Relationship between impulsivity and

suicide among the rural elderly in China:

a case-control psychological autopsy
study
Yunfang Zhou1 Zhenyu Ma2 Cun-Xian Jia3 Liang Zhou4
1
Department of Labor and Social Security, School of Public Administration, Hunan University of Finance and
Economics, Changsha, China
2
School of Public Health, Guangxi Medical University, Nanning, China
3
School of Public Health, Shandong University, Jinan, China
4
The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou,
China

ABSTRACT
Background. The relationship between impulsivity and suicide is inconsistent in
different populations. Hence, the relationship between impulsivity and suicide still
needs to be studied among the elderly population. The present study intends to explore
the relationship between impulsivity and suicide among the rural Chinese elderly.
Methods. A case-control psychological autopsy study was conducted from February 1,
2014 to December 18, 2015 among rural residents over the age of 60 who died by suicide.
The sample consisted of 242 suicides as the case group and 242 living individuals as
the control group. Data on demographic characteristics, impulsivity, previous history
of suicide attempts, social support, negative life events, and suicidal behavior were
collected.
Results. Our study found that impulsivity increased the risk of suicide. The case group
showed a higher Barratt Impulsiveness Scale score compared with the control group
(p < 0.001), which indicates that impulsivity was higher among the elderly suicides. In
addition, regression analyses show that impulsivity (odds ratio: 1.03, 95% confidence
Submitted 24 July 2020 interval: 1.01–1.06) is an independent risk factor of suicide, after controlling for the
Accepted 26 June 2021
Published 27 July 2021 effects of marital status, education, family annual income, being left behind, social
support, and negative life events. Finally, compared with elderly who do not have a
Corresponding author
Liang Zhou, history of attempted suicide, elderly with a history of attempted suicide showed higher
[email protected] impulsivity (p = 0.001).
Academic editor
Bao-Liang Zhong
Subjects Psychiatry and Psychology, Public Health
Additional Information and
Declarations can be found on Keywords Case–control study, Impulsivity, Psychological autopsy, Rural elderly, Suicide
page 10
DOI 10.7717/peerj.11801 INTRODUCTION
Copyright Suicide, which is the act of intentionally taking one’s own life (Turecki et al., 2019), has
2021 Zhou et al.
been considered as a major global health problem (Dong et al., 2015). Suicide causes
Distributed under 800, 000 deaths every year and has been listed as the 15th leading cause of death all over the
Creative Commons CC-BY 4.0
world (WHO, 2019). Although the global prevalence of suicide has remarkably dropped
OPEN ACCESS in recent years, suicide in China contributes to the overall burden of suicide, accounting

How to cite this article Zhou Y, Ma Z, Jia C-X, Zhou L. 2021. Relationship between impulsivity and suicide among the rural elderly in
China: a case-control psychological autopsy study. PeerJ 9:e11801 http://doi.org/10.7717/peerj.11801
 for approximately 1/5 of global suicides (Dong et al., 2015). In China, the risk of suicide
increases with age, with elderly aged over 65 having the highest suicide rate of 44.3-200
per 100,000, which is 4-5 times higher than the general population (Li, Xiao & Xiao, 2009).
Despite the decreasing suicide rate among the general population, suicide among the
elderly population has shown an increasing trend (Sha, Yip & Law, 2017; Wang, Chan &
Yip, 2014). Moreover, the suicide rates of elderly in rural areas are higher than those in
urban areas in China (Li & Katikireddi, 2019). China has a rapidly ageing population, but
the mental health care system in rural China is still in its infancy. In addition, most rural
areas of China are experiencing high work migration where young people move to big cities
to look for job opportunities and leave their old parents living in countryside alone. Rural
elderly, especially those living alone, are faced with tremendous difficulties and challenges
physically, mentally and socially, which put them at higher risk of suicide. Consequently,
it is both important and urgent to understand contributing factors that lead to suicide,
which is rarely studied among rural elderly population in China.
Among a range of risk factors that have been identified to predict suicide, impulsivity
is one of the most-commonly mentioned, yet also most controversial factor reported
in the literature. There is no standard definition of impulsivity, which has been defined
and operationalized in various ways by various researchers (Bakhshani, 2014). Moeller
et al. (2001) looked at impulsivity from a bio-psycho-social perspective and emphasized
three essential aspects of impulsivity: (1) decreased sensitivity to negative consequences
of behavior; (2) immediate and unplanned reaction to stimuli before processing the
information thoroughly; and (3) no regard for long-term consequences of a behavior. This
definition provides helpful insight in guiding for research and treatment on impulsivity
and its related risk behaviors.
Although impulsivity has been widely recognized as a predisposition towards risky
behaviors such as suicide (Bakhshani, 2014), studies on the relationship between impulsivity
and suicide have yielded inconsistent and variable results. A large number of research have
adopted impulsivity as a significant risk factor or waning sigh for suicide. For instance, a
literature review by Gvion & Apter (2011) showed that impulsivity was highly correlated
with suicidal behavior across both psychiatric and non-psychiatric populations. Another
literature review and meta-analysis on impulsivity in the self-harm and suicidal behavior of
young people also demonstrated significant positive associations between multiple facets
of impulsivity with suicide behaviors (McHugh et al., 2019). As a result, impulsivity has
been highlighted as an important suicide risk factor by many organizations including the
American Association of Suicidology, American Foundation for Suicide Prevention and
the Substance Abuse and Mental Health Services Administration. However, an almost
equally large number of studies have also shown small or even no association between
impulsivity and suicide. For example, Smith et al. (2008) posited that most suicide is not
a result of impulsive decisions but involve a plan. This proposition was also endorsed
by Anestis et al. (2014) who conducted a literature and meta-analysis of the association
between trait impulsivity and suicidal behavior and found very small correlations. A recent
literature review also found only limited between-group differences in various aspects of
impulsivity between suicide and non-suicide group (Beach, Gissandaner & Schmidt, 2021).

