Psychiatry 77(4) Winter 2014

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Suicide Factors in a Korean Sample Bagalkot et al.

Lifetime Prevalence of and Risk Factors for Suicidal Ideation and Suicide Attempts in a Korean Community Sample Tarique Rajasaheb Bagalkot, Jong-Il Park, Hyeong-Tai Kim, Hyun-Min Kim, Myung Sig Kim, Myeong-Sook Yoon, Sung-Hee Ko, Hye-Chung Cho, and Young-Chul Chung Objectives: Our study evaluated the lifetime prevalence of and risk factors for suicidal ideation and suicide attempts in Jeollabuk-do Province, Korea. Method: Participants were selected from the population of individuals aged 13–100 years living Jeollabuk-do Province, Korea. A total of 2,964 subjects provided information about lifetime suicidal behavior and sociodemographic and psychological characteristics, completing the Zung Depression Scale, the Scale for Suicidal Ideation, the Multidimensional Anger Inventory, and the Rosenberg Self-Esteem Scale. Results: The lifetime prevalence of suicidal ideation and suicide attempts, 24.8% and 6.2%, respectively, were higher than in previous studies. Multivariate regression revealed that family harmony had the highest odds ratio of all variables, including psychological factors. Along with depression and self-esteem, anger— which is the basic symptom of the Korean culture-related anger syndrome, Hwa-byung—was significantly associated with lifetime suicidal behavior. Conclusions: Lifetime suicidal behavior was highly prevalent in Jeollabuk-do Province. The most significant risk factors were found to be social support, family disharmony, anger, depression, and low self-esteem in Koreans. Suicide constitutes a significant problem for individuals, families, and public health systems worldwide. The suicide rate in Korea is the highest among OECD (Organization for Economic Cooperation and Development) nations, 2.6 times higher than the OECD average (OECD, 2010). Indeed, it was the fourth leading cause of death in Korea in 2011 (Korea National Statistical

Office, 2012a). Although suicide attempters make unplanned attempts in a number of cases, the majority of suicide attempts involve a series of steps that generally move from ideation to plan to attempt (Kessler, Borges, & Walters, 1999). Additionally, prior suicide attempts are the most powerful risk factor for completed suicide (Powell, Geddes, Deeks, Goldacre, & Hawton, 2000). Thus,

Tarique Rajasaheb Bagalkot, MSc, Jong-Il Park, MD, and Young-Chul Chung, MD, PhD, are affiliated with the Department of Psychiatry at Chonbuk National University Medical School and with the Research Institute of Clinical Medicine of Chonbuk National University–Biomedical Research Institute of Chonbuk National University Hospital in Jeonju, Korea. Hyeong-Tai Kim, MD, and Hyun-Min Kim, MD, are affiliated with the Maeumsarang Hospital In-san Medical Foundation in Wanju. Myung Sig Kim, PhD, is affiliated with the Department of Psychology at Jeonju University. Myeong-Sook Yoon, PhD, is with the Department of Social Welfare at Chonbuk National University in Jeonju. Sung-Hee Ko, PhD, is with the Department of Nursing at Chonbuk National University Medical School in Jeonju. Hye-Chung Cho MSW, PhD, is with the Department of Elderly Welfare at Shingyeong University in Hwaseong. Address correspondence to Tarique Rajasaheb Bagalkot, Department of Psychiatry, Chonbuk National University Medical School, Keumam Dong 634-18, Jeonju 561-712, Korea. E-mail: [email protected] © 2014 Washington School of Psychiatry

Bagalkot et al. 361

understanding the process underpinning suicide in a community population is crucial for predicting suicide attempts. The prevalence and impact of life stressors and negative emotions, such as anger, anxiety, and depression, vary among individuals, and these are correlated with suicidal behavior. Psychiatric disorders, especially mood disorders, and major life stressors have been shown to be major contributors to suicidal ideation in community samples (Jeon et al., 2010a; Nock et al., 2008; Weissman et al., 1999; Yip et al., 2003). Depression and its severity have been shown to be the most powerful predictors of suicidal ideation (Alexopoulos, Bruce, Hull, Sirey, & Kakuma, 1999), which, in turn, is a predictor of attempted and completed suicide (Kweon et al., 2012; Mireault & de Man, 1996). Painuly, Sharan, and Mattoo (2005) reported that experiences of anger were important factors in the lives of depressed patients and their family members. Anger is known to be a widespread symptom experienced by psychiatric outpatients (Posternak & Zimmerman, 2002) and the general population (Watson, O’Hara, & Stuart, 2008), with an influence that may rival that of depression and anxiety. Additionally, anger, aggression, or hostility and emotional states consistent with these experiences have long been considered significant contributors to suicidal ideation and behavior (Goldney, Winefield, Saebel, Winefield & Tiggeman, 1997). Anger is a state of arousal that results from social conditions involving threat or frustration (Averill, 1982). In Korea, anger has been a focus of research in relation to a culture-related anger syndrome (Min & Kim, 1998). Hwa-byung (HB), which literally means “anger disorder” or “fire disease” (Min, 2009), was listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) in 1994 as a syndrome specific to the Korean culture (American Psychiatric Association, 2000). HB is explained as being abbreviated from “wool-hwa,” which means dense anger-fire or pent-up anger (Min, 2008). Individuals with HB also dem-

