Annotated Abstracts of Journal Articles
2014, 3rd Quarter
Annotation by Kemuel Philbrick, MD, FAPM
Tsai AC, Lucas M, Sania A, Kim D, Kawachi I
Ann Intern Med 2014 Jul 15; 161(2):85-95
ANNOTATION (Kemuel Philbrick)
The Finding: Social integration (assessed via marital status, social network size, frequency of contact, religious participation, and participation in other social groups) was associated with a greater than two-fold reduction in risk of completed suicide in a prospective study of nearly 35,000 men aged 40-75 years. Marital status, social network size, and religious service attendance demonstrated the strongest protective benefit. The 24-year longitudinal follow-up also permitted the observation that a deteriorating trajectory of social integration was less protective than a stable or increasing trajectory.
Strengths and Weaknesses: The large size and extended duration of this study, coupled with the exclusion of competing mortality risks as a possible confounding factor, give this careful analysis particular merit. Unfortunately, data on depression among participants was not available for the first 14 years of the study, but information on antidepressant use was accessible and adjustment for this did not change the study conclusions. Whether the findings are generalizable to women, or men from a broader socioeconomic experience, or to younger men and women, is an open question.
Relevance: The consultation psychiatrist often evaluates individuals without prior psychiatric history who have aroused concern for risk of suicidality. This study lends an additional lens through which to view the broader context of the person’s life and inform the assessment of future suicide risk.
Background: Suicide is a major public health problem. Current thinking about suicide emphasizes the study of psychiatric, psychological, or biological determinants. Previous work in this area has largely relied on surrogate outcomes or samples enriched for psychiatric morbidity.
Objective: To evaluate the relationship between social integration and suicide mortality.
Design: Prospective cohort study initiated in 1988.
Setting: United States.
Participants: 34,901 men aged 40 to 75 years.
Measurements: Social integration was measured with a 7-item index that included marital status, social network size, frequency of contact, religious participation, and participation in other social groups. Vital status of study participants was ascertained through 1 February 2012. The primary outcome of interest was suicide mortality, defined as deaths classified with codes E950 to E959 from the International Classification of Diseases, Ninth Revision.
Results: Over 708,945 person-years of follow-up, there were 147 suicides. 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 (adjusted hazard ratio [AHR], 0.41 [95% CI, 0.24 to 0.69]) and second-highest (AHR, 0.52 [CI, 0.30 to 0.91]) categories of social integration. Three components (marital status, social network size, and religious service attendance) showed the strongest protective associations. Social integration was also inversely associated with all-cause and cardiovascular-related mortality, but accounting for competing causes of death did not substantively alter the findings.
Limitations: The study lacked information on participants’ mental well-being. Some suicides could have been misclassified as accidental deaths.
Conclusion: Men who were socially well-integrated had a more than 2-fold reduced risk for suicide over 24 years of follow-up.
Comment on this article:
Knox K: Approaching suicide asa public health issue
Ann Intern Med 2014 Jul 15; 161(2):151-2