Marital status integration, psychological well-being, and suicide acceptability as predictors of marital status differentials in suicide rates

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Social Science Research 34 (2005) 570–590

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Marital status integration, psychological well-being, and suicide acceptability as predictors of marital status differentials in suicide rates q Phillips Cutright a,*, Robert M. Fernquist b b

a Indiana University, Bloomington, IN, USA Central Missouri State University, Warrensburg, MO, USA

Available online 6 July 2004

Abstract Age–gender–marital status-specific 1979 and 1992–1994 US White suicide rates test the hypotheses that marital status differences in these suicide rates are caused by (1) marital status differences in marital status integration, (2) marital status differences in psychological well-being, and/or (3) marital status differences in suicide acceptability. A proxy for years spent in a marital status was included in the analysis of all age groups. The dependent variable is the standardized suicide difference coefficient. In multiple regression analysis, psychological well-being and suicide acceptability were consistently related to the dependent variable for persons aged 20–54, 55 and over, and 20 and over, while marital status integration was related to the dependent variable only for persons 20–54 and 20 and over.
2004 Elsevier Inc. All rights reserved.

q *

We thank Indiana University and Central Missouri State University for their support. Corresponding author. Present address: 400 Winfield Cove Rd. Saluda, NC 28773, USA. E-mail address: [email protected] (P. Cutright).

0049-089X/$ - see front matter
2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ssresearch.2004.05.002

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1. Introduction For over a century, sociologists have tried to understand why suicide rates vary by marital status. Typically, married persons have lower suicide rates than do the unmarried and explanations of this social fact have varied from (1) a hypothetical ÔselectionÕ hypothesis, (2) marital status differences in psychological well-being, (3) marital status differences in the norms about suicide acceptability, and/or (4) differences in role strain related to the degree of marital status integration. The first systematic quantitative effort to understand marital status differences in age- and gender-specific suicide rates (Gibbs and Martin, 1964, pp. 99–100) found that the ratio of the age-specific proportions of married to widowed persons (their measure of marital status integration) was closely related to the ratio of age-specific widowed to married 1949–1951 US White suicide rates. This finding was largely ignored in most subsequent research where investigators (e.g., Gove, 1972; Stack, 1990) offered alternative explanations. Following a review of the literature we test competing hypotheses regarding variation in marital status differences in suicide rates. We use multivariate analysis to examine how marital status integration, psychological well-being, and suicide acceptability are related to age- and gender-specific marital status differences in the US White populationÕs suicide rates in 1979 and 1992–1994.

2. Literature review Below we review research on marital status differences in suicide rates from three different approaches. First, we examine how suicide rates vary by marital status and then we discuss the marital status integration hypothesis. Next, we first review research on suicide and psychological well-being, and then summarize the suicide acceptability explanation of marital status differences in suicide rates. Finally, the Ôselection hypothesisÕ explanation of marital status differences in suicide rates is discussed. 2.1. Marital status and suicide Durkheim (1897 [1951], p. 178) presented French age-specific 1889–1891 suicide rates of married, widowed, and unmarried (i.e., single) men and women. He computed the ratio of the single to married suicide rates by age and gender, and similar ratios of the widowed to married, and the single to widowed suicide rates. The ratios showed much lower suicide rates of married compared to single or widowed men; single men had higher suicide rates than widowed men in most age groups. Married women also had lower rates than did single or widowed women. The female age-specific ratios of the single to widowed suicide rates were small and showed no consistent advantage for single women. DurkheimÕs data (pp. 186–189) on marriage, fertility, and suicide showed that suicide rates of the married were lower among those with children compared to married persons that were childless. This finding was subsequently well supported by a much larger body of French data (Danigelis and Pope,

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1979, Table 4). Building from DurkheimÕs seminal work, Danigelis and Pope (1979, Table 2) also presented the means of suicide rates from 14 developed nations for years around 1960 by age, gender, and marital status. Married persons of both genders had lower suicide rates at all ages than did single, widowed or divorced persons. Similar differential suicide rates by age and marital status have been reported for the US population (Gibbs and Martin, 1964, Chapters 8 and 9) for 1939–1941 and 1949–1951. Stack (1990, Tables 2 and 3) presented age–gender–marital status-specific suicide rates for the US White population in 1959–1961 and 1979. Married men and women had lower rates than unmarried men and women in nearly all comparisons. In his review of literature on marital status and suicide during the late 20th century, Stack (2000, pp. 167–169) finds that married persons have lower suicide rates than non-married persons. From the time of Durkheim up through the 1900s, then, it has been established at the cross-national level that married persons have lower suicide rates than non-married persons. Having laid the foundation of how marital status is related to suicide, we now turn to work on marital status integration and suicide (Gibbs and Martin, 1964). Gibbs and Martin build from DurkheimÕs discussion of marital status and suicide and develop a theory of suicide that will be one focus of this research. 2.2. Marital status integration and suicide Gibbs and Martin (1964) and Gibbs (1969, 1982) developed status integration theory. Briefly, persons are in a compatible status if their status is one that conforms to socially sanctioned expectations. The degree of ‘‘. . .role conflicts varies directly with the extent to which individuals occupy incompatible statuses. . .’’ (Stafford and Gibbs, 1988, p. 1061). Persons in incompatible statuses will have lower integration than those in compatible statuses and ‘‘. . .the suicide rate of a population will vary with the degree of status integration’’ (p. 1061). The original measure of the degree of marital integration of persons in a given age group (Gibbs and Martin, 1964) was the sum of the squared proportions of persons in that age group who are in each marital status. Gibbs and Martin (1964, Chapter 8; Gibbs 1969, 1982) provide many examples of statistically significant negative correlations of this indicator with age-specific male and female suicide rates. Although Stafford and Gibbs (1988) argued that the correlation between marital status and suicide disappears when measures of occupational integration are controlled, the most recent work done by Gibbs (2000) finds that there is indeed an inverse association between marital status integration and age-specific suicide rates. Aside from the basic measure of marital status integration (e.g., the sum of the squared proportions of persons in each marital status), Gibbs and Martin (1964, pp. 102–103) also suggested that the length of time one occupies a given marital status may affect the probability of suicide due to status inconsistency. They note that the difference in the ratio of married and widowed female suicide rates declines with age and they attribute this trend to the fact that older widowed women had been in that status longer than younger widows, and the passage of years allowed them to adjust to their inconsistent status. This implies that a newly divorced person may