onstrate typical neurotic symptoms, such as depression and anxiety (Min & Kim, 1998; Min, Lee, Kang, & Lee, 1987). Min and Suh (2010) reported that 60.7% of patients with HB had comorbid major depressive disorder. In this context, we hypothesized that anger plays a particularly important role in suicidal ideation and suicide attempts, especially in Korea. Psychological resources such as selfesteem play important roles in coping with various psychosocial stressors and in psychological functioning more generally (Premkumar, 2012). Self-esteem usually refers to selfjudgments involving approval, disapproval, and personal worth (Rosenberg, 1965) and is an important resource for protecting individuals against the effects of life stressors and suicidal ideation. Indeed, low self-esteem contributes to vulnerability to suicidal behaviors. Self-esteem has been significantly associated with suicidal ideation in psychiatric outpatients (Bhar, Ghahramanlou-Holloway, Brown, & Beck, 2008) and in the general population (Jin & Zhang, 1998; Kumar et al., 2012). Given the increasing concern about the public health problem of suicidal behavior, more comprehensive data on lifetime suicidal ideation and suicide attempts in local communities are needed to improve our understanding of the effectiveness of efforts to prevent and manage the antecedents to suicide. Previous studies have investigated lifetime suicidal behaviors in several countries (De Leo, Cerin, Spatonis, & Burgis, 2005; Jeon et al., 2010a; Kessler, Borges, & Walters, 1999; S. Lee et al., 2007; Nock et al., 2008). These studies found risk factors associated with lifetime suicidal behavior including unmarried status (S. Lee et al., 2007; Nock et al., 2008), young adulthood (Kessler et al., 1999; S. Lee et al., 2007; Jeon et al., 2010a), female sex (Kessler et al., 1999; Nock et al., 2008), low levels of education (Kessler et al., 1999; Nock et al., 2008), and mental illness, especially depression (Jeon et al., 2010a; Kessler et al., 1999; S. Lee et al., 2007; Nock et al., 2008). Previous studies investigated the effects of anger and self-

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esteem, focusing on current or recent suicidal behavior. Therefore, our study extends prior work by investigating the effects of anger and self-esteem, as well as depression and other related variables, on lifetime suicidal behaviors. The present study was designed to 1) estimate the lifetime prevalence of suicidal ideation and suicide attempts in Jeollabukdo Province and 2) identify the sociodemographic and psychological factors, especially those related to anger and self-esteem, associated with lifetime suicidal ideation and suicide attempts. METHOD Subjects Jeollabuk-do Province is located in the southwestern part of Korea. The population of Jeollabuk-do is about 1.76 million people, 3.7% of the Korean population. The total area of Jeollabuk-do measures 8,066 km and accounts for 8.06% of the total national area. For this study, we initially contacted all of the community mental health centers in Jeollabuk-do. Of the six community mental health centers, those in Gimje, Gochang, Gunsan, Jeonju, and Jeongeup agreed to participate in this study, while the one in Iksan did not. We contacted 100 community organizations associated with each community mental health center that were usually used by the general population. Organizations used by individuals at high risk for mental health problems were not included in our study, for example, centers for elderly people living alone or in prisons. Ultimately, 35 community organizations agreed to participate in this study, including schools, universities, workplaces, women’s centers, senior colleges, senior citizens’ centers, and public health centers. Before initiating the study, we met with the five individuals in charge of the community mental health centers, one from each city. The persons in charge of each mental health center met with all of the research investigators to receive information regarding research requirements, methods,

