have reported the relationship among them. In Chinese college students, passive coping styles mediated the relation between life stress and suicide ideation, but the moderating effect was not found (Zhang, Wang, Xia, Liu, & Jung, 2012). Among suicide attempters and nonattempters, the moderating effect of active and passive problem solving between negative life event stress and suicidal ideation was found (Linda, Marroqu´ın, & Miranda, 2012). Another study conducted with adolescence inpatients also showed that problem solving moderated the associations between life event stress and suicidal behavior (Grover et al., 2009). The strain theory implies that coping skills could be a moderator between negative life events and suicide: There are some people who, when facing a life crisis, have deficient coping skills and thus are at a higher risk of suicide than others (Zhang & Lester, 2008; Zhang, Tan, & Lester, 2013). A crisis may be a pressure or stress in daily life (Zhang, 2010, 2012). So, coping skills can help people to not only solve a life crisis but also reduce the risk of suicide. In other words, the relationship between negative life events and suicide can be moderated by coping skills. Although both the strain theory and previous studies suggest that coping skills can moderate between negative life events and suicide, few studies have explored the moderating effect of coping skills between negative life events and suicide victims, especially in China. Also, the different effects of both the approach and the avoidance coping skills in people who died by suicide should be discussed. In the present study, we aim to test whether the approach or the avoidance coping skill can be a moderator between negative life events and suicide, which may be helpful for suicide prevention.
Methods Study Sample and Design The sample for this study comprised people aged 15 to 34 years from rural China. We examined rural young women and men who died by suicide and various risk factors in comparison with community living controls from the same specific populations. The established psychological autopsy methods and a case–control design were used to investigate the environmental and other factors of rural young people who died by suicide. We selected three provinces in China for the study: Liaoning, an industrial province located in Northeast China; Hunan, an agricultural province in Central South China; and Shandong, a province with economic prosperity in both industry and agriculture that is located on the eastern coastal area of China midway between Liaoning and Hunan. Sixteen rural counties were randomly selected from the three provinces (six from Liaoning, five from Hunan, and five from Shandong). In each of the 16 counties, people aged 15–34 years who died by suicide were consecutively recruited from October 2005 through June 2008. Similar numbers of community living controls were recruited in the same counties about the same time periods. After successful interviews with the informants of the people who died by suicide, a total of 392 suicide cases were entered for study, among which 178 were women and 214 men. In each of the 16 counties, a project coordinator from the county-level Center for Disease Control and Prevention (CDC) monitored suicide occurrences. In each of the three provinces, a project director from either the provincial CDC or the university the study was affiliated with received reports on suicide cases each month.
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Community Control Selection The community living control group was a random sample stratified by age range and county. In each province, we used the 2005 census database of the counties in our research. For each suicide, we utilized the database of the county where the deceased lived to randomly select a living control in the same age range (i.e., 15–34). As to gender, the random selection of living controls aged 15–34 years from each county database yielded approximately 50% men and 50% women, which also approximated the gender distribution of suicide cases in the study. The control sample did not exclude individuals who had been diagnosed with mental disorders or previous suicide attempts. This way, the prevalence of mental disorders and suicidal attempts can be assessed in the rural general populations aged 15–34 years, and, more important, the effects (direct, moderating, and intervening) of mental disorders of people who died by suicide can be studied. Below we discuss specific sampling methods for suicide cases and living controls.
Information Sources We interviewed two informants for each suicide and control. We also used proxy information from the controls to obtain some parallel data from the suicide cases. However, we recognized that the type of informants, rather than the number of informants, used in psychological autopsy studies was an extremely important and complex consideration (Kraemer et al., 2003). We selected the informants based on the context or environment (how people observe the target, e.g., home vs. nonhome setting). This way, each informant was carefully selected to optimize the information available on each case so that home, work, family and nonfamily aspects were included in the data. Based on the above-mentioned considerations, we used the following three guidelines for the inclusion of informants:
r
r
r
Suicide informants were selected based on recommendations from the village head and village doctor. The control group informants were recommended by the controls themselves, who were the most familiar with the subject’s life and circumstances and were available for and consented to in-person interviews. The research team then randomly selected the informants. We tried, however, to avoid interviewing, as much as possible, the husbands and in-laws of women who died by suicide because of family disputes. Interviewing these people could result in very biased reports, especially if marital infidelity and family oppression were possible causes of suicide. Although target persons could be as young as 15 years of age, informants had to be 18 years of age or older. Characteristics of the informants for both suicides and controls were noted in a standardized fashion (i.e., most recent contact, number of contacts in the last month, frequency of contacts in the last year, number of years informant has known the target, relationships, and the informant’s impression of their familiarity with the target). For both the suicide cases and the controls, informant 1 represented a parent, spouse, or another important family member, and informant 2 was a friend, coworker, or a neighbor.
