title: The impact of improving suicide death classification in South Korea: a comparison with Japan and Hong Kong.
abstract: BACKGROUND
  The suicide rate of South Korea has increased dramatically during the past decades, as opposed to steadily decreasing trends in Japan and Hong Kong. Although the recent increase of suicide in South Korea may be related to changing socioeconomic conditions and other contextual factors, it may also reflect, in part, a reduction of misidentified suicide cases due to improving classification of manner of death.
  
  
  METHODS
  We compared the annual proportional change of suicide, undetermined death, and accidental death from South Korea with those of Japan and Hong Kong from 1992 to 2011; a greater proportional change of the manner-of-death categories during the period is indicative of a relatively less stable registration and hence a greater potential for misclassification bias on reported suicide trends. Subgroup analyses stratifying the deaths by methods were also conducted. To estimate the impact, the age-standardized rates of these three death categories in each site were calculated.
  
  
  RESULTS
  We found that, during the 20-year observation period, the proportional change of suicide, undetermined death, and accidental death in South Korea was significantly greater than Japan and Hong Kong. Similar observations were made in subgroup analyses. While death rates of the three manners in Japan and Hong Kong generally moved in a parallel fashion, the increase of suicide in South Korea occurred concomitantly with a significant reduction of its accidental death rate. 43% of the increase in suicides could be attributed to the decrease in accidental deaths, while 57% of the increase could be due to fundamental causes.
  
  
  CONCLUSIONS
  Our data suggest that, during the mid-1990s and after, the increasing burden of suicide in South Korea initially was masked, in part, by misclassification. Thus, the later apparently rapid increase of suicides reflected steadily improving classification of manner of death, as well as a more fundamental increase in the suicide rate.
authors.affiliation: Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong Special Administrative Region, China; The Hong Kong Jockey Club Centre for Suicide Research and Prevention, The University of Hong Kong, Hong Kong Special Administrative Region, China.
authors.forename: Chee Hon
authors.initials: CH
authors.lastname: Chan
authors.affiliation: The Injury Control Research Center for Suicide Prevention, Department of Psychiatry, University of Rochester Medical Center, Rochester, United States of America.
authors.forename: Eric D
authors.initials: ED
authors.lastname: Caine
authors.affiliation: Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong Special Administrative Region, China; The Hong Kong Jockey Club Centre for Suicide Research and Prevention, The University of Hong Kong, Hong Kong Special Administrative Region, China; Institute of Health Policy and Management, and Department of Public Health, College of Public Health, National Taiwan University, Taipei, Taiwan.
authors.forename: Shu Sen
authors.initials: SS
authors.lastname: Chang
authors.affiliation: Department of Preventive Medicine, Korea University College of Medicine, Korea University, Seoul, South Korea.
authors.forename: Won Jin
authors.initials: WJ
authors.lastname: Lee
authors.affiliation: Department of Preventive Medicine, Korea University College of Medicine, Korea University, Seoul, South Korea.
authors.forename: Eun Shil
authors.initials: ES
authors.lastname: Cha
authors.affiliation: Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong Special Administrative Region, China; The Hong Kong Jockey Club Centre for Suicide Research and Prevention, The University of Hong Kong, Hong Kong Special Administrative Region, China.
authors.forename: Paul Siu Fai
authors.initials: PS
authors.lastname: Yip
mesh_terms: D003643:Death; D006723:Hong Kong; D006801:Humans; D007564:Japan; D009026:Mortality / Q000639:trends; D056910:Republic of Korea; D012959:Socioeconomic Factors; D013405:Suicide / Q000639:trends*