International Journal of Social Psychiatry http://isp.sagepub.

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Suicides in Hong-Kong and Singapore: a Tale of Two Cities

Paul S.F. Yip and Roger C.E. Tan Int J Soc Psychiatry 1998 44: 267 DOI: 10.1177/002076409804400403 The online version of this article can be found at: http://isp.sagepub.com/content/44/4/267

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267-

SUICIDES IN HONG-KONG AND SINGAPORE: A TALE OF TWO CITIES

PAUL S.F. YIP &

ROGER C.E. TAN

SUMMARY Suicide statistics from Hong Kong and Singapore over the period1984-1994 were studied. The suicide behaviours in Hong Kong and Singapore are remarkably similar. Suicide rates increased with age, with a sharp increase among the elderly which was about four to five times the average. A relatively low male:female ratio and low teenage suicide were also found. Jumping from a height was the commonest method of suicide. Nevertheless, a different time trend of the suicide rates was observed, with an upward and downward trend for Hong Kong and Singapore respectively. The cultural, social and economic aspects in understand-

ing

suicidal behaviour in

Hong Kong and Singapore

INTRODUCTION

are

also discussed.

Hong Kong and Singapore share many common physical characteristics. Both countries are densely populated with more than 80% of their population living in high rise buildings. Singapore is a tiny island with a total area of about 641 square kilometers, accommodating a population of approximately 3 million people of whom 77.4% are predominantly Chinese, 14.2% Malays, 7.2% Indians and 1.2% other races. Hong Kongs 6.3 million people, comprising mainly ethnic Chinese (96%), live in an area of about 1078 square kilometers. Gcographically, both countries are strategically located with thriving free ports which are two of the busiest in the world. Unlike other South East Asian countries, Hong Kong and Singapore lack any natural resources and heavily depend on their hard working, educated workforce to drive their economies forward. Both countries have done extremely well economically during the past decades, with per capital income rising to approximately US$24,700 in 1995. The economic prosperity in both Singapore and Hong Kong has also led to rising standards of living, health care and hygiene. For example, in Singapore the infant mortality rate has reduced to 4 per thousand in 1995, compared with 11.7 per thousand in
1980. The life expectancy at birth for residents also increased from 71.5 years in 1985 to 74.2 years in 1995 for males and from 76.4 years to 78.7 years for females for the same period.

Similarly, in Hong Kong the life expectancy for males and females were 76 and 81.5 years old respectively in 1995. The infant mortality rate has reduced from 9.7 per thousand in 1981 to
4.9 per thousand in 1995.

Although Hong Kong and Singapore have become two of the most affluent nations in South-east Asia, economic prosperity may also have negative effects. Recent studies have found that the suicide rates for the elderly in Singapore and Hong Kong are very high

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(Chi et al. 1997). The fact that both countries will be facing an ageing population soon due to the baby boom years of the 1960s may exacerbate this problem. In this paper we investigate suicidal behaviour in Hong Kong and Singapore by examining the trend, age-sex distribution of suicide, methods of suicide and years of potential life lost (YPLL). Our objective is to delineate the factors which could explain the similarities and the differences in their suicidal behaviour of the two places. The first study of suicide in Singapore was carried out by Murphy (1954), who examined the suicide rate for the periods 1930-1952. Murphys study indicated a steady increase in suicide rates from 1948, especially among females. Malays had a much lower suicide rate for both sexes while the Indian community had the highest rate and followed by the Chinese. Chia (1979) examined elderly suicide in Singapore and found that the rate was extremely high in comparison with Hong Kong and Japan. He suggested that the issue of a migrant population might be one contributing factor. Chia (1981) also gave a very comprehensive account of the suicidal behaviour (including attempted suicide) in Singapore. Tsoi and Kok (1995) provided an update of suicidal behaviour in the 1980s. Yap (1958) published the first study of suicidal behaviour in Hong Kong. ~hc papers of Yap (1958), Lo and Leung (1985), Hau (1993), Ho et al. (1995), Ho (1996) and Yip (1997) showed that Hong Kong had a rather stable crude suicide rate, a low gender ratio (male:female), high elderly and low teenage suicide rates. Yip (1996a) used a component analysis method to examine the change of the crude suicide rate for the period 1981-1994. About 57% of the increase during the period can be explained by a change in the age composition and the ageing population of Hong Kong. Also, Yip (1997) showed that the suicide rate for the economically active persons was much lower than the inactive ones, especially among the elderly. Lester (1994) has also presented a comparison of suicidal behaviours in Asian countries. With the assistance of the Census and Statistics Department of Hong Kong and National Registration of Singapore we have been able to compare suicide statistics for Singapore and Hong Kong over a ten year period (1984-1994). Standardization of suicide rates are provided such that the difference would not be distorted by the difference in the age-gender composition (Pollard et at. 1980).
DATA AND METHOD
For the purpose of this study, death coded in the range E950-959 of the Ninth International Classification of Disease (World Health Organization, 1978) were classified as suicides. Suicide data for the period 1984-1994 were made available by the Census and Statistics Department (Hong Kong) and National Registration Department (Singapore). Ascertainment of suicides in Hong Kong and Singapore are very similar, under the influence of the British system. The accuracy of the data would be similar to that of most western countries. In both places, all unnatural deaths are examined by the coroner, who returns a verdict of suicide if deaths resulting from self-inflicted injuries were proved beyond reasonable doubt. Difference in suicide rates can bc explained by a change in age composition of a community aiid difference in sex-age distribution between two places. Appropriate adjustment needs to be made so that results will not be distorted (Lester, 1990). Hong Kong has a more ageing population than Singapore. In Hong Kong, there were 11% and 14%

