DEPRESSION AND ANXIETY 33:558566 (2016)

Research Article
COHORT EFFECTS OF SUICIDE MORTALITY ARE SEX
SPECIFIC IN THE RAPIDLY DEVELOPED HONG KONG
CHINESE POPULATION, 19762010
Roger Y. Chung, Ph.D.,1 Benjamin H. K. Yip, Ph.D.,1 Sandra S. M. Chan, M.R.C.Psych., M.B.Ch.B.,2
and Samuel Y. S. Wong, M.D.1

Background: To examine temporal variations of age, period, and cohort on sui-

cide mortality rate in Hong Kong (HK) from 1976 to 2010, and speculate the
macroenvironmental mechanisms of the observed trends. Methods: Poisson age-
period-cohort modeling was used to delineate the effects of age, period, and cohort
on suicide mortality. Analysis by sex was also conducted to examine if gender
difference exists for suicidal behaviours. Results: Age-cohort model provides the
best fit to the mortality data, implying that the cohort effect is likely to explain
more of the contributions to HKs suicide mortality pattern than the period effect.
Risk of suicide mortality increases nonlinearly with age and accelerates after age
6569 for both sexes. Moreover, the cohort effects differ between the sexesrisk
of mortality increases continually for men born after 1961, but no change is
observed for women since the 1941 cohort. Conclusions: With increased risk of
suicide mortality in younger cohorts and the age effect of suicide mortality, we
may see future increase in suicide mortality as these younger cohorts age. Further
studies are needed to clarify plausible associations between broader sociohistor-
ical changes in the population impacting psychological risk factors and suicidal
behaviour to better inform suicide prevention strategies. Depression and Anxiety
33:558566, 2016. 
C 2015 Wiley Periodicals, Inc.

Key words: suicide; age-period-cohort analysis; cohort effects; gender differ-

ences; Hong Kong; social environment

INTRODUCTION matic increase in suicide rates in the past two decades.[1, 2]

S uicide has been recognized as one of the top 10 leading
causes of death globally[1] , and is also becoming an im-
portant public health issue in Asian countries due to dra-
1 JC School of Public Health and Primary Care, Faculty of
Medicine, The Chinese University of Hong Kong, Hong Kong
2 Department of Psychiatry, The Chinese University of Hong
Kong, Hong Kong
Correspondence to: Samuel Y. S. Wong, 4/F School of Public
Health, Prince of Wales Hospital, Shatin, NT, Hong Kong.
E-mail: yeungshanwong@cuhk.edu.hk
Received for publication 13 May 2015; Revised 4 September 2015;
Accepted 4 September 2015
DOI 10.1002/da.22431
Published online 28 September 2015 in Wiley Online Library
(wileyonlinelibrary.com).

