Accepted Manuscript

SUICIDAL THOUGHTS AND BEHAVIORS AND SOCIAL

ISOLATION: A NARRATIVE REVIEW OF THE LITERATURE

Raffaella Calati Psy.D., Ph.D. , Chiara Ferrari , Marie Brittner MD ,

Osmano Oasi Psy.D., Ph.D. , Emilie Olié MD, Ph.D. ,
André F. Carvalho MD, Ph.D. , Philippe Courtet MD, Ph.D.

PII: S0165-0327(18)31694-X
DOI: https://doi.org/10.1016/j.jad.2018.11.022
Reference: JAD 10240

To appear in: Journal of Affective Disorders

Received date: 2 August 2018

Revised date: 27 September 2018
Accepted date: 3 November 2018

Please cite this article as: Raffaella Calati Psy.D., Ph.D. , Chiara Ferrari , Marie Brittner MD ,
Osmano Oasi Psy.D., Ph.D. , Emilie Olié MD, Ph.D. , André F. Carvalho MD, Ph.D. ,
Philippe Courtet MD, Ph.D. , SUICIDAL THOUGHTS AND BEHAVIORS AND SOCIAL ISOLA-
TION: A NARRATIVE REVIEW OF THE LITERATURE, Journal of Affective Disorders (2018), doi:
https://doi.org/10.1016/j.jad.2018.11.022

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 ACCEPTED MANUSCRIPT

Highlights

 Social isolation is strongly associated with suicidal outcomes

 The subjective feeling of loneliness has a major impact, even transculturally

 Objective and subjective social isolation should be added in suicide risk assessment

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SUICIDAL THOUGHTS AND BEHAVIORS AND SOCIAL ISOLATION:

A NARRATIVE REVIEW OF THE LITERATURE

Raffaella Calati, Psy.D., Ph.D.a, b, c, d, Chiara Ferrarie, Marie Brittner, MDb,

Osmano Oasi, Psy.D., Ph.D.e, Emilie Olié, MD, Ph.D.a, b, c,
André F. Carvalho, MD, Ph.D.f, g, Philippe Courtet, MD, Ph.D.a, b, c

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a INSERM, University of Montpellier, Neuropsychiatry: Epidemiological and Clinical

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Research, Montpellier, France

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b Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital, CHU
Montpellier, Montpellier, France
c FondaMental Foundation, Créteil, France

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d Department of Psychiatry, Mount Sinai Beth Israel, New York, NY , USA
e Department of Psychology, Catholic University of Milan, Milan, Italy
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f Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON,
Canada
g Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
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Running title: Suicide and social isolation.

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To whom correspondence should be addressed:

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Raffaella Calati, Psy.D., Ph.D.

Department of Psychiatry, Mount Sinai Beth Israel
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Zirinsky Center for Bipolar Disorder

317 East 17th Street, 5 Floor Suite 13
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New York, NY 10003, United States

E-mail: raffaella.calati@gmail.com

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Abstract
Background: Social isolation is one of the main risk factors associated with suicidal
outcomes. The aim of this narrative review was to provide an overview on the link between
social isolation and suicidal thoughts and behaviors. Methods: We used the PubMed database
to identify relevant articles published until April 13, 2018. We focused on: a) systematic
reviews, meta-analyses, and narrative reviews; b) original observational studies with large
samples (N≥500); and c) qualitative studies. We included all relevant suicidal outcomes:
suicidal ideation (SI), suicidal planning, non-suicidal self-injury, deliberate self-harm, suicide

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attempt (SA), and suicide. Results: The main social constructs associated with suicidal

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outcomes were marital status (being single, separated, divorced, or widowed) and living

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alone, social isolation, loneliness, alienation, and belongingness. We included 40 original
observational studies, the majority of them performed on adolescents and/or young adults
(k=23, 57.5%). Both the objective condition (e.g., living alone) and the subjective feeling of

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being alone (i.e., loneliness) were strongly associated with suicidal outcomes, in particular
with SA and SI. However, loneliness, which was investigated in most studies (k=24, 60%),
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had a major impact on both SI and SA. These associations were transculturally consistent.
Limitations: Confounding factors can limit the weight of the results obtained in observational
studies. Conclusions: Data from the observational studies suggest that both objective social
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isolation and the subjective feeling of loneliness should be incorporated in the risk assessment
of suicide. Interventional studies targeting social isolation for suicide prevention are needed.
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Keywords: social isolation; loneliness; living alone; suicide; review

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1. Introduction

Some sociological and psychological theories postulated a prominent role of social variables
in suicide (Stanley et al., 2016). Firstly, Émile Durkheim speculated that suicide is inversely
correlated with social integration, considered as a protective factor (Durkheim, 1897).
According to the more recent interpersonal theory of suicide by Thomas E. Joiner, the lack of
feeling of belongingness is one of the main risk factors associated with suicide (Joiner, 2005;
Van Orden et al., 2010). Particularly, the construct of Thwarted Belongingness, which

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includes self-reported loneliness, living alone, fewer friends, non-intact family, social

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withdrawal, and family conflict, is one of the core concepts of his theory. Together with

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Perceived Burdensomeness (i.e., the perception to represent a burden for others), Thwarted
Belongingness might induce suicidal ideation. According to Joiner, Thwarted Belongingness
and Perceived Burdensomeness constitute the most proximal mental states preceding suicidal

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ideation, while other factors, such as childhood maltreatment and psychiatric disorders, are
relatively more distal in the causal chain of suicide risk factors (Van Orden et al., 2010). The
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concomitant presence of the Acquired Capability for suicide (due to the repeated exposures to
painful and provocative events that decrease the fear of death and increase physical pain
tolerance) contributes to triggering lethal suicide attempts.
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Cohen and Wills, in a pioneering study, compared two different theories in which social
support has either a general, positive effect on health and well-being (main or direct-effect
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model), or protects individuals from stressful life events (stress-buffering model) (Cohen and
Wills, 1985). They found that both models are correct. In the first case, social support
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corresponds to the degree of social integration of the individual, while, in the second case,
social support is related to social resources linked to the needs elicited by stressful events.
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Hence, in the context of suicide, social support could act as the main direct protective factor
and as a protective factor in the presence of adversities. This suggests that risk factors are
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more likely to be associated with bad outcomes, such as suicide, among individuals with poor
social support.
Social factors (e.g., being single, divorced, or widowed, social isolation, loneliness,
alienation, loss of connectedness, and lack/loss of social support) have been repeatedly
reported as risk factors for death desire, suicidal thoughts and behaviors among adolescents
(King and Merchant, 2008), older adults (Draper, 2014; Minayo and Cavalcante, 2015;
O'Connell et al., 2004; van Wijngaarden et al., 2014; Yi and Hwang, 2015), and psychiatric
patients (Pompili et al., 2007).

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In agreement, two recent meta-analyses have reported the protective role of social support in
depression (Gariepy et al., 2016; Rueger et al., 2016).
However, to our knowledge, no previous recent (in the last decades) review focused on the
link between social isolation, considering all its related constructs, and suicidal thoughts and
behaviors, although its modulatory role has been largely established (see this first review on
the topic (Trout, 1980)). The aim of this review was to provide a narrative overview on this
association, focusing on all main relevant social constructs.

