chapter 4 suicide and social support

8/2/2019 Chapter 4 Suicide and Social Support

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Chapter 4: Social Support & Suicide 174

Chapter 4

Social Support and Suicide

Definitions of Social Support

Social support is a concept that is generally understood in an intuitive

sense, as the help from other people in a difficult life situation. One of the

first definitions was put forward by Cobb (1976); he defined social support

as the individual belief that one is cared for and loved, esteemed and

valued, and belongs to a network ofcommunication and mutual obligations

Moss (1973) proposes that social support is a "subjective feeling or

belonging, of being accepted, of being loved and of being needed, all for

oneself and not for what one can do".

Shumaker and Brownell (1984) defined social support as social exchanges

in which the provider or recipient perceives positive intent. Accordingly,

Social support providers who aim to promote well being must therefore take

into account not only the type of illness and type of support, but also: the

person most likely to provide a positively perceived supportive behavior.

Also it has been simply defined as the assistance and protection given to

others (shumaker and BrowrelI, 1984; Wortman and Dunkel-Schetter,

1987).

Social support describes the comfort, assistance, and/or information one

receives through formal or informal contacts with individuals or groups

(Wallston ct al., 1983).


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In MINDFUL(2008) social support was defined as the perceived

availability of people whom the individual trusts and who make one feel

cared for and valued as a person.

Social capital has a variety of definitions (Muntaner and Lynch,1999;

Whitehead and Diderichsen,2001; Durlauf S , 2002), there is general

agreement that the required conditions forsocial capital include the existence

of community networks,civic engagement, civic identity, reciprocity, and

trust. One of the most well known works, Putnams(2000)Bowling Alone,

identifies social associations and networks, norms of reciprocity,and trust as

3 key components of social capital (Kushner H, and Sterk C (2005).

In spite of these widely accepted definitions of social support, there is no

consensus in the literature about the definition. There is a need for further

research, especially about what kind of support is most important for health.

Social Support Concept

Berkman et al., (2000)stated that social integration, social network andsocial support are closely related components of social relationships.

The concept of a social network represents the ties to family, friends,

neighbors, colleagues, and others of significance to the person (Doubova et

al., 2010); there are different types of social networks , the most common

are: a) diverse, with distinct sources of potential support (family, friends,

neighbours, community groups) and with frequent contact; b) focused on

family; c) focused on friends, and; d) restricted in terms of potential sources

of support and frequency of contacts (Fiori et al.,2007,;Fiori et al.,2008)


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However, when the social network is described in structural terms, like

size, range, density, proximity and homogeneity, social support normally

refers to the qualitative aspects of the social network; within this context,

social support is the potential of the network to provide help in situations

when needed. However, the social network may also be the cause of

psychological problems. Support is accessible to all individual through

social ties with other individuals, groups and the larger community (Lin et

al., 1979).

Whereas the concept of social support mainly refers to the individual and

group level, the concept of social integration can refer to the community

level (Berkman & Glass, 2000). A well integrated community refers to well

developed supportive relationships between people in the community, with

everybody feeling accepted and included. A related concept is social capital,

which is often used as the sum of supportive relationships in the

community(Kawachi & Berkman, 2000). Social integration has been used

to refer to the existence of social ties. Social network refers to the web of

social relationships around individuals. Social support is one of the

important functions of social relationships. Social networks are linkages

between people that may provide social support and that may serve functions

other than providing support (Glanz et al, 2002).

Barnes (1954) was the first to describe patterns of social relationships that

were not explained by families or work groups; social networks are closely

related to social support. Nevertheless, these terms are no theories per se.

Social Support and Social Networks are concepts that describe the structure,


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processes and functions of social relationships. Social networks can be seen

as the web of social relationships that surround individuals.

Halle and Wellman (1985) present the interplay between social support,the social network, and psychological health in a model (figure F): The

social network as a mediating construct. This model shows that social

support can be seen as resulting from certain characteristics of the social

network, which are in turn caused by environmental and personal factors.

The model suggests that it is important to distinguish between the structural

and quantitative aspects of the social network on the one side, and social

support on the other (O'Reilly, 1988). However, it may be difficult to

distinguish between the quality of social network and social support.

Figure (F): Social network as a mediating construct(Halle & Wellman,1985)
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Perceived and Provided Support

Wethington and Kessler, (1986); Olstad et al.(2001) stated that in defining

social support a distinction can be made between the quality of support

perceived (satisfaction) and provided social support. In fact, perceived

support may be more important than the support actually received.