and tools. Then, the research investigators visited each community organization to recruit participants. In total, 3,000 potential participants were approached, and informed consent was obtained from each participant. This study was approved by the Chonbuk National University Hospital Review Board. The volunteer participants were informed about the purpose of the study and of their rights and our expectations. They were then presented with a survey package consisting of a form requesting sociodemographic data, the Zung Depression Scale (ZDS), the Scale for Suicide Ideation (SSI), the Rosenberg Self-Esteem Scale (RSES), and the Multidimensional Anger Inventory (MAI). The investigators instructed each participant to answer the questionnaires as honestly and thoroughly as possible. The investigators visited elderly participants to conduct individual interviews and monitored their understanding of and response to the questionnaires carefully. All participants cooperated in completing the survey. Assessment Sociodemographic Characteristics. We collected data regarding sociodemographic variables, including age, sex, educational status, marital status, family harmony, economic status, and social support. Educational status was divided into five categories: no education, ≤ 6 years, 7–9 years, 10–12 years, and ≥ 13 years. Marital status was categorized as: single, married, widowed, divorced, separated, or living together. However, subjects were reclassified as either married or not married for purposes of this paper. Family harmony was measured by the item asking, “Is your family harmonious?” (poor, average, good). Also, other sociodemographic variables were categorized as follows: economic status (low, middle, high) and social support (none, 1–2 persons, 3–5 persons, ≥ 6 persons). The results of our analysis of current suicidal ideation according to relevant

Bagalkot et al. 363

factors by age group were reported in another study (Jang et al., 2014). Evaluation of Suicidal Ideation and Suicide Attempts. Separate questions were asked about the lifetime occurrence of suicidal ideation (“Have you ever seriously thought about committing suicide?”) and suicide attempts (“Have you ever attempted suicide?”). We used the Scale for Suicide Ideation (SSI) to further evaluate suicidal ideation. The SSI is a self-rated scale derived from a clinician-rated instrument developed by Beck and colleagues (1979) and translated into Korean by Shin and colleagues (1990). The SSI consists of 19 items rated on a three-point Likert scale (0–2 points), with higher scores indicating higher levels of suicidal ideation. Total scores range from 0 to 38 points. The SSI takes approximately 10 minutes to administer and has been used in a wide variety of settings, such as primary care practices, emergency rooms, rehabilitation programs, and private practices. The internal consistency of the SSI in this sample was 0.890 (standardized Cronbach’s alpha). Evaluation of Depression, Anger, and SelfEsteem. We used the Zung Depression Scale (ZDS), a 20-item self-report questionnaire that measures an individual’s present level of depressive thoughts and behaviors, to evaluate depression (Zung, 1965). The Korean version of ZDS was standardized by J. H. Lee (1995). Each item is rated on a fourpoint Likert scale from 1 (a little of the time) to 4 (most of the time), with higher scores indicating higher levels of depression. We classified individuals with scores ≥ 50 as depressed (Basco, Krebaum, & Rush, 1997). The overall internal consistency of ZDS in this sample was 0.808 (standardized Cronbach’s alpha). Anger was measured with the Korean version of the Multidimensional Anger Inventory (MAI) developed by Siegel (1986) and translated by B. K. Lee (1990). This 36item scale was designed to measure different dimensions of anger, such as frequency, du-

ration, and magnitude, as well as to identify the situations that cause anger and to specify the mode of its expression. In this study, only total anger scores were used in analyses; other aspects of anger will be discussed elsewhere. Responses ranged from 1 (not at all descriptive of my anger) to 5 (completely descriptive of my anger). The MAI has shown good reliability (Cronbach’s α = 0.88) in a previous Korean study (J. Lee, Choi, Kim, Park, & Shin, 2009) and in the present study (Cronbach’s α = 0.877). Self-esteem was measured with the Rosenberg Self-Esteem Scale (RSES) (Rosenberg, 1965). The RSES is a 10-item instrument originally designed to assess adolescents’ global feelings of self-worth (Rosenberg, 1965). The instrument uses a four-point Likert-type scale, with responses ranging from 1 (strongly agree) to 4 (strongly disagree). The measure possesses good testretest reliability (0.85) (Rosenberg, 1989), and face and convergent validity have been reported (Robinson, Shaver, & Wrightsman, 1991). The RSES has been treated as the standard against which new self-esteem measures are evaluated (Robinson, Shaver, & Wrightsman, 1991). The internal consistency of the RSES in this sample was 0.794 (standardized Cronbach’s alpha). Statistical Analyses We estimated the prevalence of suicidal ideation and suicide attempts in a community sample of Koreans. Logistic regression analysis was performed to explore the relationship of lifetime suicidal ideation and suicide attempts with sociodemographic and psychological characteristics. We created a dichotomous variable to represent depression based on ZDS scores (< 50 vs. ≥ 50) (Basco et al., 1997). As no appropriate cut-off scores were available for these variables, anger and self-esteem were converted to dichotomous variables based on the median split of each set of scores: MAI (median: 98.0, ≤ 98.0 vs. > 99.0) and RSES (median: 29.0, ≤ 29.0 vs.

