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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 of communication 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 for social 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 and social 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 perceived social 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 socioeconomic 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 people lack 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 physiological effects 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 to the 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 and friends, 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 Support

Large 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 of Lehtinen et al.(2005) study, however,

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was the 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 (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 of families 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

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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 investigated how structural elements within a communitywhat is now called 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 evidence that modern life disrupts social cohesion and results in a greater risk of morbidity and mortality including self-destructive behaviors 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 of a population," Kawachi et al. (1997) wrote, "is hardly new. One-hundred years ago, Emile Durkheim demonstrated that suicide rates were higher in populations that were less cohesive". For Durkheim, social cohesion, especially traditional family life, provided the best protection against selfdestructive behavior (Baudelot and Establet, 1984). According to Durkheims theory, social isolation and household Size, disintegration, and disconnectedness lead to suicide. As a proxy for social isolation, 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 social explanatory variables based on Durkheimian sociological theory in estimation of suicide rates in a large panel of up to 68 countries during the period 1980 to 1999; suggest that economic and social factors affect cross-country differences in suicide rates in accordance with theory. More importantly this suggests that the vast majority of the existing literature, which typically fails to control for national cultures of suicide and suggests socioeconomic factors as important determinants of suicide, can still be expected to come to valid results. Houle et al. (2005) conducted a study is to investigate whether social support 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 reported in 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 high suicide 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 (Law and Liu , 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 socioeconomically 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) suggested that women most submerged in the family display the greatest female suicidal behavior. Her views have been affirmed by recent reports that the highest rates of suicide in the world are found among rural Chinese women (Law and Liu , 2008). This reinforces the conclusion of historian Roger Lane, who found that contrary to Durkheims assumptions, increases in suicide rates were linked to social integration. Lane found that as 19th-century Philadelphia urbanized, its suicide rate grew proportionally greater than its homicide rate. Lane reasoned that the increasing incidence of suicide in late-19th-century cities served as a barometer 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 views of Johnson and Lane. Social relations within extended families, Kunitz found, often resulted in negative health outcomes, including significantly higher rates of depression and selfdestructive behaviors. A study in England over 30 years period by Schapira et al. (2001) showed that 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 disorganisation of 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 belonging to 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 and divorce 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 supports the opposite conclusion, that is, that the incidence of suicide is greatest among those most subsumed in social groups. Durkheims data revealed that the highest suicide rates were found among those 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) found that feeling safe at school was one of 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 obtain social resources and modulating their perception (Suppapitiporn et al.,2004). Rehkopf and Buka (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. Rehkopf and Buka (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.

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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 betweencountry 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 evidence that modern life disrupts social cohesion and results in a greater risk of morbidity and mortality including self-destructive behaviors 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.