Most studies are based on the measurement of subjectively perceived

support, whereas others aim at measuring social support in a more objective

sense. One could also distinguish between the support received, and the

expectations when in need, and between event specific support and general

support. The definition in terms of a subjective feeling of support raises the

question whether social support reflects a personality trait, rather than the

actual social environment (Pierce et al., 1997; Sarason et al., 1986).

Types of Social Support

Types and sources of social support may vary; House ( 1981) described

four main categories of social support: emotional, appraisal, informational

and instrumental:

1.Emotional support: generally comes from family and close friends

and is the most commonly recognized form of social support. It is

associated with sharing life experiences. It involves the provision of

empathy, love, trust and caring (Thoits, 1995, 1999; Turner et al.,1999).

2.Instrumental support: is the most concrete direct form of social

support, it involves the provision of tangible aid and services that


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directly assist a person in need and encompassing help in the form of

money, time, in-kind assistance, and other explicit interventions on

the persons behalf. It is provided by close friends, colleagues and

neighbors.

3.Appraisal support: involves transmission of information in the form

of affirmation, feedback and social comparison. This information is

often evaluative and can come from family, friends, co-workers, or

community sources.

4.Informational support: involves the provision of advice, suggestions,

and information that a person can use to address problems.

Determinants of Social Support

Social support is a consequence of the interplay between individual factors

and the social environment. Therefore, factors affecting social support may

be individual or social, or both. Social support may also be partly

determined by genetic factors.

Social support in adulthood may be to some extent genetically determined

(Bergman et al., 1990). However, the strength of this assumed relationship

differs between studies. Bergman and colleagues found that genetic factors

were responsible for 30% of the variance in perceived support. However,

genetics made little contribution to individual differences in the actual

quantity of enacted support.

Furthermore, another study demonstrated only a minor role of genetic

factors in the association between perceived support and depression (Kessler

et al., 1994). In this study, depression was not so much reduced by genetic


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determinants of social support, but mainly by the stress-buffering effect of

perceived support.

Individual and personality factors that might be associated with perceivedsocial support are interpersonal trust (Rotter, 1967) and social phobia

(Barlow, 1988). Without trusting other people, it is less likely that the

person will perceive support from others, and interact with others in such a

way that social support is provided. People with social phobia have a strong

feeling of anxiety connected to contact with other people.

The position of a person within the social structure will influence the

probability of them receiving social support. The position of a person is

determined by such factors as:

1.Marital status: People who are not married and live alone are less

likely to receive social support than people who are married.

2. Family size: People with many children are likely to receive more

social support than people with few children (Broadhead et al., 1983),

because they have a more extensive family network.

3.Age: Elderly people tend to receive less social support than younger

people (Stephens et al., 1978).

4. Gender: Women tend to receive more social support than men

(MacFarlene et al., 1981).

5. Socio-economic status and migration: People with lower socio-

economic status report less social support than other people (Dalgard

et al., 2006; Dalgard et al., 2007). Social support seems to decrease

the lower the occupational status, unskilled workers reporting the

poorest social support (Marmot et al., 1991).


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Also the occurrence of social support depends on the opportunities that a

person creates to interact with other people. These opportunities are

determined by a number of contextual variables, such as (Schieflo, 1992):

The existence and availability of social arenas i.e. places where people

can meet, like shopping centres, parks, sport arenas and the like.

Purpose of social interaction. Without a unifying purpose for contact

(e.g. addressing a common problem, playing a game, celebrating an

event), social interaction will be low.

Time spent together. Without enough time, interpersonal relationships

will not develop.

Continuity of relationships. Without continuity social relationships

will easily be disrupted.

Sharing of social norms and values. If people are too different with

respect to social characteristics (such as religious and cultural

preferences), it is less likely that they will develop supportive

relationships.

The structure of the community determines to what extent people live

in a social context that is conducive to social support. In communities

characterized by social disintegration, the level of social support

among people is reduced compared to integrated communities

(Leighton, 1959; Dalgard, 1986). Typical for disintegrated

communities is that the level of social cohesion is low, that peoplelack trust in each other, and that social interaction is low.


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Effects of Social Support

With respect to health, social support may have direct or indirect (buffer)

effects (Cohen & Syme, 1985):

The direct effect implies that social support has a positive effect on

health, irrespective of life situation

The buffering or indirect effect occurs only when the person is

exposed to stressors, like negative life events and more lasting

adversities. In this instance, social support is supposed to help the

person to cope better with the situation, and hence prevent stress.