C 2015 Wiley Periodicals, Inc.
Generally, although suicide rates and mortality rates are
higher in elderly due to increased disability, chronic dis-
eases or decreased social support that may be associated
with increased prevalence of depression, increased sui-
cide rates in youth have also been observed since the
1960s[3] and received more media attention in many in-
dustrialized countries including China, as highlighted
by the media coverage on the series of suicide episodes
among Foxconn Technology employees[4] .
Hong Kong, the rst developed Chinese populations
in modern history, is also no exception to these trends.
Although there is a clear age effect on suicide mortality
in Hong Kong (i.e., the risk of suicide mortality increase
with age in general for both sexes), the trends of suicide
mortality are changing over the period from 1975 to
2010. In particular, although the suicide mortality rate
of elderly aged 65 or above is still the highest among
all age groups, there is a declining trend over the same
period.[5] On the other hand, there is an increasing trend
 Research Article: Cohort Effects on Suicide Mortality in HK
in youth suicide mortality especially among male over
the same period[5] . Nevertheless, whether the observed
changing trends represent a cohort or period effect has
not been studied in Hong Kong.
The predominance of period effect suggests that
changes in a particular calendar period that affect all
age groups in a population-wide scale account for the
observed trends. In the case of suicide, a period effect
means that suicide is more prevalent during a particu-
lar period of an event (e.g. economic bust) that affects
people of all ages in the population. On the other hand,
the predominance of a cohort effect suggests that people
born to different periods (i.e., people of different gener-
ations) have different suicidal patterns throughout their
life course as they age due to similar exposures to factors
that affect particular generations during their develop-
ment and early adult life.
Age-period-cohort (APC) models are often used to de-
lineate the temporal variations of age, period, and cohort
on disease mortality rate and speculate on the etiologi-
cal mechanisms of the observed trends. Although there
is evidence of different etiological risk factors on suicide
mortality rate in Hong Kong,[6] no study has ever em-
phasized on the temporal changes of age, period, and
cohort on suicide mortality. Moreover, the Hong Kong
population is the rst Chinese population that experi-
enced rapid socioeconomic transition within a very short
time,[7] and therefore may serve as an exemplar for many
other rapidly developing populations in China. There-
fore, to understand the occurrence of the temporal vari-
ations of suicide mortality so as to better inform preven-
tion strategies, we conducted the rst APC analysis in
any Chinese population to delineate the effects of age,
period, and cohort on suicide mortality. Additionally, we
conducted the analysis by sex to examine if there is any
gender difference in terms of suicidal behaviours.
METHOD
DATA SOURCES
The Hong Kong Census and Statistics Department provided mid-
year population gures and all known (i.e., registered) deaths in Hong
Kong from 1976 to 2010 by age, sex, and cause of death. Causes of death
were coded using the Eighth Revision of International Classication of
Diseases (ICD-8) for 19761978, ICD-9 for 19792000, and ICD-10
for 2001 onwards.
OUTCOMES
We considered as primary outcomes suicide mortality. For com-
parison, we also considered nonsuicide external causes as a control
outcome to identify if any systematic changes exist.
DATA ANALYSIS
Mortality rates for the population were expressed per 100,000 peo-
ple and directly standardized to the World Standard Population.[8]
We used quinquennial age groups, and included deaths from 1519
to 85+ years. Deaths before the age of 15 were excluded due to small
number of suicide deaths in younger ages. With mortality data over
seven quinquennial periods (from 19761980 to 20062010), 21 birth
559
cohorts were generated, ranging from the rst cohort that centred at
1891 to the last cohort that centred at 1991.
We applied sex-specic Poisson APC models using maximum like-
lihood method to estimate the relative risks (RRs) by age groups, cal-
endar period, and birth cohort, with 95% condence intervals. Under
the full APC model, the mean is specied as follows:
   
