Community Ment Health J DOI 10.1007/s10597-015-9863-7
ORIGINAL PAPER
Factors Influencing Suicidal Ideation Among Korean Adults by Age: Results of the 2010–2011 Korean Health and Nutrition Examination Survey Eun-ok Park1 • Hyo Young Lee2
Received: 5 June 2014 / Accepted: 24 March 2015 Ó Springer Science+Business Media New York 2015
Abstract Suicidal ideation increases the risk of suicide. This study investigated the age-specific contributions of sociodemographic factors, health status, and health behaviors to suicidal ideation using nationally representative data. The factors associated with suicidal ideation differ by age. Perceived bad health, stress, and depression had a significant influence on suicidal ideation in all age groups, but their specific effects differed in different age groups. The influence of perceived bad health increased with age, and the effect of stress was strongest among those aged 45–64 years. Moreover, the effect of being depressed decreased by age and was strongest among those 20–44 years of age. Disease and marital status did not have a significant effect on suicidal ideation among those 45–64 years old, and education had no effect among those 65 years or older. Keywords
Suicidal ideation Factors Age
Introduction Suicide is among the major public health concerns worldwide. In South Korea, deaths attributable to suicide increased from 14.4 per 100,000 in 2001 to 31.7 per 100,000 in 2011 (Statistics Korea 2012). Among members of the Organization for Economic Cooperation and Development (OECD), Korea had the highest suicide mortality rate in 2009 (OECD & Hyo Young Lee [email protected]; [email protected] 1
Nursing Department, Jeju National University, Jeju, South Korea
2
Department of Health Administration, Dongseo University, San 69-1, Jurae-2dong Sasang-gu, Busan, South Korea
2011); it has also experienced the most rapid increase in deaths attributable to suicide since 1995 (OECD 2011). Suicidal behaviors can be conceptualized in terms of a complex process that ranges from suicidal ideation to completed suicide (World Health Organization 2012). Suicidal ideation is considered the initial phase of a continuum that includes suicidal ideation, suicide attempts, and completed suicides (Sugawara et al. 2013). Previous studies have shown that suicidal ideation increases the risk of completed suicide (Khang et al. 2010). Thus, understanding suicidal ideation should help to prevent suicide (Chin et al. 2011). Many studies have been conducted in South Korea to understand suicidal ideation, with the aim of contributing to efforts to prevent and reduce the frequency of this phenomenon. These studies have usually focused on specific populations, such as patients with mental disorders or other chronic diseases (Han et al. 2013), adolescents (Park 2008; Park and Moon 2010), or elderly individuals (Jeon et al. 2007; Kim 2010; Shin et al. 2013; Yi et al. 2011). Several studies have investigated sex differences in suicidal ideation (Chin et al. 2011; Jeon et al. 2007), but relatively few have focused on differences by age in the general population. Suicide mortality increases as a function of age. In South Korea, the number of deaths attributable to suicide in 2011 was 24.3 per 100,000 individuals among those in their 20s and 116.9 per 100,000 individuals among those in their 80s. The figures for other age groups were 30.5 per 100,000 among those in their 30s, 34.0 per 100,000 among those in their 40s, 41.2 per 100,000 among those in their 50s, 50.1 per 100,000 among those in their 60s, and 84.4 per 100,000 among those in their 70s (Statistics Korea 2012). Suicide was the leading cause of death among individuals 10–39 years of age and the second leading cause of death in those 40–59 years of age (Statistics Korea 2012).
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Suicidal behaviors including suicidal ideation, suicide attempts, and completed suicides are influenced by numerous variables, including psychological, social, situational, and biological factors (World Health Organization 2012). Given that the risk factors for chronic diseases often cluster together because many are related to socioeconomic status (Kuh and Shlomo 2004), we expected that risk factors for suicidal ideation would differ based on life course. Previous studies have shown different patterns of risk factors for men and women (Chin et al. 2011; Sugawara et al. 2013; Takada et al. 2009), and suicidal ideation may also differ according to age group (young adults, middleaged, elderly). However, the prevalence and predictors of suicidal ideation by age group have not been established. Therefore, this study investigated whether the factors that predict suicidal ideation in Korean adults differ by age group using a large stratified-cluster randomized sample. The purpose of this study was to explore the prevalence of suicidal ideation by age group; to compare the prevalence of suicidal ideation according to sociodemographic characteristics, health status, health behavior, and mental health status; and to examine the age-specific contributions of sociodemographic factors, health status, health behaviors, and mental health status to suicidal ideation.