There is no theory adequately explaining the link between social

relationships and health .Yet social support also can affect a persons health

through different pathways: behavioral, psychological and physiological

pathways(Berkman & Glass, 2000):

In the health behavioral pathway, social support influences a persons

health behavior. A lack of social support is, for example, associated

with excess smoking (to relieve psychological distress), an unhealthy

diet and a lack of exercise, and less use of health services when ill.

In the psychological pathway social support affects mental health

through such factors as self-esteem and self-efficacy.

The perception of social support strengthens the coping abilities of the

person, and hereby reduces stress and its negative physiologicaleffects on health, for instance through the immune system or the

cardiovascular system. Cassel (1976); Shields (2004) found that

social support served as a protective factor to peoples vulnerability

on the effects of stress on health.


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Social Support Among Different Cultures

Glazer (2006) stated that propositions regarding the relationship between

social support and culture suggest that people in Anglo and Western

European nations perceived greater emotional support than people in Latin

and Eastern European nations, followed by people in Asian nations. In

addition, Eastern and Western Europeans perceived greater instrumental

support than Latinos and Anglos, who are expected to perceive greater

support than Asians. Westerners tend to view a person as independent and

separate from other people, whereas Asians tend to view a person as

fundamentally connected with others (Markus & Kitayama, 1991; Shweder

& Bourne, 1984; Triandis, 1989). This difference might lead to the

assumption that coping via social support would be especially common

among Asians, because they place emphasis on interconnectedness with

their social group. In fact, however, the opposite may be the case.

The idea that social support involves specific transactions whereby one

individual enlists the help of another in service of his or her problems may

be a particularly Western conceptualization of social support. The

independent view of the self that is prevalent in the Western cultural context

holds that individuals take actions that are oriented toward the expression of

their opinions and beliefs, the realization of their rights, and the achievement

of their goals (Fiske et al., (1998); H. Kim & Markus, (1999). The

conceptualization of social support in terms of explicit transactions

presupposes that it is appropriate to enlist others in meeting those goals.

Thus, stressed individuals may focus primarily on themselves and their goal

of coping with the stress and recruit the time and attention of others in this

process.


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In contrast, Asians tend to view a person as primarily a relational entity,

interdependent with others. In these cultural contexts, social relationships,

roles, norms, and group solidarity typically are more fundamental to social

behavior than an individuals needs. This interdependent view of the self

holds that a person should conform to social norms and respond to group

goals by seeking consensus and compromise; as such, personal beliefs and

needs are secondary to social norms and relationships (Fiske et al., (1998);

H. Kim & Markus, (1999).

In Asian cultural contexts, because emphasis is placed on maintaining

harmony within the social group, any effort to bring personal problems tothe attention of others or enlist their help may risk undermining harmony

and/or making inappropriate demands on the group (Taylor et al., 2004).

There is some research on social support transactions and their effects in

Asian countries. The research has largely focused on specific stressors, such

as managing a mentally retarded child (Shin, 2002) or caring for an elderly

parent (Ng, 2002). Many of these studies are exploratory surveys that

provide descriptions of support needs without examining cultural influences.

Nonetheless, several findings are consistent with the above reasoning.

Research shows that European Americans are more likely to report needing

and receiving social support than are Asians and Asian Americans (Hsieh,

2000; Shin, 2002; Wellisch et al.,1999). Moreover, one study (Liang &

Bogat, 1994) found that received social support had negative buffering

effects for Asians (i.e., it made Asians feel more stressed).

Taylor et al. (2004) research highlights the importance of considering

culture in order to understand why and how people seek the advice and

comfort of others when facing stressors. It reveals that there are significant


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cultural differences in the use of an important resource for managing

stressful events, namely, social support. Whereas European Americans

explicitly recruit their social networks for help and solace in coping with

stressful events, Asians and Asian Americans do so to a lesser extent

Taylor et al. (2004) research also shows that social support seeking takes

place within a cultural context in which people by and large understand and

live according to a particular view of their relationships. The decision to

seek or not to seek social support is guided by the norms and concerns of a

given culture. If what comes to a persons mind when he or she is

considering seeking social support are the faces of concerned family andfriends, then it may be a bit hard to say help out loud.

