Suicide, an urgent health issue in Korea.

The suicide rate in Korea is the highest among members of the Organization for Economic Cooperation and Development (OECD). In 2011, the suicide rate was 31.7 per 100,000 people, which is 2.6 times greater than the OECD average and represents a two-fold increase during the last decade (1). Suicide is the fourth leading cause of death following cancer, stroke, and cardiovascular disease (1). Therefore, suicide is considered one of the most serious and urgent public health and social issues in Korea.

The suicide rate among elderly individuals is particularly high and rapidly increasing. In 2011, the suicide rate was 84.4 per 100,000 people in their 70s and 116.9 per 100,000 people in their 80s (1). Male suicides outnumber women as they get older; the male:female ratio was greater than 3:1 in the elderly, while it was less than 2:1 among people under 40 years of age (1). The very rapid aging of Korean society is relevant to the high suicide rates in Korea. Indeed, the high prevalence of physical illness in elderly individuals may contribute to the high suicide rate in this population. Additionally, socioeconomic factors such as unemployment, divorce, and rapid societal changes may be more strongly associated with suicide in older adults and elderly individuals than in younger persons.

In an extremely competitive and increasingly polarized Korean society, the lack of welfare programs to assist struggling individuals and families may intensify feelings of shame and guilt that can lead individuals to consider suicide as an option (2). Moreover, the cultural belief that suicide is an individual problem makes it difficult to secure funds to expand programs to educate the public about seeking help for mental health problems or to establish training programs for physicians and other relevant service providers (2).

In addition to sociocultural contributing factors to the high suicide rate in Korea, the individual risk factors contributing to suicide should also be recognized in efforts to develop more systematic and reliable prevention strategies. These include psychiatric illness, psychiatric symptoms (impulsivity, agitation, hopelessness, and hallucinations), recent discharge from a psychiatric hospital, physical illness, sexual or physical abuse during childhood, and easy access to a method of suicide (3). Specifically, more than 90% of all suicides are attributable to an emotional or psychiatric condition, including depression, bipolar disorder, schizophrenia, and alcohol dependence (4, 5). Thus, providing appropriate treatment for psychiatric illnesses is crucial to preventing suicide. Indeed, screening depressed patients and offering better treatment for major depression are key prevention strategies (6).

Depressed patients with a history of suicide attempts tend to suffer from a more chronic and severe form of depression and respond more poorly to antidepressant treatment (7). Moreover, a previous suicide attempt is a strong predictor of future attempts and completed suicides (8). Therefore, more intensive and longer-term treatment including focused and ongoing clinical attention to suicide risk is required for patients with a history of previous suicide attempts (7). Suicidal behavior represents a unique dimension of psychopathology. Therefore, documentation of suicidal behavior as a separate part of a multiaxial diagnosis or as a highlighted section of the medical record may draw sustained clinical attention to, and lead to specialized treatment plans for, vulnerable patients (9).

The provision of case-management services to people who attempt suicide is an effective approach to reducing suicide mortality. Ongoing evaluation of mental status and consistent encouragement of adherence to psychiatric treatment regimens are essential contributors to the prevention of additional suicide attempts (10). Suicide rates have been reduced in many countries by enhancing the social and mental health systems for people at high risk (10, 11). Hospital emergency departments, which treat individuals who attempt suicide, should begin to offer routine risk evaluations and case-management services. Moreover, the Korean government should vigorously support the ability of the community mental health system to provide case-management services to those at a high risk of suicide.

As many as 83% of those who die from suicide have had contact with a primary care physician within a year of their death, and up to 66% have had such contact during the month before their death (12, 13). Therefore, improving the ability of physicians to recognize depression and evaluate suicide risk is very important for suicide prevention (6). When physicians meet persons at risk for suicidal behavior, they should incorporate the following three elements in their patient interviews: empathic communication (active listening), evaluations of suicidal ideation and risk factors, and attempts to enhance factors that protect against suicide (7). The willingness to listen to an individual's painful experiences with non-judgmental attitude is important when talking about suicide. Additionally, clinicians should perform detailed assessments of the intensity of suicidal ideation, thoughts about methods of suicide, intent to act on suicidal thoughts, and specific suicide plans. Hospitalization in a closed psychiatric ward can help to prevent suicide among those presenting with a high and immediate risk for suicide.

In terms of community interventions, educating gatekeepers whose contact with potentially vulnerable individuals provides an opportunity to identify those at risk and direct them to appropriate assessment and treatment is an effective approach to suicide prevention (14). Such gatekeepers include clergy, pharmacists, geriatric caregivers, and those employed in institutional settings, such as schools, prisons, and the military. Educational efforts should increase awareness of risks factors and relevant resources as well as attempt to reduce the stigma associated with psychiatric treatment (6).

Alcoholism is associated with increased suicide risk. Moreover, data show that alcohol-positive status is common among those who complete (up to 69%) and attempt (up to 73%) suicide (15). Indeed, alcohol consumption predisposes individuals to or precipitates suicidal behavior through its depressogenic effects, association with adverse life events, impairment of problem-solving skills, and aggravation of impulsivity, possibly through its effects on serotonergic neurotransmission (16). Therefore, interventions for problem drinking may be effective for reducing suicide rates. Moreover, restrictions on access to alcohol by those with suicidal ideation may decrease suicide attempts (6). The Korean practice of offering alcohol to depressed people to cheer them up should also be changed to reduce impulsive suicide attempts. The general public should be informed that alcohol consumption by people with suicidal ideation is tantamount to adding fuel to a fire.

Suicide rates in Korea may also be reduced by making certain changes to social and environmental systems. Pesticides, particularly paraquat (Gramoxone), are the most frequently used means of suicide in rural areas of Korea. Therefore, access to pesticides should be restricted, and these substances should be detoxified to reduce suicide mortality. The role of the mass media in reporting suicides should also be considered in efforts to reduce the imitation effect and decrease copycat suicides. Indeed, the suicide of a celebrity is often followed by an increase in suicide rates in the general population (17), and suicide rates in Korea have as much as doubled during the month following a famous celebrity's suicide. Educating journalists and establishing a system that maintains media guidelines for reporting on suicide are important in this regard.

In conclusion, suicide is a very significant public health issue in Korea. Educating physicians and gatekeepers, recognizing and intervening in psychiatric illnesses such as depression at an early stage, restricting access to lethal methods, maintaining media guidelines for reporting on suicide, and providing case-management services to individuals who have attempted suicide may help to prevent suicide. Government, society, and medical professionals should devote more attention to reducing the high suicide rate in Korea.