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2. Methods

A literature search was independently performed by RC and CF to identify studies on social

isolation and suicide. Articles published until April 13, 2018, were retrieved from the PubMed
database using broad search terms (living alone OR social isolation OR loneliness OR social
alienation) AND (suicid* OR self-harm OR self harm). Any form of suicidal outcome was
considered: suicidal ideation (SI), suicidal planning (SP), non-suicidal self-injury (NSSI),
deliberate self-harm (DSH), suicide attempt (SA), and suicide. The reference lists of the

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selected studies and reviews were also checked to identify additional relevant articles.

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Studies were included if: 1) they investigated any form of social isolation or loneliness; 2)

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they focused on any form of suicidal outcome; 3) they were: a) systematic reviews, meta-
analyses, and narrative reviews, b) original observational studies, or c) qualitative studies; 4)
they were written in English. Studies were excluded if: their main focus was social support

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only (e.g., parent support or peer support) without a measure of social isolation/loneliness;
they focused on suicidal patients only (e.g(Ferrada-Noli et al., 1995; Haw and Hawton, 2011;
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Hawton et al., 1996)inal observational studies, they had a sample <500.
This is not a systematic review but a narrative one. First, a) it summarized the findings
described in the selected systematic reviews, meta-analyses, and narrative reviews. Second, b)
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it reviewed the results of original observational studies with large samples (N≥500) that have
not been included in reviews/meta-analyses. For example, studies on Joiner’s interpersonal
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theory of suicide were not included because they were discussed in a recent meta-analysis
(Chu et al., 2017). Third, c) it included also qualitative studies.
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Concerning original observational studies, we adopted the criteria of large samples (N≥500)
to avoid spurious findings due to small sample size. If studies were performed on the same
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sample, only the most recent one was selected in the case of similar analyses (e.g., between
(Schinka et al., 2013) and (Jones et al., 2011), only ((Schinka et al., 2013) was retained), or
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both in the case of different types of analysis (e.g., (Brunstein Klomek et al., 2016; Kahn et
al., 2015)).
From each selected original observational study, RC and CF independently extracted: the
study design, follow-up duration, targeted population, sample size, sex, age, ethnicity, main
psychometric scales, suicidal outcomes, social isolation/loneliness outcomes, main results,
association metric of social isolation-related results, and presence/absence of the association
(Table 1).

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3. Results

In the following paragraphs we will present the main literature evidences on the key social
constructs: marital status and living alone, social isolation, loneliness, alienation, and
belongingness. In each section, we will first define the construct and present the findings of
the main reviews and meta-analyses published on its association with suicidal outcomes.

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Then, we will describe the results of the original observational studies according to the

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suicidal outcomes (suicidal ideation versus suicidal behaviors) and the different life periods

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(childhood and adolescence, adulthood and older adulthood).
We retained 40 observational studies (see Table 1). Most of them concerned adolescents
and/or young adults (k=23, 57.5%), four focused on adults (10%), four on older adults (10%),

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three investigated the general population (7.5%), one included men who have sex with men
(2.5%), two studied prisoners (5%), one was on adults with Human Immunodeficiency Virus
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(HIV) (2.5%), one on psychiatric patients involuntarily admitted to hospital (2.5%), and one
on adults with substance use disorders (2.5%). Only 4 studies (10%) included only men while
the majority (k=24, 60%) have a sex-balanced sample. So we were not able to separately
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consider men and women.

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3.1 Marital status and living alone

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Social isolation and lack or poor social support can be assessed in different ways. Social
isolation is often measured using objective quantifiable variables, such as socio-demographic
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data: marital status (being married/widow or cohabitation), living alone, unemployment,

frequency of social relationships, or participation to the community life.
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Marital status is frequently considered as a proxy for social support. A first meta-analysis of
54 case-control studies considered different proxies for social relationships (Crawford et al.,
2010): marital status (k=37), living alone (k=22) and also employment (k=29). Most of these
studies (85.2%) included different age groups. The odds ratios for these three suicide risk
factors were correlated with their prevalence among controls, and negative correlations were
reported for living alone and unemployment. Moreover, the impact of living alone and
unemployment appeared to be heightened when they were less prevalent in the population.
This result could be linked to the perception of being different from the majority. However,

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when studies focused only on older adults (k=6) and when young people (k=5) were
excluded, the negative correlation with living alone was no more present.
Seven observational studies focused on marital status/living alone and suicidal outcomes.
Suicidal Ideation: A study on 4,675 Asian university students found that living without
parents was a predictor of SI, but not of SA (Peltzer et al., 2017). Among European older
adults from the Study of Health, Ageing and Retirement in Europe (SHARE) cohort, being
widowed was associated with SI (Saias et al., 2012). However, data collected from patients
involuntarily admitted to hospital have shown the non-predictive role of living alone on SI.

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Conversely, being unemployed (and probably having less social contacts than employed

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people) was predictive of SI (Giacco and Priebe, 2016).

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Suicidal Behaviors: Divorced and separated subjects experience higher suicide risk, especially
men (Kposowa, 2000). In the context of the large Quebec Health Survey, living alone and
having no friends were associated with both SI and SA (Stravynski and Boyer, 2001). Among

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older adults, being unmarried and living alone is a SA predictor (Wiktorsson et al., 2010).
Finally, among adults with substance use disorders, living alone and a low level of perceived
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social support are SA predictors (You et al., 2011).

3.2 Social isolation

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The level of social isolation of a person, defined as a state in which interpersonal contacts and
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relationships are quantitatively disrupted or non-existent (de Jong Gierveld and Havens,
2004), should be assessed by considering the number of individuals with whom this person
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interacts in a given period, the frequency of social interactions, the number of qualitatively
different types of relationships the person has, and the degree of intimacy involved in his/her
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interactions (Trout, 1980).

Six observational studies focused on social isolation and suicidal outcomes.
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Suicidal Ideation: Among White and American Indian/Alaska Native adolescents, the
sensation of not being socially accepted and the perception of not being part of the school
were positively associated with SI (Zamora-Kapoor et al., 2016). Adolescents feeling socially
isolated were twice as likely to report SI then those feeling socially accepted. Similarly,
among American adolescent girls, being socially isolated from their peers was a risk factor for
SI (Bearman and Moody, 2004). Moreover, in both sexes having a dense social network was a
protective factor for SI (girls) and SA (males). However, among youths (between 14 and 20
years), friendship problems (social isolation and poor quality friendships) were not linked to

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SI and SA (Winterrowd et al., 2011). Within the same population, the lack of family support
was associated with SI and SA among Mexican-American girls. Finally, among Chinese
adults, social isolation did not have any direct effect on SI. Social isolation was only weakly
associated with SI in a path model that included depression and self-esteem (Zhang and Jin,
1998).
Suicidal Behaviors: In contrast with the already mentioned study that found no association
between friendship problems and SA (Winterrowd et al., 2011), social isolation was a
predictor of SA in adolescent boys and girls (Hall-Lande et al., 2007). Simultaneously, high

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levels of family connectedness, school connectedness and academic achievement were

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protective factors against SA. Finally, lack of friends was found to be a suicide predictor in a

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large Swedish men cohort (Allebeck et al., 1988).

