Suicidality And Financial Crisis

Transcription

1 Suicidality And Financial Crisis Theleritis C., Economou M. University Mental Health Research Institute (UMHRI) and 1 st Department of Psychiatry, University of Athens Medical School, Eginition Hospital, Athens, Greece Summary Background: Several articles refer to the negative health effects of the Greek current economic crisis. Within this context, increased percentages of suicidal attempts and ideation have been associated recently in Greece with the financial crisis. The aim of this paper is to clarify the association of suicidality (suicidal attempts and ideation) with socio-demographic, financial, psychological and psychiatric factors in the years 2009 and 2011 (before and after the implementation of the memorandum of economic and financial policies in Greece). Methods: Two nationwide, cross-sectional surveys were conducted from February to April of the years 2009 and The interview questions covered socio-demographics, the SCID I module for the detection of Major Depressive Episode (1-month prevalence) and the Index of Personal Economic Distress (IPED). Results: We have found that for the year 2011 participants who were male, and who had major depression, serious financial difficulties (high IPED score) and a history of suicide attempt(s) were more likely to experience suicidal ideation or to attempt a suicide. Conclusion: Early detection of depression especially in males and those experiencing financial distress is of great importance for reducing suicidality, especially in times of economic hardships. Introduction Suicidality is an enormous health problem; each year, worldwide, approximately a million people die by commiting suicide 1. Suicidal ideation and suicide attempts have been shown to be strong risk factors for completed suicide 2. Furthermore, there seems to be a definite association of suicidality with socioeconomic factors 3-10 and mental health disorders In fact, psychological autopsy reports demonstrate that people who die by suicide may suffer up to 90-95% from a psychiatric disorder 15 ; mood disorders, impulse control disorders, alcohol and substance abuse, psychotic and personality disorders seem to carry the greater risk as well as the presence of multiple mental disorders 11. Previous research in Greece displays a strong link of self -reported suicide ideation and suicide attempts across the years and socio-economic factors 6,16. Specifically, in a cross-sectional epidemiological study conducted in 1978, one-month prevalence of suicidal ideation was found to be 4.8%, whereas in 1984 it reached as high as 10.9%, a rise which was attributed to the economic recession. A similar trend was recorded for selfreported suicide attempt with rates being 0.7% in 1978 and 2.6% in Zacharakis et al. 17 explored suicide rates in Greece the time period and found that they were among the lowest in the world, possibly due to the strong family ties, the support and help offered by social networks and religious practices. Suicide rates had remained low until In 2009, the economic crisis affected a large population segment in Greece. In April 2010, a Memorandum of Economic and Financial Policies was implemented, which averted Greece s default, by imposing economic restriction which led the GDP to contract by 4.5% in The recession has led to job losses across all sectors of the economy and to a rise in unemployment. In the last quarter of 2010 the rate of unemployment reached 14.2% of the workforce (Bank of Greece, Annual Report for the year 2010). In the year 2011 the financial situation was even further aggravated. In adults, unemployment has risen from 6 6% in May, 2008, to 16 6% in May, 2011 (while youth unemployment rose from 18 6% to 40 1%) 18 as debt grew between 2007 and 2010 from 105 4% to 142 8% of gross domestic product (GDP; billion to billion) compared with the average change in the EU-15 (the 15 countries that were EU members before May 1, 2004) from 66 2% to 85 1% of GDP in this same period ( 6 0 trillion to 7 8 trillion) 19. The recent financial crisis in Greece has attracted a lot of attention. Several articles refer to the negative health effects of the economic crisis in Greece 6-9, Recently, increased percentage of suicidal attempts and ideation have been associated in Greece with the financial crisis 7-9. This paper presents and discusses the results of two nationwide, cross-sectional surveys that were conducted from February to April of the years 2009 and 2011.The aim of this study is to clarify the association of suicidality (suicidal attempts and ideation) with sociodemographic, financial psychological and psychiatric factors in the years 2009 and 2011 (before and after the implementation of the memorandum in Greece). Medimond. PY29C

