Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2023 Feb 21.
Published in final edited form as: J Aging Health. 2014 Jul 7;26(7):1189–1208. doi: 10.1177/0898264314541696

Suicidal Ideation in an Older U.S. Chinese Population

XinQi Dong 1, Ruijia Chen 1, Esther Wong 2, Melissa A Simon 3
PMCID: PMC9943579  NIHMSID: NIHMS1865949  PMID: 25005173

Abstract

Objective:

This study examined the prevalence and correlates of suicidal ideation among U.S. Chinese older adults.

Method:

Guided by the community-participatory research approach, the PINE (Population Study of Chinese Elderly in Chicago) study is a population-based epidemiological study conducted from 2011 to 2013 of 3,159 community-dwelling Chinese adults aged 60 years and above in the Greater Chicago area.

Results:

The 2-week prevalence of suicidal ideation, 12-month prevalence of suicidal ideation, and lifetime suicidal ideation were 3.5%, 4.8%, and 9.4%, respectively. Age, sex, marital status, education, income, living arrangement, country of origin, years in the United States, overall health status, quality of life, and health changes over the past year were significantly correlated with suicidal ideation.

Discussion:

Suicidal ideation was common among U.S. Chinese older adults in the Greater Chicago area. Further longitudinal studies should be conducted to explore the risk and protective factors associated with suicidal ideation.

Keywords: suicide, suicidal ideation, Chinese, older adults, prevalence, culture

Introduction

Suicide is the 10th leading cause of death in the United States, with an estimation of 38,364 suicidal deaths in 2010 (Centers for Disease Control and Prevention, 2012). Suicide has enormous personal and social outcomes; it not only destroys personal and family life but also increases medical care expense and lost productivity (Cerel, Jordan, & Duberstein, 2008; Knox, Conwell, & Caine, 2004). To address the issue of suicide, the 2012 National Strategy for Suicide Prevention called for efforts to improve representative surveys and other data collection instruments that included questions related to suicidal behaviors, related risk factors, and exposure to suicide (U.S. Department of Health and Human Services, 2012).

Suicide ideation is one of the most prevalent predictors for completed suicide. Emerging evidence consistently suggests the strong association between suicidal ideation, suicidal attempts, and completed suicide. For example, a study of a sample of 5,877 adults aged 15 to 54 years old from the National Comorbidity Survey found that 34% of the lifetime suicidal ideation was translated into a plan, 72% from a plan to an attempt, and 26% from ideation to an unplanned attempt (Kessler, Borges, & Walters, 1999). A study of 84, 850 adults across 17 countries around the world reported that 60% of the suicide plan and attempts occurred within the first year of suicidal ideation onset (Nock et al., 2008). In a study of 3,401 outpatients seeking psychiatric treatment, both suicide ideation at the point of investigation and suicide ideation at its worst point were the strong predictors for eventual suicide (Beck, Brown, Steer, Dahlsgaard, & Grisham, 1999). These findings imply that improved understanding of suicidal ideation with respect to time point would be critical for developing tailored suicide prevention and intervention strategies.

Older adults are especially vulnerable to suicidal ideation. Compared with the younger generation, older adults may be at higher risk of suicidal ideation because they are more likely to experience physical and cognitive decline, psychological distress, a loss of a loved partner, institutionalization, and disappointment with friends and children (Pfaff & Almeida, 2005; Szanto et al., 2002). Yet, suicidal ideation in older adults is difficult to detect, as it is often confounded by medical comorbidities, psychological distress, or dementia (Atchley, 1991). In addition, compared with other age groups, older adults are less likely to seek help from mental health professionals due to financial and transportation barriers (Conwell et al., 1998). Despite the prevalence and severity, suicidal ideation has received relatively little research attention in older adults than in younger adults (Heisel & Duberstein, 2005).

The epidemiology of suicidal ideation varies by cultural groups. The prevalence of suicide per year among Chinese older adults aged 65 and above in China was 50 to 200 per 100,000, which was 4 to 5 times of the general population (Law & Liu, 2008; Phillips, Li, & Zhang, 2002). As values of emotional retrain and collectivism are highly emphasized in Chinese culture, Chinese older adults may be more reluctant to admit having suicidal ideation for the fear of disrupting family honor or losing “face” (Kung, 2004). There has been a growing research interest in suicidal ideation among Chinese older adults in recent years (Simon, Chang, Zeng, & Dong, 2013). A study of 1,159 community-dwelling older adults aged 65 and above in Beijing, China found that 2.2% of the participants had lifetime suicidal ideation (Ma et al., 2009). In Hong Kong, a study of 917 adults aged 60 and above showed the prevalence of lifetime suicidal ideation to be 5.5% (Yip et al., 2003). Similarly, in Taiwan, studies based on large representative random samples found that the prevalence of suicidal ideation over the past week ranged from 6.1% to 16.7% (Chan, Liu, Chau, & Chang, 2011; Yen et al., 2005). A number of methodological factors, such as different sampling techniques, data collection methods, and time periods assessed, may account for the variability in prevalence found in these studies. Particularly, some studies examined lifetime suicidal ideation, whereas others focused on suicidal ideation within more recent periods. It is important to distinguish suicidal ideation in long periods of time from more recent ones, owing to the fact that suicidal ideation at different time periods may be related to different factors and require different prevention and intervention strategies. Another knowledge gap identified in existing literature is the lack of understanding of suicidal ideation among U.S. Chinese older adults, where the population may be faced with unique issues related to immigration and acculturation (Dong, Chang, Wong, Wong, Skarupski, & Simon, 2011).