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be less able to deal with his/her inconsistent status than a divorced person with 10 or more years in that status. In addition to testing Gibbs and MartinÕs hypothesis that marital status integration is inversely related to suicide rates, we also test the hypothesis that Ôlength of timeÕ in a marital status should narrow the suicide difference between pairs of marital statuses as we go from younger to older ages. Stack (1990) compared the ratio of divorced to married age–gender-specific suicide rates in 1959–1961 to the ratios in 1979. For both men and women status integration theory predicts that the suicide rates of divorced persons should decline as the proportion of persons in an age group increases. Such an increase did occur between 1959–1961 and 1979. The divorced to married suicide ratios also declined and ‘‘This finding lends support to the theory of status integration’’ (Stack, 1990, p. 124). We extend the work done by Stack by taking marital status integration data from 1979 and compare them to the 1992–1994 suicide statistics. One problem with GibbsÕ marital status integration empirical tests, though, is that no direct measure of role strain (or conflict or inconsistency) is included. While it is unlikely that simple attitudinal measures of marital status inconsistency will fully capture this broad concept, Gove (1972) proposed a measure of psychological well-being that may be a reasonable proxy for the Gibbs concept. This measure is discussed in the next section. 2.3. Psychological well-being and suicide Gove (1972) examined 1959–1961 US suicide data from a mental health perspective. He noted that Gurin et al. (1960) found significant differences in self-reported happiness between married and unmarried adults. These authors concluded that ‘‘being alone is itself probably the greatest source of stress’’ and those not married have ‘‘. . .problems of ambiguous role requirements’’ (p. 231). They also found that being married is itself the greatest source of happiness for both men and women and ‘‘Of course this source of happiness in unavailable to unmarried respondents’’ (p. 232). Another advantage available to the married is that when troubled they turn to their spouse for comfort, a resource unavailable to those not married. Gove also cites BradburnÕs (1969) study of adults ages 21–59. About 36% of married men and women said they were very happy compared to about 18% of single respondents. Only some 12% of divorced men or women said they were very happy; for widowed males and females the statistics were 7 and 14%, respectively. An earlier report (Bradburn and Caplovitz, 1965, Table 2.4) found that about 3% more married and widowed men than similar women said they were Ônot too happy.Õ This gender difference increased to 12% and then 16% among divorced or separated, and single persons. Gove (1972, p. 206) states that ‘‘. . .the most important finding of the studies of mental illness and psychological well-being is that in our society marriage appears to be more advantageous to men than women, while being single (or divorced or widowed) is probably more disadvantageous to men than women.’’ While GoveÕs interprets differences in suicide rates among marital status-, gender-, and age-specific populations as a function of differences in psychological well-being (i.e., reported

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happiness), he failed to directly link a measure of happiness to his suicide rates. This lack of quantitative analysis will be remedied in a later section, below. Stack and Eshleman (1998) note that relying only on studies of the American population may fail to account for suicide patterns in nations with different social and economic structures. Their study takes data from 17 nations collected by the World Values Study Group during 1981–1983. There were 10,127 female and 9237 male respondents. Stack and Eshleman test the hypothesis that the association of psychological well-being and marital status might be spurious. They note that both religiosity and physical health are also related to happiness and the studies cited above failed to control for these personal characteristics. For example, married persons tend to have better physical health and attend church more frequently and have a higher standard of living than do those single, widowed or divorced, and these differences might explain the observed marital status differences in happiness. They also include a marital status group not included in the research we have reviewed—cohabiting couples. This allows a test of the Gurin et al. (1960) hypothesis that being ÔaloneÕ may explain the disadvantage in psychological well-being of those not married in contrast to married (or cohabiting) couples. Stack and Eshleman also test whether persons in different marital statuses differ in their level of happiness when financial satisfaction, self-assessed physical health, church attendance, gender, age, and parental status are controlled. (Because being married may be a cause of the higher standard of living, church attendance and physical health, introducing these measures may over-control the association between married versus unmarried levels of well-being.) A dummy variable code for each nation is also included with the United States as the reference category. Net of this set of controls, the marital status with the strongest positive association with happiness was being married. Its coefficient was triple that of cohabiting couples. The divorced, separated, and widowed all took negative coefficients with happiness. Being married was also positively related to financial satisfaction, in contrast to the negative coefficients linked to all other marital statuses. The married were also the only marital status group with a positive net coefficient when satisfaction with physical health was the dependent variable (Stack and Eshleman, 1998, Table 1). With the exception of Northern Ireland, the relationship of happiness to marital status in the United States was the same in the remaining 15 countries. It appears, therefore, that psychological well-being has a direct association with marital status-specific suicide rates. Therefore, we control the level of psychological well-being in our analysis. 2.4. Suicide acceptability and suicide rates The hypothesis that the culture of suicide may affect suicide rates net of measures of societal integration or status inconsistency has been a relative newcomer to the empirical analysis of suicide rates. Just as norms regarding fertility, marriage, divorce, and other vital events vary among populations and over time, norms regarding the acceptability of suicide should also differ among populations. As suicide acceptability varies, suicide rates should also increase or decrease.

