This paper presents an empirical investigation of the hypothesis that exposure to the restrictive fertility policies of the Chinese “Later, Longer, Fewer” campaign in the 1970s contributes to the dynamics and patterns of elderly suicides in China in the period 2004–2017. We apply an identification strategy that exploits variation in exposure to this policy across birth cohorts that is based on the different timing of the implementation of the fertility policies across Chinese provinces. The results show that cohorts with a greater exposure to the restrictive fertility policy in the 1970s exhibit higher suicide rates during old ages.

Background: A recent cross-national study demonstrated a curvilinear (inverted U-shaped curve) between elderly male suicide rates and the Human Development Index (HDI) fitting the quadratic equation y = a + bx − cx2 where y is the elderly male suicide rate, x is the HDI and a, b and c are constants). This study used only one-year cross-sectional data on suicide rates, and suicide rates can randomly fluctuate year on year.

Methods: A study designed to replicate this curvilinear relationship between elderly suicide rates and the HDI was undertaken by: (i) using one-year average of five years data on suicide rates; and (ii) using more recent data on both elderly suicide rates than used in the previous study. Data were ascertained from the World Health Organization and the United Nations.

Results: There was a significant curvilinear (inverted U-shaped curve) relationship between suicide rates in males aged 65–74 years, males aged 75+ years, females aged 65–74 years and the HDI fitting the quadratic equation y = a + bx − cx2. A similar curvilinear relationship was observed in females aged 75+ years, but the significance level only approached 0.05 level.

Conclusions: The replication of the curvilinear (inverted U-shaped curve) relationship between elderly suicide rates and the HDI by using one-year average of five years data on suicide rates suggests that the observed relationship is robust and accurate.

Background: An epidemiological transition hypothesis has been developed to explain simultaneously wide cross-national variations in elderly suicide rates, trends over time for elderly suicide rates and age-associated trends in suicides rates. This speculative hypothesis suggests that there is a curvilinear (inverted U-shaped curve) relationship between elderly suicide rates and socioeconomic status fitting the quadratic equation y = a + bx − cx2 (where y is the suicide rate, x is the socioeconomic status, and a, b and c are constants).

Methods: The predicted curvilinear relationship between elderly suicide rates and gross national domestic product (GDP), a measure of socioeconomic status, fitting the above quadratic equation was examined with a curve estimation regression model using data from the World Health Organization.

Results: The relationship between suicide rates in both sexes in the age-bands 65–74 and 75+ years and the GDP was curvilinear (inverted U-shaped curve) and fitted the above quadratic equation, and was statistically significant (at least p<0.05) in all four groups.

Conclusions: Caution should be exercised in accepting this model of the epidemiological transition hypothesis for elderly suicide rates because it is generated from cross-sectional data using an ecological design. Ideally, this model requires rigorous testing by following selected countries of low socioeconomic status over time as they develop socioeconomically.

Background: The reported decline in elderly suicide rates in England may have been, in part, due to prompt and successful resuscitation of those who attempt suicide. This study examines the impact of prompt and successful resuscitation of those who attempt suicide on elderly suicide rates in England.

Methods: Possible changes in rates of attempted suicides in elderly age-bands over a nine-year period and the correlation between rates of attempted suicide and suicide in elderly age-bands in England were examined using nationally collected data.

Results: There was a significant increase in the rates of attempted suicide over the study period in the age-band 60–74 years, but not in the age-band 75+ years. There was a positive correlation between rates of attempted suicide and suicide in the age-band 75+ years, but not in the age-band 60–74 years.

Conclusions: The findings of this study were unable to confirm conclusively that prompt and successful medical resuscitation of those who attempt suicide makes a contribution to the decline in elderly suicide rates and requires further study. Public health initiatives should be designed to reduce not only suicide rates but also rates of attempted suicide; otherwise they are failing in the prevention of mental illness and suicidal behavior, early identification and treatment of those with mental illness and those at risk of suicide, and systematic follow-up of those recovering and recovered from mental illness.

Background: The elderly are at high risk of developing tuberculosis. The prevalence and incidence of depression and anxiety are higher in those with tuberculosis than in the general population. A positive correlation between national suicide rates and rates of mortality due to tuberculosis has been reported.

Methods: The relationships between elderly suicide rates and (i) the prevalence of tuberculosis, (ii) the proportion of detected cases of tuberculosis, and (iii) the proportion of cured cases of tuberculosis were examined in a cross-national study using data from the World Health Organization and the United Nations.

Results: There were no significant correlations between elderly suicide rates and the prevalence of tuberculosis and the proportion of detected cases of tuberculosis. There were weak but significant negative correlations between the proportion of cured cases of tuberculosis and suicide rates for both sexes in both elderly age-bands.

Conclusion: Caution should be exercised in interpreting the findings and the direction of the causal relationship from this cross-sectional ecological study because of ecological fallacy. However, if the findings are true then potentially the study has important implications for prevention of elderly suicides, particularly in countries with a high prevalence of tuberculosis.