Zhou et al. (2021), PeerJ, DOI 10.7717/peerj.11801 2/13

 Furthermore, Klonsky & May (2015) found no association between impulsivity and suicide
in both their own studies and by literature review.
The inconsistent results on impulsivity and suicide may be partly explained by differences
in sample, suicide outcomes (ideation, attempt, and death), measurement of impulsivity,
and study design across various studies. However, there have been no studies that examined
the association between impulsivity and suicide among older adults in China, who are most
susceptible and vulnerable to suicide. A better understanding of suicide and its association
with impulsivity among Chinese rural elderly not only contributes more evidence to the
already conflicting literature, but also help guide for further intervention programs for the
treatment of impulsivity and prevention of suicide. The current study was conducted to
fill in the research void by investigating the relationship between suicide and impulsivity
among Chinese rural older adults.

METHODS
Design and ethical statement
The study, conducted from February 1, 2014 to December 18, 2015, utilized a matched case–
control study design combined with psychological autopsy method. The study was approved
by the Institutional Review Board of the Central South University (Ethical Application
Ref: CTXY-130041-1), Shandong University (Ethical Application Ref: 20150306-1), and
Guangxi Medical University (Ethical Application Ref: 20150146).

Sample and sampling

Data on rural residents over the age of 60 who died by suicide were collected in this study.
Information on suicide deaths among the elderly, which was used as the case group, was
obtained from the local governments’ death certification system. For the control group,
living comparisons were matched 1:1 with the suicides in the case group in terms of age
(±3 years), gender, and residence. When a suicide from the case group is identified, we first
listed and enumerated all the elderly adults from the same village with matching age and
gender. Then, a computer software was used to randomly select one living comparison from
the list of matching individuals. In rare instances when no appropriate living comparisons
were available, we expanded our search to the nearest villages.
A multistage stratified cluster sampling method was adopted to recruit participants.
First, Shandong, Hunan, and Guangxi provinces were selected to correspond to eastern,
central, and western China, respectively. Second, 12 counties were randomly chosen from
the three provinces, including Zoucheng, Junan, and Gaotang from Shandong Province;
Yongding, Cili, and Sangzhi from Hunan Province; and Hengxian, Wuming, Lingchuan,
Hepu, Luzhai, and Lingyun from Guangxi Province. Elderly residents were recruited, and
information on elderly suicides was obtained from each county. Finally, 242 suicides and
242 living individuals were included in this study.

Procedure of the interview

Face-to-face interviews were conducted with two informants of both suicide group and
living controls. The two informants usually included one next-to-kin who lived with the

Zhou et al. (2021), PeerJ, DOI 10.7717/peerj.11801 3/13

 subjects, and one non-kin person such as friend, neighbor, or a remote relative. Interviewers
from the three research sites received uniform and standard training on psychological
autopsy and interview methods before the start of the interviews. Each interview took
about 90 min with one interviewer interviewing one informant each time. The aims and
procedures of the research were explained, and a written informed consent was obtained
from the participants at the start of the interview. Each interview lasted approximately
90 minutes. The details of the participant selection and interview procedures were described
in previous publications (Zhou et al., 2019).