Interviewing Procedures First, the local health agency or village administration visited the informants. After the informant signed the informed consent form, an interview time was scheduled. Interviews for informants of suicides were scheduled between 2 and 6 months after the suicide incident, and interviews for informants of living controls were scheduled as soon as the control targets and their informants were identified. One trained interviewer interviewed each informant separately, in a private place of a hospital or clinic or the informant’s home. The average time for each interview was 2.5 hours. Raters could not be blinded to case status due to the fact that the cases were deceased and the controls were living. Inter-rater reliability was established and maintained by limiting the principal data-gathering role to the 24 trained clinical interviewers and by comparing duplicate
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ratings of the interviewers on a regular basis. The same interviewers participated in data collection for both case and control samples, promoting inter-rater reliability across that study. The institutional review board of a U.S.-based university as well as the research ethical committees of the collaborating universities approved the study protocol before data collection began. Informed consent was obtained from each of the proxy information interviewees.
Measures In this study, predicting variables included gender, age, education years, religious belief, marital status, mental disorders, approach coping skill, avoidance coping skill, and negative life events. We measured gender as 0 = women and 1 = men. The sample ranged in age from 15 to 34 years, with a mean of 26.24 and a standard deviation of 6.28. Education years ranged from 0 to 18 years, with a mean of 8.29 and a standard deviation of 2.72. The variable of province was estimated by Liaoning (1), Hunan (2) and Shandong (3). There are four questions which were used to assess the religious beliefs of the target persons. The first question asked what religion the target persons believed in: Taoism, Muslim, Christianity, Catholics, Buddhism, others, or no belief. The second question asked how many times, on average, the target persons attended religious events in a month. The third question asked whether the target persons believed in God. The final question asked whether the target person believed in the afterlife. Any positive responses (having a religious belief, attending religious events, believing in God or afterlife) were recoded into 1 = yes, whereas others were recoded into 0 = no. Because there were few informants who were separated, widowed or divorced, marital status was dichotomized as 0 = never married and 1 = ever married, with the latter including those who were currently married, divorced, separated, or widowed. Those who were unmarried were asked whether they were dating or in a love relationship. In the traditional rural society of China, most girls in love or dating are in similar social and psychological status with married women. For example, they need to suffer the strain from the partner’s family. Therefore, in this study the category of never married included only those who have never married and not currently in love. Psychiatrists from each team convened at a consensus meeting to determine the diagnoses for mental disorders of both suicides and controls using a Chinese version of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID; Spitzer, Williams, Gibbon, & First, 1988; Gu & Chen, 1993), which was provided by the Kaohsiung Medical College’s Department of Psychiatry in Taiwan. Interviewers presented all of the informants’ responses, and Drs. Gu Jing-Shun and Chen Yung-Cheng were the translators. We obtained permission to use the work. The Chinese version of the SCID has been used in Taiwan and Hong Kong for the past few years as well as in our pilot data collection. Our preliminary study of the pilot data supported the validation of the Chinese version of the SCID used in Chinese samples. Subjects who were diagnosed for any mental disorders were recoded into 1 = yes, while others were recoded into 0 = no. The Coping Response Inventory (CRI; Moos, Brennan, Fondacaro, & Moos, 1990) was used to measure the coping skills of those who died by suicide and the living controls. The CRI is a 48-item scale and includes two subscales: the Approach Coping scale, which assesses logical analysis, positive reappraisal, seeking guidance and support, and taking problem-solving action, and the Avoidance Coping scale, which assesses cognitive avoidance, acceptance/resignation, seeking alternative rewards, and emotional discharge. The percentage of agreement from the two informants was 82.6%. The revised version of Interview for Recent Life Events (IRLE; Paykel, Prusoff, & Uhlenhuth, 1971) was used to measure the number of life events that happened during the 12 months before the suicide incident or the interview for living controls. The IRLE is a 64-item scale and includes 19 culturally specific items. The proxy respondents were also asked if the mentioned life event was a positive or negative one for the target person, and only the number of negative life events was involved in this study. We analyzed the correlation of the responses between the two informants: the correlation coefficient was 0.529 (p = 0.000) for the Approach Coping scale and 0.402 (p = 0.000) for the Avoidance Coping scale.
