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Try out PMC Labs and tell us what you think. Learn More. This paper addresses the relationship between suicide mortality and family structure and socioeconomic status for U. We use Cox proportional hazard models and individual level, prospective data from the National Health Interview Survey Linked Mortality File — to examine adult suicide mortality. Larger families and employment are associated with lower risks of suicide for both men and women. Low levels of education or being divorced or separated, widowed, or never married are associated with increased risks of suicide among men, but not among women.

We find important sex differences in the relationship between suicide mortality and marital status and education. Future suicide research should use both aggregate and individual level data and recognize important sex differences in the relationship between risk factors and suicide mortality—a central cause of preventable death in the United States. Suicide is shaped by social forces, and unlike many causes of death, it does not result directly from degenerative disease or old age.

The risk of suicide increases as individuals reach a point of disillusion or disconnect from the world around them Bearman, ; Durkheim, []; Gove, With some notable exceptions see, for example, Kposowa, ; Kposowa, Breault, and Singh, ; Stack, ; and Stack and Wasserman, , much of the social science literature on suicide focuses on aggregate level relationships.

This approach offers insight into a central preventable cause of death in the United States and helps determine whether the relationships that have been documented with aggregate suicide rates are operating at the individual level. Suicide was the eleventh leading cause of death and the second leading external cause of mortality behind accidents but ahead of homicides in the U. Males ed for 79 percent of the suicide deaths in the U.

And suicide was ranked as the 8 th leading cause of death for males but was ranked 16 th for females in Heron, His work cemented the idea that social factors such as family structure, religion, military service, and changes in class position, provide important contexts that shape outcomes of social ificance. Social integration refers to the important relationships that connect individuals so that they are affected by and committed to the moral demands of the group Bearman, ; Durkheim, []. Those who are well integrated into family and social life may have a stronger sense of belonging and derive greater purpose from the group.

This sense of belonging and a strong connection to the collective moral life is likely to reduce the risk of suicide among otherwise vulnerable individuals. These studies have consistently demonstrated that indicators of social disruption or a lack of integration are positively related to suicide rates.

Although aggregate analyses capture the influence of broad patterns of social disruption on community outcomes, they cannot determine whether social disruption is associated with individual-level suicide risk. To assume that geographic patterns reflect individual processes is to fall victim to the ecological fallacy van Poppel and Day, In the current research we use individual level data to examine relationships that have heretofore been tested primarily at the aggregate level. The risk of suicide may increase with decreasing family integration. At the aggregate level, Breault used the divorce rate as a proxy for low family integration and found a positive association between divorce rates and suicide rates.

Geographic areas and birth cohorts with higher levels of family formation and less family disruption demonstrate lower suicide rates. However, whether such findings result from community-level mechanisms i. Individual level analyses of marital status and suicide have relied largely on bivariate models, but have produced consistent findings that support higher suicide risk among divorced compared to married persons for a review, see Stack, b.

Being married may reduce the risk of suicide because spouses can provide social support in stressful situations, inhibit risky behaviors such as drinking and drug use, and confer a sense of meaning and obligation Umberson, ; Waite, Larger families—typically marked by the presence of numerous children and other adult relatives—might also be associated with reduced risks of suicide mortality if they provide integration across generations and offer greater opportunities for connection to the outside world Berkman and Glass, ; Rogers, Hummer, and Nam, The literature on individual sex-specific differences in suicide risk by marital status has produced some conflicting .

Stack reported that divorce increased suicide risk for males and females, while Kposowa found that divorce has a strong effect only on male suicide mortality. Notably, Kposowa does not find an increased risk of suicide for widowed or single persons of either sex. Other recent research efforts suffer from small sample sizes and can only compare married and not married individuals, although there may be important differences among those who are never married or widowed Cutright, Stack, and Fernquist, Some research suggests that marriage confers greater benefits to men than women.