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Stack (1996–1997) measured Ôsuicide ideologyÕ with a score from four questions about the acceptability of suicide using data from the General Social Survey, a probability sample of US adults. Controlling for church attendance, Roman Catholic religion, age, years of education, number of children ever-born, and gender, he found that married persons had significantly lower suicide acceptability attitudes than did persons who were not married. Stack (1997) also examined 1981–1983 suicide ideology data from 17 nations covered by the World Values Survey (WVS). Suicide ideology was measured by responses to the question ‘‘Please tell me whether or not you think that suicide can always be justified, never be justified, or somewhere in between?’’ Stack (1997, Table 1) reported that, in all 17 countries, married persons were less likely than unmarried persons to say that suicide was justified. Further analysis of WVS data in 15 nations (Stack, 1998, Table 1) showed that married persons had lower scores on suicide acceptability than those not married net of controls for years of education, political liberalism, financial satisfaction, age, drinking behavior, national residence, frequency of church attendance, having or not having children, and whether one was working full time or was self-employed. Analysis of WVS suicide acceptability data found that this variable has significant association (net of measures of female labor force participation, female tertiary school enrollment, religious book production, and income inequality) on both male and female suicide rates in 20 developed nations in the 1955–1974 period as well as the 1975–1994 years (Cutright and Fernquist, 2001, Table 3). Suicide acceptability was also significantly related to all seven age-specific 1960–1989 female suicide rates in 20 developed countries (Cutright and Fernquist, 2000, Table 4). Thus, variation in norms about suicide acceptability across marital status subgroups should be related to the suicide rates of marital status subgroups. 2.5. The selection hypothesis The selection hypothesis argues that if one marital status has a higher suicide rate than another it is because persons who are predisposed to suicide are attracted to that marital status. Thus, the low suicide rates of the married compared to the unmarried are caused by the mental stability of the married compared to the unstable suicide prone population of unmarried persons. Gibbs and Martin (1964, p. 100) note that this hypothesis ignores the very large differences in suicide rates among married persons across age groups. They comment that ‘‘. . .the ratio of the suicide rates of the single, widowed, or divorced to the married varies considerably by age. . .’’ (p. 101). For example, in their 1949–1951 US data the suicide rate of the widowed is about double that of the married at younger ages, but is little different among persons 65 and older. They add that the selection hypothesis does not explain differences in suicide rates by race or gender since both are ascribed statuses that cannot attract individuals, Ôunhealthy or otherwise.Õ Gove (1972, p. 205) also rejects the selection argument. GoveÕs (1973) study of marital status differentials in 1959–1961 causes of death other than suicide (i.e., homicide, motor vehicle accidents, pedestrian deaths, all

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other accidents, cirrhosis of the liver, lung cancer, tuberculosis, and diabetes) found that ‘‘. . .controlling for age, the married have lower mortality rates than the single, the widowed, or the divorced and the difference between the married and the unmarried statuses are much greater for men than for women’’ (p. 45). Gove rejected the selection hypothesis in favor of a Ôrole explanationÕ to understand these patterns. Briefly, Gove says that the roles married persons have (such as parent and spouse) help them develop ‘‘close interpersonal ties’’ (p. 46). Gove adds that having close interpersonal ties is a key factor in a personÕs psychological well-being. Stack and WassermanÕs (1993) study of the correlations of alcoholism with suicide and marital status also refutes the selection hypothesis. They argue that, rather than alcoholism causing social isolation, alcoholism among non-married persons is higher than that for married persons due to ‘‘their isolation from the institution of marriage’’ (p. 1021). We reject the selection hypothesis. We conclude that marital status integration, psychological well-being, and suicide acceptability, when examined one at a time, are all significantly related to variation in suicide rates. We will test the hypothesis that our measures of each concept will remain significant when all three are included in a multivariate analysis. We examine the association that each of these variables has on marital status differences in genderand age-specific suicide rates for Whites in the United States in 1979 and 1992–1994. The dependent variable and the measure of marital status integration are based on the entire US White population; suicide acceptability and psychological well-being are taken from national sample surveys. Data are broken into subgroups by gender, ages 20–34, 35–54, 55 and older, and married, widowed, divorced or single marital status.

3. Method 3.1. Sample The two time periods center around 1979 and 1992–1994. We limited data analysis to Whites because the vast majority of respondents on psychological well-being and suicide acceptability were White. Because of the manner in which suicide data are recorded (e.g., 5- or 10-year age intervals), we exclude persons under the age of 20 since our survey data on psychological well-being and suicide acceptability were collected on persons aged 18 and over. We used age group categories 20–34, 35–54, and 55 and over because such broad age ranges were necessary to maintain sufficient General Social Survey (GSS) sample size in the various subgroups. From the General Social Survey, we computed the percentage of persons in each subgroup who said they were (1) very happy and (2) accepting of suicide as a right if incurably ill. We included a specific age–gender–marital status category only if there were at least 40 respondents to the GSS question. Therefore, we excluded widowers under age 55, or widows under age 35. In Table 3, where we list the percentage of persons who said they were (1) very happy and (2) accepting of suicide, all cells with percentages listed have at least 40 respondents. The reader will notice that some cells have a footnote next to the percentage. These footnotes indicate whether the number of

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respondents was between 40 and 49 or whether the number of total respondents was between 50 and 79. All other cells that list percentages were based on at least 80 respondents. Each subgroup listed in Table 3 counts as one case. We arrive at the following sample size for each age group: for persons 20–34, we use three marital status comparisons (married—single, married—divorced, and single—divorced) for males and female separately for both 1979 and 1992–1994 (e.g., three marital status comparisons · two genders · two time periods), yielding a sample size of 12. For persons aged 35–54, we use three marital status comparisons for males (married— single, married—divorced, and single—divorced) and six marital status comparisons for females (all possible marital status comparisons) for both 1979 and 1992–1994 (e.g., nine marital status comparisons · two time periods), yielding a sample size of 18. For persons aged 55 and older, we use all marital status comparisons for both males and females for 1979 and 1992–1994 (e.g., 12 marital status comparisons · two time periods), yielding a sample size of 24. Since we have relatively few cases for regression models for persons aged 20–34 and 35–54, we combine these two age groups to arrive at a sample size of 30 for persons aged 20–54. In models examining all age groups together, the sample size is 54 (30 cases from the 20–54 age groups and 24 from the 55 and older group). 3.2. Dependent variable Age–marital status-specific data on suicide are for males and females separately. Age–marital status–gender-specific suicide rates per 100,000 population for 1979 are from Stack (1990, Tables 2 and 3). Age–marital status–gender-specific suicide counts for 1992–1994 are from the National Center for Health Statistics (NCHS, 1997– 1998). For the 1992–1994 period, we took the mean number of suicides and then calculated a rate per 100,000 population, using 1993 (the mid-point of the 1992–1994 period) age–marital status–gender-specific population data from NCHS (1997– 1998). We use Danigelis and PopeÕs (1979, p. 1086) formula to calculate the standardized suicide difference coefficient (SSDC) for each age–sex group: S
C=S þ C;

