Information on mental health, especially suicidal behaviours, is lacking in Vietnam: this is the first study on suicidal thought in a Vietnamese general population.
Methodology
In this investigation, face-to-face interviews were conducted. This procedure not only allows any misunderstanding of the questions to be clarified, but also helps to prevent non-participation. Some previous studies using questionnaires sent by post or administered by telephone have shown higher participation refusal rates than in this study [20, 21]. Even though the analysis of the data was anonymous to the researchers, and thus de-identified, the participants were not anonymous during the sampling prosedure. The answeres given might differ from data given in a totally anonymous situation. The procedure of training, pilot study, monitoring, checking, and retesting was conducive to inter-interviewer reliability.
However, the perception by the interviewed person that the interviewers were the part of the Commune' People Committee and the role of stigma cannot be ruled out. The rate of suicidal thoughts reported in the study was nearly 8.9%, but the real proportion may be higher for several conceivable reasons. People cannot remember suicidal thoughts throughout their lives, especially if no particular events take place to remind them of these thoughts. Beyond issues of memory, cultural aspects may have affected people's willingness to inform others that they have had suicidal thoughts or attempted suicide in their lifetime. This factor is assumed to be prevalent in Asian countries [22, 23].
The procedure of training, pilot study, and re-testing assured the inter-interviewer reliability. Understanding the meaning of questions on suicidal thoughts can also cause the problem of the reliability of the obtained results. A particularly low rate of lifetime suicide attempts (0.4%) calls for further investigation. The problem of bias due to social desirability of respondents is a well known phenomenon in this kind of studies [24].
The study design is a cross-section survey, so no conclusions could be drawn concerning the causality between suicidal thinking and other factors. Nonetheless, it helps to indicate a direction for further longitudinal studies.
Suicidal thoughts, suicide plans and suicide attempts during lifetime and past 12 months
Lifetime prevalence for suicidal thoughts varies among countries, and ranges from 2.1% to 18.5% in studies of nine countries [23]. The rates of suicidal thoughts on a lifetime basis and/or in the past twelve months are lower in our study than in studies in Western countries [23, 25] and China but higher than in India [14]. This may be due to cultural differences but also, in part, to the methodology used. In the nine-country study [23], for example, the Diagnostic Interview Schedule, Version III and the DSM-III were used and suicidal thought was assessed by the question" Did you ever feel so low you thought of committing suicide?" which differs from the questions about suicidal thoughts used in this study [14]. The prevalence of suicide attempts in Vietnam was the lowest among countries within the SUPRE-MISS framework, when the same methodology was used [14]. But, Vietnam reported more serious suicide attempts, based on the self-evaluation of seriousness in comparison with answers from the general population in other countries [14]. Real suicide rate in Vietnam is unknown because the rate reported by the Ministry of Health is based only on hospital data. However, most of suicides occur outside the hospital systems. There is no national system to monitor causes of death, including suicide in Vietnam. Therefore, surveillance and registration of suicide and other causes of death should be developed.
The ratio of suicidal thoughts, suicide plans, and suicide attempts in Vietnam was 22.3:2.8:1 on a lifetime basis. Suicidal thoughts are 7 times more prevalent than suicide plans, while the latter are only approximately three times as common as suicide attempts. There is the same ratio between suicide plans and suicide attempts in Vietnam (2.8:1) as in China, Australia, Stockholm but different from India, Brazil, Sri Lanka, Iran and Estonia where ratio between suicide plans and suicide attempts is in the range between 1:0.7 to 1:1.7 [14]. The ratio between suicidal thought and suicide attempts in Vietnam is 22.3: 1 which differs from Western and other Asian countries, where the ratio between suicidal thoughts and suicide attempts is smaller. A future in-depth study will be undertaken to understand the reasons for the differences.
Correlates of having suicidal thoughts
In our urban Vietnam sample, female gender is strongly associated with suicidal thoughts compared with male. This result is consistent with most of previous studies [25]. In contrast to our finding, the Finnish study reported a higher prevalence of suicidal thoughts in men than in women [26].
Suicidal thoughts are associated with single marital status or life events such as divorce, widowhood and separation. Marriage seems to be a protective factor for suicidal thoughts. These factors have, in fact, been identified in various studies in Asian and Western countries alike [22, 27–29].
In our study, the results show that participants who followed the Buddhist religion experienced less suicidal thought than those who either had no religion or followed other religions (Muslim, Protestant, Jewish). Most Vietnamese people are strongly influenced by Buddhist practices, even if they do not openly admit that they are Buddhists [30]. This cultural and religious tradition may possibly explain the low level of suicidal thoughts and suicide attempts in Vietnam compared with other countries [14, 23].
Suicidal thoughts in this study were frequent in young adults. The results of our previous study on hospitalised suicide attempters [17] showed that the largest group of patients was the group aged 15–24 years.
Several previous studies found the correlation between low income, unemployment with suicidal thought [27, 31]. It is similar to the results in this study, which show that there are only 1.4% of respondents who are unemployment but there are 44.4% who report that they have a low level of income. The unsolved financial problems for a long time can lead to distress and depression symptoms. Poor economy influences also the access to the health care service in the developing countries as Vietnam.
Suicidal thoughts and mental problems, use of alcohol, sedatives and pain relief medication
The result of our study show that nearly 90% of respondents never used sedatives or pain relief medication in their life. The habit of using this kind of medication might be a protective factor for suicidal thought in Vietnam.
Prolonged feelings of anxiety, depression and fear are predictors for suicidal thought. This research calls for training of primary health workers, and this is consistent with the WHO strategies for suicide prevention [32]. It is well known that many people who suffer from stress and mental problems over long periods do not come to the health services' attention [7] This may be connected with taboos or diverse cultural aspects of mental illness in Vietnam, but also due to a general lack of knowledge about diagnostics and treatment of mental illness [33].
Suicidal thinking is related to the use of sedatives and these kinds of medicines are a frequent means of attempting suicide in Vietnam [17]. Public-health approaches that call, for example, for careful management of medication of this kind or selling smaller pack sizes are suggested as effective means of preventing suicidal behavior [34].
Suicidal thought is highly correlated with use of alcohol on a lifetime basis. Studies from non-Asian countries illustrated the same findings [10, 35]. But in our previous study, alcoholism and alcohol addiction were rarely found in hospitalized suicide attempters [17] which may be due to the lack of attention by doctors to diagnose alcohol misuse and abuse.
Suicidal thoughts and physical health
Suicidal thoughts and attempted suicide are related not only to depression and other mental disorders, but also to general medical illnesses ranging from terminal diseases such as cancer and AIDS to acute life-threatening illnesses such as stroke, traumatic brain injury and spinal cord injury, and also more widespread illnesses, such as asthma and chronic bronchitis [9]. Although the numbers of cancer and asthma patients in our study were small as they were not selected from the hospital, suicidal thoughts were found to be significantly more frequent in these groups. The results indicate the need of paying attention to suicidal thoughts when treating somatically ill patients and the need for further studies focusing on hospitals.
