August 16, 2007

Hong Kong Suicides, Revisited

A reader asked me to help promote the Hong Kong Mental Health Support Group.  My first reaction (after being flattered) was to silently muse, "well, why Hong Kong only?"  What's the difference?   I realize that people from Hong Kong might like the sense of community, but I'd bet anyone from Hong Kong is already plugged into a community-- why another one for mental health issues?  What's the real advantage?  Understand that I am not an idiot-- I see how people would feel more comfortable, but I'm asking whether there is any real, actual, measurable benefit to a culture specific group vs. a general group.

Which got me thinking of this: in the massive push for biological bases for mental illnesses, have we ignored the very real influence of culture on mental health?  And suicide?   Cultural influences so strong, that they not only overwhelm biology but even probability?


In numerous articles (e.g. here) the debate is whether a famous suicide incites others to also commit suicide (who would not have otherwise) or if it simply incites people who would have committed suicide to simply copy the method.

It occurs to me that this question is flawed, because it assumes all people-- races, genders, nationalities, ages-- are the same.

Two articles about suicide in Hong Kong.  for background, 95% of the people in Hong Kong live in high rises.  Coincidentally, or causally, 50% of all suicides are by jumping out/off a building. 30% are hanging.

Prior to 11/23/98, almost no one ever lit charcoal briquets in a closed room and killed thmselves by CO poisoning. On that day, however, someone did do this (supposedly imitating a Japanese movie), and the case went to the front pages of the newspapers.  And then this happened:

CO suicides hong kong 


See that spike?  That's not random, man. 

What is even more unusual about Hong Kong, in comparison to the U.S., is that this increase in charcoal suicides was not at the expense of another method-- in other words, more people committed suicide overall--23% more:


all hong kong suicides 


The increase in overall suicides in Hong Kong were only related to increases in the charcoal poisonings.  In essence, it was as if a whole new subset of people were killing themselves, specifically by this method.

Who were they?  

Mean age was 39 (the second study found ages 24-39; compare to 47 for jumping and 55 for hanging) and 64% were men. 90% happened at home.  Only 20% used sedatives or alcohol coincidentally.

Interestingly, charcoal suicides are on the rise in Taiwan, China overall, and Japan, where they had a rash of charcoal suicide pacts.

So the questions to answer-- and I'm soliciting answers--

  • why does the copycat phenomenon, at least with respect to charcoal, clearly exist in east Asia, when it barely exists in the U.S./Europe?  Is it cultural, and what are the relevant factors?
  • what kind of people are using charcoal (is it different than the jumpers?)  For example, is it men creeping on middle age, who have no job, live at home, etc, shamed by their lack of success?
  • If the above evidence is true, and the charcoal suiciders would not have killed themselves otherwise, what is it about the charcoal or the copying that incites them to want to die? 




I think the adventage of a ... (Below threshold)

August 16, 2007 2:46 PM | Posted by Benita: | Reply

I think the adventage of a cultural specific group is that people will feel the fellow members will understand more. There are lots of political and social issues surrounding mental health that is specific to each country. I am not sure if such cultural research in mental health have been done in support group. Any insights?

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I don't think it's likely t... (Below threshold)

August 16, 2007 3:00 PM | Posted by Rose: | Reply

I don't think it's likely that these people suddenly wanted to die where they didn't want to die before.

Perhaps they wanted to die, but the charcoal thing was easier and less painful than other methods they may have considered. So, having this new method available lowered the, er, barrier to entry?

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OK, when you go looking for... (Below threshold)

August 17, 2007 5:09 AM | Posted by robotslave: | Reply

OK, when you go looking for charcoal suicides in Western nations, you're looking at the wrong data.

What you want to look at is suicide by carbon monoxide poisoning, which, in the West, means vehicle exhaust.

So go re-run your numbers with sealed-garage or hose-from-the-tailpipe-to-the- window type suicides, or copycats, or what have you.

The East/West difference is that the West has cars, while the East has, well, fire. Charcoal, in this case.

The similarity is the carbon monoxide poisoning. Which is supposedly painless and tranquil, according to the people who pretend to know what it's like to die in various ways.

