Exposure to suicide and suicidality in Korea: Differential effects across men and women?

Abstract

Background:

Little is known about whether exposure to suicide within close social networks is associated with the suicidality in exposed individuals, and potential gender differences regarding this association.

Aims:

This study examines the effect of exposure to suicide on the suicidality in exposed individuals.

Methods:

The data were drawn from the 2009 Korean General Social Survey, a nationally representative interview survey. Suicidality was measured by the suicidality module in the Mini International Neuropsychiatric Interview (MINI), with exposure to suicide being determined by asking about the experience of a failed or completed suicide attempt by a closely related person.

Results:

Exposure to the suicide of someone close was significantly associated with higher suicidality in exposed individuals. While the effect of a failed attempt became non-significant after controlling for psychological factors, that of exposure to a completed act of suicide remained significant. A subsample analysis by gender indicated a significant gender difference: with control for demographic and psychological factors, exposure to a completed suicide had a significant effect on the suicidality of females only. The effect of exposure to a failed attempt became non-significant both in males and females after controlling for other factors.

Conclusions:

Findings suggest the necessity of screening for prior exposure to suicide in suicide risk assessment and the need for gender-tailored suicide-prevention strategies.

Keywords

Behavioural contagion depression exposure to suicide gender suicidality social network

Introduction

Suicide has been one of the most critical social problems worldwide, and it has been so in Korea since the mid-1990s. The number of suicides in Korea has increased sharply since the Asian financial crisis of 1997. According to a report by Statistics Korea (2008), the suicide rate among Koreans climbed from 14.6 per 100,000 in 2000 to 24.2 in 2004 and 24.7 in 2008. This indicates that suicide is becoming an increasingly serious social problem in Korea. Moreover, according to a report by the Organisation for Economic Co-operation and Development (OECD) (2009), as of 2009 Korea ranked first among OECD countries in suicide.

Previous studies have identified a series of demographic, sociocultural and psychological risk factors for suicide, and the concept of ‘behavioural contagion’ has received considerable attention in that suicide can diffuse through social networks (Christakis & Fowler, 2009). Behavioural contagion has been well recognized as an important factor for suicide. A number of studies have investigated the relationship between exposure to media reports on suicide and imitative suicides, which is referred to as the Werther effect (Gould, Jamieson, & Romer, 2003). The media effect suggests that suicide can diffuse through social networks based on indirect relationships. Although the effect of exposure to the suicide of someone close is similar to the media effect in that suicide can diffuse through social networks, it may have a greater effect on the suicidality of exposed individuals because it is based on direct relationships.

Most of the previous studies have examined the beneficial effects of social relationships or networks on people’s lives, including the protective effect of social relationships or support on psychological well-being (e.g. Falcon, Todorova, & Tucker, 2009), and the risk of suicidality (Park, Cho, & Moon, 2010; Vanderhorst & McLaren, 2005). However, social networks represent a ‘double-edged sword’ (Revenson, Schiaffino, Majerovitz, & Gibofsky, 1991) in that they also have deleterious effects. To illustrate, some studies have demonstrated a relationship between exposure to suicide in social networks and the suicidality of exposed individuals (e.g. Bearman & Moody, 2004; Crosby & Sacks, 2002). The suicide of someone close, such as a friend or a family member, can be very distressing or even traumatic, jeopardizing the mental health of those left behind. The traumatic experience of loss of loved ones by suicide can increase the likelihood of post-traumatic stress disorder (PTSD) or pathological grief, which are associated with suicide risk (Jordan, 2001).

A few studies have demonstrated a significant relationship between exposure to suicide and the suicidality of exposed individuals. In these studies, people with a friend or a family member who had attempted suicide were more likely to attempt suicide or experience suicidal ideation than those without such a friend or family member (Bearman & Moody, 2004; Crosby & Sacks, 2002).

However, questions regarding the relationship between exposure to suicide and suicidality still remain. Further, this relationship may be influenced by the sociocultural context, indicating a need for research considering individuals in Korea, where the suicide rate has been increasing dramatically. Lau, Jernewall, Zane and Myers (2002) suggested that culture can play a role as a contextual factor in influencing the relevance of stressors for predicting suicidal behaviour. It might be assumed that the effect of exposure to suicide in close social networks on suicidality of Koreans might be significant given a more collectivistic culture that emphasizes the value of interdependence and interconnection in Korea (Hwang & Kim, 2002).