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TABLE 1. Sociodemographic and Psychological Characteristics of the Study Sample Lifetime suicidal ideation

Age (Mean ± SD)

No

Yes

(N = 2219)

(N = 730)

45.49 ± 23.52

40.53 ± 23.37

Lifetime suicide attempts No

Yes

(N = 2760)

(N = 181)

44.57 ± 23.52

39.43 ± 24.17

1664 (60.3%)

121 (65.1%)

1094 (39.7%)

65 (34.9%)

80 (11.6%)

258 (10.4%)

20 (11.8%)

P-values P = 0.000 P = 0.015

Sex (N, %) Female

1315 (59.3%)

473 (64.4%)

Male

902 (40.7%)

262 (35.6%)

P = 0.038

No education

198 (10.1%)

6 yrs or less

312 (15.9%)

93 (25.1%)

380 (15.3%)

24 (14.2%)

7–9 yrs

507 (25.8%)

196 (53.6%)

643 (25.9%)

60 (35.5%)

10–12 yrs

539 (27.4%)

179 (26.0%)

674 (27.2%)

41 (24.3%)

13 yrs or more

411 (20.9%)

140 (20.3%)

526 (21.2%)

24 (14.2%)

17 (2.4%)

85 (3.1%)

7 (4.0%)

P = 0.000

Economic status (N, %) High

75 (3.4%)

P = 0.059

Middle

1561 (74.6%)

459 (63.8%)

1912 (70.1%)

107 (61.5%)

Low

556 (25.4%)

243 (33.8%)

732 (26.8%)

60 (34.5%)

1504 (54.6%)

124 (68.9%)

1252 (45.4%)

56 (31.1%)

P = 0.000

Marital status (N, %) Other than married

1167 (52.8%)

464 (63.2%)

Married

1042 (47.2%)

270 (36.8%)

P = 0.000

P = 0.000

Family harmony (N, %)

P = 0.002

Good

1360 (61.1%)

326 (44.3%)

1614 (58.3%)

69 (37.5%)

Average

818 (36.8%)

351 (47.7%)

1076 (38.9%)

88 (47.8%)

47 (2.1%)

59 (8.0%)

79 (2.9%)

27 (14.7%)

Poor

P = 0.000

Social support (N, %)

P = 0.004 P = 0.202

P = 0.300

Educational status (N, %)

P-values

P = 0.000

6 or more

697 (31.8%)

199 (27.5%)

861 (31.6%)

34 (18.8%)

3–5

793 (36.2%)

230 (31.8%)

971 (35.6%)

50 (27.6%)

1–2

604 (27.6%)

240 (33.1%)

767 (28.1%)

74 (40.9%)

97 (4.4%)

55 (7.6%)

128 (4.7%)

23 (12.7%)

Depression (Mean ± SD)

41.38 ± 7.898

47.23 ± 8.390

P = 0.000

42.43 ± 8.232

49.03 ± 8.687

P = 0.000

Self-esteem (Mean ± SD)

29.97 ± 4.310

26.84 ± 4.824

P = 0.000

29.41 ± 4.559

25.92 ± 4.659

P = 0.000

95.85 ± 15.389

104.49 ± 17.518

P = 0.000

97.24 ± 16.045

109.58 ± 17.039

P = 0.000

2.59 ± 3.452

9.06 ± 6.682

P = 0.000

3.72 ± 4.695

12.22 ± 7.356

P = 0.000

None

Anger (Mean ± SD) Suicidal ideation (Mean ± SD)

Note. Chi-square test was used to assess categorical variables; independent-sample t-test was used to assess continuous variables.