The Chinese community represents the largest and oldest Asian population in the United States, with an estimate population of 4 million (American Community Survey, 2011). The population of U.S. Chinese adults aged 65 and above has increased by 55% in the past decade, far exceeding the population growth rate of 15% among U.S. older adults (U.S. Census Bureau, 2010). A study of 2,095 Asian Americans from the National Latino and Asian American study found that Chinese Americans were more likely to have lifetime suicidal ideation than other Asian American populations (Cheng et al., 2010). A recent study demonstrated that suicide attempts are significant public health concerns among community-dwelling U.S. Chinese older adults (Dong, Chen, Chang, Simon, 2014). Compared with older Chinese in other regions such as Mainland China or Hong Kong, U.S. Chinese older adults may face greater health disparities as a result of cultural and language barriers, social isolation, and dysfunctional family relationships stemmed from different acculturation levels between generations, all of which may predispose older adults to suicidal ideation (Diego, Yamamoto, Nguyen, & Hifumi, 1993; Dong, Chang, Wong, & Simon, 2012a, 2012b; Dong, Chang, Zeng, Simon, 2014). The demographic imperative coupled with the frailty of U.S. Chinese older adults warrants more attention on the suicidal ideation in this population.

The purposes of this study were to (a) describe the prevalence of 2-week suicidal ideation, 12-month suicidal ideation, and lifetime suicidal ideation among Chinese community-dwelling older adults in the Greater Chicago area; and (b) examine the correlates of 2-week suicidal ideation, 12-month suicidal ideation, and lifetime suicidal ideation to guide tailored treatments on suicidal ideation.

Method

Population and Settings

The Population Study of Chinese Elderly in Chicago (PINE) is a community-engaged, population-based epidemiological study of U.S. Chinese older adults aged 60 and above conducted in the Greater Chicago area. Briefly, the purpose of the PINE study is to collect community-level data of U.S. Chinese older adults to examine the key cultural determinants of health and well-being. The project was initiated by a synergistic community–academic collaboration among the Rush Institute for Healthy Aging, Northwestern University, and many community-based social service agencies and organizations throughout the Greater Chicago area.

To ensure the study’s relevance to the well-being of the Chinese community and increase community participation, the PINE study implemented extensive culturally and linguistically appropriate community recruitment strategies guided by a community-based participatory research (CBPR) approach (Dong, Chang, Simon, & Wong, 2011). The formation of our community–academic partnership allowed us to develop research methodology appropriate within the local Chinese cultural context. In particular, our Community Advisory Board (CAB) played a pivotal role in providing insights and strategies for our research activities. Board members were community stakeholders and residents enlisted from more than 20 civic, health, and social advocacy groups, community centers, and clinics in the city and suburbs of Chicago. The board worked extensively with investigative team to develop and test study instruments to ensure cultural sensitivity and appropriateness.

Study Design and Procedure

The research team implemented a targeted community-based recruitment strategy by first engaging community centers in the Greater Chicago area. More than 20 social service agencies, community centers, health advocacy agencies, faith-based organizations, senior apartments, and social clubs served as the basis of study recruitment sites. Eligible participants were approached through multiple strategies, including direct in-person contacts, phone calls, and letters. Community-dwelling older adults aged 60 years and above who self-identified as Chinese were eligible to participate in the study. Out of 3,542 eligible older adults approached, 3,159 agreed to participate in the study, yielding a response rate of 91.9%. Details of the PINE study design are forthcoming (Dong, Wong, & Simon, 2014).

Trained multicultural and multilingual interviewers conducted face-to-face home interviews with participants in their preferred language (English or Chinese) and dialect (e.g., Cantonese, Taishanese, Mandarin, Teochew) to ensure cultural and linguistic sensitivity. Data were collected using state-of-science innovative web-based software that recorded English, Chinese traditional and simplified characters simultaneously. Based on the available data drawn from the U.S. Census 2010 and a random block census project conducted among the Chinese community in Chicago, the PINE study is representative of the Chinese aging population in the Greater Chicago area (Simon, Chang, Rajan, Welch, & Dong, 2014). The study was approved by the Institutional Review Board of the Rush University Medical Center.

Measurements

Socio-demographics.

Basic demographic information including age (in years), sex, education (years of education completed), annual personal income ($0-$4,999 per year; $5,000-$9,999 per year; $10,000-14,999 per year; $15,000-$19,999 per year; or more than $20,000 per year), marital status (never married, married, separated, divorced, or widowed), years in the United States (in years), and country of birth were assessed in all participants. Living arrangement was categorized into four groups: (a) living alone; (b) living with one to two persons; (c) living with three to four persons; and (d) living with five or more persons.

Overall health status, quality of life, and health changes over the past year.

Overall health status was measured by “in general, how would you rate your health?” on a four-point scale (1 = poor, 2 = fair, 3 = good, 4 = very good). Quality of life was assessed by asking “in general, how would you rate your quality of life?” on a four-point scale ranging from 1= poor to 4 = very good. Health changes over the past year was measured by “compared with one year ago, how would you rate your health now?” on a three-point scale (1 = worsened, 2 = same, 3 = improved).

Suicidal ideation.

Two-week suicidal ideation was assessed by the ninth item of the Patient Health Questionnaire (PHQ-9), a screening instrument for depressive symptoms over the past 2 weeks (American Psychiatric Association, 1994). Participants were asked how often they thought they would be better off dead, or of hurting themselves in some way over the last 2 weeks. Questions were categorized as (a) not at all, (b) several days, (c) more than half the days, and (d) nearly every day. Any affirmative response to Option (b) to Option (d) was defined as having 2-week suicidal ideation. Lifetime and 12-month suicidal ideation were measured by the Geriatric Mental State Examination–Version A (GMS-A), which was a semistructure interview guide designed for the elderly (Copeland & Dewey, 1991). Participants were asked the following: (a) Have you ever felt suicidal or wished to be dead; (b) have you ever felt suicidal or wished to be dead sometime in the last 12 months. Each question elicited a yes or no answer. A “yes” response to any of the above questions classified a respondent as having lifetime or 12-month suicide ideation. The Chinese version had been validated in earlier studies (Yip et al., 2003).