log i j = age i + perio d j + c o ho rtk + log ni j ,
where age i (i = 1, . . . , I ) is the age effect, perio d j is the
period effect ( j = 1, . . . , j ) , cohortk is the cohort effect
(k = 1, . . . , K , k = I + j i), and log(ni j ) is the offset term.
APC models identify broad or macroenvironmental effects of the
social environments that may contribute to changes in disease patterns
by decomposing mortality rates by age, period, and cohort effects.[9, 10]
However, a fundamental problem inherent in all APC models is the lin-
ear dependency between these three components (i.e., cohort = period
age), making it impossible to estimate all three effects simultaneously
in a full regression model.[11] In this study, we limited our analysis to
tting age-period (AP) and age-cohort (AC) models to the data, as in
a previous APC study.[12] We used the Akaike Information Criterion
(AIC) to compare the models, in which a lower value indicates a better
tting model, and hence a signicant change in effect through time for
the relevant component. Although the choices for the reference group
for the effects have always been arbitrary in any APC analysis,[13] the
choices of reference categories for this study were made according to
previous studies using the same database,[7, 14] and no reference cate-
gories toward the two extremes of the groups were chosen due to less
number of cases. Moreover, sensitivity analyses (data not shown) also
showed that the shape and trend of the effects did not change with
different reference categories used. The morality RRs were calculated
to summarize the effects of age, period, and cohort separately by sex.
All analyses were implemented in R version 2.15.2 (R Development
Core Team, Vienna, Austria).
RESULTS
Table 1 shows the absolute number of deaths and pop-
ulation in 1976 and 2010 as well as the mean number
of deaths per year from 1976 to 2010 by sex. Figure 1
shows the age-standardized mortality rate per 100,000 of
suicide from 1976 to 2010 in Hong Kong. Overall, the
age-standardized mortality uctuated over the period,
and no obvious trend was observed. However, there was
an increase in mortality rate for six consecutive years
starting in 1998 and reached its peak in 2003. Moreover,
TABLE 1. Absolute number of suicide deaths and people
by sex in 1976 and 2010, and mean number of suicide
deaths and people by sex from 1976 to 2010
Number of Number of
Year Sex suicide deaths people
1976 M 341 1,615,200
F 245 1,536,600
T 586 3,151,800
2010 M 572 2,857,500
F 342 3,322,500
T 914 6,180,000
Mean, 19762010 M 434.8 2,385,237
F 284.2 2,437,491
T 719 4,822,729
Depression and Anxiety
560 Chung et al.
Figure 1. Age-standardized suicide mortality rate in Hong Kong,
19762010.
the mortality rate was consistently higher for men than
women over the period, and such difference was also
widening over the period in general.
Figure 2 shows a comparison of the mortality rates
from 15 years to 85+ years by calendar periods separately
for men and women.
Regardless of calendar period and sex, suicide mor-
tality increased more drastically after around age of late
60s, reaching its peak for those aged 85 or above. There
was a more apparent decline of suicide mortality rate for
women across calendar periods.
Figure 3 shows suicide mortality rates by cohorts com-
pared across four periods (i.e., 19761980, 19861990,
19962000, 20062010) for men and women. There was
generally an increase in suicide mortality toward younger
cohorts for men, but not for women.
Using the age group 4044 years as the reference
group, the relative effects of age, represented as RRs, are
presented separately in Table 2 and graphically displayed
in Fig. 4, and they were presented separately by sex. The
RRs represent the relative increase in age-specic rates
derived from the AC models. It can be seen that the
trends of the relative effect of age on suicide mortality are
similar to the ones as observed in cross-sectional calendar
periods (Fig. 2)a more rapid increase in RRs in older
ages (i.e., after 6569 years) are observed in both sexes.
However, after adjusting for the cohort component, a
linear increase in RR for men becomes apparent in ear-
lier ages, but no linear increase of RR (i.e., a plateau) is
observed for women in earlier ages until around age 50.
In all our analyses, the AC models (AIC = 1075.1 for
men and AIC = 902.0 for women) provided the best t
compared to both the AP (AIC = 1142.2 for men and
AIC = 983.1 for women) and age-drift models (AIC =
1313.1 for men and AIC = 1034.7 for women).
On the other hand, the age-adjusted relative effects
of cohort with the birth cohort centred in 1951 as the
reference group are presented as RRs in Table 3 and
graphically displayed in Fig. 5. RRs estimate the RR in
age-adjusted mortality from suicides in the various birth
cohorts. We estimated the RRs separately by sex. For
men, it can be observed that except for the very rst
Depression and Anxiety
cohort (1891) with wide condence intervals, there was
a general decline of RR from 1.29 (95% CI = 1.031.61)
in the 1901 cohort to 0.83 (95% CI = 0.760.91) in the
1936 cohort, followed by some uctuations (i.e., 1941
to 1956 cohorts), and nally a more rapid increase of
RR since the 1961 cohort till more recent cohorts. For
women, there was a more drastic decline in the RR of
suicide mortality from 3.25 (95% CI = 2.334.53) in the
1891 cohort to 0.95 (95% CI = 0.851.06) in the 1946
cohort. However, in contrast to the trend observed in
men, there was no apparent increase in RR of suicide
mortality after 1946 that is, the RR uctuated around
0.84 to 1.09 for all the post-World War II cohorts.
Finally, the different patterns in terms of age, period,
and cohort effects in external cause mortality show that
no systematic changes exist (data not shown).
DISCUSSION
SUMMARY OF MAIN FINDINGS
Despite decreasing age-specic suicide mortality rates
for older adults of both sexes in recent years, the risk
of suicide mortality nonlinearly increases with age and
shows acceleration after age 6569 for both sexes, show-
ing clear age effect in suicide mortality. Over the years,
older adults aged 65 or above still have the highest sui-
cide rate among all age groups,[5] which was found to be
linked to various risk factors, including living alone, be-
ing widowed, and being mentally unwell or depressed.[15]
This may imply that having more familial support from
children, wider social networks, and more accessible
health and social resources may be protective against sui-
cide. Nevertheless, with one of the lowest fertility rates
in the world, it is very plausible that suicide rate among
the elderly will remain to be the highest among all age
groups in Hong Kong.
On the other hand, there is a stronger predominance
of cohort effect over period effect despite marked in-
crease of suicide mortality by 57.4% from 1997 to 2003
(Fig. 1), when Hong Kongs economy was heavily inu-
enced by a string of macroenvironmental events includ-
ing the Asian nancial crisis in 1998 and the SARS out-
break in 2003. In other words, although both period and
cohort effects contribute to the risk of suicide mortality
in Hong Kong, the cohort effect is likely to explain more
of the contributions than the period effect because the
AC model provided a better t. Moreover, the apparent
cohort effects differ between the two sexesrisk of sui-
cide mortality starts to increase continually for men born
after 1961, but no apparent change in risk is observed for
women ever since the 1941 cohort. This is also reected
in Fig. 3, which shows that a general increase in suicide
mortality toward younger cohorts for men, but not for
women. Since we have taken the approach of comparing
the goodness of t of the two-term models, we did not
focus on discussing about the period effect. Neverthe-
less, this does not mean an absence of the period effect.
Although age effects estimated by the AC and AP models
 Research Article: Cohort Effects on Suicide Mortality in HK
Figure 2. Mortality rates from 15 years to 85+ years by periods among (A) males and (B) females.
share similar pattern, period effects estimated by the AP
models showed similar pattern as the age-standardized
mortality rate, that is, there was a signicant increase in
the period effects around 20012005 across both sexes.
LIMITATIONS
Before further moving on to interpret our results, we
should state the limitations of our study. First, APC mod-
eling is ecological in design and descriptive in nature.
Since routinely collected data were used for the APC
analysis, the cohort effect of older generations was based
on mortality in the older age groups, but the cohort ef-
fect of younger generations was based on mortality in
the younger age groups. In other words, there were more
uncertainties toward the older and more recent birth co-
horts, which were taken into account by the overlapping
condence intervals. A longer period of data collection
561
helps clarify the effects on the older and the more re-
cent generations. Given this imprecision and limitations
of ecologic analyses, we are cautious with our interpre-
tations. Nevertheless, APC modeling also provides in-
sights into possible etiologic factors associated with the
temporal variations of the disease trend that may other-
wise be overlooked by other study designs.
Second, the three components of age, period, and co-
hort are linearly dependent on each other, making the
full model with all three components nonidentiable
without an additional reference constraint. Even with
an additional constraint, the resulting estimates of the
model cannot be uniquely determined, and only second-
order changes in slope can be interpreted. Nevertheless,
data can be interpreted if two-term models (i.e., AC and
AP) have good t to the data, given that simple lin-
ear (drift) model is also tested because linear drift can
Depression and Anxiety
562 Chung et al.

