Psychiatrists investigating very high rates of suicide among young, rural Chinese women are finding that impulsive behaviour and the ready availability of poisonous substances are significant contributory factors, whereas mental illness is a deciding factor less often than in many other countries.

China has one of the highest suicide rates in the world and, of countries which publish suicide figures, it is the only one where more women than men take their own lives.

Surveys by the Ministry of Public Health suggest that each year around 21 out of every 100,000 Chinese people kill themselves. This amounts to some 254,000 deaths per year. The World Health Organisation, basing its calculations on World Bank estimates (which adjust the Chinese data in several ways), puts the suicide rate higher, at 33 per 100,000 in 1998, totalling 413,000 deaths. Added to these are a large number - 1.9 million per year, according to the World Bank - of unsuccessful (but nonetheless frequently damaging) suicide attempts. Altogether this makes suicide a major public health issue.

Most striking is the much higher rate of suicides in rural areas, particularly among rural women aged 15 - 24. (See table linked above.) Suicide is the leading cause of death for rural Chinese women in this age group. In other countries, men are more likely to kill themselves than women. The proportion of male to female suicides is 3:1 in North America, and as high as 7:1 in some Latin American countries. Why is China so different?

Canadian psychiatrist, Dr. Michael Phillips, has been working for several years with Chinese colleagues from the Chinese Academy of Preventive Medicine to answer this question.

Among the techniques employed by the research team has been a series of 'psychological autopsies' at twenty rural and four urban sites around the country. These consist of in-depth interviews with relatives, friends or neighbours of people who have committed suicide, several months after the event. Interviews are also conducted with family members and associates of a comparison group of people who recently died as a result of accidents.

Preliminary findings suggest that between 50% and 60% of Chinese people who commit suicide have some form of mental illness. 'Mental illness' in this sense does not imply violent, deranged, or deluded behaviour but, typically, depression, perhaps aggravated by alcohol abuse.

In fact, the importance of mental illness as an explanatory factor in Chinese suicides is not as great as in other countries, which typically report mental illness in over 90% of people who kill themselves. It is therefore a significant finding that up to 50% of young Chinese women who commit suicide may be suffering from no mental illness at all.

So why do they do it? Is it simply that the life of a young woman in China's countryside is too hard to endure, and that there are very few other ways out for those who feel their domestic situations are intolerable?

'Societal stress', Dr. Phillips says, is certainly a factor, but not the deciding factor in most cases. Suicide more commonly follows some kind of domestic crisis: typically, an argument between husband and wife over issues such as marital infidelity, workload or finances.

'I started from the hypothesis that this would have a lot to do with daughter in law and mother in law relations -- for example where the daughter in law had given birth to girl children' says Dr. Phillips. 'What are sometimes called "protest suicides" of people who feel they have no other way to express their dissatisfaction with their situation do occur, but this has proved a relatively uncommon cause of suicide.'

In a complementary research project, the team has interviewed people who attempted suicide but were taken to hospital and saved. Asked when they had first thought of committing suicide, an astonishing 29% reported that they had decided to kill themselves only ten minutes or less before the attempt. Fully 50% reported that they had contemplated suicide for less than two hours.

Having decided on this desperate remedy, young rural women typically perform the deed by drinking a lethal dose of pesticides. This is a readily available and highly effective means of suicide. In rural areas with poor or distant health facilities, swallowing pesticides is also very often an irreversible step. The high number of suicides among rural women may well therefore be partly due to a low 'failure' rate compared to other countries: a higher proportion of those in China who attempt suicide may be successful in ending their lives because of their location and the methods they employ.

However, a significant number of Chinese suicide cases do appear to have been seriously premeditated. The rate of suicide among middle-aged people is relatively low, but rises steeply again among older people. Dr. Phillips reports that they have encountered some cases where chronically sick older people have apparently taken their own lives to save the family medical bills.

Dr. Phillips directs the Research Centre of Clinical Epidemiology at Beijing's Hui Long Guan Hospital, which is the largest psychiatric facility in the country. Whilst accepting that not all suicides are indicative of mental illness, he feels that there are significant, and probably growing, mental health problems in rural areas, but almost no services to assist with these.

Most attention in China is given, he says, to mental illnesses that involve psychotic disorders - those in which the sufferer experiences delusions of some kind - particularly where these may result in violent or disruptive behaviour which threatens to disturb the social order. 'Affective disorders' such as depression - those primarily involving the feelings and emotions of the victim -- are generally less often recognised, diagnosed or treated. Indeed, according to Dr. Phillips, 'The word "depressed" is not part of the folk vocabulary here.' For that reason, he suspects, clinical depression may have been substantially under-reported in the few studies on the subject to date.

The World Health Organisation is now planning to sponsor a new survey of depression in three Chinese cities, beginning this summer.

Treatment for mental illness under the public health system is at present largely confined to hospitalisation in specialised psychiatric hospitals for acute periods of severe psychosis, such as schizophrenia. Patients are generally committed by their families. Voluntary admission is relatively uncommon. Professional treatment for depression, which only rarely requires hospitalisation, is extremely limited.

In the 1970s, the Ministry of Public Health began a number of pilot programmes to provide supervision and support to mentally ill people in the community. Although these were, in Dr. Phillips's assessment, largely successful, they have since been abandoned for lack of funding support, as health providers have been increasingly obliged to fund their services from user charges.

Because of the stigma attached to serious mental illnesses such as schizophrenia, sufferers find it very hard to obtain work, or to return to work after periods in hospital. As a result, families of mentally ill people find it extremely hard to pay for expensive inpatient treatment.