Data Analysis

Descriptive statistics were used to summarize demographic information of the participants. Chi-square statistics and Fisher’s exact test were used to compare the socio-demographic and health-related characteristics between the suicidal ideation group and the non-suicidal ideation group. Pearson correlation coefficients and Spearman’s rank correlation were calculated to examine the correlations of socio-demographic and health-related factors with 2-week suicidal ideation, 12-month suicidal ideation, and lifetime suicidal ideation, depending on the distribution of the variables. Analyses were carried out using SAS, Version 9.2 (SAS Institute Inc., Cary, NC).

Results

Characteristics of the study participants by the presence of any suicidal ideation are presented in Table 1. Overall, 297 (9.4%) participants reported having lifetime suicidal ideation. The suicidal ideation group compared with the non-suicidal ideation group had a significantly greater proportion of women (78.5% vs. 56.8%, p < .001) and widowed (38.0% vs. 22.8%, p < .001). Participants with suicidal ideation were more likely to live alone (29.6% vs. 20.5%, p < .05), have poor perceived health status (37.7% vs. 17.0%, p < .001), have poor quality of life (6.4% vs. 2.8%, p < .001), and experience worsened health conditions over past year (60.8% vs. 40.5%, p < .001).

Table 1.

Characteristics of PINE Study Participants by the Presence of Any Suicidal Ideation.

No suicidal ideation (n = 2,825) Any suicidal ideation (n = 297) p
Age, n (%)
 60–69 1,208 (42.6) 113 (38.1)
 70–79 1,039 (36.7) 116 (39.1)
 80 and above 588 (20.7) 68 (22.9) .31
Sex, n (%)
 Male 1,224 (43.2) 64 (21.6)
 Female 1,611 (56.8) 233 (78.5) <.001
Education, n (%)
 0 156 (5.5) 29 (9.8)
 1–6 1,071 (37.9) 102 (34.5)
 7–12 996 (35.3) 105 (35.5)
 13–16 524 (18.6) 51 (17.2)
 17 or above 78 (2.8) 9 (3.0) .051
Income (US$), n (%)
 0–4,999 926 (32.9) 111 (37.6)
 5,000–9,999 1,466 (52.1) 144 (48.8)
 10,000–14,999 277 (9.8) 31 (10.5)
 15,000–19,999 64 (2.3) 4 (1.4)
 More than 20,000 82 (2.9) 5 (1.7) .34
Marital status, n (%)
 Married 2,056 (72.7) 165 (55.6)
 Separated 47 (1.7) 10 (3.4)
 Divorced 66 (2.3) 8 (2.7)
 Widowed 645 (22.8) 113 (38.0)
 Never married 15 (0.5) 1 (0.3) <.001
Years in the United States, n (%)
 0–10 762 (27.0) 74 (25.0)
 11–20 872 (30.9) 86 (29.1)
 21–30 698 (24.7) 62 (21.0)
 31 and more 490 (17.4) 74 (25.0) .012
Country of origin
 China 264 (88.9) 2,642 (93.2)
 Others 33 (11.1) 193 (6.8) .006
Living arrangement, n (%)
 Living alone 582 (20.5) 88 (29.6)
 1–2 1,432 (50.5) 130 (43.7)
 3–4 435 (15.4) 48 (16.2)
 5 and more 385 (13.6) 31 (10.4) .002
Overall health status, n (%)
 Very good 126 (4.4) 13 (4.4)
 Good 1,026 (36.2) 64 (21.6)
 Fair 1,202 (42.4) 108 (36.4)
 Poor 481 (17.0) 112 (37.7) <.001
Quality of life, n (%)
 Very good 187 (6.6) 28 (9.4)
 Good 1,263 (44.6) 113 (38.1)
 Fair 1,306 (46.1) 137 (46.1)
 Poor 78 (2.8) 19 (6.4) <.001
Health changes over the past year, n (%)
 Improved 239 (8.4) 35 (11.8)
 Same 1,446 (51.0) 81 (27.4)
 Worsened 1,149 (40.5) 180 (60.8) <.001
Open in a new tab

Note. PINE = Population Study of Chinese Elderly in Chicago.

Descriptive information of the participants with lifetime suicidal ideation, 12-month suicidal ideation, and 2-week suicidal ideation is summarized in Table 2. In total, 111 participants (3.5%) had 2-week suicidal ideation and 151 participants (4.8%) had 12-month suicidal ideation. Female older adults, widows, and those who perceived lower self-reported health status were more likely to report suicidal ideation, regardless of the time interval. Differences of years in the United States (p < .05) were significant between the lifetime suicidal ideation group and the non-suicidal ideation group.

Table 2.

Comparisons of Characteristics of Study Participants by Suicidal Ideation.