Figure 2. Continued.

manifest as any age, period, or cohort effect.[16] In all
our analyses, the AC models provided the best t com-
pared to both the AP and age-drift models. Moreover,
APC analyses face another criticism that AC model will
most likely have a better t to the data simply because
it has additional complexity due to more parameters.[16]
However, AIC is advantageous in that it compares the
different models with adjustment for the models un-
equal complexity.
Third, as commonly suspected,[17] China may have
underreported their number of deaths; however, Hong
Kong has a long tradition of keeping death records since
the British colonial days, and since most of the deaths in
Hong Kong have taken place in hospitals, it allows more
accurate ascertainment of the causes of death. Although
we cannot rule out some differences in reporting across
years (ICD-8 for 19761978, ICD-9 for 19792000, and
ICD-10 for 2001 onwards), and hence a possible pres-
ence of the period effect, there is no reason to believe
that these differences carry out in a systematic manner,
especially because suicide mortality is a denite cause
of death that does not differ by denition across years.
Even if the autopsy rates have fallen,[18] there is no rea-
son to believe that misdiagnoses carry out systematically.
Moreover, the present study used the most up-to-date
data up to year 2010 for analysis. Since the lengths of
follow-up period are longer for the older birth cohorts, a
longer period of data collection gives stronger power and
condence to the ndings of the older cohorts, which
most studies from other populations focused on, thus

Depression and Anxiety

 Research Article: Cohort Effects on Suicide Mortality in HK 563

TABLE 2. Age-cohort models estimates and 95%

confidence intervals of relative risk (RR) for suicide
mortality of each age group relative to the reference age
group (4044)

RR (95% CI)
Age group Male Female

1519 0.19 (0.170.22) 0.43 (0.370.50)