Carbon monoxide poisoning is different from jumping from a building (or bridge, in your Western context) in that it doesn't require that great gathering of nerve up front, and in its supposedly gradual nature-- news articles often describe death by carbon monoxide poisoning as a "gradual loss of consciousness," or similar (do yourself a favor, and check to see if that initial Hong Kong report went into any detail regarding what dying by charcoal might feel like).

So carbon monoxide poisoning appeals to people who are less suicidal than bridge/building jumpers. Not just more cowardly-- while it does promise a more peaceful death, it also presents a much greater possibility of rescue than, well, jumping off of a tall thing.

So there's a certain subset of the suicidal population that shies away from the no-looking-back total suicide, and instead wants a sorta-kinda-maybe suicide that probably won't hurt much and might well be aborted by rescuers. This subset does not generally have uniform access to the preferred method for such cases, i.e., pills. We're not all children of pharmacists, right?

These not-completely-suicidal people do, however, have access to excess carbon monoxide, provided they live in at least somewhat urban societies (the smallish sealed-enough space is just as important as the CO source). You shouldn't think of this in terms of "news reports cause suicide," but rather in terms of "news reports make people aware of ready access to a a drug they hadn't previously known about."

Which puts us back into the realm of psychiatry, albeit in a rather sick and twisted way.

Alone's response: actually, the charcoal is a very specific method, and I think not equivalent to the car exhaust. That's my point about the demography; ask it another way, did the charcoal suicides do it because they didn't have convenient access to a car?

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Mental health support group... (Below threshold)

August 17, 2007 8:31 AM | Posted by Jayme: | Reply

Mental health support groups have been the primary factor in my TOTAL recovery from serious mental illness. I have spent years in institutions and day programs. Peer support is so underrated, though, thus the lack of measurable outcomes. Nobody is going to fund a study that serves poverty-stricken consumers at the expense of existing programs that serve drug companies and the status quo.

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I of course agree that char... (Below threshold)

August 18, 2007 5:02 AM | Posted by robotslave: | Reply

I of course agree that charcoal is a very specific means to The End, and, in response to your question, I rather doubt that the Chinese outbreak was due primarily to a lack of automobiles.

Demography is swell, sure, but how aware do you think the average suicidal Chinese person is of that scenario all too familiar to us, "Found dead sitting in the car with the garage door closed and the engine running"?

It's not the mechanics that are relevant here, it's the type of death supposedly delivered by a particular drug, Carbon Monoxide, as supplied by smoldering charcoal (or, in our Western context, vehicle exhaust).

Did you even bother to look up vehicle-exhaust suicides, and copycats, in the US?

I'm pretty sure that the vehicle-exhaust method of CO delivery didn't start lighting up the suicide stats until rather well after the invention of the internal combustion engine.

Once upon a time, plain old Natural Gas used to do the trick (the trick being anoxia). Which led to those "head in the oven" jokes, though of course that wasn't how the actual mechanics of the thing worked.

These days, I'm guessing, your USian demographic with the higher suicide rate tends not to cook with gas.

But your suicidal Chinese demographic, well, I don't know for sure, but perhaps they tend to cook with charcoal.

Something else to consider, here: in initial news reports on deaths due to both vehicle exhaust and insufficiently ventilated charcoal fires, the media might assume the deaths were accidental, and then go on to describe how very easy it might be to die from such an accident, given the supposed trajectory of "slow descent into unconsciousness, and then death."

So, you asked three questions. For the sake of clarity, I'll state my answers to those questions:

  • Because copycatting, be it of suicide or criminal behavior, happens almost exclusively within cultures, as opposed to across cultures.
  • The people using CO for suicide are less determined, and/or harboring stronger rescue fantasies, than jumpers.
  • The charcoal didn't make anyone want to die any more than they already did, what it did provide was a practical method to achieve the sort of painless-death or near-death they had been fantasizing about, where means previously considered had been too painful or final.
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Wouldn't the kind of wood f... (Below threshold)

August 19, 2007 5:54 AM | Posted by Velvet Elvis: | Reply

Wouldn't the kind of wood from which the charcoal is made have an effect on the amount of CO produced when it's burned? Perhaps there was a change in the composition of the charcoal available in the area which made it much more lethal. The statistic you're missing is the ratio of failed to successful attempts.