Women may spend more time caring for the physical and emotional health of other family members, which may increase their stress while lowering the stress of their husbands and any children Gove, ; Hochschild and Machung, ; Umberson, Family relationships may be particularly important for the psychosocial wellbeing of men, because they average fewer social ties outside of the family than women Berkman and Glass, ; Umberson et al.

Thus, marital and family ties may lower the risks of suicide more for men than for women. SES—including higher levels of educational attainment, employment, and higher income—is associated with better health and lower risks of all-cause mortality Adler et al. Although education, employment, and income are clearly related to each other, it is important to investigate their separate relationships with the risk of suicide.

For example, Kposowa and colleagues found a bivariate relationship between income and suicide that was explained away in multivariate models. Higher SES may reduce suicide risk in several ways. Higher incomes may reduce suicide risk by allowing individuals to access help from mental health professionals or paying for goods or services that ease their lives. Employment provides income, but may also foster social integration by providing meaning and organization to the routines of daily life, offering opportunities to make friends, and encouraging responsibility to co-workers by fulfilling job requirements Kasl and Jones, ; Theorell, Work is associated with lower risks of overall mortality Rogers, Hummer, and Nam, , and employed persons have lower risk of suicide mortality Stack, a , although there are some exceptions among specific occupational groups Stack, High levels of education may reduce the risk of suicide by providing individuals with a greater sense of self-control and access to tightly knit pro-social groups that promote marriage, employment, and improved social capital Kawachi and Berkman, ; Mirowsky and Ross, ; Waite, Education may also facilitate strategies for managing stressful social environments Krueger and Chang, ; Lantz et al.

Despite important sex differences in the relationship between SES and overall mortality MacIntyre and Hunt, ; MacIntyre, Hunt, and Sweeting, , prior research has not thoroughly examined sex differences in SES on the risk of suicide. But Kposowa finds that unemployment is a stronger predictor of suicide mortality among females than among males. These findings suggest a similar protective effect of employment on suicide.

Only limited research investigates the impact of educational attainment on suicide risk at the individual level. In an analysis reviewed by Stack b , individual level data revealed that each year of education for non-Hispanic white males ificantly reduced their risk of suicide. But there is little to no information on how the influence of education affects female risk in the United States. Recent cohorts of women are surpassing men in educational attainment. Education is especially important for women because it reduces the odds of divorce, unemployment, and falling into poverty DiPrete and Buchman, —outcomes that might diminish social integration and increase the risks of suicide.

First, after controlling for other relevant factors, do marital status, family size, employment, education, and family income shape individual suicide risk? We draw on the social integration perspective to examine whether the forces that connect individuals to society are associated with the risk of suicide. Divorce has been shown to increase suicide risk at the individual level Stack, , but less work has examined the relationships between suicide and other marital statuses, family size, employment status, education, or income, and no research to date has examined all of these integrative forces in one conceptual and empirical model.

Second, are the risk factors for suicide the same for men and women? Although we know that proportionately more males than females commit suicide Kung et al. Thus, the NHIS-LMF allows us to examine the risk of death with a large, nationally representative sample of non-institutionalized adults aged 18 and older in the U.

NCHS, various years, NHIS asks all members of sampled families a common set of questions on sociodemographic factors throughout the years we use here, and the NHIS-LMF contains detailed causes of death, including suicide. Our sample includes over one million adults—, males and , females—aged 18 and older, which is large enough to make detailed comparisons on the risk of suicide mortality, a relatively rare event.

We exclude respondents who are 17 years of age or younger because they cannot give consent to have their records linked to mortality. We also drop 6. Suicide mortality is defined as death from intentional self-harm codes XX84 in the 10 th revision of International Statistical Classification of Diseases, Injuries, and Causes of Death World Health Organization, Although the accuracy of suicide death certificate data rests on individuals with varying levels of medical knowledge and training Timmermans , Pescosolido and Mendelsohn demonstrated it is not misreported in a systematic way.

Over the follow-up period, 1, suicides— for males and for females—were identified. The remaining individuals survived the follow-up period or died from other causes. Sex is coded dichotomously as male and female the referent. Race is a dummy variable that compares non-Hispanic whites the referent to all others.