Methods Study Design This study is a secondary analysis of data that was previously collected in a nationally representative cross-sectional and population-based survey conducted by the Korea Centers for Disease Control (KCDC). The Korean National Health and Nutrition Examination Survey (KNHANES) was approved by the KCDC Institutional Ethics Review Board (No. 2010-02CON-21-C, 2011-02CON-06-C), and all participants provided written informed consent before data collection (Ministry of Health and Welfare and Korea Center for Disease Control and Prevention 2012). Participants Survey participants were selected using a complex, stratified, multistage probability sampling method. Sampling districts were selected based on geographic area, house type, and residents’ population characteristics (age and gender), 20 households per districts were chosen with systematic sampling method (Ministry of Health and Welfare and Korea Center for Disease Control and Prevention 2012). Face-to-face interviews by trained interviewers were conducted in mobile health examination centers. The response rates were 81.9 % in 2010 and
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80.4 % in 2011 (Ministry of Health and Welfare and Korea Center for Disease Control and Prevention 2012). Among a total of 17,476 individuals who participated, 12,148 participants aged 20 years or older were included in this study. Data were directly downloaded and protected with a password after permission to use the raw data was granted by the KCDC. The present study relied on raw data from the KNHANES 2010 and 2011 and did not involve additional contact with subjects. Procedures The questionnaires for KNHANES V were reviewed by the advisory committee of the KCDC. Participants were interviewed about socio-demographic characteristics and health status at mobile medical examination centers by trained interviewers. Self-reported information about health behaviors and mental health status, including suicidal ideation, was collected from all participants. Height and weight were measured at the mobile medical center with the participant wearing light clothing and no shoes. Measurements The socio-demographic characteristics examined in this study include sex (male, female), age group (20–44, 45–64, and 65 years and older), marital status (never married, married, separated/divorced/widowed), educational level (no education or elementary school, middle school, high school, and college or higher), engagement in economic activity (engaged, not engaged), and income level (low, lower middle, upper middle, high). Health Status Our examination of health status addressed two variables: perceived general health and disease. A single question was used to evaluate subjects’ general health status: ‘‘In general, how would you rate your health?’’ Participants could select among the following response options: excellent, good, fair, poor, and very poor. Responses were dichotomized into ‘‘healthy’’ (excellent/good/fair) and ‘‘not healthy’’ (poor/very poor). Perceived general health has been used worldwide to assess participants’ health and has been shown to be an independent predictor of mortality (Agyemang et al. 2006). The disease status of participants was diagnosed by physicians and coded as ‘‘have’’ or ‘‘does not have.’’ Health Behaviors Data on current smoking, high-risk alcohol consumption (seven drinks or more at one time for men and five drinks
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or more at one time for women, more than twice per week: seven drinks are equal to five cans of beer, five drinks are equal to three cans of beer; one can of beer is 355 cc) (Ministry of Health and Welfare and Korea Center for Disease Control and Prevention 2012), a high degree of alcohol dependency (Alcohol Use Disorders Identification Test (AUDIT) scores of at least 20) (Babor et al. 2001), physical activity (walking more than 30 min per day more than five times per week on average), and obesity (underweight, normal weight, overweight, or obese based on body mass index (BMI): \18.5, 18.5–25, and C25, respectively) were analyzed. Detailed descriptions of AUDIT and of anthropometric measurements have been published elsewhere (Ministry of Health and Welfare and Korea Center for Disease Control and Prevention 2012). Participants with AUDIT scores 12 and over were placed in the ‘‘alcohol-dependence’’ group, and those with scores lower than 12 were placed in the ‘‘normal’’ group. Mental Health Status and Suicidal Ideation Subjects’ perceived stress was measured by asking, ‘‘How much stress do you feel on an ordinary day?’’ The response options were ‘‘very much,’’ ‘‘much,’’ ‘‘moderate,’’ and ‘‘a little’’; these were collapsed into ‘‘very much/much,’’ which was coded as ‘‘much,’’ and ‘‘moderate/a little,’’ which was coded as ‘‘a little.’’ Subjects were asked a single question to assess depression: ‘‘Have you ever felt sad, blue, or depressed enough that it affected your daily life almost every day for at least two consecutive weeks in the last year?’’ Response options were ‘‘yes’’ and ‘‘no.’’ The following question was asked to examine suicidal ideation: ‘‘Have you ever seriously considered committing suicide or taking your own life in the past year?’’ Response options were ‘‘yes’’ and ‘‘no.’’ Data Analysis Data analysis was performed with SAS software (version 9.3), and all analyses relied on the pooled weights of sampling clusters to yield statistics that were representative of the Korean adult population. Chi square tests were performed to examine differences in the prevalence of suicidal ideation by participants’ characteristics according to age group. The results are presented as weighted percentages with standard errors and as adjusted odds ratios (ORs) with confidence intervals (CIs). Adjusted ORs were estimated using multiple logistic regression models controlling for socio-economic variables, health behaviors, and other risk factors. Multiple logistic regression analyses with manual backward stepwise selection were performed to explore the factors predictive of suicidal ideation by age group. In the first step, all factors were included in the
initial logistic models. In the second step, the variables with p values [.15 were removed from the full models. In the final step, the variables with p values[.05 were deleted from the remaining models. The final models for each age group are presented in the results.