Do these statistics rule out instances of ritual suicide if such a phenomena exists in Hong Kong as it does in Japan?

If the individuals were somehow connected it could explain it, ie they could have been in a cult or part of some kind of online suicide pact or something. It doesn't have to have been a copycat phenomena. It might have been group planning.

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Maybe its something about C... (Below threshold)

August 20, 2007 9:09 PM | Posted by whatever: | Reply

Maybe its something about Chinese culture that makes them more susceptible to the copycat phenomenon in relation to suicidality. You know, those generalizations about the culture internalizing their feelings more, going to a shrink being a VERY taboo thing and sign of weakness etc. Somehow this may lead them to walk around suicidal with a lid on their id until a media driven phenomenon gets them to burst and step up to the plate in an all or none phenomenon (because if they fail, then they deal with the profound shame of being mentally ill and out in the open)...and perhaps the less painful method as a previous poster suggests, is the enticing aspect of it.

Did the same phenomenon happen with a tylenol OD in China?

Or maybe there is something spiritual about breathing the gas and dying in the Chinese culture?

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there was an article about ... (Below threshold)

August 27, 2007 6:54 PM | Posted by none: | Reply

there was an article about this in the atlantic several months ago.

an interesting thing that it emphasized was that the japanese suicides by charcoal are group suicides... where the groups are composed of strangers who meet only to die together (there are apparently large internet chat rooms where people arrange this). That seems pretty peculiar, at least compared to suicide methods in the West. I can't think of a practical reason for it, like a lack of the needed resource (charcoal) or large expense associated with it (i assume it is relatively cheap).

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I would like to add a persp... (Below threshold)

April 11, 2009 4:33 AM | Posted by Andrew Grimes JFP, JSCCP, M.Sci. Pth: | Reply

I would like to add a perspective from Japan and so will limit my comments to what I know about here but would first like to suggest that western media reports on suicide rates in Asian countries should try harder to get away from the tendency to ‘orientalize’ the serious and preventable problem of increased suicide rates here over the last 10 years by reverting to stereotypical ideas of Asian people in general. In other words Asians are real people too and not lemmings. People here do not wake up one day and say “Hey, let’s commit suicide today because I hear it is all the rage in Shanghai and Tokyo and the word is that even the Changs and Suzukis are doing it!”

I am a psychologist and psychotherapist working in Japan for over 20 years and so like all of my colleagues in the mental health care field here share with them the view that copycat suicides have a lot more to do with press and media copy than western misconceptions about relatively more group oriented societies in Asia.

Mental health professionals in Japan have long known that the reason for the unnecessarily high suicide rate in Japan is due to unemployment, bankruptcies, and the increasing levels of stress on businessmen and other salaried workers who have suffered enormous hardship in Japan since the bursting of the stock market bubble here that peaked around 1997. Until that year Japan had an annual suicide of rate figures between 22,000 and 24,000 each year. Following the bursting of the stock market and the long term economic downturn that has followed here since the suicide rate in 1998 increased by around 35% and since 1998 the number of people killing themselves each year in Japan has consistently remained well over 30,000 each and every year to the present day.

The current worldwide recession is of course impacting Japan too, so unless very proactive and well funded local and nation wide suicide prevention programs and initiatives are immediately it is very difficult to foresee the governments previously stated intention to reduce the suicide rate to around 23,000 by the year 2016 being achievable. On the contrary the numbers, and the human suffering and the depression and misery that the people who become part of these numbers, have to endure may well stay at the current levels that have persistently been the case here for the last ten years. It could even get worse unless even more is done to prevent this terrible loss of life.

During these last ten years of these relentlessly high annual suicide rate numbers the English media seems in the main to have done little more than have someone goes through the files and do a story on the so-called 'suicide forest' or 'internet suicide clubs' and ‘copycat suicides’ (whether cheap heating fuel like charcoal brickettes or even cheaper household cleaning chemicals) without focusing on the bigger picture and need for effective action and solutions.

Economic hardship, bankruptcies and unemployment have been the main cause of suicide in Japan over the last 10 years, as the well detailed reports behind the suicide rate numbers that have been issued every year until now by the National Police Agency in Japan show only to clearly if any journalist is prepared to learn Japanese or get a bilingual researcher to do the research to get to the real heart of the tragic story of the long term and unnecessarily high suicide rate problem in Japan.