> 29.0). Both crude odds ratios and adjusted odds ratios with 95% confidence intervals (CIs) were calculated. Separate univariate logistic regression analyses were used to estimate the crude odds ratios of lifetime suicidal ideation and suicide attempts according to all risk factors investigated. Multivariate logistic regression analysis was used to calculate the adjusted odds ratios of lifetime suicidal ideation and suicide attempts including all risk factors. A p-value < 0.05 was considered statistically significant. All statistical analyses

were performed with SPSS for Windows (version 15.0, SPSS, Inc., Chicago, IL, USA). RESULTS Sociodemographic and Psychological Characteristics of Subjects Surveys were collected from 2,964 of 3,000 (97.9%) eligible subjects, including 1,168 males and 1,796 females ranging

Bagalkot et al. 365

from 13 to 100 years of age. The mean age of the subjects was 44.4 years (SD = 23.6). The mean scores of the entire sample on the ZDS, RSES, and MAI were 42.9 (SD = 8.4), 29.2 (SD = 4.64), and 98.1 (SD = 16.4), respectively (data not shown). Lifetime Suicidal Ideation and Suicide Attempts Estimates of the lifetime prevalence of suicidal ideation and suicide attempts were 24.8% and 6.2%, respectively. The lifetime prevalence of suicidal ideation and suicide attempts was higher in females than in males (26.5% vs. 22.5% for suicidal ideation, 6.8% vs. 5.6% for suicidal attempts). Among those reporting suicidal ideation (n = 744), the conditional probability of ever making an attempt was 22.5% (data not shown). Risk Factors for Lifetime Suicidal Ideation and Suicide Attempts Those who had experienced suicidal ideation or attempted suicide were significantly younger than were those who had not (Table 1). Those who reported suicidal ideation differed from those who did not, and those who attempted suicide differed from those who had not, with regard to all sociodemographic variables except educational status (suicidal ideation) and sex and economic status (suicide attempt). Compared with those without suicidal ideation or attempts, those with ideation or attempts had higher scores for depression (ZDS), anger (MAI), and suicidal ideation (SSI) and lower scores for self-esteem (RSES). Table 2 presents the crude and adjusted odds ratios for suicidal ideation by risk factor. The univariate regression analysis revealed that younger age (OR = 0.99), female sex (OR = 0.81), low economic status (OR = 1.93), being married (OR = 0.65), family harmony (OR = 1.79 for average family har-

mony; OR = 5.24 for poor family harmony), social support (OR = 1.40 for 1–2 persons; OR = 1.99 for no social support), depression (OR = 3.42), self-esteem (OR = 3.16), and anger (OR = 2.54) were significantly associated with lifetime suicidal ideation (Table 2). Younger age (OR = 0.98), family harmony (OR = 1.41 for average family harmony; OR = 2.86 for poor family harmony), social support (OR = 0.77 for 3–5 persons), depression (OR = 2.36), self-esteem (OR = 2.46), and anger (OR = 1.52) remained significant in the multivariate regression analysis. The fully adjusted OR for social support by 3–5 persons (OR = 0.77) was in a different direction from the crude OR (OR = 1.02). Table 3 presents the crude and adjusted odds ratios for suicide attempts by risk factor. The univariate regression analysis revealed that younger age (OR = 0.99), being married (OR = 0.54), family harmony (OR = 1.91 for average family harmony; OR = 7.99 for poor family harmony), social support (OR = 2.44 for 1–2 persons, OR = 4.55 for no social support), depression (OR = 3.33), self-esteem (OR = 4.25), and anger (OR = 3.67) were significantly associated with lifetime suicidal attempts. Poor family harmony (OR = 4.03), social support (OR = 2.20), depression (OR = 1.52), self-esteem (OR = 2.73), and anger (OR = 1.82) remained significant in the multivariate regression analysis. DISCUSSION This study examined the lifetime prevalence of and risk factors for suicidal ideation and suicide attempts in Jeollabukdo Province, Korea. Our results showed that suicidal ideation and suicide attempts are not uncommon in Jeollabuk-do. Estimates of the lifetime prevalence of suicidal ideation and suicide attempts were 24.8% and 6.2%, respectively, which is higher than those in previous studies of Korea (suicidal ideation, 15.6%, and attempts, 3.2%; Korean Ministry of Health and Welfare, 2012),

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TABLE 2. Risk Factors for Lifetime Suicidal Ideation Univariate OR Age