Measurements
Demographic characteristics
The demographic data included gender, age, educational level, marital status, family
income, physical diseases, and being left behind. Marital status was classified into currently
married (including married, remarried and cohabiting) and not currently married
(including single, separated, divorced, and widowed). Being left behind is defined as
desertion by adult children 12 months prior to suicide (for the case group) or investigation
(for the control group), residence away from the original township for at least 10 months,
and infrequent visits (no more than twice).

Barratt impulsiveness scale

Impulsivity was measured using the Barratt Impulsiveness Scale (BIS). It is a 30-item scale
designed to assess the personality and behavioral construct of impulsiveness and includes
three subscales: non-planning, motor, and attentional impulsivity (Patton, Stanford &
Barratt, 1995). Each item is rated on a five-point Likert scoring from 1 ‘‘never’’ to 5 ‘‘very
frequently’’. The total score ranges from 30 to 150, with a higher score indicating high
impulsivity. The original BIS showed good internal consistency with Cronbach’s alpha of
0.77-0.89 and a test–retest reliability of 0.68-0.89 (Patton, Stanford & Barratt, 1995). The
Chinese version of BIS has been used in a previous psychological autopsy study in China
and showed satisfactory reliability and validity (Lu et al., 2012).

Life events scale for the elderly (LESE)

Life events were measured using the Life Events Scale for the Elderly (LESES). It is 46-item
scale specifically developed for elderly adults to assess stressful life events during the last
12 months before suicide or investigation and includes three subscales: health-related
events, family problems, and social communication problems. Each event was recorded
from five dimensions: the date it happened, whether it was positive or negative, the impact
to mental health of the target person, the duration of the event, and the number of times
it happened. The intensity of each life event is calculated by the impact multiplied by the
duration and then by the number of times it happened. The total score of negative life
events is the sum of all the scores of negative life events, with higher score indicating more
negative life events. The Chinese version of LESE has been used in a previous psychological
autopsy study in China and showed satisfactory reliability and validity (Mo et al., 2019).

Zhou et al. (2021), PeerJ, DOI 10.7717/peerj.11801 4/13

 Duke social support index
Social support was measured using the Duke Social Support Index (DSSI). It is a 23-item
scale designed to assess multiple dimensions of social support in the last week before
death/investigation. The total score ranges from 11 to 45, with a higher score indicating
higher social support. The Chinese version of DSSI has been used in a previous psychological
autopsy study in China and showed satisfactory reliability and validity (Pan et al., 2020).

Suicide intent scale

The Suicide Intent Scale (SIS) was used to measure factual aspects of the suicide sttempt,
which included the attempters’ precautions, planning, communication, and expectations
about the suicide behavior (Beck & Lester, 1976). The Chinese version of SIS has been used
in a previous psychological autopsy study in China and showed satisfactory reliability and
validity (Ma et al., 2020; Zhang & Jia, 2007).

Features of suicide behavior and history of suicide attempts

Information on the time, place, and method of suicide in the case group were collected.
The data obtained included the number of suicide attempts and the timeframe and method
of the most recent suicide attempt.

Statistical analysis
The data were analyzed by using SPSS 19.0 software package. Comparisons of parametric
data for the two groups were performed using one-way blocked analysis of variance and
chi-squared test. The Wilcoxon signed-rank test was used for nonparametric data in the
two groups.
Conditioned multivariable logistic regression was used to determine the risk factors of
suicide. Conditional logistic regression is a specialized type of logistic regression used when
case subjects with a particular condition are each matched with n control subjects without
the condition and has become a standard for matched case-control data. In this study, we
adopted a 1:1 matched case-control study design matching on age, gender and residence.
In this conditioned multivariable logistic regression, the dependent variable was suicide
(case =1, control =0), and the independent variable was impulsivity, while controlling for
the following covariates: marital status, being left behind, social support, education, family
annual income, and total stimulation of negative life. Physical diseases were not included
in the regression because the total stimulation of negative life had included the effect of
physical diseases. The adjusted OR and a 95% CI were used to assess the association between
the risk factors and suicide. Finally, p < 0.05 was considered statistically significant.

