The impact of economic crisis on suicide in Asia and other regions.

Transcription

1 The impact of economic crisis on suicide in Asia and other regions. David Gunnell Bristol

2 Acknowledgements Shu-Sen Chang Nicos Middleton Jonathan Sterne Esben Agerbo Camilla Haw Andrew Cheng Robert Lu Keith Hawton Stephen Platt

3 Gross domestic product (GDP) growth (%) Gross domestic product (GDP) growth (%) Trends in GDP growth in OECD countries 20 Australia Hong Kong SAR Indonesia Korea China India Japan Taiwan France Italy Turkey Germany Russia United Kingdom Year Year

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5 Historical background Morselli (1882) An essay on comparative moral statistics Highlighted effects of economic conditions (e.g. price of food, lack of job, bankruptcy) on suicide rates Durkheim (1897) Suicide Economic changes would lead to increases in suicide because of social regulation and integration Effects would be particularly marked in societies where no efforts made to help individuals adjust to consequent abrupt changes in status in society Henry & Short (1954) Suicide and homicide Economic recession would result in increased frustration because of inability to realise financial goals, causing increased aggression, including self-aggression Thanks to Keith Hawton for this slide

6 Although some potentially important confounders were not adjusted for, the findings support the idea that unemployment or lack of job security increases the risk of suicide and that social and economic policies that reduce unemployment will also reduce the rate of suicide. Lewis BMJ 1998

7 Number of suicides, proportions of person years in each category, and odds ratios No. of % Person years Odds ratio* Adjusted odds ratio Suicides in category (95% CI) P value (95% CI) P value Men Women ( ) < ( ) <0.001 Economic activity: Employed Unemployed ( ) < ( ) <0.001 Sick/disabled ( ) < ( ) <0.001 Retired ( ) ( ) Student ( ) ( ) 0.07 Other ( ) < ( ) 0.04 *Adjusted for age, time period, sex Adjusted for age, time period, sex, marital status/living alone, car ownership, social class, education, housing tenure Source: Lewis et al BMJ1998

8 Although some potentially important confounders were not adjusted for, the findings support the idea that unemployment or lack of job security increases the risk of suicide and that social and economic policies that reduce unemployment will also reduce the rate of suicide. Lewis BMJ 1998 Our findings suggest, however, that studies of socioeconomic risk factors for suicide, that do not take the distribution of mental disorders into account, are likely to yield confounded results where the effect of these risk factors will tend to be overestimated. This factor may explain the apparent contradiction between our results on attributable risk and results from Lewis and colleagues, who estimated that about 11% of suicides could be attributed to unemployment, contrasting with our estimate of 3%. Mortensen et al. Lancet 2000

9 Predictors for suicide in the general population adjusted for age and sex IRR adjusted for sex and age (95% CI) IRR adjusted for all variables (95% CI) Employment and benefits Working* <20% unemployed 1.10 ( ) 0.93 ( ) % unemployed 1.89 ( ) 1.35 ( ) Disability pension 4.41 ( ) 1.05 ( ) Age pension 3.08 ( ) 1.69 ( ) Other social benefits 1.97 ( ) 1.31 ( ) Student 0.98 ( ) 0.82 ( ) Sickness absence 2.25 ( ) 1.42 ( ) Hospital history No psychiatric admission* Currently admitted 90.0 ( ) 62.6 ( ) Discharged <8 days before suicide 458 ( ) 337 ( ) Discharged 8-30 days before suicide 108 ( ) 68.4 ( ) Discharged 1-6 months before suicide 60.0 ( ) 35.3 ( ) Discharged 7-12 months before suicide 44.3 ( ) 28.9 ( ) Discharged >1 year before suicide 9.72 ( ) 6.51 ( ) Total admission number > ( ) *Reference category. Data not included in the univariate analysis, because these variables apply only to those ever admitted. Source: Mortensen P B et al. The Lancet 2000;355

10 Although some potentially important confounders were not adjusted for, the findings support the idea that unemployment or lack of job security increases the risk of suicide and that social and economic policies that reduce unemployment will also reduce the rate of suicide. Lewis BMJ 1998 Our findings suggest, however, that studies of socioeconomic risk factors for suicide, that do not take the distribution of mental disorders into account, are likely to yield confounded results where the effect of these risk factors will tend to be overestimated. This factor may explain the apparent contradiction between our results on attributable risk and results from Lewis and colleagues, who estimated that about 11% of suicides could be attributed to unemployment, contrasting with our estimate of 3%. Mortensen et al. Lancet 2000 Despite the fact that there was only a slight increase in deaths by suicide during the Great Depression, there were certainly a few well publicized suicides which may have fuelled the myth of a suicide epidemic. Newsletter of IASP Dec 2008

11 The importance of context

12 Context and suicide: Crawford et al. Systematic review Data from 54 case-control studies (1950 and 2006) that examined socio-demographic risk factors for suicide in clinical, occupational and general populations. Investigated associations of odds ratios for risk factors for suicide (employment, ethnicity, living circumstances and marital status) with the prevalence of these risk factors among controls.