In the past 2 weeks In the past 12 months In lifetime
Yes (n = 111) No (n = 3,019) p Yes (n = 151) No (n = 2,979) p Yes (n = 297) No (n = 2,835) p
Age, n (%)
 60–69 41 (36.9) 1,281 (42.4) 54 (35.8) 1,267 (42.5) 113 (38.1) 1,208 (42.6)
 70–79 44 (39.6) 1,110 (36.8) 61 (40.4) 1,094 (36.7) 116 (39.1) 1,039 (36.7)
 80 and above 26 (23.4) 628 (20.8) .28 36 (23.8) 618 (20.8) .25 68 (22.9) 588 (20.7) .31
Sex, n (%)
 Men 23 (20.7) 1,265 (41.9) 32 (21.2) 1,256 (42.2) 64 (21.6) 1,224 (43.2)
 Women 88 (79.3) 1,754 (58.1) <.001 119 (78.8) 1,723 (57.8) <.001 233 (78.5) 1,611 (56.8) <.001
Education, n (%)
 0 9 (8.2) 174 (5.8) 15 (10.0) 168 (5.7) 29 (9.8) 156 (5.5)
 1–6 51 (45.9) 1,122 (37.3) 61 (40.7) 1,112 (37.5) 102 (34.5) 1,071 (37.9)
 7–12 33 (29.7) 1,068 (35.5) 50 (30.3) 1,051 (35.4) 105 (35.5) 996 (35.3)
 13–16 15 (13.5) 560 (18.6) 20 (13.3) 555 (18.7) 51 (17.2) 524 (18.6)
 17 and more 2 (1.8) 85 (2.8) .20 4 (2.7) 83 (2.8) .13 9 (3.0) 78 (2.8) .05
Income (US$), n (%)
 0–4,999 47 (42.7) 990 (33.0) 58 (38.7) 979 (33.1) 111 (37.6) 926 (32.9)
 5,000–9,999 54 (49.1) 1,555 (51.9) 77 (51.3) 1,532 (51.8) 144 (48.8) 1,466 (52.1)
 10,000–14,999 9 (8.2) 299 (10.0) 13 (8.7) 295 (10.0) 31 (10.5) 277 (9.8)
 15,000–19,999 0 (0.0) 68 (2.3) 1 (0.7) 67 (2.3) 4 (1.4) 64 (2.3)
 More than 20,000 0 (0.0) 87 (2.9) .05 1 (0.7) 86 (2.9) .25 5 (1.7) 82 (2.9) .34
Marital Status, n (%)
 Married 55 (49.6) 2,165 (71.9) 81 (53.6) 2,139 (72.0) 165 (55.6) 2,056 (72.7)
 Separated 5 (4.5) 52 (1.7) 6 (4.0) 51 (1.7) 10 (3.4) 47 (1.7)
 Divorced 2 (1.8) 72 (2.4) 3 (2.0) 71 (2.4) 8 (2.7) 66 (2.3)
 Widowed 48 (43.2) 709 (23.5) 60 (39.7) 697 (23.4) 113 (38.1) 645 (22.8)
 Never married 1 (0.9) 15 (0.5) <.001 1 (0.7) 15 (0.5) <.001 1 (0.3) 15 (0.5) <.001
Living arrangement, n (%)
 Living alone 39 (35.1) 630 (20.9) 51 (33.8) 618 (20.8) 88 (29.6) 582 (20.5)
 1–2 35 (31.5) 1,268 (42.0) 64 (42.4) 1,497 (50.3) 130 (43.8) 1,432 (50.5)
 3–4 19 (17.1) 459 (15.2) 26 (17.2) 457 (15.4) 48 (16.2) 435 (15.4)
 5 or more 18 (16.2) 661 (21.9) .002 10 (6.6) 406 (13.6) <.001 31 (10.4) 385 (13.6) .002
Yeas in the United States, n (%)
 0–10 29 (26.1) 807 (26.7) 38 (25.2) 798 (26.9) 74 (25.0) 762 (27.0)
 11–20 36 (32.4) 921 (30.7) 44 (29.1) 913 (30.8) 86 (29.1) 872 (30.9)
 21–30 24 (21.6) 736 (24.5) 36 (23.8) 724 (24.4) 62 (21.0) 698 (24.7)
 31 or more 22 (19.8) 541 (18.0) .88 33 (21.9) 530 (17.9) .67 74 (25.0) 490 (17.4) .012
Country of origin
 China 102 (91.9) 2,802 (92.8) 135 (89.4) 2,769 (93.0) 264 (88.9) 2,642 (93.2)
 Others 9 (8.1) 217 (7.2) .71 16 (10.6) 210 (7.1) .10 33 (11.1) 193 (6.8) .006
Overall health status, n (%)
 Very good 5 (4.5) 134 (4.4) 6 (4.0) 133 (4.5) 13 (4.4) 126 (4.4)
 Good 7 (6.3) 1,083 (35.9) 17 (11.3) 1,073 (36.0) 64 (21.6) 1,026 (36.2)
 Fair 47 (42.3) 1,263 (41.8) 60 (39.7) 1,250 (42.0) 108 (36.4) 1,202 (42.4)
 Poor 52 (46.9) 539 (17.9) <.001 68 (45.0) 523 (17.6) <.001 112 (37.7) 481 (17.0) <.001
Health changes over the past year, n (%)
 Improved 11 (9.9) 263 (8.7) 15 (10.0) 259 (8.7) 35 (11.8) 239 (8.4)
 Same 24 (21.6) 1,503 (49.8) 34 (22.7) 1,493 (50.1) 81 (27.4) 1,446 (51.0)
 Worsened 75 (67.6) 1,252 (41.5) <.001 101 (67.3) 1,226 (41.2) <.001 180 (60.8) 1,149 (40.5) <.001
Quality of life, n (%)
 Very good 2 (1.8) 213 (7.1) 4 (2.7) 211 (7.1) 28 (9.4) 187 (6.6)
 Good 41 (36.9) 1,335 (44.2) 57 (37.8) 1,319 (44.3) 113 (38.1) 1,263 (44.6)
 Fair 58 (52.3) 1,384 (45.9) 78 (51.7) 1,364 (45.8) 137 (46.1) 1,306 (46.1)
 Poor 10 (9.0) 86 (2.9) <.001 12 (8.0) 84 (2.8) <.001 19 (6.4) 78 (2.8) <.001
Open in a new tab

Socio-demographic and health-related correlates of 2-week suicidal ideation, 12-month suicidal ideation, and lifetime suicidal ideation are presented in Tables 3 to 5. Older age (r2-week = .04, r12-month = .05, rlifetime = .04), women (r2-week = .08, r12-month = .09, rlifetime = .13), lower overall health status (r2-week = .13, r12-month = .14, rlifetime = .13), and worsened health changes over the last year (r2-week = .11, r12-month = .13, rlifetime = .12) were significantly correlated with suicidal ideation at all three time periods.

Table 3.