2 Methods The samples were selected from national phone-number databanks. A random sample of telephone numbers belonging to individuals were selected from the directory. Telephone interviews were conducted with adults aged years during the same quarter of the year (February April) in 2009 and in In the 2009 survey, responses to 2845 calls were as follows: 2192 (78%) successfully completed interviews, 119 (4.2%) hung up immediately and 506 (17.8%) refused to be interviewed or did not complete the interview; the cooperation in the study reached a rate of 78%. The sample included 1080 males and 1112 females. The maximum sampling error was ±2.12% with 95% confidence limits. In the 2011 survey, responses to 2820 calls were as follows: 2256 (80.5%) successfully completed interviews, 203 (7.2%) hung up immediately and 347 (12.3%) refused to be interviewed or did not complete the interview. The cooperation in the study reached a rate of 80.5%. The sample consisted of 1090 males and 1156 females. In both studies, no statistically significant differences were found between participants who could be interviewed and those who could not in terms of gender, age and place of residence. The method of computer assistant telephone interviewing was used 24, since it enables automatic control of questionnaire branching, on-line verification checks and automatic scheduling of future call backs (e.g., if the call is not answered or the interview is not completed). The relevant module of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) 25 was used in order to detect the occurrence of a major depressive episode, suicidal ideation and suicide attempts during the past month. SCID-I has been standardized in the Greek population and extensively used in clinical and epidemiological studies 26,27. To confirm the reliability of the diagnosis, a random sample of the calls (10%) was rated by ten interviewers. The Fleiss kappa was found to be 0.89 in 2009 and 0.90 in Furthermore, a random sample of participants (10%) agreed to be re-interviewed by a psychiatrist. The rate of diagnostic agreement was 87% in 2009 and 89% in To assess participants degree of financial strain, the Index of Personal Economic Distress (IPED) was used 6. Based on previous demographic studies, carried out in Greece, eight items were selected relating to personal economic functions. The IPED ratings on the eight items were made on a three-point scale incorporating the dimensions of frequency, ranging from never (1), sometimes (2), and often (3). The scores range from 8 no economic problems to 24 serious problems. All items covered the period of the last 6 months. A previous study identified 15 as the cut-off point producing the best results in terms of sensitivity and specificity (Madianos et al. 2011) 6 ; within this context, participants scoring 15 and above were regarded as being in high financial distress. The scale displayed good internal consistency (Cronbach a=0.93). The socio-demographic characteristics of the respondents (gender, age, family status, place of residence, education, employment status) and their previous contacts with mental health professionals, use of psychiatric medication and admissions to an inpatient service were also recorded. The study received approval from the University Mental Health Research Institute Ethics Committee. Informed consent was obtained from all participants. To explore differences between categorical variables, chisquare test with Yates correction was used. To identify predictors of suicidal ideation and recent suicide attempt, two logistic regression models were computed, with the presence/absence of suicidal ideation and recent suicide attempts to constitute the dependent variables. The models contained several independent variables (Gender, Age, Marital Status, Education, Place of Residence, Employment Status, IPED score, previous suicide attempts etc.). All analyses were performed by SPSS v.17. Results The composition of the 2009 and 2011 study samples was congruent with the 2001 population census. The proportion of respondents who reported suicidal ideation was 6.7% in 2011 vs. 5.2% in 2009 (p < 0.05). The significant predictors of suicidal ideation in 2011 [Table 1] were the presence of major depression during the previous month, financial hardship experienced, a previous history of suicide attempt and a low interpersonal trust. People who fulfilled DSM-IV criteria for major depression were 48 times more likely to present suicidal ideation than people without that diagnosis (OR = 47.72, 95% CI = , p<0.001). Respondents with a history of suicide attempt were 7 times more likely to report suicidal ideation than people without such a history (OR = 6.89, 95% CI = , p<0.01). The proportion of respondents who reported a recent suicide attempt was 1.5% in 2011 vs. 1.1% in 2009 (p=0.28). As reported in Table 2, the significant predictors of a recent suicide attempt in 2011 were the presence of major depression during the previous month, financial hardship (high IPED score), history of suicide attempt, being male and being married. People who fulfilled DSM-IV criteria for major depression were 97 times more likely to report a suicide attempt during the previous month than people without that diagnosis (OR = 97.39, 95% CI = , p<0.01). Men were 12 times more likely to report a recent suicide attempt than women (OR = 12.26, 95% CI = , p<0.05). People with a previous history of suicide attempt were 14 Medimond. PY29C

3 times more likely to report a recent suicide attempt than those without such a history (OR = 14.41, 95% CI = , p<0.01). Table 1. Logistic regression results with suicidal ideation (presence/absence) in 2011 as dependent variable Table 2. Logistic regression results with reported recent suicide attempt (presence/absence) in 2011 as dependent variable Discussion In our study 9 it was found that, for the year 2011, participants who had major depression, had experienced serious financial difficulties (high IPED score) and had reported history of suicide attempt were Medimond. PY29C