3.2.1 Correctional settings

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The specific condition of physical and social isolation of life in prison intensifies suicidal risk.
In fact, suicidal behaviors are frequent in this context. In a review focused on suicide
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prevention in jails and prisons, Pompili and colleagues highlighted that being in isolation or
segregation cells is a risk factor for suicide, while contacts with family and inmates might
represent a protective factor (Pompili et al., 2009). Similarly, in a more recent systematic
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review on risk and protective factors related to near-lethal SA among prisoners, social
isolation and low social support were included among the risk factors (Marzano et al., 2016).
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Talking with peers or staff members was indicated by prisoners themselves as a good
supportive strategy.
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Two observational studies focused on correctional institutions.

Suicidal Behaviors: A French prospective study found that suicide rate is higher among male
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prisoners in disciplinary cells than among those in regular cells, while it is lower among those
who receive regular visits from relatives or friends (Duthe et al., 2013). Similarly, in a study
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performed in New York City, being in solitary confinement could be decisive for predicting
self-harm acts, including potentially fatal ones (Kaba et al., 2014).

3.3 Loneliness

Quantitative aspects of social isolation seem to be an insufficient measure of the absence of or

poor social support and connection with others. Therefore, recent studies highlighted the
importance of taking into account also the feeling of social isolation (Perissinotto and

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Covinsky, 2014) that is estimated with subjective variables, such as loneliness and low sense
of belonging. Indeed, people who live alone are more likely to report loneliness; however,
many individuals living alone are not lonely and report effective social support. Moreover,
also people who live with others could feel lonely and have poor social support. Therefore, it
is broadly agreed that loneliness is not highly correlated with social isolation (Coyle and
Dugan, 2012), and seems to be more associated with mental problems. Conversely, social
isolation is associated with poor general health in older adults.
Loneliness, defined as the subjective feeling of being alone or without the desired level of

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intimate and social relationships (Ernst and Cacioppo, 1999), could be a better proxy of social

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isolation than living alone. Loneliness is generally assessed using the University of California,

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Los Angeles (UCLA) Loneliness Scale, a short, 20-item scale to measure the subjective
feelings of loneliness and of social isolation (Russell et al., 1980; Russell et al., 1978)
(positive: “There are people I feel close to”, “There are people who really understand me”;

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negative: “I feel isolated from others”). In other words, loneliness is the perception of social
isolation, or the subjective experience of being lonely. Weiss distinguished emotional
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loneliness (i.e., the lack of an intimate attachment) from social loneliness (i.e., the lack of
membership in a desired group) that he called "social isolation" (Weiss, 1973).
A recent meta-analysis of 31 studies considered the influence of structural social relationships
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(marital status, living alone, familial discord, social contact, social network, social isolation,
community participation, unemployment, religious affiliation, social integration) and
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functional social relationships (perceived loneliness, received social support, perceived social
support and mistreatment in late life) on SI in older adults (aged 50 years or above) (Chang et
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al., 2017). Poor relationships predicted SI, with a higher impact for poor functional measures.
Among these measures, mistreatment had the strongest impact, followed by perceived
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loneliness and poor perceived social support.

Most of the included observational studies (k=24, 60%) focused on loneliness.
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3.3.1 Children/adolescents
Suicidal Ideation: An in-depth cohort study focused on 832 American children followed until
adolescence and reported that chronically high and increasing levels of loneliness early in life
predict the presence of SI at the age of 15, together with social skill deficits, depression, and
aggression (Schinka et al., 2013). The Global School-Based Student Health Surveys (GSHS)
have been implemented by the Ministry of Health and Education of many countries.
McKinnon et al. analyzed GSHS data from 32 countries and estimated that loneliness is the

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main risk factor for SI and SP, followed by limited parental support and bullying (McKinnon
et al., 2016). Having few friends is also a risk factor, but with lower impact. Specifically, they
found a positive association between loneliness and SI among adolescents in Malaysia,
Seychelles, China, Philippines and Uganda (Chan et al., 2016; Page et al., 2011; Rudatsikira
et al., 2007; Wilson et al., 2012). Conversely, in Zambia, loneliness appeared to be negatively
associated with SI (Muula et al., 2007).
Suicidal Behaviors: Among young boys of a Stockholm cohort, self-rated loneliness and not
being a member of voluntary associations were associated with suicide and para-suicide

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during adolescence or young adulthood (Rojas, 2012). Similarly, among adolescents in

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Poland, loneliness was positively associated with SI, SP and SA (Pawlowska et al., 2016).

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Among Chinese adolescents included in the GSHS, loneliness played a significant role on
suicidal thoughts and behaviors as a mediator between problems in peer relationships (being
bullied, having no close friends and physical fighting) and both SI and SA (Cui et al., 2011).

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Also among adolescents of Benin (GSHS), loneliness was positively associated with SI, SP
and multiple SA (Randall et al., 2014), and lack of parental support was linked to SI and SP
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(Randall et al., 2014). Analysis of data collected in the multi-country study “Saving and
Empowering Young Lives in Europe” (SEYLE) showed that loneliness is associated with
DSH in univariate analyses, and only with repeated DSH in multivariate analyses (Brunstein
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Klomek et al., 2016). Moreover, parent support, peer support, and pro-social behaviors were
protective factors. Analysis of the French SEYLE cohort highlighted higher level of
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loneliness, social relationship problems and SI/suicidal behaviors among adolescents referred
for treatment because considered at risk (Kahn et al., 2015). Finally, loneliness (i.e., feeling
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lonely very often and also sometimes) was a risk factor for DSH also among adolescents in a
Finnish study (Ronka et al., 2013). On the other hand, loneliness was not associated with SI
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and SA in univariate analysis in a study on adolescents in the Netherlands (Garnefski et al.,

1992). However, this sample was smaller compared with most of the other studies. Moreover,
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the principal component analysis highlighted among girls, correlations between loneliness,
SI/SA, sexual abuse, physical abuse, low self-esteem, depression and spending money on
drugs.

3.3.2 Adults
Suicidal Ideation: In the general population loneliness has been associated with SI (Beutel et
al., 2017). Moreover, in a sample of men who had sex with men, having five or more

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psychosocial health problems (including loneliness and poor social support) increased of four
times the chance to have reported SI in the previous year (Li et al., 2016).
Suicidal Behaviors: In the context of the already mentioned Quebec Health Survey, living
alone, not having friends, and also loneliness (with a stronger association) were associated
with SI and SA (Stravynski and Boyer, 2001). Moreover, SI and SA increased with the degree
of loneliness. In another general population survey, loneliness was linked to SI and SA
(Stickley and Koyanagi, 2016). The association with SI, but not SA, was particularly strong
among individuals with common mental disorders. Furthermore, the interaction between

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loneliness and high income predicted death caused by fatal accidents or suicide (Patterson,

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2016). Finally, in a clinical sample of adults with HIV, loneliness was a major predictor of

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suicidal risk (defined as SI, SP or SA) (Carrieri et al., 2017).