Results General Characteristics of Participants A total of 12,148 Korean adults aged 20 years or older were included in this study; 4843 participants were aged 20–44 years, 4469 were aged 45–64 years, and 2836 were aged 65 years or older. Women comprised 57 % of all participants (6953), 48.6 % of 20–44 year olds, 50.1 % of 45–64 year olds, and 58.8 % of those 65 years or older. Men comprised 51.4 % (20–44 years), 49.9 % (45–64 years), and 41.2 % (65 years or older) of each age group, respectively. Most participants in all age groups were married, including 59.2, 88.1, and 63.1 % of those aged 20–44, 45–64, and 65 years or older, respectively. As for education level, the highest proportion was ‘university’ in the group aged 20–44 years (49.5 %), ‘high school’ in those aged 45–64 years (34.2 %), and ‘none or elementary’ in those aged 65 years or older (72.0 %). Economic activity was least prevalent among individuals aged 65 years or older (35 %). The prevalence of perceived good health decreased and that of diseases increased as a function of age. Additionally, the rates of smoking and high-risk drinking increased with age, but the number of hours slept decreased with age. In terms of mental health, stress decreased (32.1, 24.5, and 22.6 % among those aged 20–44, 45–64, and 65 years or older, respectively), but suicidal ideation increased (11.3, 14.9, and 23.9 % among those aged 20–44, 45–64, and 65 years or older, respectively) as a function of age. Suicidal Ideation According to Subjects’ Characteristics by Age Group The rate of suicidal ideation was higher among women than among men, and it increased with age for both sexes (15.6 vs. 7.5 %, 18.5 vs. 11.4 %, and 29.5 vs. 16.1 % in women vs. men, among those aged 20–44, 45–64, and 65 years or older, respectively). Suicidal ideation among the never-married group also increased with age (12.5, 22.1, and 42.8 % among those aged 20–44, 45–64, and 65 years or older, respectively). Among middle school graduates, suicidal ideation was most prevalent in those aged 20–44 years (25.5 %), but suicidal ideation was more prevalent among those with no education or elementary
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school only (28.0 %), and its prevalence in this group increased as a function of age (21.6, 23.6, and 28.0 % among those aged 20–44, 45–64, and 65 years or older, respectively). Suicidal ideation increased with age among both those who were and those who were not engaged in economic activity (9.9, 13.0, and 19.5 % among those aged 20–44, 45–64, and 65 years or older, respectively, who were so engaged and 14.5, 20.1, and 26.2 % at ages 20–44, 45–64, and 65 years or older, respectively, among those who were not engaged in economic activity). The relationship between suicidal ideation and income became stronger with age, with those in the low income level showing the highest suicidal ideation at 14.2, 21.1, and 28.0 % of those aged 20–44, 45–64, and 65 years or older, respectively. Suicidal ideation was more prevalent among those with perceived bad health than among those with perceived good health, and the rate of suicidal ideation in both groups increased with age (25.2, 31.2, and 39.1 % among those aged 20–44, 45–64, and 65 years or older, respectively, who were unhealthy and 9.6, 10.9, and 15.8 % at ages 20–44, 45–64, and 65 years or older, respectively, among those who were healthy). The results of the analysis according to disease status followed the same pattern as that of perceived health. The analysis according to specific health behaviors yielded no statistically significant correlations. However, suicidal ideation was more prevalent in those who slept fewer than 6 h than in those who slept more than 6 h among those aged 20–44 years. Additionally, suicidal ideation was more common among those reporting high levels of stress and depression, and high levels of stress were particularly strongly associated with suicidal ideation (23.1, 36.5, and 51.5 % among those aged 20–44, 45–64, and 65 years or older, respectively, who felt much stress and 5.8, 7.9, and 15.9 % at ages 20–44, 45–64, and 65 years or older, respectively, among those who felt little stress). As for depression, feelings of melancholy were strongly associated with suicidal ideation (50.8, 54.0, and 64.2 % among those aged 20–44, 45–64, and 65 years or older, respectively, who felt melancholy and 6.5, 8.0, and 16.4 % at ages 20–44, 45–64, and 65 years or older, respectively, among those who did not feel melancholy. Multiple Logistic Regression Analyses: Predictive Factors for Suicidal Ideation by Age Group The factors that predicted suicidal ideation differed by age group. The influence of suicidal ideation was observed only among those aged 20–44 years, and the OR for suicidal ideation among women in this age group was 2.23 (95 % CI 1.69–2.95). Level of education had a significant impact on suicidal ideation only among those younger than 65 years of age. Compared with university graduates, the
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OR for middle school graduates aged 24–44 years was 3.01 (95 % CI 1.57–5.79), and that for those with no education or with an elementary school education aged 45–64 years was 1.70 (95 % CI 1.16–2.51). Marital status did not have a significant influence on the suicidal ideation in those aged 45–64 years, but the OR for those who were never married and aged 20–44 years was 1.39 (95 % CI 1.05–1.85). Additionally, the OR among those who were separated/divorced/widowed in those aged 65 years or over was 1.91 (95 % CI 1.43–2.56). Suffering from a disease had no influence on the suicidal ideation of those aged 45–64 years. However, having a disease had a similar influence on suicidal ideation among those aged 20–44 years (OR 1.39, 95 % CI 1.02–1.90) and those aged 65 years and older (OR 1.43, 95 % CI 1.05–1.95). High-risk drinking exerted a significant influence on suicidal ideation only among those 20–44 years old (OR 1.98, 95 % CI 1.25–3.14). Engagement in economic activity and income level had a significant influence on the suicidal ideation of only those 45–64 years old. Those in this age group who were not engaged in economic activity had 1.49 times the risk of suicidal ideation (95 % CI 1.09–2.03). Additionally, people with the lowest income had a 1.60-fold higher risk for suicidal ideation (95 % CI 1.09–2.35) compared with those with high income among participants aged 45–64 years. Perceived health, stress, and depression had a significant effect on suicidal ideation in all age groups. The influence of perceived bad health increased with age, from an OR of 1.67 (95 % CI 1.21–2.32) among those aged 20–44 years to 2.13 (95 % CI 1.62–2.79) among those aged 65 and older. The influence of stress was significantly stronger in those aged 45–64 years (OR 4.05, 95 % CI 3.10–5.29), and the effect of depression was strongest among those aged 20–44 years (OR 9.17, 95 % CI 6.69–12.56). This effect was also significant among those aged 45–64 years (OR 8.02, 95 % CI 5.94–10.83) and those aged 65 years and older (OR 5.32, 95 % CI 3.90–7.26).