RESULTS
Comparison of socio-demographic and psycho-social characteristics
between suicides and living controls
Table 1 shows a comparison of socio-demographic and psycho-social characteristics
between 242 pair of matched suicides and living controls. Compared to the control group,
the suicide group were more likely to be not currently married (49.6% vs. 29.8%, p < 0.001),
unemployed (80.6% vs. 69.8%, p = 0.021), being left behind (16.9% vs. 10.3%, p = 0.034),

Zhou et al. (2021), PeerJ, DOI 10.7717/peerj.11801 5/13

 Table 1 Summary information of suicides and living controls.

Variables Suicides Living controls χ2 /F/z p

N 242 242 – –
Gender – –
Male 135(55.8) 135(55.8)
Female 107(44.2) 107(44.2)
Age (years) 1.12 0.569
60–69 73(30.2) 70(28.9)
70–79 100(41.3) 111(45.9)
≥80 69(28.5) 61(25.2)
Education 1.92 0.383
Below primary school 111(45.9) 96(39.7)
Primary school 105(43.4) 116(47.9)
Above primary school 26(10.7) 30(12.4)
Marital status 19.89 <0.001
Currently marrieda 122(50.4) 170(70.2)
Not currently marriedb 120(49.6) 72(29.8)
Employment 7.84 0.020
Employed 40(16.5) 59(24.4)
Unemployed 195(80.6) 169(69.8)
Retired 7(2.9) 14(5.8)
Family annual income 1.87 0.394
(CNYc )
<3600 88(36.4) 74(30.6)
3600–9999 88(36.4) 98(40.5)
≥10000 66(27.3) 70(28.9)
Being left-behind 4.49 0.034
Yes 41(16.9) 25(10.3)
No 201(83.1) 217(89.7)
Physical diseases 18.52 <0.001
Yes 202(83.5) 161(66.5)
No 40(16.5) 81(33.5)
Total scores of negative life events 49.76 ± 30.19 25.24 ± 28.46 79.95 <0.001
Social support ( mean ±SD ) 22.88 ± 5.98 27.47 ± 6.81 78.20 <0.001
d
BIS score 98.79 ± 16.63 86.91 ± 15.18 78.99 <0.001
Nonplanning impulsivity 35.18 ± 7.24 31.07 ± 7.07 45.34 <0.001
Motor impulsivity 28.43 ± 8.28 23.70 ± 6.05 50.91 <0.001
Attentional impulsivity 35.18 ± 5.95 32.13 ± 5.67 41.35 <0.001
Notes.
a
Included married and living with spouse or cohabiting.
b
Included single, divorced, widowed and married but living apart.
c
CNY, Chinese Yuan.
d
BIS: Barratt Impulsiveness Scale.

and having physical diseases (83.5% vs. 66.5%, p < 0.001). The suicide group had higher
score in negative life events (49.76 ± 30.19 vs 25.24 ± 28.46, p < 0.001) and lower score in
social support (22.88 ± 5.98 vs 27.47 ± 6.81, p < 0.001) than living controls. The suicide

Zhou et al. (2021), PeerJ, DOI 10.7717/peerj.11801 6/13

 Table 2 Comparisons of suicide behaviors by high and low impulsivity group.

Variables High impulsivitya Low impulsivity χ2 /t/z p

Suicides 120 (49.6) 122 (50.4) – –
Suicide time 0.71 0.447
6:00–17:59 95 (79.2) 91 (74.6)
18:00–5:59 25 (20.8) 31 (25.4)
Suicide place 0.19 0.700
Home 104 (86.7) 108 (88.5)
Others 16 (13.3) 14 (11.5)
Suicide means 1.199 0.945
Pesticides 63 (52.5) 62 (50.8)
Hanging 45 (37.5) 50 (41.0)
Drowning 5 (4.2) 4 (3.3)
Non-pesticides poisoning 5 (4.2) 3(2.5)
Jumping off a building 1(0.8) 2(1.6)
Cutting throat 1(0.8) 1(0.8)
History of attempted suicide 8.24 0.005
Yes 31(25.8) 14(11.5)
No 89(74.2) 108(88.5)
Suicide intent 4.93 ± 2.58 4.85 ± 2.41 −0.23 0.821
Notes.
a
High impulsivity was defined by BIS score above the median.

group also showed higher scores in overall BIS scores (98.79 ± 16.63 vs. 86.91 ± 15.18,
p < 0.001), as well as its three sub-scales (all p values < 0.001).