3.3.3 Older adults

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Passive Suicidal Ideation: Analysis of the SHARE data indicated that loneliness and partner’s
loss increases passive SI, whereas the social network size protects older people from passive
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SI (Stolz et al., 2016). Similarly, low level of perceived mastery and financial problems,
loneliness and small social networks are variables strongly associated with death wishes
among older adults after depressive symptoms (Rurup et al., 2011).
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Suicidal Behaviors: In an already mentioned study loneliness was linked to SA (Wiktorsson et

al., 2010).
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3.3.4 Qualitative studies

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Suicidal Ideation: In a sample of 32 older outpatients who reported SI, the feeling of
loneliness was listed among the psychological changes that contributed to SI, while loss of
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family support was identified as an SI trigger (Huang et al., 2017). On the other hand, social
support from family and friends was a strategy to deal with suicidal thoughts. An analysis of
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17 Tumblr accounts, based on posts connected with depression or suicide (and two other
categories: “self-mutilation” and “cutting”) highlighted the link between these terms and the
common themes of loneliness and feeling unloved (Cavazos-Rehg et al., 2017).
Suicidal Behaviors: Among 10 adolescent girls of Latin American origin from low-income
families in New York City who attempted suicide, emotional isolation (loneliness or lack of
sense of connection with friends or parents) was one of the several themes linked to their
suicidal behavior (Gulbas and Zayas, 2015). Among 10 patients after a SA, the experience of
connectedness with other and of being accurately listened to by the healthcare personnel and

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loved ones were among the most crucial resources to maintain their will to live and hope
(Vatne and Naden, 2016). Eight older inpatients who attempted suicide described the sense of
disconnection and alienation from significant others and the feeling of loneliness as preceding
their attempt (Bonnewyn et al., 2014). A study on the life experiences of 35 older Korean
adults after SA found having more sadness and loneliness than before among the reported
experiences (Kim, 2014). Similarly, 23 patients with a serious mental illness and who
attempted suicide described loneliness and isolation as two emotional precursors to the
attempt (Montross Thomas et al., 2014). In a photovoice study that included 20 men with

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previous SI, SP and/or SA, participants were asked to take photographs to describe their

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experiences of suicidality and perspectives about male suicide (Oliffe et al., 2017). Analysis

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of the interviews indicated that isolation and feeling of separation from others were factors
that increased the suicide risk.
Declarations about a sense of solitude, lack of comprehension from parents and the

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consequent feeling of isolation were particularly associated with suicidal behaviors in a
sample of 47 young immigrant women (South Asian-Surinamese, Turkish, and Moroccan) in
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the Netherlands (van Bergen et al., 2012).
Among 20 male veterans with HIV/Acquired Immunodeficiency Syndrome (AIDS),
loneliness and social isolation were identified as stressors for self-directed violence, whereas
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social support was recognized as a protective factor (Signoracci et al., 2016).

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3.4 Alienation
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The construct of alienation has been sometimes reported as associated with suicidality,
although the link is less clear than for other constructs. Three observational studies focused on
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alienation in adolescents/youths.
Suicidal Behaviors: Among Native American adolescents, alienation from family and
community (i.e., the feeling of lack of care from significant others) was associated with SA
(Grossman et al., 1991). Moreover, interpersonal alienation reported by young people (early
parent-child relationships) predicted NSSI (Bureau et al., 2010). These results concerned the
analysis of the entire sample, and then of only girls. Finally, parental criticism predicted a
pathway to NSSI via alienation towards parents, especially in boys (Yates et al., 2008). In the

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last two studies alienation was measured using the Inventory of Parent and Peer Attachment
(IPPA) alienation subscale.
Qualitative approach: From the analysis of interviews with older psychiatric inpatients who
reported SI, the sensation of not feeling cared for and to be distant from significant others was
among the themes emerged as relevant (Moore, 1997).

3.5 Thwarted Belongingness/Sense of Belongingness

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Another frequently used term is the sense of belonging that could be defined as appertaining,

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relationship, a particular feeling related to the quality and the number of interactions with

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others. The Sense of Belonging Instrument (SOBI) (Hagerty and Patusky, 1995) includes two
subscales: the SOBI-Antecedents (SOBI-A) (i.e., the antecedents of belonging, such as, “I
want to be a part of things going on around me”), and the SOBI-Psychological state (“If I died

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tomorrow very few people would come to my funeral” or “I could disappear for days and it
wouldn’t matter to my family”). The Interpersonal Needs Questionnaire (INQ) (Van Orden et
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al., 2008) also can be used to measure Thwarted Belongingness (“other people care about
me”, “I feel like I belong”, “I rarely interact with people who care about me”, “I am fortunate
to have many caring and supportive friends”, “I feel disconnected from other people”, “I often
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feel like an outsider in social gatherings”, “I feel that there are people I can turn to in times of
need”, “I am close to other people”, “I have at least one satisfying interaction every day”).
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A recent meta-analysis including 122 published and unpublished samples supports the
interpersonal theory of suicide by Joiner (Chu et al., 2017). When Thwarted Belongingness
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(measured with the INQ) was considered alone in univariate analyses, it was moderately
associated with the risk of SI and suicide, and only weakly associated with history of SA.
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Conversely, Perceived Burdensomeness seemed to have a stronger impact on suicidal

outcomes. Indeed, the authors underlined how the considered constructs and their interaction
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“appear to not be better predictors of suicide risk than many traditional and often-studied risk
factors”. Most studies included in the meta-analysis were performed in young adults (18-24
years; 48.4%) and adults (older than 25 years of age; 37.7%). However, in the meta-analysis
the association between thwarted belongingness and SI was stronger among older adults
(k=9). Therefore, this construct needs to be better investigated in adolescents and older adults.
According to a systematic review that included 16 studies, low Sense of Belongingness is
associated, even if weakly, with both SI and SA mainly in non-clinical populations (Hatcher

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and Stubbersfield, 2013). Sense of Belongingness was measured with the INQ (k=5), the
SOBI (k=7), or other tools.

3.6 Additional aspects to be considered in future studies

Other factors have been linked to loneliness and mental health outcomes: unemployment,
living in rural communities, low population density, and sedentary lifestyles.
A proposed model of the mechanisms linking economic recession to suicide considered the
association between unemployment/financial difficulties and social isolation (Haw et al.,

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2015). Furthermore, suicide rates are higher in rural communities (Fontanella et al., 2015;

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Helbich et al., 2017). An explanation could be that living in rural areas can lead to social

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isolation, and this could contribute to suicide. In addition, low population density (under-
crowding) has been associated with youth suicide (Seiden, 1984).
Among adolescents, sedentary lifestyles (i.e., total amount of time spent in front of screens for

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leisure, TV viewing, computer/internet use, video gaming, and other sedentary behaviors)
were investigated, in a systematic review, in relation to mental health outcomes, including
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depressive symptomatology, SI, loneliness, stress and psychological distress (Hoare et al.,
2016). The evidence was insufficient concerning the relationship between screen time and
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loneliness, although only studies showing absence of associations were included (Donchi and
Moore, 2004; Gross, 2004). Moreover, the lack of association could be explained by the fact
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that time spent online communicating and time spent talking on the phone were among the
included behaviors.
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4. Discussion
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The aim of this narrative review was to provide an overview on the link between social
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isolation and suicidal thoughts and behaviors. We focused on: a) systematic reviews, meta-
analyses, and narrative reviews; b) 40 original observational studies on large samples
(N≥500); and c) some qualitative studies.
The main constructs associated with suicidal outcomes were: marital status (being single,
separated, divorced, or widowed) and living alone, social isolation, loneliness, alienation, and
belongingness.
Both the objective condition of being alone (e.g., living alone) and the subjective feeling of
being alone (i.e., loneliness) were strongly associated with suicidal outcomes, in particular

