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Original Investigation |

Association Between Social Integration and Suicide Among Women in the United States

Alexander C. Tsai, MD, PhD1,2,3; Michel Lucas, PhD, RD4,5,6; Ichiro Kawachi, MD, PhD7,8
[+] Author Affiliations
1Center for Global Health, Massachusetts General Hospital, Boston
2Harvard Center for Population and Development Studies, Cambridge, Massachusetts
3Mbarara University of Science and Technology, Mbarara, Uganda
4Department of Social and Preventive Medicine, Université Laval, Québec City, Québec, Canada
5Population Health and Optimal Health Practices Research Unit, Centre Hospitalier Universitaire de Québec Research Centre, Québec City, Québec, Canada
6Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
7Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
8Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Psychiatry. 2015;72(10):987-993. doi:10.1001/jamapsychiatry.2015.1002.
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Importance  Suicide is one of the top 10 leading causes of mortality among middle-aged women. Most work in the field emphasizes the psychiatric, psychological, or biological determinants of suicide.

Objective  To estimate the association between social integration and suicide.

Design, Setting, and Participants  We used data from the Nurses’ Health Study, an ongoing nationwide prospective cohort study of nurses in the United States. Beginning in 1992, a population-based sample of 72 607 nurses 46 to 71 years of age were surveyed about their social relationships. The vital status of study participants was ascertained through June 1, 2010.

Exposures  Social integration was measured with a 7-item index that included marital status, social network size, frequency of contact with social ties, and participation in religious or other social groups.

Main Outcomes and Measures  The primary outcome of interest was suicide, defined as deaths classified using the codes E950 to E959 from the International Classification of Diseases, Eighth Revision.

Results  During more than 1.2 million person-years of follow-up (1992-2010), there were 43 suicide events. The incidence of suicide decreased with increasing social integration. In a multivariable Cox proportional hazards regression model, the relative hazard of suicide was lowest among participants in the highest category of social integration (adjusted hazard ratio, 0.23 [95% CI, 0.09-0.58]) and second-highest category of social integration (adjusted hazard ratio, 0.26 [95% CI, 0.09-0.74]). Increasing or consistently high levels of social integration were associated with a lower risk of suicide. These findings were robust to sensitivity analyses that accounted for poor mental health and serious physical illness.

Conclusions and Relevance  Women who were socially well integrated had a more than 3-fold lower risk for suicide over 18 years of follow-up.

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Figure.
Cumulative Incidence of Suicide Among Women in the Nurses’ Health Study

The follow-up period was from 1992 to 2010, with estimates of the incidence of suicide stratified by social integration category measured in 1992.

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