Published online Jun 16, 2023.
https://doi.org/10.3346/jkms.2023.38.e218
A Three-Year Longitudinal Study of Risk Factors for Suicidality in North Korean Defectors
Abstract
Background
This longitudinal study examined risk factors for future suicidality among North Korean defectors (NKDs) living in South Korea.
Methods
The subjects were 300 NKDs registered with a regional adaptation center (the Hana Center) in South Korea. Face-to-face interviews were conducted using the North Korean version of the World Health Organization’s Composite International Diagnostic Interview to diagnose mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Subjects were also asked about sociodemographic and clinical factors at baseline. At follow-up after three years, the NKDs (n = 172 respondents) were asked to participate in an online survey, responding to self-questionnaires about suicidality. Logistic regression analyses were used to explore associations between baseline variables and future suicidality among NKDs.
Results
Thirty (17.4%) of the 172 survey respondents reported suicidality at follow-up. The presence of health problems over the past year, any prior suicidality at baseline, a higher score on a trauma-related scale, and a lower score on a resilience scale at baseline were associated with greater odds of suicidality at follow-up after adjusting for age, sex, and educational level. Of all mental disorder categories, major depressive disorder, dysthymia, agoraphobia, and social phobia were also associated with significantly increased odds of suicidality at follow-up after adjusting for age, sex, educational level, and prior suicidality at baseline.
Conclusion
Resilience, a previous history of suicidality, and the presence of lifetime depressive disorder and anxiety disorder should be given consideration in mental health support and suicide prevention in NKDs.
Graphical Abstract
INTRODUCTION
The number of persons defecting from North Korea has increased considerably since the late 90s, and as of 2019, the total number of North Korean defectors (NKDs) residing in South Korea is estimated at about 33,523.1 Like other refugees, NKDs are often exposed to psychological trauma over the course of their residence in North Korea and during their escape.2 Even after they have settled in South Korea, NKDs often experience high levels of acculturative stress in adapting to an unfamiliar culture.3 Given this series of stressful events, NKDs are highly vulnerable to mental health problems.
A number of studies report that NKDs exhibit high prevalence and severity of psychiatric symptoms such as depression, anxiety, and somatization. Prevalence of major psychiatric disorders including major depressive disorder and posttraumatic stress disorder (PTSD) in NKDs is much higher than in the general Korean population.4, 5, 6 Suicidality rates among NKDs have been reported as being higher than those of the general South Korean population; in one study, 31.3% experienced lifetime suicidal ideation, suicidal plan, or suicide attempt.7 According to the 2019 NKDs’ social survey8 conducted by the Korea Hana Foundation, 12.4% of respondents reported suicidal ideation over the past year, this rate more than double that of South Koreans (5.1%).9 Previous studies of other refugees have also reported higher prevalence of suicidal thoughts and behaviors among refugees than in the general population.10, 11, 12 Considering the high rate of suicidal ideation among NKDs, addressing post-defection adjustment problems, including suicidality, is a priority.
A previous study of suicidal ideation among youth NKDs reported that lower levels of familial cohesion and higher levels of emotional suppression were associated with suicidal ideation.13 However, this study was limited to subjects aged 13 to 27 years and did not investigate the relationship between suicidal thoughts and mental disorders. Our previous cross-sectional study of suicidality among NKDs investigated factors related to lifetime suicidal thoughts and behaviors,7 finding that female sex; the presence of health problems in the past year; and the presence of mental disorders including agoraphobia listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) were associated with greater odds of lifetime suicidal thoughts and behaviors. However, to the best of our knowledge, no prior studies have investigated future suicidality among NKDs living in South Korea and the wide range of factors contributing to such.
The purpose of this longitudinal study was therefore to examine associations of previously recorded sociodemographic characteristics, clinical factors (e.g., depressive symptoms, resilience, trauma-related symptoms, and loneliness) and mental disorders with future suicidality among NKDs in South Korea.