Social-Demographic and Health-Related Variables Associated With Suicidal Ideation in the Past 2 Weeks.

Age Sex Edu Income MS Living Origin Yrs in U.S. OHS HC QOL Suicidal ideation
Age 1.0
Sex .01 1.0
Edu −.12*** −.21*** 1.0
Income .05** .00 .01 1.0
MS −.33*** −.32*** .22 −.03 1.0
Living −.35*** −.07*** .02 .16*** .24*** 1.0
Origin .04* −.01 −.08*** −.20*** .05** .05** 1.0
The United States .35*** .03 −.10*** .35*** −.2*** −.31*** −.2*** 1.0
OHS −.08*** −.06** .06*** .12*** .05** .00 −.03 −.01 1.0
HC −.11*** −.03 .02 .05** .07*** .01 .00 −.04* .35*** 1.0
QOL .06*** .05** .09*** .08*** −.03 −.01 −.04* .00 .32*** .15*** 1.0
Suicidal ideation .04* .08*** −.04* −.05** −.09*** −.04* −.01 .00 −.13*** −.11*** −.07*** 1.0
Open in a new tab

Note. Edu = education; MS = marital status; Living = living arrangement; Origin = country of origin; Yrs in U.S. = years in the United States; OHS = overall health status; HC = health changes over the past year; QOL = quality of life.

*p < .05.

**p < .01.

***p < .001.

Table 5.

Socio-Demographic and Health-Related Variables Associated With Any Suicidal Ideation.

Age Sex Edu Income MS Living Origin Yrs in U.S. OHS HC QOL Suicidal ideation
Age 1.0
Sex .01 1.0
Edu −.12*** −.21*** 1.0
Income .05** .00 .01 1.0
MS −.33*** −.32*** .22 −.03 1.0
Living −.35*** −.07*** .02 .16*** .24*** 1.0
Origin .04* −.01 −.08*** −.20*** .05** .05** 1.0
The United States .35*** .03 −.10*** .35*** −.2*** −.31*** −.2*** 1.0
OHS −.08*** −.06** .06*** .12*** .05** .00 −.03 −.01 1.0
HC −.11*** −.03 .02 .05** .07*** .01 .00 −.04* .35*** 1.0
QOL .06*** .05** .09*** .08*** −.03 −.01 −.04* .00 .32*** .15*** 1.0
Suicidal ideation .04* .13*** −.02 −.03 .11*** −.03 −.05** .04* −.13*** −.12*** −.02 1.0
Open in a new tab

Note. Edu = education; MS = marital status; Living = living arrangement; Origin = country of origin; Yrs in U.S. = years in the United States; OHS = overall health status; HC = health changes over the past year; QOL = quality of life.

*p < .05.

**p < .01.

***p < .001.

However, lower income (r2-week = .05, r12-month = .04), lower education (r2-week = .04, r12-month = .04), living with fewer household members (r2-week = .04, r12-month = .05), and lower quality of life (r2-week = .07, r12-month = .07) were significantly correlated with 2-week and 12-month suicidal ideation but not with lifetime suicidal ideation. By contrast, being born outside China (rlifetime = .05) and being in the United States for more years (rlifetime = .04) were significantly correlated with lifetime suicidal ideation but not with 2-week and 12-month suicidal ideation.

Discussion

This study demonstrates that suicidal ideation was common among U.S. Chinese older adults in the Greater Chicago area. In addition, correlates of suicidal ideation varied by different time periods assessed. Older age, being female, lower health status, and worsening health over the past year were positively correlated with any suicidal ideation in all three time periods. However, not being married was positively correlated with 12-month and lifetime suicidal ideation while negatively correlated with 2-week suicidal ideation. Country of origin and residing more years in the United States were positively correlated with lifetime suicidal ideation only. Lower income, lower education, living with fewer people, and poor quality of life were correlated with 2-week suicidal ideation and 12-month suicidal ideation only.

This study represents the largest study on the epidemiology of suicidal ideation among community-dwelling U.S. Chinese older adults. The finding of our study demonstrates that suicidal ideation was a significant public health concern among U.S. Chinese older adults. In a recent national representative study of 5,191 African American older adults aged 55 years and above, the prevalence of lifetime suicidal ideation was lower (6.1%) than that of our study (9.4%; Joe, Ford, Taylor, & Chatters, 2014). Lifetime suicidal ideation was also higher than studies conducted among Chinese older adults older adults in Hong Kong (5.5%) and Beijing (2.2% ; Ma et al., 2009; Yip et al., 2003). We suspect that U.S. Chinese older adults, in which the majority of the population was first-generation immigrants, may experience significant acculturation stress that predispose them to higher risk for suicidal ideation than those who live in their home countries.

In addition, the implementation of the CBPR approach may also be attributable to the reporting of suicidal ideation. Although suicidal ideation is a sensitive issue in Chinese culture, the CBPR approach likely diminished underreporting problems (Dong, Chang, Wong, & Simon, 2011). Through our collaboration with local communities, participants may have been more comfortable conversing in their preferred dialects with trusting research assistants and more willing to express emotions and acknowledge their feelings. However, the comparisons of prevalence of suicidal ideation across studies should be interpreted with cautions because of the varying methodology used among these studies.

Through examining suicidal ideation at different time intervals, this study facilitates a more comprehensive understanding of suicidal ideation among U.S. Chinese older adults. In our study, staying in the United States for a longer period of time was correlated with lifetime suicidal ideation but not with 2-week and 12-month suicidal ideation. We suspect that older adults who had been in the United States for more years may be more likely to immigrate to the United States at their middle ages, during which they had to rebuild their life and struggle to feed their families with limited language proficiency. Although older adults with higher education were less likely to report 2-week and 12-month suicidal ideation, such trend was not observed for lifetime suicidal ideation. Perhaps higher educated Chinese older adults were more likely to be victimized by China’s Cultural Revolution—a devastating political upheaval and period when the majority of educated youth were sent to the country side for brainwashing and hard labor and the suicide rate increased dramatically (Lester, 2005; Phillips, Liu, & Zhang, 1999). Consequently, higher educated older adults may not experience lower risk for lifetime suicidal ideation than lower educated older adults. Yet, these findings should be interpreted in light of the fact that we did not capture the onset of suicidal ideation, and the extent to which immigration, culture, and historical factors influenced suicidal ideation among Chinese older adults remained unclear.