Conservatism vs. Autonomy culture values likely explains variations in

social support. People in Autonomous cultures reported greater emotional

support and less instrumental support than people in Conservative cultures

(Glazer, 2006)

Mental Health and Social SupportLarge number of studies suggest that poor social support is associated with

mental health problems, such as depression (Brown & Harris, 1978; House,

1981; Schaefer et al., 1981; Dalgard et al.,1995). Low level of perceived

support is associated with ill-health (both e.g. depression and somatic

diseases (MINDFUL, 2008)

Lehtinen et al. (2005) conducted a study which revealed the strong

association between mental health and social support. Strong link between

social support and mental health has also been found in many other studies

(Julian et al., 1992; Dalgard et al., 1995; Kendler et al., 2000, Sohlman B,

2004). The most interesting finding ofLehtinen et al.(2005) study, however,


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was the evidence that the level of social support predicted the state ofpositive mental health in between-country comparisons.

Countries with the highest level of social support (i.e. Sweden and Ireland)

tend to report the lowest levels of psychological distress and vice versa

(EORG, 2003). A significant association between strong social support and

positive mental health, in the sense of coping resources, like energy and

vitality, was found (EORG, 2003; Lehtinen et al., 2005).

Okasha (2005) stated that eastern cultures emphasize social integration

more than autonomy (i.e., the family and not the individual is the unit of

society). An Egyptian study was carried out to determine the effect offamilies expressed emotions and patients perception of family criticism in

predicting depression and to evaluate trans-cultural differences in

assessment of these measures. The results showed that criticism level that

best differentiated relapsers and nonrelapsers was much higher than

previously reported in Western studies (Okasha et al., 1994)

Cavalheri (2010) found that a new paradigm for treatment and

management of the mentally ill through deinstitutionalization, rehabilitation

and psychosocial reintegration. In this model, the ways they are treated have

been transformed, and the object of treatment is no longer the disease and

became the life; the suffering of the individual and their relationship to the

social body. So the emphasis is not focused more on the healing process but

the project of "invention of health" and "social reproduction of the patient

The living with the disease, physical or psychiatric, is very difficult and

stressful for the family group, which worsens when it tends to be prolonged,

repeated displays of acute manifestations and, especially, is experienced as

disabling and stigmatizing that generates overhead of a physical, emotional
http://www.ncbi.nlm.nih.gov/pubmed?term=%22Okasha%20A%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Cavalheri%20SC%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Cavalheri%20SC%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Okasha%20A%22%5BAuthor%5D


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and economic, altering the family dynamics and compromising health, social

life, relationship between members, leisure, financial status, domestic

routine, work performance, and countless other aspects of living (Melman,

2001; Pegoraro and Caldanha, 2006)

To address these issues have been suggested family interventions, through

educational activities for informational purposes, extension of emotional

resources and coping skills to intervene in particular situations, beyond

deconstruction of representations prejudiced about mental illness. It is

therefore relevant to the role of mental health services to host and prepare

them in expanding their capabilities (Mao, 2003).

Social Support and Suicide

Since the late-nineteenth century, scholars have investigatedhow structural

elements within a communitywhat is nowcalled social supportrelate to

suicide (Winfree and Jiang , 2010).CDC (2007) listed family and community support in the list of protective

factors from suicide.

Research dating back over 100 years suggests that social fragmentation

may influence suicide as Durkheim recognized the importance of anomie

(social fragmentation) in influencing suicide (Durkheim, 1897, 1952).

Durkheims work on suicide has been cited as evidencethat modern life

disrupts social cohesion and results in a greaterrisk of morbidity and

mortality including self-destructivebehaviors and suicide (Kushner and

Sterk, 2005), and a growing body of evidence supports his view that lack of

social support by family or community is believed to be a risk factor for

suicide and emotional and psychological support in friends and family


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members helps as a safeguard against suicide (Lester, 1988; Whitley et al.,

1999; Smith et al., 2004; Masocco et al., 2009).

In deed "The notion that social cohesion is related to the health ofa

population,"Kawachi et al. (1997) wrote, "is hardly new. One-hundredyears

ago, Emile Durkheim demonstrated that suicide rates were

higher in

populations that were less cohesive".

For Durkheim,

social cohesion,

especially traditional family life, providedthe best protection against self-

destructive behavior (Baudelot and Establet, 1984).