Discussion This study found that the factors associated with suicidal ideation differ by age. Although perceived bad health, stress, and depression had a significant influence on suicidal ideation in all age groups, their specific effects differed in different age groups. The influence of perceived bad health increased with age and was strongest among those 65 years or older, and the effect of stress was strongest among those aged 45–64 years. Moreover, the effect of being depressed decreased by age and was strongest among those 20–44 years of age. Disease and marital status did not have a significant effect on suicidal ideation among
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those 45–64 years old, and education had no effect among those 65 years or older. Among those 20–44 years old, being female, never married, and engaging in high-risk drinking were additional contributors to suicidal ideation. Among those 45–64 years old, economic activity and low income level were additional contributing factors. Perceived health, stress, and depression have been established as contributors to suicidal ideation, and the results of this study are consistent with those of previous research in this regard (Chin et al. 2011; Han et al. 2013; Wasserman 2001). Depression had the strongest effect on suicidal ideation irrespective of age group, although its impact decreased gradually as a function of age. In general, senses and feelings become duller with age (Eliopoulos 2013), which might reduce the impact of depression on suicidal ideation among those aged 65 and older. It could also be that the effects of other factors, such as perceived health and stress, were stronger, reducing the relative influence of depression. Nevertheless, depression still had the greatest influence on suicidal ideation compared with other factors in this age group. The effect of stress was the strongest among those aged 45–64 years. This finding may relate to the numerous changes that occur during this stage in life, to the pressure for improved job performance due to unstable employment and economic conditions, and/or to impending retirement (Cunningham and Brookbank 1988). In contrast, the influence of perceived health increased with age, from an OR of 1.67 among those 20–44 years of age to an OR of 2.13 among those 65 years and older. Additionally, perceived health status decreased significantly as people aged, and the influence of perceived health on suicidal ideation increased with age. Elderly individuals experience more disabilities and illnesses than do younger individuals, which may increase the influence of perceived health relative to that of other factors. Moreover, perceived health has been presumed to be a reliable and valid indicator of general health and has been shown to be correlated with more objective measures of acute and chronic illness as well as with general discomfort (Sturgis et al. 2001). The effect of stress was strongest, and that of other factors was reduced, in those aged 45–64 years. We found that sex had a significant influence on suicidal ideation only in those aged 20–44 years. It is possible that the suicidal ideation was significantly more prevalent in women than in men in this age group due to the burden of multiple gender-related roles such as child rearing, working outside the home, and caring for families. Indeed, women in Korea usually work irregular hours under poor working conditions and earn low salaries (Jeon et al. 2007). In terms of the effect of marital status, being unmarried had its strongest influence on suicidal ideation among those aged 20–44 years, whereas being separated, divorced, or widowed exerted more influence on suicidal ideation among
those 65 years and older. Suicidal ideation may be affected by the unique stressors associated with different developmental stages, such as retirement or the loss of a spouse or loved one (Juurlink et al., 2004) for those aged 65 and older and being unmarried among those aged 20–44 years (Hong et al. 2003; Nock et al. 2008). Previous studies have reported similar results, namely that living alone and having depressive symptoms were strongly associated with suicidal ideation among elderly Koreans (Jeon et al. 2007) and that never marrying was strongly associated with suicidal ideation in those aged 20–44 than in other age groups (Chin et al. 2011). Educational level had a significant effect on suicidal ideation only among those aged 64 and younger. This finding may relate to the fact that most Koreans aged 65 and older in our study had little or no formal education. Thus, this lack of effect of educational level is similar to the absence of any effect of participation in economic activities among those aged 65 and older. Among those 20–44 years old, sex, marital status, and high-risk drinking were additional factors influencing suicidal ideation. These results show that effect sizes may differ according to the life events associated with different life stages. Additionally, the relationship between high-risk drinking and suicidal ideation among those in this age group may be bidirectional; that is, high-risk drinking may result from increased suicidal ideation. Economic activity and income level were additional factors with significant influence on the suicidal ideation of those aged 45–64 years. Economic activity and income level exerted significant influence among only those aged 45–64 years, which may relate to the life events associated with this stage, such as spending considerable money to educate one’s children, caring for parents (including with regard to health problems), and paying for the marriage of one’s children. In Korea, 80 % of those who graduate from high school enter college or university, and parents usually provide their registration fees and tuition as well as pay for their children’s marriage ceremonies (Lee and Sung 1998). Retirement and the onset of chronic diseases are also associated with this stage in life, and these may constitute additional burdens. As for the effects of related factors on suicide, failing health, debilitating conditions, and living alone all influence suicide, particularly in older adults (Antai-Otong 2003). Additionally, previous studies have shown that the risk of suicide increases with age, consistent with the results of our study (Blazer 2000). Accordingly, older adults should be evaluated for suicide and depression during regular health check-ups so that an opportunity to intervene is not missed (Gallo and Lebowitz 1999). On the other hand, regardless of age group, stressful life events and significant losses, particularly those that generate feelings
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of helplessness and hopelessness, often contribute to depression (Antai-Otong 2003). Our results also showed that stress was an important factor in suicidal ideation in all age groups. Our study has several limitations that should be considered as we examine the results. First, this study used single questions to assess suicidal ideation, stress, and depression. Furthermore, because these variables were measured dichotomously by a ‘‘yes’’ or ‘‘no’’ response, the degree to which each variable existed for the individual participant was not reflected in the responses. Nevertheless, although the single-question health measure probably had limited reliability, this question has been shown to be a valid predictor of morbidity in previous research, even after controlling for known socio-demographic and medical risk factors (Idler and Benyamini 1997). Single-item measures offer a practical tool for assessing stress in large prospective epidemiologic studies that cannot accommodate longer measures (Littman et al. 2006). Second, our study was a secondary analysis of previously collected data, so we could not easily manage the variables of interest. However, our results showed that suicide ideation was associated with known factors in expected ways. Furthermore, the fact that our data were derived from a nationally representative cross-sectional and population-based survey can be considered a strength of this study. Third, the findings may be subject to underreporting and biased recall, as the data were based on retrospective self-report. Fourth, our study was cross-sectional, precluding any inferences regarding causation. Thus, reverse causality or a mixture of causal effects in both directions must be considered. Nevertheless, although this study had several limitations, it provides information confirming that the factors associated with suicidal ideation differed by age, and their specific effects differed in different age groups.
Conclusions This study, which suggests that the factors that affect suicidal ideation differ by age group, should be helpful for targeting suicide prevention programs according to age. Most importantly, because depression was the strongest predictor of suicidal ideation among all age groups, regular health screenings or check-ups should include questions about this symptom. Additionally, interventions to promote perceived good health (e.g., by promoting social participation) (Lee et al. 2008) and prevent chronic diseases (e.g., by providing health screening and health education) are needed, especially among elderly individuals. Programs directed at those 20–44 years of age should offer methods to prevent and alleviate stress, support systems for working women, and interventions to prevent and
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treat binge drinking. Because this study also confirmed the relationship between binge drinking and suicidal ideation, appropriate interventions should be developed. As stress or/and economic factors exerted their strongest influence on suicidal ideation among those aged 45–65 years, these issues must be considered when developing health education for this population. Indeed, it may be possible to identify the economic problems encountered by this age group via social programs. Additionally, interventions, including social support and health education, should be targeted at separated, divorced, or widowed elderly individuals. Acknowledgments The data for this research were supplied by the Korean Centers for Disease Control and Prevention (KCDC). This research was supported by an academic research fund provided by Jeju National University 2014 and Dongseo University 2014.