Family relationships include marital status and family size. Marital status is coded categorically as married or living with a partner referent , divorced or separated, never married, and widowed. Cohabiters were included with married persons because they contributed only 11 deaths and our were not sensitive to their inclusion.

Family size is a continuous variable and is top coded at four or more family members. Socioeconomic variables include income, employment status, and education. The reference person for each family reports the total family income in defined by NCHS. We take the midpoint of each category to approximate a continuous measure, estimate a median value for the open-ended category see Parker and Fenwick, , adjust the value for the purchasing power of different sized families see Van der Gaag and Smolensky, , and use the consumer price index to adjust for changes in purchasing power over time. We incorporated stochastic variation into the predicted values to better represent the variability in the actual income data Gelman and Hill, Finally, we took the log of the family income variable to for its skewed distribution, and include that in our analyses.

Separate analyses not shown included a dummy variable for missing income values but we found no difference compared to the imputed incomes. Education is coded categorically as those with 0—11 years of school, high school graduates, and those with more than a high school education referent. Employment status is coded as employed referent and not employed or looking for work at time of interview. We combined those who were not in the labor force and those who were unemployed because they were not ificantly different not shown.

There are important geographic differences in suicide that might result from differences in social integration or imitation Baller and Richardson, We code census region categorically as Northeast referent , South, Midwest, and West; more detailed geographic location is not available in the NHIS public-use data. We also adjust for self-rated health, as measured on a five-point scale that ranges from 0 poor health to 4 excellent health. Although the core NHIS data do not provide information on mental health, individuals consider many dimensions of their mental and physical health when rating their own health Idler, Hudson, and Leventhol, We employ Cox proportional hazard models to examine the risk of suicide mortality Allison, Age in quarter year intervals is used to identify the hazard of death in the survival models, which adjusts all for age see Korn, Graubard, and Midthune, Cox proportional hazard models are ideal because they do not impose a particular hazard function or distribution of suicide across age on the data and because the overall utility of the model is strong when based on large nationally representative samples Therneau and Grambsch, We report all in the form of hazard ratios, and use Stata 9.

Table 1 presents hazard ratios of suicide mortality risk for each of the covariates. Model 1 shows that males have nearly 4. Models 2 through 6 reveal that the risk of suicide mortality for men increases to almost 4. Marital status and family size are associated with the risk of suicide. Model 3 demonstrates that larger family sizes partially for the relationship between marital status and suicide mortality.

Model 4 reveals that family income initially has a protective effect on suicide risk, but adjusting for educational attainment and employment status in Model 5 attenuates that relationship. Adjusting for socioeconomic factors also reduces the relationship between marital status and suicide risk, but the protective effect of larger families remains stable.

Model 5 demonstrates that men are nearly 4. Consistent with Baller and Richardson , we find that the West is associated with increased suicide risk. Self-rated health is also related to suicide risk. Adjusting for region and self-rated health have little impact on the relationships between suicide risk and marital status and family size, but these factors do partially for the relationships between suicide mortality and education and employment compare Models 5and 6.

Table 2 estimates separate models for men and women. Without adjusting for other covariates Model 1 , divorced or separated males and females have increased risks to suicide, relative to those who are married. But the relationship between marital status and the risk of death is reduced among males and is explained entirely among females after adjusting for family size and socioeconomic status Models 2 and 3.

Although the hazard ratios are similar in magnitude with the exception of widowhood , the marital status variables are not ificantly associated with suicide risk among females in Model 3. Widowhood, in particular, is associated with much higher risks of suicide mortality among males than among females. In contrast, family size is similarly protective for both men and women. Education is not ificantly associated with the risk of suicide among women. Both men and women who are not currently working have increased risks of suicide; although the hazard ratio is larger among women, that difference in magnitude is not statistically ificant Model 3.

Model 2 shows that higher incomes are associated with lower risks of suicide among males, but not among females. Consistent with the in Table 1 , family income is not associated with the risk of suicide among men or women after adjusting for other covariates Model 3.

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