4 more likely to experience suicidal ideation or to attempt a suicide in the last month. Male respondents were also more likely to attempt suicide. However, due to the cross-sectional nature of the design, causal inferences cannot be drawn. Association of suicidality with socioeconomic factors There seems to be a definite association of suicidality with socioeconomic factors 3-10.In our sample there was a significant association of high IPED score with suicide attempt and suicidal ideation, while there was a significant increase in the percentage of unemployed participants who attempted suicide. So far, it is not known exactly which factors mediate the connection between economic crisis and suicide. Indeed, other studies have also underlined the association of rise in unemployment rate and suicide amid a climate of economic crisis and uncertainty 5,28,29. Furthermore, in controlled psychological autopsy studies 30,31 unemployment was found to be associated with suicide even when mental health disorders and other confounding factors were taken into account. Chang et al. 5 proposed that unemployment and low income might lead to depressive symptoms, which have often been associated with suicide. In fact, Hintikka et al. 32 in a 3-year prospective study in a population sample found that depressive mood appears to be a prerequisite for the occurrence of suicidal ideation even after adverse life events. Association of suicidality with mental health disorders Suicidality has long been associated with the presence of mental health disorders Inskip et al. 33 estimated the lifetime risk for suicide to be 6% for affective disorder, 7 % for alcohol dependence,and 4% for schizophrenia. Bostwick and Pankratz 34 estimated the risk to be 4% for patients hospitalized for affective disorders and 8.6% for those hospitalized for affective disorder and suicidality. The European Association Study on the Epidemiology of Mental Disorders (ESEMED) has reported that the population attributable risks for lifetime suicidal attempt was 28% for major depression 35. Apart from affective disorders and schizophrenia, substance abuse and anorexia should be included in all suicide preventive programs 14,36. In the population study by Spijker et al. 37 who investigated the predictors of suicidality in depressive spectrum disorders, suicide attempts were significantly related with comorbid anxiety, previous suicidal ideation and attempts and living alone. Nordendoft 13 in a seminal review reported that the most frequently reported risk factor is previous suicide attempt. It is worth noting that both in the 2009 and 2011 surveys we conducted, suicidal ideation and suicide attempt were significantly associated with history of previous suicide attempt. Other frequently reported risk factors are alcohol and drug abuse, depression, previous inpatient treatment, sociopathy, unemployment, frequent change of address, hostility, hopelessness, and living alone 13. Depression and other psychiatric disorders are often under-recognized by primary care physicians 38 ; given the relationship of affective disorders with suicidality this constitutes a major public health issue. Furthermore, patients that do not meet the criteria for major depression, they might still be at substantial risk of suicide due to sub-syndromal depressive symptoms, since it was found that the risk of suicide is linearly related with the severity of depressive symptoms 39. It is worth noting that both in 2009 and 2011 surveys, all the respondents who have recently attempted suicide presented with depressive mood (less or for at least 2 weeks) and experienced of self-harm or suicidal ideation; in fact, even if some of the patients did not meet the criteria for a diagnosis of major depression, still attempted suicide. Association of suicidality with gender and age group Generally, being woman, younger and divorced or widowed was associated with a higher prevalence of suicide ideation and attempts (ESEMED study) 35. Male sex has been often reported as a risk factor for completed suicide worldwide with the exception of India and China (for a review see 11 ). It is worth noting that in our 2011 survey male respondents were 12 times more likely to attempt suicide. Studies have shown mixed results regarding whether men 5,40,41, or women 4,42, have increased rates of suicide during economic downturns. In a study by Chang et al. 5 in Japan, Hong Kong and Korea working-age men appeared more likely to be affected by the economic crisis than retired men. Similarly, rises in suicide mortality during the economic crisis in the early 1990s in Russia were more prominent in young and middle-aged adults than in the elderly 3. Fairweather-Schmidt et al. 29 found that males aged not in the labour force had increased odds of serious suicidality (OR = 4.08, 95% CI = ) compared to their equivalently aged and employed counterparts. It seems that compared with older people, young and middle-aged adults are more likely to be directly influenced by change in economic circumstances such as employment and income. It should be underlined in the 2011 survey, compared to the 2009 study, significant increases regarding recent suicide attempts were observed in male participants, respondents aged 25-44, married participants, respondents belonging to the higher education group (>13 years of education), and unemployed participants. Medimond. PY29C