13 R=-0.65 (CI to -0.88)

14 Context: unemployment and suicide in Hong Kong Year Unemployed (%) 4.9% 7.9% 4.8% Suicide rate per 100,000 Unemployed Overall Yip and Caine 2010

15 Evidence from ecological studies

16 rate per 100,000 Age standardised suicide rates England & Wales Females Males year

17 Source: Swinscow D, BMJ June ;

18 Suicide rate per 100,000 Association between unemployment and suicide rates (non poisons and gases) in year old males ( ) Proportion of working population unemployed Gunnell et al BJPsych 1999

19 Rate per 100,000 population Suicide rates in United States Age-adjusted rate Total rate Year Source: Monk M, Epidemiologic Review 1987;9:51-69

20 Unemployment rate (%) Hong Kong Japan Korea Singapore Taiwan Thailand Year Chang S-S et al, Soc Sci Med 2009

21 Divorce per 1000 married Marriage per 1000 unmarried Results: trends in divorce and marriage rates Hong Kong Japan Korea Singapore Taiwan Thailand Year Hong Kong Japan Korea Singapore Taiwan Thailand Year Chang S-S, unpublished

22 Results: trend in suicide rates in Japan Year Chang et al, Soc Sci Med 2009

23 The impact of the economic crisis on suicide rates in East Asia Chang et al, Soc Sci Med 2009

24 Suicide rate per Unemployment rate (%) Trend in suicide rates in Taiwan, Male Suicide 6 45 Female Suicide 40 Unemployment Year Chang et al, Public Health 2010

25 10,400 excess suicides in 1998 compared to 1997 in Japan, Korea and Hong Kong Associations stronger in men than women, young than old Associations not seen in all affected countries

26 The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis Examined changes in mortality with changes in unemployment and effects of government expenditure in 26 EU countries, % increase in unemployment associated with 0.79% rise in suicide in persons <65 years >3% increase in unemployment associated with 4.45% rise in suicides in persons <65 years Stuckler et al. 2009

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28 Japan Karoshi death by overwork In one case in 1999 a woman sued a pharmaceutical company (133million yen / 750,000) after husband killed himself working almost non-stop to detect a fault in the firm's quality control system Signs: mistakes on duty, missing deadlines or quotas, and having trouble with clients Guidelines issued by Labour Ministry in 1999 Appropriate working hour guidelines issued in Watts, Lancet 1999 p 1273

29 Factors: Japan Karoshi case series: Amagasa 2005 (J Occup Hlth) 11/22 recently promoted; 6/22 recently transferred Low levels of social support at work (82%); high psychological demand (82%) and low decision latitude (77%) 41% worked hours per day (median excess 5 hours) Work seemed so central to these individuals selfesteem that inability to cope with work demands was perceived as a very salient problem

30 Evidence reviewed indicates that. Mental illness explains some of the association of unemployment with suicide in cohort studies HOWEVER Economic recession and associated rises in unemployment do appear to lead to increases in suicide ALTHOUGH effect vary by country / context Rises in unemployment may be the tip of the iceberg of psychological distress

31 The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis Examined changes in mortality with changes in unemployment and effects of government expenditure in 26 EU countries, Every US$10 per person increased investment in active labour market programmes reduced effect of unemployment on suicide by 0.038% Adverse effects on suicide were mitigated when investments in active labour market programmes were high (>US$190 per head) NB Finland and Sweden Stuckler et al. 2009

32 Interventions to offset impact of economic Social policy: Job creation crisis on suicide Alternatives to paid work e.g. community work Increased resource to agencies providing advice for unemployed / people in debt Support from employers Remind media about responsible reporting

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34 Interventions to offset impact of economic Social policy: Job creation crisis on suicide alternatives to paid work e.g. community work Increased resource to agencies providing advice for unemployed / people in debt Support from employers Remind media about responsible reporting Group therapy / group CBT for unemployed

35 Research priorities Monitor impact of crisis on mental health Use opportunity of this crisis to investigate / pilot interventions Cross-national studies to compare impact on suicide rates of different approaches to tackling the crisis and supporting those most affected Qualitative and cohort studies with people who lose their jobs and get into financial difficulties

36 Summary Ecological studies indicate there is a strong association of economic crisis with suicide Such an association may be under-estimated in cohort studies Many mechanisms contribute to heightened risk State interventions may offset the impact of the crisis on suicide More research is required on the best person-based and area based interventions

37 Author: Masaryk TG 1881

38 Thank you