Comparison of suicidal behaviors between high and low impulsive

suicides
Suicide cases were dichotomized into two groups, higher impulsivity and lower impulsivity
group, based on the median of BIS scores. Characteristics of suicide behavior in these
two groups were compared (Table 2). The proportion of previous suicide attempt was
significantly higher in the higher impulsivity group than that in the lower impulsivity
group (25.8% vs. 11.5%, p = 0.005), while no significant differences were found in time,
location, or means of suicide, or suicide intent between the high and low impulsivity
group.

Multivariate logistic regression on risk factors of suicide

Multivariate logistic regression was used to determine the risk factor of suicide (Table 3).
Independent variables included in the regression were marital status, being left-behind,
income, years of school education, impulsivity, social support, and life events. Four variables
entered the final model: impulsivity (OR: 1.03, 95% CI [1.01-1.06]), marital status (OR:
2.26, 95% CI [1.04–4.92]), social support (OR: 0.93, 95% CI [0.88–0.99]), and life events
(OR: 1.02, 95% CI [1.01–1.03]). We also run additional regressions with each subscales of
impulsivity as independent variable and found only motor impulsivity was independently
associated with suicide in the final model (OR:1.08, 95% CI [1.03–1.13]).

Zhou et al. (2021), PeerJ, DOI 10.7717/peerj.11801 7/13

 Table 3 Risk factors of suicide among rural elderly in China.

Independent variables OR (95% CI) p

Impulsivity 1.03 (1.01–1.06) 0.015
Marital status
Currently married 1(ref)
Not Currently married 2.26 (1.04–4.92) 0.039
Being left-behind
No 1(ref)
Yes 0.63 (0.22–1.83) 0.392
Social support 0.93 (0.88–0.99) 0.023
Education
Below primary school 1(ref)
Primary school 1.58 (0.43–5.86) 0.491
Above primary school 0.72 (0.24–2.11) 0.547
Family annual income
(CNYa )
<3600 1(ref)
3600–9999 0.59 (0.24–1.43) 0.241
≥10000 0.51 (0.21–1.25) 0.143
Total scores of negative life events 1.02 (1.01–1.03) 0.001
Notes.
a
CNY, Chinese Yuan.

DISCUSSION
In the present study, we found that the suicide group had significantly higher scores in the
total and three sub-scale scores of impulsivity than the control group. Within the suicide
group, those with higher impulsivity were more likely to have a history of previous suicide
attempt than those with lower impulsivity. Conditioned multivariable logistic regression
showed that impulsivity was independently associated with suicide, after controlling for
socio-demographic characteristics, social support, and life events.
Our major finding was that impulsivity was an independent risk factor for suicide among
rural older adults in China. This finding was consistent with most studies conducted
among youth in both urban and rural areas, and in China and abroad (Florez et al.,
2019; Swahn et al., 2012; Zhang et al., 2011). Zhang et al. (2011) investigated suicide among
rural youth from three provinces using case–control psychological autopsy method and
found dysfunctional impulsivity as a risk factor for suicide. When compared with other
studies conducted among rural elderly, our finding was in line with some studies while
contrasted with others. Neufeld & O’Rourke (2009) examined impulsivity and hopelessness
in predicting suicide-related ideation among older adults and found impulsivity played a
stronger impact than hopelessness. However, in Liu et al.’s (Liu, Qin & Jia, 2018) research
on comparing suicide risk factors between elderly suicides and non-elderly suicides, they
found impulsivity as a risk factor for suicide in non-elderly, but not the elderly. While it has
been widely recognized that impulsivity is a common feature of youth suicide, impulsivity
in elderly suicide is more controversial and needs further research attention to understand