METHODS
Subjects and study design
This prospective cohort study included a total of 300 NKDs selected from eight regional resettlement centers (Hana Center) across the country. The subjects were all eligible residents aged 18 to 70 years who had arrived in South Korea within the last three years before the first assessment. All subjects who voluntarily agreed to participate in the research were fully informed about the purpose and research procedure in advance.
The first assessments were conducted through face-to-face interviews between June and October 2016. The interviewers included psychology, nursing, and social work graduate students in mental health-related departments who had received training in World Health Organization—recommended Composite International Diagnostic Interview (CIDI) administration. Subjects were also asked to complete questionnaires including sociodemographic variables and self-rating scales for clinical factors at the baseline interview.
Follow-up evaluations were conducted through an online survey three years later. Of the original 300 subjects, 172 NKDs responded to a questionnaire on suicidality at follow-up. Each subject’s data were collected using an anonymized identification number to protect personal information.
Measures
Assessment of lifetime DSM-IV disorders
This study administered the North Korean version of the CIDI version 2.1 (NK-CIDI 2.1) to each participant to assess lifetime DSM-IV disorders at the baseline interview. The CIDI (World Health Organization, 1990) is a fully structured diagnostic interview designed to confirm psychiatric diagnoses using the definitions and criteria of the DSM-IV.14 The NK-CIDI tool was developed by Lee et al.,15 who modified the Korean language version of CIDI to suit the North Korean sociocultural background. Satisfactory reliability and validity of the new NK-CIDI 2.1 tool was confirmed among NKDs. Lifetime DSM-IV disorders included major depressive disorder, dysthymia, PTSD, generalized anxiety disorder, panic disorder, agoraphobia, social phobia, specific phobia, alcohol use disorder (both alcohol dependence and abuse), and nicotine use disorder.
Assessment of suicidality (suicidal thoughts and behaviors)
The NK-CIDI module on suicide was used to assess lifetime suicidality at the baseline interview. The presence of suicidality was defined on a lifetime basis, with subjects answering “yes” to at least one of three questions: “Have you ever seriously thought of dying by suicide?” “Have you ever made a plan for suicide?” or “Have you ever attempted suicide?” classified as having suicidality. During the three-year follow-up assessment, subjects were asked the three following questions and those who answered “yes” to at least were regarded as having experienced suicidality over the past year: “Have you ever seriously thought of dying by suicide in the past year?” “Have you ever made a plan for suicide in the past year?” and “Have you ever attempted suicide in the past year?”
Assessment of psychiatric clinical factors
In addition to being asked about basic sociodemographic variables, subjects were also asked about their mental health status including depressive symptoms, trauma-related symptoms, loneliness, and resilience at the baseline interview. Depressive symptoms were assessed with the 20-item North Korean version of the Center for Epidemiological Studies–Depression Scale (CES-D-NK), which has previously been validated with Cronbach’s alpha coefficients 0.91 for male and 0.93 for female.16 The CES-D total score ranges from zero to 60 points, with higher scores indicating greater depressive symptoms. Trauma-related symptoms were assessed with the 22-item Impact of Event Scale Revised–North Korea Scale (IES-R-NK), with a total score that ranges from zero to 88 points. The IES-R-NK has previously been validated (Cronbach’s alpha coefficients 0.95 for male and 0.94 for female).17 Also, we measured loneliness at baseline evaluation with the 10-item University of California, Los Angeles (UCLA) loneliness scale (Cronbach’s alpha coefficients 0.93).18 Subjects were asked to rate how often they felt the way described by the items on a scale ranging from one (never) to four (often) points, with higher scores reflecting greater loneliness. Finally, the 25-item Connor–Davidson Resilience Scale (CD-RISC) was administered to assess resilience.19, 20 The CD-RISC is a reliable and valid instrument for measuring resilience (Cronbach’s alpha coefficients 0.89) and has been administered and validated in several different populations including a community sample, psychiatric outpatients, and patients with PTSD and generalized anxiety disorder. Each item is rated on a five-point scale (0–4 points), with a possible total score ranging from zero to 100 points. Higher scores indicate greater resilience.
Statistical analyses
The χ2 test and logistic regression analyses were conducted to examine baseline characteristic differences between those who participated in follow-up assessment and those who did not respond to the follow-up survey invitation.