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with SA and SI. However, the subjective feeling of loneliness, which was investigated in most
studies (k=24, 60%), seemed to have a major impact on both SI and SA.
Remarkably, most of the included observational studies reported a positive association
between all the constructs of social isolation and suicidal outcomes, with the exception of four
(one reported a negative association (Muula et al., 2007), and three a lack of association
(Garnefski et al., 1992; Giacco and Priebe, 2016; Zhang and Jin, 1998)). Mula et al. did not
propose any explanation concerning the negative association between feeling lonely and SI
among in-school adolescents in Zambia (Muula et al., 2007). The hypothesis of a cultural

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difference is not consistent with other studies performed in Africa (in Benin (Randall et al.,

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2014) and Uganda (Rudatsikira et al., 2007)). However, Zambia could be classified as a

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lower-middle income country, while Benin and Uganda are low-income countries, and this
factor could have influenced the results. Nevertheless, we must underline that, in the global
GSHS analysis, the association was positive. Concerning the three studies with the lack of

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association (Garnefski et al., 1992; Giacco and Priebe, 2016; Zhang and Jin, 1998), in the first
one, living alone was not predictive of SI, but to be unemployed was related to SI, and being
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unemployed could be a good proxy for reduced or lack of social contacts. In the second one,
no association was found between loneliness and SI and SA; however, among girls,
loneliness, SI/SA, sexual abuse, physical abuse, low self-esteem, depression and spending
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money on drugs were inter-correlated. In the third one, social isolation was only weakly
associated with SI in a path model including depression and self-esteem. In this Chinese
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group, interpersonal conflicts and difficulties in interactions had an effect on SI, and this
finding could be linked to cultural specificities.
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However, overall, results were transculturally consistent. Therefore, to be alone and feeling
lonely are associated with suicidal outcomes across different countries and populations.
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4.1 Future research directions

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We have to underline that the present review is extremely preliminary. The next step should
be to perform one or more meta-analyses on this topic, similarly to what has been done with
the protective role of social support in depression (Gariepy et al., 2016; Rueger et al., 2016),
but including both social isolation and social support. Concerning social support, Rueger et al.
underlined that disaggregating the sources of support could be useful to better understand
subtle differences in the roles of others in our lives (e.g., family members, teachers, general
peers and close friends in the case of young people) (Rueger et al., 2016). We think that this is
the case of social isolation as well. The “disaggregation” of social isolation could help the

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development of more focused interventions with the aim of specifically reducing social
isolation and loneliness.
Moreover, as the majority of studies focused on adolescents and/or young adults (k=23,
57.5%), additional analyses on different life periods, especially adulthood and also older
adulthood, could be useful. Furthermore, since results on sex differences are mixed, their
further evaluation is warranted. In the suggested future meta-analysis both sensitivity analyses
and meta-regressions should be carried out to control for age, sex, and different social
isolation/social support constructs. Moreover, the main confounding factors reported in the

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association between social isolation and suicide, such as temperament/personality, low socio-

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economic status, abuse/life events/interpersonal conflicts, unemployment, low self-esteem,

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depression and other psychiatric disorders, alcohol/drugs abuse/dependence, medical
conditions and loss, should be considered (see Figure 1).
Finally, it could be useful to distinguish between social isolation and deficits in social

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functioning present in some neuropsychiatric disorders, such as Alzheimer's disease and
schizophrenia, with specific pathophysiological mechanisms (Porcelli et al., 2018).
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4.2 Clinical perspectives

Four primary strategies have been identified to reduce loneliness: 1) developing or improving
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social skills, 2) increasing social support, 3) increasing the occasions for social contacts, and
4) focusing on maladaptive social cognition (Masi et al., 2011). Integrated interventions that
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combine cognitive behavioral therapy focused on loneliness reduction and short-term

adjunctive pharmacological treatments have been recently proposed (Cacioppo et al., 2015).
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A review on interventions targeted to older adults found that flexibility, involvement in the
development of activities, and the focus on productive engagement were features related to
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their success (Gardiner et al., 2018).

In the context of suicide prevention programs, these strategies could be useful for patients
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who are alone and/or who feel alone. The strengthening of protective factors by
increasing/developing social contacts and by modifying the perceived social isolation could
be a strategy, particularly of subjects at risk. For adolescents, the activation of prevention
programs where the theme of belonging to the peer group is salient (e.g., in schools) could be
another strategy. Moreover, the family’s involvement could be another useful approach.
Finally, the fact that half of suicides communicate their intentions prior to death (Pompili et
al., 2016) strengthens the importance of social support as protective factor.

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4.3 Limitations
The main limitation of the present review is the non-inclusion of studies on social support.
For instance, an American longitudinal study on 72,607 women underlined that the risk of
suicide was linked to low level of social integration, formulated as marital status, the size of
social network, the frequency of social contacts, and the participation in different social
groups (Tsai et al., 2015). Moreover, according to a French study on employees of Electricity
of France-Gas of France, low social integration is a predictor of elevated risks of dying not

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only from suicide, but from cancer and accidents (Berkman et al., 2004). Furthermore, this

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was neither a systematic review nor a meta-analysis, and we could not determine the extent of

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the risk or control for confounding factors. Particularly, as already mentioned, confounding
factors can limit the weight of the results obtained in observational studies.

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In conclusion, data from observational studies suggest that both objective social isolation and
the subjective feeling of loneliness should be incorporated in the risk assessment of suicide.
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The design of interventional studies targeting social isolation for the prevention of suicide is
needed. Furthermore, a meta-analysis on this topic is warranted, considering the modulation
of confounding factors such as age, sex, different social isolation constructs, and depression
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and other psychiatric diagnoses.

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IP
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AN
M
ED

Figure 1. When studying the association between social isolation/loneliness and suicidal
outcomes, a number of confounding factors must be considered (e.g., specific
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temperament/personality, low socio-economic status, abuse/life events, unemployment, low

self-esteem, psychiatric disorders, alcohol/drugs abuse/dependence, medical conditions and
loss). Social support is protective against suicidal outcomes.
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Acknowledgments
We would like to thank Dr. Elisabetta Andermarcher for her careful linguistic revision of the
manuscript. Dr. Raffaella Calati received a grant from the FondaMental Foundation, Créteil,
France (2015-2016). Dr. Emilie Olié received research grants from AstraZeneca, Servier,
Institut UPSA de la Douleur and fees for presentations at congresses from Janssen, Lundbeck,
Otsuka, Servier. Prof. Philippe Courtet received research grants from Servier, and fees for
presentations at congresses or participation in scientific boards from Janssen, Lundbeck,
Otsuka, Servier.

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Conflicts of interest
None.