Zhou et al. (2021), PeerJ, DOI 10.7717/peerj.11801 8/13

 the underlying mechanism (Demircin et al., 2011). In general, our study finding indicates
future development of suicide prevention programs among rural elderly need to pay
attention to their impulsivity level, and provide timely assessment and effective treatment
to reduce their risk of suicide.
This study compared suicidal behavior feature between higher impulsivity and lower
impulsivity group. Impulsivity is associated with the history of attempted suicide, which
is consistent with the finding of previous studies. Studies have showed that impulsive
people are likely to attempt suicide repeatedly (Mann et al., 1999) and that people with
repeated suicide attempts are more impulsive than those with first-time suicide attempts
(Dougherty et al., 2004). A psychological autopsy study in youth suicides in China shows
that the more impulsive population is prone to commit suicide through pesticide (Zhang
& Li, 2013). This finding suggests past history of suicide as a risk factor for impulsivity,
which may increase future risk of suicide. In future suicide prevention programs, more
caution needs to be paid to individuals who had a past history of suicide attempt, with
necessary screening of impulsivity and suicide risk conducted to these individuals and more
psycho-social support provided to them. However, we do not find significant difference
between the suicide means used by suicides with high and low impulsivity, with pesticides
suicide being the most commonly means for both groups. The patterns of suicide methods
in our study were in keeping with that in Liu et al.’s study on both elderly and non-elderly
suicide (Liu, Qin & Jia, 2018). This finding suggests that easy access to pesticides in rural
areas may be a potential facilitator for elderly suicide, regardless their impulsivity level.
One implication may be that controlling suicide means such as limiting the purchase of
lethal pesticides may serve as an effective preventive strategy for suicide.
Aside from impulsivity, our study also demonstrated other important risk factors related
to suicide, such as low social support, not being currently married status, and experiencing
more negative life events. This finding was in accordance with most of the previous studies
showing poorer living conditions of the rural elderly such as living alone, lower social
support and negative life events may aggravate their risk of suicide (Liu, Qin & Jia, 2018).
The elderly, especially those who are not married, usually have few social network and
receive little social support, which makes them more vulnerable to negative life events and
more easily to take extreme risk behaviors such as suicide. It turns out that an abnormal
psychological status and the instability of emotion and actions are responsible for the
tendency to extreme behavior including suicide. All these findings indicate that suicide is
not only the consequence of impulse ridden personality, but also be affected by complicated
interaction of various risk factors (Paris, 2005). Implications of this finding include more
social support, more psycho-education need to be provided to rural elderly to improve
their psychosocial well-being, especially among those who had experienced significant
negative life events.
In interpreting results of the present study, two major limitations should be noted. First,
psychological autopsy is a retrospective method that relies on interviews with third-party
informants, which has certain shortcomings such as sampling bias, recall bias, external
confounders, and lack of standard procedure, and thus may lead to inaccurate assessment
and unreliable conclusions (Pouliot & De Leo, 2006). However, psychological autopsy has

Zhou et al. (2021), PeerJ, DOI 10.7717/peerj.11801 9/13

 been in use for over 30 years as a prime approach in identifying risk factors for suicide
and is the best available method so far. Besides, we used a case-control study design to
collect the data from both the case and control groups using the same method, which may
minimize the risks of external confounders. Future research may benefit from combining
psychological autopsy with qualitative approaches and interviewing as many proxies of the
suicides as possible to further strengthen its reliability and validity (Hjelmeland et al., 2012).
Second, in examining risk factors of suicide, we didn’t include some other well-known
factors such as mental illness and prior suicide attempt. Although mental illness, especially
mood disorder, has been identified as a most prominent predictor for suicide in western
world, studies in Asian countries such as China showed different patterns where suicides
without a diagnosis of mental illness were more common (Milner, Sveticic & De Leo, 2013).
Future research that includes assessment on mental illness diagnosis in Chinese rural
elderly suicide population and comparison with other countries is warranted to test such
a difference. For previous suicide attempt, we found only a few cases of previous suicide
attempt in living controls, which may result in low power of hypothesis testing if included
in the multivariate analysis. Future research with larger sample size is needed to examine
the association between precious suicide attempt and suicide death with more power.

CONCLUSIONS
In conclusion, our finding showed that impulsivity was a significant independent risk factor
of suicide among rural elderly in China, which warrants future research to further test such
association and examine its underlying mechanism. Future suicide intervention programs
may consider adding impulsivity assessment into its routine risk evaluation and treat high
risk population in time and properly. In addition, social support may be provided to the
elderly, especially those who experienced significant negative life events, to improve their
psycho-social well-being and prevent suicide.

ADDITIONAL INFORMATION AND DECLARATIONS

Funding
The authors received no funding for this work.

Competing Interests
The authors declare there are no competing interests.

Author Contributions
• Yunfang Zhou performed the experiments, analyzed the data, prepared figures and/or
tables, and approved the final draft.
• Zhenyu Ma and Cun-Xian Jia performed the experiments, authored or reviewed drafts
of the paper, and approved the final draft.
• Liang Zhou conceived and designed the experiments, authored or reviewed drafts of the
paper, and approved the final draft.

Zhou et al. (2021), PeerJ, DOI 10.7717/peerj.11801 10/13

 Human Ethics
The following information was supplied relating to ethical approvals (i.e., approving body
and any reference numbers):
Xiangya School of Public Health, Central South University granted Ethical approval to
carry out the study within its facilities (Ethical Application Ref: CTXY-130041-1).

