In October 2016, Tong et al ^{Reference Tong, Phillips and Conner1} published a study that aimed to describe the prevalence of Axis II personality disorders in suicides and suicide attempts in China, and to estimate risks for these outcomes associated with personality disorders. The authors found that personality disorders as defined by DSM-IV are much less prevalent in mainland China compared with other countries. Another finding that was not emphasised was that cluster B personality disorders did not confer increased risk relative to the other clusters, which is in contrast to other studies mostly conducted in Europe and North America.

The authors provide possible explanations for the low prevalence of personality disorders, including that they may be obscured by Axis I disorders, and that individuals with personality disorders do not seek treatment or get referred for treatment. This appears to imply that there may be a higher prevalence of personality disorders in China, which was not detectable owing to the sensitivity of measurements and lack of mental health awareness.

Although this is possible, the authors do not adequately explore possible environmental reasons for their findings, or question the validity of their approach. The theory and diagnosis of mental illnesses, including personality disorders, occur within prevailing cultural expectations. ^{Reference Summerfield2} While the cultural differences between ‘East’ and ‘West’ are stereotyped and crude, they nonetheless provide hints as to why DSM-IV personality categories may not be appropriate tools for understanding suicidal behaviour in China. Social norms, cultural attitudes towards suicide and motivations for suicidal behaviour can differ markedly compared with the West. For example, although suicide as a result of shame is most commonly associated with Japan, the Chinese have also typically viewed suicide out of loyalty to the family or to ‘save face’ as acceptable. ^{Reference Lester3}

Socio-economic factors can also explain why strategies designed in high-income countries may not be appropriate to use in low- or middle-income countries. The rural areas of China still face challenges such as relative poverty compared with urban areas and limited health services. ^{Reference Milner and De Leo4} As well as creating different pressures on individual lives compared with the West, a lack of available mental health interventions may hamper any meaningful diagnostic findings.

The authors use the findings from this study to advocate for using a dimensional model of personality traits to understand suicidal behaviour. The validity of this approach was not clearly explained: could it adequately distinguish between fixed traits and the states of an underlying Axis I disorder, for example, and does it also risk obscuring the environmental influences on behaviour? It is clearly important to try to understand suicidal behaviour in China, but a focus on personality without a social context and cultural narrative may limit the scope of inquiry.