Baseline sociodemographic and clinical characteristics of those with and without suicidality over the follow-up period of three years were summarized using descriptive statistics. We used logistic regression analyses to examine associations between baseline variables and suicidality at follow-up, adjusting for the potentially confounding effects of sex, age, and educational status. Next, to identify which variables were independent predictors for future suicidality, baseline variables showing a significant association in prior logistic analyses, and potential confounding factors including sex, age, educational status, and severity of depressive symptoms, were entered into multivariable logistic analyses.
Logistic regression analyses were carried out to examine the association between lifetime DSM-IV psychiatric disorders and future suicidality. First, we regressed suicidality at follow-up on each baseline DSM-IV disorder (model 1). Then, confounding variables were sequentially entered into models: model 2 was adjusted for sex, age, and educational status, and model 3 was additionally adjusted for lifetime suicidality as assessed at baseline evaluation. Although age, sex, or educational level were not significant variables in this study, they are typically adjusted for and analyzed together in previous studies regarding psychiatric epidemiology studies for NKDs and other refugees.21, 22 Multicollinearity among univariate variables was not observed in the multivariable models. A Hosmer-Lemeshow goodness of fit test indicated a P value of 0.52.
Some of the baseline variables had missing data. Missing cases were excluded in statistical analyses. All statistical analyses were performed with the Statistical Package for the Social Sciences version 25.0 software program (IBM Corp., Armonk, NY, USA) with a statistical significance cutoff set at an alpha level of 0.05.
Ethics statement
This study was approved by the Institutional Review Board of Samsung Medical Center (SMC 2015-05-042-002). Informed consent was obtained from all subjects prior to the interview. We have obtained permissions for all mental health scales (NK-CIDI, CES-D-NK, IES-NK, Korean version of CD-RISC) used in this study, and we have confirmed that no authorization is needed to use the UCLA loneliness score for research purposes.
RESULTS
In the three-year follow-up study, 172 of the original 300 subjects responded to an online survey. Subjects participating in follow-up were more often married (38.4% vs. 22.8%; P = 0.028), more frequently living with someone else (34.3% vs. 21.9%; P = 0.019), had more lifetime suicidality (36.6% vs. 23.4%; P = 0.015), had more PTSD diagnoses (19.2% vs. 10.2%; P = 0.032), had less alcohol abuse diagnoses (7.6% vs. 15.6%; P = 0.027), and had more lifetime DSM-IV disorders (62.2% vs. 48.4%; P = 0.017) at baseline than not participating in follow-up. No differences between groups were found for any of the other sociodemographic and clinical characteristics assessed at baseline.
At baseline, the mean age of the study sample (n = 172) was 38.8 years (standard deviation [SD], 11.9 years), 80.2% of the population was female, and the mean years of education of the respondents was 11.2 years (SD, 2.5 years). Sixty-three respondents (36.6%) reported lifetime suicidality at baseline. Mean CES-D-NK score was 14.1 points (SD, 13.2 points), mean IES-NK score was 29.8 points (SD, 20.2 points), mean CD-RISC was 73.5 points (SD, 19.0 points), and mean UCLA loneliness scale score was 17.9 points (SD, 5.4 points).
Table 1 summarizes the characteristics of subjects with future suicidality vs. those without suicidality at follow-up. Thirty (17.4%) of the 172 surveyed subjects reported suicidality at follow-up. In both unadjusted and adjusted analyses, significant evidence for association of future suicidality with presence of health problems over the past year (adjusted odds ratio [OR], 3.82; 95% confidence interval [CI], 1.22–11.97; P = 0.021), lifetime suicidality at baseline (OR, 6.42; 95% CI, 2.60–15.86; P < 0.001), higher trauma-related scale (IES-NK) score (OR, 1.03; 95% CI, 1.01–1.05; P = 0.007), and lower resilience scale (CD-RISC) score (OR, 0.97; 95% CI, 0.95–0.99; P = 0.009) was found. There was also weak evidence of association between female sex (OR, 3.85; 95% CI, 0.86–17.14; P = 0.077) and future suicidality.
