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Authors' reply

Published online by Cambridge University Press:  02 January 2018

Yongsheng Tong ,
Michael R. Phillips  and
Kenneth R. Conner
Yongsheng Tong
Affiliation:
Beijing Suicide Research and Prevention Center, Beijing Hui Long Guan Hospital, Beijing, China; WHO Collaborating Center for Research and Training in Suicide Prevention, Beijing, China. Email: [email protected]
Michael R. Phillips
Affiliation:
Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Departments of Psychiatry and Public Health, Emory University, Atlanta, Georgia, USA; and Beijing Suicide Research and Prevention Center, Beijing Hui Long Guan Hospital, Beijing, China
Kenneth R. Conner
Affiliation:
Department of Emergency Medicine and Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
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Abstract

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Type
Columms
Information
The British Journal of Psychiatry , Volume 210 , Issue 2 , February 2017 , pp. 167 - 168
Copyright
Copyright © The Royal College of Psychiatrists 2017 

We appreciate Liu's interest in our case–control study of DSM-IV Axis II personality disorders and suicidal behaviour in China; however, the commentary does not accurately represent the purpose of the report or our conclusions.

Liu was critical of our focus on personality disorders, stating that ‘the authors do not adequately explore possible environmental reasons for their findings […] DSM-IV personality categories may not be appropriate tools for understanding suicidal behaviour in China’. One possible explanation for the much lower reported prevalence of mental disorders in suicide and attempted suicide in China compared with high-income countries Reference Yang, Phillips, Zhou, Wang, Zhang and Xu1,Reference Jiang, Li, Phillips and Xu2 is the failure to consider Axis II personality disorders in the relevant studies. One of the goals of this study was to test this hypothesis by examining the relationship between personality disorders and suicidal behaviour in China using case–control methodology. We did not make an a priori assumption about the role of such disorders in suicidal behaviour. In fact, as stated in the introduction of the paper, ‘The purpose of the current study is to address the gaps in data on personality disorders and suicidal behaviour in China’.

We found that a low percentage of suicide decedents (7%) and suicide attempters (6%) in China had one or more Axis II personality disorders, and that a very low percentage of living community controls (1%) had such a disorder. Despite some concerns about the sensitivity of available instruments for measuring personality in China and about respondents' reluctance to report negative traits, our conclusion was that ‘personality disorders as defined by DSM-IV are much less prevalent in mainland China’. This result confirms our initial impression that failure to consider the categorically defined DSM-IV personality disorders is not the main reason for the previously reported low prevalence of mental disorders among individuals with suicidal behaviour in China. Reference Phillips3 Of course, it remains possible that using dimensional measures of personality traits (rather than the categorical classification of personality disorders) could identify personality characteristics that are important predictors of suicidal behaviour in China. Prior research on the relationship of dimensional measures of impulsivity to suicidal behaviour in China Reference Zhang, Xiao and Zhou4,Reference Ai, Chen, Wang, Gan, Shen and Li5 is an example of the type of work needed to assess this possibility.

Liu suggested other targets for research and prevention that should take precedence over the examination of Axis II personality disorders, including environmental influences, culture and economic factors. We agree that these are potentially important foci, but they were intentionally not considered in the current report that focused on the relative importance of Axis I and Axis II mental disorders as predictors of fatal and non-fatal suicidal behaviour. These other factors will be addressed in subsequent reports on this study.

References

1 Yang, GH, Phillips, MR, Zhou, MG, Wang, LJ, Zhang, YP, Xu, D. Understanding the unique characteristics of suicide in China: national psychological autopsy study. Biomed Environ Sci 2005; 18: 379–89.Google Scholar
2 Jiang, CL, Li, XY, Phillips, MR, Xu, YC. Matched case-control study of medically serious attempted suicide in rural China. Shanghai Arch Psychiatry 2013; 25: 22–31.Google ScholarPubMed
3 Phillips, MR. Rethinking the role of mental illness in suicide. Am J Psychiatry 2010; 167: 731–3.Google Scholar
4 Zhang, J, Xiao, S, Zhou, L. Mental disorders and suicide among young rural Chinese: a case-control psychological autopsy study. Am J Psychiatry 2010; 167: 773–81.Google Scholar
5 Ai, M, Chen, JM, Wang, MJ, Gan, Y, Shen, Y, Li, DQ, et al The impulsiveness and aggression among suicide attempters in college students (in Chinese). Chin J Nerv Ment Dis 2011; 37: 650–5.Google Scholar
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