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Table 1 The Number of Missing Items for the CRI Percentage of the missing < 1% 1%–2% 2%–3% 3%–4%
Item number 3, 8, 11, 19, 1, 2, 7, 12, 16, 20, 24, 27, 31, 32, 33, 36, 39, 40, 44, 46, 4, 6, 9,13, 14, 15, 18, 22, 23, 25, 26, 28, 30, 34, 35, 37, 38, 41, 47 5, 10, 17, 21, 29, 42, 43, 45, 48
Note. CRI = Coping Response Inventory.
Integrating the Information From Different Sources There were two proxy interviews for each suicide case and living control. The majority of the responses pertaining to the target person were the same or quite similar. For different responses, we integrated the data with the following three principles. For demographic information, we basically relied on the answers from the informant, who had the best access to the information. For example, a family member should be able to tell the target person’s age and birth date more accurately than a friend. Second, in estimating the cultural values of the target person, we used the higher score of the two informants’ responses if they were different. Finally, to determine a diagnosis with the SCID, we selected the response representing a positive symptom, because the other informant may not have had an opportunity to observe the specific characteristic or behavior. We applied these three guidelines in integrating responses of both suicide cases and controls. We used mean imputation to fill all of the missing data. The following four variables did not have missing data: gender, age, education years, and province. For religious belief, there was only one response (0.1%) that was missing, and for marital status, there were three responses (0.4%) that were missing. We listed the number of missing responses for each item of the CRI in Table 1. In this study, we used integrated information reported from two informants. The methodology which has been tested in previous studies were shown to be reliable (Zhang et al., 2003).
Statistical Analysis We used SPSS for Windows (version 16.0) for data analysis and t tests or chi-square tests to compare the difference on categorical and continuous variables across groups. We performed a hierarchical logistic regression analysis to examine the moderating effect of coping skills between negative life events and suicide. All tests were two-tailed and a p value of < 0.05 was considered statistically significant.
Results Characteristics of Suicide Cases and Controls In this study, the sample comprised 392 suicide cases and 416 community living controls. The characteristics of the sample and study variables are shown in Table 2. The people who died by suicide were older and had a lower level of education (t = 9.661, p = 0.000), suffered from a mental disorder (χ2 = 206.365, p = 0.000), had a lower level of the approach coping skill (t = 23.138, p = 0.000), had a higher level of the avoidance coping skill (t = −1.867, p = 0.048), and had more negative life events (χ2 = 152.686, p = 0.000) than community living controls.
The Moderating Effect of Coping Skills Between Negative Life Events and Suicide We conducted a hierarchical logistic regression analysis to examine the moderating effect of coping skills between negative life events and suicide (see Table 3). The results of the moderating effect of the avoidance coping skill were statistically significant, shown Model B, but the results
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Table 2 Comparison of Sample Characteristics Between Suicides and Controls Variables
Cases (n = 392)
Controls (n = 416)
t/χ2
214 (54.6) 26.84 (6.37) 7.39 (2.76)
202 (48.6) 25.69 (6.16) 9.14 (2.39)
2.942 −2.591** 9.661*** 0.763
174 (44.4) 119 (30.4) 99 (25.3) 31 (7.9) 263 (67.1) 187 (47.7) 20.72 (12.29) 36.72 (9.70) 355 (90.6)
179 (43.0) 138 (33.2) 99 (23.8) 24 (5.8) 297 (71.4) 16 (3.8) 38.92 (10.01) 35.48 (9.08) 211 (50.7)
Gender, male, n (%) Age, mean (SD), yrs Education, mean (SD), yrs Province, n (%) Liaoning Hunan Shandong Religion belief, yes, n (%) Marital status, ever married, n (%) Mental disorders, yes, n (%) Approach coping skill, mean (SD) Avoidance coping skill, mean (SD) Negative life events, yes, n (%)
1.456 1.756 206.365*** 23.138*** −1.867* 152.686***
Note. A one-tailed test was used. *p < 0.05. **p < 0.01. ***p < 0.001.