Table 1
Odds ratios of baseline sociodemographic and clinical factors among survey respondents with and without suicidalitya at three years of follow-up
Table 2 shows the results of multivariate logistic regression analyses of potential baseline sociodemographic and clinical characteristics. Lifetime suicidality at baseline (OR, 6.37; 95% CI, 2.03–19.97; P = 0.001) and a lower resilience scale (CD-RISC) score (OR, 0.96; 95% CI, 0.93–0.99; P = 0.011) were significantly associated with future suicidal thoughts and behaviors. There was weak evidence of association with female sex (OR, 9.61; 95% CI, 0.96–96.58; P = 0.055) and presence of health problems over the past year (OR, 4.22; 95% CI, 0.79–22.49; P = 0.092).
Table 2
Sociodemographic and clinical variables associated with future suicidalitya (n = 147)
Table 3 shows associations between each baseline DSM-IV disorder and suicidality at follow-up assessment. Lifetime major depressive disorder (OR, 1.31; 95% CI, 1.04–1.64; P = 0.023), dysthymia (OR, 1.52; 95% CI, 1.07–2.15; P = 0.018), agoraphobia (OR, 1.63; 95% CI, 1.01–2.64; P = 0.046), and social phobia (OR, 1.43; 95% CI, 1.04–1.97; P = 0.030) were significantly associated with suicidality at follow-up, even after adjusting for age, sex, educational level, and lifetime suicidality at baseline (model 3). Although lifetime PTSD was positively associated with future suicidality in model 1, the association disappeared following adjustment for potential confounding variables including lifetime suicidality (OR, 1.12; 95% CI, 0.88–1.43; P = 0.360). There was significant association between specific phobia and future suicidality in model 1 and model 2, yet the association disappeared after adjusting for lifetime suicidality (OR, 1.11; 95% CI, 0.88–1.41; P = 0.365). Of all measured mental disorder categories, subjects with lifetime agoraphobia had the highest odds of future suicidality (OR, 1.63; 95% CI, 1.01–2.64; P = 0.046).
Table 3
ORs for each DSM-IV/CIDI mental disorder among respondents with vs. without suicidalitya at the time of follow-up (n = 172)
DISCUSSION
To our knowledge, this is the first longitudinal cohort study investigating risk and protective factors associated with future suicidality in a sample composed of NKDs aged 18 to 70 years having arrived in South Korea within the last three years. The rate of suicidality among respondents was higher than in the South Korean general population. The key finding is that the presence of health problems over the past year, lifetime suicidality, higher trauma-related scale (IES-NK) score, and lower resilience scale (CD-RISC) score at initial assessment were significantly associated with future suicidality among NKDs. Lifetime suicidality and a lower resilience scale score were significantly associated with future suicidality even after multiple regression. Also, lifetime mental disorders including major depressive disorder, dysthymia, agoraphobia, and social phobia at initial assessment were significantly associated with higher suicidality at follow-up, even after adjusting for age, sex, educational level, and lifetime suicidality.
Due to the control of the government, it is difficult to conduct actual research on the free culture and emotional differences of North Koreans, so most of the studies have been conducted indirectly through defectors. North Korean culture places less emphasis on individual unconsciousness and more on sharing and distribution, with a strong focus on survival and present-oriented thinking, resulting in a culture that suppresses emotions and lacks information about mental health.23 This may be related to the fact that North Koreans commonly express depression, anxiety, and stress through nonspecific somatic symptoms such as headaches, insomnia, and digestive problems.4 Furthermore, since suicide is considered a crime of betraying the nation in North Korea, its incidence rate is not well known. It is also possible that the suicide rate among NKDs may increase after their escape from the socialist regime.
The results of the study provide additional validation for the societal concerns of increased suicidality among NKDs living in South Korea. In the present study, 17.4% of respondents reported experience of suicidal thoughts or behaviors over the past year, this rates higher than that recorded among the South Korean general population (5.1%).9 This finding is consistent with previous studies of refugees suggesting that suicidality among refugees is higher than in the general population.10, 11, 12 The rate of suicidality at follow-up assessment observed in this study was also similar to that found in a 2019 social survey assessing NKDs, where 12.4% of NKDs reported suicidal ideation in the past year.
