department of social medicine university of bristol the relationship of economic factors and suicide...

Department ofSOCIAL MEDICINE

University ofBRISTOL

The relationship of economic factors and suicide

David Gunnell, University of Bristol, UK



Geography of suicide in males aged 15-44:

England & Wales 1988-1994

LondonBirmingham

Manchester

Middleton, Sterne, Gunnell (JECH 2006)Bristol



Outline Person based studies

Ecological studies

Mechanisms

Interventions



Suicide and the Labour Market

(Platt and Hawton 2000) Systematic review: 9 prospective studies

Unemployment associated with 2-3 fold increased risk in all studies

Weaknesses: variable follow-up; limited control for possible confounders in some



Unemployment and suicide: Denmark

Mortensen et al Lancet 2000

*Income, marital status, wealth, education, place of residence

Rate ratio (RR) adjusted RR adjusted for all for sex and age (95% CI) variables (95% CI)*

Employment

Working 1.00 1.00

<20% unemployed 1.10 0.93 (0.66-1.33)

20-100% unemployed 1.89 1.35 (1.03-1.76)

Disability pension 4.41 1.05 (0.74-1.50)

Psychiatric history

None 1.00 1.00

Discharge 1-6 months 60.00 35.3 (24.0-52.1)



Risk factors for suicide in Taiwan: case control

study N=113 suicides and n=226 living controls

64.6% cases and 45.1% controls unemployed (OR 3.5 (CI 1.9 to 6.5))

Association p>0.05 in multivariable models

Cheng ATA et al BJPsych 2000



Debt and suicide in Hong Kong

Study of N=1,088 suicides in 2002

24.5% had debt problems

Main sources of debt: Gambling: 34% Business difficulties/failure: 11% Over-consumption goods/services: 8% Residential rent: 7%

Yip et al J Appl Soc Psych 2007



Ecological studies



Age standardised suicide rates England & Wales 1905-1999

0

5

10

15

20

25

30

35

1905 1910 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995

rate

per

100

,000

Females

Males



Source: Swinscow D, BMJ June 23 1951; 1417-1423



0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

0.00 5.00 10.00 15.00 20.00 25.00

Proportion of working population unemployed

Su

icid

e ra

te p

er 1

00,0

00

Gunnell et al BJPsych 1999

Association between unemployment and suicide rates (non poisons and gases) in 25-34 year old males (1921-1995)



Source: Morrell S et al, Soc. Sci. Med. 1993; Vol 36, 6, 749-756



Suicide rates in New Zealand

0

10

20

30

1889 1900 1911 1922 1933 1944 1955 1966 1977 1988

Male

Female

Year

Ra

te (

pe

r 1

00

,00

0)

Source: Deavoll BJ et al, Acta Psychiatr Scand 1993;87:81-85

Recession



Suicide rates in United States20

18

16

14

12

10

8

01900 1910 1920 1930 1940 1950 1960 1970 1980

Year

Ra

te p

er

10

0,0

00

po

pu

lati

on

Age-adjusted rate

Total rate

Source: Monk M, Epidemiologic Review 1987;9:51-69



Suicide rates in Japan

Source: Motohashi Y, J biosoc. Sci 1991;23:221-227

Secular trends in suicide rate, unemployment and proportions applied in primary and tertiary industry, 1953-72 and 1973-86

MEN WOMEN

0

10

20

30

40

0

1

2

3

4

55 60 65 70 75 80 85Year

Su

icid

e d

eath

rat

e (p

er 1

00,0

00)

(

)

Un

emp

loym

ent

rate

(%

) (

)

Pro

po

rtio

n o

f em

plo

yed

(%

)in

pri

mar

y in

du

stry

(

)an

d t

erti

ary

ind

ust

ry (

)

0

10

20

30

40

0

1

2

3

4

55 60 65 70 75 80 85Year

Su

icid

e d

eath

rat

e (p

er 1

00,0

00)