In addition, previous studies have suggested gender differences in the extent and manifestation of suicidality as well as in risk factors for suicide (Qin, Agerbo, Westergard-Nielsen, Eriksson, & Mortensen, 2000). For instance, females are more likely to experience suicidal ideation and behaviour than males, but are less likely to die from suicide than males in Korea (Kim, Kim, Ju, & Lee, 2009) as well as in western countries (e.g. Canetto & Sakinofsky, 1998). Several studies have explained this gender gap by considering economic (Chung, 2009) and cultural (Moller-Leimkuhler, 2003) factors. In terms of risk factors, the impact of economic or occupational factors tend to be more pronounced in male suicidality than female suicidality (Qin et al., 2000).

These findings suggest that there may be gender differences in the relationship between exposure to suicide and suicidality. It is probable that women are vulnerable to the loss of loved ones more than men because of the gendered nature of social roles (Lee & Carr, 2007). Women, in general, value interpersonal relationships and a closer bond with significant others and provide emotional support. However, most of the previous studies of the effect of exposure to suicide have not considered this gender gap (e.g. Crosby & Sacks, 2002; Mercy et al., 2001; Watkins & Gutierrez, 2003), and thus, there is a need to examine gender differences because it is well known that gender is an important determinant of health and that men and women are likely to be different in their vulnerability and responses to stress (Moller-Leimkuhler, 2003).

The present study determines whether exposure to the suicide of someone close has a significant effect on suicidality by using a representative sample of Koreans aged 18 years or older. Further, the study investigates potential gender differences in suicidality by focusing on the effect of exposure to suicide on the suicidality of exposed individuals.

Methods

Data

The data were drawn from the 2009 Korean General Social Survey (KGSS) and the response rate was 63.4%. The KGSS is a nationally representative, face-to-face interview survey conducted every year since 2003 by the Survey Research Centre at Sungkyunkwan University, Korea. The sampling (i.e. the multi-stage area proportional probability sampling method), interview and data-processing procedures used for the KGSS conform to those used for the General Social Survey (GSS) in the USA. The 2009 KGSS included a suicide module that contained items on attitudes towards suicide, suicidal ideation, suicide attempts and suicidal behaviour. It also contained some related items such as stress and depression as well as socio-demographic factors.

Measures

Suicidality

Suicidality was measured by using the standardized Korean version of the suicidality module in the Mini International Neuropsychiatric Interview (MINI) (Agoub, Moussaoui, & Kadri, 2006; Yoo et al., 2006), and the severity of suicidality was determined by summing points assigned to positive answers to the following six questions:

In the past month, did you,

1. think you would be better off dead or wish you were dead? (1 point)

2. want to harm yourself? (2 points)

3. think about suicide? (6 points)

4. have a suicide plan? (10 points)

5. attempt suicide? (10 points)

In your life,

6. did you ever attempt suicide? (4 points)

The higher the value, the higher the suicide risk is, and the logged variable was used in analytic models for skewness.

Exposure to suicide

Exposure to suicide was measured by using the following two questions: (1) ‘Was there a person close to you who made a failed suicide attempt?’; and (2) ‘Was there a person close to you who committed suicide?’ Both of these variables were measured as categorical variables (exposure to suicide = 1; no exposure = 0).

Demographic variable

The demographic variables included age, gender (female = 1), educational attainment, marital status and monthly household income. Age was measured in years and household income was logged because it was skewed. Marital status was measured by asking the respondents whether they were married, widowed, separated/divorced or never married. Educational attainment was treated as a continuous variable ranging from ‘no school’ (1) to ‘graduate school for a PhD’ (8).