Contributors
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Prof. Philippe Courtet proposed the topic. Dr. Marie Brittner performed the first literature
search and wrote a first draft of the manuscript. Dr. Chiara Ferrari performed the search of the
studies, extracted data from the included studies, and wrote a second draft of the manuscript.
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Dr. Raffaella Calati supervised the work of Marie Brittner and Chiara Ferrari, performed an
independent search of the studies, independently extracted data from the included studies, and
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wrote the final version of the manuscript. Prof. Osmano Oasi, Dr. Emilie Olié, Prof. André F.
Carvalho, and Prof. Courtet supervised the manuscript writing.
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CE
AC

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 ACCEPTED MANUSCRIPT

Stu Stud Fol Targe Sa Se Mean Ethnici Main Suic Social Main results Associatio Pr
dy y lo ted mp x age ty (%) scales idal isolati n metric of es
desi w- popul le (fe (years outc on/ social en
gn up ation siz ma ± S.D. ome loneli isolation- ce/
du e le and/or s ness related ab
rat %) range) results: se
ion HR, IR, nc
(ye OR, RR, e
ars and 95% of
) CI th
e
as
so
cia
tio
n
(All Coh 13- Swedi 50, 0 18-20 - - S Lack Both bivariate and RR +

T
ebec ort 14 sh 46 years at of multivariate (number of
k et yea men 5 baselin friend analyses: friends):

IP
al., rs born e s Lack of friends  1.32 (1.15-
198 in S 1.51)
8) 1949-
51

CR
(Be Coh 1 Adole 13, 50 15.82± Black In- SI, Si Multivariate OR: +
arm ort yea scents 46 1.75 Other school SS analysis: 2.01 (1.07-
SA
an r 5 (Native questio (densi Females: 3.76)
and Americ nnaire ty of Si  SI
Mo an, In- friend SS: protector
ody,
200
4)
Asian,
Hispani
c, and
mixed-
US
race/eth
home
intervie
w
ship
ties)
factor for SI
Males:
SS: protector
factor for SA
AN
nicity
student
s)
(Be Cros - Adult 15, 49. 54.9±1 - PHQ-9 SI L Both bivariate and OR: +
utel s- s 01 4 1.1 (SI multivariate 1.31 (1.19-
et secti 0 item) analyses: 1.44)
M

al., onal L: L  SI
201 single
7) item
(Br Cros - Adol 11, - 14.9±0. - SEYLE DSH L Bivariate analysis: OR: +
ED

unst s- esce 11 89 questio Parent L  any DSHL  4.02 (3.30-

ein secti nts 0 nnaire suppo occasional DSH 4.91)
Klo onal rt RR:
mek Peer L  repetitive 2.33 (1.81-
et suppo DSH 2.99)
PT

al., rt, RR:

201 Pro- Multivariate 8.39 (6.62-
6) social analysis: 10.64)
behav L  repetitive
ior DSH RR:
CE

1.52 (1.10-
Protective factors: 2.09)
Parent support
Peer support, Pro-
social behavior
AC

(Bu Cros - Stude 1,2 71. 19.4±1. Caucasi OSI NSS A Multivariate OR: +
rea s- nts 38 6 5 an=72. IPPA analysis: 1.10 (1.03-
I
u et secti (adole 1 Females: 1.17)
al., onal scents Black= A predictor of
201 /youn 6.7 NSSI
0) g Asian=
adults 6.5
) Other=
14.7
(Ca Cros - Adult 2,9 33. 18-59 Nationa Face- Suic L Both bivariate and Bivariate +
rrie s- s with 73 3 lity: to-face multivariate analysis:
ide
ri et secti HIV Non- intervie analyses: IR:
al., onal French w risk: L  Suicide risk 4.94 (3.36-
201 from 7.26)
SI,
7) EU: 2.7 Multivariat
Non- SP, e analysis:
French IR:

27
 ACCEPTED MANUSCRIPT

not SA 4.62 (3.06-

from 6.97)
EU:
22.7
(Ch Cros - Adol 2,7 52 16-17 Malay: GSHS SI L Both bivariate and Bivariate +
an s- esce 89 78.6 YRBSS Have multivariate analysis:
et secti nts Chines close analyses: OR:
al., onal e: 14.3 friend L, no close friends, 6.27 (4.26-
201 Indian: s and lack of 9.23)
6) 7.1 Suppo supportive peers Multivariat
rtive  SI e analysis:
peers OR:
Parent 2.54 (1.57-
al 4.11)
super
vision
Parent

T
al
conne

IP
ctedne
ss
Parent
al

CR
bondi
ng
(Cui Cros - Adol 8,7 51 11-17 - GSHS SI, L Multivariate SI: +
et s- esce 78 analysis: OR:
SA
al., secti nts L as mediator 16.04
201
1)
onal

US between problems
in peer
relationships and
SI/SA
(10.92-
23.56)
SA:
OR:
16.92
AN
(11.45-
25.01)
(Du Coh - Priso 19 0 ≥18 Nationa French S Si Multivariate HR: +
the ort ners 6,9 lity: penal (visits analysis: 0.4 (0.3-
et 16. French: adminis from S was lower in the 0.5)
al., 8 80.22 tration relativ presence of visits
M

201 Other: data es and from relatives

3) 19.78 discip
linary
cell)
ED

(Ga Case - Adol 57 64. 15-16 - Ad hoc SI, L Bivariate analysis: - L

rnef - esce 0 9 items No association A
SA
ski contr nts between L and
et ol SI/SAInter-
al., correlation in girls
199 between: L, SI/SA,
PT

2) sexual abuse,
physical abuse,
low self-esteem,
depression and
CE

spending money
on drugs
(Gia Coh 3 Psyc 2,7 44. 38.9±1 - Intervie SI LA Bivariate analysis: - L
cco ort mo hiatri 70 8 1.5 w E No predictive A
and nth c BPRS value of LA on SI
AC

Prie s patie Both bivariate and

be, nts multivariate
201 invol analyses:
6) untar No E  SI
ily
admi
tted
to
hospi
tal
(Gr Cros - Ad 7,2 51 Median Navajo Navajo SA A Both bivariate and Bivariate +
oss s- ole 54 age: Adoles Adoles from multivariate analysis:
man secti sce 14.4 cents cent family analyses: OR:
et onal nts Health and A  SA 5.0
al., Survey comm Multivariat
199 unity e analysis:
1) OR

28
 ACCEPTED MANUSCRIPT

3.2 (2.1-
4.4)

(Hal Cros - Ad 4,7 49. 14.9 White: Ad hoc SI, Si Multivariate OR: +
l- s- ole 46 8 (11-18) 48.5 items SA Famil analysis: Boys:
Lan secti sce Asian yC Si  SA 1.8 (1.1-
de onal nts Americ Schoo Protective factors: 3.0)
et an: lC Family C Girls:
al., 19.2 School C 1.7 (1.1-
200 African Academic 2.7)
7) Americ achievement
an:
19.0
Hispani
c: 5.8

T
Native
Americ
an: 3.5

IP
Mixed/
other
race:

CR
3.9
(Ka Cros - Inma 13 9.2 ≤18 Non- Medica Self- Si Multivariate OR: +
ba s- tes 4,1 (6.4%) Hispani l (being analysis: Self-harm:
har
et secti in 88 c records in Si  Self-harm 6.89 (6.07-
al., onal corre Black: m solitar and potentially 7.82)

US
201 ction 56.1 y fatal self-harm Potentially
4) al Hispani confin fatal self-
instit c: 31.6 Pote ement harm:
ution Non- ntial ) 6.27 (3.92-
s Hispani 10.01)
ly
AN
c
White: fatal
8.4
Other: self-
3.9 har
m
M