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of persons aged 60 or above in 1984 and 1994 respectively. Comparatively, this figure is only 8% and 10% in Singapore for the same period of time. Age-gender standardization is used to account for the effect of variations in the population age-gender structure when comparing suicide rates. In this paper we used direct standardization (Pollard et al. 1990) by applying the age-gender specific suicide rates for a particular year to a standard population. Age-gender standardized rates based on their respective 1984 mid-year populations were calculated to examine the changes in the last decade. Singapore suicide rates were also standardized by Hong Kong 1984 mid-year population so as to examine the difference in suicide rates of the two places. Additionally, a Poisson regression model was used to analyse the suicide trends in Hong Kong and Singapore. The model can be expressed as:

10gE(Dit) = 10g(Nit) + ~~xt where t denotes number of years since 1981~, i - age group, E(Di,) - expected number of deaths in year t and age group i, l~Tlt is the mid-year population of age group i and year t; and (~xl is the linear predictor which can be used to explain the effects of age group, gender and year on the suicide rates in Hong Kong and Singapore respectively. (See Aitkin et al. (1992)
for further

details.)

One of the potential problems in examining suicide statistics is the number of undetermined deaths due to injuries and accidents. The number have decreased significantly in Hong Kong but remained about the same and relatively high in Singapore in the last decade. The effect of rr~isclassification in Singapore appears to be more severe than in Hong Kong since Singapores figures indicate a relatively large number of undetermined cause of deaths, as shown in Table 1. In Singapore, the Coroner has to be satisfied not only that
Table 1 Number of suicide and undermined deaths of

Hong Kong &

Sg~~~p®ae9

1984-1994

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270

death is self-inflicted, but also that the deceased intended to take his own life. Hence the undetermined deaths could be reclassified as suicide (Chia, 1981).

some

of

RESULTS

Suicide trends
were standardized by their respective 1984 age-gender population distributions in Hong Kong and Singapore. The age-standardized suicide rates for males and females of Hong Kong and Singapore in the reference period are given in Table 2 and Figure 1. The agestandardized rates were consistently lower than crude suicide rates (the elderly suicide rate was higher than that of the general population). Furthermore, Singapore suicide rates

The rates

Table 2 Standardized suicide rates

(per 100~000)

of

Hong Kong

~z

Singapore,

1984-1994

Remark: (a) Two unknown cases in 1984 is not included in the Hong Kong data. (b) One unknown case in 1989 & one unknown case in 1994 is not included in the Singapore data (c) First number inside the brackets are the crude rates (d) Second number inside the brackets are Singapore suicide rates standardized by 1984 Hong Kong population