Depressive symptoms and stress

For determining whether exposure to suicide would have a significant effect on suicidality even after controlling for psychological status, depressive symptoms and stress were included in the analytic models. Depressive symptoms were measured using the standardized Korean version of the Patient Health Questionnaire-9 (PHQ-9), which inquired about nine major depressive symptoms in the last two weeks (Han et al., 2008; Kroenke, Spitzer, & Williams, 2001). The respondents rated each symptom on a four-point scale from 1 (‘not at all’) to 4 (‘nearly every day’), where the higher the score, the more severe the depressive symptom. The reliability of PHQ-9 was 0.837 (Cronbach’s α).

Economic stress and family stress were measured respectively by asking the respondent to rate – on a four-point scale from 1 (‘not at all’) to 4 (‘very much’) – the degree to which he or she felt stressed because of economic or family problems.

Analytic strategy

Multivariate regression analysis was used to estimate the parameters. Also, a subsample analysis was conducted across men and women to determine whether and how exposure to suicide has differential effects on suicidality.

Results

Sample characteristics

Table 1 presents the means and standard deviations for all the variables and the t-test results for men and women. The mean for male suicidality was significantly greater than that for female suicidality. Among demographic factors, the level of education was higher for men than for women, whereas age and family stress were higher for women than for men. Women were more likely to be widowed than men, whereas men were more likely to be never married than women, reflecting the higher percentage of females in Korea’s adult population.

Table 1.

Descriptive statistics for variables and t-tests for men and women.

	Total(N = 1,602)^a	Men(n = 769)^a	Women(n = 833)^a	t-test
Suicidality (logged)	0.460	0.509	0.407	*
	(0.876)	(0.914)	(0.830)
Exposure to suicide
Had someone close who attempted suicide	0.099	0.103	0.096
Had someone close who committed suicide	0.172	0.181	0.163
Age	43.519	42.786	44.195	*
	(15.227)	(15.148)	(15.278)
Gender (female = 1)	0.520
	(0.500)
Educational attainment	3.613	3.878	3.367	***
	(1.490)	(1.393)	(1.535)
Marital status
Married	0.669	0.653	0.683
Widowed	0.066	0.018	0.111	***
Divorced/separated	0.034	0.030	0.037
Never married	0.231	0.299	0.169	***
Household income (logged)	5.623	5.655	5.593
	(1.002)	(1.019)	(0.985)
Depressive symptoms	13.465	13.301	13.619	+
	(4.487)	(4.338)	(4.619)
Family stress	2.398	2.276	2.510	***
	(0.893)	(0.869)	(0.900)
Economic stress	2.772	2.790	2.755
	(0.844)	(0.833)	(0.855)

p < .05, ** p < .01, *** p < .001

The number of cases may vary due to missing data.

Note: Numbers in parentheses are standard deviations. Standard deviations of binary variables are excluded.

Exposure to suicide and suicidality

Table 2 summarizes the results of the multiple regression models of the effect of exposure to suicide on suicidality. After controlling for other covariates, we used four models to determine whether and how the effect of exposure to suicide on the suicidality of the respondents remained significant. In Models 1 and 2, both of the variables for exposure to suicide were significant. Respondents with someone close who attempted or committed suicide showed higher suicidality than their counterparts. Having someone close with a history of failed suicide attempts, however, became non-significant after depressive symptoms were controlled for in Model 3. In contrast, even when the variables for depressive symptoms and stress were controlled for, exposure to committed suicide had a significant effect on the suicidality of exposed respondents.

Table 2.

Multivariate regression analyses of suicidality.