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ORIGINAL PAPER
Factors Influencing Suicidal Ideation Among Korean Adults by Age: Results of the 2010–2011 Korean Health and Nutrition Examination Survey Eun-ok Park1 • Hyo Young Lee2
Received: 5 June 2014 / Accepted: 24 March 2015 Ó Springer Science+Business Media New York 2015
Abstract Suicidal ideation increases the risk of suicide. This study investigated the age-specific contributions of sociodemographic factors, health status, and health behaviors to suicidal ideation using nationally representative data. The factors associated with suicidal ideation differ by age. Perceived bad health, stress, and depression had a significant influence on suicidal ideation in all age groups, but their specific effects differed in different age groups. The influence of perceived bad health increased with age, and the effect of stress was strongest among those aged 45–64 years. Moreover, the effect of being depressed decreased by age and was strongest among those 20–44 years of age. Disease and marital status did not have a significant effect on suicidal ideation among those 45–64 years old, and education had no effect among those 65 years or older. Keywords
Suicidal ideation Factors Age
Introduction Suicide is among the major public health concerns worldwide. In South Korea, deaths attributable to suicide increased from 14.4 per 100,000 in 2001 to 31.7 per 100,000 in 2011 (Statistics Korea 2012). Among members of the Organization for Economic Cooperation and Development (OECD), Korea had the highest suicide mortality rate in 2009 (OECD & Hyo Young Lee [email protected]; [email protected] 1
Nursing Department, Jeju National University, Jeju, South Korea
2
Department of Health Administration, Dongseo University, San 69-1, Jurae-2dong Sasang-gu, Busan, South Korea
2011); it has also experienced the most rapid increase in deaths attributable to suicide since 1995 (OECD 2011). Suicidal behaviors can be conceptualized in terms of a complex process that ranges from suicidal ideation to completed suicide (World Health Organization 2012). Suicidal ideation is considered the initial phase of a continuum that includes suicidal ideation, suicide attempts, and completed suicides (Sugawara et al. 2013). Previous studies have shown that suicidal ideation increases the risk of completed suicide (Khang et al. 2010). Thus, understanding suicidal ideation should help to prevent suicide (Chin et al. 2011). Many studies have been conducted in South Korea to understand suicidal ideation, with the aim of contributing to efforts to prevent and reduce the frequency of this phenomenon. These studies have usually focused on specific populations, such as patients with mental disorders or other chronic diseases (Han et al. 2013), adolescents (Park 2008; Park and Moon 2010), or elderly individuals (Jeon et al. 2007; Kim 2010; Shin et al. 2013; Yi et al. 2011). Several studies have investigated sex differences in suicidal ideation (Chin et al. 2011; Jeon et al. 2007), but relatively few have focused on differences by age in the general population. Suicide mortality increases as a function of age. In South Korea, the number of deaths attributable to suicide in 2011 was 24.3 per 100,000 individuals among those in their 20s and 116.9 per 100,000 individuals among those in their 80s. The figures for other age groups were 30.5 per 100,000 among those in their 30s, 34.0 per 100,000 among those in their 40s, 41.2 per 100,000 among those in their 50s, 50.1 per 100,000 among those in their 60s, and 84.4 per 100,000 among those in their 70s (Statistics Korea 2012). Suicide was the leading cause of death among individuals 10–39 years of age and the second leading cause of death in those 40–59 years of age (Statistics Korea 2012).
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Suicidal behaviors including suicidal ideation, suicide attempts, and completed suicides are influenced by numerous variables, including psychological, social, situational, and biological factors (World Health Organization 2012). Given that the risk factors for chronic diseases often cluster together because many are related to socioeconomic status (Kuh and Shlomo 2004), we expected that risk factors for suicidal ideation would differ based on life course. Previous studies have shown different patterns of risk factors for men and women (Chin et al. 2011; Sugawara et al. 2013; Takada et al. 2009), and suicidal ideation may also differ according to age group (young adults, middleaged, elderly). However, the prevalence and predictors of suicidal ideation by age group have not been established. Therefore, this study investigated whether the factors that predict suicidal ideation in Korean adults differ by age group using a large stratified-cluster randomized sample. The purpose of this study was to explore the prevalence of suicidal ideation by age group; to compare the prevalence of suicidal ideation according to sociodemographic characteristics, health status, health behavior, and mental health status; and to examine the age-specific contributions of sociodemographic factors, health status, health behaviors, and mental health status to suicidal ideation.