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271

Figure

1. Standardized suicide rate

(per 100,000)

of

Hong Kong

~z

Singapore, 1984-1994

standardized by 1984 Hong Kong population were also higher than its own rates, since Hong Kong has a higher proportion of elderly population and the elderly suicide rates in Singapore were higher than those of Hong Kong. (Suicide rates for the persons of ages 75 or over had the rates of 78 and 54 per 100,000 in the period for Singapore and Hong Kong respectively.) For teenagers aged 15-24, these figures were 10 and 7 per 100,000 respectively. The suicide rate for persons aged 25-74 in the two places were similar. Suicide rates increased with age, dramatically at age 60-74 and 75 or over, as shown in Figures 2 and 3 for Hong Kong and Singapore respectively. The elderly suicide rate in Singapore had a peak of l 10 per 100,000 in 1988 during the reference period whereas the peak in Hong Kong was 63 per 100,000 in 1992. From the Poisson regression model, a linear term for the reference period is shown to be adequate to fit the Hong Kong data whereas a quadratic fit is required for the Singapore data. For Singapore, suicide rates had experienced an increase in earlier years and a decrease subsequently. Furthermore, the rate of decrease was more significant among the elderly and females. On the other hand, a significant rise in suicide rates in Hong Kong was observed during the reference period. The rate of increase was more significant among teenagers. The results are given in Table 3.
Gender ratio

gender ratio of the male and female suicide rates in 1994 were 1.3 and 1.4 for Hong Kong and Singapore respectively. Young females aged 10-14 in both places had a relatively higher suicide rate than their male counterpart. Nevertheless, male suicide rates were consistently higher than females for all groups aged 15 and above, as shown in Table 4.
The

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272

Figure 2. Age-specific suicide rates (per 100,000) of Hong Kong,

1984-1994

Figure 3. Age-specific suicide rates (per 100,000)

of

Singapore, 1984-1994

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273

Table 3 GLIM output for the Poisson models for and Hong Kong suicide data

Singapore

(A) Singapore:

Remarks:

Age(l): 15-24; Age(2): 25-59; Age(3): 6074 ; Age(4): 75 or over. Sex(l): Male; Sex(2): Female; Year: 1984:1, 1985:2,...,
1994:11.

(+): p-value <.05,

than the first level.

the estimate is

significantly higher

(-): p-value <.05, the estimate is significantly lower than the first level. The scale deviance was 94.4 on 75 degrees of freedom. Note that all the effects are expressed relative to the first level. For example, a negative value in the estimate of sex(2) implies that female suicide rate was less than their male counterparts. The quadratic term (with a minus sign) for the year is significant.

(B) Hong Kong

fit: +age: +sex: + year: +age.sex: +age.year

Remarks: The scale deviance was 94.0 on 76 degrees of freedom. Only the linear term (with a positive sign) for the year is significant. The quadratic term is not needed for Hong Kong data.

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274

Age-specific gender

Table 4 ratio of suicide rates of Hong

Kong

&

Singapore,

1984-1994

Methods of suicide There has been a change in suicide methods used in Hong Kong between the years 1984 and 1994, as shown in Table 5. In 1984 suicide deaths from hanging accounted for 41 %&reg; of total suicides. By 1994 this had decreased to 28%, whereas jumping showed a marked increase from 40% in 1984 to 59% in 1994. In Singapore, there was not much change over the decade. Suicides from poisoning, firearms and drowning in both places were much less than by jumping and hanging, which accounted for about 87% of all suicides. Young people used jumping as the suicide method more often than the aged. Years of potential life lost Years of potential life lost (YPLL) measures the extent of premature mortality, where premature mortality is assumed to be deaths of persons between the ages 1 and 76 years (Crowe, 1994). By estimating years of potential life lost due to suicides of people aged 1 to 75 years, it is possible to have an idea of this trauma as a cause of untimely death. Table 6 presents years of potential life lost. Increases in the YPLL can be explained by an increase in suicide rate and/or increase in teenage suicide (or both). The latter has a larger effect on the increase in YPLL. The standardized rates of YPLL were 321 and 371 for Hong Kong and Singapore, respectively, in 1994. The average YPLL over the study period were 306 and 374 respectively. Singapore had a higher YPLL than Hong Kong.