Fully adjusted OR

OR

95% CI

P-values

OR

95% CI

P-values

0.99

0.98, 0.99

P = < 0.001

0.98

0.98, 0.99

P = < 0.001

0.68, 0.96

P = < 0.05

0.67, 1.02

P = 0.070

Sex Female*

1.00

Male

0.81

1.00 0.82

Educational status No education*

1.00

—

1.00

—

6 yrs or less

0.74

0.52, 1.05

P = 0.087

0.74

0.48, 1.13

P = 0.160

7–9

0.96

0.70, 1.30

P = 0.778

0.71

0.44, 1.14

P = 0.157

10–12 yrs

0.82

0.60, 1.12

P = 0.215

0.82

0.53, 1.28

P = 0.383

13 yrs or more

0.84

0.61, 1.16

P = 0.300

1.04

0.65, 1.66

P = 0.883

Economic status High*

1.00

—

1.00

—

Middle

1.30

0.76, 2.22

P = 0.342

1.43

0.76, 2.70

P = 0.263

Low

1.93

1.12, 3.33

P = < 0.05

1.65

0.86, 3.16

P = 0.130

Marital status Other than married*

1.00

—

Married

0.65

0.55, 0.77

P = < 0.001

1.00

—

0.96

0.74, 1.24

P = 0.749

Family harmony Good*

1.00

—

1.00

—

Average

1.79

1.50, 2.13

P = < 0.001

1.41

1.14, 1.74

P = < 0.05

Poor

5.24

3.50, 7.83

P = < 0.001

2.86

1.73, 4.72

P = < 0.001

Social Support 6 or more*

1.00

—

1.00

—

3–5

1.02

0.82, 1.26

P = 0.886

0.77

0.60, 0.99

1–2

1.40

1.12, 1.73

P = < 0.01

0.87

0.66, 1.13

P = 0.290

None

1.99

1.38, 2.87

P = < 0.001

0.96

0.59, 1.57

P = 0.865

Depression

3.42

2.83, 4.13

P = < 0.001

2.36

1.84, 3.02

P = < 0.001

Self-esteem

3.16

2.62, 3.81

P = < 0.001

2.46

1.95, 3.10

P = < 0.001

Anger

2.54

2.13, 3.03

P = < 0.001

1.52

1.23, 1.87

P = < 0.001

P = < 0.05

Note. *Reference category; OR = odds ratio; CI = confidence interval.

China (suicidal ideation, 3.1%, and attempts, 1.0%; S. Lee et al., 2007), and the United States (suicidal ideation, 13.5%, and attempts, 4.6%; Kessler et al., 1999). The total suicide mortality rate in Korea was 31.7 people per 100,000 in 2011. The suicide mortality rate in Jeollabuk-do, which was 37.3 people per 100,000 in 2011, was the fourth highest among the 16 Korean Administrative Divisions (Korea National Statistical Office, 2012b). The suicide mortality rate in Jeollabuk-do is consistent with the high lifetime rates of suicidal ideation and suicide attempts revealed by our results. Suicide

rates in Korea seemed to be stable at fairly low rates until the early 1990s. In 1997, the South Korean government issued an official request to the International Monetary Fund for an emergency rescue loan, which led to an economic crisis. Suicides began to increase in the mid-1990s, and the suicide rate increased dramatically around the economic crisis (Kim, Kim, Kawachi, & Cho, 2011). Since the mid-1990s, a neo-liberal economic agenda aimed at privatization, commoditization, and the increasingly “free” movement of finance and commodities across the boundaries of nation-states has dominated