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Anyone else here ever attem... (Below threshold)

May 20, 2010 1:35 AM | Posted by Anonymous: | Reply

Anyone else here ever attempted suicide? No? Awesome.

The reasons outlined from above commentors are pretty spot on. It's a variety of factors that culminate in an (il)informed decision. Would I recomend it for you? That depends. Are you beyond your years of usefulness? If you answered yes, seek immediate psychiactric help. If you think the Internet is a series of tubes or complain about kids these days, chances are you're not reading this and your answer is then debatable.

I've never found a person that's said, "what for," when prompted for an answer about poor health choices, but that's just indicative of deeper issues. Unless, again, the person is of age. For the sake of argument, we'll set that age at 130 and adjust as our lifespans increase. Sometimes life sucks, but there's hardly a reason to kill yourself over it unless you're in a concentration camp. Can you imagine how quickly the diamond markets would react if all of the laborers suddenly killed themselves? Enough wet-dreaming.

Before you ask, yes mine was a narcissistically motivated attempt in as much as I've come to understand the term over the years I've been reading this blog. And before I answer, why would ask a person who attempted the act such a question? What are you a sadist, stupid, naive, what?

I'm just glad someone does ask. This probably marks the first time in our species that we're offing ourselves in statistically relevant numbers and it deserves a deeper look.

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In most suicide cases there... (Below threshold)

June 4, 2011 9:02 PM | Posted by mei : | Reply

In most suicide cases there is no mental illness involved, the majority of suicides are committed by people who have some kind of external/material problem, for example:
1 people who feel lonely or abandoned by someone;
2 people who begun to have monetary problems;
3 people who lost some physical capacity or have some physical problem;
4 people who feel hurt and bullied by someone,
5 and those who are no longer are useful to society and therefore feel outcast.
Resuming, almost all suicides are related to real physical problems rather than psychological illness. The psychologically ill try to kill themselves several times, but fail most of the times, because they don’t plan their suicide.
I don’t think that the people who try to commit suicide using the charcoal method want to be saved, otherwise they wold have chosen to use some random pain killers and alcohol, besides the CO causes brain damages in case they are saved, no one wants to live with some brain damage.

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That doesn't make sense. Ev... (Below threshold)

June 7, 2011 2:48 PM | Posted, in reply to mei 's comment, by Anonymous: | Reply

That doesn't make sense. Even if they "don't plan it", they are engaging in high-risk behavior at such a greater rate that it would only make sense that they periodically succeed.

If there are thousands of more suicide attempts by the mentally ill, how couldn't that translate into higher numers of suicides?

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"If there are thousands of ... (Below threshold)

July 23, 2011 1:22 PM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

"If there are thousands of more suicide attempts by the mentally ill, how couldn't that translate into higher numbers of suicides?"
Because the majority of the population is not mentally ill, and in most cases, the mentally ill are monitored and fed up with drugs that aim to reduce their suicidal tendencies. If you analyze the news of suicides carefully you will see that the majority of people who managed to commit suicide had a 'normal life' and no record of mental illness. of course some psychoanalyst and psychiatrist will say that: "they had a mental illness that was not detected", well that does not make any sense, the majority of psychological illness have several visible symptoms that most people would be able to identify and warn the family or the authorities about them, and yet that does not happen very often, simply because most people who commit suicide are not psychologically ill.
During economic crisis the suicide rate increases, in excessively competitive societies the suicide rates are higher, this proves that most suicides are not caused by psychological illness.

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The dogleg increase at the ... (Below threshold)

March 2, 2013 1:26 PM | Posted by Mike: | Reply

The dogleg increase at the end of the 1990s coincides with the loss of British control. It seems much less likely attributable to the novelty of "death by charcoal" and much more the stress of being a Hong Kong citizen as it was brought within the political sphere of China.

The wealthy could get into Commonwealth escape pods and run, need be. Even they were under a lot of stress though.

Don't burn down the trees with rum in search of the forest so we all end up with only charcoal---or whatever.

[Great blog!]

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