Methods Study Design This study is a secondary analysis of data that was previously collected in a nationally representative cross-sectional and population-based survey conducted by the Korea Centers for Disease Control (KCDC). The Korean National Health and Nutrition Examination Survey (KNHANES) was approved by the KCDC Institutional Ethics Review Board (No. 2010-02CON-21-C, 2011-02CON-06-C), and all participants provided written informed consent before data collection (Ministry of Health and Welfare and Korea Center for Disease Control and Prevention 2012). Participants Survey participants were selected using a complex, stratified, multistage probability sampling method. Sampling districts were selected based on geographic area, house type, and residents’ population characteristics (age and gender), 20 households per districts were chosen with systematic sampling method (Ministry of Health and Welfare and Korea Center for Disease Control and Prevention 2012). Face-to-face interviews by trained interviewers were conducted in mobile health examination centers. The response rates were 81.9 % in 2010 and
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80.4 % in 2011 (Ministry of Health and Welfare and Korea Center for Disease Control and Prevention 2012). Among a total of 17,476 individuals who participated, 12,148 participants aged 20 years or older were included in this study. Data were directly downloaded and protected with a password after permission to use the raw data was granted by the KCDC. The present study relied on raw data from the KNHANES 2010 and 2011 and did not involve additional contact with subjects. Procedures The questionnaires for KNHANES V were reviewed by the advisory committee of the KCDC. Participants were interviewed about socio-demographic characteristics and health status at mobile medical examination centers by trained interviewers. Self-reported information about health behaviors and mental health status, including suicidal ideation, was collected from all participants. Height and weight were measured at the mobile medical center with the participant wearing light clothing and no shoes. Measurements The socio-demographic characteristics examined in this study include sex (male, female), age group (20–44, 45–64, and 65 years and older), marital status (never married, married, separated/divorced/widowed), educational level (no education or elementary school, middle school, high school, and college or higher), engagement in economic activity (engaged, not engaged), and income level (low, lower middle, upper middle, high). Health Status Our examination of health status addressed two variables: perceived general health and disease. A single question was used to evaluate subjects’ general health status: ‘‘In general, how would you rate your health?’’ Participants could select among the following response options: excellent, good, fair, poor, and very poor. Responses were dichotomized into ‘‘healthy’’ (excellent/good/fair) and ‘‘not healthy’’ (poor/very poor). Perceived general health has been used worldwide to assess participants’ health and has been shown to be an independent predictor of mortality (Agyemang et al. 2006). The disease status of participants was diagnosed by physicians and coded as ‘‘have’’ or ‘‘does not have.’’ Health Behaviors Data on current smoking, high-risk alcohol consumption (seven drinks or more at one time for men and five drinks
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or more at one time for women, more than twice per week: seven drinks are equal to five cans of beer, five drinks are equal to three cans of beer; one can of beer is 355 cc) (Ministry of Health and Welfare and Korea Center for Disease Control and Prevention 2012), a high degree of alcohol dependency (Alcohol Use Disorders Identification Test (AUDIT) scores of at least 20) (Babor et al. 2001), physical activity (walking more than 30 min per day more than five times per week on average), and obesity (underweight, normal weight, overweight, or obese based on body mass index (BMI): \18.5, 18.5–25, and C25, respectively) were analyzed. Detailed descriptions of AUDIT and of anthropometric measurements have been published elsewhere (Ministry of Health and Welfare and Korea Center for Disease Control and Prevention 2012). Participants with AUDIT scores 12 and over were placed in the ‘‘alcohol-dependence’’ group, and those with scores lower than 12 were placed in the ‘‘normal’’ group. Mental Health Status and Suicidal Ideation Subjects’ perceived stress was measured by asking, ‘‘How much stress do you feel on an ordinary day?’’ The response options were ‘‘very much,’’ ‘‘much,’’ ‘‘moderate,’’ and ‘‘a little’’; these were collapsed into ‘‘very much/much,’’ which was coded as ‘‘much,’’ and ‘‘moderate/a little,’’ which was coded as ‘‘a little.’’ Subjects were asked a single question to assess depression: ‘‘Have you ever felt sad, blue, or depressed enough that it affected your daily life almost every day for at least two consecutive weeks in the last year?’’ Response options were ‘‘yes’’ and ‘‘no.’’ The following question was asked to examine suicidal ideation: ‘‘Have you ever seriously considered committing suicide or taking your own life in the past year?’’ Response options were ‘‘yes’’ and ‘‘no.’’ Data Analysis Data analysis was performed with SAS software (version 9.3), and all analyses relied on the pooled weights of sampling clusters to yield statistics that were representative of the Korean adult population. Chi square tests were performed to examine differences in the prevalence of suicidal ideation by participants’ characteristics according to age group. The results are presented as weighted percentages with standard errors and as adjusted odds ratios (ORs) with confidence intervals (CIs). Adjusted ORs were estimated using multiple logistic regression models controlling for socio-economic variables, health behaviors, and other risk factors. Multiple logistic regression analyses with manual backward stepwise selection were performed to explore the factors predictive of suicidal ideation by age group. In the first step, all factors were included in the
initial logistic models. In the second step, the variables with p values [.15 were removed from the full models. In the final step, the variables with p values[.05 were deleted from the remaining models. The final models for each age group are presented in the results.