DISCUSSION

Singapore has a higher suicide rate than Hong Kong for the period 1984-1994, especially in elderly age group. Females in both territories have a relatively higher suicide rate as compared to western countries. The male to female ratio was about 1.3, whereas this figure was 4 in Australia in 1994 (Crowe, 1994). The Hong Kong female suicide rate is higher than Singapore. The higher female suicide rate in Asian countries has been said to be related to a
the

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275 Table 5 Suicide rates

(per 100,000) and proportion of suicide methods

~ ~ ~~

of

Hong Kong &

~

S~a~g~p&reg;~~9 1984-1994
~~ ~

~~

Remark:

(a)

Others include

drowning,

firearm

explosives

and others

low female social status in that society (Diekstra, 1992). Recent studies (Yip, 1998) have indicated that the ratio between suicide rate of never married to married for males was larger than females. This suggests that females may not have benefited as much as males in a marriage than their counterparts in western countries, one possible reason why Asian countries have a relatively higher female suicide rate (Yip, 1996b). Our data also indicated an increase in suicide rate among the teenagers in Hong Kong. With a high cost of living in both places, women working participation rate has increased considerably in the past decades. It is thus common for both parents to be in the work force. This may have resulted in a lack of proper parental care and guidance for teenagers. It is not uncommon in Hong Kong that children are left with their grandparents or relatives who do not live in the same household. Some parents may only have time to visit them on a weekly basis due to their hectic life-styles and long working hours. Although the material needs of these teenagers are well taken care of, the time that parents spend with their children has been dramatically reduced. Teenagers seem to have more emotional problems than before. Family support has been shown to be closely related to the psychological well-being of Hong Kong teenagers. The general health scores of teenagers especially among the females are not good, over 50% indicating that they might have potential problems (Family Planning Association,

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276

Death of persons

aged 1

to 75 years:

Table 6 Suicides

by years of potential life lost of

Remark:

(a) Years of potential life lost is standardized for age according 1984 mid-year population (b) Value inside the brackets are the crude numbers & rates

to

the

respectively

1997). About 50% of teenagers in Hong Kong who committed suicide had a history of mental (Chi et al. 1997). Mental illness was also a major risk factor among suicide victims in Singapore and this is more commonly so among the teenage group (Tsoi & Kok, 1995). It is
illness
thus

possible that effective treatment of psychiatric illness may help to prevent suicide. Although economic progress has brought many changes and raised the standard of living in Hong Kong and Singapore over the decade 1984-1994, the mental health situation in both countries has not improved. The prevalence of psychiatric illness in Hong Kong and Singapore is high. In 1994, there were 6629 in-patient admissions in Singapore, of which 1833 or approximately 28% were new cases. In the same year, there were 118,577 out-patient attendances, of which 6242 were new cases. In Hong Kong, there were 5056 in-patients in 1995. The one year period prevalence of in-patient admission is approximately 0.8 and 2.2 per 1,000 persons in Hong Kong and Singapore respectively. Nevertheless, teenage suicides in Hong Kong and Singapore are still relatively low compared to western countries. The elderly suicides in Hong Kong and Singapore are a serious problem: approximately 4 to 5 times the average. In contrast, elderly suicides are not excessive in western countries such as Canada (Kirsling, 1986) and Australia (Crowe, 1994). In order to better understand suicide among the elderly, their financial, emotional and psychological needs need to be explored. A recent study indicated that 80% of the elderly suicide victims in Hong Kong suffered from serious or painful illness (Chi et al. 1997). The medical services provided by public hospitals for the elderly in Hong Kong are commonly inadequate as is the rehabilitation service provided by Hong Kong health care system. Most of the elderly do not have medical insurance or money to seek private treatment. Singapore has a more developed health care system, with the government playing a major role in implementing policies to keep basic health care cost affordable and accessible to all Singaporeans. The government in Singapore