Table 3
The Moderating Effect of Approach and Avoidance Coping Skill (N = 808) Variable Male Age Education years Province (Reference = Shandong) Liaoning Hunan Religion belief Ever married Mental disease Negative life events Approach coping skill Negative life events * Approach coping skill Avoidance coping skill Negative life * Avoidance coping skill Constant Pseudo R2
Model A
Model B
Model C
1.026 1.014 0.751***
0.841 1.008 0.747***
0.912 1.024 0.794***
0.814 1.051 1.920 0.620** 22.394***
0.845 1.798* 1.645 0.487* 14.163*** 3.338***
0.941 2.956** 1.762 0.399** 10.243*** 2.212*** 0.898*** 0.992
5.492** 0.420
1.026 0.984** 0.982 0.420
28.722*** 0.704
*p < 0.05. **p < 0.01. ***p < 0.001.
of the approach coping skill were not statistically significant, shown in Model C. The moderating effect of the avoidance coping skill was a negative sign (odds ratio = 0.984). More specifically, a high level of the avoidance coping skill had a moderating effect between negative life events and suicide. As shown in Figure 1, people with high levels of negative life events (one standard deviation above the mean) and low levels of the avoidance coping skill have the highest risk of suicide.
Discussion In this sample of young people who died by suicide in rural China, we found that 90.6% of them had experienced negative life events during the past year, similar to the results of previous studies (Li et al., 2008; Zhang & Ma, 2012). According to our analysis, the results of the moderating
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Figure 1. The moderating effect of the avoidance coping skill.
effect of the avoidance coping skill were statistically significant, but not for the approach coping skill. Several studies conducted in both China and Western countries (Abu-Hijleh, 1998; Liu & Tein, 2005; Rubenowitz et al., 2001) have also indicated that negative life events are significant predictors of suicide. Nevertheless, experiencing negative life events cannot be an independent factor for suicide, as some people may respond to the same negative life events in a different way. This study tested the moderating effect of coping skills between negative life events and suicide and found that the avoidance coping skill can be a moderator between them. To the best of our knowledge, this is the first study to test the moderating effect of coping skills between negative life events and suicide. For suicide ideation, some studies illustrated that problem solving moderated the associations between life event stress and suicidal behaviors (Clum & Febbraro, 1994; Grover et al., 2009; Yang & Clum, 1994). Another study showed that the moderating effect of coping skills was not found between life stress and suicide ideation (Dixon, Heppner, & Anderson, 1991; Zhang et al., 2012). Their results revealed that suicide can be aroused by negative life events, and that a low level of the avoidance coping skill can strengthen the risk of suicide. In other words, the avoidance coping skill could be an effective method for ameliorating negative life events. The reason can be explained as follows: As we know, the avoidance coping skill cannot modify the situation, but it is helpful in reducing psychological discomfort. Psychological factors are the most important risk factors for suicide. So, if the avoidance coping skill reduces the level of psychological discomfort, which is an important risk factor of suicide, then the risk of suicidal behavior would be reduced. And since the avoidance coping skill is also helpful for reducing the probability of suicide promoted by negative life events, receiving training in the avoidance coping skill would be helpful for suicide prevention. Our results support that the approach coping skill cannot be a moderator between negative life events and suicide. Our findings also indicate that the approach coping skill did not work effectively when facing negative life events, possibly because the results were based on rural people with low levels of education (about 7 years, the first year in middle school in our sample). Although the approach coping skill was not found to be a moderating effect in our study, it can be an independent, protective factor for suicidal behavior. So, receiving training in approach coping skills can also be helpful for suicide prevention.
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Limitations There are several limitations that should be addressed when interpreting these results. First, the psychological autopsy method was used for the data collection in this study. As data were obtained from the proxy informants, errors and biases can be a problem for the truth of the data. For example, mental disorders diagnosed with SCID without the presence of the target person may not be as accurate as a face-to-face interview between the patient and the psychiatrist. Second, we focused only on the number of negative life events, and the classification of negative life events may also be important risk factors for suicide behavior. Third, researchers could not be blinded to case status, so potentially they might be biased. Fourth, we did not control for the differences between suicides and controls in the analysis; for example, the age among suicides was older than the controls. Finally, the coping skill was measured by the CRI, and the reliability and validity of the scale deserve further tests in Chinese societies.
Conclusion Despite these limitations, the study can still contribute to our understanding of the mechanism of how negative life events and coping skill affect suicide. The major finding is that a low level of the avoidance coping skill may represent a promising variable for screening for suicide risk in rural China. Training in the avoidance coping skill is also helpful for suicide prevention. The moderating effect of avoidance coping skill between negative life events and suicide may be translated into practical measures in suicide prevention in China as well as elsewhere in the world.
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