According to Durkheims theory, social isolation and household Size,

disintegration, and disconnectedness lead to suicide. As a proxy for socialisolation, variables such as household size and proportion of one-person

households are used (Chen et al., 2009)

Neumayer,s (2003) study shows that household size has a significantly

negative effect on female suicide rates and an insignificantly negative effect

on male suicide rates.

Burr et al. (1994) used the proportion of one-person households in a

metropolitan area as the indicator of social isolation and shows a positive

relationship between the proportion of one-person households and suicide

rates.

Daly and Wilson (2006)showed that as per U.S. aggregate data, the share of

married people had a significantly negative impact on suicide rates in both

1990 and 2000, whereas that of single/never married people had a

significantly positive impact on suicide rates in the individual level data.

Chuang and Huang (2003) used the proportion of widowed population in

each region in Taiwan as the indicator of social isolation and shows that its

impact is significantly negative on the total suicide and female suicide rates


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but not on the male suicide rate. It is surprising that a region with a greater

proportion of widows has a significantly lower suicide rate. The researchers

argue that the existing widowed population may include those who have

been widowers for some time and have built enough resilience; therefore,

they are at less risk for suicidal behavior than widowers who have just lost

their husbands. Daly and Wilson (2006) also found that the share of

widowed people had a negative relationship with suicide rate in U.S.

counties in 1990 and 2000; however, they provided no explanation for it.

Neumayers (2003) research results on wide range of socialexplanatory

variables based on Durkheimian

sociological theory in estimation

of suiciderates in a large panel of up to

68 countries during the period 1980 to 1999;

suggestthat economic and social factors affect cross-country differences

in

suicide rates in accordance with theory. More importantly this suggests that

the vastmajority of the existing literature, which typically fails to

control for

national cultures of suicide and suggests socioeconomicfactors as important

determinants of suicide, can still be expectedto come to valid results.

Houle et al. (2005) conducted a study is to investigate whether socialsupport may constitute a protective factor for attempted suicide among men

and, if so, to identify the most important sources and forms of support.

Results indicated that the men who attempted suicide perceive less support;

and are less satisfied with the support they received following the stressful

event that occurred.These results are in the same direction as those reportedin previous studies (Sokero et al. 2003;Botnick et al. 2002; Eskin, 1995,

Lewinsohn et al. 1993;Veiel et al., 1988).

Tangible support (lend money, temporary shelter, helping to move, for

example) and the assurance of its value (valuing the individual, recognizing


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his skills, for example) are forms of are the forms of support that appear to

be of most importance. This study highlights the importance of social

support in the prevention of suicidal behavior among men (Houle et al.,

2005).

Social support was found to have a significant independent protective

effect on suicide (Chen et al., 2006). The association between poor social

integration and suicide is robust and largely independent of the presence of

mental disorders (Dubersteinet al., 2004), negative correlation between

societal suicide rates and social integration was found by (Shah, 2008).

Studies indicate that people living in deprived areas generally have highsuicide rates (Gunnell et al., 1995; Bunting and Kelly, 1998; Whitley et al.,

1999). A review of the risk of suicide in the homeless showed increased

suicide mortality among the homeless persons (Nordentoft, 2007).Other

analyses suggest that the proportion of single person households in an area

may be the strongest predictor of suicide (Ashford and Lawrence, 1976;

Saunderson et al, 1998).

Zhang et al. (2010) stated that risk factors among suicide victims include

lower level of social support. Recent research on suicide in China reveals

increasing rates of suicide duo to high number of rural, young females who

experience acute interpersonal crises and then commit suicide (LawandLiu

,2008)

As a general rule, suicide rates are highest among relatively more prosperous

countries, particularly those which have developed rapidly. Within these

countries, suicide rates are highest for sub-groups that have remained socio-

economically disadvantaged. And this has been associated with a heightened

risk of suicide among those remaining in rural settings, perhaps because of
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economic hardship, lack of social support and isolation (Vijayakumar et al.,

2008).

On the contrary and in contrast to Durkheim; Steinmetz (1894) found that

women living in the most socially integrated societies had a greater

incidence of suicide than men. Johnson (1979) suggestedthat women most

submerged in the family display the greatestfemale suicidal behavior. Her

views have been affirmed by recentreports that the highest rates of suicide

in the world are foundamong rural Chinese women (Law and Liu, 2008).