Results General Characteristics of Participants A total of 12,148 Korean adults aged 20 years or older were included in this study; 4843 participants were aged 20–44 years, 4469 were aged 45–64 years, and 2836 were aged 65 years or older. Women comprised 57 % of all participants (6953), 48.6 % of 20–44 year olds, 50.1 % of 45–64 year olds, and 58.8 % of those 65 years or older. Men comprised 51.4 % (20–44 years), 49.9 % (45–64 years), and 41.2 % (65 years or older) of each age group, respectively. Most participants in all age groups were married, including 59.2, 88.1, and 63.1 % of those aged 20–44, 45–64, and 65 years or older, respectively. As for education level, the highest proportion was ‘university’ in the group aged 20–44 years (49.5 %), ‘high school’ in those aged 45–64 years (34.2 %), and ‘none or elementary’ in those aged 65 years or older (72.0 %). Economic activity was least prevalent among individuals aged 65 years or older (35 %). The prevalence of perceived good health decreased and that of diseases increased as a function of age. Additionally, the rates of smoking and high-risk drinking increased with age, but the number of hours slept decreased with age. In terms of mental health, stress decreased (32.1, 24.5, and 22.6 % among those aged 20–44, 45–64, and 65 years or older, respectively), but suicidal ideation increased (11.3, 14.9, and 23.9 % among those aged 20–44, 45–64, and 65 years or older, respectively) as a function of age. Suicidal Ideation According to Subjects’ Characteristics by Age Group The rate of suicidal ideation was higher among women than among men, and it increased with age for both sexes (15.6 vs. 7.5 %, 18.5 vs. 11.4 %, and 29.5 vs. 16.1 % in women vs. men, among those aged 20–44, 45–64, and 65 years or older, respectively). Suicidal ideation among the never-married group also increased with age (12.5, 22.1, and 42.8 % among those aged 20–44, 45–64, and 65 years or older, respectively). Among middle school graduates, suicidal ideation was most prevalent in those aged 20–44 years (25.5 %), but suicidal ideation was more prevalent among those with no education or elementary
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school only (28.0 %), and its prevalence in this group increased as a function of age (21.6, 23.6, and 28.0 % among those aged 20–44, 45–64, and 65 years or older, respectively). Suicidal ideation increased with age among both those who were and those who were not engaged in economic activity (9.9, 13.0, and 19.5 % among those aged 20–44, 45–64, and 65 years or older, respectively, who were so engaged and 14.5, 20.1, and 26.2 % at ages 20–44, 45–64, and 65 years or older, respectively, among those who were not engaged in economic activity). The relationship between suicidal ideation and income became stronger with age, with those in the low income level showing the highest suicidal ideation at 14.2, 21.1, and 28.0 % of those aged 20–44, 45–64, and 65 years or older, respectively. Suicidal ideation was more prevalent among those with perceived bad health than among those with perceived good health, and the rate of suicidal ideation in both groups increased with age (25.2, 31.2, and 39.1 % among those aged 20–44, 45–64, and 65 years or older, respectively, who were unhealthy and 9.6, 10.9, and 15.8 % at ages 20–44, 45–64, and 65 years or older, respectively, among those who were healthy). The results of the analysis according to disease status followed the same pattern as that of perceived health. The analysis according to specific health behaviors yielded no statistically significant correlations. However, suicidal ideation was more prevalent in those who slept fewer than 6 h than in those who slept more than 6 h among those aged 20–44 years. Additionally, suicidal ideation was more common among those reporting high levels of stress and depression, and high levels of stress were particularly strongly associated with suicidal ideation (23.1, 36.5, and 51.5 % among those aged 20–44, 45–64, and 65 years or older, respectively, who felt much stress and 5.8, 7.9, and 15.9 % at ages 20–44, 45–64, and 65 years or older, respectively, among those who felt little stress). As for depression, feelings of melancholy were strongly associated with suicidal ideation (50.8, 54.0, and 64.2 % among those aged 20–44, 45–64, and 65 years or older, respectively, who felt melancholy and 6.5, 8.0, and 16.4 % at ages 20–44, 45–64, and 65 years or older, respectively, among those who did not feel melancholy. Multiple Logistic Regression Analyses: Predictive Factors for Suicidal Ideation by Age Group The factors that predicted suicidal ideation differed by age group. The influence of suicidal ideation was observed only among those aged 20–44 years, and the OR for suicidal ideation among women in this age group was 2.23 (95 % CI 1.69–2.95). Level of education had a significant impact on suicidal ideation only among those younger than 65 years of age. Compared with university graduates, the
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OR for middle school graduates aged 24–44 years was 3.01 (95 % CI 1.57–5.79), and that for those with no education or with an elementary school education aged 45–64 years was 1.70 (95 % CI 1.16–2.51). Marital status did not have a significant influence on the suicidal ideation in those aged 45–64 years, but the OR for those who were never married and aged 20–44 years was 1.39 (95 % CI 1.05–1.85). Additionally, the OR among those who were separated/divorced/widowed in those aged 65 years or over was 1.91 (95 % CI 1.43–2.56). Suffering from a disease had no influence on the suicidal ideation of those aged 45–64 years. However, having a disease had a similar influence on suicidal ideation among those aged 20–44 years (OR 1.39, 95 % CI 1.02–1.90) and those aged 65 years and older (OR 1.43, 95 % CI 1.05–1.95). High-risk drinking exerted a significant influence on suicidal ideation only among those 20–44 years old (OR 1.98, 95 % CI 1.25–3.14). Engagement in economic activity and income level had a significant influence on the suicidal ideation of only those 45–64 years old. Those in this age group who were not engaged in economic activity had 1.49 times the risk of suicidal ideation (95 % CI 1.09–2.03). Additionally, people with the lowest income had a 1.60-fold higher risk for suicidal ideation (95 % CI 1.09–2.35) compared with those with high income among participants aged 45–64 years. Perceived health, stress, and depression had a significant effect on suicidal ideation in all age groups. The influence of perceived bad health increased with age, from an OR of 1.67 (95 % CI 1.21–2.32) among those aged 20–44 years to 2.13 (95 % CI 1.62–2.79) among those aged 65 and older. The influence of stress was significantly stronger in those aged 45–64 years (OR 4.05, 95 % CI 3.10–5.29), and the effect of depression was strongest among those aged 20–44 years (OR 9.17, 95 % CI 6.69–12.56). This effect was also significant among those aged 45–64 years (OR 8.02, 95 % CI 5.94–10.83) and those aged 65 years and older (OR 5.32, 95 % CI 3.90–7.26).