ð1Þ

where S is the suicide rate of a ÔspecificÕ marital status and C is the suicide rate of the ÔcomparisonÕ group. Durkheim used the term ÔpreservationÕ when one marital status has a lower suicide rate than another; ÔaggravationÕ is the label applied to a marital status that has a higher suicide rate than another. In our data set DurkheimÕs ratios correlate .96 with both male and female SSDCs. As Danigelis and Pope explain ‘‘. . .the sign of the standardized suicide difference coefficient signifies the state of preservation or aggravation for any specific group (represented by the rate ÔSÕ) relative to any comparison category (ÔCÕ). . .’’ (1979, p. 1086). For example, in 1979 for males 20– 34 the standardized suicide difference coefficient was
.87 taking married as the ÔspecificÕ or ÔSÕ group, and widowed as the ÔCÕ or comparison group. The married minus the widowed suicide rate was 87% less than the sum of the married and widowed rates. A helpful characteristic of the standardized suicide difference coefficient is that its range is from
1 to +1, allowing meaningful comparisons of one standardized suicide

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difference coefficient to another marital status combination. The same male and female standardized suicide difference coefficients can also be compared. This cannot be done with the traditional measure of the ratio of, say, the male widowed to married suicide rate compared to the ratio of female widowed to married suicide rates. 3.3. Independent variables Two independent variables come from the General Social Survey website (GSSDIRS, 2001). The measure of suicide acceptability is from this question: ‘‘Do you think a person has the right to end his or her own life if this person has an incurable disease’’? The percent in each subgroup answering ÔyesÕ was taken as our measure of suicide acceptability. The General Social Survey has asked four different questions on attitudes toward suicide, and these questions deal with the following topics: Dishonoring oneÕs family, not wanting to live any longer, having gone bankrupt, and having an incurable disease. In each instance, respondents were asked whether or not they felt suicide was an acceptable behavior under these conditions. All four measures on attitudes toward suicide correlated .90 or greater. We chose the question on having an incurable disease as our indicator of suicide acceptability because it had the highest level of approval and most variation among marital status subgroups. The standardized difference coefficient for suicide acceptability uses the formula for the standardized suicide difference coefficient, substituting the percent saying suicide is a ÔrightÕ for the suicide rates. The measure of psychological well-being is from the question, ‘‘Taken all together, how would you say things are these days? Would you say that you are very happy, pretty happy, or not too happy?’’ The percent answering very happy was taken as the measure of psychological well-being. The standardized difference coefficient for psychological well-being also uses the standardized suicide difference coefficient formula, substituting the percent very happy for the suicide rates. We wanted to get average results from the GSS polls rather than use polls from a single year since we felt single-year polls might not accurately represent long-term attitudinal trends. Therefore, for psychological well-being, we take the average response percentages during 1972–1985 and 1988–1996. We choose these time periods since 1979 and 1992–1994 are mid-points during these respective periods. We use the same methodology for suicide acceptability, except that we use 1977–1985 as the first time period since data on suicide acceptability only go back to 1977. The measure of marital status integration comes from the percent of persons who are in each marital status for each age–gender group. Census data for 1980 (U.S. Bureau of the Census, 1984) and National Center for Health Statistics data for 1993 (NCHS, 1997) measure marital integration in the two periods. Although Census data are measured the year following our 1979 suicide data, we felt that (1) decennial census data would more correctly measure the actual number of persons in each marital status compared to other data sources and (2) the percentage of people in each marital status for each age group would not fluctuate significantly between 1979 and 1980. We use marital status data for 1993 since it is the mid-point of the 1992–1994 period. The years in a marital status proxy are measured with a code of 1 to ages 20–34, 2 for

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ages 35–54, and 3 for the 55 and older stratum. (We lacked more exact data.) Dummy variables for gender and period were included. Although it might be helpful to include control variables such as religiosity or fertility in our statistical analysis, such data specific to age, gender, and marital status are not available. 3.4. Statistical procedures We test two models. The first follows Gibbs and Martin hypothesis (1964, Chapter 8) that marital status integration is inversely related to suicide rates. We report the regression of only their marital integration measures on standardized suicide difference coefficients. The second model tests whether the association of marital status integration with standardized suicide difference coefficients holds when we add measures of psychological well-being and suicide acceptability. Rejection of the selection hypothesis implies that psychological well-being is nearly the same in a population before people marry and that the subsequent marital status differences in these characteristics are caused by changes in marital status. GoveÕs theory implies that marital status integration effects suicide rates because it is a cause of psychological well-being. In fact, we found that marital status integration does have a strong positive correlation with psychological well-being. Therefore, the second model assumes the effect of marital status integration on standardized suicide difference coefficients is at least partially indirect, via its relationship to psychological well-being. To measure the effect of marital status integration on suicide net of psychological well-being we residualized marital status integration. Marital status integration coefficients were residualized by regressing them on psychological well-being. The resulting errors of prediction in marital status integration (i.e., the residuals) are not correlated with psychological well-being. These errors of prediction are the measure of residualized marital status integration. If residualized marital status integration has a significant effect net of psychological well-being, this would indicate that psychological well-being was not an adequate proxy for marital status integration; a search for an additional indicator of role strain or inconsistency could be a focus of future research. Therefore, the second model includes residualized marital status integration, psychological well-being, and suicide acceptability. The years in a marital status variable could only be included in analysis of all three age groups; it is omitted from age-specific equations. Since we are using longitudinal data, care must be taken that autocorrelation will not bias results. All regression models in Table 5 are corrected for first-order autocorrelation with Cochrane–Orcutt iterative estimation (1949) as used by the Shazam (2001) statistical package. We also checked for problematic collinearity among the independent variables and skewness of data. Each independent variable is regressed on all others simultaneously, and we then use the formula 1/(1
R2) to calculate Variance Inflation Factor (VIF) for each independent variable. No VIF in any regression model exceeded AllisonÕs (1999) limit of 2.5. Goodness of Fit tests found that the standardized suicide difference coefficient errors of prediction are normally distributed, indicating no evidence of skew.