	Model 1	Model 2	Model 3	Model 4
Exposure to suicide
Had someone close who attempted suicide	0.205^a **	0.196 *	0.085	0.074
	(0.076)	(0.076)	(0.072)	(0.071)
Had someone close who committed suicide	0.224 ***	0.194 ***	0.154 **	0.156 **
	(0.060)	(0.061)	(0.057)	(0.057)
Age		0.028 **	0.030 ***	0.022 *
		(0.010)	(0.009)	(0.009)
Age^2		0.000 ***	0.000 ***	0.000 *
		(0.000)	(0.000)	(0.000)
Female		0.088 +	0.058	0.041
		(0.046)	(0.043)	(0.043)
Educational attainment		-0.054 **	-0.059 ***	-0.058 ***
		(0.019)	(0.018)	(0.018)
Marital status (married = 0)
Widowed		0.184	0.145	0.101
		(0.113)	(0.106)	(0.107)
Divorced/separated		0.366 **	0.246 *	0.288 *
		(0.122)	(0.116)	(0.118)
Never married		0.179 *	0.180 *	0.213 **
		(0.077)	(0.073)	(0.072)
Household income (logged)		-0.085 ***	-0.038	-0.032
		(0.025)	(0.024)	(0.024)
Depressive symptoms			0.067 ***	0.059 ***
			(0.005)	(0.005)
Family stress				0.116 ***
				(0.026)
Economic stress				0.021
				(0.028)
Constant	0.401 ***	0.440	-0.750 **	-0.878 **
	(0.024)	(0.287)	(0.282)	(0.285)
N	1,596	1,539	1,526	1,513
F	14.71 ***	8.8 ***	26.88 ***	24.94 ***
R²	0.018	0.054	0.163	0.178

p < .05, ** p < .01, *** p < .001

Unstandardized coefficient (standard error)

The effects of other independent variables were straightforward. Age and suicidality had a non-linear relationship. The higher the educational attainment, the lower the suicidality. The respondents who were divorced, separated or never married showed higher suicidality than their married counterparts. Those suffering from depressive symptoms and family stress were more likely to show suicidality. However, economic stress did not have a significant effect on suicidality.

Differential effects of exposure to suicide on men and women

Table 3 summarizes the results of the multiple regression models of the differential effect of the independent variables on men and women. In Model 1, which did not control for any other independent variable, the two variables measuring exposure to suicide were significant for both men and women. However, when the other independent variables were controlled for, gender differences were detected.

Table 3.

Multivariate regression analyses of suicidality for men and women.

	Model 1		Model 2		Model 3		Model 4
	Men	Women	Men	Women	Men	Women	Men	Women
Exposure to suicide
Had someone close who attempted suicide	0.198^a +	0.215 +	0.215 *	0.180	0.169 +	0.003	0.142	0.012
Had someone close who attempted suicide	(0.103)	(0.111)	(0.101)	(0.112)	(0.097)	(0.104)	(0.097)	(0.104)
Had someone close who committed suicide	0.192 *	0.260 **	0.132	0.254 **	0.069	0.237 **	0.066	0.242 **
Had someone close who committed suicide	(0.081)	(0.088)	(0.081)	(0.089)	(0.078)	(0.083)	(0.077)	(0.082)
Age			0.040 **	0.023	0.042 ***	0.023 +	0.033 **	0.018
			(0.013)	(0.015)	(0.013)	(0.014)	(0.013)	(0.014)
Age^2			0.000 ***	0.000 *	0.000 ***	0.000 *	0.000 *	0.000 +
			(0.000)	(0.000)	(0.000)	(0.000)	(0.000)	(0.000)
Educational attainment			-0.051 *	-0.068 *	-0.047 +	-0.078 **	-0.042 +	-0.087 **
			(0.025)	(0.030)	(0.024)	(0.027)	(0.024)	(0.028)
Marital status (married = 0)
Widowed			0.656 **	0.168	0.610 **	0.075	0.357	0.071
			(0.234)	(0.150)	(0.224)	(0.139)	(0.231)	(0.139)
Divorced/separated			0.254	0.443 **	0.173	0.272 +	0.178	0.359 *
			(0.178)	(0.168)	(0.175)	(0.157)	(0.177)	(0.161)
Never married			0.171 +	0.283 *	0.204 *	0.229 *	0.232 *	0.270 *
			(0.101)	(0.121)	(0.096)	(0.112)	(0.096)	(0.112)
Household income (logged)			-0.068 *	-0.099 *	-0.008	-0.075 *	0.005	-0.076 *
Household income (logged)			(0.032)	(0.041)	(0.031)	(0.038)	(0.031)	(0.038)
Depressive symptoms					0.059 ***	0.074 ***	0.051 ***	0.067 ***
					(0.007)	(0.007)	(0.007)	(0.007)
Family Stress							0.099 **	0.136 ***
							(0.036)	(0.038)
Economic Stress							0.067 +	-0.033
							(0.040)	(0.041)
Constant	0.352 ***	0.445 ***	0.002	0.828 *	-1.217 **	-0.284	-1.443 ***	-0.305
	(0.033)		(0.389)	(0.412)	(0.398)	(0.393)	(0.400)	(0.400)
N	767	829	746	793	742	784	734	779
F	6.68 ***	8.43 ***	5.01 ***	5.86 ***	12.11 ***	18.8 ***	11.22 ***	16.8 ***
R²	0.0172	0.02	0.0578	0.0631	0.1421	0.1956	0.1573	0.2084

