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on to live long and productive lives. Means restriction is an eective population-based approach that should be considered for inclusion in all comprehensive suicide prevention strategies. *E Michael Lewiecki, Sara A Miller
New Mexico Clinical Research and Osteoporosis Center, Albuquerque, NM, USA (EML); and Harvard University, Boston, MA, USA (SAM) mlewiecki@gmail.com
EML and SAM are the father and ance, respectively, of a victim of impulsive suicide. They both declare that they have no conicts of interest. 1 Niederkrotenthaler T, Fu KW, Yip PS, et al. Changes in suicide rates following media reports on celebrity suicide: a meta-analysis. J Epidemiol Community Health 2012; published online April 21. DOI:10.1136/ jech-2011-200707. Boyce N. Suicide clusters: the undiscovered country. Lancet 2011; 378: 1452. Hannan C. Samantha Kuberski, six years old, youngest suicide victim in Oregon State history. http://blogs.seattleweekly.com/dailyweekly/ 2010/04/samantha_kuberski_six-years-ol.php (accessed April 24, 2012). Erlangsen A, Bille-Brahe U, Jeune B. Dierences in suicide between the old and the oldest old. J Gerontol B Psychol Sci Soc Sci 2003; 58: 31422.

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Lewiecki EM, Miller SA. A piece of my mind: time to reconsider. JAMA 2011; 305: 107071. Hawton K, Saunders KEA, OConnor RC. Self-harm and suicide in adolescents. Lancet 2012; 379: 237382. Pitman A, Krysinska K, Osborn D, King M. Suicide in young men. Lancet 2012; 379: 238392. Yip PSF, Caine E, Yousuf S, Chang S-S, Wu KC-C, Chen Y-Y. Means restriction for suicide prevention. Lancet 2012; 379: 239399. WHO. Preventing suicide: a resource for general physicians. Last updated 2000. http://www.who.int/mental_health/media/en/56.pdf (accessed June 1, 2012). Fishbain DA, Bruns D, Meyer LJ, Lewis JE, Gao J, Disorbio JM. Exploration of the relationship between disability perception, preference for death over disability, and suicidality in patients with acute and chronic pain. Pain Med 2012; 13: 55261. Geulayov G, Gunnell D, Holmen TL, Metcalfe C. The association of parental fatal and non-fatal suicidal behaviour with ospring suicidal behaviour and depression: a systematic review and meta-analysis. Psychol Med 2011; published online Dec 1. DOI:10.1017/S0033291711002753. Cheatle MD. Depression, chronic pain, and suicide by overdose: on the edge. Pain Med 2011; 12(suppl 2): 4348. Florentine JB, Crane C. Suicide prevention by limiting access to methods: a review of theory and practice. Soc Sci Med 2010; 70: 162632. Harvard Injury Control Research Center. Characteristics of victims of suicide. http://www.hsph.harvard.edu/hicrc/nviss/documents/Suicide%20 Summary%202001.pdf (accessed June 1, 2012).

The changing global face of suicide

See Editorial page 2314 See Articles page 2343

On the basis of WHO estimates for 2004, India and China account for 49% of global suicides, and all low-income and middle-income countries (LAMICs) combined account for 84% of all suicides.1 However, high-quality research on suicide in LAMICs is very restricted, so the Article in The Lancet by Vikram Patel and colleagues,2 the rst nationally representative study to estimate suicide rates in India, is an important contribution to available knowledge. The high estimated overall suicide