(

)

Un

emp

loym

ent

rate

(%

) (

)

Pro

po

rtio

n o

f em

plo

yed

(%

)in

pri

mar

y in

du

stry

(

)an

d t

erti

ary

ind

ust

ry (

)



0

5000

10000

15000

20000

25000

30000

35000

40000

45000

85 87 89 91 93 95 97 99 01 03 05

Year

GD

P p

er

cap

ita b

ase

d o

np

urc

ha

sin

g-p

ow

er-

pa

rity

Hong Kong Japan Korea

Singapore Taiwan Thailand

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

85 87 89 91 93 95 97 99 01 03 05

YearU

ne

mp

loym

en

t ra

te (

%)

Hong Kong Japan Korea

Singapore Taiwan Thailand

Results: trends in GDP and unemployment

2%

8%

1998

1999

1998

2006

5%

Chang S-S et al, Soc Sci Med 2009



Results: trends in suicide rates in East Asia

Chang et al Soc Sci Med 2009



Results: time-series analyses on male suicides

Chang S-S et al, Soc Sci Med 2009



10,400 excess suicides in 1998 compared to 1997 in Japan, Korea and Hong Kong

Associations stronger in men than women, young than old

In Korea and Hong Kong, but not Japan in part mediated by rises in unemployment



Suicide risk factors in 25-34 year old males: Unemployment, divorce, income inequality

& alcoholism

0

50

100

150

200

250

300

350

400

1950

1952

1954

1956

1958

1960

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

unemployment per 1,000 economically active

Divorce Rates per 10000 married population (crude)

GINI coefficient (x 1000, post tax)

cirrhosis mortality per 10 million

Year



Causal pathway underlying unemployment – suicide

association

Unemployment mental illness suicide

Mental illness unemployment suicide



Source: Swinscow D, BMJ June 23 1951; 1417-1423



Unemployment and the incidence of suicidal thoughts (Q: have you thought of

taking your life even if you would not really do it?)

18 month follow-up of National Psychiatric Morbidity Survey (2000) n=2,404

Annual incidence of suicidal thoughts 2.3%

Compared to those who were employed at baseline and follow-up,

OR for job loss: 3.7 (0.9 to 15.1) OR for continued unemployment: 14.0 (1.6 to 120.0)

(controlling for baseline CIS-R/age/sex)

Gunnell et al 2004



Interventions to offset impact of economic crisis on suicide Social policy:

Job creation alternatives to paid work e.g. community work

Advice / support to people made redundant

Increased resource to agencies providing advice for unemployed / people in debt

Remind media about responsible reporting

Support from employers Group therapy / group CBT for unemployed



Interventions to offset impact of economic crisis on

suicide Social policy:

Job creation alternatives to paid work e.g. community work

Advice / support to people made redundant

Increased resource to agencies providing advice for unemployed / people in debt

Remind media about responsible reporting

Support from employers

Group therapy / group CBT for unemployed



Group CBT for long term unemployed (Proudfoot et al

Lancet 1997) Intervention: 3 hour group sessions once per week

for 7 weeks

N=289 volunteers randomised (56% GHQ>5)

After training between group differences in GHQ improvement 3.9 (p=0.05) at 3 month f-up

34% in CBT group vs 13% in control group had found work (p<0.001) at 4 months after completion of training



Summary Ecological and person based analyses provide evidence

that unemployment increases the risk of suicide

Current economic crisis likely to lead to an increase in suicide

Need to advise Government / Policy makers about how best to offset risk

Research to evaluation measures taken



Acknowledgements

Shu-sen Chang Nicos Middleton Jonathan Sterne Robert Lee Andrew Cheng Keith Hawton Stephen Platt

Roger Harbord Glyn Lewis Nicola Singleton Danny Dorling Tom Lopatatzidis Rachel Jenkins

department of social medicine university of bristol the relationship of economic factors and suicide...

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