p < 0.05 **p < 0.01 ***p < 0.001

Unstandardized coefficient (Standard error)

In Model 2, which included demographic factors as covariates, the effect of exposure to suicide on male respondents with someone close who attempted suicide was significant at the 5% level. However, when the variables for depressive symptoms and stress were controlled for, the effect became non-significant. In Models 2–4, having someone close who committed suicide did not have a significant effect on the suicidality of male respondents, whereas it had a significant effect on the suicidality of female respondents in all models. However, when the other covariates were controlled for, having someone close who attempted suicide did not have a significant effect on the suicidality of either men or women.

The direction of effects of the other covariates was similar across men and women. In Model 4, the effects of age, marital status (‘never married’), depressive symptoms and family stress on the suicidality of male respondents were significant at the 5% level. Age is non-linearly associated with male suicidality. The suicidality of those male respondents who were never married was higher than that of their married counterparts. Male suicidality increased as depressive symptoms and family stress became more severe. For women, the effects of educational attainment, marital status, household income, depressive symptoms and family stress were significant at the 5% or higher level. Those female respondents with higher educational attainment and household income were less likely to show suicidality. The female respondents who were divorced, separated or never married were more likely to show suicidality than their married counterparts. Similar to their male counterparts, the female respondents suffering from depressive symptoms and family stress were more likely to show suicidality.

Discussion

In this study, we explored the effect of exposure to suicide on suicidality in a nationwide representative sample of Koreans aged 18 years or older. The effect on the suicidality of those respondents with someone close who had either attempted or committed suicide was significant, and it remained significant even after various demographic factors such as age, educational attainment, marital status and household income were controlled for. However, when depressive symptoms were controlled for, the effect was significant only in the case in which the respondent had someone who had committed suicide. Those respondents with someone close who had committed suicide were more likely to show suicidality than their counterparts.

These results are consistent with the findings of previous studies showing a significant relationship between exposure to suicide and suicidality (e.g. Bearman & Moody, 2004; Crosby & Sacks, 2002). To illustrate, suicide attempts in the social network were independently associated with increased risk of suicidal behaviours in Hong Kong adolescents (Wong, Stewart, Ho, Rao, & Lam, 2005). Family history of suicidal behaviour and exposure to suicidal behaviour by others were associated with suicide (Goodwin, Beautrais, & Fergusson, 2004; Hawton & van Heeringen, 2009).

The suicide of someone close, such as a friend or a family member, can be very distressing or even traumatic, deeply affecting the lives of those left behind. The loss of someone close by suicide can take a heavy emotional toll, including guilt, anger and depression, on those grieving the death of a loved one and may lead to emotional trauma that could result in PTSD, which is a proven risk factor for suicidality. According to Stein et al.’s (2010) cross-national study of the relationship between traumatic events and suicidal behaviour, the most commonly reported trauma was from the death of a loved one (30.5%), and among respondents with a history of suicide attempts, about one in five (20.9%) reported the loss of a loved one. Similarly, Belik, Cox, Stein, Asmundson and Sareen (2007) reported that, even when the effect of mental disorders was controlled for, traumatic events made suicide attempts by respondents more likely.

The extraordinary circumstance of the suicide is likely to make a normal bereavement process elusive for those left behind, resulting in pathological grief, which can be a risk factor for suicidality. In fact, bereavement from suicide can increase the risk of PTSD, complicated grief and suicidal ideation and behaviour (Qin, Agerbo, & Mortensen, 2002). Purposelessness and meaninglessness, which can accompany complicated grief, may expose those left behind to suicidal thoughts and behaviour (Prigerson et al., 1999).