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4. Results Table 1 displays age–gender–marital status-specific suicide rates for 1979 and 1992–1994. The upper panel shows a pattern of increasing male suicide rates as we move from married to single to divorced and then widowed men. This is true of the three male age groups in both periods. In both periods the suicide rates of married, single, and divorced men all increase with age; in contrast, the rates for widowed men decline with increasing age. All marital status groups in the three age strata show declining male suicide rates between 1979 and 1992–1994. The lower panel finds that single women have higher suicide rates than married women in all three age strata for both periods. In the 20- to 34-year stratum divorced women have higher suicide rates than do single women, with widows ages 20–34 having the highest rates. In the two older age groups divorced women had higher rates than widowed women in both periods. All age and marital status groups show declining female suicide rates between 1979 and 1992–1994. Standardized suicide difference coefficients are in Table 2. The male coefficients in the top panel measure marital status differences taking married as the ÔSÕ (or ÔspecificÕ) group and the remaining three statuses as the ÔCÕ (or ÔcomparisonÕ) groups. If one reverses this order one has only to reverse the sign; compare the married–single standardized suicide difference coefficient with the single–married coefficients. A negative sign indicates that the marital status coded as ÔSÕ had lower suicide rates than the marital status group coded as ÔCÕ. For all three ages and both periods the gap favoring the married is widest between the married and the widowed, followed by the married and divorced, with the smallest difference being between married and single men. The male coefficients show steady declines with age only for the married–widowed comparison; the married–divorced pair declines only at ages 55 and older, while the married–single combination increases and then declines.

Table 1 Suicide rates of the White population by age, gender, and marital status: United States, 1979 and 1992– 1994 Marital status

Age group and period 20–34

35–54

55 and older

1979

1992–1994

1979

1992–1994

1979

1992–1994

Male Married Single Divorced Widowed

15.9 34.8 66.5 227.3

13.2 15.6 60.8 178.8

17.0 46.6 70.6 108.8

13.4 36.7 54.0 89.0

24.0 54.2 75.0 75.8

20.4 41.6 67.3 73.1

Female Married Single Divorced Widowed

4.9 9.5 20.1 22.5

2.6 5.3 11.9 18.5

8.7 14.9 25.2 18.9

4.4 11.2 14.6 13.4

6.9 7.9 16.8 9.0

4.0 5.8 11.9 6.3

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Table 2 Standardized suicide difference coefficients (SSDC) by gender and age: United States White populations, 1979 and 1992–1994 SSDC combinations ‘‘S’’–‘‘C’’

Age and period 20–34

35–54

55 and older

1979

1992–1994

1979

1992–1994

1979

1992–1994

Males Married–widowed Married–divorced Married–single


.87
.61
.37


.86
.64
.32


.73
.61
.47


.74
.60
.47


.52
.51
.39


.56
.53
.34

Mean


.62


.61


.60


.60


.47


.48

Single–widowed Single–divorced Single–married


.73
.31 .37


.75
.41 .32


.40
.21 .47


.42
.19 .47


.17
.16 .39


.27
.24 .34

Mean


.22


.28


.05


.05

.02


.06

Divorced–widowed Divorced–married Divorced–single


.55 .61 .31


.49 .64 .41


.21 .61 .21


.24 .60 .19


.01 .51 .16


.04 .53 .24

Mean

.12

.19

.20

.18

.22

.23

Widowed–married Widowed–divorced Widowed–single

.87 .55 .73

.86 .49 .75

.73 .21 .40

.74 .24 .42

.52 .01 .17

.56 .04 .27

Mean

.72

.70

.45

.42

.23

.29

Females Married–widowed Married–divorced Married–single


.64
.61
.32


.75
.64
.34


.37
.49
.26


.51
.54
.44


.13
.43
.07


.22
.50
.18

Mean


.52


.58


.37


.50


.21


.30

Single–widowed Single–divorced Single–married


.41
.36 .32


.55
.38 .34


.12
.26 .26


.09
.13 .44


.06
.36 .07


.04
.35 .18

Mean


.15


.20


.04

.07


.12


.07

Divorced–widowed Divorced–married Divorced–single


.06 .61 .36


.22 .64 .38

.14 .49 .26

.04 .54 .13

.30 .43 .36

.31 .50 .35

Mean

.30

.27

.30

.24

.36

.39

Widowed–married Widowed–divorced Widowed–single

.64 .06 .41

.75 .22 .55

.37
.14 .12

.51
.04 .09

.13
.30 .06

.22
.31 .04

Mean

.37

.51

.12

.19


.04


.02

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The means of the three male coefficients in each column compare 1979 with 1992– 1994 mean values, and measure the stability over time of a given marital status versus the three other marital statuses. For the married compared to other marital statuses the means are virtually the same in all three ages, indicating little influence on standardized suicide difference coefficient coefficients of changes in societal level or other causes of suicide declines between 1979 and the early 1990s. In the single versus other status comparisons, the single status suicide advantage holds versus both widowed and divorced men at all ages, but is largest among younger single compared to younger widowed men. This pattern is reversed when the single are compared to married men. For both periods mean values are similar in all three age groups. The divorced–widowed combination shows divorced men with lower rates at younger ages, an advantage that vanishes among men 55 and older. Divorced men have higher suicide rates than either married or single men at all ages. Again, mean values indicate remarkable stability over time. The panel of widowed versus other marital statuses finds widowed men with higher rates in all age groups, although the difference between widowed and divorced is trivial among men 55 and older. The 1979 and 1992–1994 mean values are not very different. The bottom half of Table 2 shows the standardized suicide difference coefficient combinations for women. The negative signs of married versus other marital status and of single–widowed and single–divorced follows the male pattern. The single– married sign is positive, as it was for males. The lower divorced than widowed suicide rates among men under age 55 largely disappears for women, but the higher divorced than married rates continue to hold for both sexes. Widowed women ages 20–34 have higher rates than do women in most other marital statuses, but this disadvantage is less than found for males. Widows ages 35–54 and 55 and older have lower rates than do divorced women of the same ages, a reversal of the male pattern. Table 3 presents data used to compute the coefficients comparing the psychological well-being and normative approval of suicide in the six pairs of marital status combinations. The upper panel gives the percent of respondents reporting that they were Ôvery happyÕ in polls from 1972–1985 and 1988–1996. At all ages both female and male married persons are more likely than the unmarried to report being very happy. At all ages single females are more likely than are single males to report higher levels of being very happy, and single females are also happier than divorced females or divorced males. At ages 55 and older single women are also more likely to be very happy than older widowed women; this is not the case for males. There were fewer than 40 widowed males in each period at ages 20–34 and 35–54 and this was true also for widowed women 20–34. Therefore, data for these cells are omitted. There is little evidence of a 1979 to 1992–1994 trend in reporting being very happy among either men or women at any age. Women are more likely than men to report being very happy in nearly every age marital status–age comparison. This gender gap is larger among older than younger persons and is typically greater between single, divorced or widowed men and women than among those married.