Discussion This study found that the factors associated with suicidal ideation differ by age. Although perceived bad health, stress, and depression had a significant influence on suicidal ideation in all age groups, their specific effects differed in different age groups. The influence of perceived bad health increased with age and was strongest among those 65 years or older, and the effect of stress was strongest among those aged 45–64 years. Moreover, the effect of being depressed decreased by age and was strongest among those 20–44 years of age. Disease and marital status did not have a significant effect on suicidal ideation among
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those 45–64 years old, and education had no effect among those 65 years or older. Among those 20–44 years old, being female, never married, and engaging in high-risk drinking were additional contributors to suicidal ideation. Among those 45–64 years old, economic activity and low income level were additional contributing factors. Perceived health, stress, and depression have been established as contributors to suicidal ideation, and the results of this study are consistent with those of previous research in this regard (Chin et al. 2011; Han et al. 2013; Wasserman 2001). Depression had the strongest effect on suicidal ideation irrespective of age group, although its impact decreased gradually as a function of age. In general, senses and feelings become duller with age (Eliopoulos 2013), which might reduce the impact of depression on suicidal ideation among those aged 65 and older. It could also be that the effects of other factors, such as perceived health and stress, were stronger, reducing the relative influence of depression. Nevertheless, depression still had the greatest influence on suicidal ideation compared with other factors in this age group. The effect of stress was the strongest among those aged 45–64 years. This finding may relate to the numerous changes that occur during this stage in life, to the pressure for improved job performance due to unstable employment and economic conditions, and/or to impending retirement (Cunningham and Brookbank 1988). In contrast, the influence of perceived health increased with age, from an OR of 1.67 among those 20–44 years of age to an OR of 2.13 among those 65 years and older. Additionally, perceived health status decreased significantly as people aged, and the influence of perceived health on suicidal ideation increased with age. Elderly individuals experience more disabilities and illnesses than do younger individuals, which may increase the influence of perceived health relative to that of other factors. Moreover, perceived health has been presumed to be a reliable and valid indicator of general health and has been shown to be correlated with more objective measures of acute and chronic illness as well as with general discomfort (Sturgis et al. 2001). The effect of stress was strongest, and that of other factors was reduced, in those aged 45–64 years. We found that sex had a significant influence on suicidal ideation only in those aged 20–44 years. It is possible that the suicidal ideation was significantly more prevalent in women than in men in this age group due to the burden of multiple gender-related roles such as child rearing, working outside the home, and caring for families. Indeed, women in Korea usually work irregular hours under poor working conditions and earn low salaries (Jeon et al. 2007). In terms of the effect of marital status, being unmarried had its strongest influence on suicidal ideation among those aged 20–44 years, whereas being separated, divorced, or widowed exerted more influence on suicidal ideation among
those 65 years and older. Suicidal ideation may be affected by the unique stressors associated with different developmental stages, such as retirement or the loss of a spouse or loved one (Juurlink et al., 2004) for those aged 65 and older and being unmarried among those aged 20–44 years (Hong et al. 2003; Nock et al. 2008). Previous studies have reported similar results, namely that living alone and having depressive symptoms were strongly associated with suicidal ideation among elderly Koreans (Jeon et al. 2007) and that never marrying was strongly associated with suicidal ideation in those aged 20–44 than in other age groups (Chin et al. 2011). Educational level had a significant effect on suicidal ideation only among those aged 64 and younger. This finding may relate to the fact that most Koreans aged 65 and older in our study had little or no formal education. Thus, this lack of effect of educational level is similar to the absence of any effect of participation in economic activities among those aged 65 and older. Among those 20–44 years old, sex, marital status, and high-risk drinking were additional factors influencing suicidal ideation. These results show that effect sizes may differ according to the life events associated with different life stages. Additionally, the relationship between high-risk drinking and suicidal ideation among those in this age group may be bidirectional; that is, high-risk drinking may result from increased suicidal ideation. Economic activity and income level were additional factors with significant influence on the suicidal ideation of those aged 45–64 years. Economic activity and income level exerted significant influence among only those aged 45–64 years, which may relate to the life events associated with this stage, such as spending considerable money to educate one’s children, caring for parents (including with regard to health problems), and paying for the marriage of one’s children. In Korea, 80 % of those who graduate from high school enter college or university, and parents usually provide their registration fees and tuition as well as pay for their children’s marriage ceremonies (Lee and Sung 1998). Retirement and the onset of chronic diseases are also associated with this stage in life, and these may constitute additional burdens. As for the effects of related factors on suicide, failing health, debilitating conditions, and living alone all influence suicide, particularly in older adults (Antai-Otong 2003). Additionally, previous studies have shown that the risk of suicide increases with age, consistent with the results of our study (Blazer 2000). Accordingly, older adults should be evaluated for suicide and depression during regular health check-ups so that an opportunity to intervene is not missed (Gallo and Lebowitz 1999). On the other hand, regardless of age group, stressful life events and significant losses, particularly those that generate feelings
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of helplessness and hopelessness, often contribute to depression (Antai-Otong 2003). Our results also showed that stress was an important factor in suicidal ideation in all age groups. Our study has several limitations that should be considered as we examine the results. First, this study used single questions to assess suicidal ideation, stress, and depression. Furthermore, because these variables were measured dichotomously by a ‘‘yes’’ or ‘‘no’’ response, the degree to which each variable existed for the individual participant was not reflected in the responses. Nevertheless, although the single-question health measure probably had limited reliability, this question has been shown to be a valid predictor of morbidity in previous research, even after controlling for known socio-demographic and medical risk factors (Idler and Benyamini 1997). Single-item measures offer a practical tool for assessing stress in large prospective epidemiologic studies that cannot accommodate longer measures (Littman et al. 2006). Second, our study was a secondary analysis of previously collected data, so we could not easily manage the variables of interest. However, our results showed that suicide ideation was associated with known factors in expected ways. Furthermore, the fact that our data were derived from a nationally representative cross-sectional and population-based survey can be considered a strength of this study. Third, the findings may be subject to underreporting and biased recall, as the data were based on retrospective self-report. Fourth, our study was cross-sectional, precluding any inferences regarding causation. Thus, reverse causality or a mixture of causal effects in both directions must be considered. Nevertheless, although this study had several limitations, it provides information confirming that the factors associated with suicidal ideation differed by age, and their specific effects differed in different age groups.
Conclusions This study, which suggests that the factors that affect suicidal ideation differ by age group, should be helpful for targeting suicide prevention programs according to age. Most importantly, because depression was the strongest predictor of suicidal ideation among all age groups, regular health screenings or check-ups should include questions about this symptom. Additionally, interventions to promote perceived good health (e.g., by promoting social participation) (Lee et al. 2008) and prevent chronic diseases (e.g., by providing health screening and health education) are needed, especially among elderly individuals. Programs directed at those 20–44 years of age should offer methods to prevent and alleviate stress, support systems for working women, and interventions to prevent and
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treat binge drinking. Because this study also confirmed the relationship between binge drinking and suicidal ideation, appropriate interventions should be developed. As stress or/and economic factors exerted their strongest influence on suicidal ideation among those aged 45–65 years, these issues must be considered when developing health education for this population. Indeed, it may be possible to identify the economic problems encountered by this age group via social programs. Additionally, interventions, including social support and health education, should be targeted at separated, divorced, or widowed elderly individuals. Acknowledgments The data for this research were supplied by the Korean Centers for Disease Control and Prevention (KCDC). This research was supported by an academic research fund provided by Jeju National University 2014 and Dongseo University 2014.
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