Background: Elderly suicides rates are associated with socio-economic status and life expectancy. Although suicide rates in younger people are associated with both higher and lower levels of educational attainment, little is known about this association in the elderly.

Method: The relationship between Human Development Index (HDI) – a composite index measuring average achievements on three basic dimensions of human development (life expectancy, educational attainment and socio-economic status) – and elderly suicide rates was examined in a cross-national study utilizing secondary data from the World Health Organization and the United Nations.

Results: There was a significant curvilinear (inverted U-shaped curve) relationship between elderly suicide rates in males and the HDI, fitting the quadratic equation y = a + bx − cx2. A similar curvilinear relationship was observed in females, but the significance level only approached 0.05.

Conclusions: A model with four sequential stages was proposed to explain the findings: (i) low elderly suicide rate – low human development society; (ii) high elderly suicide rate – low human development society; (iii) high elderly suicide rate – high human development society; and (iv) low elderly suicide rate – high human development society.

Background: Elderly suicide rates may be influenced by mental health service provision.

Methods: A cross-national study examining the hypothesis that the relationship between elderly suicide rates and markers of mental health service provision would be curvilinear (inverted-U shaped curve) and fit the quadratic equation y = a + bx − cx2 (where y is the elderly suicide rate, x is a marker for mental health service provision, and a, b and c are constants) was undertaken by utilizing data from the World Health Organization.

Results: The relationship between the logarithm of suicide rates in both sexes in both the elderly age-bands and the percentage of the total health budget spent on mental health, the total number of psychiatric beds per 10,000 population and the total number of psychiatrists per 10,000 population were curvilinear (inverted U-shaped curve) and fitted the quadratic equation y = a + bx − cx2 with statistical significance.

Conclusions: The direction of the causal relationship could be examined in longitudinal studies, after further improvement in levels of mental health service provision, in individual countries segregated by low and high levels of existing mental health service provision.

Background: Elderly suicide rates may be influenced by mental health funding, service provision and national policy.

Methods: A cross-national study examining the relationship between elderly suicide rates and (i) the presence of national policy on mental health, (ii) funding for mental health, and (iii) measures of mental health service provision was undertaken by utilizing data from the World Health Organization website.

Results: The main findings are: (i) there is no relationship between suicide rates in both sexes in both elderly age-bands and different measures of mental health policy, except they were increased in countries with a substance abuse policy; and (ii) suicide rates in both sexes in both elderly age-bands were higher in countries with greater provision of mental health services, including the number of psychiatric beds, psychiatrists, psychiatric nurses, and the availability of training in mental health for primary care professionals.

Conclusions: Cross-national ecological studies using national-level aggregate data are not helpful in establishing a causal relationship (and the direction of this relationship) between elderly suicide rates and mental health funding, service provision and national policies. The impact of introducing national policies on mental health, increasing funding for mental health services and increasing mental health service provision on elderly suicide rates requires further examination in longitudinal within-country studies.

Background: Cultural factors may influence cross-national variations in elderly suicide rates.

Methods: A cross-national study examining the relationship between elderly suicide rates and elderly dependency ratios was conducted with the a priori unidirectional hypothesis that lower elderly dependency ratios (ratio of people over the age of 65 years to people under the age of 65 years) may imply a greater number of younger people being potentially available to provide support and respect to the elderly and to hold them in high esteem, and this would lead to a reduction in elderly suicide rates. Data on elderly suicide rates, and the total number of elderly and young people were ascertained from the World Health Organization website.

Results: Significant positive correlations were found between the natural logarithm of suicide rates, in both sexes in two elderly age-bands (65–74 years and 75+ years), and the elderly dependency ratio for males, females and both sexes combined.

Conclusions: The impact of elderly dependency ratios on elderly suicide rates may interact with and be modified and mediated through cultural factors. The contribution of cross-national differences in cultural factors on elderly suicide rates require further study by formally measuring cultural factors with validated instruments.

Background: Socioeconomic status may influence cross-national variations in elderly suicide rates.

Methods: The relationship between suicide rates in both sexes in the age-bands 65–74 years and 75+ years and (i) life expectancy, (ii) measures of socioeconomic status (per capita gross national domestic product (GDP) and the Gini coeffcient), and (iii) measures of the quality and quantity of available healthcare services (the proportion of GDP spent on health, per capita expenditure on health and child mortality rates) was examined using data from the World Health Organization and the United Nations.

Results: The main findings were: (i) a significant negative correlation between the Gini coefficient and suicide rates for both sexes in both age-bands; (ii) a significant positive correlation between per capita expenditure on health and suicide rates for both sexes in both age-bands; (iii) the significant positive correlation between the proportion of GDP spent on health and suicide rates was only evident in males in both age-bands; (iv) a significant negative correlation between child mortality rates and suicide rates for both sexes in both age-bands; and, (v) the significant positive correlation between life expectancy and suicide rates was evident in females in both age-bands.

Conclusions: A potentially testable model with five sequential stages was proposed to explain these findings.