This reinforcesthe conclusion of historian Roger Lane,

who found that

contrary

to Durkheims assumptions, increases in suicide rates

were linked tosocial integration. Lane found that as 19th-century

Philadelphia urbanized,

its suicide rate grew proportionallygreater than its homicide rate. Lane

reasoned that the increasingincidence of suicide in late-19th-century cities

served as abarometer of social integration because suicide, unlike homicide,

indicated internalization of social anger (Kushner and Sterk, 2005).

Kunitzs (2004)study on the effect of over-integration in the family in the

southwestern United States supports the viewsof Johnson and Lane. Social

relations within extendedfamilies, Kunitz found, often resulted in negative

health outcomes,including significantly higher rates of depression and self-

destructivebehaviors.

A study in England over 30 years period bySchapira et al. (2001) showedthat nearly threefold increase in the number living

alone in the general

population was associated with a marked fall in suicide among them,

suggesting that the social disorganisationof urban areas with high suicide

rates found by Sainsbury (1955) did not occur . However, living alone was

still associated with a significantly increased suicide risk.
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Suicide in Asia is a significant and complex phenomenon. The

epidemiological profile of suicide in Asian countries differs from the typical

profile reported in the scientific literature, because the latter has generally

been gleaned from studies conducted in European countries and the United

States of America. This may be explained, at least in part, by the complex

web of socio-economic, cultural and religious factors in Asian countries

(Vijayakumar et al., 2008)

In their study on suicide in the Asian region(Vijayakumar et al., 2008)

included three South Asian countries (India, Sri Lanka, and Thailand),

belonging to the WHO South-East Asia Region, and one country belongingto the WHO Eastern Mediterranean Region (Pakistan), and eight countries

(Australia; China; Japan; Malaysia; New Zealand; the Republic of Korea;

Singapore; Viet Nam; and China, Hong Kong, Special Administrative

Region [Hong Kong SAR]),belonging to the WHO Western Pacific Region.

(Vijayakumar et al., 2008) found that with the exception of Australia and

New Zealand, which share similarities with European countries and the

United States of America, participating Asian countries; have traditionally

been characterized by the dominance of extended family systems,

dependence on the family, and the fact that family loyalty overrides

individual concerns these factors may help to explain some of the patterns of

suicide that are characteristic of these countries; the role of the family seems

to be changing. Being married, for example, appears to be less protective

against suicide in developing Asian countries than it is in Europe and the

United States of America, with studies in China and India finding that single

individuals are no more vulnerable to suicide than their married counterparts

(Phillipset al., 2002)


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Weissman et al. (1999) assessed suicide ideation and attempts in 9

different countries; the United States, Canada, Puerto Rico, France, West

Germany, Lebanon, Taiwan, Korea and New Zealand, results revealed that

while the rates of suicide ideation varied widely by country, the rates of

suicide attempts were more consistent across most countries. The variations

were only partly explained by variation in rates of psychiatric disorders and

divorce or separation among countries.

The convergence of socio-demographic effects on suicide appears to vary

across cultures. For instances, an epidemiological study in Japan found that

suicide rates were higher in people where marriage was more common anddivorce was less common (Chandler and Tsai, 1993); a Pakistan study also

revealed that more married women committed suicide than did unmarried

women (Khan and Reza,2000) .

Brown (2001) stated that an increase in suicides in developing countries was

observed, with loss of tradition, social cohesion, and spontaneous social

support. The culture of these countries became more individualistic and so

making the people more vulnerable to suicide.

Faupel et al. (1987) show that the percentage of people living alone has the

most negative effect on suicide rates in the most urban counties as compared

to the middle urban or least urban counties.

Nevertheless, a reading of Durkheims evidence supportsthe opposite

conclusion, that is, that the incidence of suicideis greatest among those most

subsumed in social groups. Durkheimsdata revealed that the highest suicide

rates were found amongthose who were most socially integrated (Kushner,

1995).


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Bille-Brahe et al. (1999) surprisingly found that suicide attempters in their

study agree in feeling that their needs for support were met to a great extent.

While consistent with many studies, lived alone (Duberstein et al., 2004;Heikkinen et al.,1997) and never married (Kposowa ,2000; Qin et al., 2003)

were found to be significant risk factors for the middle-aged suicides .

Wong et al. (2008) in their study found that a few protective factors

including social support and social problem-solving ability, did not achieve

statistical significance among adults aged 3049years. However, they were

found statistically significant as risk factors.

While Winfree and Jiang (2010) foundthat feeling safe at school was

oneof the most consistent protective factors in their study about youthful suicide

andsocialsupport.