Data Availability
The following information was supplied regarding data availability:
Raw data are available as a Supplemental File.

Supplemental Information
Supplemental information for this article can be found online at http://dx.doi.org/10.7717/
peerj.11801#supplemental-information.

REFERENCES
Anestis MD, Soberay KA, Gutierrez PM, Hernandez TD, Joiner TE. 2014. Reconsid-
ering the link between impulsivity and suicidal behavior. Personality and Social
Psychology Review 18:366–386 DOI 10.1177/1088868314535988.
Bakhshani NM. 2014. Impulsivity: a predisposition toward risky behaviors. International
Journal of High Risk Behaviors and Addiction 3:e20428.
Beach VL, Gissandaner TD, Schmidt AT. 2021. The UPPS model of impulsivity and
suicide: a systematic literature review. Archives of Suicide Research 1–22 Epub ahead
of print Mar 2 2021.
Beck AT, Lester D. 1976. Components of suicidal intent in completed and attempted
suicides. Journal of Psychology 92:35–38 DOI 10.1080/00223980.1976.9921330.
Demircin S, Akkoyun M, Yilmaz R, Gokdogan MR. 2011. Suicide of elderly persons:
towards a framework for prevention. Geriatrics & Gerontology International
11:107–113 DOI 10.1111/j.1447-0594.2010.00660.x.
Dong X, Chang ES, Zeng P, Simon MA. 2015. Suicide in the global chinese aging
population: a review of risk and protective factors, consequences, and interventions.
Aging and Disease 6:121–130 DOI 10.14336/AD.2014.0223.
Dougherty DM, Mathias CW, Marsh DM, Papageorgiou TD, Swann AC, Moeller FG.
2004. Laboratory measured behavioral impulsivity relates to suicide attempt history.
Suicide and Life-Threatening Behavior 34:374–385 DOI 10.1521/suli.34.4.374.53738.
Florez IA, Au J, Morrisette N, Lamis DA. 2019. Risk factors for suicide attempts among
rural youth with a history of suicidal ideation. Death Stud 3:1–7.
Gvion Y, Apter A. 2011. Aggression, impulsivity, and suicide behavior: a review of the lit-
erature. Archives of Suicide Research 15:93–112 DOI 10.1080/13811118.2011.565265.
Hjelmeland H, Dieserud G, Dyregrov K, Knizek BL, Leenaars AA. 2012. Psychological
autopsy studies as diagnostic tools: are they methodologically flawed? Death Studies
36:605–626 DOI 10.1080/07481187.2011.584015.

Zhou et al. (2021), PeerJ, DOI 10.7717/peerj.11801 11/13

 Klonsky ED, May AM. 2015. Impulsivity and suicide risk: review and clinical impli-
cations. 32, (8) p. 13. Gale Academic OneFile. Psychiatric Times. (accessed on 14
March 2021).
Li M, Katikireddi SV. 2019. Urban-rural inequalities in suicide among elderly people
in China: a systematic review and meta-analysis. International Journal for Equity in
Health 18:2 DOI 10.1186/s12939-018-0881-2.
Li X, Xiao Z, Xiao S. 2009. Suicide among the elderly in mainland China. Psychogeriatrics
9:62–66 DOI 10.1111/j.1479-8301.2009.00269.x.
Liu BP, Qin P, Jia CX. 2018. Behavior characteristics and risk factors for suicide among
the elderly in rural China. Journal of Nervous and Mental Disease 206:195–201
DOI 10.1097/NMD.0000000000000728.
Lu CF, Jia CX, Xu AQ, Dai AY, Qin P. 2012. Psychometric characteristics of Chinese
version of Barratt Impulsiveness Scale-11 in suicides and living controls of rural
China. Omega 66:215–229.
Ma Z, He Q, Nie G, Jia C, Zhou L. 2020. Reliability and validity of short Beck Hopeless-
ness Scale in psychological autopsy study among Chinese rural elderly. International
Psychogeriatrics 32:525–531 DOI 10.1017/S1041610219001315.
Mann JJ, Waternaux C, Haas GL, Malone KM. 1999. Toward a clinical model of suicidal
behavior in psychiatric patients. American Journal of Psychiatry 156:181–189.
McHugh CM, Lee RSChun, Hermens DF, Corderoy A, Large M, Hickie IB. 2019.
Impulsivity in the self-harm and suicidal behavior of young people: A sys-
tematic review and meta-analysis. Journal of Psychiatric Research 116:51–60
DOI 10.1016/j.jpsychires.2019.05.012.
Milner A, Sveticic J, De Leo D. 2013. Suicide in the absence of mental disorder? A review
of psychological autopsy studies across countries. International Journal of Social
Psychiatry 59:545–554 DOI 10.1177/0020764012444259.
Mo Q, Zhou L, He Q, Jia C, Ma Z. 2019. Validating the life events scale for the elderly
with proxy-based data: a case-control psychological autopsy study in rural China.
Geriatrics & Gerontology International 19:547–551 DOI 10.1111/ggi.13658.
Moeller FG, Barratt ES, Dougherty DM, Schmitz JM, Swann AC. 2001. Psychi-
atric aspects of impulsivity. American Journal of Psychiatry 158:1783–1793
DOI 10.1176/appi.ajp.158.11.1783.
Neufeld E, O’Rourke N. 2009. Impulsivity and hopelessness as predictors of suicide-
related ideation among older adults. Canadian Journal of Psychiatry. Revue Canadi-
enne de Psychiatrie 54:684–692.
Pan YF, Ma ZY, Zhou L, Jia CX. 2020. Psychometric characteristics of duke so-
cial support index among elderly suicide in rural China. Omega 82:105–119
DOI 10.1177/0030222818805356.
Paris J. 2005. The development of impulsivity and suicidality in borderline personality
disorder. Development and Psychopathology 17:1091–1104.
Patton JH, Stanford MS, Barratt ES. 1995. Factor structure of the Barratt impulsiveness
scale. Journal of Clinical Psychology 51:768–774
DOI 10.1002/1097-4679(199511)51:6<768::AID-JCLP2270510607>3.0.CO;2-1.