In this longitudinal study, low resilience at initial assessment predicted greater odds of suicidality at follow-up, controlling for several confounding factors including suicidality at initial assessment. Resilience is defined by Conner and Davidson as “[a series of] qualities that enable one to thrive in the face of adversity.” One’s ability to cope with stressful internal and external life events is influenced by both successful and unsuccessful adaptations to previous disruptions.19 Resilience has been presented as a protective factor among refugees for successful adaptation to a new culture, healthy functioning over time, withstanding adversities including traumatic events, and sustaining well-being.24, 25 For NKDs, resilience has been shown to mitigate the effects of depression and suicidal ideation. One study revealed that depressive symptoms and the resilience level of NKDs are inversely related, and that the resilience score measured by CD-RISC was significantly lower for women, for subjects having resettled more than one year ago, and for unmarried individuals.26 The relationship between suicidal ideation and resilience in youth NKDs was previously investigated in a cross-sectional study, which showed that subjects with suicidal ideation exhibited significantly lower resilience than those without.13 This supports our finding that the suicidality and resilience profiles of NKDs are inversely related across time. It is noteworthy that resilience may be a protective factor mitigating risk of suicidality. Considering that resilience can be modifiable and can improve with pharmacotherapeutic and psychotherapeutic intervention,19 our findings have important implications for clinical care and for guiding future research efforts to increase resilience among NKDs with high suicidality.
A previous history of suicidality (e.g., suicidal ideation, suicidal plan, and suicidal attempt) is a known risk factor for suicide. In our study, lifetime suicidality was significantly associated with future suicidality among NKDs even after controlling for possible confounding factors. Although we did not investigate the individual impacts of suicidal ideation, suicidal plan, and suicidal attempt, our results imply that a previous history of suicidality may be an important suicide risk factor among NKDs.
Other factors related to future suicidality included the presence of health problems over the past year and a higher trauma-related scale score measured using the IES-NK. In our study, both of these factors were significantly associated with future suicidality after adjusting for age, sex and educational level; however, the association was not apparent in multiple regression analysis.
One refugee study showed that poor physical health is associated with increased levels of thwarted belongingness and perceived burdensomeness, which are two main factors underpinning interpersonal theory of suicide hypotheses.27 Our previous cross-sectional study also reported an association between presence of health problems and lifetime suicidality.7 Poor state of health may contribute to increased suicidal behavior via several aspects such as psychological stress and poor access to social support. Meanwhile, trauma exposure among refugees is extremely high and about 49.3% of NKDs reported having experienced or witnessed traumatic events such as the death or arrest of family members and/or suffered physical abuse from acquaintances.28, 29 There is some evidence that exposure to chronic fear and repeated trauma is associated with increased risk of suicide among refugees.27 In this study, it is possible that the effects of the presence of health problems and trauma on future suicidality were overshadowed in multivariate analysis by the influence of other factors such as previous suicide and resilience. Further research and replication will be necessary to discern the causal relationship of health problems and trauma experience to future suicidality among NKDs.
Mental disorders are known to be associated with an elevated risk of suicide in the general population. For refugees, inconsistent findings have been reported regarding the association between mental disorders and suicidality. One study showed that rates for suicide attempt in individuals with mental disorders were lower in refugees within a Swedish-born reference group,30 while other studies found that patients with mental disorders such as depression and PTSD showed greater frequency of suicidal thoughts and behaviors.7, 31 In our study, the presence of lifetime mental disorders diagnosed according to the DSM-IV was associated with significantly increased odds of future suicidality among NKDs. Agoraphobia was most strongly associated with future suicidality, consistent with a previous cross-sectional study.7 Other depression and anxiety disorders including major depressive disorder, dysthymia, and social phobia also showed significant association with future suicidality, even after controlling for lifetime history of suicide. However, the association between PTSD and future suicidality disappeared after adjusting for confounding factors. This result was inconsistent with those of previous cross-sectional refugee studies reporting possible association between PTSD and suicide.31 Considering the high coexistence rate of depression and anxiety disorders in PTSD patients and the greater risk of suicide in the presence of these coexisting disorders,31 in the long term, depression and phobia may be more likely than PTSD to cause impairment in one’s functioning and to affect future suicidality. Further research is needed to investigate the relationship between PTSD and future suicidality in the NKD population.