(Ka Cros - Adol 1,0 - 15.2±0. - SEYLE SI, L/Soc According to the - +
hn s- esce 07 8 questio ial analysis of the
NSS
et secti nts nnaire relatio proportion for each
ED

al., onal I, nships scale, among

201 proble students referred
SA
5) ms for treatment: High
level of L/Social
relationships
PT

problems and
suicidal
ideation/behaviors
(Kp Coh 10 Popu 47 52. ≥15 White: ICD-9- S MS Multivariate RR: +
ort yea latio 1,9 6 84.9 R analysis: 2.08 (1.58-
CE

oso
wa, rs n 22 African Highest S rate 2.72)
200 Americ among divorced
0) an: 9.7 and separated
Hispani
c: 5.4
AC

(Li Cros - Men 54 0 30.5 - ULS-8 SI L Both bivariate and OR: +

et s- who 7 (17.3- MSPSS SS multivariate Bivariate
al., secti have 65.3) analyses: analysis:
201 onal sex L  SI 2.10 (1.19-
6) with Lower SS  SI 3.72)
men Multivariat
e analysis:
2.06 (1.14-
3.74)
(Mc Cros - Adol 16 - 13-17 32 low- GSHS SI, L Multivariate RR: +
Kin s- esce 4,7 and Lack analysis: African
SP
non secti nts 70 middle- of L  SI and SP Region:
et onal income parent 1.51 (1.39-
al., countri al 1.63)
201 es suppo Region of
6) rt the
Few Americas:

29
 ACCEPTED MANUSCRIPT

close 2.58 (2.40-

friend 2.77)
s Eastern
Mediterran
ean Region:
2.04 (1.90-
2.18)
South-East
Asia and
Western
Pacific
Regions:
2.34 (2.12-
2.55)
(Mu Cros - Adole 1,9 46 - - GSHS SI L Both bivariate and OR: -
ula s- scents 70 multivariate Bivariate
et secti analyses: analysis:

T
al., onal Negative 0.90 (0.90-
200 association 0.91)

IP
7) between L and SI Multivariat
e analysis:
0.92 (0.91-
0.92)

CR
(Pa Cros - Adole 16, 52. 11-17 Chines GSHS SI, L Multivariate OR: +
ge s- scents 35 08 e: SP analysis: Chinese
et secti 3 44.90 L  SI/SP Students:
al., onal Philippi SI:
201 ne: 2.12 (2.06-
1) 55.1

US 2.17)
SP:
1.61 (1.55-
1.66)
Philippine
AN
Students:
SI:
1.59 (1.56-
1.61)
SP:
1.03 (1.01-
M

1.04)
(Pat Coh 34 Adult 6,7 - 21 - Ad hoc Acci L, no Multivariate HR: +
ters ort yea s 89 years questio dent close analysis: Lonely
on, rs or older nnaire s friend Interaction often ×
ED

201 at and s between L and income:

6) baselin S high income on 1.278
e cons accidents/S No close
idere friends ×
d income:
toget 1.454
PT

her
(Pa Cros - Adole 5,6 30 16-19 - Ad hoc Self- L Bivariate analysis: Correlation: +
wlo s- scents 85 questio injur L  Self-injury 0.34
wsk secti nnaire y:
CE

a et onal SI,
al., SP,
201 SA
6)
(Pel Cros - Unive 4,6 59. 20.6±2. - Ad hoc SI, LA Both bivariate and OR: +
AC

tzer s- rsity 75 2 7 items SA multivariate SI:

et secti studen SSQ analyses: Bivariate
al., onal ts LA  SI analysis:
201 LA was not 0.60 (0.47-
7) associated with SA 0.76)
Multivariat
e analysis:
0.70 (0.50-
0.97)
SA:
Bivariate
analysis:
1.14 (0.33-
3.93)
(Ra Cros - Adole 2,6 33. ≥12 - GSHS SI, L Multivariate RR: +
ndal s- scents 90 1 SP, SS analysis: SI/SP:
l et secti SA L  SI/SP 1.86 (1.30-

30
 ACCEPTED MANUSCRIPT

al., onal L  multiple SA 2.67)

201 Lack of parental Multiple
4) support  SI/SP SA:
2.06 (1.44-
2.97)
(Ro Cros - Adole 7,0 51. 15.5 Finnish YSR DSH L Both bivariate and OR: +
nka s- scents 14 9 : 100 multivariate Girls:
et secti analyses: Bivariate
al., onal L  DSH analysis:
201 Somewhat/
3) sometimes:
3.9 (3.1-
4.8)
Very/Often:
9.6 (6.6-
13.9)
Multivariat

T
e analysis:
Somewhat/

IP
sometimes:
2.4 (1.9-
3.1)
Very/Often:

CR
4.1 (2.7-
6.3)

Boys:
Bivariate

US analysis:
Somewhat/
sometimes:
5.2 (3.8-
7.8)
AN
Very/Often:
11.2 (5.8-
21.7)
Multivariat
e analysis:
Somewhat/
M

sometimes:
2.4 (1.5-
3.9)
Very/Often:
ED

3.2 (1.4-
7.3)
(Roj Coh 16 Adole 4,4 0 - - Ad hoc S L Both bivariate and RR: +
as, ort yea scents 17 questio and multivariate Bivariate
201 rs /youn nnaire para analyses: analysis:
2) g - L  S and para- 2.68 (1.19-
PT

adults suici suicide 6.05)

de Multivariat
e analysis:
2.83 (1.22-
CE

6.56)
(Ru Cros - Adole 1,5 44. 11-13 - GSHS SI L Both bivariate and OR: +
dats s- scents 06 9 (13.4% multivariate Bivariate
ikir secti ) analyses: analysis:
a et onal 14 L  SI 1.79 (1.37-
AC

al., (21.0% 2.32)

200 ) Multivariat
7) 15 e analysis:
(29.4% 1.59 (1.12-
) 2.26)
16-17
(36.2%
)
(Ru Coh Int Older 1,7 No 58-98 - Specifi SI L Multivariate OR: +
rup ort erv adults 94 SI: c items Social analysis: L:
et iew 52 Netw L and small social 2.3 (1.1-
al., eve Pas ork networks  SI 4.8)
201 ry t Smaller
1) 3 SI: network:
yea 68 1.1 (1.0-
rs Cu 1.1)
rre

31
 ACCEPTED MANUSCRIPT

nt
SI:
67

(Sai Cros - Older 11, 58. Over - EURO- SI MS Multivariate OR: +

as et s- adults 44 9 64 D12 analysis: 1.35 (1.12-
al., secti 0 questio To be widowed  1.63)
201 onal nnaire SI
2)
(Sch Coh 8 Childr 83 51. 7-15 Caucasi LSDQ SI, L Multivariate OR: +
inka ort yea en 2 1 an: 79 YSR SA analysis: Stable low
et rs until African CBCL Both chronically L versus
al., adoles - high and high
201 cence Americ increasing levels increasing
3) an: of L  increased L:
10.5 SI at age 15 10.99
Hispani Stable low

T
c: 5.6 L versus
Asian: chronic L:

IP
1.2 7.41
Other: Moderate
3.7 increasing
L versus

CR
high
increasing
L:
4.55
High

US increasing
L versus
decreasing
L:
0.04
AN
Decreasing
L versus
chronic L:
18.89
(Sti Cros - Popul 7,4 56. ≥16 White Ad hoc SI, L Both bivariate and OR: +
ckle s- ation 03 5 British: items SA SS multivariate Bivariate
M

y secti 87.5 SFQ analyses: analysis:

and onal L  SI/SA SI past 12
Koy months:
ana 51.53
ED

gi, (33.97-
201 78.15)
6) SI lifetime:
18.99
(13.76-
26.21)
PT

SA past 12
months:
121.54
(39.59-
CE

373.11)
SA
lifetime:
15.18
(10.35-
AC

22.26)