2024 0.55 (0.500.60) 0.89 (0.791.00)
2529 0.81 (0.750.88) 1.02 (0.921.14)
3034 0.85 (0.790.92) 1.01 (0.921.12)
3539 0.93 (0.861.00) 1.05 (0.951.17)
4044 1.00 1.00
4549 1.17 (1.091.27) 1.07 (0.961.19)
5054 1.22 (1.121.32) 1.21 (1.081.35)
5559 1.34 (1.231.47) 1.29 (1.151.46)
6064 1.49 (1.351.64) 1.37 (1.211.56)
6569 1.77 (1.601.96) 1.45 (1.271.66)
7074 2.19 (1.972.44) 1.97 (1.722.25)
7579 2.84 (2.543.17) 2.10 (1.822.42)
8084 3.18 (2.793.61) 2.56 (2.202.98)
85+ 3.42 (2.943.98) 2.73 (2.333.20)

The quality of the data, and thus study power, as well as

the analytical approaches employed and different study
periods may be possible reasons for the different ndings
as observed in the other studies. Nevertheless, these dif-
ferences may reect true variations in the patterns of
suicide.

POSSIBLE EXPLANATIONS FOR COHORT

Figure 3. Suicide mortality rates by cohorts in different periods
among (A) males and (B) females.
enhancing robustness of our ndings for international
comparison.
COHORT EFFECTS ON SUICIDE IN OTHER
POPULATIONS
Similar to the present study, different studies using
national mortality data in the western countries includ-
ing USA,[19] England and Wales,[20] Canada,[21] Italy,[22]
Australia,[23] New Zealand,[24] Spain,[25] Sweden,[26] and
Belgium [27] have reported increased suicide risks in suc-
cessive male birth cohorts in the post-war period. Japan,
on the other hand, has seen such increased cohort effects
in earlier male birth cohorts of the mid-1920s.[2] In con-
trast, no signicant cohort effect was found in a Danish
study of birth cohorts up to 1971.[28]
However, ndings for the female suicides are less con-
sistent than those for male suicides. Similar to the present
study, no effects were observed in England and Wales,[20]
Italy,[22] New Zealand,[24] Sweden[26] and Denmark.[28]
On the other hand, increased cohort effects were ob-
served in successive female post-war birth cohorts in the
USA,[19] Canada,[21] Australia,[23] Spain,[25] Belgium, [27]
and Japan.[2]
EFFECTS
First, it is reasonable to observe a predominance of
cohort over period effects because increasing mortality
rates are observed in younger men, especially those in the
working age groups, across the observed calendar years
(i.e., increasing suicide mortality rates have been ob-
served in subsequent younger cohorts), but not in older
men. Similarly, calendar period did not exhibit similar
effect on the younger and older women.
Second, there was an increasing risk of suicide mortal-
ity in subsequent male cohorts born after 1961 but not
in female cohorts. Suicide is a complex response to stress
linking to various psychological, sociocultural, biologi-
cal, and genetic variables.[2931] On one hand, men of the
post-1961 cohorts were essentially middle-aged working
class people in the post-2000 period, who tend to shoul-
der responsibilities for both their older and younger gen-
erations. Therefore, the nancial crisis in 1998 and the
SARS outbreak in 2003 that brought another property
price crash in Hong Kong might have impacted the most
on these men. On the other hand, changing levels of ex-
posure to various macroenvironmental factors in early
life could affect long-term attitudes as well as psycho-
logical health in later life. These factors may include in-
creasing prevalence of parental separation,[32] substance
abuse,[3338] media portrayals of suicide being culturally
acceptable or normal,[39, 40] as well as greater exposure
Depression and Anxiety
564 Chung et al.