In this study, older age was significantly correlated with suicidal ideation. Age-related physical and cognitive decline may increase older adults’ dependence on children for activities in daily life such as shopping or scheduling doctor’s appointments. Such intensive demands on support from adult children may result in older adults’ higher levels of perceived burdensomeness that may be related with suicidal ideation (Cukrowicz, Cheavens, Van Orden, Ragain, & Cook, 2011). Women in the present study were more likely to report having suicidal ideation. This may be explained by that women were more emotionally expressive and were more inclined to open up to others with regard to suicidal thoughts and plans (O’Donnell, O’Donnell, Wardlaw, & Stueve, 2004). Alternatively, perhaps Chinese women’s low social and economic status resulting from the traditional patriarchal culture may expose them to financial, educational, and employment disadvantages, and predispose them to greater risk of suicide and suicidal ideation (Dong, Beck, & Simon, 2009, 2010).

The present study also revealed an inverse correlation between income and suicidal ideation. One possible explanation was that older adults with lower income were more likely to develop psychological distress germane to financial strain, which was closely associated with suicidal ideation (Almeida et al., 2012). An alternative explanation may be that older adults, especially recent immigrants with lower income levels were more likely to be uninsured (Dong et al., 2011). Even if enrolled in the Medicare or Medicaid program, they were less able to afford mental health service given that government-supported insurance programs such as the Medicare only reimburse mental health cost at a 50% rate (Karlin & Humphreys, 2007). The delay in needed medical care and the distress brought from untreated medical comorbidities may affect older adults’ will for living and contributed to the high rates of suicidal ideation.

In the study, poorer overall health status and worsening health over the last year were significantly correlated with suicidal ideation. Although the association between suicidal ideation and health status was well established in prior studies (Brown & Vinokur, 2003; Goodwin & Olfson, 2002; Yip et al., 2003), the mechanism through which health status interrelated with suicidal ideation remained unclear. Intolerable chronic and psychological pains accompanied with medical comorbidities may initiate suicidal ideation in older adults (Santos, Hubbard, & Overholser, 1994). By contrast, it was also likely that the presence of suicidal ideation decreased older adults’ motivation for taking medication and engaging in social activities, exacerbating their health status. Or perhaps older adults with suicidal ideation were more likely to develop a negative worldview and thus, perceived and reported their health status as poor. Future longitudinal studies should be conducted to better understand the association between suicidal ideation and health among U.S. Chinese older adults.

The results of this study should be interpreted with limitations in mind. First, although our study examined a representative sample of U.S. Chinese older adults in the Greater Chicago area, the findings may not be generalizable to other Chinese populations in the United States or in Asia. Second, this study did not explore potentially modifiable factors associated with suicidal ideation such as filial piety, social support, depressive symptoms, and elder abuse. Third, we did not have data on the onset of the suicidal ideation, which impeded our understanding of how immigration and cultural factors affected the occurrence of suicidal ideation. Fourth, our lifetime suicidal ideation measure relied on retrospective recall of earlier life. Potential recall bias may cause an underestimation of the prevalence of lifetime suicidal ideation. In addition, this study used a cross-sectional design, and we could not postulate on the potential temporal relationships. Future longitudinal studies should be conducted to improve the understanding of the temporal relationship of suicidal ideation and its risk factors.

Despite limitations of the present study, our findings have important research, policy, and clinical implications. Our study suggests that suicidal ideation was a significant public health issue among U.S. Chinese older adults, but current understanding on the issue was limited. More studies should be conducted to explore the risk factors and outcomes associated with suicidal ideation among Chinese older adults. The CBPR approach that we utilized in this study could be a potential model for future research to address culturally sensitive issues, especially suicidal ideation, among minority older adults. The correlates of suicidal ideation found in this study demonstrates that when developing suicide prevention and intervention in U.S. Chinese communities, special attention should be given to women, widowed, lower income, and those having poorer health conditions. The finding that the epidemiology of suicidal ideation differed by time period assessed implies that prevention and intervention strategies for reducing suicidal ideation should take the time period into account. The socio-demographic and health-related correlates in our study will be important for physicians and health care professionals alike to screen older adults at risk of suicidal and provide timely professional help.

Conclusion

In summary, this study suggests that suicidal ideation was prevalent among U.S. Chinese older adults in the Greater Chicago area. The prevalence of suicidal ideation differed by socio-demographic and health-related characteristics. This study emphasizes a need for studying suicidal ideation at different time periods and developing targeted interventions for Chinese older adults. It sets the groundwork for better understanding the risk and protective factors associated with suicidal ideation in future studies.

Table 4.

Socio-Demographic and Health-Related Variables Associated With Suicidal Ideation in the Past 12 Months.

Age Sex Edu Income MS Living Origin Yrs in U.S. OHS HC QOL Suicidal ideation
Age 1.0
Sex .01 1.0
Edu −.12*** −.21*** 1.0
Income .05** .00 .01 1.0
MS −.33*** −.32*** .22 −.03 1.0
Living −.35*** −.07*** .02 .16*** .24*** 1.0
Origin .04* −.01 −.08*** −.20*** .05** .05** 1.0
The United States .35*** .03 −.10*** .35*** −.2*** −.31*** −.2*** 1.0
OHS −.08*** −.06 ** .06*** .12*** .05** .00 −.03 −.01 1.0
HC −.11*** −.03 .02 .05** .07*** .01 .00 −.04* .35*** 1.0
QOL .06*** .05** .09*** .08*** −.03 −.01 −.04* .00 .32*** .15*** 1.0
Suicidal ideation .05* .09*** −.04* −.04* .08*** −.05** −.03 .02 −.14*** −.13*** −.07*** 1.0
Open in a new tab

Note. Edu = education. MS = marital status; Living = living arrangement; Origin = country of origin; Yrs in U.S. = years in the United States; OHS = overall health status; HC = health changes over the past year; QOL = quality of life.

