Upload
penelope-dorsey
View
212
Download
2
Embed Size (px)
Citation preview
Department ofSOCIAL MEDICINE
University ofBRISTOL
The relationship of economic factors and suicide
David Gunnell, University of Bristol, UK
Department ofSOCIAL MEDICINE
University ofBRISTOL
Geography of suicide in males aged 15-44:
England & Wales 1988-1994
LondonBirmingham
Manchester
Middleton, Sterne, Gunnell (JECH 2006)Bristol
Department ofSOCIAL MEDICINE
University ofBRISTOL
Outline Person based studies
Ecological studies
Mechanisms
Interventions
Department ofSOCIAL MEDICINE
University ofBRISTOL
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
Department ofSOCIAL MEDICINE
University ofBRISTOL
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)
Department ofSOCIAL MEDICINE
University ofBRISTOL
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
Department ofSOCIAL MEDICINE
University ofBRISTOL
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
Department ofSOCIAL MEDICINE
University ofBRISTOL
Ecological studies
Department ofSOCIAL MEDICINE
University ofBRISTOL
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
Department ofSOCIAL MEDICINE
University ofBRISTOL
Source: Swinscow D, BMJ June 23 1951; 1417-1423
Department ofSOCIAL MEDICINE
University ofBRISTOL
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)
Department ofSOCIAL MEDICINE
University ofBRISTOL
Source: Morrell S et al, Soc. Sci. Med. 1993; Vol 36, 6, 749-756
Department ofSOCIAL MEDICINE
University ofBRISTOL
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
Department ofSOCIAL MEDICINE
University ofBRISTOL
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
Department ofSOCIAL MEDICINE
University ofBRISTOL
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 (
)
Department ofSOCIAL MEDICINE
University ofBRISTOL
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
Department ofSOCIAL MEDICINE
University ofBRISTOL
Results: trends in suicide rates in East Asia
Chang et al Soc Sci Med 2009
Department ofSOCIAL MEDICINE
University ofBRISTOL
Results: time-series analyses on male suicides
Chang S-S et al, Soc Sci Med 2009
Department ofSOCIAL MEDICINE
University ofBRISTOL
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
Department ofSOCIAL MEDICINE
University ofBRISTOL
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
Department ofSOCIAL MEDICINE
University ofBRISTOL
Causal pathway underlying unemployment – suicide
association
Unemployment mental illness suicide
Mental illness unemployment suicide
Department ofSOCIAL MEDICINE
University ofBRISTOL
Source: Swinscow D, BMJ June 23 1951; 1417-1423
Department ofSOCIAL MEDICINE
University ofBRISTOL
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
Department ofSOCIAL MEDICINE
University ofBRISTOL
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
Department ofSOCIAL MEDICINE
University ofBRISTOL
Department ofSOCIAL MEDICINE
University ofBRISTOL
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
Department ofSOCIAL MEDICINE
University ofBRISTOL
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
Department ofSOCIAL MEDICINE
University ofBRISTOL
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
Department ofSOCIAL MEDICINE
University ofBRISTOL
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
Department ofSOCIAL MEDICINE
University ofBRISTOL
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