Table 3 Psychological well-being (percent very happy) and suicide acceptability by gender, age, marital status, and period: United States White respondents in GSS polls Gender and marital status Female

Male

Married (%)

Widowed (%)

Divorced (%)

Single (%)

Married (%)

Widowed (%)

Divorced (%)

Single (%)

Well-being 1972–1985 1988–1996

55 and older 46.5 43.9

27.2 24.7

28.0 23.8

34.5 34.5

44.9 47.3

20.0 20.6

19.3 24.7

21.1 20.5

1972–1985 1988–1996

35–54 42.4 39.3

12.4 21.7b

20.3 19.4

25.5 19.4

36.7 38.7

— —

19.5 16.6

16.9 19.9

1972–1985 1988–1996

20–34 42.4 42.5

— —

20.8 17.6

27.4 28.2

32.6 36.5

— —

18.4 13.1

20.8 22.1

Suicide acceptability 1977–1985 1988–1996

55 and older 28.7 45.9

26.1 42.0

36.1 46.4

27.9b 44.8b

39.5 56.9

40.4 63.4

48.2b 65.4

42.9a 55.2b

1977–1985 1988–1996

35–54 38.8 60.6

34.1a 71.1a

51.9 69.8

32.7b 71.4

45.6 66.8

— —

65.1 73.5

65.8b 70.2

1977–1985 1988–1996

20–34 54.9 63.6

— —

58.1 69.1

65.2 72.8

52.8 64.0

— —

64.5b 83.8b

64.7 75.8

a b

P. Cutright, R.M. Fernquist / Social Science Research 34 (2005) 570–590

Variable name and period

N = 40–49. N = 50–79. 583

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Table 4 Zero-order correlations, means, and standard deviations of variables in analysis of standardized suicide difference coefficients, United States White populations ages 20–54 and 55 and older: 1979 and 1992–1994a Variables

SSDC SDC well-being SDC suicide acceptability Res. marital integration SDC marital integration Ages 20–54 Mean SD a

Rows

(1) (2) (3) (4) (5)

Columns

Ages 55+

(1)

(2)

(3)

(4)

(5)

Mean

SD

1.00
.61 .59
.22
.52


.67 1.00
.21
.00 .53

.71
.18 1.00 .13
.00


.37
.00
.47 1.00 .85


.74 .73
.45 .69 1.00


.23 .18
.01
.00 .19

.24 .16 .07 .43 .62


.36 .20

.23 .16


.05 .08


.00 .33

.53 .39

Ages 20–54 (N = 30) are below and ages 55 and older (N = 24) are above the diagonal.

The lower panel displays the percent saying a person has a right to suicide if one has an incurable disease. With few exceptions, married respondents are less likely than are those unmarried to say that suicide is a right—a response that may reinforce the higher levels of married psychological well-being in reducing married suicide rates. There is strong evidence of a large shift among both men and women in all marital statuses and ages accepting suicide as a right of persons with an incurable disease between 1977–1985 and 1988–1996. There is also a strong pattern among both males and females of declining approval of suicide with advancing age in all marital status groups. Women are less likely to approve of suicide than are men and this gender gap is wider among those 55 and older than at younger ages. The gender gap is also wider among single, divorced, and widowed persons than among the married. Marital status data are reported in the first table of Appendix A. Table 4 displays zero-order correlations, means, and standard deviations of variables used in the analysis of standardized suicide difference coefficients for ages 20– 54 (N = 30) and those aged 55 and older (N = 24). Data for ages 20–54 are below and those 55 and older are above the diagonal. The respective correlations of the standardized well-being difference coefficient with standardized suicide difference coefficient of
.61 and
.67 are about the same. The standardized suicide acceptability difference coefficient correlation with standardized suicide difference coefficient is stronger in the older (.71) than the younger (.59) group. Residualized standardized marital status integration difference coefficient correlates
.22 with ages 20–54 standardized suicide difference coefficients; the correlation is
.37 in the 55 and older stratum. The correlation of standardized marital status integration difference coefficient is
.52 with standardized suicide difference coefficient in the younger and
.74 in the older stratum. (Similar data for all ages, N = 54, are in the second table of Appendix A.) 4.1. Testing Gibbs and MartinÕs marital integration measures The upper panel of Table 5 reports the unstandardized (b) and standardized (b) regression coefficients for ages 20–54, 55 and older, and all age groups combined

P. Cutright, R.M. Fernquist / Social Science Research 34 (2005) 570–590

585

Table 5 Unstandardized (b) and standardized (b) regression coefficients from analysis of standardized suicide marital status difference coefficients, United States White population, 1979 and 1992–1994 Independent variables

Age groups 20–54

Gibbs and Martin model SDC marital status integration Years in marital status Constant R2 The extended model SDC well-being SDC suicide acceptability Res. marital integration Years in marital status Constant R2 N *

55 and older

20 and older

b

b

b

b

b


0.16*


.30 —


0.32*


.83 —


0.14*
.34 .04 .12
.32 .58


.57 .56
.11 —


0.75*
.50 1.28* .45
0.13*
.24 .02 .08
.17 .76 54


.24 .52
0.60* 1.08*
0.17*
.17 .65 30


.16 .59
.46 .45
.28 —


0.88* 1.82*
0.06
.06 .79 24

b

p 6 .01.

for the Gibbs and Martin model; we include marital status integration and years in marital status as independent variables. The respective number of observations (bottom row of the table) are 30, 24, and 54. All equations include both male and female standardized suicide difference coefficients because we found that a dummy variable for gender (1 = male, 0 = female) was unrelated to standardized suicide difference coefficient and it was omitted. A dummy variable for period (1 = 1979, 0 = 1992– 1994) was also unrelated to standardized suicide difference coefficients, and it, too, was dropped. The standardized marital status integration difference coefficient is highly significant and inversely related to standardized suicide difference coefficients in all three equations and explained variance in the dependent variable, corrected for degrees of freedom, ranges from .52 to .59. Years in a marital status was not significant in the model for persons aged 20 and over. 4.2. Testing the extended model A rigorous test of marital status integration is displayed in the lower panel where we test what we call the Extended Model: added to marital status integration and years in marital status are (1) psychological well-being and (2) suicide acceptability. In the 20–54 age group, psychological well-being, suicide acceptability, and residualized marital status integration were all statistically significant, the b coefficients for well-being and acceptability are larger than the b of residualized status integration. The signs of the regression coefficients are also in the predicted direction. Explained variance adjusted for degrees of freedom is 65.