Bagalkot et al. 367

TABLE 3. Risk Factors for Lifetime Suicide Attempts Univariate OR Age

Fully adjusted OR

OR

95% CI

P-values

OR

95% CI

P-values

0.99

0.98, 0.99

P = < 0.01

0.99

0.98, 1.00

P = 0.075

0.60, 1.12

P = 0.203

0.63, 1.36

P = 0.683

Sex Female*

1.00

Male

0.82

1.00 0.92

Educational status No education*

1.00

—

1.00

—

6 yrs or less

0.82

0.44, 1.51

P = 0.513

0.81

0.38, 1.74

P = 0.591

7–9

1.20

0.71, 2.04

P = 0.490

1.03

0.45, 2.34

P = 0.942

10–12 yrs

0.79

0.45, 1.37

P = 0.391

0.84

0.38, 1.86

P = 0.671

13 yrs or more

0.59

0.32, 1.09

P = 0.090

0.77

0.32, 1.84

P = 0.549

Economic status High*

1.00

—

1.00

—

Middle

0.68

0.31, 1.51

P = 0.341

0.59

0.24, 1.45

P = 0.248

Low

0.99

0.44, 2.25

P = 0.991

0.51

0.20, 1.32

P = 0.165

Other than married*

1.00

—

1.00

—

Married

0.54

0.39, 0.75

0.76

0.46, 1.24

Marital status

P = < 0.001

P = 0.269

Family harmony Good*

1.00

—

1.00

—

Average

1.91

1.38, 2.65

P = < 0.001

1.35

0.90, 2.03

P = 0.148

Poor

7.99

4.85, 13.1

P = < 0.001

4.03

2.13, 7.62

P = < 0.001

Social Support 6 or more*

1.00

—

1.00

—

3–5

1.30

0.84, 2.04

P = 0.243

0.90

0.54, 1.50

1–2

2.44

1.61, 3.71

P = < 0.001

1.39

0.85, 2.29

P = 0.188

None

4.55

2.60, 7.97

P = < 0.001

2.20

1.07, 4.55

P = < 0.05

Depression

3.33

2.45, 4.52

P = < 0.001

1.52

1.00, 2.31

P = < 0.05

Self-esteem

4.25

2.87, 6.30

P = < 0.001

2.73

1.65, 4.50

P = < 0.001

Anger

3.67

2.59, 5.22

P = < 0.001

1.82

1.19, 2.77

P = < 0.01

P = 0.684

Note. *Reference category; OR = odds ratio; CI = confidence interval.

Korean society, with an attendant surge in the level of income inequality (Khang, Lynch, & Kaplan, 2005; Kim & Wainwright, 2010; Mann & Riley, 2007), rising job insecurity, and inadequate social protections (Joung, Seoung, Sohn, & Hong, 2006). As a result, considerable attention has been paid to such social consequences as unemployment and suicide (Khang et al., 2005; Kim, Song, Yi, Chung, & Nam, 2004). Additionally, the rapid aging of the Korean population has made it difficult to cope with this problem in an appropriate manner as the country’s

social welfare system has failed to evolve in tandem with the rate at which its population has been aging, while at the same time, the traditional family support system has broken down (Kim et al., 2011). Our results revealed that family harmony was a significant predictor of lifetime suicidal behavior. These results are interesting, as family harmony had the highest odds ratio of all the variables, including those measuring psychological phenomena, in both the univariate and multivariate regression analyses. The results of the multivariate

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regression analysis demonstrated that family harmony was significantly related to both suicidal ideation (OR = 1.41 for average family harmony; OR = 2.86 for poor family harmony) and suicide attempts (OR = 4.02 for poor family harmony). These results may be related to our study design in that our goal was to survey a community rather than a clinical or high-risk sample. Low levels of family cohesion have been positively related to depression and suicidal ideation in a community sample (Harris & Molock, 2000). Our result is somewhat consistent with that of the study conducted by Fortuna, Perez, Canino, Sribney, and Alegria (2007), which reported that family conflict was significantly associated with lifetime suicide attempts and had a higher OR than did any single mental disorder (depressive disorder, anxiety disorder, substance-use disorder). Jeon and colleagues (2010b) reported that familial conflict was the most common precipitant for both unplanned and planned suicide attempts among the Korean general population; familial conflict was followed by other reasons, economic problems, separation, and medical illness. Similarly, in their prospective study, Mullany and colleagues (2009) demonstrated that the most frequent precipitant for suicide attempts was conflict involving family members or intimate partners. Recent sociocultural changes in Korea, including greater contact with Western cultures and rapid industrialization, may have influenced Koreans’ traditional values (Hyun, 2001). Social changes include the shift from an extended to a nuclear family and the abandonment of Confucianism for individualism. High-rise apartments in larger cities in Korea and urbanization have also changed family living patterns and diet, resulting in the fragmentation of the Korean extended family system (Park & Cho, 1995). According to our results, social support is significantly related to lifetime suicide attempts, but we could not confirm an association between social support and suicidal ideation. Social support was related to lifetime suicidal ideation in the univariate