Multivariat
e analysis:
SI past 12
months:
11.09
(6.91-
17.79)
SI lifetime:
5.82 (4.09-
8.29)
SA past 12
months:
17.37
(5.51-
54.72)

32
 ACCEPTED MANUSCRIPT

SA
lifetime:
3.45 (2.13-
5.60)
(Sto Coh - Older 6,7 57. 80.50± - Ad hoc Pass L Multivariate OR: +
lz et ort adults 91 6 4.49 items ive Social analysis: 1.85 (1.32-
al., from SI netwo L  SI 2.58)
201 EURO- rk Worsened L  SI 2.14 (1.58-
6) D scale size Negative 2.90)
and association 0.93 (0.87-
others between social 1.00)
network size and
SI
(Str Cros - Popul 19, - ≥15 - Ad hoc SI, LA Bivariate analysis: OR: +
avy s- ation 72 items SA Havin LA, having no SI:
nski secti 4 g no friends, and L  LA:
and onal friend SI/SA 2.5 (2.1-

T
Boy s 2.9)
er, L Having no

IP
200 friends:
1) 2.3 (1.7-
3.1)
L:

CR
10.5 (8.4-
13.1)
SA:
LA:
1.9 (1.3-

US 2.6)
Having no
friends:
2.2 (1.2-
3.8)
AN
L:
13.5 (9.3-
19.6)
(Wi Case - Older 51 55 79.7±5. - Ad hoc SA MS Bivariate analysis: OR: +
ktor - adults 1 3 items LA MS, LA and L  Married/co
sson contr L SA habiting:
M

et ol 0.51 (0.31-
al., 0.84)
201 LA:
0) 1.90 (1.16-
ED

3.11)
L:
7.07 (4.2-
12.0)
2.8 (1.3-
6.1)
PT

(adjusted
for
depression)
(Wil Cros - Adole 1,4 52 11-17 - GSHS SI, L Multivariate RR: +
CE

son s- scents 27 SP analysis: 3.36 (1.93-

et secti L  SI/SP 5.84)
al., onal
201
2)
AC

(Wi Cros - Youth 64 53 16.58± Mexica Ad hoc SI, Si Lack of FS (girls) OR: +
nter s- s 8 1.12 n- items SA Friend  SI/SA SI:
row secti Americ and ship Mexican-
d et onal an: 52 questio qualit American:
al., Europe nnaires y 0.60 (0.37-
201 an- proble 0.97)
1) Americ ms SA:
an: 48 FS Mexican-
American:
0.62 (0.40-
0.97)
European-
American:
0.52 (0.28-
0.95)

33
 ACCEPTED MANUSCRIPT

(Yat Cros Youth 1,0 51. 11-18 Caucasi IPPA NSS Parent Poisson path - +
es et s- s 36 9 an: (alienat I al A analysis:
al., secti 70.7 ion Parental criticism
200 onal Asian: subscal predicts NSSI via
8) 18.1 e) A
Hispani FASM
c: 2.4
Black:
1.5
Other
minorit
y: 1
Multira
cial:
6.3
Coh 6 245 53. Caucasi
ort yea 1 an: 89

T
rs Hispani
c: 5

IP
Asian,
African
Americ
an,

CR
other,
multira
cial: 6
(Yo Cros - Adult 81 28. 39.0±1 Non- Ad hoc SI, LA Both bivariate and OR: +
u et s- s with 4 01 1.33 Hispani items SA Interp multivariate Bivariate
al.,
201
1)
secti
onal
substa
nce
use
disord
ers
c
White:
58.6
Non-
US
Hispani
INQ
KPSS
TENSE
ersona
l
confli
cts
Belon
analyses:
LA was predictor
of SA
Interpersonal
conflicts and
analysis:
1.57 (1.04-
2.35)
Multivariat
e analysis:
AN
c gingn Belongingness 1.74 (1.11-
Black: ess were predictors of 2.72)
34.6 Percei SI
Other: ved Belongingness and
6.8 SS Perceived SS were
predictors of SA
M

(Za Coh - Adole Wh Wh White: White: Ad hoc SI Si Multivariate OR: +

mor ort scents ite: ite: 15.1± 94.4 items analysis: Feels not
a- 12, 49. 1.7 AI/AN: Si  SI socially
Kap 10 8 AI/AN: 5.6 accepted:
ED

oor 7 AI/ 15±1.7 2.03 (1.68-

et A AN 2.45)
al., me : Feels not
201 ric 52. part of the
6) an 3 school:
Ind 1.33 (1.14-
PT

ian 1.57)
and
Ala
ska
CE

Nat
ive
(AI
/A
N):
AC

72
1
(Zh Cros - Adult 1,4 49. ≤25 Chines Ad hoc SI Si No direct effect of - L
ang s- s 33 1 (29.8% e items Si on SI A
and secti ) Si was only
Jin, onal 26-40 weakly associated
199 (32.6% with SI in a path
8) ) model including
41-55 depression and
self-esteem
(26.8%
)
≥56
(10.8%
)

34
 ACCEPTED MANUSCRIPT

Table 1. Features of the 40 included observational studies on the association between social
isolation/loneliness and suicidal outcomes (studies are in alphabetical order).

Symbols: : presence of a positive association between the mentioned variables; +: positive

association; -: negative association; LA: lack of association.

Abbreviations: Scales: BPRS: Brief Psychiatric Rating Scale; CBCL: Child Behavior Check
List; FASM: Functional Assessment of Self-Mutilation; GSHS: Global School-based Student
Health Survey; ICD-9-R: International Classification of Diseases, Ninth Revision; INQ:
Interpersonal Needs Questionnaire; IPPA: Inventory of Parent and Peer Attachment; KPSS:
Kessler Perceived Social Support scale; LSDQ: Loneliness and Social Dissatisfaction

T
Questionnaire; MSPSS: Multiple Scales of Perceived Social Support; OSI: Ottawa Self-Injury

IP
Inventory; PHQ-9: Patient Health Questionnaire; SAVY: Survey Assessment of Vietnamese
Youth; SEYLE: Saving and Empowering Young Lives in Europe study; SFQ: Social
Functioning Questionnaire; SIS: Suicide Intent Scale; SSQ: Social Support Questionnaire;

CR
TENSE: Test of Negative Social Exchange; ULS-8: UCLA Loneliness Scale – 8 items;
YRBSS: Youth Risk Behavior Surveillance System; YSR: Youth Self-Report Scale. Suicidal
outcomes: DSH: Deliberate Self-Harm (self-harm regardless of the suicidal intent); NSSI:

US
Non-Suicidal Self-Injury; S: Suicide; SA: Suicide Attempt; SI: Suicidal Ideation; SP: Suicidal
Planning. Social isolation/loneliness: A: Alienation; C: Connectedness; E: Employment; FS:
Family Support; L: Loneliness; LA: Living Alone; MS: Marital Status; Si: Social isolation;
AN
SS: Social Support. Association metrics: HR: Hazard Ratio; IR: Incidence Ratio; OR: Odds
Ratio; RR: Relative Risk Ratio; CI: Confidence Intervals.
M
ED
PT
CE
AC

35