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Analysis of the standardized suicide difference coefficients of the 55 and older stratum again found highly significant b coefficients for psychological well-being and suicide acceptability; residualized marital status integration was not significant. Adjusted explained variance is .79. The proxy for years in a marital status is included in the analysis of ages 20 and older and its b coefficient is not significant. It is possible that future research with better measures of time in a marital status may find a more robust relationship. For ages 20 and older, the b coefficients of psychological well-being and suicide acceptability are nearly equal, while residualized marital status integration is significant but weaker than either psychological well-being or suicide acceptability. Adjusted explained variance is .76. We note that comparing the equations in the extended model in Table 5 with similar equations that use unadjusted martial integration shows that residualization of marital status integration decreases the bs of psychological well-being, slightly increases the bs of marital integration and has no effect on the bs of suicide acceptability or explained variance. Marital integration remains insignificant in the 55 and older stratum.

5. Discussion The primary goal of this research was to measure and test three competing hypotheses that may explain why age- and gender-specific suicide rates differ between pairs of gender- and age-specific marital statuses. In the extended model using all predictors we find partial support for Gibbs and MartinÕs hypothesis that marital status integration is inversely related to suicide rates. Marital status integration and standardized suicide difference coefficients are inversely related for persons aged 20–54, but no significant association exists for persons aged 55 and older. Why would marital status integration be significantly related to standardized suicide difference coefficients for the two younger, but not the older age group? Although a large majority of older males are married, the proportion of older women who are married or widowed is nearly equal. The mean 1979 and 1992– 1994 SSDCs for the married versus widowed males (
.54) and females (
.17) reflect the gender difference in marital status integration. The gender difference among younger persons is much smaller and this difference across age groups may help explain the age difference in the impact in marital status integration. We also found that psychological well-being and suicide acceptability are significantly associated with standardized suicide difference coefficients. These results support the hypotheses that (1) psychological well-being is directly related to suicide for persons of different marital statuses (and that it is not some pre-existing set of conditions which both effect psychological well-being and the level of suicide) and (2) attitudes that people have toward suicide are also related to the level of suicide. We found that, as married people have lower levels of suicide acceptability than persons of other marital statuses, so, too, do married persons have lower levels of suicide relative to persons in other marital statuses. These results strongly suggest that

P. Cutright, R.M. Fernquist / Social Science Research 34 (2005) 570–590

587

psychological well-being and a culture of suicide are predictor variables that need to be considered when examining variation in the levels of suicide in a given population. How similar are the US standardized suicide difference coefficients to those in 14 developed countries in the 1960 period? Danigelis and PopeÕs (1979, Table 2) analysis of this 14 nation data set measured the marital status suicide differences with the standardized suicide difference coefficient statistic and they examined five of the six possible marital status pairs, omitting only the divorced–widowed combination. They report only ages 25–34, 35–44, . . ., 65–74 and found declining standardized suicide difference coefficients with age in all five marital status pairs and a greater male than female advantage of being married. The largest male marital status advantage was among the younger married compared to younger widowed men. The greatest married advantage among women was among younger married versus the divorced. In the United States single men and women have lower suicide rates than do the widowed and divorced and this is also the case in the 14 developed nations. These patterns are consistent with our US data. Although their age groups are not identical to ours, they do allow rough comparisons of standardized suicide difference coefficient levels and these levels are remarkably close for both men and women in the three married versus other marital status pairs. Because Danigelis and Pope report only the 14 nation averages and only ages 25– 74, it is probable that an analysis of individual countries and younger and older age groups would find that some follow the US pattern, while others do not. For example, World Health Organization (1968, Table 3.2) data for around 1960 show that at ages 15–24 married men have higher suicide rates than single males in 7 of the 14 populations and younger married women had the higher rates than single women in five countries. Widowed men and women do not always have higher rates than those who are single. For example, single women have higher rates than widows in four 10-year age groups in Norway and Sweden, three age groups in Finland, West Germany, and Switzerland, and one age group in Australia, Canada, Italy, New Zealand, and Scotland. Single men ages 65–74 and/or 75 and older had higher rates than widowers in seven of their 14 countries. Future cross-national analysis could test hypotheses on the role of structural factors such as female labor force participation, income inequality, divorce rates, levels of psychological well-being, marital status integration, and the level of suicide rates on marital status differences in suicide rates. 5.1. Limitations of the present study Our sample was limited to US Whites, while Gibbs most recent work (2000) examined various racial groups and found support for the marital status integration hypothesis. Unfortunately, it is not possible to test our model on non-whites in the US because the number of respondents in surveys of well-being and suicide acceptability rapidly dwindle in size as the number of marital status–age–gender-specific subgroups increase. We also could have benefitted from including relevant control variables such as religion, but were unable to obtain such data specific to age, gender,

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and marital status. Still, Stack and Eshleman (1998) did control physical health, church attendance, gender, age, and parental status and still found the expected relationship of marital status differences with psychological well-being. Although marital status differences in US suicide rates are common to 13 other countries, this does not mean that this relationship is the result of the same predictors used in this research. For example, it may be the case that suicide acceptability is more important than psychological well-being only in countries with suicide rates higher than those in the US, while this hypothesis may not be supported in countries with rates lower than those in the US. Sociologists might expect such a finding because changes in the normative order regarding vital rates (e.g., birth or suicide rates) generally affect rich and poor, rural or urban, North or South, Protestant and Catholic, etc. alike. On the other hand, changes in the well-being of an individual lacks the moral force of a change in the normative order of suicide acceptability and may, therefore, be less likely to increase or decrease the risk of suicide.

