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The relationship of economic factors and suicide David Gunnell, University of Bristol, UK

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. Manchester. London. Birmingham. Bristol. Middleton, Sterne, Gunnell (JECH 2006). Outline. Person based studies

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The relationship of economic factors and suicide David Gunnell, University of Bristol, UK

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  1. The relationship of economic factors and suicide David Gunnell, University of Bristol, UK

  2. Geography of suicide in males aged 15-44: England & Wales 1988-1994 Manchester London Birmingham Bristol Middleton, Sterne, Gunnell (JECH 2006)

  3. Outline • Person based studies • Ecological studies • Mechanisms • Interventions

  4. 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

  5. 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) *Income, marital status, wealth, education, place of residence Unemployment and suicide: Denmark Mortensen et al Lancet 2000

  6. 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

  7. 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 JAppl Soc Psych 2007

  8. Ecological studies

  9. Age standardised suicide rates England & Wales 1905-1999

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

  11. Association between unemployment and suicide rates (non poisons and gases) in 25-34 year old males (1921-1995) Gunnell et al BJPsych 1999

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

  13. Suicide rates in New Zealand Recession Male Rate (per 100,000) Female Year Source: Deavoll BJ et al, Acta Psychiatr Scand 1993;87:81-85

  14. 20 18 16 14 12 10 8 0 Age-adjusted rate Rate per 100,000 population Total rate 1900 1910 1920 1930 1940 1950 1960 1970 1980 Year Suicide rates in United States Source: Monk M, Epidemiologic Review 1987;9:51-69

  15. MEN WOMEN Suicide death rate (per 100,000) ( ) Suicide death rate (per 100,000) ( ) Proportion of employed (%)in primary industry ( )and tertiary industry ( ) Proportion of employed (%)in primary industry ( )and tertiary industry ( ) Unemployment rate (%) ( ) Unemployment rate (%) ( ) 55 60 65 70 75 80 85 Year 55 60 65 70 75 80 85 Year Suicide rates in Japan Secular trends in suicide rate, unemployment and proportions applied in primary and tertiary industry, 1953-72 and 1973-86 Source: Motohashi Y, J biosoc. Sci 1991;23:221-227

  16. Results: trends in GDP and unemployment 8% 5% 2% 2006 1998 1999 1998 Chang S-S et al, Soc Sci Med 2009

  17. Results: trends in suicide rates in East Asia Chang et al Soc Sci Med 2009

  18. Results: time-series analyses on male suicides Chang S-S et al, Soc Sci Med 2009

  19. 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

  20. Suicide risk factors in 25-34 year old males: Unemployment, divorce, income inequality & alcoholism Year

  21. Causal pathway underlying unemployment – suicide association • Unemployment mental illness suicide • Mental illness unemployment suicide

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

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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 Acknowledgements

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