Zhou et al. (2021), PeerJ, DOI 10.7717/peerj.11801 12/13

 Pouliot L, De Leo D. 2006. Critical issues in psychological autopsy studies. Suicide Life
Threat Behav 36:491–510 DOI 10.1521/suli.2006.36.5.491.
Sha F, Yip PSF, Law YW. 2017. Decomposing change in China’s suicide rate, 1990-2010:
ageing and urbanisation. Injury Prevention Journal of the International Society for
Child & Adolescent Injury Prevention 23:injuryprev2016-042006.
Smith AR, Witte TK, Teale NE, King SL, Bender TW, Joiner TE. 2008. Revisiting
impulsivity in suicide: implications for civil liability of third parties. Behavioral
Sciences and the Law 26:779–797 DOI 10.1002/bsl.848.
Swahn MH, Ali B, Bossarte RM, Van Dulmen M, Crosby A, Jones AC, Schinka KC.
2012. Self-harm and suicide attempts among high-risk, urban youth in the U.S.:
shared and unique risk and protective factors. nternational Journal of Environmental
Research and Public Health 9:178–191 DOI 10.3390/ijerph9010178.
Turecki G, Brent DA, Gunnell D, O’Connor RC, Oquendo MA, Pirkis J, Stan-
ley BH. 2019. Suicide and suicide risk. Nature Reviews Disease Primers 5:74
DOI 10.1038/s41572-019-0121-0.
Wang CW, Chan CL, Yip PS. 2014. Suicide rates in China from 2002 to 2011: an update.
Soc Psychiatry Psychiatr Epidemiol 49:929–941 DOI 10.1007/s00127-013-0789-5.
WHO. 2019. World Health Organization. (2019). Mental health. Available at https:
// www.who.int/ gho/ mental_health/ en/ .
Zhang J, Jia CX. 2007. Validating a short version of the Suicide Intent Scale in China.
Omega 55:255–265 DOI 10.2190/OM.55.4.a.
Zhang J, Li Z. 2013. Characteristics of Chinese rural young suicides by pesticides. Inter-
national Journal of Social Psychiatry 59:655–662 DOI 10.1177/0020764012450995.
Zhang J, Li N, Tu XM, Xiao S, Jia C. 2011. Risk factors for rural young suicide
in China: a case-control study. Journal of Affective Disorders 129:244–251
DOI 10.1016/j.jad.2010.09.008.
Zhou L, Wang GJ, Jia CX, Ma ZY. 2019. Being left-behind, mental disorder, and elderly
suicide in rural China: a case-control psychological autopsy study. Psychological
Medicine 49:458–464 DOI 10.1017/S003329171800106X.

Zhou et al. (2021), PeerJ, DOI 10.7717/peerj.11801 13/13