rates in India of 186 per 100 000 boys and men (upper bound 157, lower bound 198) and 127 per 100 000 girls and women (107, 130), and the fact that suicide is the second most important cause of death in young adults aged 1529 years, parallel ndings from China3 and conrm what has been suspected for decadessuicide is a major public health problem in LAMICs that has not received the attention it deserves. Their data suggest that Indias National Crime Records Bureau underestimates suicides in men by at least 25% and suicides in women by at least 36%, showing that treating suicide as a criminal oence, as is done in India and many Islamic countries, can result in the frequent misclassication of suicide deaths and, thus, undermine prevention eorts. As better information about suicide in LAMICs emerges it is starting to challenge conventional beliefs about suicide that, up until the past decade, have been almost completely based on research from high-income countriescountries that account for only 16% of worldwide suicides.1 Largely based on epidemiological research from high-income countries, most international experts and the WHO Division of Mental Health report that global suicide rates are more than three times higher in men than in women;4 but the male-to-female ratio reported for India was 15 to 1 and the ratio in China is
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about 1 to 1, so the global male-to-female ratio of suicide rates, on the basis of 2004 global burden of disease estimates,1 is actually 167 to 1 not 3 to 1 (as estimated by WHO).4 The rural suicide rates in both India and China are more than double urban rates, quite dierent from the picture in high-income countries, where dierences in urban and rural suicide rates are small and vary by location. Young women in rural areas in both countries are at especially high risk of dying by suicide, a nding that initially surprised experts in high-income countries. The most common method of suicide globally is selfpoisoning with pesticides5 (accounting for about a third of all suicides), a fact that was not recognised until data for the method of suicide started to emerge from LAMICs. The papers surprising nding that suicide was higher in Indias richer states and that divorce, separation, and widowhood in women were protective factors for suicidea similar nding has been reported in some studies in China6,7contradicts ndings from many studies in high-income countries that identify low socioeconomic status and divorce as important risk factors for suicide.8 And the results of many high-quality studies in China that recorded, despite detailed diagnostic examinations by well-trained mental health professionals, no mental illness in about a third of individuals who die by suicide and two-thirds of people who attempt suicide912 are very dierent from the ndings in high-income countries where suicidal behaviour is almost always associated with a mental illness.8 Taken together these unexpected ndings from India and China show that the importance of some of the demographic, social, and psychological factors that have been assumed to be universal risk factors for suicide can, in fact, vary greatly between cultures and over time. These demographic and risk-factor proles of suicide are, of course, not uniform across all LAMICs. Like many high-income countries,13 China has much higher suicide rates in elderly people than in young and middle-aged adults, but this pattern is not seen in India. And the striking 18-fold dierential in female suicide rates in dierent Indian states and 10-fold dierential in male suicide rates in dierent states reported by Patel and colleagues is not seen in China. These cross-national and cross-regional dierences have major implications for prevention. As LAMICs undergo the epidemiological transition and start to turn their attention to chronic diseases and intentional
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and unintentional injuries, they cannot rely on the approaches developed in high-income, high-resourced countries. They will need to develop and test new prevention strategies for suicide that are based on the very dierent demographic characteristics, risk factor proles, community attitudes, and social resources that exist in their own countries. India, China, and other LAMICs should rst do nationally representative case-control psychological autopsy studies, attitudinal surveys, and resource inventories to understand these dierences. They can then actively engage the public and professionals to change perceptions about suicide and, most importantly, develop and test innovative strategies to prevent suicide in a way that suits the situation in their own countries and communities. Patel and colleagues work will continue to challenge conventional wisdom about suicide and help put a global face on our understanding of this important public health problem. *Michael R Phillips, Hui G Cheng
Suicide Research and Prevention Centre, Shanghai Mental Health Centre, Shanghai Jiao Tong University School of Medicine, China (MRP, HGC); and Departments of Psychiatry and Global Health, Emory University School of Medicine, Atlanta, GA, USA (MRP) phillipschina@yahoo.com
We declare that we have no conicts of interest. 1 2 WHO. The global burden of disease: 2004 update. Geneva: World Health Organization, 2008. www.who.int/evidence/bod (accessed June 6, 2012). Patel V, Ramasundarahettige C, Vijayakumar L, et al, for the Million Death Study Collaborators. Suicide mortality in India: a nationally representative survey. Lancet 2012; 379: 234351. Phillips MR, Li XY, Zhang YP. Suicide rates in China, 199599. Lancet 2002; 359: 83540. WHO. Distribution of suicide rates (per 100 000) by gender and age, 2000. www.who.int/mental_health/prevention/suicide/suicide_rates_chart/ (accessed June 6, 2012). Gunnell D, Eddleston M, Phillips MR, Konradsen F. The global distribution of fatal pesticide self-poisoning: systematic review. BMC Public Health 2007; 7: 357. Li XY, Phillips MR, Ji HY, Xu YC, He FS. Why is the suicide attempt rate higher in women? Chin Ment Health J 2004; 18: 19195. Gao SY, Phillips MR, Zhang YP, Ji HY, Zhang FG, Yang GH. Comparison of suicide characteristics in young rural females and males from 20 parts of China. Chin J Psychiatry 2004; 37: 23235. Hawton K, van Heeringen K. Suicide. Lancet 2009; 373: 137281. Phillips MR. Rethinking the role of mental illness in suicide (editorial). Am J Psychiatry 2010; 167: 73133. Yang GH, Phillips MR, Zhou MG, Wang LJ, Zhang YP, Xu D. Understanding the unique characteristics of suicide in China: national psychological autopsy study. Biomed Environ Sci (China CDC) 2005; 18: 37989. Zhang J, Xiao S, Zhou L. Mental disorders and suicide among young rural Chinese: a case-control psychological autopsy study. Am J Psychiatry 2010; 167: 77381. Li XY, Xu YC, Wang YP, et al. Characteristics of attempted suicides treated in rural general hospitals. Chin Ment Health J 2002; 16: 68184. Harwood D, Jacoby R. Suicidal behavior among the elderly. In: Hawton K, van Heeringen K, eds. International handbook of suicide and attempted suicide. Chichester: Wiley, 2000: 27591.

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