1. Department of SOCIAL MEDICINE University of BRISTOL The relationship of economic factors and suicide David Gunnell, University of Bristol, UK

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

3. Department of SOCIAL MEDICINE University of BRISTOL Outline  Person based studies  Ecological studies  Mechanisms  Interventions

4. Department of SOCIAL MEDICINE University of BRISTOL 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. Department of SOCIAL MEDICINE University of BRISTOL 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 Working1.001.00 <20% unemployed1.100.93 (0.66-1.33) 20-100% unemployed1.891.35 (1.03-1.76) Disability pension4.411.05 (0.74-1.50) Psychiatric history None1.001.00 Discharge 1-6 months60.0035.3 (24.0-52.1)

6. Department of SOCIAL MEDICINE University of BRISTOL 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. Department of SOCIAL MEDICINE University of BRISTOL 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

8. Department of SOCIAL MEDICINE University of BRISTOL Ecological studies

9. Department of SOCIAL MEDICINE University of BRISTOL Age standardised suicide rates England & Wales 1905-1999

10. Department of SOCIAL MEDICINE University of BRISTOL Source: Swinscow D, BMJ June 23 1951; 1417-1423

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

12. Department of SOCIAL MEDICINE University of BRISTOL Source: Morrell S et al, Soc. Sci. Med. 1993; Vol 36, 6, 749-756

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

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

15. Department of SOCIAL MEDICINE University of BRISTOL 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 55 60 65 70 75 80 85 Year Suicide death rate (per 100,000) ( ) Unemployment rate (%) ( ) Proportion of employed (%) in primary industry ( ) and tertiary industry ( ) 55 60 65 70 75 80 85 Year Suicide death rate (per 100,000) ( ) Unemployment rate (%) ( ) Proportion of employed (%) in primary industry ( ) and tertiary industry ( )

16. Department of SOCIAL MEDICINE University of BRISTOL Results: trends in GDP and unemployment 2% 8% 199819991998 2006 5% Chang S-S et al, Soc Sci Med 2009

17. Department of SOCIAL MEDICINE University of BRISTOL Results: trends in suicide rates in East Asia Chang et al Soc Sci Med 2009

18. Department of SOCIAL MEDICINE University of BRISTOL Results: time-series analyses on male suicides Chang S-S et al, Soc Sci Med 2009

19. Department of SOCIAL MEDICINE University of BRISTOL  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. Department of SOCIAL MEDICINE University of BRISTOL Suicide risk factors in 25-34 year old males: Unemployment, divorce, income inequality & alcoholism Year

21. Department of SOCIAL MEDICINE University of BRISTOL Causal pathway underlying unemployment – suicide association  Unemployment mental illness suicide  Mental illness unemployment suicide

22. Department of SOCIAL MEDICINE University of BRISTOL Source: Swinscow D, BMJ June 23 1951; 1417-1423

23. Department of SOCIAL MEDICINE University of BRISTOL 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. Department of SOCIAL MEDICINE University of BRISTOL 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. Department of SOCIAL MEDICINE University of BRISTOL

26. Department of SOCIAL MEDICINE University of BRISTOL 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. Department of SOCIAL MEDICINE University of BRISTOL 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

28. Department of SOCIAL MEDICINE University of BRISTOL 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

29. Department of SOCIAL MEDICINE University of BRISTOL 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

30. Department of SOCIAL MEDICINE University of BRISTOL 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