TABLE 3. Age-cohort models estimates and 95%

confidence intervals of relative risk (RR) for suicide
mortality of each birth cohort relative to the reference
cohort group (1951)

RR (95% CI)
Birth cohort Male Female

1891 1.70 (0.972.98) 3.25 (2.334.53)

1896 1.08 (0.741.58) 2.91 (2.323.66)
1901 1.29 (1.031.61) 2.87 (2.403.42)
1906 1.24 (1.051.47) 2.13 (1.812.51)
1911 1.21 (1.061.38) 1.84 (1.582.13)
1916 1.21 (1.081.35) 1.50 (1.301.73)
1921 1.16 (1.051.29) 1.26 (1.101.44)
1926 1.04 (0.941.14) 1.26 (1.111.43)
1931 0.95 (0.861.03) 1.15 (1.021.30)
1936 0.83 (0.760.91) 1.09 (0.971.23)
1941 0.89 (0.810.97) 0.96 (0.851.09)
1946 0.98 (0.911.06) 0.95 (0.851.06)
1951 1.00 1.00
1956 0.96 (0.891.03) 1.01 (0.911.11)
1961 0.98 (0.911.06) 0.93 (0.841.02)
1966 1.17 (1.081.27) 0.92 (0.821.02)
1971 1.40 (1.281.53) 1.03 (0.921.16)
1976 1.55 (1.411.72) 1.09 (0.961.24)
1981 1.66 (1.471.86) 0.96 (0.831.12)
1986 1.67 (1.421.95) 0.93 (0.761.14)
1991 1.93 (1.472.54) 0.84 (0.581.20)

To explain such gender differences, risk factors that

Figure 4. Age-cohort models parameter estimates and 95% con-
fidence intervals of age effects among (A) men and (B) women
for suicide mortality in Hong Kong, 19762010.
to the means of suicide via different medium.[20] Besides,
the younger generations nowadays were born to a labor
market that is skill demanding and highly competitive;
and with inated property price, they may also have dif-
culties to secure a mortgage for home properties. Given
that psychosocial disorders are found to be major risk
factors for suicide,[41, 42] it is possible that at least some
of the rise in youth suicide is attributable to increas-
ing rates of these disorders among the younger cohorts.
Nevertheless, the rise in these psychosocial disorders are
more or less constant across the two sexes and thus may
not be able to elucidate the gender differences observed
in the present study.
Depression and Anxiety
can differentially affect men and women in the younger
cohorts need to be identied. Various studies suggested
that the outstanding risk in male over female may al-
lude to differential complex biological vulnerability to
gender-specic sociocultural stressors.[4346] Other stud-
ies have suggested unemployment to be an associated risk
factor of suicide that affects the younger cohorts more
than the older cohorts;[47] however, with increased fe-
male participation in the labor market in most developed
populations,[48] unemployment still may not be able to
explain the apparent gender differences. We hereby pro-
pose an additional job-related factor, the lack of upward
social mobility, as a likely broad sociohistorical determi-
nant that may not only affect the younger generations but
also differentially affect men and women. It has been ar-
gued that lack of social mobility affects men more than
women due to the fact that men tend to be more ori-
ented in career development and many married women
are not solely dependent on their own earning power
for their standard of living,[49] but there was generally
less expectations for career development for women de-
spite the gender role modernization of the females.[50]
In Hong Kong, the population boomed in the 1960s,
which was then followed by a rapid decline in birth
rate from 25.3/1,000 in 1966 to 9.6/1,000 in 2006.[51] In
other words, the 1960s birth cohorts compose a much
larger proportion of the working population in Hong
Kong than the younger birth cohorts. Since older co-
horts tend to enter the working environment earlier and
 Research Article: Cohort Effects on Suicide Mortality in HK
Figure 5. Age-cohort models parameter estimates and 95% con-
fidence intervals of cohort effects among (A) men and (B) women
for suicide mortality in Hong Kong, 19762010.
thus occupy positions of higher ranking than the younger
cohorts, it is reasonable to argue that younger cohorts
in Hong Kong tend to face less social mobility, at least
until the 2020s assuming that most of the 1960s cohorts
will work until their legal retirement age of 60. Never-
theless, it has been extensively reported in the literature
that men are less prone to help seeking despite adverse
circumstances.[5255]
CONCLUSIONS
With the increased risk of suicide mortality in younger
cohorts (who are contingent on carrying their increased
risk into their later lives), together with the age effect of
suicide mortality, we may see an increase in suicide mor-
tality into the future as these younger cohorts age. The
importance of preventive measures for suicide especially
among young male cohorts born after the 1960s should
be emphasized. Further studies are needed to clarify the
plausible associations between the broader sociohistori-
cal changes in the population that impact psychological
risk factors and suicidal behavior in order to better in-
form suicide prevention strategies.
Financial support. None declared.
565
Conflict of interest. The authors have no competing
interests.
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