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regression analysis, but only the OR for social support from 3–5 persons (OR = 0.77) remained significant in the multivariate regression analysis, possibly due to undetected confounding variables. Social support refers to the level and quality of support or contact a person receives from her or his “social network” (i.e., those people with whom the individual has meaningful contact) (Wu, Stewart, Huang, Prince, & Liu, 2011). Social support is clearly an important factor affecting the formal and informal help-seeking behaviors of individuals considering suicide. Previous community-based studies have found poor social support to be an important risk factor for suicidal ideation (Wilcox et al., 2010; Yip et al., 2003) and suicide attempts (Perez-Smith, Spirito, & Boergers, 2002). Prior contact with medical services and help-seeking from informal sources provide important opportunities for prevention, and the U.S. “Question, Persuade, Refer” prevention program emphasizes the importance of gatekeeper training and high-risk identification through the engagement of the general public (Wyman et al., 2008). In the same way, research has suggested that gatekeeper training is a promising approach to the reduction of suicide rates (Beautrais et al., 2007; Mann et al., 2005). Despite the lack of association between social support and lifetime suicidal ideation in the multivariate regression analysis, the association between social support and lifetime suicide attempts still suggests that strategies aimed at enhancing social support systems, such as gatekeeper training and public health education about suicide, contribute to suicide prevention. As hypothesized, we found that anger was a significant predictor of lifetime suicidal ideation and suicide attempts. In previous studies, anger and anger expression were related to suicidal ideation (Park et al., 2010), and those reporting suicidal ideation had higher levels of anger and poorer anger control than did those without suicidal ideation (Lamb & Pusker, 1991). Hostility, physical aggression, and trait anger have been re-

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ported to predict suicidal behavior (suicidal ideation, suicide plans, and suicide attempts) (Zhang et al., 2012). Especially in Koreans, anger has been identified as a basic symptom of hwa-byung (HB), along with feelings of unfairness, heat sensation with anger-related somatization, behavioral symptoms, and general neurotic symptoms such as depression and anxiety (Min et al., 1987; Min & Kim, 1998). HB has been found in 4.1% of the general Korean population (Min, Namkoong, & Lee, 1990; Park, Kim, SchwartzBarcott, & Kim, 2002) and in about 11.9% of Korean-American individuals (Lin et al., 1992). HB is also highly comorbid with major depressive disorder, and 60.7% of patients with HB have been diagnosed with major depressive disorder (Min & Suh, 2010). This culture-bound characteristic may affect the association between anger and lifetime suicidal behavior in Korea. Our findings also revealed that depression and self-esteem were significant predictors of lifetime suicidal ideation and suicide attempts. This relationship is consistent with the results of the majority of previous studies of suicidal ideation and suicide attempts. Depression was a strong predictor of both lifetime suicidal ideation and suicide attempts (Fortuna et al., 2007; Joe, Baser, Breeden, Neighbors, & Jackson, 2006; Kessler et al., 1999; S. Lee et al., 2007; Weissman et al., 1999). Self-esteem has also been significantly associated with suicidal ideation (Kumar et al., 2012; McGee, Williams, & Nada-Raga, 2001; Wilburn & Smith, 2005) and suicide attempts (Dieserud, Roysamb, Ekeberg, & Kraft, 2001). Preventive strategies focusing on the management of anger along with depression and self-esteem should be highlighted by public mental health programs. Our results reflect a sex difference in the prevalence of lifetime suicidal behavior. These results are consistent with those of the previous Korean National Survey, which also reported higher lifetime prevalence of suicidal ideation and suicide attempts in females (17.9% and 4.1%) than in males (13.4%

and 2.4%) (Korean Ministry of Health and Welfare, 2012). However, the results of our multivariate regression analysis showed that sex was not a significant predictor of either suicidal ideation or suicide attempts, which differs from previous studies in China (S. Lee et al., 2007), which showed that females had significantly higher odds than did males for lifetime suicidal ideation but that the two sexes did not differ significantly in attempts. The results reported herein are limited by the fact that the survey used a cross-sectional design in which information about lifetime suicidal ideation and suicide attempts was based on retrospective self-reports. Also, the target sample was conveniently selected. Therefore, the study findings may not represent all of the Korean population. Additionally, individuals who completed suicide were excluded from these results. Further studies using longitudinal data are necessary to better understand the development of suicidal ideation and the role of various factors in this process. However, the strengths of our study include our use of a sufficiently large community sample and standardized instruments. Prospective and longitudinal research is necessary to achieve a better understanding of suicidal behavior. CONCLUSION The lifetime prevalence of suicidal ideation and suicide attempts in Jeollabuk-do was higher than in Korea as a whole (Korean Ministry of Health and Welfare, 2012). Suicide results from various unbearable circumstances and psychosocial factors. Our results revealed that lifetime suicidal ideation and suicide attempts are associated with family harmony and anger as well as with depression, self-esteem, and social support. The results of the present study have implications for intervention programs, and preventive strategies focusing on these risk factors may reduce suicidal behaviors.

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