*p < .05.

**p < .01.

***p < .001.

Acknowledgments

We are grateful to Community Advisory Board members for their continued effort in this project. Particular thanks are extended to Bernie Wong, Vivian Xu, Yicklun Mo with Chinese American Service League (CASL), Dr. David Lee with Illinois College of Optometry, David Wu with Pui Tak Center, Dr. Hong Liu with Midwest Asian Health Association, Dr. Margaret Dolan with John H. Stroger Jr. Hospital, Mary Jane Welch with Rush University Medical Center, Florence Lei with CASL Pine Tree Council, Julia Wong with CASL Senior Housing, Dr. Jing Zhang with Asian Human Services, Marta Pereya with Coalition of Limited English Speaking Elderly, and Mona El-Shamaa with Asian Health Coalition.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by National Institute on Aging grants (R01 AG042318, R01 MD006173, R01 CA163830, R34MH100443, R34MH100393, P20CA165588, R24MD001650 & RC4 AG039085), Paul B. Beeson Award in Aging, The Starr Foundation, American Federation for Aging Research, John A. Hartford Foundation and The Atlantic Philanthropies.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

  1. Almeida OP, Draper B, Snowdon J, Lautenschlager NT, Pirkis J, Byrne G, … Pfaff JJ (2012). Factors associated with suicidal thoughts in a large community study of older adults. The British Journal of Psychiatry, 201, 466–472. [DOI] [PubMed] [Google Scholar]
  2. American Community Survey. (2011). American Community Survey: 2011 estimates Retrieved from https://www.census.gov/acs/www/.
  3. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders Washington, DC: American Psychiatric Association. [Google Scholar]
  4. Atchley RC (1991). Social forces and aging: An introduction to social gerontology Belmont, CA: Wadsworth. [Google Scholar]
  5. Beck AT, Brown GK, Steer RA, Dahlsgaard KK, & Grisham JR (1999). Suicide ideation at its worst point: A predictor of eventual suicide in psychiatric outpatients. Suicide & Life Threatening Behavior, 29, 1–9. [PubMed] [Google Scholar]
  6. Brown SL, & Vinokur AD (2003). The interplay among risk factors for suicidal ideation and suicide: The role of depression, poor health, and loved ones’ messages of support and criticism. American Journal of Community Psychology, 32, 131–141. [DOI] [PubMed] [Google Scholar]
  7. Centers for Disease Control and Prevention. (2012). Suicide facts at a glance Retrieved from http://www.cdc.gov/violenceprevention/pdf/suicide_datasheet-a.pdf.
  8. Cerel J, Jordan JR, & Duberstein PR (2008). The impact of suicide on the family. Crisis, 29, 38–44. [DOI] [PubMed] [Google Scholar]
  9. Chan HL, Liu CY, Chau YL, & Chang CM (2011). Prevalence and association of suicide ideation among Taiwanese elderly population-based cross-sectional study. Chang Gung Medical Journal, 34, 197–204. [PubMed] [Google Scholar]
  10. Cheng JKY, Fancher TL, Ratanasen M, Conner KR, Duberstein PR, Sue S, & Takeuchi D (2010). Lifetime suicidal ideation and suicide attempts in Asian Americans. Asian American Journal of Psychology, 1, 18–30. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Conwell Y, Duberstein PR, Cox C, Herrmann J, Forbes N, & Caine ED (1998). Age differences in behaviors leading to completed suicide. American Journal of Geriatric Psychiatry, 6, 122–126. [PubMed] [Google Scholar]
  12. Copeland JRM, & Dewey ME (1991). Neuropsychological diagnosis (GMS-HAS-AGECAT Package). International Psychogeriatrics, 3, 43–49. [Google Scholar]
  13. Cukrowicz KC, Cheavens JS, Van Orden KA, Ragain RM, & Cook RL (2011). Perceived burdensomeness and suicide ideation in older adults. Psychology and Aging, 26, 331–338. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Diego AT, Yamamoto J, Nguyen LH, & Hifumi SS (1993). Suicide in the elderly: Profiles of Asians and Whites. Asian American and Pacific Islander Journal of Health, 2, 49–57. [PubMed] [Google Scholar]
  15. Dong X, Beck T, & Simon MA (2009). Loneliness and mistreatment of older Chinese women: Does social support matter? Journal of Women & Aging, 21, 293–302. [DOI] [PubMed] [Google Scholar]
  16. Dong X, Beck T, & Simon MA (2010). The associations of gender, depression, and elder mistreatment in a community-dwelling Chinese population: The modifying effect of social support. Archives of Gerontology and Geriatrics, 50, 202–208. [DOI] [PubMed] [Google Scholar]
  17. Dong X, Chang E-S, Simon M, & Wong E (2011). Sustaining community–university partnerships: Lessons learned from a participatory research project with elderly Chinese. Gateways: International Journal of Community Research and Engagement, 4, 31–47. [Google Scholar]
  18. Dong X, Chang E-S, Wong E, & Simon M (2011). Working with culture: Lessons learned from a community-engaged project in a Chinese aging population. Aging Health, 7, 529–537. [Google Scholar]
  19. Dong X, Chang E-S, Wong E, & Simon M (2012a). Perception and negative effect of loneliness in a Chicago Chinese population of older adults. Archives of Gerontology and Geriatrics, 54, 151–159. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Dong X, Chang E-S, Wong E, & Simon M (2012b). The perceptions, social determinants, and negative health outcomes associated with depressive symptoms among US Chinese older adults. The Gerontologist, 52, 650–663. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Dong X, Chang E-S, Wong E, Wong B, Skarupski KA, & Simon MA (2011). Assessing the health needs of Chinese older adults: Findings from a community-based participatory research study in Chicago’s Chinatown. Journal of Aging Research, 2010. doi: 10.4061/2010/124246 . [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Dong X, Chang E-S., Zeng P, & Simon M (2014). Suicide in the global Chinese aging population: A review of risk and protective factors, consequences, and interventions. Aging and disease, 5(5), 1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Dong X, Chen R, Chang E-S., & Simon M. (2014). The prevalence of suicide attempts among community-dwelling US Chinese older adults-findings from the PINE study. Ethnicity and inequalities in Health and Social Care, 7, 23–35. [Google Scholar]