Interestingly, social and economic factors such as age, marital status, and employment status were not significantly associated with depression and suicide among NKDs with a relatively short period of settlement but showed an increasing relationship as the settlement period lengthened.21, 32 The participants in this study had a relatively short settlement period and did not experience significant difficulties in adapting to South Korean culture, possibly due to the provision of early settlement support policies. Therefore, further in-depth studies are needed to examine the temporal relationship between stress experiences and suicide risk during the settlement process among NKDs.
This study has several limitations to consider. First, this longitudinal follow-up study included a relatively small sample size, and 128 out of 300 subjects did not respond to the follow-up assessment. The small sample size and rarity of suicide attempts in our sample precluded meaningful investigation of correlates of suicidality in those who have attempted suicide as compared with those who only had suicidal ideation or a suicidal plan. Previous studies on NKDs also employed the same methodology, and as this population is considered a special group, the sample cohort in studies related to this topic typically ranges from 150 to 300 individuals.4, 6, 7 Further longitudinal research is needed to explore whether there are differences in the risk factors between those who only think about suicide and those who have attempted suicide. Second, it is also possible that serious suicide cases, such as complete suicide or suicide attempts with severe sequelae, have not been tracked. However, the assessment of suicidality is the standard of clinical care and a proxy for assessing the risk of suicide. Third, our study did not include other possible factors that may be associated with future suicidality such as occupation before defection, whether family members defected together, and postmigration challenges. Fourth, there may be a possibility of recall bias because lifelong history of suicidality and psychiatric diagnoses were self-reported. Finally, although the high correlation between bipolar disorder and suicide is well-known in the general population, none of the subjects in the present study was diagnosed with bipolar disorder. It is possible that bipolar disorder-related functional decline deters persons with the disorder from even attempting the escape from North Korea. Thus, in this study, the relationship between suicide and bipolar disorder among NKDs may have been underestimated.
Despite these limitations, this study is the first longitudinal follow-up study to date investigating associations of sociodemographic and mental disorder risk factors with future suicidality among NKDs within three years of entry into South Korea. It is noteworthy that our study diagnosed DSM-IV mental disorders using a fully structured diagnostic interview tool (NK-CIDI 2.1) and evaluated mental disorders as possible predictors of future suicidality in this high-risk group. The study can be considered an important step toward the development of targeted suicide prevention programs for NKDs and other immigrants and refugees.
In conclusion, lower resilience and previous history of suicidality were strongly associated with future suicidality among NKDs. Also, NKDs with a lifetime history of mental disorders including major depressive disorder, dysthymia, agoraphobia, and social phobia are at high risk for future suicide. Further research should focus on tracking changes in suicide risk factors at each post-defection adaptation stage, and on the development of preventive therapeutic interventions, especially those geared toward suicide prevention.
Funding:This work was supported by the Korea Healthcare Technology R&D project, Ministry of Health and Welfare, Republic of Korea (HM15C1072, HL19C0018).
Disclosure:The authors have no potential conflicts of interest to disclose.
Data Availability Statement:The data supporting the findings of the present study are available from the corresponding author upon reasonable request with permission from the Korean National Center for Mental Health.
Author Contributions:
Conceptualization: An JH, Lee H, Chang HI, Jun JY, Hong JP.
Data curation: Jun JY.
Formal analysis: An JH, Lee H.
Investigation: An JH.
Methodology: Lee H, Chang HI, Jun JY.
Supervision: Hong JP.
Writing - original draft: An JH, Lee H.
Writing - review & editing: Chang HI, Jun JY, Hong JP.
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ORCID IDs
Funding Information
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Ministry of Health and Welfare
HM15C1072HL19C0018
