title: "I just couldn't step out of the circle. I was trapped": Patterns of endurance and distress in Chinese-Canadian women with a history of suicidal behaviour.
abstract: Recent studies have highlighted higher rates of suicidal ideation and behaviour and associated themes of gender role stress in Chinese women residing in North America. However, qualitative studies, which privilege their voices in the discourse of suicide prevention and provide insight into their experiences, are lacking.
  
  
  
  To gain an understanding of the life histories, patterns of distress and constructions of suicide of Chinese-Canadian women with a history of suicidal behaviour.
  
  
  
  Ten women were recruited from four mental health programs in Toronto, Canada and participated in qualitative interviewing and analysis informed by constructivist grounded theory.
  
  
  
  Chinese-Canadian women describe experiencing "stress" or "pressure" leading to the exacerbation of depressive symptoms. Stress and pressure are managed through a coping strategy of endurance, informed by the cultural conception of "ren". Cultural influences contribute to the manifestation of stress and pressure as somatic symptoms and sleeplessness. Finally, the women describe feeling unable to endure through worsening distress, reaching a "breaking point"; suicidal behaviour is constructed as a strategy to disrupt this cycle.
  
  
  
  This study challenges the binary notion that suicidal behaviour is either a consequence of mental illness or a reaction to interpersonal stress. Rather, the women describe an ingrained pattern of enduring through psychosocial problems without acknowledging worsening anxiety, depressive and physical symptoms. The pattern of endurance also prevents early treatment of these difficulties, resulting in the intensification of symptoms until a breaking point is reached. Knowledge of these patterns and coping strategies can allow for earlier identification and intervention for women at risk to prevent the worsening of distress leading to suicidal thoughts and behaviour.
authors.affiliation: Health Outcomes and Performance Evaluation (HOPE) Research Unit, Social and Epidemiological Research (SER) Program, Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario M5T 1R8, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada. Electronic address: juveria.zaheer@camh.ca.
authors.forename: Juveria
authors.initials: J
authors.lastname: Zaheer
authors.affiliation: Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor St W, Toronto, Ontario M5S 1V4, Canada. Electronic address: wes.shera@utoronto.ca.
authors.forename: Wes
authors.initials: W
authors.lastname: Shera
authors.affiliation: Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor St W, Toronto, Ontario M5S 1V4, Canada. Electronic address: k.tsang@utoronto.ca.
authors.forename: A Ka Tat
authors.initials: AK
authors.lastname: Tsang
authors.affiliation: St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada. Electronic address: laws@smh.ca.
authors.forename: Samuel
authors.initials: S
authors.lastname: Law
authors.affiliation: North York General Hospital, 555 Finch Avenue West, Toronto, Ontario M2R 1N5, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada. Electronic address: alan.fung.a@utoronto.ca.
authors.forename: Wai Lun Alan
authors.initials: WL
authors.lastname: Fung
authors.affiliation: Lawson Health Research Institute, Schulich School of Medicine and Dentistry, Western University, 750 Base Line Road East, Suite 300, London, Ontario N6C 2R5, Canada. Electronic address: rahel.eynan@lhsc.on.ca.
authors.forename: Rahel
authors.initials: R
authors.lastname: Eynan
authors.affiliation: Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada. Electronic address: june.sh.lam@gmail.com.
authors.forename: June
authors.initials: J
authors.lastname: Lam
authors.affiliation: Department of Psychiatry, Yuquan Hospital, Tsinghua University, 5 Shijingshan Rd., Beijing 100049, China. Electronic address: xiaoqian1211@163.com.
authors.forename: Xiaoqian
authors.initials: X
authors.lastname: Zheng
authors.affiliation: Department of Psychiatry, Yuquan Hospital, Tsinghua University, 5 Shijingshan Rd., Beijing 100049, China. Electronic address: liupozi@tsinghua.edu.cn.
authors.forename: Liu
authors.initials: L
authors.lastname: Pozi
authors.affiliation: Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London Health Sciences Centre LHSC, Victoria Hospital, Room B8-132, London, Ontario N6A 4H1, China. Electronic address: paul.links@lhsc.on.ca.
authors.forename: Paul S
authors.initials: PS
authors.lastname: Links
mesh_terms: D000223:Adaptation, Psychological; D000328:Adult; D044466:Asian People / Q000208:ethnology / Q000523:psychology; D002170:Canada / Q000208:ethnology; D003863:Depression / Q000150:complications / Q000208:ethnology / Q000523:psychology; D054242:Emigrants and Immigrants / Q000523:psychology; D005260:Female; D005783:Gender Identity; D006801:Humans; D008875:Middle Aged; D036301:Qualitative Research; D012307:Risk Factors; D013315:Stress, Psychological / Q000150:complications / Q000208:ethnology / Q000523:psychology; D013405:Suicide / Q000208:ethnology / Q000523:psychology*
keywords: Canada; Culture; Gender; Mental health; Qualitative; Suicide