Current findings may also be explained in part by Joiner et al.’s (2009) interpersonal-psychological theory of suicidal behaviour. This theory posits that an individual will desire for death if he or she perceives himself or herself as burdensome and feels socially alienated. However, the individual with a desire for death will act on his or her suicidal wish only when he or she has the capability to do so, which can be developed through exposure to a painful and/or fearsome experience such as past suicidal behaviour or non-suicidal self-injury or physical abuse. Joiner et al. (2009) suggested that the ability to act on a suicidal wish can be acquired through an indirect route such as exposure to others’ pain or injury. Experiencing the suicide of someone close may trigger pre-existing suicidal ideation or induce a suicidal wish, making the idea of suicide no longer unthinkable or undoable.

The results of the present study indicate differential effects of exposure to suicide on the suicidality of Korean men and women. The subsample analysis by gender indicates that this effect was significant only for female respondents and that it was non-significant for male respondents when depressive symptoms were controlled for. By contrast, even when depressive symptoms, family stress and economic stress were controlled for, the effect remained significant for female respondents, implying that exposure to suicide has a greater effect on women than on men.

Why does exposure to the suicide of someone close have differential effects across men and women? This gender gap may be explained by different values and roles influencing social relationships between men and women. That is, women are more likely than men to value interpersonal relationships and find meaning in their life through such relationships. Women may be more susceptible to the suicide of someone close in that they may value relationships more than men and problems in relationships are likely to make women particularly vulnerable to suicidal ideation or behaviour. This is supported in part by previous studies of the gender gap in suicidal behaviour and motives for suicide. For instance, in terms of motives for suicide, social and family relationships influence women more than men (Kim et al., 2009). Women who attempt suicide are more likely than their male counterparts to identify relationship problems as a motive for their suicide attempt (Wandrei, 1985).

In this sense, the gender gap in the relationship between exposure to suicide and suicidality may partially reflect gender differences in the enactment of social roles and values. Women are more likely than men to have a closer bond with significant others and a social role in providing emotional and social support to those around them. Thus, the suicide of a close person may take a more serious emotional toll for women than for men. It is also possible that women are more likely than men to feel guilty about any perceived failure associated with their social role (e.g. their failure to prevent the suicide of someone close). Social stressors associated with highly valued social roles are more harmful than those associated with less salient roles (Lee & Carr, 2007).

It is worthy of note that family stress was a significant risk factor for the suicidality of Koreans, which is consistent with the findings of previous studies considering Asian populations (Cheng et al., 2010). Leong, Leach and Gupta (2008) suggested that suicide from family conflicts are particularly likely in Asian cultures as a result of their strong emphasis on family cohesion. Also, being married had significant protective effects on the suicidality of both male and female respondents. The finding that the household income was associated with female suicidality was consistent with prior findings that economic difficulties are a triggering factor of suicide for Asian women (Yusuf, Akhter, Rahman, Chowdhury, & Rochat, 2000).

Limitations

This study has some limitations. First, the respondents might have interpreted ‘a close person’ differently (e.g. a family member, a friend, a colleague or an acquaintance), and thus future research should use a clearer definition to better identify the paths or mechanisms through which exposure to suicide in close social networks influences suicidality. Further, we did not have any information on when the respondents were exposed to suicide and on the depth of the relationship between the respondents and the person who attempted or committed suicide. According to Mercy and colleagues (2001: 123), ‘the emotional and temporal distance between the exposed individual and the suicide model’ mattered in that an increase in this distance is likely to reduce the risk of suicide from exposure to the suicidal behaviour of friends or acquaintances. Second, because of the cross-sectional nature of the data, the level of the respondent’s suicidality and other pre-existing risk factors for suicidality before experiencing the exposure to suicide could not be controlled for. Thus, future research may consider longitudinal data analysis to provide a better understanding of the relationship between exposure to suicide and suicidality.

Conclusion

Despite the above limitations, this study demonstrates that exposure to suicide in close social networks is a significant risk factor for suicidality, which can be gender specific, and that screening for prior exposure to suicide should be an important part of any suicide prevention and intervention strategies.

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