5 Protective factors-prevention measures Among the protective factors that have been associated with a decreased probability of suicide attempts are social and family support, religious beliefs and practice, and spirituality (for a review see 11 ). Regarding selective prevention, the most important risk groups both in terms of magnitude of the increased risk and size of the risk group are the mentally ill, including those with alcohol and substance abuse, and those who have attempted suicide 13,14. This was also shown in our study. What should be underlined is that, in a population study, Kessler et al. 43 have shown that about 90% of unplanned and 60% of planned first attempts occurred within one year of the first onset of suicidal ideation. Within this context, early detection of mental health disorders and of depression in particular is of great importance 44. Programs which were specifically designed to train primary care physicians in the recognition and treatment of depression have reported increased prescription rates of antidepressants and reductions in the suicide rate 45. Dialectical behavior therapy 46, cognitive behavioural therapy 47 regularly sending letters 48 or communicating by telephone 49 were proven to be of help for persons who have attempted suicide. The expansion of social protection programs 20 such as labor force expansion programs, social support systems, and access to health care and health insurance might mitigate the increased suicidality and other negative mental health effects of the economic crisis in Greece. References 1. WORLD HEALTH ORGANIZATION. Suicide prevention (SUPRE). Geneva, Switzerland: World Health Organization; SUOMINEN K., ISOMETSA E., SUOKAS J., HAUKKA J., ACHTE K., LONNQVIST J. Completed suicide after a suicide attempt: a 37-year follow-up study. Am J Psychiatry, 161: , GAVRILOVA N.S., SEMYONOVA V.G., EVDOKUSHKINA G.N., GAVRILOV L.A. The response of violent mortality to economic crisis in Russia. Population Research and Policy Review, 19: , GUNNELL D., MIDDLETON N., WHITLEY E., DORLING D., FRANKEL S. Why are suicide rates rising in young men but falling in the elderly? a time-series analysis of trends in England and Wales Soc Sci Med, 57: , CHANG SS, GUNNELL D, STERNE JAC, LUC TH, CHENG ATA. Was the economic crisis responsible for rising suicide rates in East/Southeast Asia? A time-trend analysis for Japan, Hong Kong, South Korea, Taiwan, Singapore and Thailand. Soc Sci Med, 68: , MADIANOS M., ECONOMOU M., ALEXIOU T., STEFANIS C. Depression and economic hardship across Greece in 2008 and 2009: two cross-sectional surveys nationwide. Soc Psychiatry Psychiatr Epidemiol, 46: , ECONOMOU M., MADIANOS M., THELERITIS C., PEPPOU L.E., STEFANIS C.N. Increased suicidality amid economic crisis in Greece. Lancet, 378:1459, ECONOMOU M., MADIANOS M., PEPPOU L.E., THELERITIS C., STEFANIS C.N. Suicidality and the economic crisis in Greece. Lancet, 380:337, ECONOMOU M., MADIANOS M., PEPPOU L.E., THELERITIS C., PATELAKIS A., STEFANIS C. Suicidal ideation and reported suicide attempts in Greece during the economic crisis. World Psychiatry, 12: 53 59, CATALANO R., GOLDMAN-MELLOR S., SAXTON K., ET AL. The health effects of economic decline. Annu Rev Public Health, 32: , NOCK M.K., BORGES G., BROMET E.J., CHA C.B., KESSLER R.C., LEE S. Suicide and suicidal behavior. Epidemiol Rev., 30: , NOCK M.K., HWANG I., SAMPSON N., KESSLER R.C., ET AL. Cross-national analysis of the associations among mental disorders and suicidal behavior: findings from the WHO World Mental Health Surveys. PLoS Med 2009; 6(8):e NORDENTOFT M. Prevention of suicide and attempted suicide in Denmark. Epidemiological studies of suicide and intervention studies in selected risk groups. Dan Med Bull, 54: , NORDENTOFT M. Crucial elements in suicide prevention strategies. Prog Neuropsychopharmacol Biol Psychiatry, 35: , CAVANAGH J.T., CARSON A.J., SHARPE M., ET AL. Psychological autopsy studies of suicide: a systematic review. Psychol Med., 33: , MADIANOS M., MADIANOU-GEFOU D., STEFANIS C.N. Changes in suicidal behavior among nation-wide general population samples across Greece. Eur Arch Psychiatry Clin Neurosci., 243: , Medimond. PY29C

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