Suicide rates declined in China: The social, cultural and economic factors

The suicide rates in the world have been growing in the past century [1] and the rates in the United States have rapidly increased by about 33%, from 10.5 per 100,000 population in 1999 to 14.0 in 2017 [2], regardless of prevention efforts with affl uent funding [3]. On the other hand, the overall suicide rate in China has decreased from 23.0/100,000 in 1999 to 8.6/100,000 in 2017, marking a 63% drop over past two decades [4]. The most marked decrease has been observed in young women in rural areas under 35 years of age, whose suicide rate appears to have dropped by as much as 90% [4].


Fast economic development has rapidly improved the quality of life
The Chinese GDP per capita increased from $312 in 1980 to $8,836 in 2017, and the average annual income increased from 29,229 RMB in 2008 to 74,318 RMB in 2017 for urban residents [5]. In the rural regions, the central government has lifted all taxes and tariffs for the farmers since 2006 and has provided stipends for those who can sell agricultural products to the state.
Rapidly improved quality of life both in rural and urban areas of China have obviously reduced those people's strains (confl icting stressors) resulting from relative deprivation and frustrated aspirations. Relatively, the improvement of life is more perceived in the rural areas than in the urban areas, and that may be why the suicide rate in rural areas is falling faster than that in cities. Based on the Strain Theory of Suicide, lack of psychological strains brought about less frustration, anger, and psychological pain, and, therefore, lower suicide risks [6]. The Strain Theory of Suicide also poses the importance of relative deprivation (poverty) on suicidality, and therefore, poorer communities or countries may not have higher mortality rates due to suicide. Another speculation is that when the China's economy slows down, its suicide rates may rise to some extent, as people's living reality may quickly lagged behind their life aspirations.

Migration to urbanized areas reduced rural populations
The marked decline in the Chinese suicide rates happened partly because so many rural young people who were at the highest risk of suicide moved from the rural countryside to the cities, where suicide has been less frequent. About twenty years ago, more than three quarters of the suicides in China were rural young people, but now most young people are working in the cities, far away from the social, cultural, and economic environments that put their predecessors at a high risk of suicide. However, it is also noted that the left-behind children and the elderlies may still be exposed to suicide risks and their decrease of the suicide rates is slower than that of the midaged people [4].
Although entering the city, those young people are faced with pressure from employment, housing, and children's education, etc., better living conditions and more opportunities make them happier than before. Usually, immigrants, domestic or international, enjoy better physical and mental health than non-immigrants [7]. For many rural young women, the migration has liberated them from traditional family pressures, bad marriages, overbearing parents-in-law and other stresses of poverty and rural life. Migrants have also stayed away from the easiest means of impulsive suicide, swallowing pesticides, the method used by nearly 60% of rural suicides. Furthermore, higher incomes and better education may also have contributed to the decrease of psychological strains among young migrants.

Modernized social values liberated rural women
Traditional values such as Confucian teachings have been declining among youths as China has become more globalized and modernized since China opened the door to the West in 1980s. The traditional values concerning marriage, dating, fi lial piety, and women's status that were in confl ict with modern Western ideas are weakening among young people [8]. Therefore, the psychological strains formed by confl icting values are less prevalent in this high risk, rural, young, female population.
There are now more opportunities for rural women, who now have more freedom in moving to cities, getting educated, and fi nding jobs. Today, they are more socially and professionally active. Family sizes become smaller, reducing the burden of child rearing and providing more time for women to engage in activities outside of home.

One-child one-family policies made today's marriage age women more valued
The one-child one-family policies that started in China about 40 years ago and ended in 2016 has created an imbalance in the gender ratio of the marriage-age populations today [9]. With the Chinese cultural preference of boys as the only children, many parents, especially those in rural areas, selected a son through pregnancy, abortion, giving out for adoption, or even brutal female infanticide [10]. As the sex ratio at birth in 2000 was 119.9, there are approximately 33 million more males than females at the age for marriage in the country [11]. This defi cit in the numbers of marriable women is attributed to the traditional sexism in favor of having male children, the adoption of baby girls to overseas couples, and abortion and infanticide. With lower number of marriage age females, young women may have felt more valuable and respected. They may have more resources and enjoy life more than their predecessors and their male counterparts. Three quarters of the suicides in China were females, and the decline of female suicides has signifi cantly contributed to the decline of the overall suicide rates in China.

Surveillance-based counseling monitored youths on campuses
The college student suicide rate is much lower than the national average and lower than the rate of same age noncollege population, as a result of the mandatory residence requirement and the administrative surveillance of the dorms commonly practiced in China. Students are typically watched and controlled on campus. Each dorm is supervised, and every student is monitored by university-assigned psychological counsellors for any risk signs for suicidal ideation and attempts, as well as, of course, any political actions the government does not like.

The governmental media control curbed the contagion of suicide
Chinese government-run media typically do not report negative social events, such as crimes. Suicide incidents, sometimes reported by some small, non-offi cial, and marketoriented media sources, are not encouraged by the government.
A side effect of this is to prevent a suicide story from spreading and going viral, which reduces copy-cat of the behavior.
Free media as a form of freedom of speech are considered responsible for the health of society and the well-being of the people. On the other hand, media can be used to promote the awareness and prevention of suicide, but China is yet ready for this endeavor.

The strain theory of suicide
Proposes that suicidality and related mental problems are usually preceded by psychological strains which are resulted from negative life events, that make individuals frustrated, hopeless, angered, and psychologically painful [12]. Any of the following can make an individual psychologically strained: differential values, discrepancy between aspiration and reality, relative deprivation (poverty), and crisis with a lack of coping skills [13]. People with severe psychological strains usually have one of the two ways to become less painful: aggression towards others through violence or aggression towards self by suicide [12]. As a primary and population based prevention strategy, reduction of psychological strains may be an option to reduce suicide risks. In the past three decades, Chinese people's strains have been lessened through rapid economic growth, social and cultural change, augmented rural-to-urban migration, and the increased life satisfaction brought about by the improved quality of life.