Appendix A The following table presents data used to compute the standardized difference coefficients for marital status integration. For each gender and period the four percentages add to 100.0% if there is no rounding error. From 1980 to 1993 at ages 55 and older there is little change in marital status. At ages 35–54 the decline in the percentage married over time is related to large gains in the percentage divorced. At ages 20–34 the drop in percent married between the first and second period in largely due to an increase in the percent single. Marital status pairs are the same as in Table 2. For example, with S as the percent of women 20–34 married, and C as the percent of women 20–34 single, the standardized marital status integration difference coefficient value for 1980 = 64.8
26.6/64.8+26.6 =
0.418. Marital status by gender, age, and period: United States White population in general social survey polls Period

Gender and marital status Female Married (%)

Male Widowed (%)

Divorced (%)

Single (%)

Married (%)

Widowed (%)

Divorced (%)

Single (%)

1972–1985 1988–1996

55 and older 47.9 40.4 42.2 43.1

6.3 10.5

5.3 4.3

78.7 69.1

11.2 13.3

4.7 11.2

5.4 6.4

1972–1985 1985–1996

35–55 78.4 64.3

4.8 3.1

13.0 24.2

3.9 8.4

83.3 69.1

1.0 1.0

8.5 17.1

7.2 12.8

1972–1985 1988–1996

20–34 68.0 52.9

0.6 0.4

8.7 11.8

22.7 35.0

58.8 44.3

0.2 0.4

5.0 6.3

36.0 49.0

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589

The following table reports the zero-order correlations, means, and standard deviations for variables in the regression analysis of standardized suicide difference coefficients using all 54 observations of men and women ages 20 and older in 1979 and 1992–1994. The standardized difference coefficients of psychological well-being and residualized marital integration take expected negative correlations of
.65 and
.34, respectively, with standardized suicide difference coefficient while suicide acceptability is a positive .66 with standardized suicide difference coefficient. Zero-order correlations, means, and standard deviations of variables in analysis of standardized suicide difference coefficients, United States White populations ages 20 and older: 1979 and 1992–1994 (N = 54) Variables

Row

(1)

(2)

(3)

(4)

(5)

(6)

SSDC SDC well-being SDC suicide acceptability Res. SDC marital integration Years in marital status SDC marital integration

(1) (2) (3) (4) (5) (6)

1.00
.65 .66
.15 .34
.49

1.00
.22 .00
.16 .54

1.00 .00 .26
.15

1.00
.10 .75

1.00
.17

1.00


.30 .23

.21 .16


.03 .08

.00 .43

.34 .52

2.22 .79

Mean SD

References Allison, P.D., 1999. Multiple Regression: A Primer. Pine Forge Press, Thousand Oaks, CA. Bradburn, N.M., 1969. The Structure of Psychological Well-Being. Aldine, Chicago. Bradburn, N.M., Caplovitz, D., 1965. Reports on Happiness: A Pilot Study of Behavior Related to Mental Health. Aldine, Chicago. Cochrane, D., Orcutt, G.H., 1949. Application of least squares regression to relationships containing autocorrelated error terms. Journal of the American Statistical Association 44, 32–61. Cutright, P., Fernquist, R.M., 2000. Societal integration, culture, and period: their impact on female agespecific suicide rates in 20 developed countries, 1955–1989. Sociological Focus 33, 299–319. Cutright, P., Fernquist, R.M., 2001. The relative gender gap in suicide: societal integration, the culture of suicide, and period effects in 20 developed countries, 1955–1994. Social Science Research 30, 76–99. Danigelis, N., Pope, W., 1979. DurkheimÕs theory of suicide as applied to the family: an empirical test. Social Forces 57, 1081–1106. Durkheim, E., 1897 [1951]. Suicide: A Study in Sociology. Free Press, New York. Gibbs, J.P., 1969. Marital status and suicide in the United States: a special test of the status integration theory. American Journal of Sociology 74, 521–533. Gibbs, J.P., 1982. Testing the theory of status integration and suicide rates. American Sociological Review 47, 227–237. Gibbs, J.P., 2000. Status integration and suicide: occupational, marital, or both? Social Forces 79, 363– 384. Gibbs, J.P., Martin, W.T., 1964. Status Integration and Suicide: A Sociological Study. University of Oregon Books, Eugene, OR. Gove, W.R., 1972. Sex, marital status, and suicide. Journal of Health and Social Behavior 13, 204–213. Gove, W.R., 1973. Sex, marital status, and mortality. American Journal of Sociology 79, 45–67. Gurin, G., Veroff, J., Feld, S., 1960. Americans View Their Mental Health. Basic Books, New York. GSSDIRS, 2001. General Social Survey Directory. Retrieved March 13, 2002. Available from: . National Center for Health Statistics, 1997–1998. Multiple Cause-of-Death File, CD-ROM Series 20, Nos. 10–12, Hyattsville, Maryland.

590

P. Cutright, R.M. Fernquist / Social Science Research 34 (2005) 570–590

Shazam User Reference Manual, Version 9.0, 2001. Northwest Econometrics, Vancouver. Stack, S., 1990. New micro-level data on the impact of divorce on suicide, 1959–1980: a test of two theories. Journal of Marriage and the Family 52, 119–127. Stack, S., 1996–1997. Does being a parent affect suicide ideology? Omega 34, 71–80. Stack, S., 1997. A comparative analysis of the effect of domestic institutions on suicide ideology. Journal of Comparative Family Studies 28, 304–319. Stack, S., 1998. Gender, marriage, and suicide acceptability: a comparative approach. Sex Roles 38, 501– 520. Stack, S., 2000. Suicide: a 15-year review of the sociological literature part II: modernization and social integration perspectives. Suicide and Life-Threatening Behavior 30, 163–176. Stack, S., Eshleman, J.R., 1998. Marital status and happiness: a 17-nation study. Journal of Marriage and the Family 60, 527–537. Stack, S., Wasserman, I., 1993. Marital status, alcohol consumption, and suicide: an analysis of national data. Journal of Marriage and the Family 55, 1018–1024. Stafford, M.C., Gibbs, J.P., 1988. Change in the relation between marital integration and suicide rates. Social Forces 66, 1060–1079. U.S. Bureau of the Census, 1984. Detailed Characteristics of the Population. Volume 1, Part 1, Section A. U.S. Government Printing Office, Washington, DC. World Health Organization, 1968. World Health Statistics Report, vol. 21, No. 6. World Health Organization, Geneva, Switzerland.