A study led by Cook et al. (2002) proved that the strong religious faith

and social support of older African Americans may be key factors in why

they die by suicide far less often than whites. While Wiktorsson et al. (2010)

found that attempted suicide in the elderly was associated with being

unmarried and living alone. Lower social interaction patterns and lower

perceived social support were significantly related to suicidal ideation as

found by (Rowe et al., 2006), neither objectively determined size of social

network nor instrumental support was associated with suicidal ideation;

concluding that subjective social support is a potentially modifiable risk

factor for suicide in later life (Rowe et al., 2006).

Suppapitiporn et al., (2004); Holma et al., (2010) found that depressed

patients who attempted suicide were more likely to report fewer of friends

and a lower level of social support.


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Social environment factors including deficits in family functioning, lower

levels of family adaptability and family cohesion, deficits in social support

and lower levels of social embeddedness were associated strongly with

suicide attempts and increased the relative rate of suicide attempts among

low-income African American men and women (Compton et al.,2005;Kaslow et al., 2005).

Assessment of patient's support network as well as their perception of

available social support should be included in the evaluation of depressed

patients particularly in those with substance use disorder and intervention to

prevent suicide should focus more on increasing their capacity to obtainsocial resources and modulating their perception (Suppapitiporn et

al.,2004).

RehkopfandBuka (2006) found that analyses at the community level are

significantly more likely to demonstrate lower rates of suicide among higher

socio-economic areas. Also measures of area poverty and deprivation were

most likely to be inversely associated with suicide rates.RehkopfandBuka(2006) concluded that the heterogeneity of associations is mostly accounted

for by study design features that have largely been neglected in literature.

Wong et al., (2008) further added that these inconsistent findings suggest

that the relationship between social factors and suicide is equivocal when

cultural issues were taken into account.
http://www.ncbi.nlm.nih.gov/pubmed?term=%22Rehkopf%20DH%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Buka%20SL%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Rehkopf%20DH%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Rehkopf%20DH%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Buka%20SL%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Buka%20SL%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Buka%20SL%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Rehkopf%20DH%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Buka%20SL%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Rehkopf%20DH%22%5BAuthor%5D


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Summing Up

Social support is defined as the individual belief that one is cared for and

loved, esteemed and valued, and belongs to a network of communication and

mutual obligations.

The concept of a social network represents the ties to family, friends,

neighbors, colleagues, and others of significance to the person, there are

different types of social networks , the most common are:

a) Diverse, with distinct sources of potential support (family, friends,

neighbors, community groups) and with frequent contact;b) Focused on family

c) Focused on friends, and

d) Restricted in terms of potential sources of support and frequency of

contacts.

There are four main categories of social support: emotional, appraisal,

informational and instrumental.

Social support is a consequence of the interplay between individual factors

and the social environment e.g. age, sex, marital status, etc... Social support

may also be partly determined by genetic factors. However, when the social

network is described in structural terms, like size, range, density, proximity

and homogeneity, social support normally refers to the qualitative aspects of

the social network.

Social support affects a persons health through different pathways:

behavioral, psychological and physiological pathways.

Current research highlights the importance of considering culture in order to

understand why and how people seek the advice and comfort of others when

facing stressors. It reveals that there are significant cultural differences in the


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use of an important resource for managing stressful events, namely, social

support. Whereas European Americans explicitly recruit their social

networks for help and solace in coping with stressful events, Asians and

Asian Americans do so to a lesser extent. There was evidence that the level

of social support predicted the state of positive mental health in between-

country comparisons.

Countries with the highest level of social support (i.e. Sweden and Ireland)

tend to report the lowest levels of psychological distress and vice versa.

Large number of studies suggested that poor social support is associated

with mental health problems, such as depression.Despite the extensive literature, there have been widely divergent findings

regarding the direction of the association between socio-economic

characteristics and suicide rates, with high-quality studies finding either a

direct relation (higher rates of suicide in higher socio-economic areas), an

inverse relation (lower rates of suicide in higher socio-economic areas) or no

association.

Durkheims work on suicide has been cited as evidencethat modern life

disrupts social cohesion and results in a greaterrisk of morbidity and

mortality including self-destructivebehaviors and suicide, and a growing

body of evidence supports his view that lack of social support by family or

community is believed to be a risk factor for suicide and emotional and

psychological support in friends and family members helps as a safeguard

against suicide.

chapter 4 suicide and social support

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