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

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 interestwas 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.