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277

has introduced three schemes, namely, Medisave, Medishield and Medifund. Every working individual Singaporean, including the self-employed, is required by law to contribute to Medisave under his/her own personal account. Contributions to Medisave are shared equally between employer and employee, are tax-exempt, and earn interest. Medishield is a basic, low-cost, catastrophic illness insurance scheme to help Medisave members meet the medical expenses from major prolonged illness. While Medisave is compulsory, Medishield is voluntary. There is also a Medifund scheme which is an endowment fund set up by the government specially to help the poor and needy Singaporeans pay for their medical care. Furthermore, in Singapore, the central provident fund, which is a compulsory saving for retirement of any working person provides financial support for the retired elderly. Employer and employee are required to contribute equally 20% of the employees salary into this fund before the age of 55. The percentage is progressively less after the employee reaches the age of 55. Hence most elderly should not have much financial difficulty after retirement. The psycho-social needs of the elderly in Singapore have been emphasised. The Maintenance of Parents Bill became law in 1995. This states that to be old in Singapore does not mean being denied care or comfort by those who are held most dear&dquo; . In contrast economically, Hong Kong elderly are worse off. There is no pension and only minimal support is provided by the government. Poverty among the elderly in Hong Kong has recently become more serious. The Elderly Commission set up by the Hong Kong Government is an attempt to make a concerted effort to improve the well-being of the elderly in Hong Kong, especially in housing, medical services and living allowances. Even for those elderly whose material well-being is assured, their emotional and psychological needs may not be fulfilled. The most loving offspring may often have more money than time to spare. This is especially so when husband and wife are both working. Some of the elderly have been left behind by their family members who migrate to other countries. A mismatch of expectation between the young and old is quite common. Also, the extensive housing programmes in both Hong Kong and Singapore in the past decade also led to widespread population redistribution as well as changes in living patterns and social-familial relations. In Hong Kong, the redevelopment of the old districts has forced the elderly to move to the new towns, resulting in their social ties being dramatically reduced. A recent study (Chi et al. 1997) has indicated that elderly suicides in these new towns have increased considerably. The high suicide rate identified in Singapore, despite the policies and programmes in place to help the elderly cope with their lives after retirement is disappointing. It is estimated that by the year 2030, one in four Singaporeans will be at least sixty years old and this is likely to make the needs of this group of people significantly more important. However, the Singapore Action Group of Elders (Sage) counselling centre will be planning more programmes to address the needs of the elderly. For example, schools will be targeted in this programme by holding talks to teach the young how to interact and communicate with the elderly. Forums on preventing suicide among the elderly will also be organized regularly, focusing on suicide awareness campaigns. More counselling centres will be set up to let the elderly ventilate their problems and talk about their needs. In Hong Kong, the situation of high suicide rate among the elderly is unlikely to improve without concerted action. Hong Kong is also facing an ageing population and it is estimated that approximately twenty per cent of Hong Kong people will be sixty or above by the year 2030.

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As regard to the method of suicide, jumping from a height showed a significant increase in both countries in the period 1984-1994, in Hong Kong, increasing from 40% to 60%. In Singapore deaths by jumping increased from 20% in 1965 to 60% in 1994. These changes can be related to an increase in the percentage of high-rise buildings from 23% in 1965 to more than 85% in 1994. Easy accessibility and availability are two important factors in understanding suicide methods in both places. The small number of suicide deaths from firearms and explosives in both countries can be mainly attributed to the strict control and heavy penalty for individual possession of firearms and explosives. Although the high density of high-rise residential blocks in Hong Kong and Singapore provides a readily available and a highly effective means for committing suicide, however, the effect on the total increase was marginal. It seems that increased access to high places in Hong Kong and Singapore have substituted jumping for other methods of suicides rather than inflating the overall suicide rate. Unfortunately, little can be done to limit the easy accessibility of this method. Suicide is the most disturbing of all kinds of death, not only because of its disastrous and lasting effects on the survivors, but also because, especially when occurring among the teenagers, it eliminates potentially valuable members of the community. Suicide thus carries with it the ideas of tragedy, personal loss and also societal loss (Chia, 1981). If suicide rate could be used as an indicator of the health of a society, Hong Kong and Singapore have not been doing well. It is of great sadness to see the wastage of potential life especially among teenagers. It is also a great pity that our senior citizens, after making so much contribution to the community, choose to end their lives by committing suicide. We should by all means help them fight off their misfortunes.

ACKNOWLEDGEMENTS
The authors would like to thank the Census and Statistics Department of Hong Kong and National Registration of Singapore for supplying the data in this paper; Calvin Chius assistance in preparing the data and the useful suggestions of the referee. This work is supported by a CRCG grant from the University of Hong Kong and a RGC grant of the Hong Kong Government.

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Paul S.F.

Yip, The University of Hong Kong Roger C.E. Tan, National University of Singapore Correspondence to Dr. Paul Yip, Ph.D., Department of Statistics, The University of Hong Kong, Pokfulam Road, Hong Kong E-mail: SFPYIP@HKUCC.HKU.HK Fax: (852) 28589041

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