  24. Dong X, Wong E, & Simon M (2014). Study design and implementation of the PINE study. Journal of Aging and Health, 26, 1085–1099. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Goodwin R, & Olfson M (2002). Self-perception of poor health and suicidal ideation in medical patients. Psychological Medicine, 32, 1293–1299. [DOI] [PubMed] [Google Scholar]
  26. Heisel MJ, & Duberstein PR (2005). Suicide prevention in older adults. Clinical Psychology: Science and Practice, 12, 242–259. [Google Scholar]
  27. Joe S, Ford BC, Taylor RJ, & Chatters LM (2014). Prevalence of suicide ideation and attempts among Black Americans in later life. Transcultural Psychiatry, 51(2), 190–208. [DOI] [PubMed] [Google Scholar]
  28. Karlin BE, & Humphreys K (2007). Improving Medicare coverage of psychological services for older Americans. American Psychologist, 62, 637–649. [DOI] [PubMed] [Google Scholar]
  29. Kessler RC, Borges G, & Walters EE (1999). Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Archives of General Psychiatry, 56, 617–626. [DOI] [PubMed] [Google Scholar]
  30. Knox KL, Conwell Y, & Caine ED (2004). If suicide is a public health problem, what are we doing to prevent it? American Journal of Public Health, 94, 37–45. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Kung WW (2004). Cultural and practical barriers to seeking mental health treatment for Chinese Americans. Journal of Community Psychology, 32, 27–43. [Google Scholar]
  32. Law S, & Liu P (2008). Suicide in China: Unique demographic patterns and relationship to depressive disorder. Current Psychiatry Reports, 10, 80–86. [DOI] [PubMed] [Google Scholar]
  33. Lester D (2005). Suicide and the Chinese cultural revolution. Archives of Suicide Research, 9, 99–104. [DOI] [PubMed] [Google Scholar]
  34. Ma X, Xiang YT, Cai ZJ, Li SR, Xiang YQ, Guo HL, …Chiu HF. (2009). Lifetime prevalence of suicidal ideation, suicide plans and attempts in rural and urban regions of Beijing, China. Australian and New Zealand Journal of Psychiatry, 43, 158–166. [DOI] [PubMed] [Google Scholar]
  35. Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A, …William D (2008). Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. British Journal of Psychiatry, 192, 98–105. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. O’Donnell L, O’Donnell C, Wardlaw DM, & Stueve A (2004). Risk and resiliency factors influencing suicidality among urban African American and Latino youth. American Journal of Community Psychology, 33, 37–49. [DOI] [PubMed] [Google Scholar]
  37. Pfaff JJ, & Almeida OP (2005). Detecting suicidal ideation in older patients: Identifying risk factors within the general practice setting. British Journal of General Practice, 55, 269–273. [PMC free article] [PubMed] [Google Scholar]
  38. Phillips MR, Li X, & Zhang Y (2002). Suicide rates in China, 1995–99. The Lancet, 359, 835–840. [DOI] [PubMed] [Google Scholar]
  39. Phillips MR, Liu H, & Zhang Y (1999). Suicide and social change in China. Culture, Medicine and Psychiatry, 23, 25–50. [DOI] [PubMed] [Google Scholar]
  40. Santos JF, Hubbard RW, & Overholser JC (1994). Elder suicide: Research, theory and treatment Washington, DC: American Psychological Association. [Google Scholar]
  41. Simon M, Chang E-S, Rajan KB, Welch MJ, & Dong X (2014). Demographic characteristics of U.S. Chinese older adults in the Greater Chicago area: Assessing the representativeness of the PINE study. Journal of Aging and Health, 26, 1100–1115. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Simon M, Chang E-S, Zeng P, & Dong X (2013). Prevalence of suicidal ideation, attempts, and completed suicide rate in Chinese aging populations: A systematic review. Archives of Gerontology and Geriatrics, 57, 250–256. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, & Reynolds CF III. (2002). Identification of suicidal ideation and prevention of suicidal behavior in the elderly. Drugs & Aging, 19, 11–24. [DOI] [PubMed] [Google Scholar]
  44. Census Bureau US. (2010). American fact finder Retrieved from http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml.
  45. U.S. Department of Health and Human Services. (2012). 2012 National strategy for suicide prevention: Goals and objectives for action Retrieved from http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full-report.pdf. [PubMed]
  46. Yen YC, Yang MJ, Yang MS, Lung FW, Shih CH, Hahn CY, & Lo HY (2005). Suicidal ideation and associated factors among community dwelling elders in Taiwan. Psychiatry and Clinical Neurosciences, 59, 365–371. [DOI] [PubMed] [Google Scholar]
  47. Yip PS, Chi I, Chiu H, Chi WK, Conwell Y, & Caine E (2003). A prevalence study of suicide ideation among older adults in Hong Kong SAR. International Journal of Geriatric Psychiatry, 18, 1056–1062. [DOI] [PubMed] [Google Scholar]

RESOURCES